Neurogenic Bladder
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For the urinary system to do its job, muscles and nerves must
work together to hold urine in the bladder and then release it at
the right time. Nerves carry messages from the bladder to the brain
to let it know when the bladder is full. They also carry messages
from the brain to the bladder, telling muscles either to tighten or
release. A nerve problem might affect your bladder control if the
nerves that are supposed to carry messages between the brain and the
bladder do not work properly.
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Nerves carry signals from the brain
to the bladder and sphincter. |
Nerves that work poorly can lead to three different kinds of
bladder control problems.
Overactive bladder. Damaged nerves may send signals to the
bladder at the wrong time, causing its muscles to squeeze without
warning. The symptoms of overactive bladder include
- urinary frequency--defined as urination eight or more
times a day or two or more times at night
- urinary urgency--the sudden, strong need to urinate
immediately
- urge incontinence--leakage of urine that follows a
sudden, strong urge
Poor control of sphincter muscles. Sphincter muscles
surround the urethra and keep it closed to hold urine in the
bladder. If the nerves to the sphincter muscles are damaged, the
muscles may become loose and allow leakage or stay tight when you
are trying to release urine.
Urine retention. For some people, nerve damage means that
their bladder muscles do not get the message that it is time to
release urine. If the bladder becomes too full, urine may back up
and the increasing pressure may damage the kidneys. Or urine that
stays too long may lead to an infection in the kidneys or bladder.
Urine retention may also lead to overflow incontinence.
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Many events or conditions can damage nerves and nerve pathways.
Some of the most common causes are
- vaginal childbirth
- infections of the brain or spinal cord
- diabetes
- stroke
- accidents that injure the brain or spinal cord
- multiple sclerosis
- heavy metal poisoning
Some children are born with nerve problems that can keep the
bladder from releasing urine, leading to urinary infections or
kidney damage.
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Any evaluation for a health problem begins with a medical history
and a general physical examination. Your doctor can use this
information to narrow down the possible causes for your bladder
problem.
If nerve damage is suspected, the doctor may need to test both
the bladder itself and the nervous system (including the brain).
Three different kinds of tests might be used:
Urodynamics. These tests involve measuring pressure in the
bladder while it is being filled to see how much it can hold and
then checking to see whether the bladder empties completely and
efficiently.
Imaging. The doctor may use different types of
equipment--x rays, magnetic resonance imaging (MRI), and computed
tomography (CT)--to take pictures of the nervous system and urinary
tract.
EEG and EMG. An electroencephalograph (EEG) is a test in
which wires are taped to the forehead to sense any dysfunction in
the brain. The doctor may also use an electromyograph (EMG) to test
the nerves and muscles of the bladder.
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The treatment for a bladder control problem depends on the cause
of the nerve damage and the type of voiding dysfunction that
results.
In the case of overactive bladder, your doctor may suggest a
number of strategies, including bladder training, electrical
stimulation, drug therapy, and, in severe cases where all other
treatments have failed, surgery.
Bladder training. Your doctor may ask you to keep a
bladder diary, a record of your fluid intake, trips to the bathroom,
and episodes of urine leakage. This record may indicate a pattern
and suggest ways to avoid accidents by making a point of using the
bathroom at certain times of the day--a practice called timed
voiding. As you gain control, you can extend the time between trips
to the bathroom. Bladder training also includes Kegel
exercises to strengthen the muscles that hold in urine.
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| A device can be placed under your skin
to deliver mild electrical pulses to the nerves that control bladder
function. |
Electrical stimulation. Mild electrical pulses can be used
to stimulate the nerves that control the bladder and sphincter
muscles. Depending on which nerves the doctor plans to treat, these
pulses can be given through the vagina, or by using patches on the
skin. Another method is a minor surgical procedure to place the
electric wire near the tailbone. If you have this procedure, it will
involve two steps. In the first step, the wire will be placed and
connected to a temporary stimulator, which you carry with you for
several days. If your condition improves during this trial period,
then you go on to the second step. The wire is placed next to the
tailbone and attached to a permanent stimulator under your skin. The
Food and Drug Administration (FDA) has approved this device,
marketed as the InterStim system, to treat urge incontinence,
urgency-frequency syndrome, and urinary retention in patients for
whom other treatments have not worked.
