Bladder Function and Dysfunction

after Neurologic Insult: Preventing

Secondary Conditions and
Improving Function
Suzanne L. Groah, MD, MSPH
National Rehabilitation Hospital
RRTC on Secondary Conditions after SCI
Supported by National Institute for Disability and Rehabilitation Research, Grant #
H133B031114
Anatomy and Physiology

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H133B031114
Bladder - Anatomy
Neuroanatomy of Voiding
 Neuroanatomy of Voiding
 Frontal lobe
 Micturition center
 Sends inhibitory signals
 Pons (Pontine Micturition Center)
 Major relay/excitatory center
 Coordinates urinary sphincters and the bladder
 Affected by emotions
 Spinal cord
 Intermediary between upper and lower control
 Peripheral Nervous
System
 Somatic (S2-S4)
 Pudendal nerves
 Excitatory to external
sphincter
 Parasympathetic (S2-S4)
 Pelvic nerves
 Excitatory to bladder,
relaxes sphincter
 Sympathetic (T10-L2)
 Hypogastric nerves to
pelvic ganglia
 Inhibitory to bladder body,
excitatory to bladder
base/urethra
 Normal Voiding
 SNS primarily controls bladder and the IUS
 Bladder increases capacity but not pressure
 Internal urinary sphincter to remain tightly closed
 Parasympathetic stimulation inhibited
 Somatics (pudendal N) regulate
 External urinary sphincter
 Pelvic diaphragm
 PNS
 Immediately prior to PNS stimulation, SNS is suppressed
 Stimulates detrusor to contract
 Pudendal nerve is inhibited  external sphincter opens 
facilitation of voluntary urination
 Innervation of the Lower
Urinary Tract
Function
Balance between suprasacral
modulating pathways, sacral cord
and the pelvic floor
Emptying phase: “Voiding
Reflex”
Series of coordinated events
involving outlet relaxation,
detrusor contraction
Storage phase: “Guarding
reflexes” constant afferent input
to maintain continence
Bladder Dysfunction

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H133B031114
 Functional Classification
 Failure to store
 Because of bladder
 Because of outlet
 Failure to empty
 Because of bladder
 Because of outlet
 Combination
 Pathophysiology of
Voiding
 Brain lesion above pons destroys master
control center
 Ex – stroke, brain tumor, hydrocephalus, CP,
Shy-Drager
 Result – urge incontinence, night incontinence,
coordinated sphincter
 Spinal cord lesion, myelomeningocele, MS
 Detrusor hyperreflexia
 Spastic bladder
 Areflexic bladder
 Pathophysiology of
Voiding
 Lumbosacral spinal lesion
 Ex – spinal tumor, sacral SCI, herniated disc,
lumbar laminectomy, radical hysterectomy,
pelvic trauma
 Result – areflexic bladder
 Peripheral nerve injury
 Ex – AIDS, diabetes, polio, GBS
 Result – urinary retention
Medication Options

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H133B031114
 Medications
 Failure to store due to outlet
 Alpha-adrenergic drugs
 Location - Bladder neck receptors
 Function - Increase bladder outlet resistance by
contracting the bladder neck
 Example - pseudoephedrine
 Medications
 Failure to store due to outlet
 Estrogen derivatives
 Mechanism - Increases the tone of urethral
muscle by up-regulating the alpha-adrenergic
receptors in the surrounding area
 Mechanism - Enhances alpha-adrenergic
contractile response to strengthen pelvic
muscles
 Use in…Stress incontinence
 Medications
 Failure to store due to bladder
 Anticholinergic drugs
 Function - Inhibit involuntary bladder contractions
 Adverse effects
• Blurred vision
• Dry mouth
• Heart palpitations
• Drowsiness
• Facial flushing
 Ex. Pro-banthine, Levsin
 Medications
 Failure to store due to bladder
 Antispasmodic drugs
 Function - Relax the smooth muscles of the
urinary bladder
 Function – Directly relaxes the smooth muscle of
the bladder
 Adverse effects similar to anticholinergic agent
 Impaired mental alertness and physical coordination
 Ex. Ditropan, Detrol
 Medications
 Failure to store due to bladder
 Tricyclic antidepressant drugs
 Mechanism - Increase norepinephrine and
serotonin levels
 Mechanism - Anticholinergic and direct
muscle relaxant effects on the urinary
bladder and bladder neck
 Ex. imipramine
 Medications
 Failure to empty due to outlet/DSD
 Botox
 MOA
 Inhibition of Ach release at neuromuscular junction
 Relax spastic/overactive muscles
 Relaxes sphincter when DSD present
 Effect not permanent
 DSD is often present with reflex voiding
 Injection transurethrally or transperineally into the
urinary sphincter mechanism
 Re-injection necessary as effect is lost after 3-6 months
 Effect of Foods
 Heightened urge incontinence
 Spicy foods
 Caffeine/chocolate
 Citrus fruits
 Carbonated beverages
Bladder Management Options

