Published Online: July 31, 2013
David Ginsberg, MD
Clinicians managing patients with neurogenic bladder (NGB) and neurogenic detrusor overactivity (NDO) are faced with a myriad of complex choices when deciding on appropriate medical and/or surgical interventions to relieve bothersome symptoms associated with NGB and NDO, especially urinary incontinence. Therapies must provide maximum benefits while minimizing patients’ risk for adverse events. A thorough knowledge and understanding of available and emerging medical and surgical treatment options for NGB/NDO is vital to assist clinicians in choosing appropriate treatment pathways and optimize response to therapy and individual outcomes.
(Am J Manag Care. 2013;19:S197-S204)
Neurogenic Bladder: Goals of Therapy
Neurogenic bladder (NGB) with lower urinary tract dysfunction is found in patients with underlying neurologic diseases, including multiple sclerosis (MS), Parkinson’s disease, traumatic spinal cord injury (SCI), and spina bifida, among others.1,2 Once a diagnosis of NGB has been made and neurourologic evaluation has been performed, clinicians are faced with the challenge of finding appropriate therapies and treatment pathways to relieve urinary incontinence (UI) and other symptoms associated with NGB while avoiding adverse events and treatment complications to enhance patient quality of life (QoL).1 Individualized treatment of NGB will depend on the type of neurologic disease underlying the lower urinary tract dysfunction and its general evolution (prognosis, degree of disability, progression), patient symptoms, urodynamic findings, and also on the general health and condition of the patients and available resources.1,2 There are several critical goals for management of the patient with NGB dysfunction, especially for patients with poor bladder compliance and/or neurogenic detrusor overactivity (NDO) and detrusor sphincter dyssynergia, which can result in elevated intravesical storage pressures and subsequent upper urinary tract damage. Clinicians should strive to use treatments that (1) achieve and maintain urinary continence to avoid the physical and psychological damage associated with incontinence, (2) preserve renal function by maintaining appropriately low bladder storage pressures, (3) minimize risk of other conditions associated with NGB such as urinary tract infections (UTIs) and bladder stones, and (4) optimize the patient’s QoL. Management of NGB may include such interventions as timed voiding, reflex voiding into a condom catheter or diaper, intermittent catheterization, indwelling urinary catheterization, oral and/or intravesical medications, and surgical reconstruction of the lower urinary tract. Patient education is a key component of any management plan for NGB.1 Clinicians must be aware of conservative and lifestyle-based treatments, along with standard, new, and emerging medications and other technologies to optimize treatment of NGB dysfunction and improve health-related QOL (HRQoL) in patients with NGB and underlying neurologic disease.
Conservative and Lifestyle-Based Therapies
Bladder Retraining/Fluid Schedule/Catheterization
Regular and adequate emptying of the bladder is a critical component of optimal healthcare for patients with NGB. Regular bladder emptying (through self-catheterization or other means) reduces intravesical bladder pressure and allows for appropriate cycling of bladder contents to lower patient risk for UTIs.1,3 Behavioral training is a frequent component of urologic management in patients with neurologic disorders. Behavioral measures are most valuable in patients who have some degree of bladder control and intact bladder sensation. This has been found to be helpful for patients with neurologic lesions involving the brain such as cerebrovascular disease, Parkinson’s disease, multiple system atrophy, dementia, and cerebral palsy, as well as for patients with MS, incomplete SCI, transverse myelitis, and diabetes mellitus.2,4
Several different bladder management techniques may be utilized to assist in optimizing bladder function in patients with neurologic disorders and NGB/NDO. Timed voiding consists of fixed intervals between episodes of urination/ toileting. It is initiated by the patient and/or their caregiver and can depend on both bladder function and the working schedules of the caregivers if they are involved. The primary goal of timed voiding is for the patient with urge incontinence to void before urinary urgency and incontinence occur.2,4 Depending on the individual patient and the state of his or her bladder and neurologic disorder, bladder retraining may be utilized to avoid incontinence and involuntary bladder contractions by decreasing voiding intervals. The maintenance of a voiding diary by the patient/caregiver can be helpful in both the evaluation of voiding dysfunction and following therapy. Bladder expression is a bladder emptying technique sometimes used for patients with a combination of an areflexic detrusor and a sphincter that is also areflexic or anatomically incompetent, such as following sphincterotomy. The most common techniques used are Valsalva (abdominal straining) and Crédé maneuver (manual compression of the lower abdomen). Although bladder expression techniques can be effective in bladder emptying, they can be complicated by potential urine reflux into the upper urinary tract, genital-rectal prolapse, hemorrhoids, and incomplete emptying. Urine reflux into the prostate and seminal vesicles may cause epididymo-orchitis in male patients.2 None of these techniques are strongly recommended because of the risk of long-term urinary complications and the inability to empty the bladder adequately.5
