1. LONG-TERM UROLOGIC MANAGEMENT FOLLOWING SPINAL CORD INJURY William McKinley MD Director SCI Rehab Services Dept PM&R MCV/VCU

2. Objectives • Areflexic vs Reflexic Bladder • Importance: “DSD” and Urodynamics • Current Rxs • “Potential” new Rxs • Urologic Rx in females • UTI’s • Long Term follow-up

3. Mortality Associated with Renal Dysfunction Following SCI • World War I - 80% • World War II - 40% • Korean War - 25% • Vietnam War - Minimal • Today - Negligible

4. Renal Failure is No Longer the #1 Cause of Death (Reasons): • Antibiotics • Catheterization (Guttman) • Understanding complications of the “high pressure bladder” • Education to patient/family • Follow-up Testing

5. Complications of Neurogenic Bladder • Morbidity • UTI, Pyelonephitis, Stones, Renal dz. • Spasticity, Aut. Dys., Pressure Ulcers • Mortality • Sepsis, Renal dz • Social • Incontinence • Sexuality

6. Potential Treatments • Catheters • Fluid Control • Medications • Surgery • “Manual” techniques • Depends (diapers) • “New” alternatives • “Do Nothing”

7. “Acute” Urological Care Following SCI • “temporary” use of indwelling Catheter & fluids (Lloyd) • Intermittent Cath (IC) + Fluid Control • Sterile vs. “Clean” IC

8. Sterile vs. “Clean” IC • Sterile technique • sterile gloves • new catheters • costlier $$ • “Clean” technique (Lapides) • wash hands • reuse catheters (povidine-iodine/boiling) and storage • easier compliance, safe and effective (Maynard)

9. Complications with “long-term” Indwelling Catheter • recurrent/chronic UTI’s • prostatitis/epididymitis • urethral fistulas • bladder stones • bladder cancer (10% with >10 yrs)

10. Suprapubic vs. Urethral Catheter • invasive • similar risks: UTI’s, stones, cancer • reserved for those with urethral injury

11. “Ideal” Outcome of long-term Rx: “Balanced Bladder” • Minimize UTI’s • Low Pressure voiding • Low post-void residuals • Continence

12. Bladder Anatomy • Pontine micturation center • Bladder (detrusser muscle) - Parasympathetic (S2-4) cholinergic innervation (+stretch sens.) • Sympathetic (T9-12) inhibits bladder (+Pain) • Internal sphincter - Sympathetic (T9-12) alpha adrenergic innervation • External sphincter - Somatic (S2-4) innervation (Pudendal n.)

13. SCI Bladder Classifications • Uninhibited bladder (Brain) • Reflexic (UMN) bladder • Areflexic (LMN) bladder

14. Reflexic (R) vs. Areflexic (A) bladder: Clinical Distinctions • Level of injury (above T10 = R, below L1 = A) • Spasticity (R) • Bulbocavernosis (S2-4) reflex (R) • bladder “kick-off” (R) • Urodynamics (UD) at @ 3 months

15. Urodynamics • Cystometrogram + sphincter EMG • “key” findings about bladder • sensation, filling/emptying • involuntary contractions (reflexic) & duration • bladder pressure • “Dysynergia”!!!

16. Urodynamics

17. Areflexic Bladder • No emptying ability w/o • catheterizaiton • external compression (“crede”) • overflow! • Long-term hypocompliance is seen (10%) • high pressure bladder • long-term renal deterioration • Rx-IC (fluids) vs. crede

18. Reflexic Bladder • Non-voluntary contractions with filling • can assist with emptying bladder • post void residuals (UTI’s) • Detrusser-sphincter dysynergia (DSD) • long-term renal dysfunction

19. Detrusser Sphincter Dysynergia (DSD) • Normal (synergistic) Micturation is initiated by: • increase in detrusser pressure • relaxation of urethral sphincter • voiding pressure<40 cm • In reflex bladder, we see: • simultaneous contraction of sphincter & detrusser • no synergy (Dysynergia = DSD)

20. DSD • Incidence = up to 50% (Blaivas, Yallo) • Increased bladder reflex voiding Pressures to lead to renal complications • UD parameters not well established • High pressures • (McGuire, Bennet)>50 • (Wyndale)>70 • Duration of contraction

21. Potential Complications of DSD • Bladder reflux (urine, pressure, bacteria) • Hydronephrosis • Pyelonephritis, urosepsis • Renal stones • Renal dysfunction

22. Bladder Reflux

23. Management of DSD • Establish low pressure storage and emptying • Ideal Rx should be: • Least invasive • Non-permanent • Lifestyle dependent • Of low risk

24. “Current” DSD Management • Recommended Rx: • Anticholinergics+ IC, (? Alpha blockers) • suprapubic tapping • Sphincterotomy (males) + Ext. cath. • Bladder Augmentation • Not recommended: • Indwelling cath. • Crede • Cholinergics (bethanachol)

25. Pharmacological Rx • Anticholinergics (Ditropan, Imiprimine) relax spastic bladder • SE’s - dry mouth, dizziness • Tolterodine (Detrol - ? Less SE’s • Cholinergics (Bethanechol) don’t work well - not rec’d • Alpha-blockers (Phenoxybenzamine, Hytrin,) partially block “internal” sphincter - some clinical effectiveness, hypotension

26. Pharmacological Rx (cont.) • Alpha stimulants (Ephedrine) may increase sphincter pressure - limited usefulness • no drug selectively relaxes the striated muscle of the pelvic floor & “external” sphincter (Baclofen, Valium, Dantrium)

