Mikolaj Przydacz

What do we know about neurogenic bladder prevalence and management in developing countries and emerging regions of the world

OBJECTIVE To summarize information on Neurogenic Bladder (NB) epidemiology, management and access to patient treatment in developing countries and emerging regions of the world in order to propose future interventions and help governmental as well as non-governmental organizations design their action plans. METHODS Different search methods were used to gather the maximum available data. They included strategic searches; reference checks; grey literature searches (reports, working papers, government documents, civil society information); contacting professional societies, registries, and authors; requesting unpublished data from organizations; and browsing related websites and journals. RESULTS The incidence and prevalence rates of NB in developing countries are difficult to establish because epidemiological reports are few and far between. The frequency of bladder dysfunction in neurologically impaired populations can be approximately estimated in some of these countries. Similar information paucity affects diagnostic and therapeutic approaches to NB patients living in less-developed regions of the world. The assessment and management of NB seems to vary markedly between countries, and care of patients from emerging regions of the world is often inadequate. CONCLUSION Strong concerted efforts are needed on the part of international scientific societies, non-governmental organizations and local governments to work together to change the prognosis for these patients and to improve their quality of life.

Medical History and Physical Examination

The first step in a consultation of patients after spinal cord injury suffering from lower urinary tract symptoms is a comprehensive medical history and detailed examination. Good communication is important to reduce patients’ anxieties and fulfill their expectations. Patient history should be started with an assessment of general condition, psychological status, and quality of life. The symptom history is both an important summary of the patient’s problems and a useful guide for physical examination and further diagnostic procedures. It should particularly investigate urological, bowel, and sexual dysfunctions. Patient self-completed and interviewer-administered questionnaires can be a suitable method for assessing the patient’s perspective of bothersome symptoms and impact on patients’ quality of life. Further investigation of related comorbidities and current medications is also important. Evaluation of patient’s social situation should complete a well-taken medical history. Physical examination is a continuation of a comprehensive history. In addition to standard procedures, special attention must be paid to sensation within urogenital area, lumbosacral reflexes, as well as function of anal sphincter and pelvic floor muscles. They may help to localize anatomical lesions and estimate the extent of dysfunction. Both patient history and physical examination should be performed with standardized methods and recommended tools.

Book Presentation with Overview of Bladder Physiology

The bladder and the urethra serve two main functions: storage and periodic release of urine. These two functions are controlled by peripheral and central nervous systems. Afferent and efferent pathways of the lower urinary tract are included in hypogastric, pelvic, and pudendal nerves. Coordinated activities of the peripheral nervous system innervating the bladder and the urethra depend on multiple reflex pathways organized in the brain and spinal cord. Special role belongs to sacral and pontine micturition centers additionally supported by cerebral cortex. Whereas the sacral micturition center is primarily a reflex center for bladder contractions, the pontine micturition center is primarily responsible for coordinating relaxation of the urinary sphincter when the bladder contracts. Cortical influence has a role in determining when and where void may be safely performed.

Benign Prostatic Hyperplasia and Neurogenic Bladder

Patients with neurogenic bladder dysfunction who have developed benign prostatic hyperplasia represent a unique population. Proper diagnosis and treatment of these individuals remain a challenge for urologists. Therapy should aim to preserve renal function and maintain a low-pressure bladder system as well as help to minimize distress and pain by continued bladder decompression. Initial management should include pharmacotherapy (α-blockers often in combination with 5-α reductase inhibitors). When medical therapy has failed or is contraindicated, surgery or indwelling catheterization should be considered in carefully selected patients.

Urinary Tract Infection

Patients with neurogenic bladder dysfunction are at risk for urinary tract infection (UTI) both because of their disease and the method by which they manage their bladder. Neurogenic patients frequently present with atypical symptoms of UTI, including urinary incontinence, increased spasticity, malaise, lethargy, sense of unease, and autonomic dysreflexia. Consensus states that asymptomatic bacteriuria should not routinely be treated in neurogenic patients because of rising resistance patterns and lack of clinical efficacy. Treatment of UTI in neurogenic patients remains a challenge for urologists and other clinicians, as antibiotic choice and therapy duration are complicated by the variability of microorganisms and high rates of antimicrobial resistance in this population. Because of an increased incidence of resistant bacterial species in persons with neurogenic lower urinary tract dysfunction, the treatment employed should rely on urine culture with sensitivity to guide antibiotic therapy. Currently, no single preventive agent has been identified as a gold standard therapy. Multiple UTI prevention methods involve mechanical techniques and pharmacologic prophylaxis with antibiotics and infection inhibitors. Nevertheless, prevention of UTI in patients with neurogenic lower urinary tract dysfunction is highly limited and may be associated with a risk of emergence of resistant organisms. Optimizing bladder management remains one of the most important modifiable factors to prevent UTI.