Initiation of a fluid intake schedule is another important step in managing a patient with NGB requiring intermittent catheterization and may also benefit patients with uninhibited detrusor activity. Fluid schedules permit a predictable degree of bladder filling without the risk of overdistention. Repetitive overdistention of the detrusor can result in permanent muscle damage and lead to a flaccid bladder with overly large capacity known as myogenic bladder. An example of a recommended schedule would be ingestion of 400 cc of fluid with meals, and an additional 200 cc in the morning and afternoon (eg, 10:00 am, 2:00 pm, and 4:00 pm) with only sips of fluid in the evening to reduce nighttime incontinence. Accounting for fluid loss through respiration and sweating, urine formation would be approximately 1600 cc daily. With intermittent catheterization (IC) performed every 6 hours, the urine volume eliminated with each catheterization would be about 400 cc. IC would be timed to prevent bladder distension and keep bladder volumes at an optimal level of 400 cc to 500 cc. Patients with indwelling catheters will likely benefit from increased fluid intake to help minimize the risks of bacterial colonization, calcium and phosphate crystal formation, and other potential complications related to the use of indwelling catheters. With all the techniques available for bladder management and their complexities, patient education is a crucial component of bladder management. These plans must be individualized for each patient, and both teaching and monitoring of appropriate techniques will assist in achieving optimal bladder management and reduce risks of infection and other adverse events that may negatively affect HRQoL for these patients.1
The purpose of catheterization is to empty the bladder of urine.2 Clean, intermittent catheterization (IC) is the preferred bladder management technique for patients with NGB dysfunction who experience complete or partial urinary retention.1,3 The purpose of IC is to resume normal bladder storage and regularly complete bladder emptying and urine evacuation.2 Self-administered IC enhances patient self-care and independence and reduces barriers to activity and sexual functioning compared with use of an indwelling catheter.1,3 Properly administered IC can make a patient with NGB continent if bladder capacity is adequate; bladder pressure remains low; and a balance is achieved between fluid intake, residual urine volume, and catheterization frequency.2 The maintenance of appropriately low bladder storage pressures and minimization of detrusor overactivity are often achieved with the simultaneous use of medications such as antimuscarinics, which are discussed later.6 If the patient has some ability to void voluntarily, voiding can be attempted every 2 to 4 hours or when the urge to void occurs. IC can be used as part of a bladder retraining program to gradually reduce residual urine volumes.7 Complications may occur with IC, the most frequent complication being UTI.1 One review of the risks of IC indicated an 11% prevalence of asymptomatic UTI and a 53% prevalence of symptomatic bacteriuria reported in various studies.1,8 Catheterization frequency and the avoidance of bladder overfilling are key measures to prevent infection, and asymptomatic bacteriuria (presence of bacterial infection in the urine without patients experiencing symptoms) is often not treated with antibiotics.2,8 Antibiotic prophylaxis for use in IC overall is controversial; however, it may be indicated if a patient on regular IC continues to get recurrent UTI without another demonstrable cause.1,8 The best UTI prevention techniques are appropriate education of patients and caregivers involved in IC, good patient compliance, proper materials, and application of optimal catheterization techniques.8 Closed IC systems are available that do not come into direct contact with the inserter’s hands and are designed to reduce the risk of bacterial contamination. Catheter trauma is fairly common but does not usually create lasting damage. Development of urethral strictures and false passages may occur with long-term IC. Rare complications include loss of a catheter within the bladder and bladder perforation.1
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