Bladder Function and Dysfunction after Neurologic Insult: Preventing Secondary Conditions and Improv

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Bladder Function and Dysfunction after Neurologic
Insult Preventing Secondary Conditions and
Improving Function

• Suzanne L. Groah, MD, MSPH
• National Rehabilitation Hospital
• RRTC on Secondary Conditions after SCI

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Anatomy and Physiology
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Bladder - Anatomy
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Neuroanatomy of Voiding
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Neuroanatomy of Voiding

• Frontal lobe
• Micturition center
• Sends inhibitory signals
• Pons (Pontine Micturition Center)
• Major relay/excitatory center
• Coordinates urinary sphincters and the bladder
• Affected by emotions
• Spinal cord
• Intermediary between upper and lower control

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Peripheral Nervous System

• Somatic (S2-S4)
• Pudendal nerves
• Excitatory to external sphincter
• Parasympathetic (S2-S4)
• Pelvic nerves
• Excitatory to bladder, relaxes sphincter
• Sympathetic (T10-L2)
• Hypogastric nerves to pelvic ganglia
• Inhibitory to bladder body, excitatory to bladder
  base/urethra

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Normal Voiding

• SNS primarily controls bladder and the IUS
• Bladder increases capacity but not pressure
• Internal urinary sphincter to remain tightly
  closed
• Parasympathetic stimulation inhibited
• Somatics (pudendal N) regulate
• External urinary sphincter
• Pelvic diaphragm
• PNS
• Immediately prior to PNS stimulation, SNS is
  suppressed
• Stimulates detrusor to contract
• Pudendal nerve is inhibited ? external sphincter
  opens ? facilitation of voluntary urination

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Innervation of the Lower Urinary Tract

• Function
• Balance between suprasacral modulating pathways,
  sacral cord and the pelvic floor
• Emptying phase Voiding Reflex
• Series of coordinated events involving outlet
  relaxation, detrusor contraction
• Storage phase Guarding reflexes constant
  afferent input to maintain continence

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Bladder Dysfunction
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Functional Classification

• Failure to store
• Because of bladder
• Because of outlet
• Failure to empty
• Because of bladder
• Because of outlet
• Combination

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Pathophysiology of Voiding

• Brain lesion above pons destroys master control
  center
• Ex stroke, brain tumor, hydrocephalus, CP,
  Shy-Drager
• Result urge incontinence, night incontinence,
  coordinated sphincter
• Spinal cord lesion, myelomeningocele, MS
• Detrusor hyperreflexia
• Spastic bladder
• Areflexic bladder

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Pathophysiology of Voiding

• Lumbosacral spinal lesion
• Ex spinal tumor, sacral SCI, herniated disc,
  lumbar laminectomy, radical hysterectomy, pelvic
  trauma
• Result areflexic bladder
• Peripheral nerve injury
• Ex AIDS, diabetes, polio, GBS
• Result urinary retention

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Medication Options
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Medications

• Failure to store due to outlet
• Alpha-adrenergic drugs
• Location - Bladder neck receptors
• Function - Increase bladder outlet resistance by
  contracting the bladder neck
• Example - pseudoephedrine

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Medications

• Failure to store due to outlet
• Estrogen derivatives
• Mechanism - Increases the tone of urethral muscle
  by up-regulating the alpha-adrenergic receptors
  in the surrounding area
• Mechanism - Enhances alpha-adrenergic contractile
  response to strengthen pelvic muscles
• Use inStress incontinence

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Medications

• Failure to store due to bladder
• Anticholinergic drugs
• Function - Inhibit involuntary bladder
  contractions
• Adverse effects
• Blurred vision
• Dry mouth
• Heart palpitations
• Drowsiness
• Facial flushing
• Ex. Pro-banthine, Levsin

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Medications

• Failure to store due to bladder
• Antispasmodic drugs
• Function - Relax the smooth muscles of the
  urinary bladder
• Function Directly relaxes the smooth muscle of
  the bladder
• Adverse effects similar to anticholinergic agent
• Impaired mental alertness and physical
  coordination
• Ex. Ditropan, Detrol

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Medications

• Failure to store due to bladder
• Tricyclic antidepressant drugs
• Mechanism - Increase norepinephrine and
  serotonin levels
• Mechanism - Anticholinergic and direct muscle
  relaxant effects on the urinary bladder and
  bladder neck
• Ex. imipramine

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Medications

• Failure to empty due to outlet/DSD
• Botox
• MOA
• Inhibition of Ach release at neuromuscular
  junction
• Relax spastic/overactive muscles
• Relaxes sphincter when DSD present
• Effect not permanent
• DSD is often present with reflex voiding
• Injection transurethrally or transperineally into
  the urinary sphincter mechanism
• Re-injection necessary as effect is lost after
  3-6 months

