Management Of Neurogenic Bladder Dysfunction Research Articles

Management of neurogenic bladder dysfunction in children update and recommendations on medical treatment

ABSTRACTIntroduction:Defective closure of the neural tube affects different systems and generates sequelae, such as neurogenic bladder (NB). Myelomeningocele (MMC) represents the most frequent and most severe cause of NB in children. Damage of the renal parenchyma in children with NB acquired in postnatal stages is preventable given adequate evaluation, follow-up and proactive management. The aim of this document is to update issues on medical management of neurogenic bladder in children.Materials and Methods:Five Pediatric Urologists joined a group of experts and reviewed all important issues on “Spina Bifida, Neurogenic Bladder in Children” and elaborated a draft of the document. All the members of the group focused on the same system of classification of the levels of evidence (GRADE system) in order to assess the literature and the recommendations. During the year 2020 the panel of experts has met virtually to review, discuss and write a consensus document.Results and Discussion:The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies. Clean intermittent catheterization (CIC) should be implemented during the first days of life, and antimuscarinic drugs should be indicated upon results of urodynamic studies. When the patient becomes refractory to first-line therapy, receptor-selective pharmacotherapy is available nowadays, which leads to a reduction in reconstructive procedures, such as augmentation cystoplasty.

Diagnosis and Management of Neurogenic Bladder Dysfunction

Background: The function of the LUT is mainly storage and voiding of urine, which is regulated by the nervous system that coordinates the activity of the urinary bladder and bladder outlet. The part of the nervous system that regulates LUT function is disseminated from the peripheral nerves in the pelvis to highly specialized cortical areas. Any disturbance of the nervous system involved, can result in neuro-urological symptoms [1]. Methods: this article was done after retrospective longitudinal and observational study including patients with neurogenic bladder and reviewing national and international recent and related literatures to overview neurogenic bladder and most advanced medical and surgical diagnostic procedures and treatment modalities of neurogenic bladder. Results: Among patients included, 52% had an early referral. The majority were diagnosed as neurogenic bladder with high bladder pressure and low bladder compliance and were treated with oxybutynin and intermittent catheterization. Urodynamic follow-up results showed 68% of improvement at the second urodynamic examination decreasing bladder pressure and increasing bladder capacity and compliance. The percentage of incontinence and urinary tract infections decreased over treatment. Conclusion: Multiple conservative modalities, i.e pharmacologic agents, medical devices and neuro modulation, should be promoted before undertaking surgical interventions. Intermittent catheterization and drug therapy are usually sufficient for maintaining continence and preserving upper tracts. Surgical procedures should be considered if conservative measures fail to achieve continence between catheterizations or preserve upper tracts. However today the improvement of Quality of life is the final goal.

Urinary Symptoms and Bladder Dysfunction in Patients with Neuromyelitis Optica Spectrum Disorders: Evaluation with Urodynamics and Management.

Objective To assess lower urinary tract symptoms (LUTSs) in patients with neuromyelitis optica spectrum disorders (NMOSDs) and bladder dysfunction through urodynamics (filling and voiding phase of cystometrography) and management based on findings. Patients and Methods The study included 42 (34 females) patients admitted to the rehabilitation department. Neurologic evaluation was performed and severity of myelitis was assessed using the American Spinal Injury Association Impairment Scale. All patients underwent urodynamics, and management was based on the findings. Results Mean age was 34.5 years (range: 11–64 years; standard deviation: 13.1). Twenty-three (54.8%) patients had a first episode of myelitis, whereas 19 patients had relapses (number of episodes varying from 2 to 7). Eleven (26%) patients had increased frequency, 16 (37%) had urgency, 12 (28%) had urge incontinence, 8 (18.6%) had stress incontinence, 22 (52.4%) had nocturia, 31 (72%) had retention of urine, 22 (52.4%) had incomplete evacuation, and 14 (33.3%) patients had mixed urinary complaints. The common urodynamic findings were neurogenic detrusor overactivity (NDO) with detrusor-sphincter dyssynergia (DSD) in 14 (33.3%) patients, NDO without DSD in 8 (19%), and acontractile detrusor in 20 (47.6%). Pharmacotherapy was advised to 22 (52.4%) patients, whereas clean intermittent catheterization (CIC)/self-catheterization was advised to 39 (92.9%) patients. Conclusions Urinary retention was observed to be the most common urinary complaint in patients with NMOSD followed by NDO with or without sphincter dyssynergia. Urodynamics should be performed in all patients with LUTSs for best management. CIC remains the gold standard for the management of neurogenic bladder dysfunction.

