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1
Neurogenic bladder in patients with spinal cord
lesion
JJ Wyndaele MD DBMSci PhD FEBU FISCOS
2007
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Myelodysplasia 90% -97% (Smith 1965)
Spinal stenosis 61-62% (Tammela et al 1992, Kawaguchi 2001)
Spine surgery 38%-60% (Boulis et al 2001, Brooks, ME 1985)
Disc disease 28%-87% (Bartolin et al 1999, O’Flynn et al 1992)
Spinal cord injury ? majority
Prevalence neurogenic bladder in spinal lesion
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History
05
101520253035404550
1961 1968 1973 1983
urorenalmortality%
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UK survey GPRD• Increased risk renal failure paraplegia
versus general population
1994 x 7.51995 x 81996 x 5.91997 x 3.5
Lawrenson, Wyndaele, Vlachonikolas, Farmer, Glickman Neuroepidemiology 2001; 20: 138-143
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Bladder management
• Life
• Quality of life
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Management neuro-urology after spinal cord lesion
• Prevent deterioration of the kidneys
= permit to survive
• Prevention of incontinence and infection
= permit a good life
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S2S3S4
Innervation lower urinary tract
T10-L1
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Neurogenic ActionsSym PSym Som
Bladder - +
Bladder neck
+ -
Extern US (?) (?) +
Pelvic floor +
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S2S3S4
Neuropathy lower urinary tract
T10-L1
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Status upper tract depends greatly on
function of lower tract
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Importance of
intravesical pressure
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• Pressure development during filling
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• Pressure development during filling
• Pressure development during voiding
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SCL Urinary Function
1. Spinal shock bladder
2. Diagnosis type neurogenic bladder
3. Treatment - rehabilitation
4. Follow-up
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1. Spinal shock bladder
• Bladder drainage– intermittent catheterization– suprapubic catheter– indwelling transurethral catheter
• Avoid overdistention and infection
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2. Urologic Diagnosis
• Urodynamic function • Status upper tract• Other complications
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Diagnosis
• Most tests as used in non neurogenic: History, clinical examination and neurourologic testing, urine test, renal function
Voluntary control of anal sphincter and
perineal muscles
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Combination of these data permits a fairly accurate diagnosis of
completeness, detrusor function and sphincter function
in up to 80 %
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Clinical observation is very important
• Spontaneous voiding• Leakage when moving• Smelly urine, Fever and
other signs of infection• Calculi evacuated• et al
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Diagnosis
• Urodynamic investigation: cornerstone of the diagnosis and prognosis. Preferably video urodynamics
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Main types of LUT neuropathy in SCL
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Further diagnostics
• Ultrasound
• Endoscopy
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Expectations of management
Rehab team
1. Kidneys safe
2. No complications
3. Continent
4. Affordable
Patient
1. Continent
2. No complications
3. Affordable
4. Kidneys safe
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Conservative treatment neurogenic bladder
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Conservative treatment overview
• Behavioural therapyB.1 Behavioural methods Toiletting assistanceB.2 Triggered reflex voidingB.3 Bladder expression (Crede and Valsalva manouvre)
• CathetersC.1 Intermittent catheterisationC.2 Indwelling catheterisationC.3 Condom catheter and external appliances
• Pharmacotherapy
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Behavioural methods
• Scheduled voiding• Consecutive voids• Increased interval• Drinking habits• Toilet accessibility• Patient’s mobility• Keeping voiding diary
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Triggered voiding and Valsalva-Crede voiding
• Prove first urodynamically safe:
Basically dangerous methods.
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Intermittent catheterisation
• First choice of treatment
• Proper education and teaching necessary.
CIC
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Pharmacological treatment
• Decrease bladder overactivity• Anti bacterial• Peroral, Intravesical instillation,
transdermal, transrectal
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Indwelling catheters
• Short-term ID during the acute phase
• Transurethral ID not safe for long-term use
in neuropathic patients
• Bladder screening for bladder cancer is
mandatory especially in those with ID/SC more than 5-10 years.
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Suprapubic catheter
Less urethral complications
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Condom Catheter
• Long-term use does not increase the risk of UTI
• Complications less if good hygiene care, frequently change CC and low bladder pressures.
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Surgery neurogenic bladder
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Surgery to increase detrusor contractility + abolish reflex
activity• SARS + Dorsal Rhizotomy
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Possible alternatives to avoid rhizotomy: under research
• Selective anodal block• Cryotherapy deafferentation• SPARSI (anterior + posterior rooths)
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Surgery decrease outlet resistance
• TUI sphincter • Intraurethral stents • Botulinum Toxin
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Surgery to lower detrusor contractility – intravesical pressure
• Botulinum Toxin in detrusor
• Enterocystoplasty
• Autoaugmentation
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Surgery to increase sphincter resistance
• Artificial urinary sphincter
• Sling procedures
• Resorbable or non –resorbable bulking agents
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Diversion
• Acceptable treatment in selected cases
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Future ?
• Restoring function by nerve transplants?
• Cell therapy ?• Stem cell therapy ?
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4. Follow-up
• Lifelong every 1 – 2 years• Must include
– Imaging UT / function UT– Urine– Blood– (Urodynamics)
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Quality of life (meta-analysis)
• SCI significantly lower in all subscales compared with normative population
• Neurogenic pain, spasticity, and neurogenic bladder and bowel problems give lower QL scores.
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Quality of life in primary caregivers (meta-analysis)
• significantly lower compared to age-matched healthy population based controls
• No significant relation was demonstrated with the duration of injury, lesion levels, ASIA scores, degree of spasticity, bladder and/or bowel incontinence and pressure sores respectively.
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Causes for readmission
• “The leading cause of rehospitalization are diseases of the genitourinary system, including urinary tract infections”
• Cardenas et al Arch Physic Med Rehab 2004
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Do spinal cord injury patients always get the best treatment for
neuropathic bladder after discharge from regional spinal injuries centre?
Vaidyanathan et al Spinal Cord 2004
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Conclusions
• Urinary problems less dangerous for life expectancy than some decades ago
• Follow up life long• Urinary problems still very much
influencing quality of life• Bladder management cross-
disciplinary work• Patient is central• Do not forget relatives
48
Thanks for listening