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Effect of Foods

• Heightened urge incontinence
• Spicy foods
• Caffeine/chocolate
• Citrus fruits
• Carbonated beverages

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Bladder Management Options
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Management Options
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Management Options
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Management Options
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Electrical Stimulation

• Electrical Stimulation and Posterior Sacral
  Rhizotomy
• To produce effective voiding and reduce urinary
  tract infection
• Electrodes surgically implanted on the sacral
  nerves
• Stimulator placed under the skin of the abdomen
  or chest
• Battery-powered remote control
• Posterior sacral rhizotomy
• Abolishes hyper-reflexia of the detrusor and
  sphincter
• Increases bladder capacity and compliance
• Reduces reflex incontinence
• Reduces autonomic dysreflexia
• Abolishes reflex erection, reflex ejaculation,
  sacral sensation, and reflex defecation
• 1 risk of infection of the implant
• 1 fault per 20 implant-years

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Electrical Stimulation

• Consider in
• ? PVR
• Chronic/recurrent UTI
• Problems with catheters
• Reflex incontinence
• ? bladder capacity and compliance
• Intolerance of anticholinergic medication
• DSD
• AD

• Evidence
• ? Reflex incontinence (post rhiz)
• ? Bladder capacity and compliance
• ? need for anticholinergics
• ? DSD
• ? AD if posterior rhizotomy
• ?AD if no posterior rhizotomy

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Bladder Augmentation

• Procedure that increases bladder capacity using
  intestinal segments
• Ileum, colon, or stomach are used
• Goals
• Decreasing intravesicle pressure
• Restore urinary continence
• Preserve upper urinary tracts by alleviating
  reflux and hydronephrosis
• Can combine with a continent abdominal stoma
• Consider in patients with
• Intractable involuntary bladder contractions
  causing incontinence
• Patients who are able and motivated to perform
  CIC
• Reflex voiders wishing to convert to CIC
• Females with paraplegia

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Urinary Diversion

• Diverts the urine flow from the bladder
• Secondary form of bladder management when primary
  methods have failed
• Ureters transected just above the bladder and
  connected to a segment of intestine (terminal
  ileum) which is in turn brought to the skin of
  the lower abdominal wall
• External appliance used as collection device
• Considered if
• Lower urinary complications secondary to
  indwelling catheters
• Urethrocutaneous fistulas, perineal decubitus
  ulcers
• Urethral destruction in females
• Hydronephrosis secondary to a thickened bladder
  wall and for hydronephrosis secondary to
  vesicoureteral reflux or failed reimplant.
• Bladder malignancy requiring cystectomy

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Yet To Be Released PVA Guideline Recommendations
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Recommendations from the PVA Guidelines

• Recommendation 1 Intermittent catheterization is
  the preferable method for bladder emptying for
  men and women who have adequate hand function or
  a willing caregiver to perform the
  catheterization and have bladders that do not
  empty adequately.
• Recommendation 2 Intermittent catheterization
  should be ideally performed every 4 to 6 hours to
  keep bladder volumes below 400ccs.

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Recommendations from the PVA Guidelines

• Recommendation 5 Consider sterile
  catheterization for those individuals with
  recurrent symptomatic infections occurring with
  clean intermittent catheterization. Rationale
  Lower infection rates can be achieved with
  sterile techniques and with pre-lubricated self
  contained catheter sets

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Recommendations from the PVA Guidelines

• Recommendation 5 Risk of symptomatic infection
  is at least comparable and may be less in
  individuals with indwelling catheters than those
  managing their bladders with clean intermittent
  catheterization.

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Recommendations from the PVA Guidelines

• Recommendation 6 Patient should be advised of
  long-term complications of indwelling
  catheterization, including
• Bladder stones
• Kidney stones
• Urethral erosions
• Bladder cancer
• Epididymitis
• Recurrent symptomatic urinary tract infections

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Genitourinary Assessment of Function
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Assessment of Function

• U/a and c s
• BUN Cr
• if compromised renal function is suspected
• Postvoid residual urine
• If high, the bladder may be contractile or the
  bladder outlet may be obstructed

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Renal/Bladder US

• Mainstay of screening in many institutions

• Advantages
• Simple
• Eval kidney, parenchymal loss, abnl echogenicity
• Eval for hydronephrosis, stones

• Disadvantages
• Low sensitivity for small stones
• Ureters not evaluated well

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Nuclear Renal Scan

• Advantages
• Functional info
• No nephrotoxic reactions
• Low radiation

• Disadvantage
• Less anatomic info
• Cannot detect stones

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KUB

• Historically, routinely used to detect renal and
  bladder stones
• Disadvantages
• Poorly sensitive to stones
• KUB not justified in routine f/u of urinary
  tract in SCI
• Tins et al. Spinal Cord 2005

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Filling Cystogram

• Bladder capacity
• Bladder compliance
• Presence of phasic contractions (detrusor
  instability)