Neurogenic Bladder Pathophysiology

Pathophysiology of neurogenic bladder (NB) is multifactorial, ununiform, and highly complex. Underlying mechanism of neurogenic detrusor overactivity may include a lack of inhibition of motor pathway or enhancement of sensory input and/or motor output. Pathophysiology of neurogenic detrusor underactivity may involve dysfunctions of sensory input, decrease of motor output, reduction of central excitatory transmission, or enhancement of central inhibition. Detrusor-sphincter dyssynergia is the result of increased motor output to the urethral sphincter during contractions of detrusor smooth muscle. Sphincter deficiency is the outcome of decreased motor enhancement to the sphincter. Understanding the basic pathophysiology of NB helps to diagnose and treat NB patients.

Reports and Guidelines on Neurogenic Bladder

Numerous reports and guidelines have been developed to support clinicians in their day-to-day clinical practice of neurourology. These documents have been constantly changing and should be followed to properly manage neurogenic individuals.

Incontinence Due to Neurogenic Sphincter Deficiency

Incontinence due to neurogenic sphincter deficiency (NSD) typically occurs in individuals with myelodysplasia, sacral agenesis, sacral/infrasacral spinal cord injury, laminectomy complications, vertebral disk disease, severe pelvic fractures, and nerve injury from resection of low colorectal cancers. A comprehensive history and physical examination should be supported by a bladder diary, symptom questionnaires, urinalysis, urine culture, pad-weighing test, renal assessment, and optional other investigations. Urodynamic testing provides objective data of NSD presented as stress urinary incontinence. Low maximal urethral closure pressure and low abdominal leak point pressure are commonly used as indicators of intrinsic sphincter deficiency. Management includes conservative treatment with pelvic floor rehabilitation, artificial urinary sphincters, slings (autologous and synthetic), peri-urethral bulking agents, adjustable continence devices, bladder neck reconstruction techniques, and supraurethral diversion with bladder neck/urethra closure.

Incontinence Due to Neurogenic Detrusor Overactivity

Incontinence due to neurogenic detrusor overactivity (NDO) is often the most bothersome symptom that significantly decreases patients’ quality of life. It typically occurs when neurological lesions affect suprapontine and/or suprasacral pathways regulating functions of the bladder. This mainly includes patients after stroke or suprasacral spinal cord injury as well as those with multiple sclerosis and Parkinson disease. Comprehensive history and physical examination need to be supported by a bladder diary, symptom questionnaires, urinalysis, urine culture, pad-weighing test, renal assessment, and other investigations. Urodynamic study is the cornerstone in the diagnosis and management of patients suffering from incontinence due to NDO. Investigated abnormalities include involuntary detrusor contractions, decreased compliance, increased bladder sensation, and/or decreased cystometric capacity. Treatment of NDO aims to protect renal function and improve quality of life. Management includes conservative treatment, pharmacotherapy, bladder injections with botulinum toxin A, nerve stimulation, and surgery.

Other (Bladder Cancer, Sexual Dysfunction)

Bladder cancer is a significant oncologic complication in patients suffering from neurogenic lower urinary tract dysfunction. Available data suggest that bladder cancer occurs more often in neurogenic individuals than in the general population. It is also associated with significant mortality. Several risk factors have been identified, but the proposed screening strategies still remain a matter of dispute because available screening tests do not fulfill multiple criteria of a proper screening test. The potential morbidity, financial burden, and lack of proven benefit discourage currently available screening strategies in this specific population. Neurogenic individuals continue to have active sexual lives and to consider sexuality as one of their priorities. Sexual dysfunction is highly prevalent and adversely affects the quality of life of neurogenic patients. Neurogenic sexual dysfunction remains difficult to diagnose and treat effectively. Neurogenic patients, regardless of sex, should be specifically queried about sexual function. In males, treatment includes oral and local pharmacotherapy, mechanical (vacuum constriction) devices, and prosthetics. Treatment of sexual dysfunction in neurologically impaired women is rather limited and poorly studied.