Management of the Neurogenic Bladder in Late Childhood to Adulthood

Overview
What is transitional urology? When is it appropriate to consider transition? How to transition urological care Neurogenic bladder
protecting kidney function

Neurogenic bladder
managing bladder function

Growing Up
Children with spina bifida grow up to become adults Preparation for adulthood is essential

Encourage them to look after themselves and take part in normal family lifefrom the beginning

Growing Up
How do things change? Urologically

Sexually

Growing Up

CHALLENGE
Transition of care for this growing population

Growing Up
Renal failure remains the most common cause of death Pulmonary and cardiac disease are becoming more common Increased risk of atherosclerosis

Problem

Finding a urologist who understands your problems!!!

TRANSITION

Transitional urology
Subspecialty care with a focus on adolescents and adults with congenital anomalies or chronic urological issues Requires specialty expertise in:
anatomy/congenital anomalies reconstructive urology knowledge of long-term effects of prior interventions/operations

Transitional Urology
May also need support of social work or financial services to help patients navigate medical coverage issues

Also functions as patient advocate/liaison for other subspecialists within urology and other specialties (cardiology, neurology, etc.)

Issues addressed at initial visit

Current urological problems/needs Current living situation, work/school, and goals for the future Key players (care-providers, significant others, dependents) in patients life Quality of life concerns from parents/care-givers and patient

Issues addressed at initial visit

Detailed review of prior surgeries/interventions, complications, and signed medical release for records

Assessment of current status of the following:

Renal function - Stone history Bladder management - Sexuality issues/goals Infection history - Fertility issues/goals Fecal continence history/goals Urinary continence history/goals

When is it appropriate to consider transition?

Age alone is not a good criteria Patient, care-provider, pediatric urologist mutually agree that the urological issues are more adult in nature When the current urologist is uncomfortable or not capable of addressing the relevant issues

When is it appropriate to consider transition?

When a urologist with subspecialty interest/expertise in transitional urological care can be identified The patient has a change of life (moving, new job, marriage, etc.) where it is reasonable to change medical care venue

How to transition urological care

Discuss with key players (family, care-givers, urologist) Gather records (and keep a copy) of all prior interventions, radiological and lab tests. Request a referral, consult SBA or other local resources for guidance

How to transition urological care

Talk with other care providers (cardiologist, neurologist, etc.) Think about and prioritize relevant urological goals/issues Bring someone with you who knows your history Request last appointment slot of the day or double-slot

Urinary Tract Anatomy

Urinary tract innervation

Urinary tract innervation

Control of micturition

Normal urodynamics
Measure:
Bladder pressure (Pves) Rectal (abdominal) pressure (Pabd)

Calculate:
Detrussor Pressure Pdet = Pves - Pabd

Volitional control of micturition

Storage & voiding reflexes

NEUROGENIC BLADDER
Urinary problem in which the bladder does not empty properly due to a neurological condition such as spina bifida

NEUROGENIC BLADDER: Primary Goals for Management

The primary goal of the urologist is always to maintain and preserve renal function

What do the kidneys do?

Filter the blood = eliminate waste Maintain acid-base balance
Impacts growth & stone development

Produce some hormones

Impacts growth & puberty

Help regulate blood pressure Regulate fluid balance by making urine

What can go wrong with the kidneys? Infections Hydronephrosis Stones Loss of function

What can go wrong with the kidneys? Infections

Prophylaxis

Prevention
Treatment

Treat when have symptoms

What can go wrong with the kidneys?

Hydronephrosis
Persistent New Changes in bladder dynamics Poor catheterization technique Blockage

What can go wrong with the kidneys?

Stones
Decreased mobility Calcium metabolism Electrolyte abnormalities Anatomical abnormalities

What can go wrong with the kidneys?

LOSS OF FUNCTION
Renal failure was the most common cause of death in spina bifida patients in past Renal failure still occurs in spina bifida It can be prevented!

x
Drink water Prevent infection Cath or void as directed (TAKING CARE OF YOUR BLADDER TAKES CARE OF YOUR KIDNEYS!!) Take your medicine See your doctor
Check renal function, check bladder function

Treat infections

Goals for the adolescent/adult patient with neurogenic bladder

Prevent problems before they arise Identify which factors can be improved and which cannot Identify the risks of each line of treatment Balancing the risks and benefits of any treatment

Pelvic floor muscles affected by neurogenic bladder

Bladder function
Stores urine

Bladder Outlet

Stores urine

OUTLET

Bladder function
May worsen due to outlet resistance or a tethered cord Outlet resistance increases
Not always a positive

Bladder function: tethered cord

25% patients age 2-8

Usually combination of new-onset neurological, orthopedic and urological problems

10% present with isolated new urologic problem

Bladder function: tethered cord

Urologic symptoms:
new onset of upper tract dilatation (hydronephrosis) vesicoureteral reflux urinary incontinence urinary tract infection

