Bladder dysfunction in ALD and AMN Sara Simeoni, MD Department of Uro-Neurology National Hospital for Neurology and Neurosurgery Queen Square, London 10:15 Dr Sara Simeoni- Bladder issues for AMN patients 1
Bladder dysfunction is unfortunately very common in both men and women! -overactive bladder (urinary urgency, frequency, nocturia and incontinence) MOST COMMON -stress urinary incontinence (involuntary leakage on effort or exertion, or on sneezing or coughing) -low stream Significant impact on quality of life but frequently under-reported and under-treated! Bladder disfunction common in AMN and ALD, because the bladder is controlled by the nervous system, which is heavily affected by this condition. In 2015, London study of 48 people focused on problems with the bladder in people with AMN. The most common problem was an overactive bladder, creating increased urgency and frequency in passing urine as well as nocturia (needing to wake up in the night to urinate) and incontinence caused by weak pelvic floor muscles. These symptoms are quite common in AMN and can have a significant impact on quality of life. They are underreported and undertreated. 2
Severity of bladder symptoms in AMN 67% of patients reported symptoms to be of moderate or severe grade and having a significant impact on the quality of life Despite this high figure, only a third of patients receive treatment for managing bladder symptoms 67% of study participants reported moderate to severe bladder symptoms which were having a significant impact on their quality of life. 3
What happens during the assessment? Ask a few questions Keep a diary of visits to the toilet Test the urine for an infection See if the bladder is emptying after urination Urodynamics? Talk about treatments There are a lot of options for treatment for these symptoms, as long as the patient is properly referred to uro-neurology departments. Patients are asked to fill out a questionnaire and to complete a bladder diary recording all fluid intake, frequency of urination, nocturia and so on. Checks are carried out to test if the patient can completely empty the bladder, through a bladder scan. In some cases, a urodynamics test is also needed. This helps to understand how the bladder works and to uncover any problems. 4
Measuring the post void residual 5
Storage symptoms Urgency Frequency Nocturia Incontinence Hesitancy Straining Interrupted stream Double voiding Voiding symptoms The function of the bladder is simple, with just two phases: storage and voiding. Possible issues in the voiding phase include hesitancy, in which patients struggle to begin to pass urine, the need to strain in order to pass urine, and stopping and starting during urination. Double voiding may also be a problem, in which the patient must keep returning to the toilet due to an inability to empty the bladder. Storage phase issues include urgency, frequency, incontinence and nocturia (waking at night to urinate) 6
Lifestyle modifications Fluid intake of around 1 2 l a day, although this should be individualized. Drinks that CAN irritate the bladder Caffeinated tea and coffee Green tea Hot chocolate Fizzy drinks, especially Cola Caffeinated energy drinks Fresh acidic drinks Drinks that DON T irritate the bladder Decaffeinated tea and coffee Water All types of diluted fruit juices Non-acidic fresh drinks Herbal tea Red bush tea There are several treatment options available, particularly for issues in the storage function (urgency, frequency, nocturia, etc). Lifestyle modifications are the first course of action: fluid intake should be around 1-2L per day, leaflets are provided explaining which fluids are most and least likely to irritate the bladder. Caffeinated and fizzy drinks, for example, are discouraged. 7
Bladder training Bladder training involves training yourself to voluntarily hold on for increasingly longer periods You begin with small delays, such as 30 minutes, and gradually work your way up to urinating every three to four hours. Another simple option is bladder training, in which the patient tries to gradually increase the time between urination. 8
Pelvic floor muscles exercises They help strengthen your pelvic floor muscles and urinary sphincter. These strengthened muscles can help you stop the bladder's involuntary contractions. A physiotherapist can help you learn how to do the exercises correctly. Useful especially if you have involuntary leakage on effort or exertion, or on sneezing or coughing. Pelvic floor muscle exercises are helpful if there is stress and incontinence, as this is usually due to weakness in these muscles. These exercises are arranged by physiotherapists. 9
