Spinal Cord Injury: Managing the Neurogenic Bladder

Kristy M. Borawski, M.D. Assistant Professor, Division of Urology

Disclosures/Conflict of Interest

Pfizer: speaker

Off Label Use

Medication
Indication Dosage

Overview

Spinal cord injury epidemiology Voiding physiology Neurogenic bladder physiology Management options Surveillance for SCI induced neurogenic bladder

Spinal Cord Injury (SCI)

Annual incidence 40 per million population

10,000 new injuries yearly in US 200,000 living with SCI in US

4:1 male to female ratio Average age 30.7

Bracken, et al. Am J Epi 133: 615, 1981. Jamison, et al. Cochrane Database Sys Rev 1: 2009. Linsenmeyer, et al. J Spinal Cord Med 29: 527, 2006

Spinal Cord Injury (SCI)

Vast majority of patients with SCI have associated neurogenic voiding dysfunction ~11% have associated head injury

Linsenmeyer, et al. J Spinal Cord Med 29: 527, 2006

Life Expectancy in SCI patients

Life expectancy compared to normal population

70% of normal for complete tetraplegia 86% of normal for compete paraplegia 92% incomplete lesion with motor function capabilities

Yeo, et al. Spinal Cord, 36: 329, 1998

Causes of Death in SCI patients

Renal disease historically a major cause of death in paraplegics

1940s- 1950s: Genitourinary disorders accounted for 43% of deaths

1980-1990: 10% of deaths due to GU disorders

Clemens, et al. J Urol, 184: 213, 2010. Yeo, et al. Spinal Cord, 38: 604, 2008.

Are we really doing better?

JD Yeo, et al: Leading cause of death among SCI patients is pneumonia

Influenza Septicemia** Cancer Heart disease Diseases of urinary system Suicide CVA

Yeo, et al. Spinal Cord, 38: 604, 2000.

Are we really doing better?

Causes of septicemia
Causes Urinary tract Pressure areas Respiratory tract Number 11 7 5

Strangulated bowel
Gangrene of the leg Meningitis Digestive tract

3
2 2 1

Gas gangrene
Obstruction of ileal conduit Cellulitis Ischemic heart disease

1
1 1 1

Brain stem CVA

Chronic lymphatic leukemia Total

1
1 37
Yeo, et al. Spinal Cord, 38: 604, 2000.

Neural Control of the Lower Urinary Tract

Function of the lower urinary tract

Fill to normal capacity at low pressures Store urine until socially acceptable time to void Empty to completion at acceptable pressures

Wein, et al. Campbell-Wash Urology, Vol 3, 2007

Neural Control

Three sets of peripheral nerves innervate the lower urinary tract

Parasympathetic Sympathetic Somatic

Wein, et al. Campbell-Wash Urology, Vol 3, 2007

Neural Control: Parasympathetic

Originate from sacral cord at S2-S4

Preganglionic efferent fibers travel via pelvic nerves to provide excitatory input to the bladder

Post ganglionic nerves excite bladder smooth muscle via:

Cholinergic (muscarinic receptors)

M2/M3 exist in bladder M3 mediate bladder contractions

Non-adrenergic, non cholinergic (ATP) acting on P2X1 purinoreceptors

Wein, et al. Campbell-Walsh Urology, Vol 3, 2007

Neural Control: Sympathetic

Begins in intermediolateral gray column from T11 L2 Route to bladder

Sympathetic chain ganglia inferior mesenteric ganglia hypogastric nerves to pelvic ganglia

Activation results in:

Bladder relaxation: via fibers Contraction of bladder outlet & urethra: via fibers

Wein, et al. Campbell-Walsh Urology, Vol 3, 2007

Neural Control: Somatic

S2-4 motor innervation (Onufs nucleus) Travels to external sphincter via Pudendal nerve

Wein, et al. Campbell-Walsh Urology, Vol 3, 2007

Micturition Centers

Cerebral Cortex

Inhibitory signal to the sacral micturition center Coordinating relaxation of urinary sphincter when bladder contracts Efferent parasym. signals cause bladder contraction Afferent impulses provide information on bladder fullness
Wein, et al. Campbell-Walsh Urology, Vol 3, 2007