Anatomical feasibility of anastomosing intercostal nerves (D10&D11) and subcostal nerve (D12) to S2 ventral root and lumbar plexus for management of bladder function after spinal cord injury

ObjectiveThe transfer of peripheral nerves originating above the level of injured spinal cord into the nerves/roots below the injury is a promising approach. It facilitates the functional recovery in lower extremity, bladder/bowel and sexual function in paraplegics. We assessed anatomical feasibility of transfer of lower intercostal nerves to S2 ventral root in human cadaver for management of neurogenic bladder dysfunction in patients with spinal cord injury. MethodsStudy was performed in five formalin fixed cadavers. Cadavers were placed in prone position. A transverse incision was made along 11th ribs on both sides and 10th, 11th Intercostal nerves (ICN) and subcostal nerve were harvested up to maximum possible length. In four cadavers the ventral root of S2 was exposed by endoscope and in one by the standard open laminectomy. Intercostal nerves were brought down to lumbo-sacral region, S2 ventral root was cut cranially and feasibility of intercostal to S2 anastomosis was assessed. ResultsThe mean length of intercostal nerves was 18.4 cm for the 10th 19.5 cm for the 11th and 22.15 cm for the subcostal nerve. The length of harvested nerve and the nerve length necessary to perform sacral roots neurotization were possible in all cases by only by subcostal nerve while T11 and T10 ICN fall short of the required length. ConclusionFor Spinal cord lesions located at the conus, subcostal nerve could be connected to ventral root of S2 in an attempt to restore bladder function while 10th and 11th ICN had enough length to neurotize lumbar plexus.

Neurogenic lower urinary tract dysfunction: Clinical management recommendations of the Neurologic Incontinence committee of the fifth International Consultation on Incontinence 2013

Evidence-based guidelines for the management of neurological disease and lower urinary tract dysfunction have been produced by the International Consultations on Incontinence (ICI). These are comprehensive guidelines, and were developed to have world-wide relevance. To update clinical management of neurogenic bladder dysfunction from the recommendations of the fourth ICI, 2009. A series of evidence reviews and updates were performed by members of the working group. The resulting guidelines were presented at the 2012 meeting of the European Association of Urology for consultation, and consequently amended to deliver evidence-based conclusions and recommendations in 2013. The current review is a synthesis of the conclusions and recommendations, including the algorithms for initial and specialized management of neurogenic lower urinary tract dysfunction. The pathophysiology is categorized according to the nature of onset of neurological disease and the part(s) of the nervous system affected. Assessment requires clinical evaluation, general investigations, and specialized testing. Treatment primarily focuses on ensuring safety of the patient and optimizing quality of life. Symptom management covers conservative and interventional measures to aid urine storage and bladder emptying, along with containment of incontinence. A multidisciplinary approach to management is essential. The review offers a pragmatic review of management in the context of complex pathophysiology and varied evidence base. Neurourol. Urodynam. 35:657-665, 2016. © 2016 Wiley Periodicals, Inc.

Neurogenic bladder in spinal cord injury patients.

