Neurogenic Bladder Treatment

During my November Webinar, issues in neurogenic bladder were discussed. However, there are treatments that can avoid most of these issues. Starting and maintaining a neurogenic bladder program is essential for maintaining bladder health. If the bladder is not functioning, you can develop serious issues with kidney function. Bladder issues can affect your physical and mental well-being, especially if you have damage to your kidneys, urinary incontinence, or develop skin breakdown. A bladder program aims to prevent incontinence, control your bladder function, avoid skin breakdown, and maintain kidney health.

The first action is to establish a bladder management program. This is based on your diagnosis as well as testing through urodynamics. Urodynamics assesses bladder function using a specialized catheter with sensors to establish bladder pressures. The amount of sensation and responses to bladder filling is measured. You may need yearly urodynamic testing to assess the bladder for changes or may have the test performed less frequently based on your clinical picture as decided by your healthcare professional.

A bowel program should also be strictly followed for the best in urological care. Pressure from a full or impacted bowel can be placed on the bladder and urethra, affecting function. Making sure your bowel is properly managed will ensure better neurogenic bladder function.

The goals of a bladder management program are to maintain kidney health, ensure continence, and avoid social embarrassment. Options exist for bladder control.

Clean, intermittent catheterization is a common treatment for neurogenic bladder. The individual should have some hand or arms control to be able to accomplish this activity independently or have the support of someone who can do it for them. This process is done using a clean technique requiring careful hand washing immediately before catheter entry and after the procedure is completed. Most individuals will catheterize on a schedule of every four to six hours and monitor their fluid intake.

There are a variety of catheters that can be used in this procedure. Most will use a basic catheter and apply lubricant themselves. There are other types of catheters that might be used depending on specialized needs. These include pre-lubricated, hydrophilic (lubricant activated with sterile water), antibacterial, coudé tip for males with enlarged prostate glands, and short catheters for women. Generally, for specialized catheters, a demonstration of medical need is required. Catheters provided today are mostly single-use. However, some members of the community use a catheter multiple times, cleaning them by boiling and air drying between uses.

If autonomic dysreflexia (AD) is a concern or potential issue, a sphincterotomy may be done in men. This is a small incision of the internal sphincter to keep urine continuously flowing out of the bladder. An external catheter is used to collect urine in a drainage system. In more intense cases of AD in men and women, a suprapubic catheter is placed through a surgical opening just over the bladder for continuous drainage.

For individuals with poor hand control or when intermittent catheterization is anatomically challenging, a Mitrofanoff procedure can be electively performed. A connection is made from the top of the bladder through the navel using the appendix or a small piece of the bowel. A catheter is then inserted intermittently through the navel to the bladder for the removal of urine. This procedure is often used with children, women, or men with a retracted penis.

If an individual has an areflexive or flaccid bladder with low sphincter pressure due to lower-level injury and has some abdominal muscle and diaphragm use, they may be able to empty their bladder using alternative techniques. Valsalva or bearing down using the abdominal muscles can assist with bladder emptying. Credé or rolling the fingers over the bladder from the top of the bladder down can assist with pushing urine out of the bladder. WARNING: These techniques have been dangerous in many individuals as they increase pressure in the bladder, especially if performed improperly. Do not attempt these maneuvers unless specifically directed and with education by your healthcare professional.

If there is a preserved sacral arc reflex, stretching the rectal opening may cause the automatic voiding of urine. This may occur in individuals with incomplete injuries. If you notice that you automatically expel urine when performing your bowel program, discuss this technique with your healthcare professional as a possibility for urine elimination. Testing to assess for complete bladder emptying using bedside ultrasound or urodynamic testing will assess to ensure complete emptying occurs.

Medications can be used if there are issues with bladder function. For reflexive bladders that have tone (spasticity), anticholinergic medications are most often used. There are a variety of these medication options. If you find one does not agree with you, ask for an alternative that may be more conducive to your needs. Alpha-blockers are used to treat detrusor sphincter dyssynergia (DSD). There are also a number of these medications available. Botulinum toxin (BOTOX) injections can be used to calm a reflexive bladder. These injections need to be repeated on a regular schedule but have fewer whole-body side effects as they act locally in the bladder.

Some surgical options to improve bladder programs include the previously mentioned sphincterotomy, suprapubic catheter placement, and the Mitrofanoff procedure. Bladder augmentation can be performed to increase the size and capacity of the bladder. Other surgical interventions include stents to open the urethra or ureters, urinary diversions, and ostomies. These should be considered only if procedures that mimic natural bladder functioning are challenging.

Nerve transfers in the cauda equina are being performed to increase and enhance bladder, bowel, and sexual function in men and bladder and bowel function in women. As the nerves in the cauda equina are peripheral nerves, these nerves can be rerouted, transferred, and grafted to enhance bladder function.

For some individuals with cerebral palsy, a dorsal rhizotomy can be performed to reduce the number of nerve fibers (not the entire nerve) that increase tone (spasticity) to increase movement as well as bladder and bowel function.

Functional electrical stimulation procedures are increasing options for individuals. Implanted and external electrodes are increasing bladder and bowel function.

Tips for bladder care:

• Bladder emptying can best be done when an individual is upright or nearly upright. The effects of gravity help empty urine from the bladder.
• Catheterization is more efficient and complete when the catheter is withdrawn slowly to remove urine from the lower part of the bladder.
• Wash your hands before the catheterization set up, not touching anything else, like wheels or clothes, prior to touching or inserting a catheter.
• Clean the area around the urethra prior to inserting a catheter to reduce your risk of infection.
• Lubricate a catheter thoroughly prior to insertion.
• Drink water according to your bladder management plan.
• Avoid drinks high in sugar, caffeine, and sugar substitute as they increase the amount of urine rapidly produced.
• Move your legs to stimulate muscle movement in the abdomen which helps stimulate function in the bladder, bowel, and muscles of your legs and reduce edema.
• Practice excellent hygiene to avoid urinary tract infections.
• Maintain your bowel program.

Careful attention to your bladder management will keep your health well. Nurse Linda

Pediatric Consideration:

Catheterization may be foreign to you as a parent, but it is your child’s normal. Therefore, treat the situation as a matter of fact as it makes it more comfortable and acceptable to your child of any age. If you are starting your child with a bladder management program, describe what you are doing and why. Then, involve your child as they develop.

A good time to have your child transition to self-catheterization is during potty training. Many children might not be developmentally ready for this responsibility at such an early age, but they should be by the time for school is a time to be ready. Older children just starting with a self-catheterization program will need some time to adjust, but if they were toileting independently previously, they should be taught about the procedure as their new normal.

It can be difficult as a parent to turn control over to your older child. But you were not toileting them before, so why would you do this now? Privacy is essential to the older child. They may make some errors and may need your help occasionally, but this is their responsibility. If bladder management is a natural part of their life, it is not as challenging as they age. Nurse Linda