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A. If you have a neuro-urological problem, the main goal is to protect your kidneys and ureters. These organs compose the upper urinary tract.
Kidney failure may result from many neurological conditions, for instance, spinal cord injuries. Your urologist may suggest a treatment to protect your kidney function even if you don’t have bothersome symptoms.
Provided that your kidneys are safe, priorities in neurourology treatment are:
A. Management of Neurogenic bladder consists of following:
A. Non-Assisted bladder emptying: Incomplete bladder emptying is a serious risk for urinary tract infection, high pressure inside the bladder (with kidney damage), and incontinence. Methods to improve urination are usually necessary. Methods can be performed outside the body (non-invasive), by putting a device inside the body (invasive), or using drug therapy (pharmacological).
Bladder expression (Credé manoeuvre) and urinating by abdominal straining: These manoeuvres can help empty the bladder but are rarely recommended. Pressure inside the bladder may rise over acceptable limits and impair kidney function over time.
Only in very specific cases may your urologist suggest these techniques. The same applies to triggered reflex voiding, which is possible in some patients-for instance, by repeated light taps on a specific body location-but only following medical advice.
External appliances: These devices are designed to catch urine that leaks during incontinence. Pads and diapers are the most well-known external appliances. For men, a condom catheter with a urine collection device is a practical alternative. Penile clamps should only be used in selected patients and after full medical evaluation.
A. A variety of techniques are available for rehabilitation of neurourological problems and can be performed in the doctor’s office. Treatments that have shown some positive results for specific neurourological problems include:
Ask your urologist which methods are available and recommended in your situation.
A. None of the available medical therapy is optimal for treatment.
Medications are often used in combination (one drug or more) with other techniques, such as intermittent catheterisation. Treatments are tailored to the patient.
Drugs for storage symptoms: Antimuscarinic drugs are used in neurourological patients:
These medications have some side effects, such as dry mouth, than can be reduced by lowering the dose or by taking the drug a different way (for instance, through the skin).
Some antimuscarinic drugs are oxybutynin, trospium, tolterodine, propiverine, darifenacin, and solifenacin.
A new category of medications called beta-3 adrenergic receptor agonists (Mirabegron) was recently introduced. Their use in neurourological patients is currently being studied.
Drugs for voiding symptoms: Drugs called alpha blockers seem to improve urination and may reduce the risk of sudden high blood pressure (autonomic dysreflexia). Some alpha blockers are tamsulosin and silodosin.
Drug therapy is not recommended if your bladder does not contract enough (underactive bladder) or if your sphincter is not strong enough (severe stress urinary incontinence).
A. Catheterisation: If you cannot empty your bladder naturally, you or your healthcare provider can use a catheter as needed for emptying. This technique is called intermittent catheterisation.
It can be done by the patient at home and is recommended for neuro-urological patients. Intermittent catheterisation prevents many complications associated with catheters that stay in place (indwelling), including a high risk of urinary tract infections.
Intermittent catheterisation must be performed correctly to prevent infection. This is most important in managing the urinary tract of patients with neuro-urological symptoms.
Botulinum toxin injections in the bladder: This treatment is most effective for overactive bladder caused by multiple sclerosis or spinal cord injury.
The drug is given by injection inside the bladder. In this procedure, a device called a cystoscope is inserted in your bladder and the botulinum toxin is injected in the bladder wall using a special needle.
The drug causes the bladder muscle to stop contracting regularly for about 9 months. Repeated injections may be necessary, but the treatment continues to be effective after new injections.
After the injection, the bladder may not empty completely. Intermittent catheterisation may be necessary for a time.
Urinary tract infections also may occur with this treatment.
Bladder neck and urethral procedures: A neuro-urological condition might make urination difficult by causing a lot of resistance at the bladder neck or the sphincter. In this case, your doctor might suggest minimally invasive treatment to improve urination and to protect the upper urinary tract. These include:
Sphincterotomy: The urinary sphincter can be cut to reduce the sphincter’s resistance to the passage of urine. The urethra will still be able to close somewhat. Incontinence may occur afterwards and can be managed. In many patients, this procedure has to be repeated. It does not have severe complications. Some patients may be able to have a urethral stent implanted, but the costs, complications, and need for further surgery have limited their use.
Bladder neck incision: Injury and previous procedures can cause the tissue at the bladder neck to thicken or scar. If this has happened, this tissue can be cut to help passage of urine through the bladder neck.
A. Sometimes conservative or minimally invasive treatment will not control the symptoms or the risk of kidney damage.
In this case, your doctor will suggest more invasive surgical treatment. Depending on the problem, several procedures can be performed.
Bladder neck and urethral procedures: Some procedures may be recommended to increase bladder neck or sphincter resistance for continence. This should be attempted only after careful study of the bladder and urethra. Several procedures are available and your doctor may recommend a particular technique based on your situation.
Urethral slings (synthetic, autologous): A piece of material is placed as a sling in women to compress the bladder neck and increase resistance to urine flow; material can be man-made (synthetic) or tissue taken from another part of the patient’s body (autologous).
Artificial urinary sphincter: This device is composed of a cuff that compresses the urethra, a balloon that prevents urine from leaking, and a pump that controls the release of urine; it is surgically implanted.
Bladder neck and urethral surgical reconstruction: Surgical reconstructions may be an alternative only in selected cases and generally after failure of more conservative techniques.
Sacral anterior root stimulation, sacral rhizotomy and sacral neuromodulation: In patients with a complete spinal lesion, the nervous system cannot send signals below the level of the injury.
A device can be implanted that is connected to parts of the spinal cord below the lesion to stimulate the bladder and cause urination if activated. This is called sacral anterior root stimulation. It can also be used to induce defecation or erection. This approach has been used successfully in some patients.
Severing of other nerves, called sacral rhizotomy, is used mostly in support of this procedure but also can reduce overactive bladder symptoms.
Sacral neuromodulation is a less invasive technique. Small electrodes are implanted next to the sacral nerves and modulate nerve activity. This technique is widely used in patients without neurological disease. It also might help neuro-urological patients, but its role has not been well established.
Bladder covering by striated muscle: Covering the bladder with muscle tissue from the belly or the back can strengthen the bladder. It can establish a new way to control urinary function (voluntarily or by electrical stimulation). This complex surgical procedure has been used successfully in some neuro-urological patients.
Bladder augmentation: Bladder capacity may be increased and overactivity reduced by surgical expansion of the bladder. This may be achieved by surgery using part of the bladder muscle (auto-augmentation) or intestine or other expandable tissue. The procedure is called augmentation cystoplasty.
It has possible complications such as infections that come back, formation of stones in the urinary tract, and tissue perforation. Patients should be chosen carefully to undergo such major reconstructive surgery.
Urinary diversion: Urinary diversion means creating an artificial way to pass urine from the kidneys without going through the bladder. When all other therapies have failed, this option can protect the kidneys and improve quality of life. Although a diversion can be undone, it may be technically difficult.
Discuss this treatment in detail with your doctor before choosing this option.
Continent diversion: A pouch can be constructed in the body for intermittent catheterisation. Frequent complications may occur such as leakage or narrowing of the tube that carries urine (stenosis).
Incontinent diversion: The surgeon will create a stoma, which is a small portal in the belly. The urine flows through the stoma to an attached collecting bag. This is technically easier to achieve than a continent diversion and usually has fewer complications.
Incontinent diversion cannot be used if you are not able to catheterise or already have severe kidney damage.