Reconstructive Urology & Men's Health

Neurogenic Bladder & Spinal Cord Injuries

What is neurogenic bladder?

The causes of neurogenic bladder include spinal cord injury and neurologic diseases. These causes include diseases like multiple sclerosis, spinal cord injury, transverse myelitis, cerebral palsy, diabetes, peripheral neuropathy, spina bifida, head injury, vertebral disk herniation and stroke.

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More about neurogenic bladder:

What causes neurogenic bladder?

The causes of neurogenic bladder include spinal cord injury and neurologic diseases. These causes include diseases like multiple sclerosis, transverse myelitis, cerebral palsy, diabetes, peripheral neuropathy, spina bifida, head injury, vertebral disk herniation and stroke.

How is neurogenic bladder diagnosed?

One of the most helpful tests in the evaluation of neurogenic bladder is called a urodynamic test. Urodynamic testing is also called a cystometrogram (CMG). In this test a very small catheter is passed into the bladder and another catheter is placed into the rectum. The bladder is filled and several measures of the bladder and sphincter function can be determined. These measures can include the cause of incontinence, the capacity of the bladder, as well as the pressures in the bladder during bladder contraction and filling of the bladder. This test allows the urologist to recommend a multitude of treatments depending upon factors like the cause of incontinence and the capacity of the bladder. It also allows the identification of patients with dangerous pressures within their bladder that might lead to progressive damage to the kidneys and kidney failure.

What are some of the treatments for neurogenic bladder?

Medical therapy: Often the first line therapy for patients that have urgency, frequency and leakage from neurogenic bladder is the use of several medicines known as anti-cholinergic medicines. These medicines act to relax the bladder and decrease leakage and urgency of urination from bladder spasms or overactivity. Anti-cholinergic medicines are notorious for causing side effects and often patients need to be changed from one medicine to another to find one that is tolerated well. Treatment with anti-cholinergic medicines may be all that is required for patients that do not have severely contracted bladders with high pressures.

Botulinum toxin injection: (Botox treatment for the bladder): Botulinum toxin is a drug that is used to paralyze the bladder muscle. This drug has been used in many applications and recently has been used for overactive bladder and neurogenic bladders. The medicine is injected into the muscle of the bladder in a scope procedure done in clinic. The medicine acts to decrease the activity of the bladder muscle and may act to decrease the amount of leakage from bladder spasms and eliminate dangerous pressures in the bladder. Unfortunately, the medicine only lasts between six and eight months and then must be injected again into the bladder. One side effect is when the bladder muscle becomes completely paralyzed and will not contract effectively. This is temporary, because the medicine only lasts between six to eight months, however, during this time frame patients may need to catheterize in order to drain the bladder. For this reason this approach is best used when patients are familiar with self-catheterization.

Bladder augmentation: When the bladder is severely contracted and has pressures that may lead to kidney failure, surgery to expand the bladder volume is often the best method of treatment. This surgery is known as bladder augmentation or enterocystoplasty. In this surgery, a patch of bowel is brought down to the bladder and used to dramatically increase the volume of the bladder. This eliminates problems with bladder spasms and urinary incontinence as well as creating a large capacity low-pressure reservoir for urine. Patients need to perform intermittent catheterization to drain these bladders via the urethra. If patients are unable to catheterize the urethra due to scarring, pain or difficulty in localizing the urethra than a small caliber tube of bowel can be created for catheterization that comes out to the belly button or the lower abdomen. This bowel tube is called a Monti tube or a Mitrofanof tube. This is an unobtrusive stoma that does require a stoma bag or any external appliance. Usually this tube is created at the time of bladder augmentation. Patients catheterize this small stoma to drain the bladder four to six times per day. The bladder capacity after augmentation is usually about 500 ml.

