Patients with spinal cord injury (SCI) may suffer from. Approach to Neurogenic Bladder in Patients with Spinal Cord Injury

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1 Original Article Nepal Journal of Neuroscience 3:78-84, 2006 Approach to Neurogenic Bladder in Patients with Spinal Cord Injury Pankaj Kumar, MS GK Singh, MS, DNB Amit Agarawal, MCh Department of Surgery Neurogenic bladder following spinal cord injury is a difficult problem for patients as well as for the treating physician. In this article we describe the basic anatomy, pathophysiology, physical examination, lab investigation and current, pharmacological and surgical and behavioral options for management of the neurogenic bladder in spinal cord injured patients. Key Words: bladder, rehabilitation, spinal cord injury Guru Prasad Khanal, MS Address for correspodence: Pankaj Kumar, MS drpankaj06@yahoo.co.in Received, May 10, 2006 Accepted, June 25, 2006 Patients with spinal cord injury (SCI) may suffer from either paraplegia / quadriplegia and many patients can have urinary symptoms that negatively impact on their quality of life. Medical staffs are intimately involved in the management of neurogenic bladder, seen frequently in patients with SCI. We all need to be aware of the basic patho-physiology, types of presentations, appropriate assessment techniques, and treatment options in such patients for optimal management. 22 In this article we present a review of basic pathophysiology, current behavioral, pharmacological and surgical options for management of the neurogenic bladder. Pathophysiology The basic anatomy of the lower urinary tract consists of two ureters leading into the posterosuperior angles of the inverted pyramidal bladder. The bladder consists of the mucosa, the muscle and the outer facial layer, the condensation of fascia transversalis. Except between the trigone, the triangular area between the two ureteric orifices and the internal opening of the urethra, the mucosa is rugosed to adapt to the greater surface needed during distension. The muscle layer is arranged from circular fashion inside to longitudinal outside. The arteries pierce the muscles to reach the mucosa; thus a contracted bladder would stop bleeding. Increased pressure in a distended bladder would block venous return whereas the arteries would keep pumping blood; the mucosa will get congested and ultimately bleed. On the posterior wall just above the urethral opening is the eminence caused by the median lobe of the prostate in males which if enlarged in the elderly, acting like a ball valve, may close the opening like a lid during contraction leading to the classical symptom of effort retention. The nerve supply of the bladder is sympathetic (L1, L2) which causes the bladder muscles to relax and internal sphincter to contract and parasympathetic (S2-4) through pelvic splanchnic nerves. The somatic sensations and control of the external sphincter comes from S2-4 sacral nerve roots, which also supply the anal sphincter. (Figure 1). Normally, when the bladder distends the increased luminal pressure leads to increased muscle activity in the rest of the bladder but decreased muscle activity at the vescico urethral junction leading to urine leaking in the membranous urethra. The chemo-receptors on the prominence of the posterior wall in the urethra called Verumontanum sense the urine and send impulses to the spinal cord through the splanchnic plexus. From the cord the information ascends to the brain and subsequently back 78

2 Neurogenic Bladder Spinal Cord Somatic Sacral Roots Sympathetic nerves L1,2 S2 S3 S4 Inferior Hypogastric Plexus Parasympathetic outflow Pelvic Nerves Pudendal Nerve Detrusor Muscle + = Excitatory Synapse - = Inhibitory Synapse Internal Sphincter External Sphincter Urethra Figure 1. Nerve supply of the sphincter and bladder. to the bladder internuncial neuron system causing bipolar rhythmic contractions. The brain searches for the appropriate time and place and finally relaxes the external sphincter causing a stream of urine to flow through the urethra, powered by the bipolar rhythmic contractions till the last drop passes the chemoreceptors on the verumontanum. Thus the bladder empties completely and with less that 50 milliliters of residual urine. When the spinal cord is injured the facilitatory electrical discharges to the internuncial neuron system of the cord below the lesion through the reticulospinal pathways are lost (spinal shock), and therefore the spinal reflex becomes ineffective. Initially even the local reflex in the bladder is lost therefore there is retention of urine. Then the local reflex recovers leading to dribbling overflow incontinence. In this situation the residual urine is high above 50 ml. Such a bladder is called autonomous. Then the spinal reflex recovers and the urine comes out in a stream as a result of bipolar coordinated contraction of the bladder leaving residual urine of less than 50 ml. The bladder is called automatic bladder. Morbidities Associated with Neurogenic Bladder Urinary tract infection with subsequent urosepsis and/ or pyelonephritis, is a frequent cause of morbidity in patients with neurogenic bladder. 