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Cystogram

• Static Cystogram
• Confirm the presence of stress incontinence
• Degree of urethral motion
• Presence of a cystocele
• Intrinsic sphincter deficiency
• Vesicovaginal fistula
• Bladder diverticulum

• Voiding cystogram
• Bladder neck and urethral function (internal and
  external sphincter) during filling and voiding
  phases
• Urethral diverticulum
• Urethral obstruction
• Vesicoureteral reflux

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Cystometrogram

• Volume vs pressure graph
• Evaluates
• Detrusor compliance
• Stability of detrusor

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Urodynamics

• Filling cystometry
• Flow/pressure study
• Detrusor pressure at maximum flow
• Obstruction to passage of urine can be
  distinguished from a lack of tone in the detrusor
  muscle
• Electromyography
• Coordinated or uncoordinated voiding
• Detrusor sphincter dyssynergia
• Videocystourethography
• Combined x-ray or ultrasound

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UD - Stable Bladder
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Detrusor Hyperactivity and Low Bladder Capacity
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Cystoscopy

• Bladder cancer
• Bladder stone
• Indicated in persistent irritative voiding
  symptoms or hematuria

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Selected Genitourinary Secondary Conditions After
Bladder Dysfunction due to Neurologic Disease
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Secondary Conditions

• Increased risk of
• Bladder infection
• Kidney infection
• Hydronephrosis
• Urethral trauma/laxity

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Urinary Stones and SCI

• Higher incidence, especially in first 6 mos
• 3-6 upper tract
• 11-15 bladder
• Etiology
• Stasis
• Calcium metabolism
• Infection
• Diagnosis
• CT is gold standard

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Bladder Cancer Epidemiology

• 5th most common cancer
• 12th leading cause cancer mortality
• Adjusted yearly incidence 17/100,000 py
• 54,400 new cases per year
• Males at greater risk
• Majority are transitional cell carcinoma

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Risk Factors for Bladder Cancer

• Smoking
• Male gender
• Exposure to aromatic amines
• Schistosomiasis infection
• UTI

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Is there a heightened risk of bladder cancer
after SCI?If so, why?
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The Evidence in SCI
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The Evidence in SCI
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Recent Evidence

• Groah SL. Arch Phys Med Rehabil 2002
• 3,670 subjects contributed 39,729 p-y
• Stratified by bladder management method
• Age-adjusted incidence
• Indwelling catheter 77/100,000 py
• Mixed methods 56.1/100,000 py
• Non-indwelling catheter 18.6/100,000 py

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Retrospective Cohort
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Recent Evidence

• Groah SL. Arch Phys Med Rehabil 2002
• Using cox regression, only bladder management
  method and age predicted disease

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Cumulative Incidence of Bladder Cancer
Wilcoxan lt 0.05
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Cumulative Incidence of Bladder Cancer
Wilcoxan lt 0.05
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Bladder Cancer Mortality by Age
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Proportional Mortality Due to Bladder Cancer
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Recent Evidence

• Subramonian et al. BJU Int, 2004.
• 4 cases/1334 people followed
• 30.7/100,000 person-years
• Reported as not statistically different from
  general population and lower than reported in
  other studies

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Risk Factors for Bladder Cancer
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Part 3 Design Case-control
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Presentation
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Potential Associated Risk Factors
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Risk Factors
RF IDC use, tobacco use, calculi, or
pyelonephritis
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Bladder Cancer Surveillance
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Genitourinary Surveillance
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Surveillance Practices of the MSCIS Centers

• 16 centers surveyed
• 13 responded
• 12/13 have a GU surveillance protocol
• 6/13 have a bladder cancer surveillance protocol

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Initial GU Surveillance from the MSCIS Centers
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Initial GU Surveillance from the MSCIS Centers
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Bladder Cancer Surveillance from MSCIC

• Protocols
• If IDC, cysto at 5 yrs and yearly thereafter
• Cysto every 5-10 years
• Cysto if hematuria
• Cysto for long-term IDC
• Cysto if IDC hematuria
• Cysto at 10 years then yearly if IDC
• Cysto yearly if IDC (2 centers)

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Bladder Cancer Surveillance

• Yang CC. Spinal Cord 199937204-7
• Cysto if gt10yrs catheter, smoker cath (5yrs)
• 59 subjects had 156 cystos
• No cancer diagnosed
• 4 other cases diagnosed during same period (2 did
  not meet criteria1 not unit patient1 had screen
  4 months prior)

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Bladder Cancer Surveillance

• Groah SL. JSCIM 200326339-44
• 8 survivors with bladder cancer compared with 13
  deceased
• Surveillance cystoscopy identified cancer in
• 14 survivors
• 11 deceased
• Survivors had fewer surveillance cystoscopies and
  biopsies than deceased group