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H133B031114
 Management Options
Type of Advantage Disadvantage
Management
Indwelling catheter Convenience Infection
Less caregiver ± Urethral damage
assistance ± Bladder cancer
Intermittent catheter ± Reduced infection Need anticholinergic
± Urethral damage
Assistance
Cost
Labor
 Management Options
Type of Advantage Disadvantage
Management
Reflex voiding Non-invasive ± High pressure
± Continence
± High residuals
± Need for
sphincterotomy
Electrical stimulation + Improved bowel fxn Significant surgery
rhizotomy Reduced labor/cost Side effects- rhizotomy
Cosmetically appealing ↓ Reflex erection
↓ Reflex ejaculation
 Management Options
Type of Advantage Disadvantage
Management
Surgical diversion May produce Significant surgery
continence Committed to
Continent pouch easier collection device/cath
for female to cath Risk of cancer
 Electrical Stimulation
 Electrical Stimulation and Posterior Sacral Rhizotomy
 To produce effective voiding and reduce urinary tract infection
 Electrodes surgically implanted on the sacral nerves
 Stimulator placed under the skin of the abdomen or chest
 Battery-powered remote control
 Posterior sacral rhizotomy
 Abolishes hyper-reflexia of the detrusor and sphincter
 Increases bladder capacity and compliance
 Reduces reflex incontinence
 Reduces autonomic dysreflexia
 Abolishes reflex erection, reflex ejaculation, sacral sensation, and
reflex defecation
 1% risk of infection of the implant
 1 fault per 20 implant-years
 Electrical Stimulation
 Consider in  Evidence
 ↑ PVR  ↓ Reflex incontinence
 Chronic/recurrent UTI (post rhiz)
 Problems with catheters  ↑ Bladder capacity and

 Reflex incontinence compliance

 ↓ need for anticholinergics
 ↓ bladder capacity and
 ↓ DSD
compliance
 Intolerance of  ↓ AD if posterior

anticholinergic rhizotomy
medication  ↑AD if no posterior
 DSD rhizotomy
 AD
 Bladder Augmentation
 Procedure that increases bladder capacity using intestinal
segments
 Ileum, colon, or stomach are used
 Goals
 Decreasing intravesicle pressure
 Restore urinary continence
 Preserve upper urinary tracts by alleviating reflux and
hydronephrosis
 Can combine with a continent abdominal stoma
 Consider in patients with
 Intractable involuntary bladder contractions causing incontinence
 Patients who are able and motivated to perform CIC
 Reflex voiders wishing to convert to CIC
 Females with paraplegia
 Urinary Diversion
 Diverts the urine flow from the bladder
 Secondary form of bladder management when primary methods have
failed
 Ureters transected just above the bladder and connected to a segment
of intestine (terminal ileum) which is in turn brought to the skin of the
lower abdominal wall
 External appliance used as collection device
 Considered if:
 Lower urinary complications secondary to indwelling catheters
 Urethrocutaneous fistulas, perineal decubitus ulcers
 Urethral destruction in females
 Hydronephrosis secondary to a thickened bladder wall and for
hydronephrosis secondary to vesicoureteral reflux or failed reimplant.
 Bladder malignancy requiring cystectomy
Yet To Be Released PVA Guideline
Recommendations

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H133B031114
 Recommendations from
the PVA Guidelines
 Recommendation 1: Intermittent
catheterization is the preferable method for
bladder emptying for men and women who
have adequate hand function or a willing
caregiver to perform the catheterization and
have bladders that do not empty adequately.
 Recommendation 2: Intermittent
catheterization should be ideally performed
every 4 to 6 hours to keep bladder volumes
below 400ccs.
 Recommendations from
the PVA Guidelines
 Recommendation 5: Consider sterile
catheterization for those individuals with
recurrent symptomatic infections occurring
with clean intermittent catheterization.
Rationale: Lower infection rates can be
achieved with sterile techniques and with
pre-lubricated self contained catheter sets
 Recommendations from
the PVA Guidelines
 Recommendation 5: Risk of symptomatic
infection is at least comparable and may be
less in individuals with indwelling catheters
than those managing their bladders with
clean intermittent catheterization.
 Recommendations from
the PVA Guidelines
 Recommendation 6: Patient should be
advised of long-term complications of
indwelling catheterization, including:
 Bladder stones
 Kidney stones
 Urethral erosions
 Bladder cancer
 Epididymitis
 Recurrent symptomatic urinary tract
infections
Genitourinary Assessment of
Function