Pontine micturition center

Sacral micturition center

Afferent Bladder Signals

Pelvic nerve afferents

Monitor volume of bladder & amplitude of bladder contraction Myelinated A and Unmyelinated C axons

C fibers are not essential for normal voiding

Wake up and respond to bladder distention & stimulate uninhibited bladder contractions in animal models with suprasacral spinal cord injury

Wein, et al. Campbell-Walsh Urology, Vol 3, 2007

General Patterns of Neurogenic Bladder after Neurologic Injury

Lesions above Brainstem

Removes cerebral cortex micturition center

Detrusor overactivity Coordinated sphincter control Sensation may be normal or altered Overall: urinary urgency +/- urge incontinence

Detrusor areflexia may occur initially or as permanent dysfunction

Suprasacral Spinal Cord Injury

Removes cerebral cortex & pontine micturition centers

Spinal shock at first Detrusor overactivity No (reduced) sensation Detrusor external (striated) sphincter dyssynergia

Present in >90% of patients with suprasacral SCI If lesion above T6, results in dyssynergic smooth sphincter

Detrusor internal (smooth) sphincter synergia

Overall: incontinence due to detrusor overactivity with obstruction due to DSD

Sacral Spinal Cord Injury

Removes all micturition centers

Spinal shock at first Detrusor areflexia Decreased compliance may occur Open internal (smooth) sphincter Residual resting striated sphincter tone not under voluntary control Result: retention +/- incontinence

Kaplan, et al: Urodynamic findings of 489 SCI patients

Cervical lesion
15% detrusor acontractility 85% NDO & DSD

Thoracic

NDO with 90% showing DSD

Lumbosacral
40% detrusor acontractility 30% NDO 30% NDO and DSD

Kaplan, et al. J Urol, 1991.

Kaplan, et al: Urodynamic findings of 489 SCI patients

Sacral level lesion

Small portion with normal urodynamics 64% with detrusor acontractility

Kaplan, et al. J Urol, 1991.

Changes in Afferent Activity After Spinal Cord Injury

Changes in Afferent Activity After Spinal Cord Injury

Spinal Shock
Absent somatic reflex activity and flaccid muscle paralysis Suppression of autonomic activity & somatic activity

Bladder is acontractile & areflexic Bladder neck is usually closed (unless prior surgery)

Urinary retention is the rule Lasts 6-12 weeks Return of reflex bladder activity occurs along with recovery of lower extremity deep tendon reflexes

After resolution of spinal shock, there is slow development of autonomic micturition with neurogenic detrusor overactivity
Mediated by spinal reflex pathways Voiding usually is inefficient due to presence of non coordinated sphincters

Bladder contracts and external sphincter contracts rather than relaxes detrusor sphincter dyssynergia

Yashimura, et al. Neurol Urod, 29: 63, 2010

Afferent Changes

Recovery of bladder function after SCI is dependent on:

Plasticity of bladder afferent pathways Unmasking of reflexes triggered by unmyelinated, capsaicin-sensitive C-fiber bladder afferent neurons

C-fiber afferents are activated

Administering C-fiber neurotoxin capsaicin to SCI cats blocks reflex bladder contractions

No effect in spinal cord intact cats

Yashimura, et al. Neurol Urod, 29: 63, 2010

Afferent Bladder Signals: Changes After SCI

Reactivation of neonatal perineal-to-bladder and bladder-to-bladder excitatory reflexes Activation of C mediated afferents Alteration in epithelial layer

In rat model, removing mucosa eliminated NDO

Morphological & chemical change of afferents Remodeling of synapses in spinal cord Alteration in neurotransmitter mechanisms in spinal cord
De Groat, et al. Exp Neurol, 2011.

Evaluating the Neurogenic Bladder after SCI

Guidelines

Third International Consultation on Incontinence

Committee on neurogenic bladder management No SCI specific protocols

European Association of Urology

Overall management recommendations for neurogenic bladder No SCI specific protocols

Wyndaele, et al. The 3rd International Consultation of Incontinence, 2004. Stohrer, et al. European Association of Urology Guidelines, 2007.

