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Neurogenic Bladder

Although all patients with SCI will have a neurogenic bladder, the type and symptoms will depend on the level and completeness of the lesion. Lesions L1 and above may have neurogenic detrusor overactivity, detrusor sphincter dyssynergia. Lesions below L1 may have detrusor areflexia.

Neurogenic bladder symptoms have a large impact on quality of life therefore proper management is important aiming to promote continence and preserve renal function

Methods of bladder management need to be simple, socially acceptable, enable personal control and from a medical perspective are safe, allowing low pressure storage and complete and efficient emptying.

Most of these approaches will be initiated and followed by a specialist; however, it is important for GP to be aware of the different methods and possible complications.

UTIs are a frequent complication of neurogenic bladder and may present with atypical signs and symptoms

Noxious stimulation to the bladder, including bladder distension, is the most common cause of Autonomic Dysreflexia (AD), which is a life threatening condition

Definitions

Neurogenic Bladder
A malfunctioning urinary bladder due to neurologic dysfunction or insult emanating from internal or external trauma, disease, or injury. There are three types of neurogenic bladder: UTIs are a frequent complication for individuals with spinal cord injury.
Detrusor Sphincter Dyssynergia (DSD)
A lack of coordination between contraction and relaxation of the detrusor muscle and external sphincter. Both contract at the same time causing high intravesical pressure, interrupted or incomplete voiding, and risk of vesico-ureteric reflux. Individuals with lesions L1 and above affected.
Neurogenic Detrusor Overactivity (NDO)
An increased activity of the detrusor muscle. This is usually combined with impaired contractility of the muscle, which leads to overactive bladder symptoms including bladder distention and incontinence.
Detrusor Areflexia
The inability of the detrusor muscle to contract, leading to an inability to empty the bladder. Individuals with lesions below L1 affected.

Investigations

Urodynamic studies (Cystometrogram with or without video fluoroscopy) - used to evaluate detrusor pressure, maximum bladder filling capacity, urge response, motor response. Involves catheterisation (urethral or suprapubic), rectal probe line, saline filling plus or minus xray.

Ultrasound flow rate - used to evaluate flow pattern (sign of obstruction), timing, capacity, residual. Involves pre-filled bladder (patient should have catheter clamped 1 hour prior and have consumed approximately 250mls, 1hr beforehand), pre-void USS, voiding onto flow rate machine, post-void/residual USS.

Pathophysiology

The new facility at Bolsover StreetThe image above shows the innervation of the bladder.

Reproduced from Neurogenic Bladder. Caring for Persons with Spinal Cord Injury - e-learning resource for family physcians.Ontario Neurotrauma Foundation.

Lesions above L1: Neurogenic Detrusor Overactivity (NDO) and Detrusor Sphincter Dyssynergia (DSD)
Injuries affecting the UMNs result in a lack of coordination between the sphincter and the detrusor. Detrusor overactivity, reflexively contracting at small volumes, and contracting against an overactive sphincter, to cause high pressures in the bladder leads to:

  • Incontinence (when the detrusor contracts hard enough to overcome the sphincter contraction)
  • Incomplete emptying (due to the sphincter co-contraction)
  • Vesico-urethral Reflux (due to the high bladder pressures)

These result in recurrent bladder infections, stones, hydronephrosis, pyelonephritis, and renal failure.
(used with permission from scireproject.com)

Lesions below L1: Detrusor areflexia
Injuries affecting LMNs results in loss of detrusor muscle tone which prevents bladder emptying, leads to bladder wall damage from over-filling, urine reflux, and an increase in infection risk due to stasis. Loss of external sphincter tone (flaccid) causes incontinence, especially with manoeuvres that increase intraabdominal pressure e.g. sneezing, coughing or straining during transfers. Internal sphincter tone may be intact due to the higher origin of the sympathetic innervation, thus complete emptying, even with externally applied suprapubic pressure, may be difficult.
(used with permission from scireproject.com)

Signs and symptoms

Variable depending on level of lesion and type of neurogenic bladder. Include:

  • Incontinence
  • Overactive bladder
  • Urinary retention

May also have signs and symptoms of UTI. Patients with spinal cord injury are less likely to have typical symptoms of UTI. Look for:

  • Pelvic pain
  • Dysuria
  • Incontinence
  • Increased spasticity
  • Autonomic Dysreflexia (AD)
  • Malaise
  • Fever/chills
  • Nausea
  • Headache

Management and recommendations

Prevention and early recognition and treatment of UTIs and Autonomic Dysreflexia (AD) (AD may occur in individuals with T6 thoracic spinal cord lesions or above) and to refer them to a specialist when appropriate.

