How is Neurogenic bladder treated?

How is Neurogenic bladder treated?

Goals of managing a case of neurogenic bladder in the order of priority are:

1. Prevention of kidney failure
2. Prevention of recurrent and sever infections and sepsis
3. Preventing urinary leakage and keeping the patient dry
4. Spontaneous Voiding of urine from natural urinary passage

In effect, the expectation which the patient has of being able to pass urine on his own is the last priority for us because other life threatening issues take up priory. 

The most of the damage that a neurogenic bladder can do to kidneys happens not during attempt to pass urine but while trying to store the urine!!

Allow me to explain this by telling you about the two phases of bladder. Our Urinary bladder is in one of the two states I.e. Storage phase or Emptying phase. During the storage phase, its job is to keep the pressures low at all volumes of bladder filling from nearly zero ml soon after passing urine to 400-500 ml just before passing urine. During this phase it just keeps alerting our mind about the level of fullness so that we look for a loo at appropriate time. The outlet of the bladder remains closed throughout to prevent anything from coming out when we are happily storing urine. During the emptying phase, the bladder outlet relaxes and bladder contracts from all around very similar to emptying of a balloon and we pee!.

Our bladder is in the emptying phase only for few times during a day when we visit the bathroom, if we calculate, may be not more than 10 minutes in a day. Rest of 23 hours and 50 minutes of the day it is storing urine. Hence maintaining bladder pressures low during storage phase is of paramount importance to urologists to avoid the pressure going back to kidneys and causing damage. That is why more potential for damage exists during storage phase. Emptying, if not effectively happening naturally, can be managed in other ways also (read below)

How to improve the bladder storage in Neurogenic bladder?

A combination of tactics can help keep the bladder storage at low pressures. Fluid control so that bladder does not fill to high pressure levels to threaten kidneys is an effective starting point. This can be clubbed with frequent bladder emptying. If this alone is not enough then bladder muscle relaxants (anticholinergic medicines) can be added. Sometimes a combination of drugs are required to keep the bladder storage pressures safe. However more medication also comes with a price that is of more chances of retention of urine, dry mouth and constipation (which is already a significant problem in neurogenic bladder).

If medication is not enough to keep bladder at low pressures during storage or if there is frequent leakage of urine even on bladder relaxants, bladder is injected with botulinum toxin (BOTOX®). Botox Injections cause temporary paralysis of the bladder muscle by blocking the mechanism of muscle fibre contraction which helps in reducing the bladder pressure. However, the effect lasts for 4-6 months and then the injections need to be repeated. It has been seen though that that patients keep on responding to the repeated injections. If all these measures fail, then surgical reconstructions are possible to enhance the capacity of the bladder using intestine (bladder Augumentation) or diverting the urine away from the bladder to keep the kidneys safe (urinary diversion). Both these methods have their own set of advantages and challenges and a decision can be achieved only after repeated discussions with the patient.

Sacral Neuromodulation (A pacemaker in the nerve roots) is still experimental in cases of neurogenic bladder.

How to make the patients empty their bladders when peeing is not safe or possible?

When peeing is not safe means when passing urine on own causes risk of severe infections or kidney damage. In fact, when neurogenic bladder patients rejoice on on their ability to pass urine and give credit to either physiotherapy or traditional medicines, I get more worried about them. More often than people think (including doctors), such voiding is not natural and one can know that when we look for residual urine on ultrasound after the patient has passed urine or looking at the abdominal straining (Valsalva Voiding) or direct pressure on the lower abdomen one has to apply in order to pass urine (Crede’ manoeuvre). Such unnatural passing of urine can be risky for patients kidneys and is not recommended. In all patients with neurogenic conditions, any ability to spontaneously passing urine should be checked multiple times for its efficacy in emptying the bladder (no residues) before they can be left alone to practice that in long term. Also Crede voiding or Valsalva voiding, irrespective of their efficacy in emptying may be risky in long term for kidneys, infections and risk of hernia and bleeding piles (haemorrhoids).

Similarly external catheters (condom catheters) are safe only when self voiding and storage are safe for the patient. Otherwise all above mentioned risks apply apart from the skin complications and poor maintenance of hygiene which comes with these external catheters.

The most efficacious way to empty the bladder has been intermittent self catheterisation. Yes, you read it right!!- A patient himself or herself passing a catheter up their own bladder to empty the urine thereby taking care of emptying part of the bladder cycle. Clean Intermittent Self catheterisation – CISC. That then leaves us with problem to manage only the storage phase which can be done with medication or botox injections as described above. You can check more about CISC in a separate blog that I have written.

Lastly, there is continuous catheters which remain in the bladder throughout (indwelling catheters). They can be through the natural route (per urethral Indwelling catheter) or can be passed through a surgically created opening right above the bladder in the lower abdomen (Suprapubic tube). Although it keeps the bladder always empty and are supposed to be safe to keep the kidneys away from risk and may be the last resort for some patients who cannot catheterise themselves but as a first choice they are harmful because of risk of more severe catheter related infections, stone formation, and tearing of the urethra (urethral erosion).

These measures, often in combination (and often not to perfection!!), usually suffice to take care of the first three goals of neurogenic management.

The last goal of allowing safe natural peeing is the most difficult to achieve because that essentially means that the nervous connections between the bladder and the brain are re-established. And that does not happen, beyond a certain time period, in neurogenic conditions. The research is ongoing to artificially stimulate the remaining nervous connections  to bring back normality (Sacral Neuromodulation) but we are still away from success. The second ongoing effort is to regenerate the damaged connections by stem cell therapy. But that is also in its very initial phases and is far from seeing the light of the day as far as clinical application is concerned. There is still a silver lining to this incurable condition. Most cases can be managed well and kidney damage can be prevented. Not only that, inspite of the physical limitations because of the neurologic condition and the need for self catheterisation, most of the patients live their life uninhibitedly and are able to come out of dependency and contribute to their surroundings. All they seem to need is a will and discipline about their daily routines. Stories of the neurogenic bladder patients from my clinic have taught me so many things about life.