European SCI Think Tank

Defines 4 stages of management

Immediate (within first few days) Early management (0-2 weeks) Intermediate management (2-12 weeks) Long term management (>12 weeks)

Abrams, et al. BJU Int, 101: 989, 2008

European SCI Think Tank

Immediate management
Resuscitation time Usually requires indwelling catheter (urethral) for monitoring

Early management (0-2 weeks)

Remove indwelling catheter Institute clean intermittent catheterization (CIC)

Abrams, et al. BJU Int, 101: 989, 2008

European SCI Think Tank

Intermediate management (2-12 weeks)

Transition from inpatient rehabilitation home Introduce/refer to urology Discuss urological options Consider obtaining baseline testing

Abrams, et al. BJU Int, 101: 989, 2008

Baseline Interventions: 3-6 months

After resolution of spinal shock Renal function

Serum creatinine Creatinine clearance until muscle mass stable

Renal/bladder ultrasound Frequency/volume bladder chart Video urodynamics

Abrams, et al. BJU Int, 101: 989, 2008

Urodynamics in the SCI patient

Grade A evidence to support the use of video urodynamics in patients with neurogenic lower urinary tract dysfunction

Stohrer, et al. Eur Urol, 56: 81, 2009.

Urodynamics in the SCI patient

Fill/Storage phase

Normal capacity Normal compliance

>12.5mL/cmH20

No detrusor overactivity Competent outlet Sphincter relaxation Sustained detrusor contraction Minimal residual urine

Emptying phase

Normal Urodynamics

Detrusor Pressure = Pves - Pabd

Urethral Catheter

Rectal catheter

Filling

Storage

Voiding

Urodynamics findings that place upper tracts at risk

Poor Compliance

High storage pressure VUR Upper tract deterioration

McGuire, et al
Storage pressure >40cmH2O associated with renal dysfunction Detrusor leak point pressure Ideally, would keep pressure <25cmH20 during fill/storage

McGuire, et al. J Urol 129: 823, 1983. Cameron, et al. J Urol 182: 1062, 2009

Urodynamics findings that place upper tracts at risk

Detrusor external sphincter dyssynergia

Results in high voiding pressures

Vesicoureteral reflux

Incomplete bladder emptying Symptoms:

Weak stream Intermittent stream

Urodynamics findings that place upper tracts at risk

Three types of detrusor sphincter dyssynergia

Urodynamics findings that place upper tracts at risk

Neurogenic detrusor overactivity

Options for Bladder Management

Options for Management

Patient abilities
Tetraplegic vs. paraplegic Concurrent head injury

Patient preference Family support

US Clinical Practice Guidelines

CIC is optimal option for bladder emptying

Recommend institution of CIC program prior to discharge from rehabilitation unit

Popularized by Lapides in 1972 Safe method for bladder drainage

Decreased rates of UTI, bladder stones & erosion

Numerous studies documenting patient acceptance

Kessler, et al. Neurourol & Urod, 28: 18, 2009. J Spinal Cord Med, 29: 527, 2006

US Clinical Practice Guidelines

Cameron, et al: long term data available on bladder management for 12,984 SCI patients

Cameron, et al. J Urol 184: 213, 2010.

US Clinical Practice Guidelines

Use of CIC drastically declined

Cameron, et al. J Urol 184: 213, 2010.

US Clinical Practice Guidelines

CIC use not indicated / difficult in patients with:

Abnormal urethral anatomy Bladder capacity <200mL Inability or unwillingness to adhere to cath schedule

Volumes <500mL per cath

Recurrent episodes of autonomic dysreflexia with bladder filling despite treatment

Cameron, et al. J Urol 184: 213, 2010.

