Outline of presentation

Neuropathic bladder and

A primer on the bladder
bowel dysfunction ●

● Normal bladder function

● Bladder dysfunction

Rama Jayanthi, M.D.

Section of Urology
Columbus Children’s Hospital

Importance of bladder
Basic anatomy
dysfunction

● Number one cause of death in spinal

cord injury patients in first half of
20th century
• Renal failure secondary to complications
of bladder dysfunction
● Renal failure is distinctly rare at
present time due to efficacy of
modern medical therapy

Normal bladder function Normal storage function

• Storage ● Bladder capacity is less important

• Emptying
• Which function is more important?
• Emptying: If one voids 4 - 5 times per day and
each void takes 5 minutes, emptying function
fills less than 30 minutes per day
• Storage: 23.5/24 = 97.9%
than bladder pressure
● Pressure in bladder is low during
storage and should only increase
during voluntary voiding
● High storage pressures may lead to
renal damage

1
 Do you need a brain to
How does one void?
urinate?

● First step: Sphincter relaxation ● Stroke victims

● Second step: Coordinated bladder may void
contraction normally but
● No need for abdominal muscles not at the
right time or
location

Overview of neuronal Main types of bladder

pathways dysfunction

● “spastic bladder”
• examples: spinal cord injury
● “atonic bladder”
• Pelvic injury, surgical complications
● Mixed lesions
• spina bifida, congenital neurological
lesions

Abnormal bladder function Simple minded approach

● Many classifications/descriptions • Failure to empty

exist • due to bladder
• For example • due to outlet
• “Upper/lower motor neuron lesions”
• “Sensory/Uninhibited/Reflex neurogenic • Failure to store
bladder • due to bladder
• Such formal classifications are
• due to outlet
impractical
• Both

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 How to diagnose bladder
What are urodynamics?
dysfunction

● History ● A test of bladder

● Symptoms storage function
● Degree of incontinence ● Bladder slowly filled
● Urinary tract infections via catheter and
pressure response
● Urodynamics measured

Management of bladder
Urodynamics
dysfunction

● Based on underlying pathophysiology

● No “right” answer
Variables measured: ● Must individualize based on age of
patient, home situation, motivation
Bladder pressure for dryness, etc.
Abdominal pressure
Sphincter activity

Causes of failure to empty Failure to empty

● Poor detrusor contraction ● Easiest form of bladder dysfunction

to treat
● Non-coordinated bladder
● Intermittent catheterization has
contraction revolutionized management of
● Non-relaxation of urinary neuropathic bladders
sphincter ● Previously patients would have
indwelling catheters or urinary
diversion

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Chronic indwelling catheters
● Great short term solution
● Lousy long term solution
• chronic infections
• stones
• urethral erosion
• cancer
Failure to store
●A more common problem
• clinical manifestation is
“incontinence”
● A potentially much more complex
problem than failure to empty
How can we differentiate
between these three?
● History
● Urodynamics
Failure to empty
● Ineffective or poor methods
• pharmacological stimulation
• noncoordinated contraction
• Crede maneuver
• no preceding sphincter relaxation
● Problem associated with these
methods
• potentially large post-void residuals
Causes of failure to store
● Bladder hyperactivity
● Poor sphincter mechanism
● Poorly compliant bladder
Bladder instability
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 Treatment of bladder Patient MB: High pressure
instability bladder

● Anticholinergics

• Ditropan XL (oxybutinin)
• Detrol (tolteridine)
• Levsinex (hyoscyamine)

Treatment of high pressure Patient MB: Study on

bladder anticholinergics

● Anticholinergics
● Surgery
• Bladder augmentation
• Addition of healthy tissue (the
intestine) into unhealthy tissue (the
abnormal bladder)

Patient MB:Study on higher 28 year old with

dose of anticholinergics incontinence

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 Treatment of sphincter
Sphincter deficiency
dysfunction

● Medical therapy
• adrenergics: Pseudofed
● Surgical therapy
• “less than ideal”
• Bladder neck reconstruction
• Artificial sphincter
• “Sling”

Importance of pressure- Timing of surgical

volume relationship intervention

● No correct answer
● Main issue to consider:
• Child’s and not parents motivation and
interest in continence
• Ideal time for surgical intervention is
when child is interested and is willing to
participate in his/her medical care
250 cc - safe volume, 450 cc - unsafe volume

Bladder stimulation Bowel dysfunction

● Stated advantages ● Bladder ↔ Bowel

• Increase bladder capacity • Dysfunction in one commonly associated
• May teach child to sense need to void with dysfunction in the other
• May obviate the need to perform bladder
augmentation
● Bowel dysfunction harder to
analyze/treat
● Disadvantages
• Labor intensive ● Much greater number of variables
• Little appreciable impact on daily life

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 Differences between bowel
Bowel management
and bladder

Bowel Bladder ● Rectal stimulation

● Intermittent enemas/suppositories
● Volume hard to ● Volume easy to
measure measure ● “Miralax” - The MIRacle LAXative
● Consistency may ● Urine always ● MACE procedure
vary depending on “watery” • “antegrade enema procedure”
diet ● Can easily empty
● Difficult to “easily” bladder (with
empty catheter)

Go Columbus!!!!!!!