Management of Neurogenic Bladder
-
Upload
theo-referat -
Category
Documents
-
view
26 -
download
0
description
Transcript of Management of Neurogenic Bladder
-
Management of Neurogenic Bladder Disorders
Andrea Staack, MD, PhD
Pelvic Reconstructive Surgery,
Urinary Incontinence & Female Urology
Department of Urology
Loma Linda University, CA
-
What will you learn during the next 20 min?
1. What is happening to my bladder?
2. How will I get evaluated?
3. How can I improve my symptoms?
4. Therapy with medication
5. Invasive interventions
2
-
What will you learn during the next 20 min?
1. What is happening to my bladder?
2. How will I get evaluated?
3. Simple measurements for therapy
4. Therapy with medication
5. Forms of interventions
-
1. What is happening to my bladder?
You are not alone!
40-50% in the elderly population will suffer from bladder disease in the U.S.
Risk increases with age
Can happen out of the blue or
Can have neurological causes
4
-
1. What is happening to my bladder?
Dual control of urination:
1. Autonomic nervous system control
Nerve coming from the spinal cord and go directly to the bladder
When bladder gets fuller, signals are sent to the brain
2. Central nervous system
Voluntary control to choose when to void
Both can be altered by aging or neurological disease
5
-
Friedreichs ataxia andneurogenic bladder disorder
6
BLADDER MUSCLE SPHINCTER MUSCLES
INCONTINENCE Over activity:
Muscles squeezes without
warning
Too loose:
Urethra is not supported
URINARY
RETENTION
Less or none activity:
Muscle is too lazy
Too tight:
Urination is difficult
-
Uncontrolled Contraction of the
Bladder MuscleNormal bladder Patients with urge
incontinence
Patients with urge
or frequency
Urethral resistance Uncontrolled bladder
muscle contractions
7
-
1. What is happening to my bladder?
Friedreichs ataxia and neurogenic bladder disorder:
More patients will most likely develop incontinence from bladder overactivity than from difficulties to empty bladder
Degenerative disease of nerve tissue in the spinal cord and peripheral nerves
Exact mechanism of bladder disorders remains unclear
8
-
1. What is happening to my bladder?
9
Overactive Bladder Symptom:
Experiencing a strong urge to go to the bathroom.
Urinary Urgency
-
1. What is happening to my bladder?
10
Overactive Bladder Symptom:
Going to the bathroom frequently.
Have to go to the bathroom, where the bladder wakes me up at night.
Urinary Frequency
-
1. What is happening to my bladder?
11
Overactive Bladder Symptom:
Loosing involuntary urine accompanied with the strong desire to void.
Urge Urinary
Incontinence
-
What will you learn during the next 20 min?
1. What is happening to my bladder?
2. How will I get evaluated?
3. Simple measurements for therapy
4. Therapy with medication
5. Forms of interventions
-
Hello, incontinence helpline Can you hold?
2. How will I get evaluated?
-
2. How will I get evaluated?-History-
Fluid intake pattern
Number of continent and incontinence episodes
Night time urgency
Voiding Pattern
Quality of stream
Incomplete voiding
Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.
Wyman JF, et al. Obstet Gynecol. 1988;71:812-817.
14
-
2. How will I get evaluated?-History-
Alterations in bowel habits
Changes in sexual function
OB/GYN history
Medications
Neurologic history
Back pain, back surgery
Stroke
Numbness, weakness, balance problems
-
2. How will I get evaluated?-Quantification of symptoms-
Voiding diary day and night for >24 hours:
Document of fluid intake
Quantification of urine output with voiding hat
Uncontrolled loss of urine at day and night
Degree of urge to go to the bathroom
Use and number of pads
Raz, S and Rodriguez, LV: Female Urology. 3rd
edition. Saunders Elsevier, 2008.
-
2. How will I get evaluated?-Physical examination-
General examination
Focused neurological examination
Genitalia and pelvic floor examination
Rectal examination
Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.