US Clinical Practice Guidelines

Complications/problems associated with CIC

UTI Bladder overdistention Urinary incontinence Urethral trauma with false passage Urethral stricture Bladder stones Autonomic dysreflexia

Cameron, et al. J Urol 184: 213, 2010. . J Spinal Cord Med, 29: 527, 2006

US Clinical Practice Guidelines

Crede Voiding / Valsalva Voiding

Application of suprapubic pressure or abdominal straining to empty bladder

Only consider if patient has low outlet resistance

Current recommendation: Consider avoiding Crede and Valsalva as primary methods of bladder emptying
Grade C recommendation Avoid if known history of vesicoureteral reflux

Cameron, et al. J Urol 184: 213, 2010. . J Spinal Cord Med, 29: 527, 2006

US Clinical Practice Guidelines

Reflex voiding into external collection device / pads

Only consider if:

Low voiding pressures on urodynamics Low post void residuals Absent / rare episodes of autonomic dysreflexia with bladder filling Rare UTIs

Cameron, et al. J Urol 184: 213, 2010. . J Spinal Cord Med, 29: 527, 2006

US Clinical Practice Guidelines

Indwelling catheter (urethral / suprapubic)

23% of SCI patients are discharged from rehab units with indwelling catheters Higher complication rates compared to CIC

53.5% complication rate in indwelling group vs. 27% for CIC

Cameron, et al. J Urol 184: 213, 2010. . J Spinal Cord Med, 29: 527, 2006. Dmochowski, et al. J Urol, 163: 768, 2000.

US Clinical Practice Guidelines

Cameron, et al. J Urol 184: 213, 2010. . J Spinal Cord Med, 29: 527, 2006, Dmochowski, et al. J Urol, 163: 768,

US Clinical Practice Guidelines

Increased risk of upper tract deterioration with indwelling catheter

Low bladder compliance

Leads to increase risk of VUR pyelonephritis

Mean serum creatinine is higher Proteinuria is greater in patients with indwelling catheters

Cameron, et al. J Urol 184: 213, 2010. . J Spinal Cord Med, 29: 527, 2006

US Clinical Practice Guidelines

Increased risk of upper tract deterioration with indwelling catheter

Addition of anticholinergic may help

Improved bladder compliance Lowers detrusor leak point pressure Decreased rates of hydronephrosis No change in:

Infection rates VUR Serum creatinine Renal scars

Kim, et al J Urol 159: 193, 1998. J Spinal Cord Med, 29: 527, 2006

US Clinical Practice Guidelines

Increased risk of bladder cancer with indwelling catheter

Reported incidence of squamous cell carcinoma (SCC) is 2.3 10% in patients with indwelling catheter

8% risk after 25 years of catheterization

Pathogenesis: chronic urothelial irritation and inflammation leading to metaplasia neoplasia Surveillance guidelines for cystoscopy differ

Annual surveillance for patients with indwelling catheters is advised

J Spinal Cord Med, 29: 527, 2006. Corcos, et al. Neurourol & Uds 27: 475, 2008.

Urethral vs. Suprapubic Catheter

Similar overall complication rates with notable exceptions

Urethral complications significantly higher in urethral catheter group

Erosion (especially in women), abscess, fistula, stricture

Slight decreased risk of UTI with suprapubic catheter

Benefit may be offset by increased risk of insertion

Recent studies using modernized techniques show improved outcomes for indwelling catheters

J Spinal Cord Med, 29: 527, 2006. Corcos, et al. Neurourol & Uds 27: 475, 2008.

When bladder drainage alone is not enough

Signs/Symptom of Insufficient Treatment

Worsening upper tracts

Hydronephrosis on RUS Increased serum creatinine

Worsening urodynamics

Loss of compliance, elevated DLPP, increased voiding pressures, worsening NDO

Increased incontinence Increased episodes of autonomics dysreflexia Patient dissatisfaction

Medications

Medications

Goal of medical therapy

Improve bladder compliance Increase bladder capacity Decrease neurogenic detrusor overactivity decrease incontinence

Acceptable side effects

Antimuscarinics

First line agents for patients with neurogenic bladder

Some advocate starting immediately Normally, M3 receptors mediate bladder contractions

5 muscarinic receptor subtypes; 2 in bladder

Cameron, et al. J Urol, 182: 1062, 2009. Stevens, et al. Eur Urol 52: 531, 2007.