8,14,25,31,38 Predisposition to bladder stone formation is noted at four weeks in patients with SCI as a result of hypercalcemia and hypercalciuria and may persist months or even longer. Incidence of kidney stone formation is highest in patients with indwelling catheters, up to 8%. Kidney stones are the leading cause of renal dysfunction in SCI.24,26 The prevalence of bladder cancer (Squamous cell carcinoma, transional cell carcinoma) is higher with indwelling Foley catheter for 10 years. 24 Physical Examination A complete General physical and neurological evaluation is mandatory for any spinal cord injured patient. For the purpose of this review following point merit emphasis Determine the motor level of the lesion, including completeness of lesion in SCI patients. Ascertain the extent of the patient s hand function and ability to perform transfers and activities of daily living. Hand function is especially important in SCI patients who are to perform self-catheterization. Conduct sensory testing to determine sensory level. Include testing with light touch, pinprick, proprioception, and sacral sensation. Test reflexes and include normally tested muscle stretch reflexes, the bulbocavernosus reflex, cremasteric, and anal reflexes. Use the bulbocavernosus reflex to test the integrity of the pudendal nerve and the S2-S4 segments. Determine the condition of the skin in the perianal area. Establish the state of vaginal and bladder supports, particularly in patients with suspected stress incontinence. Relaxation of the bladder neck and weakness of the sphincter mechanism are common in these patients. Urodynamic evaluation is mandatory for the diagnostic assessment and therapy of bladder dysfunction in patients with acute SCI. 7 Labortory and Imaging and other Investigations Generally these patients require frequent urinary examinations (both routine and culture) to rule out urinary tract infection at the slightest suspicion. In addition these patients need 24 hour creatinine clearance done. Large amount of residual urine after voiding is a major concern in these group of patients with attendant risks. It reflects bladder and outlet activity during emptying phase of micturition. Residual urine volume is usually determined by bladder scanning after void; or it may be measured 79

3 Kumar, et al. directly by catheterization if bladder scan is not available. Acceptable quantity is of up to 50 ml of postvoid residual urine with voiding frequency greater than every two hours, if patient is not experiencing frequent urinary tract infections. Patients with SCI require frequent imaging studies performed, the modality depending on the level of suspicion of the lesion: Plain film of the urinary tract, bladder, and kidneys is indicated to determine presence of radiopaque calculi in conjunction with ultrasonography. Excretory urography or intravenous pyelography can be used for visualization of the collecting system. Excretory urography is a type of contrast study used to verify and localize upper urinary tract disease. In some instances, information regarding renal function and disease pathophysiology can also be obtained. With the recent advances in small animal ultrasonagraphy, excretory urography has become an underutilized procedure. 18 If decided, intravenous pyelography should be performed immediately after the onset of renal insufficiency to obtain maximal information, as deterioration in renal function from total ureteral obstruction rapidly causes inadequate excretion and concentration of contrast material and prevents visualization of an obstructed collecting system. 1 Isotope studies (eg, technetium Tc 99m dimercaptosuccinic acid [DMSA]) are used for evaluation of function of renal cortex. Ultrasonography (USG). This is a relative safe and easy -to-use investigation that is very useful in a variety of circumstances in the SCI patients. USG is especially useful to routinely evaluate of the upper urinary tract for any hydro or pyonephrosis or to detect any stones or tumors. A limited computed tomography urography examination is adequate for the majority of patients requiring excretory urography and a superior replacement of conventional intravenous urography. Information provided by a multiphase computed tomography urography examination is beneficial only in a small number of patients. 29 Excretory phase CT urography was comparable with IV urography for evaluation of the urinary tract in patients with painless haematuria. 