Noninvasive treatments

Noninvasive treatment options for NGB dysfunction include intermittent catheterization, Crede and Valsalva, indwelling catheterization, lifestyle changes/behavioral modification, and oral pharmacotherapy.

Lifestyle changes/behavioral modification. These approaches may be helpful for patients with lower urinary tract rehabilitation.11 These include moderate fluid intake, reducing or eliminating caffeine, dietary changes, pelvic 
floor muscle exercises, biofeedback, timed voiding, toileting assistance, and bladder education/retraining.12

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Clean intermittent catheterization (CIC). CIC is one of the most 
commonly used methods for patients with NGB that fails to empty. Adequate hand function or a caregiver willing to perform CIC is necessary for this 
method to be successful. Abnormal 
urethral anatomy, strictures, bladder capacity <200 mL, adverse reaction 
to catheters, or autonomic dys­­-
reflexia with high bladder volumes 
may interfere with the ability to conduct CIC. Urinary tract infections, one potential side effect of CIC, may be avoided by using hydrophilic-coated catheters; for example, in patients with SCI.13 Strictures, hematuria, and bladder stones are other side effects that can occur.14

Crede and Valsalva. Third-party bladder expression (Crede) and voiding by abdominal straining (Valsalva) may 
be appropriate for patients with low outlet resistance. Risks include high intravesical pressures, which can lead to worsening vesicoureteral reflux or hydronephrosis; incomplete bladder emptying, leading to chronic urinary tract infections; pelvic organ prolapse; hernia; and hemorrhoids. 

Indwelling and suprapubic catheterization. Considered temporary methods, these may be preferred when other approaches have failed. Complications can include bladder stones, infections, and malignancies.

Oral pharmacotherapy. Anticho­linergics/antimuscarinics, the most commonly used class of agents for NGB, bind to muscarinic receptors in the detrusor muscle, reducing bladder storage pressure and increasing capacity (Table 2).15-17 They are generally used in conjunction with CIC to treat NGB dysfunction.

Perceived lack of efficacy, costs of medication, polypharmacy, dosing frequency, poor counseling, and adverse effects—including dry mouth (a well-known effect), facial flushing, dizziness, constipation, and neurologic deficits—can all lead to patients discontinuing treatment with anticholinergics.4

Studies have shown that among 6 therapeutic classes—angiotensin receptor blockers, bisphosphonates, oral antidiabetics, overactive bladder agents, prostaglandin analogs, and statins—medication for overactive bladder had the lowest adherence rate.18 One study found that at 1 year after initiating therapy for overactive bladder, <30% of patients are still taking antimuscarinics;19 another showed that of patients initiated on either oxybutynin and tolterodine, <14% continued for 1 year, with a median of 31 days until discontinuation.20

Individual responses to anticholinergics vary; therefore, patients may find another medication or a combination of agents can increase efficacy or reduce adverse effects.21 Other oral agents that have been used in patients with NGB include phosphodiesterase type 5 inhibitors, gonadotropin-releasing hormone antagonists, neurokinin receptor-1 antagonists, beta-3 adrenoceptor agonists,22 and desmopressin.23