17
-
2. How will I get evaluated?-Invasive Tests-
Urodynamic studies assess:
Uncontrolled bladder contractions
Urethral competence during filling
Bladder function during voiding
Left-over urine after urination
Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682. 18
-
2. How will I get evaluated?-Laboratory tests-
Urine tests
To rule out blood in the urine, kidney problems, urinary tract infections
Blood work as appropriate Blood sugar
PSA (prostate cancer)
Fantl JA et al. Agency for Healthcare Policy and Research;
1996; AHCPR Publication No. 96-0686. 19
-
2. How will I get evaluated?-Invasive Tests-
Bladder scanning with a camera (Cystoscopy)
To rule out any growth, inflammation, or stones inside the bladder
Imaging Studies
Ultrasound
X-ray studies with contrast fluid during
MRI
Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.
20
-
What will you learn during the next 20 min?
1. What is happening to my bladder?
2. How will I get evaluated?
3. How can I improve my symptoms?
4. Therapy with medication
5. Forms of interventions
-
3. How can I improve my symptoms?
-Dietary changes-
Adequate fluid intake:
Not too much to avoid too frequency
Not too little to avoid bladder irritation and urinary tract infections
Reduce evening fluids to manage nighttime urination
1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.22
-
3. How can I improve my symptoms?
-Dietary changes-
Certain fluids can irritate the bladder:
Carbonated drinks
Citrus juices
Caffeinated drinks, e.g. soda, tea, coffee
Alcoholic beverages
1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.23
-
3. How can I improve my symptoms?
-Dietary changes-
Dietary adjustments Fruits
Vegetables
High fiber intake
Bowel regulation
Avoid constipation and straining
Routine defecation schedule
1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.24
-
3. How can I improve my symptoms?
-Lifestyle changes-
Stop smoking
To reduce chronic coughing reduces downward pressure on the pelvic floor
Weight reduction
Excessive body weight affects bladder pressure, blood flow, and nerves
1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.25
-
3. How can I improve my symptoms?-Exercises-
1. Helps strengthen the muscles of the pelvic floor improves bladder stability
2. Helps suppress the feeling of urgency
Contraction
Bladder
Relaxation
26
Pelvic floor exercise:
-
3. How can I improve my symptoms?-Exercises-
1. Find your pelvic floor muscles.
2. Squeeze your pelvic floor muscles as hard as
you can and hold them (squeeze 3-5 sec
and relax for 5 sec).
3. Do sets of repetitions of squeezing (start with
5 repetitions: squeeze, hold, relax).
4. Increase lengths, intensity, and repetitions
every couple of days.
5. Perform Kegel exercises 3-4x during the day.27
Kegel exercise for men and women:
-
3. How can I improve my symptoms?
Biofeedback therapy:
Monitors correct muscular contraction to develop conscious control of pelvic
musculature
Voluntary contraction of the pelvic floor muscles controls urge to urinate
28
-
3. How can I improve my symptoms?
Bladder training:
1. Scheduled voiding at set times during the day
2. Active use of muscles to prevent urine loss
3. Increase voiding intervals after the initial goal is
achieved
4. Keep own input and output chart
5. Reward increasing volumes of urinary output
29
-
3. How can I improve my symptoms?
Alternative therapies:
Hypnotherapy
Yoga
Acupuncture
30
-
4. How can I improve my symptoms?-Summary-
6 steps for continence:
1. Drink less than 5 glasses/day (40 oz)
2. Stop drinking after dinner
3. Elevate legs
4. Timed voiding
5. Regular pelvic floor exercises
6. Voiding diary
31
-
What will you learn during the next 20 min?
1. What is happening to my bladder?
2. How will I get evaluated?
3. How can I improve my symptoms?
4. Therapy with medication
5. Forms of interventions
32
-
Each capsule contains your medication plus a treatment for each of its side effects.
-
4. Therapy with medication
Drug Treatment for Overactive Bladder:
Targets bladder nerves to block uncontrolled contractions
Anticholinergics
Not very bladder specific
34
-
4. Therapy with medication
Side effects:
Dry mouth Tachycardia
Constipation Fatique
Blurred vision Dizziness
Slow thinking
35
-
4. Therapy with medication
Drug interactions between anticholinergics and:
Beta-blocker
Drowsiness
Dizziness
Confusion
Blurred vision
Amantadine
Urinary retention
Dry skim
36
-
What will you learn during the next 20 min?