23 Electromyography (EMG). EMG is used to measure electrical potentials generated by depolarization of the detrusor muscle and urethral sphincter.anticipated normal findings include incremental increase in EMG activity in the external sphincter during filling phase secondary to increased recruitment of motor units. Prior to voiding, diminished EMG activity in the external sphincter is expected. Relaxation of the external sphincter is followed by bladder contraction. Abnormal EMG patterns include absence of recruitment and low levels of EMG activity as in patients with complete SCI. Inappropriate increase may be observed in EMG activity of the sphincter, leading to detrusor contraction against a closed sphincter or detrusor sphincter dyssynergia. Some potential findings will include confirmation of detrusor sphincter contraction dyssynergia, increased duration of bladder contractions, and uninhibited bladder contractions. Cystometry. This helps to evaluate filling and storage phases of detrusor function by measuring changes in intravesical pressure with increases in bladder volume. Bladder volumes can be determined and recorded during first sensation of filling, voiding urgency, and maximal filling. It can assess the voluntary voiding phase after filling and the efficacy of emptying Cystoscopy. This is useful for the evaluation of the bladder outlet and urethra. Rehabilitation Programs Physical Therapy Early mobilization and transfer training is recommended to minimize urinary incontinence and other complications such as pressure sores. Pressure sores can easily become infected in patients who are incontinent. Occupational Therapy Activities of daily living and self-care training are important to encourage maintenance of hygiene and a more efficient use of hand and upper extremity function. Medical Issues/Complications A variety of techniques are used to maintain continence and/or empty the bladder. Initiation of reflex bladder contraction. Pinching or stimulating the lumbar and sacral dermatomal levels is used to provoke reflex bladder contraction if there is no outlet obstruction or detrusor sphincter dyssynergia. A program of timed voiding is useful in patients with weak sphincters or in patients with hyperreflexic bladders. These patients are put on a schedule of frequent bladder emptying before actual bladder contraction. Timed voiding should be scheduled every 2-4 hours. Clean Intermittent Catheterization (CIC) CIC with or without baldder relaxants has replaced urinary diversion as the treatment of choice for patients with neurogenic bladder. 12,39 Prerequisites for use include sufficient outflow resistance to maintain continence between catheterizations, bladder with low pressure, and adequate bladder capacity, ideally more than 300 ml. One should encourage fluid restriction to limit bladder volumes to less than 600 ml. In addition one should schedule catheterization 3-6 times per day. Problems with this technique include urethral trauma and predisposition to bacteriuria and/or urinary tract infections. Usually SCI patients with lesions at C 7 and below can manage selfcatheterization. To avoid development of latex allergy, nonlatex catheters should be utilized for chronic use. And lubrication with 2% lidocaine helps to limit pain and trauma. At times, use of a curved tip (coudé) catheter may be necessary if there is difficulty introducing a standard catheter. Patient reaction and acceptance of intermittent catheterisation is extremely variable. Some patients take it well, particularly if they have spoken to another patient who has benefited from performing the technique. Others always find it difficult and do not persist with it. Use of 80

4 Neurogenic Bladder hydrophilic-coated catheters have beneficial effect regarding UTI. 10 Sterile catheter for each void did not decrease the high frequency of bacteriuria in patients with neurogenic bladder on intermittent catheterization. 33 The prelubricated nonhydrophilic catheter is a safe, effective and comfortable option in spinal cord injured patients on intermittent self-catheterization. 15 Catheter care includes monthly catheter changes, sterilization of collection bags, and irrigation. Urinary colonization and infections are common. Urinary tract infections (UTIs) in the SCI population frequently are asymptomatic, polymicrobial, caused by antibiotic-resistant bacteria, and very likely to recur or relapse. 19 Long-term users should have routine cystoscopy to rule out bladder cancer. Credé Maneuver This is nothing but the manual compression of the bladder, used in patients with decreased bladder tone or areflexia and low outlet resistance. Facilitation of the Credé maneuver by an attendant is useful, at least in the initial period and is required in individuals who are quadriplegic. Intravesical pressure can also be increased through the Valsalva maneuver (ie, abdominal straining). External Condom Catheters Men with spinal cord lesions higher than C 7 who are unable to perform self-catheterization are the ones most likely to benefit from the use of external condom catheters. If outlet obstruction is present, a sphincterotomy is needed. One prerequisite is that they must have reflex bladder contractions for this to work. Skin breakdown can occur, especially in patients with poor hygiene. Medical Treatment The mainstay of the treatment of the symptoms of urgency, frequency, and urge incontinence is anticholinergic medication. Several alternative drugs are available for treatment of the overactive detrusor but, for the most, clinical use is based on the results of preliminary, open studies rather than randomised, controlled clinical trials. Capsaicin was used but its use is limited by its pungent smell, and was replaced by resiniferatoxin (RTX). Resiniferatoxin is significantly less uncomfortable. Unfortunately multi-center trials failed to demonstrate the efficacy of RTX. Cranberry tablets were not found to be effective at changing urinary ph or reducing bacterial counts, urinary WBC counts, or UTIs in individuals with neurogenic bladders. 