Drug therapy. Different drugs can affect the nerves and
muscles of the urinary tract in different ways.
- Drugs that relax bladder muscles and prevent bladder
spasms include oxybutynin chloride (Ditropan), hyoscyamine
(Levsin), and propantheline bromide (Pro-Banthine), which belong
to the class of drugs called anticholinergics. Their most common
side effect is dry mouth, although larger doses may cause blurred
vision, constipation, a faster heartbeat, and flushing. A newer
drug, tolterodine (Detrol), has similar effects on the bladder but
has a lower incidence of side effects. Another way to help
decrease the side effects is to use new time-release formulations
that deliver a low level of the drug continuously in the body--for
example, Ditropan XL or Detrol LA.
- Drugs for depression that also relax bladder muscle
include imipramine hydrochloride (Tofranil), a tricyclic
antidepressant. Side effects may include fatigue, dry mouth,
dizziness, blurred vision, nausea, and insomnia.
Surgery. In extreme cases, when incontinence is severe and
other treatments have failed, surgery may be considered. The bladder
may be made larger through an operation known as augmentation
cystoplasty, in which a part of the diseased bladder is replaced
with a section taken from the patient's bowel. This operation may
improve the ability to store urine but may make the bladder more
difficult to empty so that regular catheterization is needed. There
is also a risk that the bladder may break open and leak urine into
the body. Other risks include bladder stones, mucus in the bladder,
and infection.
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The first step is to find the right muscles. Imagine that you are
sitting on a marble and want to pick up the marble with your vagina.
Imagine "sucking" the marble into your vagina.
Try not to squeeze other muscles at the same time. Be careful not
to tighten your stomach, legs, or buttocks. Squeezing the wrong
muscles can put more pressure on your bladder control muscles. Just
squeeze the pelvic muscles. Don't hold your breath.
Repeat, but don't overdo it. At first, find a quiet spot to
practice--your bathroom or bedroom--so you can concentrate. Pull in
the pelvic muscles and hold for a count of 3. Then relax for a count
of 3. Work up to 3 sets of 10 repeats. Start doing your pelvic
muscle exercises lying down. This is the easiest position to do them
because the muscles do not need to work against gravity. When your
muscles get stronger, do your exercises sitting or standing. Working
against gravity is like adding more weight.
Be patient. Don't give up. It takes just 5 minutes a day. You may
not feel your bladder control improve for 3 to 6 weeks. Still, most
people do notice an improvement after a few weeks.
Some people with nerve damage cannot tell whether they are doing
Kegel exercises correctly or not. If you are not sure, ask your
doctor or nurse to examine you while you try to do them. If it turns
out that you are not squeezing the right muscles, you may still be
able to learn proper Kegel exercises by doing special training with
biofeedback, electrical stimulation, or both.
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The job of the sphincter muscles is to hold urine in the bladder
by squeezing the urethra shut. If the urethral sphincter fails to
stay closed, urine may leak out of the bladder. When nerve signals
are coordinated properly, the sphincter muscle relaxes to allow
urine to pass through the urethra as the bladder contracts to push
out urine. If the signals are not coordinated, the bladder and the
sphincter may contract at the same time, so urine cannot pass
easily.
Drug therapy for an uncoordinated bladder and urethra.
Scientists have not yet found a drug that works selectively on the
urethral sphincter muscle, but drugs used to reduce muscle spasms or
tremors are sometimes used to help the sphincter relax. Baclofen
(Lioresal) is prescribed for muscle spasms or cramping in patients
with multiple sclerosis and spinal injuries. Diazepam (Valium) can
be taken as a muscle relaxant or to reduce anxiety. Drugs called
alpha-adrenergic blockers can also be used to relax the sphincter.