Medications that relax the bladder Antimuscarinics (e.g. tolterodine, oxybutinin, trospium, solifenacin, darifenacin, fesoterodine) possible side effects are dry eyes, dry mouth and constipation Mirabegron possible side effects are hypertension and palpitations When these lifestyle changes and exercises are not sufficient, medication can be used to relax the bladder. There are two groups of these medications, which act on different receptors in the bladder wall and so can be used together if needed. Antimuscarinics have different effects and side effects, they can cause dry eyes and dry mouth, and cannot be used on patients with glaucoma. Mirabegron has more cardiovascular side effects such as palpitations. 10
Percutaneous tibial nerve stimulation to relax the bladder -Treatment option for overactive bladder (frequency, urgency, nocturia, incontinence) -A nerve in the leg called the posterior tibial nerve is stimulated near the ankle -It modulates the nerve that control bladder function -No major safety concerns -60-80% of patients benefit from this treatment -12 weeks of treatment When these medications are still not sufficient, nerve stimulation (PTNS) is another option, similar to acupuncture. Stimulating a nerve in the leg can modulate the function of the bladder and improve bladder symptoms, the reasons for this are unclear. This treatment is given once a week for 12 weeks and can also treat bowel disfunction. 11
Percutaneous Tibial Nerve Stimulation (PTNS) Courtesy Uroplasty A 34-gauge stainless steel needle is inserted approximately 3 4cm about three fingerbreadths cephalad to the medial malleolus, 9V stimulator (Urgent PC, Uroplasty Inc., US) with an adjustable pulse intensity of 01 10mA, a fixed pulse width of 200 microseconds and a frequency of 20Hz. 12
Botulinum toxin injections to relax the bladder Botulinum toxin type A injected into the detrusor muscle under cystoscopic guidance appears to be a highly promising treatment for intractable detrusor overactivity. Duration < 15 minutes Discomfort score 3.4 (0.5 9) Effect lasts 9-13 months Often need to perform catheterisation afterwards. It significantly improves frequency, urgency and nocturia and quality of life. Fewer urinary tract infections and reduced urethral leakage when using an indwelling catheter (catheter bypassing). Another option is botulinum toxin A injections into muscles in the bladder, which can benefit the patient for up to 13 months. This can also be effective for patients with catheters. 13
How to manage difficulties in emptying the bladder Complete bladder emptying is important for avoiding recurrent urinary tract infections and maintaining renal function. As there are no effective medications for improving voiding, catheterisation is usually the best option. These options are all used to relax the bladder and treat overactivity. There are no medications for inability to empty the bladder, the only way to manage this is catheterisation. This has a low risk of infection. The patient can use an intermittent catheter or an indwelling catheter- usually a suprapubic catheter, because it is easier to manage. 14
Catheterisation Clean intermittent self-catheterisation is preferred as it avoids the long term complications associated with a permanent indwelling catheter. Frequency of catheterization depends on the postvoid residual volume and fluid intake. If the symptoms become refractory to all treatments a long term indwelling catheter may be an option This should be a suprapubic rather than a urethral catheter because of the impact of the latter on urethral integrity, perineal hygiene and sexuality. 15
Urine infections -Urine should not be routinely tested unless there are symptoms suggesting infection. -Antibiotics should be limited to symptomatic urinary tract infections. -Unrestricted use of prophylactic antibiotics can lead to drug resistance; however, in individuals with proven recurrent urinary tract infections it is sometimes reasonable to start prophylactic low dose antibiotics; this decision should be taken in consultation with a urology specialist team. -Cranberry extract tablets and D-Mannose may be helpful to prevent infections due to E.Coli Urinal infections can also be a problem. Any symptoms of a urine infection should prompt the patient to go to the GP and have the urine culture tested. Different prophylactic measures can be taken depending on what is causing the infection. Prophylactic antibiotics are not prescribed unless other measure have not worked 16
To recap Bladder dysfunction is frequent in ALD/AMN Check to see if the bladder is emptying or not Treatments- Fluids Exercise Tablets Electrical stimulation of nerves (PTNS) Botox 17
Get in touch Primary care- community continence team Uro-Neurology department- we are here to help National Hospital for Neurology and Neurosurgery Queen Square, London WC1N 3BG 18
Thanks for your attention! Questions? 19