Download Management of the Neurogenic Bladder in Late Childhood to

Management of the Neurogenic Bladder in
Late Childhood to Adulthood
Rosalia Misseri, MD
James Whitcomb Riley Hospital for Children
Indiana University School of Medicine Indianapolis, Indiana
Hadley Wood, MD
Glickman Urological and Kidney Institute
Cleveland Clinic Cleveland, Ohio
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 life…from 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
patient’s 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
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
Bladder function
Stores urine
Bladder Outlet
OUTLET
Stores urine
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
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
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!