Case Study: Managing Neurogenic Bladder
Mr. J. is a 25-year-old male graduate student. Two years ago, he suffered a complete SCI at T4 as a result of a motor vehicle accident. Although confined to a wheelchair, he has recovered sufficiently to return to graduate school to complete his degree and obtain a job as an educator.
He has good health overall, with strong upper body function, and lives independently. He has continuing UI, managed with anticholinergic medication and CIC, which his schedule, hand function, and mobility permit.
Mr. J has tried 3 anticholinergic drugs and formulations without success. He has a moderate degree of dry mouth and a worsening of baseline constipation. He also has occasional symptoms of autonomic dysreflexia and 2 to 3 UTIs per year, treated easily with no complications. He fears a higher dose will lead to worse adverse effects and asks about alternative options.
His clinician evaluates Mr. J. Urodynamics reveal detrusor overactivity and DESD with a detrusor pressure of 60 cm H2O at 165 mL. This and the fact that he continues to leak urine between catheterizations suggest that he has failed therapy with CIC and anticholinergics. Since Mr. J prefers to continue CIC, alternatives such as an indwelling catheter or reflex voiding to a condom catheter are not options. To continue with CIC and maintain low intravesical storage pressures urodynamically and continence clinically, his only choices are intradetrusor injection of botulinum toxin A (onaBoNTA) or surgery.
OnaBoNTA, FDA-approved for neurogenic detrusor overactivity for patients with NGB who failed or cannot tolerate therapy with anticholinergics, reduces incontinence episodes and can significantly improve urodynamic parameters. Mr. J decides to pursue this option instead of a more invasive procedure such as bladder augmentation.
Evaluating current treatment options: an overview
Treatment includes nonpharmacologic and pharmacologic interventions, bladder injection, surgery, and urinary diversion using catheters (Table 2).
The primary goals of treatment include preserving the upper urinary tract, maintaining adequate bladder capacity, promoting low-pressure micturition, and avoiding bladder overdistention.8 Another key objective is to prevent UTIs and minimize the use of indwelling catheters. The patient as a whole needs to be considered, and therapy should minimize risk while maximizing social, emotional, and vocational acceptability. The ability/ willingness of the patient to perform clean intermittent catheterization (CIC) also must be considered.
In patients with elevated bladder storage pressures or vesicoureteral reflux at higher risk for renal complications, the primary goal is to protect kidney function and prevent further complications. Conversely, in patients not at high risk for kidney damage, quality-of-life issues such as UI may be of greatest concern.
Clinicians need to consider the patient’s degree of disability, mobility, hand function, cognitive status, general condition, likelihood of progression of the neurologic disease, goals and concerns, and available resources.12
Behavioral/nonpharmacologic interventions include lifestyle interventions, the use of external appliances such as pads and/or portable urinals, and the use of CIC, or condom or indwelling catheters for patients with incomplete bladder emptying.13-15 These conservative approaches are often used in combination with medications.13
Lifestyle intervention includes timed voiding, fluid alterations, pelvic floor muscle exercises, biofeedback, toileting assistance, and bladder education/ retraining.16 These interventions, primarily applicable to patients with idiopathic overactive bladder (OAB), may not be helpful for all patients with NGB.
Urinary diversion via catheterization is a mainstay of anti-incontinence therapy.
Intermittent catheterization is the preferred method for patients with NGB who cannot adequately void volitionally. CIC decreases the risk of infection17 and lowers the risk for long-term complications such as hydronephrosis, bladder and renal calculi, and autonomic dysreflexia.18 However, for patients with poor hand function or who lack a caregiver, CIC is not an option. It also may be less than optimal in patients with bladder capacity <200 mL, abnormal urethral anatomy such as bladder neck obstruction and strictures, poor cognition, or who cannot adhere to a catheterization schedule.18 Using a hydrophilic-coated catheter reduces and delays the onset of symptomatic UTIs and can also decrease the risk of complications related to UTIs.19
CIC can be more challenging for obese patients and those with higher-level injuries, and for the female confined to a wheelchair because of difficulty accessing the urethra. Women with NGB may more often use a chronic indwelling catheter (or wear a diaper).20,21 However, for most patients with adequate upper-extremity function and hand function, CIC works well over the long term without complications.22
Indwelling catheters, often considered a last resort, may still be the best option for certain patients. Remaining on anticholinergics may be preferable for bladder health with an indwelling catheter. It may be used in patients with acute central nervous system trauma who require precise monitoring of urinary output, those with no available alternatives, and those unable, or lacking a caregiver, to perform CIC or reflex voiding.6,18
Long-term indwelling catheters cause UTIs and may lead to reduced compliance and a thickened bladder. Over time, patients may develop vesicoureteral reflux that leads to bladder stones, a higher risk for kidney stones, and renal damage. A suprapubic catheter is less traumatic to the urethra and more hygienic.18