Neurogenic bladder dysfunction due to spinal cord injury poses a significant threat to the well-being of patients. Incontinence, renal impairment, urinary tract infection, stones, and poor quality of life are some complications of this condition. The majority of patients will require management to ensure low pressure reservoir function of the bladder, complete emptying, and dryness. Management typically begins with anticholinergic medications and clean intermittent catheterization. Patients who fail this treatment because of inefficacy or intolerability are candidates for a spectrum of more invasive procedures. Endoscopic managements to relieve the bladder outlet resistance include sphincterotomy, botulinum toxin injection, and stent insertion. In contrast, patients with incompetent sphincters are candidates for transobturator tape insertion, sling surgery, or artificial sphincter implantation. Coordinated bladder emptying is possible with neuromodulation in selected patients. Bladder augmentation, usually with an intestinal segment, and urinary diversion are the last resort. Tissue engineering is promising in experimental settings; however, its role in clinical bladder management is still evolving. In this review, we summarize the current literature pertaining to the pathology and management of neurogenic bladder dysfunction in patients with spinal cord injury.

Long-term functional outcomes after management of neurogenic bladder dysfunction with ileal conduit in an adult spina bifida population: A monocentric experience among a multidisciplinary team

Long-term functional outcomes after management of neurogenic bladder dysfunction with ileal conduit in an adult spina bifida population: A monocentric experience among a multidisciplinary team

A Mini-Invasive Approach to Severe Neurogenic Bladder as an Alternative to Diversion and Augmentation with Reimplantation in Selected Children

Purpose In the past years we demonstrated as combined endoscopic injection of botulinum toxin type A (BTXA) and dextranomer/hyaluronic acid (DHA) could be effective in the management of vesicoureteral reflux (VUR) in neurogenic bladder dysfunction (NBD) not responding to clean intermittent catheterization (CIC) and anticholinergics. When patients or caregivers are unable to catheterize native urethra other options must be considered. We present our preliminary experience in the treatment of VUR and NBD in children, unabled to perform CIC, using a new combined mini-invasive approach. Material and Methods 3 patients with NBD and VUR enabled to perform CIC, aged from 5 to13 yrs (mean 8.5) were treated, after ethical and scientific committee approval, and written consent obtained. All patients presented severe urinary tract infections (UTI) and VUR was present in all renal units. VUR and NBD were evaluated with videourodynamics, pre and post-op. First suburetheral injection of DHA (0.5-1 ml/side) and bladder BTXA injections (10 IU/Kg, max 300 IU) were performed and then percutaneous cistostomy (Mic-Key gastrostomy) button was inserted according to original Subramaniam's technique, under endoscopic control. Results The mean operative time was 40 minutes.No complications were reported either intraoperative either at the follow-up (mean 5.5 months).UTI was solved in all, as well as VUR, but in one unit, where VUR decreased only (5° to 3°).All buttons are functioning and in situ. Buttons were changed every 3 months,and bladder drainage was found easy to perform in all.Urodynamics data (capacity, leak point pressure)improved in all. Conclusions Today the management of NBD is mainly conservative, but in selected cases surgery is required. However surgical procedure is not always related to an improvement of quality of life. For this reason button cistostomy endoscopic insertion associated to endoscopic treatment of VUR and NBD could be a valid alternative to derivation, augmentation and reimplantation in the short and medium- term period, in selected children.

Neurogenic continence. Part 1: pathophysiology and quality of life

There are a number of neurological conditions that cause bladder and bowel problems in the form of neurogenic bladder and bowel dysfunction. Both have a considerable impact on a person's quality of life. Nurses have an important role to play in supporting patients when considering the options available to manage their neurogenic bladder and bowel problems. This article is the first of a series of three. Part 1 outlines the physiology of micturition and defecation. It discusses the pathophysiological changes in neurogenic bladder and bowel in spinal cord injury, spina bifida, multiple sclerosis, stroke and acquired brain injury, cerebral palsy, Parkinson's disease and diabetes mellitus. The psychosocial impact of this neurogenic dysfunction is addressed. Part 2 discusses the physical and psychosocial issues related to the management of neurogenic bowel dysfunction, and part 3 goes on to discuss the physical and psychosocial management of neurogenic bladder dysfunction.

Strategies to promote intermittent self-catheterisation in adults with neurogenic bladders: A systematic review.