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H133B031114
 Assessment of Function
 U/a and c & s
 BUN & Cr
 if compromised renal function is suspected
 Postvoid residual urine
 If high, the bladder may be contractile or
the bladder outlet may be obstructed
 Renal/Bladder US
Mainstay of screening in many institutions

 Advantages  Disadvantages
 Simple  Low sensitivity for
 Eval kidney, small stones
parenchymal loss, abnl  Ureters not evaluated
echogenicity well
 Eval for
hydronephrosis, stones
 Nuclear Renal Scan
 Advantages  Disadvantage
 Functional info  Less anatomic info
 No nephrotoxic  Cannot detect stones
reactions
 Low radiation
 KUB
 Historically, routinely used to detect renal
and bladder stones
 Disadvantages
 Poorly sensitive to stones
 “KUB not justified in routine f/u of urinary
tract in SCI”
 Tins et al. Spinal Cord 2005
 Filling Cystogram

 Bladder capacity
 Bladder compliance
 Presence of phasic
contractions
(detrusor instability)
 Cystogram
 Static Cystogram
 Confirm the presence of
stress incontinence
 Degree of urethral motion
 Presence of a cystocele
 Intrinsic sphincter
deficiency
 Vesicovaginal fistula
 Bladder diverticulum
 Voiding cystogram
 Bladder neck and
urethral function (internal
and external sphincter)
during filling and voiding
phases
 Urethral diverticulum
 Urethral obstruction
 Vesicoureteral reflux
 Cystometrogram

 Volume vs pressure graph

 Evaluates
 Detrusor compliance
 Stability of detrusor
 Urodynamics
 Filling cystometry
 Flow/pressure study
 Detrusor pressure at maximum flow
 Obstruction to passage of urine can be distinguished from a lack of
tone in the detrusor muscle
 Electromyography
 Coordinated or uncoordinated voiding
 Detrusor sphincter dyssynergia
 Videocystourethography
 Combined x-ray or ultrasound
UD - Stable Bladder
Detrusor Hyperactivity
and Low Bladder Capacity
 Cystoscopy

 Bladder cancer
 Bladder stone
 Indicated in persistent irritative voiding
symptoms or hematuria
Selected Genitourinary Secondary
Conditions After Bladder
Dysfunction due to
Neurologic Disease

Supported by National Institute for Disability and Rehabilitation Research, Grant #

H133B031114
 Secondary Conditions
 Increased risk of
 Bladder infection
 Kidney infection
 Hydronephrosis
 Urethral trauma/laxity
 Urinary Stones and SCI
 Higher incidence, especially in first 6 mos
 3-6% upper tract
 11-15% bladder
 Etiology
 Stasis
 Calcium metabolism
 Infection
 Diagnosis
 CT is gold standard
 Bladder Cancer
Epidemiology
 5th most common cancer
 12th leading cause cancer mortality
 Adjusted yearly incidence 17/100,000 py
 54,400 new cases per year
 Males at greater risk
 Majority are transitional cell carcinoma
 Risk Factors for Bladder
Cancer
 Smoking
 Male gender
 Exposure to aromatic amines
 Schistosomiasis infection
 UTI
Is there a heightened risk of bladder
cancer after SCI?
If so, why?

Supported by National Institute for Disability and Rehabilitation Research, Grant #

H133B031114
 The Evidence in SCI
Source “Incidence” Interpretation
Reported
Paraplegia, 1966 290/100,000 (.0029) Period prevalence
Unspecified time
Paraplegia, 1981 25/6744 (.0037) Prevalence/case series
Unspecified time
J Urology, 1991 8 cases, 1 year Case series
No population
denominator
Urology, 1999 130/33,565; (.0039) Appropriately reported
5 yr reporting period as prevalence
 The Evidence in SCI
Source “Incidence” Interpretation
Reported
J Urology, 1981 10 cases/10,052 Case series
(.0009)
Unspecified time
J Urology, 1977 6 cases/62 (.097) Prevalence
Unspecified time
Urology, 2002 48 cases/43,561 Prevalence
(.0011)
Questionnaire data
J Urology, 1985 2/25 (.08) Case series/prevalence
Unspecified time
 Recent Evidence
 Groah SL. Arch Phys Med Rehabil 2002
 3,670 subjects contributed 39,729 p-y
 Stratified by bladder management method
 Age-adjusted incidence
 Indwelling catheter – 77/100,000 py
 Mixed methods – 56.1/100,000 py
 Non-indwelling catheter – 18.6/100,000 py
 Retrospective Cohort

SCI > 1 year

Indwelling Non-Indwelling
Multiple
Catheter Use Catheter Use
Methods (Multi)
(IDC) (NIDC)

No No No
Bladder Bladder Bladder
Bladder Bladder Bladder
cancer cancer cancer
Cancer Cancer Cancer

