Overview of the Treatment Options available for SCI/D 

1. Treatment Options available for SCI/D

  • SCI/D is a long term chronic disease therefore an inappropriate selection of a management method not only adversely affects patient quality of life, but also has a significant impact on the economic status of the health care system [Weld 2000].
  • Various treatment modalities are currently considered for the treatment of the patients with SCI/D neurogenic bladder. However, only a discrete number of such therapies are practically available.
  • The followings are the most representative and commonly performed modalities. More detailed information will be found in each specific section.

Therapy to decrease intravesical pressure (to facility urine storage)

Conservative Bladder Emptying Methods

  • Bladder Expression: Crede or Valsalva Maneuver
  • Triggered Reflex Voiding
  • Urethral Catheter Indwelling
  • Suprapubic Cystostomy
  • Intermittent Catheterization
  • External Catheter System
  • Incontinence Clamp
  • Neuromodulation

Medical Treatment

  • Bladder problem
    • Antimuscarinic agents
    • Drugs with mixed actions
    • Calcium antagonists
    • Potassium channel openers
    • Prostaglandin inhibitors
    • β-Adrenergic agonists
    • Tricyclic antidepressants
    • Dimethyl sulfoxide (DMSO)
    • Polysynaptic inhibitors
    • Capsaicin or resiniferatoxin
  • Urethral problem
    • Decreasing outlet obstruction
      • α-Adrenergic antagonists
      • Skeletal muscle relaxants
    • Increasing outlet obstruction
      • α-Adrenergic agonists
      • Tricyclic antidepressants

Surgical Treatment

  • Bladder problem:
    • Botox injection to the detrusor
    • Mymectomy
    • Enterocystoplasty
    • Other treatment options:
      • Sacral rhizotomy
      • Myoplasty for Functional Sphincter Reconstruction
  • Urethral problem
    • Decrease outlet resistance
      • Surgical sphincterotomy
      • Urethral stent prosthesis
      • Botox injection to the sphincter
    • Increase outlet resistance
      • Sling operation [VIDEO]
      • Artificial Sphincter
      • Surgical Bladder Outlet Reconstruction
    • Closure of the Bladder Outlet

Urinary Diversion

  • Ileovesicostomy, augmentation cystoplasty, ileal conduit
  • Continent catheterizable stoma

Treatment for VUR

  • Bulking Agent Injection [VIDEO]
  • Operative Correction

2. Selection of Treatment

  • It is still uncertain what is the best treatment of the neurogenic bladder to prevent long-term urological complications in the SCI/D patients because of the lack of randomized controlled comparative studies to prove this issue.
  • Several methods of bladder management are available in the post-acute phase of SCI. A number of pharmacological interventions including anticholinergic drugs are used. CISC alone or combined with anticholinergics is usually the primary recommendation as a long-term conservative bladder emptying method.
  • For practical reasons, other methods including reflex voiding and Crede or Valsalva methods are still commonly in use, often combined with condom drainage in men. In addition, indwelling catheterization (urethral or suprapubic) remain in common use. However, before deciding these other options, potential long-term complications should be considered and these should also be communicated to patients.
  • Reversible and less invasive treatment options, like botulinum toxin for the overactive detrusor or the sphincter, can be applied before more invasive treatment options.
  • Once the conservative bladder management and medical management have been tried, surgical options also exist. More complicated procedures like enterocystoplasty, bladder neck reconstruction, sacral anterior root stimulator can be considered for providing a definite solution to neurogenic voiding dysfunction.

3. Considerations Before Initiating Treatments for SCI/D

  • The method of bladder management the post-acute phase should be based on urodynamic evaluation and diagnosis of the type of bladder dysfunction.
  • The type, site, extent of neurological impairment of the patients, medical resources available, the type of treatment options available, will obviously influence the choice of management.
  • It is rational approach to start treatment with the least invasive, simple, and reversible methods: If this fails, more invasive, irreversible and complex options should be considered.
  • In general the earlier a treatment is started the better the outcome will be.
  • Neurogenic lower urinary dysfunction after spinal cord injury evolves from a low pressure situation to a progressively higher pressure state.
  • In most situations, multimodal approaches are necessary: that is one two or three agents to suppress bladder activity and CIC
  • It is important that making the patient and his/her family understand the results of treatment of voiding dysfunction are perfect.
  • The goals of the treatment
  • Any treatment method has to be based on the results of a good urodynamic study.

4. Special Considerations for Treatments for MS

  • Consideration of the natural history of the disease
  • Multiple sclerosis is a progressive disease, slowly or rapidly.
  • Unlike SCI/D there is no time reached where lower urinary tract function is stable.
  • There are three basic types of lower urinary tract dysfunction in this disease.
    • The most common type is DSD with high bladder pressures and moderate residual urine volumes. This requires, ultimately, medication (one, two, or three agents) and CIC.
    • Uncommon is simple, coordinated, uninhibited contractility, with minimal residual. This is almost always seen in very slowly progressive multiple sclerosis
    • Rarely patients present with overflow incontinence but this invariably progresses to DSD.
  • Temporizing measures:
  • In simple OAB without residual urine small doses of an anticholinergic agent , or an alpha blocking agent may relieve symptoms of urgency and difficulty initiating urination and precipitant incontinence
  • In some cases of early DSD, botulinum toxin (100 Units) can be injected into the sphincter (->linked to the Tx-3-2-ii. Botulinum Toxin injection to the sphincter / 1. Concept)
  • Patients who experience a flare up of MS symptoms will lose bladder control, but with subsidence of the flare, bladder symptoms will return to baseline. Surprisingly there are no urodynamic changes associated with these common flare up states.
  • Problems
    • Multiple sclerosis patient will progress.
    • Complex surgery in long standing MS patients is high risk.
    • Younger patients with less advanced disease do better than those with a long standing condition.
    • Reconstruction of a low pressure continent lower urinary tract in MS patients after long periods of treatment by indwelling catheters is especially high risk and a satisfactory result may not be attainable.
Key Points of This Section
  • Control of bladder pressure within rather narrow limits provides definitive treatment od neurogenic vesical dysfunction.
  • There are many diverse ways to do this, but they are all more or less effective. The most effective treatments are those started very early.
  • Spinal cord injury related neurogenic bladder dysfunction evolves toward higher pressure s during the first 2 years after injury. The most effective treatments involve control of bladder pressure very early on in the course of this evolution.
  • Multiple sclerosis is a chronic progressive degenerative disease which never stops evolving.

Reference

  • Weld KJ, Dmochowski RR. Effect of bladder management on urological complications in spinal cord injured patients. J Urol. 2000 Mar;163(3):768-72.

©2007 University of Michigan - Tx

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