Urinary diversion: In some cases the bladder cannot be salvaged with augmentation surgery. Some bladders are so contracted that augmentation of their volume is not practical. Also other patients may have problems like fistula out of the bladder, tumors in the bladder or radiation damage that is so severe that the bladder is not suitable to be used for reconstruction. In these cases the bladder needs to be bypassed and patients need to undergo urinary diversion. There are many types of urinary diversion that range from creation of a new bladder out of a sphere of bowel to creation of a simple conduit to conduct urine from the kidneys to a bowel stoma at the skin.

What are the goals of treatment for neurogenic bladder?

The goals for the treatment of neurogenic bladder are to eliminate bothersome leakage and create a low-pressure reservoir that will preserve kidney function. In many cases this involves conservative management with medical therapy or the use of botulinum toxin, but in other cases surgery may be needed.

How does spinal cord injury affect the bladder?

Spinal cord injury has a profound effect upon bladder as well as bowel function. There are several patterns of bladder dysfunction that develop. The problems that occur are very dependent on how the bladder and the urinary sphincter respond to spinal cord injury. The bladder can generally be either severely contracted and spastic or dilated without any contractile function (“atonic”). These types of bladder problems are treated very differently. The first can lead to kidney failure through very high pressures that are generated within the bladder. These patients need close monitoring to make sure that pressures are not high and may need treatments to decrease the pressure and resultant leakage, which often occurs. In the second type of bladder dysfunction, the main problem is with adequate emptying of the bladder. Usually these patients need to perform intermittent catheterization in order to empty their atonic bladder.

What are the management goals in patients with spinal cord injury?

The goals are establishing a method of reliably emptying the bladder, and to make sure the bladder has adequate volume and does not develop high pressures that can damage the kidneys. It is also very important to control urinary leakage so chronic pressure sores do not develop.

What are chronic catheters, like suprapubic and chronic Foley catheters, and how are they used?

Chronic inflammation within the bladder, seen through a cystoscope, in a patient with an indwelling catheter.

One issue that is a common problem is the use of chronic catheters in patients that have had a spinal cord injury. Most patients that have a spinal cord injury do not empty their bladder reliably and for this reason it is common to see patients that are reliant on a chronic indwelling catheter. This catheter is either placed in the urethra or through a puncture in the abdomen above the pubic bone. The catheter placed in the urethra is known as a Foley catheter and the one placed through the abdomen is known as a suprapubic catheter.

These chronic catheters are very different from catheters that patients use to intermittently catheterize a few times a day to drain the bladder. Most patients eventually develop problems with chronic catheters. These problems mostly involve infections, chronic sores in the buttocks (sacral decubiti) and renal failure. It is very common to see patients that have had a chronic catheter for many years that begin to develop very severe urinary tract infections. These infections can require intravenous antibiotics or admission to the hospital and eventually become constant. These are the result of the body’s natural reaction to chronic foreign material in the urinary system.

Patients and even their doctors often think that just having a catheter will drain the bladder and prevent high pressures and urinary leakage. Unfortunately these catheters do not do well at either task. Bladders are often somewhat distended with a catheter in place and the catheters do not protect the kidneys well from damage and the development of kidney failure. Also, patients often leak around the catheter when the bladder spasms. This urinary leakage can dramatically worsen pressure sores called decubiti. If these sores progress they can cause terrible damage.

Often in an attempt to control urinary leakage catheters are upsized to larger and larger catheters. These measures usually do not improve and may even worsen things. Other common strategies to control infection are the use of suppressive antibiotics and frequent catheter changes. These measures may improve infection for a time, but usually once these kinds of problems manifest themselves when a patient has a chronic catheter it is time to consider other options.

What is the surgical option?

The other options include reconstructive surgery, which will increase the capacity of the bladder and eliminate high pressures in the bladder or to establish a catheterizable channel that can be intermittently catheterized to drain out the bladder. Every case is unique, but there is not much doubt that if a strategy can be found, which avoids chronic catheterization the patient’s long-term kidney function and overall health will be much better preserved.

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