Antimuscarinics

Dose requirements are usually higher than in patients with idiopathic detrusor overactivity (Grade A) Not all anticholinergics have data for neurogenic population

Abrams, et al. BJU Int, 101: 989, 2008. Stohrer, et al. Eur Urol, 56: 81, 2009.

Anticholinergics

Muscarinic Receptor Subtypes

Distribution Brain (cortex, hippocampus), Salivary gland Heart, brain, smooth muscle Smooth muscle, glands, eye Brain (forebrain, striatum) Brain (substantia nigra), eye Role Cognitive function, memory; saliva secretion Regulation of heart rate & HR variability; behavioral flexibility Smooth muscle contraction, iris contraction, gland secretion Dopamine dependent behaviors Regulation of striatal dopamine release

Subtype M1 M2 M3 M4 M5

Anticholinergics

Antimuscarinics & M3 Receptor Selectivity

Anticholinergics

Antimuscarinics & Side Effects

Dry mouth Constipation Blurred vision

Anticholinergics
Constipation Enablex 7.5mg 15mg Vesicare 5mg 10mg Sactura XL 60mg Detrol LA 4mg Toviaz 4mg 8mg 14.8% 21.3% 5.4% 13.4% 8.5% 7% 4.2% 6% Dry Mouth 20.2% 35.3% 10.9% 27.6% 10.7% 35% 18.8% 34.6%

Anticholinergics: Cognitive Side Effects

Merchant, et al.

Prevalence of cognitive impairment more than doubled with the use of drugs with anticholinergic activity in community dwelling older persons

CNS Penetration

Entry into the brain via BBB by passive diffusion dependent on:

Molecular size, polarity, lipophilicity

Highly lipophilic, non polar small molecules will more readily cross the BBB by passive diffusion
Oxybutynin: 357kDareadily passes BBB Darifenacin, solifenacin, tolterodine, fesoterodine all >475kDa unlikely to pass via passive diffusion Tropsium (Sancura) hydrophilic, polar compound, 428kDa low propensitiy for BBB penetration

Cognitive Impairment & Receptor Selectivity

M1 & M2 receptors are important in cognitive functioning and memory & behavioral flexibility & learning
More data that central blockade of M1 receptors has a key functional role in cognitive impairment Less M3 selectivity may be associated with increased risk of cognitive impairment

Sanctura (tropsium): although relatively non-selective, low BBB penetration should have low potential for cognitive risk as long as BBB integrity is not compromised As of now, best evidence is with darifenacin (enablex): 3 trials

Alpha Blockers

Detrusor has 2 types 1 adrenergic receptor 1/3: 1-d 2/3: 1-a Bladder neck, prostate: predominantly 1-a Sundin, et al: Increase in adrenergic receptor sites and a switch to -adrenergic contractive function from the typical -adrenergic relaxation function during bladder filling Tamsulosin (flomax) RCT: no significant increase in bladder capacity

Cameron, et al. J Urol, 182: 1062, 2009.

Tricyclic antidepressants (TCAs)

Imipramine has been shown to suppress bladder overactivity by various mechanisms

Muscarinic receptor antagonist Direct smooth muscle inhibitor Blocks reuptake of serotonin reduces bladder overactivity

Also shown to stimulate fibers at dome resulting in improved bladder compliance TCAs (Imipramine) have been shown to increase compliance in the pediatric neurogenic population No RCT supporting their use Cardiac side effects use with caution

Cameron, et al. J Urol, 182: 1062, 2009.

Combination therapy

McGuire, et al: retrospectively evaluated group of patients initially on no medications or antimuscarinics only No initial medications

2 medications (n=22)

Mean bladder pressure at capacity decreased 52% (3617cmH20) Mean compliance increased 5-fold (11.3 56.3 mL/cmH20) Bladder pressure decreased 67% (35.9 11.9cmH20) Compliance increased 9.7 fold (7.2 69.6mL/cmH20)

3 medications (n=28)

Initial antimuscarinics 3 drug therapy (n=27)

Bladder pressure decreased 60% (27.2 10.9 cmH20) Compliance increased 3-fold (18.4 54.3 mL/cmH20)

Cameron, et al. J Urol, 182: 1062, 2009.