Review Objective The purpose of this systematic review is to establish the best available evidence on strategies to promote intermittent urethral self-catheterisation in adults with neurogenic / neuropathic bladders. More specifically, the review questions are: What are the extrinsic and/or intrinsic factors that influence the suitability of individuals to perform self intermittent [urethral] catheterisation (SIMC)? What strategies promote long term compliance with SIMC? What are the advantages and disadvantages of using SIMC? Does SIMC improve the quality of life for people using this bladder management strategy? Criteria for considering studies for this review Types of Studies This review will incorporate the best available evidence for each of the sub-topics identified by the objectives and specific questions asked in this systematic review. Quantitative This component of the review will consider any randomised controlled trials (RCT) that examine the effectiveness of strategies to promote long term compliance with self-intermittent catheterisation. In the absence of RCT other quantitative research designs such as non-randomised experimental and quasi experimental, before and after studies, cohort studies and case series/case reports will be considered for inclusion in a narrative summary. For the remaining three sub-topics, i.e. quality of life, advantages and disadvantages of SIMC, and factors influencing suitability of individuals to perform SIMC, all quantitative research designs will be considered for inclusion. Qualitative This component of the review will consider any interpretive studies that draw on the experiences of intermittent self-catheterisation by adults for each of the sub-topics. This will include, but not be limited to, designs such as phenomenology, grounded theory and ethnography. Studies excluded from this review include: Those involving children and adolescents, i.e. > 18 years of age, Catheterisation performed by a carer or health professional, Catheterisation of a surgically created stoma, Indwelling catheters, Comparison of catheter types, Strategies to specifically reduce infection. Types of participants The review will include adults who are 18 years or older, who undertake urethral self-catheterisation for management of their neurogenic bladder dysfunction. Types of interventions/phenomena of interest The interventions, programs and strategies of primary interest are those TRUNCATED AT 350 WORDS

SACRAL NEUROMODULATION FOR NEUROGENIC BLADDER DYSFUNCTION IN CHILDREN

We report a prospective randomized controlled study to evaluate the possible benefits of sacral neuromodulation (SNM) for the management of neurogenic bladder dysfunction in children. We included in the study subjects between the ages of 5 and 21 years presenting with urinary incontinence due to neurogenic bladder. Before study inclusion all previous treatment was discontinued. Patients were randomly divided into the control group treated conventionally and the implant group treated with SNM. Treatment outcome was compared every 3 months for a minimum of 12 months based on clinical examination, voiding diary and urodynamic evaluation. A total of 26 boys and 16 girls with a mean age of 11.9 years were enrolled in this study. There were 21 patients in each group. The main underlying etiology was spina bifida. The 2 groups were comparable with regard to sex, age and urodynamic variables. Total disappearance of urinary leakage was observed in 1 patient who underwent implantation but he still required intermittent catheterization. Comparison of urodynamic variables disclosed no significant statistical difference except with regard to functional bladder capacity which was better in the control group and the leak point pressure which was better in the implant group (p <0.05). Evaluation of interindividual variations in the implant group revealed significant improvement in compliance and functional bladder capacity at 6 and 9 months but not at 12 months. Nine patients in the implant group reported improvement in intestinal transit, 5 total disappearance of urinary infection and 6 persistent sensation of a full bladder. No patient in the control group reported any improvement. Revision surgery was required in 3 cases due to lead migration, faulty connection and wound infection. SNM is a promising new therapeutic modality. Implant placement is minimally invasive, nondestructive and reversible. Use in children with neurogenic bladder has not been previously reported. Although some improvement was noted in patients treated with SNM, the difference with the control group was not significant. A larger multicenter study is warranted to evaluate SNM.

Investigation and management of neurogenic bladder dysfunction

Because of the complex nature of the neural control of the lower urinary tract, complaints about bladder function are common in patients with neurological disease. The main neural circuits controlling...

Abstract 9: Maximal bladder capacity as the predictor of response to desmopressin on nocturnal enuresis in patients with spinal cord injuries.