20 A highly promising recent development has been the use of intra-detrusor injections of botulinum toxin. First described from Switzerland in the treatment of patients with spinal cord disease, it has been found to be effective in other causes of neurogenic bladder overactivity as well as non-neurogenic cases. The injections are given through a cystoscope at between 20 and 30 different sites in the detrusor muscle wall, avoiding the trigone. The beneficial effect seems to be remarkable, in that it increases bladder capacity and virtually eliminates the sense of urgency, the effect lasting for between 6 9 months. The efficacy of second and subsequent injections does not seem to be diminish and reports are now appearing of patients who have had repeat injections on at least four occasions with continuing benefit. As with botulinum toxin injections at other sites, very few adverse events have been reported. The range of patients for whom this treatment will be suitable remains to be defined. 28,34,35 It is hoped that continued investigation of neurotoxins that have the potential to act on afferent innervation will lead to other treatment strategies for bladder disorders and other disorders involving afferent dysfunction. 13 Studies are currently underway looking at the effect of 5-hydroxytryptamine (5-HT) antagonists as well as alpha delta ligands. It seems likely that in the not too distant future there will be a number of oral alternatives to the antimuscarinics to treat overactive bladder symptoms. 2 Attempts to use selective antimuscarinic agents (Muscarinic M3 antagonists) have not significantly improved the efficacy, but have reduced the major adverse effect of excessively dry mouth. 3 Unfortunately at the moment there is no medication that improves neurogenic incomplete bladder emptying or retention. Salomon, et al., in an observational pilot study designed a novel approach for the prevention and treatment of UTI. They showed the benefit of weekly oral cyclic antibiotic (WOCA) in preventing UTI in SCI patients. 31 On the other hand according to Garcia, asymptomatic bacteriuria need not be treated with antibiotics. 8 Detrusor overactivity may be controlled by modulating the afferent input from the bladder and the excitability of the sacral reflex center and suggest a novel method to treat overactive bladder patients. 5 Although availability of effective therapies remains a cornerstone of neurogenic bladder treatment, consideration must also be given to the non-pharmacological and surgical issues related to the global management of this population. Improved crossspeciality interactions and development of patient-specific treatment and follow-up plans, which are in keeping with the current guidelines of each speciality involved, may serve to enhance physicians understanding of the importance of effective urinary incontinence treatment as well as the overall management of the patient. 10 Use of Stimulator Direct sacral root stimulation through an implanted stimulator may restore a degree of pelvic organ control; however, a dorsal rhizotomy is required to abolish reflex detrusor contractions. Such an implant is not used in patients with incomplete cord lesions. The technique, which stimulates the pelvic plexus through electrodes inserted through a sacral foramen, is known as neuromodulation and is mostly reserved for patients with severe idiopathic detrusor overactivity or complete urinary retention. Because of the expense of the stimulator device and the considerable surgical re-operation rate for the implant or the stimulating lead, these are not recommended for patients with progressive neurological disease. Long-term indwelling catheters should be avoided in such circumstances. External electrical stimulation can be used to correct the neurogenic dysfunction by neuromodulation and/or to induce a direct therapeutic response in the lower urinary tract. 17,19 Pudendal nerve stimulation has beneficial effects on numerous pelvic 81