Combination therapy

Other studies support the use of combination therapy Gossl, et al: 41 children with MMC treated with oral oxybutinin
40% increase in capacity 158% increase in compliance

Swierzewski, et al: added terazosin (alpha blocker) to existing CIC + anticholinergic therapy
Compliance increased by 73% Capacity increased by 157mL Bladder pressure decreased by 36cmH20 Results reversed when medication stopped

Cameron, et al. J Urol, 182: 1062, 2009. Swierzewski, et al. J Urol, 151: 951, 1994.

Failure Despite Maximal Medical Therapy

Historically, progressed to surgical management or an indwelling catheter

Sphincterotomy Bladder Augmentation Ileovesicostomy Urinary Diversion

Botox

Botulinum Toxin A

Isolated in 1897 by van Ermengem 150-kD amino acid di-chain

Mechanism of action

Binds to pre-synaptic nerve endings of cholinergic neurons

Enters neuron via endocytosis

Cleaves SNAP-25 protein that is needed for synaptic vesicle fusion Results in inhibition of acetylcholine secretion

Karsenty, et al. Eur Urol 53: 275, 2008. Reitz, et al. Eur Urol 45: 510, 2004.

Botox

Increasing evidence of increased activity

Inhibits release of acetylcholine, adenosine triphosphate and several neurotransmitters (substance P) Down-regulates expression of purinergic & capsaicin receptors on afferent neurons in the bladder

Botox can treats neurogenic detrusor overactivity via motor & sensory pathways

Karsenty, et al. Eur Urol 53: 275, 2008.

Botulinum toxin

Seven distinct structurally similar serotypes of botulinum toxin (BTX)

BTX-A & BTX-B have been used in various neurological disorders

BTX-A (Botox, Allergan, Inc) approved for use in US by FDA for strabismus, blepharospasm, hemifacial spasm & cervical dystonia

Karsenty, et al. Eur Urol 53: 275, 2008.

Botulinum toxin: update!!

August 24, 2011

BOTOX (onabotulinumtoxinA) Receives U.S.

FDA Approval For The Treatment Of Urinary Incontinence In Adults with Neurological Conditions Including Multiple Sclerosis And Spinal Cord Injury

Karsenty, et al. Eur Urol 53: 275, 2008.

Significant improvement in continence rates

Significant improvement in QOL parameters

Karsenty, et al. Eur Urol 53: 275, 2008.

Significant improvement of maximum detrusor pressure

Karsenty, et al. Eur Urol 53: 275, 2008.

RCT Botox vs. Placebo for NGB Secondary to SCI/MS

Herschorn, et al.

RCT comparing 300 Units or placebo

30 injection sites Trigone sparing

Herschorn, et al. J Urol, 2011.

Adverse Events

Herschorn, et al. J Urol, 2011.

Ideal Dosage for Botox Still Unknown

Cruz. Eur Urol, 2011.

Improvement with 200 & 300 units in SCI population

Cruz. Eur Urol, 2011.

Improvement with 200 & 300 units in SCI population

Cruz. Eur Urol, 2011.

Slight increase in SE for 300 Units

Cruz. Eur Urol, 2011.

Long Term Data

Multiple studies document long term success despite the need for repeat injections

4-9 months

Pannek, et al: declining results with repeated injections

1 in 4 subjects required surgical intervention

Pannek, et al. BJU Int 104: 1246, 2009.

Are the Results Sustainable?

Giannantoni, et al

Improvement in QOL index

Giannantoni, et al. 2009 Eur Urol; 55: 705-712

Repeated Injections

Treatment resistance or lack of response

Antibody formation a concern for repeated injection No formal studies documenting the presence of antibodies in non responders in urologic literature

In cervical dystonia: subjects with antibodies required shorter intervals between injections and required larger doses

Schulte-Baukloh, et al

Of 25 subjects who received BoNTA, 4 tested + for antibodies & 4 were borderline

Only 3/8 were considered treatment failures

Dowson, et al. 2010 Nat Rev Urol; 7: 661-667.

