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Neurogenic bladder: treatment
Last reviewed: 23.04.2024
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Treatment of a neurogenic bladder should pursue the following goals: preservation of kidney function, creating conditions for adequate emptying of the bladder or holding the urine, and improving the quality of life. In each case, an individual approach is important to determine the tactics of treatment. Treatment of a neurogenic bladder depends on the type of impairment of the function of the lower urinary tract, taking into account the function of detrusor and sphincters of the bladder.
Disturbance of urine accumulation in the bladder
Violation of urine accumulation in the bladder due to neurological diseases and injuries is expressed in neurogenic detrusor hyperactivity (one of the forms of a hyperactive bladder). Approaches to treatment of a hyperactive bladder are detailed in the relevant chapter of this manual.
[4], [5], [6], [7], [8], [9], [10]
Disturbance of emptying the bladder
Detrusor-sphincter dissynergy, violation of detrusor contractile activity and violation of adequate relaxation of sphincters lead to impairment of emptying of the bladder.
Intermittent autoclotification of the bladder, proposed by Lapides in 1972, is by far the best method for treating patients with impaired bladder emptying due to neurological diseases. However, in patients with impaired function of the hands (can not perform periodic self-cate- geration), as well as in patients who for one reason or another refuse this type of emptying the bladder, other methods are used.
The smooth muscles of the neck of the bladder and the proximal urethra are controlled by tonic sympathetic stimuli through alpha-adrenergic receptors. Blockade of alpha-adrenergic receptors can improve the emptying of the bladder. Despite the fact that alpha-adrenoblockers (tamsulosin, alfuzazine, doxazosin and others) are successfully used in the treatment of patients with prostate adenoma, they have not found wide application in functional disorders of emptying the bladder. Nevertheless, most authors consider it advisable to use alpha-adrenoblockers in mild forms of impairing the function of emptying the bladder.
With detrusor-sphincter dissipation accompanied by high detrusor pressure (more than 40 cm of water), it is very important to choose an adequate method of emptying the bladder during urination.
Medicamentous treatment of the neurogenic bladder includes benzodiazepines and muscle relaxants of central action. The most commonly used muscle relaxants are central action. They reduce the excitation of motor neurons and interneurons and are able to inhibit the transmission of the nerve impulse in the spinal cord, reducing spasticity of the striated muscles. However, when using these drugs, even in the maximum allowable doses, only 20% of patients have a positive effect.
Drug treatment of a neurogenic bladder (metoclopramide) is also not significant in treating patients with a decrease or lack of detrusor contractile activity. Some patients with a decrease or lack of detrusor contractile activity and with a paralytic condition of the urethral transverse striatal sphincter can empty the bladder by artificially increasing intraabdominal pressure by digital compression of the lower abdominal parts (receiving Creed). With the spastic condition of the external sphincter of the urethra, the reception of Creed does not lead to adequate emptying of the bladder.
If the patient is unable to perform or refuse the autocatheterization, as well as in the ineffectiveness of drug treatment, patients with both detrusor-sphincter dissynergy and with violation of detrusor contractile activity in combination with the spastic condition of the external sphincter of the urethra, surgical methods of treatment. In particular, an injection of botulinum neurotoxin type A into the region of the urethral transverse striatal sphincter is used. TUR of the neck of the bladder, incision of the transverse striatal sphincter of the urethra and implantation of special stents into the zone of the external sphincter of the urethra.
100 units of botulinum neurotoxin type A diluted in 8 ml sterile 0.9% sodium chloride solution. The drug is injected into the external sphincter of the urethra. In men, the drug is administered transurethral at four points on 3,6,9 and 12 hours on the conventional dial, and in women - in two points on the left and right of the urethra. Chemodenervation of the external sphincter of the urethra reduces intra-urethral resistance, thereby improving the emptying of the bladder, and in some cases restoring self-urination.
TUR of the neck of the bladder is used for obstruction of the neck of the bladder and the proximal part of the urethra, established according to the results of the video-dynamic study. The bladder neck is dissected through all layers for 5 and / or 7 hours according to the conventional dial (in men - from the base of the bladder to the seminal tubercle).
Injection of the transverse striatal sphincter of the urethra (sphincterotomy) is performed with a cold knife or with a laser for 12 hours on a conventional dial. Positive results mark in 70% of patients. Possible complications: bleeding, impotence, urinary swells.
Treatment of a neurogenic bladder also requires the use of permanent metal stents. Stents are installed transurethral in such a way that only the transverse striatal sphincter of the urethra is to be ligated. In this position, the smooth muscle fibers of the bladder neck provide urine retention. Of the complications, spontaneous stent migrations and stent encrustation most often occur with salts.
Electrostimulation of the anterior sacral roots is also used in the treatment of neurological patients with impaired function of emptying the bladder. The technique was first proposed by Brindley. Applied in patients with complete spinal cord injury. Electrostimulation of the anterior roots of the sacral spinal cord simultaneously stimulates autonomous detrusor fibers and somatic fibers of the external sphincter of the urethra and pelvic diaphragm. Due to the fact that the striated muscle fibers are not capable of prolonged tonic contraction, the intraurethral pressure decreases, and the reduction of the smooth muscle fibers of the detrusor contributes to urination.
In special cases of severe course of neurogenic dysfunction of the lower urinary tract and severe disability of the patient, urinary discharge from the bladder is carried out by installing a permanent urethral catheter or suprapubic cystostomy.
Treatment of sphincter incontinence in case of violation of the innervation of the transverse striatal sphincter of the urethra is performed by an operative intervention. Women use urethral sling and artificial sphincter, men have artificial sphincter.
Thus, the manifestations of violations of the act of urination in patients with neurogenic dysfunction of the lower urinary tract are quite diverse. In all cases, it is necessary to carry out a complex UDI to clarify the functional state of the bladder and its sphincters. Unfortunately, the modern treatment of a neurogenic bladder in the vast majority of patients does not allow to completely restore the normal function of the lower urinary tract, and then the treatment consists in choosing an adequate method of emptying the bladder that is appropriate for a particular patient.