27. Other Pharmacological Rx’s • Intravesicular oxybutinin (ditropan) • well tolerated, costly • Capsacin (intravesicular) • blocks afferents C-fibers • inc’s bladder capacity • not well tolerated (burning, AD, hematuria) • DDAVP (anti-diuretic hormone) • intranasal

28. “Invasive” bladder Rx’s • Intrathecal Baclofen (Nanninga) • dec. pressure, inc. residual & continence • Pudendal nerve block (7% phenol) • decreased bladder pressure @20cm (Ko)

29. Botulism A Toxin (botox) • local perineal M. injection • inhibits Ach. at NMJ • relaxes external sphincter • effective (Petit: “decreased bl. Pr.20cm & residual by 175ml) • repeat at 3 months • Indications: • consideration for sphincterotomy • difficulty with IC

30. External Sphincterotomy • indicated with refractory DSD • not recommended before 9-12 months • Potential complications: • reoperation (15-25%) • XS bleeding (5%) • erectile dysfunction (3-60%) - 12-o’clock location rec’d • Laser Sphicterotomy

31. Augmentation Enterocystoplasty • “entero”=GI tract, “cysto” = bladder • Goal: convert a “small” non-compliant bladder to a “low pressure” urine reservoir • Indications: • failure of med. Rx • upper tract deter./reflux • (Bennett) decr’d - Bl Pr. 55cm • Inc’d-Bl capacity (350ml) • inc’d QOL

32. Abdominal Urinary Stoma • Ureterostomy • Ileal conduit diversion

33. Sphincter Balloon Dilation • Balloon dilation of the prostatic urethra • some long-term success • decreased voiding pressure • decreased residual

34. “Urethral Stents” • endoluminal “wire mesh” prosthesis to maintain patency of the membranous urethra (Chancellor) • Goal: decrease voiding pressure & residual urine, resolve hydronephrosis • Long-term results disappointing (Low) • failure, residual urine, stones, reflux • high removal rate

35. Urethral Stents

36. Bladder Functional Electrical Stimulation (FES) • FES: • bladder storage • bladder emptying

37. Bladder FES • FES to increase bladder storage • reflex inhibition (pudendal, penile n’s, anal plugs) • FES to Restore Bladder Emptying • sacral root stim. (Brindley ‘70) • accompanied by post. Root rhizotomy • good success rate • compl’s: loss of erectile fnt • detrusser myoplasty • gracilis muscle E. stim

38. “VOCARE” Bladder FES System (Neurocontrol)

39. “VOCARE” Bladder System (Neurocontrol) • Benefits • Elimination of urethral catheters • Decreased incidence of wetness • Improved bladder emptying • Decreased incidence of UTI’s • Indications • “complete” SCI • “reflexic” bladder

40. VOCARE (cont.) • Surgery • posterior rhizotomy (prevents reflex cont’s) • FES to bladder nerves • receiver-stimulator implanted in abdominal wall • external controller - transmits signal • (Brindley): the 1st 500 patients • 84% still utilize (mean 4 yrs) • inadequate (6%), painful (1%)

41. Urologic Rx in Females • Recs: Antichol. + IC • non-suitable external incontinence device • inability (Tetra’s) to perform IC • Abhorrence of “padding” • Indwelling cath remains an option • added compl. of leakage around cath. • Functional Electrical Stim. • Priority: better Rx options in females/SCI (NIDRR)

42. Urinary Tract Infections (UTI) • 1 million UTI’s in USA • 1/2 of all hospital-acquired infections = UTI • strong asso. with catheters • most frequent acute & chronic medical complication following SCI

43. Urinary Tract Infections • def = bacteriuria (>100K) + tissue response (>8WBC/hpf) • >90% incidence w/indwelling cath • 66% with long-term IC will have recurrent/chronic UTI’s • 80% with reflex void & ext. cath. - UTI’s • sphict. + CC Reveals dec. bacteriuria (Cardenas)

44. Risks for Recurrent UTI’s • Lapides ‘74 • bladder mucosa changes and decreased host resistance • increased pressure • overdistension • foreign bodies (catheters) • IC at discharge but condom cath at f/u

45. Rx of UTI’s • maximize fluids, keep abdomen, perineum, urethra, catheters CLEAN! • Treat all UTI’s but utilize antibiotics only for “symptomatic” UTI’s • bacterial resistance with overuse of antibiotics • symptomatic UTI = fever, pain, malaise, hematuria, incont., spasticity, cloudy urine • Dx: bacteriuria + pyuria >8-10 WBC/hpf

46. Rx of UTI’s (cont.) • ? Effectiveness • prophilactic abx. (Bactrim, Nitrofurantoin) • acidifying urine with mandelamine, vit. C, etc. • R/o bladder/renal Stones • nidus for infection • R/o hypercalciuria, hyperuricosuria • Prompt removal • Lithotripsy • percutaneous nephrolithotomy

47. Long-term Renal Monitoring • Goal - functional (F) and anatomical (A) assessment w/o invasiveness (I) • intravenous pyelogram - (A), (I) • renal ultrasound - (A) • Urodynamics - (A) & (F), (I) • Renal scan - (F) • Creatinine Clearance • BUN/Creatinine, U/A, cytology

48. Conclusions • IC & Fluids • Evaluate for Reflexic vs Areflexic bladder • consider antichol. Med, alpha stim’s • later: sphincterotomy, augmentation • recurrent UTI warrants investigation • long-term renal/bladder monitoring

49. Promising studies • Intravesicular drugs • nerve blocks • stents • bladder FES

50. “Urologic care of patients with SCI is one of the more important factors to define their prognosis and quality of life”