Side Effects

Side effects are usually mild Injection site pain Procedure-related UTI (2-23%) Mild hematuria (2-21%) Elevated PVR De novo need for CIC (6-88%) Localized muscle weakness reported Documented reports of generalized weakness / fatigue following Botox injections Warn patients about black box warning with BoNTA Potential to spread beyond treatment area & produce difficulty swallowing and breathing
Pannek, et al. BJU Int 104: 1246, 2009. Karsenty, et al. Eur Urol 53: 275, 2008.

Contraindications

Pregnancy category C Relative contraindication in patients with neuromuscular disease Use caution with certain medications that can potentiate the results of BoNTA

Aminoglycosides Clindamycin Succinylcholine

Gomez, et al. 2010 Curr Urol Rep; 11: 353-359.

Sacral Neuromodulation

Sacral Neuromodulation: Interstim

Sacral Neuromodulation: Interstim

Complete spinal cord injury

Poor outcomes reported with use of Interstim Limited data available that appears to support its use

Incomplete injuries

Lombardi, et al. Spinal Cord, 47: 486, 2009.

Early Sacral Neuromodulation (SNM)?

Could early neuromodulation prevent the plasticity that results in a neurogenic bladder?

Sievert, et al: 10 patients received bilateral SNM

6 who refused served as controls All were complete SCI above T12 Prior to intervention, UDS confirmed areflexia during spinal shock period Time to SNM implantation: 2.9 months (0.8 4.5 months)

Sievert, et al. Ann Neurol, 67: 74, 2010

SNM group

Control

Sievert, et al. Ann Neurol, 67: 74, 2010

How should we monitor the SCI patient?

How should we monitor the SCI patient?

US Practice Guidelines

No definitive recommendations Upper & lower tract evaluation annually

How should we monitor the SCI patient?

Veterans Affairs Health Care policy

Annual UA, C&S Annual BUN, serum creatinine Annual anatomical exam (renal US / CT) Urodynamics should be performed when objective information on voiding function is needed Cystoscopy every 10 years in patients with indwelling catheters or who use tobacco products

How should we monitor the SCI patient?

Proposed European Guidelines

Annual urodynamics for high risk group (detrusor overactivity, low bladder compliance, reflex voiding, Crede voiding) Biannual urodynamics for low risk group

How should we monitor the SCI patient?

Prior guidelines recommended annual UDS every 5 years & then with symptom / upper tract change Nossier, et al: 3/80 patients did not require treatment modification (mean f/u 67 months)

If UDS were repeated based on symptom/upper tract findings only, 68% of treatment failure (i.e. those needing treatment modification) would not have been identified
Nossier, et al. Neurourol Urodyn 26(2): 228, 2007.

Other Considerations

Bladder Cancer

Relative risk of bladder cancer 16 28 times that of the normal population Recent review of 1319 spinal cord patients
32 developed cancer 46.9% SCC, 31.3% TCC, 9.4% adenocarcinoma, 12.5% mixed SCC/TCC Bladder management: 44% urethral catheter, 48% external catheter, 8% CIC 42% found on screening cystoscopy

Kalisvaart, et al. Spinal Cord, 48: 257, 2010. Goath, et al. Arch Phys Med Rehabil, 83: 346, 2002.

Bladder Cancer

Causes of increased bladder cancer

Chronic irritation
Recurrent UTI Bladder stones Indwelling catheter

Alteration in bladder urothelial due to interaction of bladder mucosa with high volume of urine 34 years

Average time from injury bladder cancer dx

Kalisvaart, et al. Spinal Cord, 48: 257, 2010. Goath, et al. Arch Phys Med Rehabil, 83: 346, 2002.

Cystoscopy Recommendations

With symptoms
Hematuria Recurrent UTI Any significant change in urinary habits

Annual
Consider in indwelling catheter group Consider in high risk patients (recurrent UTI, bladder stones, tobacco use, etc..)

Kalisvaart, et al. Spinal Cord, 48: 257, 2010. Goath, et al. Arch Phys Med Rehabil, 83: 346, 2002.

Conclusion

SCI associated with significant GU dysfunction Prompt referral to center of excellence for SCI patients is preferred

Early & lifelong GU involvement

If you care for SCI patients, ensure that they are receiving urologic care.