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Illnesses We Treat
Spinal Cord Injury - Neurogenic Bladder
What is this?
A condition where, due to an interruption of the nerve messages between the brain and the bladder, the bladder fails to store or release urine properly.
What causes it?
- Spinal cord injury
- Brain tumor
- Stroke
- Congenital disorders such as spina bifida
- Diseases such as multiple sclerosis or diabetes mellitus
What are the symptoms?
Depending where the lesion or injury is, and its severity, a person may experience a variety of lower urinary tract symptoms such as
- An inability to store urine – urgency, frequency and incontinence. This is caused by an overactive bladder or a weak sphincter (outlet).
- An inability to release urine – difficulty urinating and urinary retention. This is caused by a weak bladder or an overly tight sphincter.
Many patients will come to a urologist for these symptoms, unaware that they have a neurologic problem. Others will have other longstanding manifestations of neurologic disease.
How is it evaluated?
Every neurogenic bladder is different and it is important to do a thorough evaluation to diagnose the disease so that treatment is specific and directed. Blood tests and ultrasound to evaluate the kidneys are important. Tests called uroflowmetry and post void residual tell how well the bladder empties. Urodynamic testing with video xray are performed by placing a small catheter in bladder and filling the bladder with radiopaque contrast dye. The pressure in the bladder is measured during filling and voiding, electromyography (EMG) records the activity in the external sphincter during voiding, and xray gives anatomic information about what happens in the bladder. With this test, a very specific diagnosis can be made about whether there is a problem with the bladder, the outlet or both.
Treatment
Goals of Therapy
There are two main concerns in patients with neurogenic bladders: The first is to protect the kidneys as they have the potential to be harmed. The second is to improve the quality of life by decreasing symptoms.
Conservative Management
Oftentimes, simple things can be done to improve ability to store and empty.
- Timed voiding, in which patients void according
to the clock, rather than waiting for an urge is often helpful in
patients with sensation problems.
- Crede (manual) voiding, where one presses on the
lower abdomen to empty the bladder, is sometimes useful but it works
better for women than for men.
- Patients who cannot effectively empty there bladders are sometimes
placed on a regimen of clean intermittent catheterization
(CIC) in which they empty there own bladders through a
small tube four to six times a day. Chronic indwelling catheters
are generally not recommended for treatment of chronic retention,
but may be used as a last resort in select patients.
- Medications such as anticholinergics (Ditropan
XL®, Detrol LA® and Oxtrol®)
are sometimes used in conjunction with CIC programs to relax the bladder
and decrease episodes of incontinence.
Surgical Therapy
- Botulinum toxin-A (Botox®) Injection:
A new therapy for patients with neurogenic overactive bladder, Botox
injection into the bladder holds great promise. An office procedure,
Botox is injected into the bladder through a telescope. The effects
usually last from 6 to 9 months. Botox can also been injected into
the sphincter to treat a non-relaxing outlet.
- Intraurethral stents can be placed to help a non-relaxing
sphincter. The alternative is sphincterotomy where
the sphincter is cut through a telescope to keep it open.
- Neuromodulation (Interstim®),
where a pacemaker like device is implanted to stimulate the nerves
to the bladder, is also investigational for neurogenic bladder dysfunction.
- Augmentation Cystoplasty: This is an operation
to make the bladder larger using a piece of the patient’s own bowel.
Usually, patients will have to catheterize themselves afterward in
order to empty.
- Complete Urinary Diversion where a new bladder
is created with a piece of intestine. Patients may either be able
to void on their own, or catheterize themselves through an inconspicuous
stoma on the abdominal wall.
For more information or to make an appointment, please contact:
Nicole B. Fleischmann, M.D.
Thomas Grimaldi, M.D.
5 East 98th Street, Box 1272
New York, NY 10029
Tel: (212) 241-4812
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