CUA 2018: What Every Urologist Should Know About Neurogenic Bladder

Halifax, Nova Scotia ( Anne Pelletier-Cameron, MD, provided a State-of-the-Art lecture at CUA 2018, discussing what every urologist should know about neurogenic bladder. Dr. Pelletier-Cameron notes that her top 5 lists for every patient with neurogenic bladder is:
  1. Keep the patient safe (protect the kidneys) and dry
  2. Manage their catheters
  3. Know when not to panic
  4. Keep the patient infection free
  5. Know when to “throw in the towel”
Neurogenic bladder results secondary to a disruption in communication between the brain and bladder, at any level. This may include at the level of (i) the brain, (ii) the spinal cord (any level), or (iii) pudendal nerves. Neurogenic bladder prevalence is as follows:
  • Spinal cord injury patients: ~100% have bladder symptoms and 80% cannot void
  • Multiple sclerosis patients: 80% have bladder symptoms, which increases to 96% at 10 years after disease onset
  • Spina bifida patients: 90% have bladder symptoms
The priorities of these patients are: #1 to retain some level of bowel/bladder and sexual function and #2 to retain mobility of hand function. The goals of bladder management from a urologist’s standpoint is:
  1. Prevent upper tract deterioration – by keeping bladder pressure low
  2. Maintain continence – by keeping bladder pressure low and the bladder empty
  3. Maintain an empty bladder by voiding – which is easiest for the patient
Dr. Pelletier-Cameron then highlighted keys to urologic follow-up for patients after a spinal cord injury:
Do not:
  • Screen for cancer with a cystoscopy or cytology
  • Screen for UTIs with routine cultures in asymptomatic patients
  • Screen for kidney dysfunction with serum creatinine
  • Obtain KUBs
  • Upper tract screening with an ultrasound – this is appropriate for identifying stones in the bladder or kidney, and for assessing hydronephrosis (if hydronephrosis is present, obtain and nuclear medicine renal study)
  • Perform urodynamics at presentation and at some point during follow-up. Dr. Pelletier-Cameron notes that the frequency of urodynamic evaluation in follow-up is somewhat unclear
Dr. Pelletier-Cameron states that the mainstay of treatment for patients with neurogenic bladder is medical therapy, notably with antimuscarinics and beta-3 agonists. Her treatment algorithm is as follows:
neurogenic bladder treatment algorithm
When performing botox injections, Dr. Pelletier-Cameron typically injects 10 sites, including 200 mg of botox for those unable to void (100 mg for those who wish to void volitionally), and typically injects patients every 3-12 months, based on symptoms. 

When managing the patients who require catheterization, Dr. Pelletier-Cameron notes that it is important to develop a bladder management plan. She is a huge proponent of clean intermittent catheterization (CIC) rather than indwelling catheters, even though these are often placed for incontinence or difficulty with CIC. Several complications of indwelling catheters in spinal cord injury patients are as follows:
  • 6x more likely to develop an infection
  • 4.9 increased RR of malignancy
  • 20x more likely to develop bladder stones, and 2x more likely to develop kidney stones
  • Devastating cases of urethral erosion and decubitus ulceration
For those that are unable to perform CIC, Dr. Pelletier-Cameron recommends a suprapubic catheter. Secondary to a rate of bowel injury of 5% during placement of suprapubic catheters in the spinal cord injury population (due to distended, neurogenic bowels), Dr. Pelletier-Cameron prefers placement of the suprapubic catheter using a Lowsley retractor in the operating room, which allows immediate placement of a 22Fr large bore catheter (less likely to get clogged with sediment). 

Dr. Pelletier-Cameron notes that it is not time to panic when assessing high post-void residual (PVR) volumes. No studies to date have been able to deem a PVR volume as worrisome, as these patients are no more likely to develop infections or upper tract deterioration. Bladder compliance is more important than a specific PVR number, according to Dr. Pelletier-Cameron. 

It is also important to keep these patients infection free. Neurogenic bladder patients are more prone to infection for several reasons:
  • Decreased bladder glycosaminoglycan layer
  • Poor bladder compliance leading to less blood flow to the bladder
  • Poor urine hydrokinetics
  • Changes in urothelial immune response
  • Vesicoureteral reflux
  • Catheterization 
  • Perineal soiling and flora changes
Conservative measures for decreasing risk of infection include: (i) drinking more fluids, (ii) cleaning the meatus, (iii) hand washing, (iv) catheterizing often enough (at least every 4 hours), and (v) using catheter lubricant. Although the data isn’t strong, Dr. Pelletier-Cameron suggests that using Hiprex supplementation may be of use in certain patients. However, Dr. Pelletier-Cameron is a proponent of bladder irrigations using gentamicin, which is an aminoglycoside antibiotic that is highly polar and not absorbed via the bladder. To do this, she mixes 480 mg of gentamicin in 1L of saline and has the patient instill 30-60 mL once every day. In a study from her institution, this practice led to a median decrease in infections from 4 to 1. Her clinical strategy for decreasing infections is as follows:
neurogenic bladder clinical strategy
Despite the number of non-surgical options available for assisting patients, Dr. Pelletier-Cameron notes there are certain times when one must “throw in the towel” and perform a surgical procedure. These situations include severe urethral erosion and severe decubitus ulcers. Dr. Pelletier-Cameron’s preferred procedure is creation of a continent catheterizable stoma. In instances where urine or fecal soiling in the setting of decubitus ulcers may lead to life-threatening infections, she is a strong advocate of urgent dual urinary and bowel ostomy diversion.

Presented by: Anne Pelletier-Cameron, MD, University of Michigan, Ann Arbour, MI

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, Twitter: @zklaassen_md, at the 73rd Canadian Urological Association Annual Meeting - June 23 - 26, 2018 - Halifax, Nova Scotia