Objectives: To evaluate the efficacy of intranasal desmopressin inhalation on nocturnal enuresis in patients with spinal cord injury (SCI) and to investigate the validity of maximal bladder capacity as the predictor of response to intranasal desmopressin inhalation. Design: Before and after interventional trial. Setting: University-affiliated hospital. Participants: 22 adults SCI with nocturnal enuresis were divided into 2 groups: the large bladder capacity group (bladder capacity, >250mL; n=11) and the small bladder capacity group (bladder capacity, <250mL; n=11). Intervention: All participants were treated with intranasal desmopressin, 10μg daily at bedtime for 4 weeks. Main Outcome Measures: Total volume of daily nocturnal incontinence and serum electrolytes. Maximal bladder capacities were measured by urodynamic evaluation. Results: After intranasal desmopressin inhalation, mean volume of nocturnal incontinence decreased significantly in the large bladder capacity group ( P<.05), but not in the small bladder capacity group ( P>.05). The mean maximal bladder capacity of responders was larger than that of nonresponders ( P<.05). Neither hyponatremia nor serum electrolytes abnormalities occurred. Conclusions: Intranasal desmopressin inhalation is safe and effective in symptomatic management of neurogenic bladder dysfunction in selected patients with SCI. Maximal bladder capacity is a valuable predictor of response to desmopressin.

Ultrasonic measurement of bladder weight as a novel urodynamic modality.

Although pressure-flow studies (PFS) are currently recognized as the gold standard for the diagnosis of infravesical obstruction, their clinical use is limited, due to the invasive nature of procedure. Recently, we developed a new urodynamic parameter, ultrasound estimated bladder weight (UEBW), which was calculated from the bladder wall thickness measured ultrasonically and intravesical volume. Our comparative study between UEBW and PFS showed that UEBW diagnosed infravesical obstruction with a diagnosis accuracy of 73% using a cut-off value of 35 gm. UEBW could also be used as a reliable tool in monitoring therapeutic effects on BPH patients in terms of the relief of obstruction. In addition, UEBW is of clinical use in the management of neurogenic bladder dysfunction, in which there was a significant negative correlation noted between UEBW and bladder compliance. Consequently, UEBW could be a reliable predictor for a low-compliant bladder. Since UEBW can be obtained non-invasively, it is readily applicable to pediatric urology. In healthy children, UEBW increased significantly with age. For the evaluation of UEBW in an individual child patient, the deviation from age-matched UEBW, obtained from the formula of the linear correlation between UEBW and age, was employed. In our recent studies, the deviation from age-matched UEBW is likely to be used as a predictor for bladder dysfunction in children, such as secondary vesicoureteral reflux and a low-compliant bladder. In conclusion, UEBW is promising as a non-invasive urodynamic modality capable of evaluating bladder hypertrophy with its functional abnormalities.

Management of neurogenic bladder dysfunction with incontinent ileovesicostomy

Objectives. Incontinent ileovesicostomy is an alternative form of urinary management applied to patients with neurogenic vesical dysfunction who are either unable or unwilling to perform clean intermittent self-catheterization or assisted catheterization. We review our operative results, urodynamic data, and complications observed in patients who underwent creation of incontinent ileovesicostomy at our institution. Methods. Thirteen patients (mean age 43.2 years) with neurogenic bladder dysfunction underwent an incontinent ileovesicostomy between 1994 and 1998. The etiologies of the neurogenic bladder dysfunction were spinal cord injury in 8 patients, multiple sclerosis in 4 patients, and tuberculous meningitis in 1 patient. The preoperative data, surgical records, urodynamic findings, and postoperative complications were assessed. Results. All patients experienced complications of their pretreatment bladder management. The mean operating room time was 242 minutes (range 170 to 395), including 14 additional procedures in 11 patients. The mean estimated blood loss was 403.8 mL (range 50 to 2000). No patient required blood transfusion. There were no intraoperative complications. Only 1 patient required reoperation for stomal revision. One patient had a ureteral stone 2 years after surgery; 1 patient has continued to have urinary tract infections despite a negative workup. The mean follow-up was 23 months (range 6 to 57). The mean bladder leak point pressure through the stoma was 8.2 cm H 2O. Conclusions. The incontinent ileovesicostomy is a useful technique in the treatment of patients with neurogenic bladder unable to perform clean intermittent catheterization. It provides patients with a low-pressure urinary conduit that empties readily without an indwelling catheter.