1. What is happening to my bladder?
2. How will I get evaluated?
3. How can I improve my symptoms?
4. Therapy with medication
5. Interventions
-
5. Interventions-Botox-
Neurotoxin, Clostridium botulinum
Injections into the bladder under direct vision
Blocks chemically nerve ends
As early as 2 days after injections it improves urgency and frequency
38
-
5. Interventions-Botox-
Duration between 3-6 months
Not FDA-approved for neurogenic bladder, but is widely used for failure of medical therapy
Not indicated in patients with difficulties to empty their bladders
39
-
5. Interventions-Botox-
Local side effects:
Excessive bladder muscle relaxation can cause urinary retention
Pain
Infections
Bleeding
General side effects:
Muscular weakness
Less effective during prolonged time
Some people build up a resistance40
-
5. Interventions-Electrical stimulation of the tibial nerve-
Objective alternative to medical therapy
Least invasive form of neuromodulation
Indirect stimulation of bladder nerves using a nerve at the lower leg
Recommended treatment is 12 weekly sessions of 30 minutes each
Peters KM, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. J Urol. 2009;182:105561
-
5. Interventions-Sacral Neuromodulation-
Pacemaker for the bladder
Treatment for urgency, frequency, urge incontinence, and urinary retention
Proven efficacy in patients for whom more conventional therapy has been unsatisfactory
Over 14 years FDA-approved
Neurologic diseases -like MS, Parkinson's disease and SCI injuries- are undergoing sacral neuromodulation with good success
42
-
5. Interventions-Sacral Neuromodulation-
How does it work?
Leads float next to bladder nerves
Leads are connected to a battery placed at the buttocks
Leads sent mild electrical impulses out to the sacral nerves
Can be discontinued at any time
43
-
5. Interventions-Sacral Neuromodulation-
Side effects:
Skin irritation Pain Wire movement Device problems Interaction with other devices MRI exam not possible
44
-
5. Interventions
Surgery:
Bladder denervation
Bladder augmentation
Bladder becomes enlarged with an extension made out of bowel
Larger reservoir with lower bladder pressures
45
-
1. What is happening to my bladder?
Friedreichs ataxia and neurogenic bladder disorder:
1. Overactive bladder or
2. Poor control of sphincter muscles or
3. Urine retention
47
-
2. How will I get evaluated?
-History-
Risk factors:
Previous surgeries
Back pain
History of lumbar disc prolapse
History of other urological or gynecological conditions: Bladder prolapse
Uterine prolapse
Rectal prolapse
48
-
2. How will I get evaluated?
-History-
Excluding secondary causes:
Diabetes
Congestive heart failure
Bladder cancer
Urinary tract infections
Pregnancy
Medications
Raz, S and Rodriguez, LV: Female Urology. 3rd edition. Saunders Elsevier, 2008.
-
Normal Voiding Cycle
Filling & storage phaseEmptying
phase
Bladder filling
Normal desire
to voidFirst sensation
to voidBladder filling
Bla
dd
er
pre
ssu
re
Abrams P, Wein AJ. The Overactive Bladder A Widespread and Treatable Condition.
Stockholm, Sweden: Erik-Sparre Medical AB; 1998.
-
2. How will I get evaluated?
Anti-water meds (Diuretics)
Antidepressants
Blood pressure meds
Hypnotics
Pain meds
Narcotics
Sedatives
OTC-Sleep aids and cold remedies
Antipsychotics
Herbal remedies
51
Medications That May Influence Bladder Function:
-
Ive reached that age where Ive given up on Mind Over Matter and am concentrating on
Mind Over Bladder.
-
2. How will I get evaluated?-Quantification of symptoms-
1. Do you have to rush to the toilet to urinate?
2. Does urine leak before you can get to the toilet?
3. How often do you pass urine during the day?
4. During the night, on average, how many times do you have to get up to urinate?
5. Does urine leak after you feel a sudden need to go to the toilet?
International Consultation on Incontinence Modular
Questionnaire on Overactive Bladder in
Raz, S and Rodriguez, LV: Female Urology. 3rd ed., 2008
-
2. How will I get evaluated?-Physical examination-
Genitalia and pelvic floor examination:
Evaluate for uterine, bladder, rectal prolapse
Vaginal tissue thinning
Cough test
Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682. 54
-
3. How can I improve my symptoms?
Program to train yourself at home:
1. Regular Kegel exercise
2. Set up voiding schedule aiming to expanding voiding intervals
3. Active use of muscles to prevent urine loss
4. Dietary changes
55