Mortality Survival Mortality Survival Mortality Survival

 Recent Evidence
 Groah SL. Arch Phys Med Rehabil 2002
 Using cox regression, only bladder
management method and age predicted disease
 Cumulative Incidence of
Bladder Cancer
0.010%
0.009%
IDC
0.008%
Cumulative Incidence

NIDC
0.007%
0.006%
0.005%
0.004%
0.003%
0.002%
0.001%
0.000%
0 5 10 15 20 25 30 35 40 45 50 55 60

Years Post-SCI
Wilcoxan < 0.05
 Cumulative Incidence of
Bladder Cancer
0.010%
0.009%
IDC
0.008%
Cumulative Incidence

NIDC
0.007%
0.006%
0.005%
0.004%
0.003%
0.002%
0.001%
0.000%
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Age
Wilcoxan < 0.05
 Bladder Cancer Mortality
by Age

180
160
Mortality in 100,000 P-Y

140 IDC
120 SEER
100
80
60
40
20
0
0-9 10-19 20-29 30-39 40-49 50-59 60+
Age (years)
 Proportional Mortality
Due to Bladder Cancer
100%
90%
IDC
80%
Proportion Surviving with BC

70%
60%
50%
40%
30%
20%
10%
0%
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39
Years post-SCI
 Recent Evidence
 Subramonian et al. BJU Int, 2004.
 4 cases/1334 people followed
 30.7/100,000 person-years
 Reported as not statistically different from
general population and lower than reported in
other studies
 Risk Factors for Bladder
Cancer
Source Results

Groah SL. JSCM 2003;26:339-44 Multiple risk factors (2 or more)

(mortality study) Catheter, tobacco

Hess MK. JSCM 2003;26:335-8 Gross hematuria present in 14/16

Vereczkey ZA. JSCM 1998;21:230- 19 RF and 12 interactions analyzed

9 Duration of indwelling catheter use
>10 years
 Part 3 Design: Case-
control

Bladder Age at SCI

cancer Duration of SCI
survivors Age at BC
Level of SCI
ASIA
Method of bladder
Medical record
management
review Histology
Presentation
Controls Diagnosis
deceased Surveillance
due to Biopsy results
bladder Risk Factors
cancer
 Presentation
70%
Survivor Control
60%

50%

40%

30%

20%

10%

0%
S/Sx H/O gross Gross hematuria Renal failure
hematuria
 Potential Associated Risk
Factors
100%
Survivor Control
*
75%

*
50%

25%

0%
IDC use Tobacco use Calculi Pyelonephritis Prophylactic
antibiotic
 Risk Factors
50%
Survivor
*
Control

*
25%
*

0%
0 RF 1 RF 2 RF 3 RF 4 RF

RF: IDC use, tobacco use, calculi, or pyelonephritis

 Bladder Cancer
Surveillance
Survivor Control p value

Mean
number 7.8 16.8 .06
cystoscopies
Mean
number 1.6 3.6 > .1
biopsies
Genitourinary Surveillance

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H133B031114
 Surveillance Practices of
the MSCIS Centers
 16 centers surveyed
 13 responded
 12/13 have a GU surveillance protocol
 6/13 have a bladder cancer surveillance
protocol
 Initial GU Surveillance
from the MSCIS Centers
1 2 3 4 5 6 7 8 9 10 11 12 13
U/A
          
C/S
         
Bun/Cr
        
Creat
Clear     
US
    
VCUG
    
Renal
Scan
   
 Initial GU Surveillance
from the MSCIS Centers
1 2 3 4 5 6 7 8 9 10 11 12 13
Cytol

IVP
 
CMG

UD

Bl US

KUB

CScope

 Bladder Cancer
Surveillance from MSCIC
 Protocols
 If IDC, cysto at 5 yrs and yearly thereafter
 Cysto every 5-10 years
 Cysto if hematuria
 Cysto for long-term IDC
 Cysto if IDC + hematuria
 Cysto at 10 years then yearly if IDC
 Cysto yearly if IDC (2 centers)
 Bladder Cancer
Surveillance
 Yang CC. Spinal Cord 1999;37:204-7
 Cysto if >10yrs catheter, smoker + cath (5yrs)
 59 subjects had 156 cystos
 No cancer diagnosed
 4 other cases diagnosed during same period (2
did not meet criteria;1 not unit patient;1 had
screen 4 months prior)
 Bladder Cancer
Surveillance
 Groah SL. JSCIM 2003;26:339-44
 8 survivors with bladder cancer compared with
13 deceased
 Surveillance cystoscopy identified cancer in
 14% survivors
 11% deceased
 Survivors had fewer surveillance cystoscopies
and biopsies than deceased group