Examples of these drugs are terazosin (Hytrin) and doxazosin
(Cardura). The main side effects are low blood pressure, dizziness,
fainting, or nasal congestion. All of these drugs have been used to
relax the urethral sphincter in patients where the sphincter does
not relax well.
Botox injection. Botulinum toxin type A (Botox) is best
known as a cosmetic treatment for facial wrinkles. Doctors have also
found that botulinum toxin is useful in blocking spasms like eye
ticks or relaxing muscles in patients with multiple sclerosis.
Urologists have found that injecting botulinum toxin into the tissue
surrounding the sphincter can help the sphincter to relax. Although
the FDA has approved botulinum toxin only for facial cosmetic
purposes, researchers are studying the safety and effectiveness of
botulinum toxin injection into the sphincter for possible FDA
approval in the future.
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Urine retention may occur either because the bladder wall muscle
cannot contract or because the sphincter muscle cannot relax.
Catheter. A catheter is a thin tube that can be slid
through the urethra into the bladder to let urine flow out into a
collection bag. If you are able to place the catheter yourself, you
can learn to carry out the procedure at regular intervals, a
practice called clean intermittent catheterization (CIC). Some
patients cannot place their own catheters because nerve damage
affects their hand coordination as well as their voiding function.
These patients need to have a caregiver place the catheter for them
at regular intervals. If this is not feasible, the patients may need
to have an indwelling catheter that can be changed less often.
Indwelling catheters have several risks, including infection,
bladder stones, and bladder tumors. However, if the bladder cannot
be emptied any other way, then the catheter is the only way to stop
the buildup of urine in the bladder that can damage the kidneys.
Urethral stent. Stents are small tube-like devices
inserted into the urethra and allowed to expand, like a spring,
widening the opening for urine to flow out. Stents can help prevent
urine backup when the bladder wall and sphincter contract at the
same time because of improper nerve signals. However, stents can
cause problems if they move or lead to infection.
Surgery. Men may consider a surgery that removes the
external sphincter (sphincterotomy) or a piece of it (sphincter
resection) to prevent urinary retention. The surgeon will pass a
thin instrument through the urethra to deliver electrical or laser
energy that burns away sphincter tissue. Possible complications
include bleeding that requires a transfusion and problems with
erections. This procedure causes loss of urine control and requires
the patient to collect urine by wearing an external catheter that
fits over the penis like a condom. No external collection device is
available for women.
Urinary diversion. If other treatments fail and urine
regularly backs up and damages the kidneys, the doctor may recommend
a urinary diversion, a procedure that may require an outside
collection bag attached to a stoma, a surgically created opening
where urine passes out of the body. Another form of urinary
diversion replaces the bladder with a continent urinary reservoir,
an internal pouch made from sections of the bowel or other tissue.
This method allows the person to store urine inside the body until a
catheter is used to empty it through a stoma.
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The National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK) has many research programs aimed at finding
treatments for urinary disorders, including bladder control problems
caused by nerve damage. NIDDK-supported researchers have narrowed
the search for a gene that causes neurological problems in bladder,
bowel, and facial muscles. Finding the gene may lead to greater
understanding of how nerves and muscles work together and how nerve
damage can cause urination problems.
NIDDK is supporting another team of researchers that is testing
an injectable form of oxybutynin, a drug for overactive bladder
currently available in pill form. Injections may deliver a more
effective and efficient dose of oxybutynin because the drug would
not be broken down by the digestive system as the oral form is.
The National Institute of Child Health and Human Development is
supporting Collaborative Urological Research in Spinal Cord Injury,
a program devoted to finding novel strategies to treat bladder
control problems in people with spinal cord injury.
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American Foundation for Urologic
Disease
National Association for Continence
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Bladder Cancer