Synchronous Cystoscopy and Cystometry in the Management of Neurogenic Bladder Dysfunction

The physical difficulties associated with cystoscopy and cystometry in the spinal cord injury patient led to a clinical trial of synchronous cystoscopy and cystometry in these individuals. Following a disappointing experience with external transducer methodology, a recently available fiberoptic microtransducer system was used and an effective system was developed.A total of 20 individuals with spinal cord injury underwent a standard water cystometrogram on an examination table followed by synchronous flexible cystoscopy and cystometry using a 5F fiberoptic microtransducer while seated in a chair. The results showed both pressure tracings to be clinically identical. Uninhibited contraction spikes, compliance curves and leak point pressures were essentially the same by both methods and artifact was not a problem. Given the speed, ease and reproducibility of this method, the difficulties with patient transfer for these studies have been virtually eliminated. Two urethral instrumentations have been replaced by 1. Examination room time was decreased from 60 to approximately 10 to 15minutes with half of the required personnel. Perhaps more importantly, these occasionally problematic individuals clearly prefer this streamlined approach and patient compliance with followup has improved.

Neurogenic Bladder Dysfunction

The neurophysiology of lower urinary tract function is followed by a discussion of the causes, evaluation, and management of neurogenic bladder dysfunction in children. All forms of injured bladders require early assessment and proper treatment, the basis for which is provided. Clues to what the pediatrician can look for and care for are presented.

Current management of neurogenic bladder dysfunction

Current management of neurogenic bladder dysfunction

Regulation of Urinary Bladder Capacity by Endogenous Opioid Peptides

Naloxone administered to chloralose or ketamine anesthetized cats reduced urinary bladder capacity. Successive cystometrograms revealed that naloxone in doses of 0.5μg./kg. to 15μg./kg. i.v. reduced the volume necessary to evoke micturition by 10 to 50 per cent, respectively. The effect was maximal within a few minutes, remained constant for about ½ hour and returned to control values over the next 2 to 3 hours. Following return to control, subsequent doses of naloxone produced no further effect on capacity. In chloralose anesthetized animals naloxone also increased the frequency and amplitude of low amplitude pressure waves on the tonus limb of the cystometrogram. Intrathecal administration of naloxone to the sacral spinal cord did not significantly reduce the volume necessary to evoke micturition even at large doses, but did increase the amplitude of micturition contractions. These data, along with previous reports, suggest that mu receptors in the brainstem alter urinary bladder capacity, while delta receptors in the spinal cord modulate the magnitude of bladder contractions. Pharmacological manipulation of these receptor systems could provide a tool for the management of neurogenic bladder dysfunction.

Naloxone Induced Micturition in Unanesthetized Paraplegic Cats

AbstractIn chronic spinal cats 2 to 10 weeks after transection of the spinal cord at the lower thoracic level (T12-T13), the administration of naloxone, an opiate antagonist, (32-500 µg./kg./kg. i.p.). stimulated micturition. The total quantity of urine released after administration of naloxone ranged from 10 to 70 per cent, (mean 39 per cent) of the initial bladder volume. The response to the drug occurred 5 to 10 minutes after injection and was characterized by repeated periodic expulsion of small quantities of urine (5 to 10ml.) which coincided with a pattern of hind-limb movement which resembled walking behavior. The effects of naloxone persisted for about 1 hour. The motor activity following administration of naloxone was dependent upon activation of bladder afferents since it did not occur when the bladder was empty. Naloxone also facilitated the release of urine induced by stimulation of somatic afferents. With repeated administration of naloxone, tolerance developed which was evident for several days. These observations suggest that an endogenous opiate may have a tonic inhibitory role in regulation of micturition. Pharmacologic manipulation of this putative inhibitory mechanism may facilitate management of neurogenic bladder dysfunction.