Treatment: cord release (surgery)

Bladder function: neurogenic bladder

A bladder that stores urine at pressures that are too high to keep the kidneys from deterioration

Requires consistent management

Intermittent catheterization Anticholinergic medications Often both Usually first line therapy

Bladder function: neurogenic bladder

RISKS
End stage renal damage Social stigma and complications of incontinence

GOALS
Maintain healthy kidneys Continence

Bladder function: incontinence

Causes:
Decreased outlet resistance (sphincter) Bladder irritation (stone/infection) Increased bladder storage pressure (neurogenic bladder) Overflow

Bladder function: incontinence

With aging, other risk factors can increase the risk for incontinence:
Surgery of the prostate () Vaginal childbirth () Weight gain

Neurogenic bladder types

Treatments of incontinence
Behavioral: timed voiding, catheterization, avoid bladder irritants in diet Pharmacologic: anticholinergics

Surgical:

Decrease storage pressure Botox, bladder augmentation Increase outlet resistance sling, artificial sphincter

Combination

Treatment of neurogenic bladder: Intermittent Catheterization

LONG TERM RISKS
STRICTURE 0-20% TRAUMA EPIDIDYMITIS

ACCESS SUPPLIES

Treatment of neurogenic bladder: Anticholinergics

SIDE EFFECTS
Dry mouth Constipation Headache

COST
Only oxybutinin is generic

Anticholinergic Medications: Treatment Considerations

COST!! Frequency of dosing Characteristics to limit sleepiness Limitation of other side effects (constipation) Antispasmotic effect (intravesical oxybutinin) Drug interactions Delivery mechanism: oral versus topical/transdermal/intravesical

Treatment of neurogenic bladder: Surgery

Botox injection
Endoscopic procedure/outpatient Onset within 2 weeks after treatment Effect lasts ~ 6 months Side effects rare and minor (<10%) Efficacy:
Reduction from baseline incontinence: 40%-80% 65%-87% of patients became completely continent (between caths) after Botox

Main issue is cost/insurance coverage

Treatment of neurogenic bladder: Surgery Make the bladder larger/lower pressure

Bladder augmentation

Make the outlet tighter

Sling, artificial sphincter

Treatment of neurogenic bladder: Surgery

Risks with increasing age Risks with increasing obesity
Infection Cardiovascular status Pulmonary status Deep venous thrombosis

Treatment of neurogenic bladder: Surgery

Significant periods of immobility Difficulty positioning Difficulty accessing abdomen Potential for fracture Increased incidence of Latex allergies Decline in respiratory reserve Worsening scoliosis

Treatment of neurogenic bladder: Surgery

How do we decide what to do? Urodynamics
Gives us an idea of bladder storage pressure
> 40 mmHg is dangerous

Gives us an idea of bladder capacity

Low capacity means frequent voiding/ISC

Gives us an idea of outlet resistance

Tells us whether sling/sphincter can reduce leakage

Treatment of neurogenic bladder: Surgery

Surgery Catheterizable channel

Monti-Yang Mitrofanoff Appendicovesicostomy

Diversion of Urine
Continent Abdominal Stoma with reservoir (Serum creatnine <2 mg%) Free external diversion in Renal failure Cutaneous ureterostomy Ileal conduit

Treatment of neurogenic bladder: Surgery Augmentation: Long-term concerns Catheterization Stricture Continence Tumors

Treatment of neurogenic bladder: Catheterization

LONG-TERM CONCERNS Stricture Continence Positioning

Treatment of neurogenic bladder: Bladder augmentation

LONG-TERM CONCERNS Calculi Vitamin B12 deficiency Rupture Malignancy

Treatment of neurogenic bladder: Tumors

Chronic urinary tract infections Smoking Inflammation
Stones

Indwelling catheter Augmentation cystoplasty

Estimated risk 1.2% to 3.8%

Treatment of neurogenic bladder:

Catheterizations, Bladder Augmentation & Tumors

Seek medical assistance

Hematuria Recurrent UTIs Difficulties catheterizing

Surveillance cystoscopy Cytology Biopsy LIFELONG UROLOGIC FOLLOW-UP

Treatment of neurogenic bladder: outlet procedures

Treatment of neurogenic bladder: outlet procedures

May change storage pressures and jeopardize kidney function Requires postoperative urodynamics/monitoring Sphincter is not a good choice if the patient requires catheterization (prior augmentation) Device failure Sphincter- 15-30% (10 years) Sling- depends Device infection Sphincter- 1%

Summary
Bladder function changes Goals/priorities of the patient change Risks of interventions change Critical to have a urologist who:
Understands the issues Can counsel you on realistic expectations Has surgical and medical expertise in this field AND IS WITH YOU FOR THE LONG HAUL!