When to refer

Consider referral to urologist if:

  • Current bladder management method is not effective (e.g., episodes of incontinence, not voiding regularly (high filling pressures))
  • >3 UTIs per year
  • Kidney or bladder stones
  • Urethral complications
  • Changing or worsening symptoms
  • Hydronephrosis on ultrasound (ultrasound every 1-2 years)
  • Repeated episodes of Autonomic Dysreflexia (AD) that are secondary to urological issues
  • Patient has high level spinal cord lesion as they will be more prone to complications
  • Have had an indwelling or suprapubic catheter for >15 years (for cystoscopy due to increased risk of bladder cancer as a result of prolonged catheter use)

Goals of bladder management

  1. Achieve regular complete bladder emptying
  2. Avoid high filling and voiding pressures and preserve kidney function
  3. Maintain continence and avoid symptoms of frequency and urgency
  4. Prevent and treat complications and UTIs (avoid overtreating asymptomatic bacturia)

Approaches for bladder management

Approaches used to achieve bladder management goals will vary depending on the level and severity of the lesion. Most of these approaches will be initiated and followed by a specialist; however, it is important to be aware of the different methods and possible complications. Many of these may be used in combination.

Intermittent catheterisation (IC)

  • Typically done every 4-6 hours to keep bladder volume under 500 ml
    If high bladder volumes, increase frequency of catheterisation or consider alternative method
  • Patient or carer must have sufficient hand dexterity
  • Changes in prostate over time can affect patient’s ability to use this method
  • Patient must be willing to spread fluid consumption of 1.8-2 litres every 24 hours over the day. Reduce intake in evenings.
  • Maybe used in conjunction to anticholinergics (which relax detrusor muscle causing urinary retention)
  • Complications: UTI, bladder overdistension, incontinence, urethral trauma or stricture, bladder stones, Autonomic Dysreflexia (AD)

Indwelling catheterisation

  • Urethral or suprapubic
  • Long-term use of indwelling catheter has a higher rate of urological and kidney complications than other bladder management methods
  • Requires more frequent cystoscopic evaluation due to greater incidence of squamous cell bladder carcinoma with indwelling catheter. Consider cystoscopy if indwelling catheter >15 years
  • May be used in combination with anticholinergics (which relax the detrusor muscle causing urinary retention)
  • Clamping - used to maintain bladder capacity; patients should clamp their catheters daily unless symptomatic UTI or intercurrent illness (e.g requiring IV fluids). Catheter can be left on free drainage over night. Patients bladder capacity is determined from cystometry, usually between 300-500mls. Patients can build up their clamping times daily by increasing by 15mins each day, they will need to monitor fluid intake to ensure they do not exceed their bladder capacity volume whilst clamped.
  • Complications: Kidney or bladder stones, urethral erosions, epididymitis, UTI, incontinence, hydronephrosis, bladder cancer
  • Blockages - Sediment or blockage may indicate UTI or stones and these should be ruled out as soon as possible. Blockage may be cleared by flushing the cathter with 30mls of normal saline/ If unable to clear then catheter will need to be changed, if SPC can not be reinsterted then a urethral catheter should be put in. Recurrent blockage from sediment can be managed with daily saline instillations, if this does not help then the patient may require acidic maintenance solution such as 3.23% Citric acid solution (Suby G) bladder instillation which should be done three times a week which helps prevent the build up of encrustation and catheter blockage.

Reflex voiding and applying Suprapubic pressure: Credé and Valsalva

  • Reflex voiding is emptying by means of overactive detrusor contractions and urine containment. Used by those with reflexic bladder Contractions can be triggered by squeezing the penis or scrotum or tapping the suprapubic area. However, most occur spontaneously in response to stimuli, such as intravesical volume and the chemical composition of the urine
  • "Credé is a method of applying suprapubic pressure to express urine from the bladder. Credé is usually used when the bladder is flaccid . (Consortium for Spinal Cord Medicine Clinical Practice Guidelines, p. 19).
  • "Valsalva" is a method in which an individual uses the abdominal muscles and the diaphragm to empty the bladder. Used in those with flaccid bladder (Consortium for Spinal Cord Medicine Clinical Practice Guidelines, p. 19).
  • Not advocated as generally not effective and due to complications: Incomplete emptying, high pressures, hydronephrosis, abdominal bruising, hernias, haemorrhoids, leakage, skin breakdown, urethral fistula, UTI, poor bladder emptying, high bladder pressure, Autonomic Dysreflexia (AD)