5 Kumar, et al. floor function impairments such as urinary and/or fecal incontinence, retention, and constipation. 37 Research in restoring functional micturition has mainly focused on electrical stimulation for many decades with good progress, but it is still not the definitive solution for majority of the SCI patients. An alternative approach has been to investigate restoring cross over nerve surgery for reinnervation to the lower urinary tract after spinal SCI. 40 Surgery on the Bladder Bladder augmentation is used primarily in patients with refractory hyperreflexic bladders when medical treatment has failed to alleviate symptoms. In this procedure, the bladder is opened and patched using a reconfigured segment of bowel. Augmentation also is used to achieve a normal bladder capacity in children and adolescents, often in conjunction with an artificial sphincter. Laparoscopic retropubic auto-augmentation is a procedure that allows a brief hospital stay and minor postoperative discomfort. 36 The Mitrofanoff procedure uses the appendix to create a channel between the abdominal wall and the bladder. This procedure is particularly useful in patients who are unable to reach the urethra for CIC or in patients with limited hand function due to SCI. In general, it is easier to manipulate clothing and pass the catheter through the umbilicus than to transfer, remove lower extremity garments, and perform urethral CIC. Tube cystostomy is performed routinely for temporary or permanent urinary diversion. Temporary diversion may be performed concurrently with surgical repair of urethral trauma or to relieve acute urethral obstruction. Permanent cystostomy may be performed in cases of neurogenic bladder atony or bladder cancer. 6 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. 16 As urethral diameters are narrow in pediatric patients and adult spastic paraplegic patients in whom an endoscopic approach could not be performed, percutaneous sprapubic cystolithotripsy is a safe alternative with low morbidity and complication rate. The technique has an advantage over open surgery with regard to cosmetic outcome and length of the hospital stay. 9 The artificial sphincter has been utilized for urinary incontinence due to intrinsic sphincteric insufficiency, with good fixation of the urethra and a maximum urethral closing pressure of cms H 2 O, or after failed attempts at correction using other techniques. This procedure is difficult to perform since the patients have generally undergone several operations and it is necessity to prepare the cleavage between the urethra and vagina. Marques Queimadelos proposed a modified combined vaginal and suprapubic approach for artificial sphincter implantation with urinary incontinence of the technique described by Appell and Abbassian in 1988 for enhanced exposure of the urethra and bladder neck and easy access. 27 Over the last two decades, the evolution of complex reconstruction for lower urinary tract dysfunction has resulted in an improved quality of life for children afflicted with upper urinary tract changes or incontinence despite maximum utilization of nonoperative therapies. 21 Urethral irregularity (impeding catheterization) and failure to achieve continence are common complications in surgery for urinary incontinence. 30 Electrical stimulation involves use of electrodes driven by an implanted receiver to stimulate detrusor contractions. Electrodes usually are placed in the anterior sacral roots. Bilateral S2-S4 rhizotomies are performed along with this to prevent spontaneous hyperreflexic contractions. This technique may be useful for patients who can transfer independently but who have incontinence between catheterizations. Some medical institutions have been successful using injections of bovine collagen into the urethra and bladder neck to increase tissue bulk around the bladder neck in patients with decreased outlet resistance. 24 Further Out Patient Care An outpatient visit one month after discharge is recommended. This is to provide support for patients with SCI who are unable to meet their needs independently by arranging for nursing services and attendants for home care. Diagnostic Follow-up Patients with indwelling catheters must undergo annual cystoscopy for detection of bladder tumors since they have increased risk for squamous cell and transitional cell carcinoma if they have had indwelling catheters for more than 10 years. Cystoscopy is recommended more frequently if the patient has other risk factors (eg, smoking, history of recurrent urinary tract infections etc.) for bladder tumor. Following diagnostic work-ups are recommended in patients with SCI: Annual renal and bladder ultrasounds are recommended. Perform voiding cystourethrogram as needed. Schedule dimercaptosuccinic acid scanning as indicated. Determine glomerular filtration rate as needed. Order urinalysis and urine culture with sensitivity at least once a year and as needed. 4 Prognosis The prognosis for recovery depends on the type, severity, and location of the lesion causing the bladder problem. Most patients with SCI with complete lesions remain on intermittent or indwelling catheterization for the rest of their lives. Conclusions Detail understanding of basic pathophysiology of bladder function following spinal cord injury supplemented with appropriate management protocols 82

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