Pharmacological Management

Alpha-blockers

  • Examples: Tamsulosin, Alfuzosin, Doxazosin.
  • Used to lower outlet resistance
  • Often used in combination with other methods
  • Complications: Orthostatic hypotension (patients should take at night while lying down), interaction with phosphodiesterase inhibitors

Anticholinergics

  • Examples: Oxybutynin, Tolterodine , Trospium chloride and M3-receptor specific medications darifenacin and solifenacin
  • Used for NDO
  • Side effects: Dry mouth , sedation, urinary retention if not on catheter management (should check post-void residual before and after initiating treatment)

Botulinum toxin injection in detrusor muscle

  • Requires a urologist who is trained to do procedure
  • Patients must be able to do intermittent catheterisation or have a carer who can
  • Used to relax overactive bladder
  • Can take 1 week before effective and lasts 6-9 months
  • Often used in combination with other methods
  • Caution in patients with neuromuscular disease and/or if patient on an aminoglycoside
  • Complications: Autonomic Dysreflexia (AD), haematuria during injection

Surgical options (if catheter and medical management are not effective)

  • Transurethral sphincterotomy
  • Electrical stimulation and posterior sacral rhizotomy
  • Bladder augmentation
  • Continent catheterisable stoma
  • Incontinent urinary diversion (e.g., ileal conduit)
  • Cutaneous ileovesicostomy

Urethral stent

  • Used in DSD
  • Results in continuous drainage therefore patient will require collecting device for urine (usually males with condom catheters)
  • Complications: Stent migration, stone encrustation, Autonomic Dysreflexia (AD), urethral trauma, urethral pain, tissue growth in stent, need for removal/replacement, recurrent UTIs

Follow-up

  • Review bladder management at least yearly
  • Refer to urologist if >3 UTIs per year (see management section for other times to refer)
  • Check creatinine and electrolytes yearly
  • Ultrasound every 1-2 years
  • Urodynamics if required (usually requested by specialist)
  • Consider cystoscopy if indwelling catheter >15 years due to increased risk of bladder cancer as a result of prolonged catheter use
  • Consider PSA testing after age 50 years

UTIs

  • UTIs are the most common complication of neurogenic bladder.
  • Patients with spinal cord injury are less likely to have typical UTI symptoms. Instead they may present with fever/chills, nausea, headache, increased spasticity, Autonomic Dysreflexia (AD).
  • The majority of persons with spinal cord injury have bacteriuria therefore treatment should only be initiated if symptomatic. This can be a diagnostic dilemma as symptoms are often atypical e.g. increased spasticity. Always do a culture and sensitivity of clean/mid-stream or catheter urine specimen before treating UTI to ensure organism is not resistant and to guide antibiotic therapy. Patient education is key.
  • Change catheter before taking urine sample to avoid false-positives.
  • Patients should be given requisitions and sample bottles to keep at home so they may submit a sample as soon as they feel symptomatic.
  • Only high risk or unwell patients (e.g., single kidney, previous urosepsis) should be treated empirically, all others should await culture results.
  • Urine culture should be used to guide choice of antibiotic .
  • Patients with frequent UTIs (>3/year) may require antibiotic prophylaxis (these should be given in a cyclical fashion) and should be referred to a urologist.
  • There is conflicting level 1 evidence to support the effectiveness of cranberry juice/capsule in preventing UTI in patients with neurogenic bladder due to spinal cord injury.
References

Consortium for Spinal Cord Medicine. (2006). Bladder management for adults with spinal cord injury: A clinical practice guideline for health-care providers. Washington, DC: Paralyzed Veterans of America.

The Canadian Continence Foundation

Ontario Neurotrauma Foundation. Caring for Persons with Spinal Cord Injury - e-learning resource for family physicians. eprimarycare.onf.org/NeurogenicBowel.html

Wathen, N., Watson, G., Caldwell, S., & Lewis, N. (2007). Research summary: Improving continence care in complex continuing care. Ontario Women’s Health Council.

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