Hello,
Thanks for asking your question. Although I am an internal medicine
physician, please see your primary care physician for specific
questions regarding any individual cases – please do not use Google
Answers as a substitute for medical advice. I will be happy to answer
factual medical questions.
You asked the following:
"I can't sense the need to urinate. Have had the problem since birth.
I
use a cathator to empty my bladder. Is there a surgical procedure or
medical treatment that will solve this problem?"
What you are describing is a neurogenic bladder.
From eMedicine:
"Neurogenic bladder is a malfunctioning bladder due to any type of
neurologic disorder."
http://www.emedicine.com/med/topic3176.htm
Here are some symptoms of neurogenic bladder:
"The muscles and nerves of the urinary system work together to hold
urine in the bladder and then release it at the appropriate time.
Nerves carry messages from the bladder to the brain and from the brain
to the muscles of the bladder telling them either to tighten or
release. In a neurogenic bladder, the nerves that are supposed to
carry these messages do not work properly". Symptoms can include
"loss of sensation of bladder fullness."
http://www.jeffersonhospital.org/e3front.dll?durki=5292
The specific symptom of loss of sensation to urinate is addressed
here:
"Diabetes mellitus and AIDS are 2 of the conditions causing peripheral
neuropathy resulting in urinary retention. These diseases destroy the
nerves to the bladder and may lead to silent, painless distention of
the bladder. Patients with chronic diabetes lose the sensation of
bladder filling first, before the bladder decompensates. Similar to
injury to the sacral cord, affected individuals will have difficulty
urinating. They also have lazy bladders.
Other diseases manifesting this condition are poliomyelitis,
Guillain-Barré syndrome, severe herpes in the genitoanal area,
pernicious anemia, and neurosyphilis (tabes dorsalis)."
http://www.emedicine.com/med/topic3176.htm
You asked about medical and surgical treatments to solve this problem.
Detailed treatment for neurogenic bladder is from eMedicine.com:
"1) Indwelling urethral catheters
Commonly known as Foley catheters, indwelling urethral catheters
historically have been the mainstay of treatment for bladder
dysfunction. If urethral catheters are used for a long-term condition,
they must be changed monthly. These catheters may be changed at an
office, a clinic, or at home by a visiting nurse.
The usual practice is to change indwelling catheters once every month.
The catheter and bag are replaced on a monthly basis; however,
catheters that develop encrustations and problems with urine drainage
must be changed more frequently. All indwelling catheters in the
urinary bladder for more than 2 weeks become colonized with bacteria.
In spite of its apparent advantages, the use of a Foley catheter for a
prolonged period of time (eg, months to years) is strongly
discouraged. Chronic dependence on these catheters is extremely risky
because long-term use of urethral catheters poses significant health
hazards. Indwelling urethral catheters are a significant cause of
urinary tract infections that involve the urethra, bladder, and
kidneys. Within 2-4 weeks after catheter insertion, bacteria will be
present in the bladder of most women. Asymptomatic bacterial
colonization is common and does not pose a health hazard. However,
untreated symptomatic urinary tract infections may lead to urosepsis
and death. The death rate of nursing home residents with urethral
catheters has been found to be 3 times higher than that of residents
without catheters.
Another problem of long-term catheterization is bladder contracture,
which occurs with urethral catheters as well as suprapubic tubes.
Anticholinergic therapy and intermittent clamping of the catheter in
combination have been reported to be beneficial for preserving the
bladder integrity with long-term catheter use. Individuals who did not
use the medication and daily clamping regimen experienced a decrease
in bladder capacity and vesicoureteral reflux. For this reason, some
physicians recommend using anticholinergic medications with
intermittent clamping of the catheter if lower urinary tract
reconstruction is anticipated in the future.
2) Suprapubic catheters
A suprapubic tube is an attractive alternative to long-term urethral
catheter use. The most common use of a suprapubic catheter is in
individuals with spinal cord injuries and a malfunctioning bladder.
Both people who are paraplegic and people who are quadriplegic have
benefited from this form of urinary diversion. Like the urethral
catheter, change the suprapubic tube once a month on a regular basis.
Suprapubic catheters have many advantages. With a suprapubic catheter,
the risk of urethral damage is eliminated. Multiple voiding trials may
be performed without having to remove the catheter. Because the
catheter comes out of the lower abdomen rather than the vaginal area,
a suprapubic tube is more patient-friendly. Bladder spasms occur less
often because the suprapubic catheter does not irritate the trigone as
does the urethral catheter. In addition, suprapubic tubes are more
sanitary for the individual, and bladder infections are minimized
because the tube is away from the perineum.
A suprapubic catheter is an alternative solution to an indwelling
urethral catheter in women who require chronic bladder drainage.
Potential problems unique to suprapubic catheters include skin
infection, hematoma, bowel injury, and problems with catheter
reinsertion. Long-term management of a suprapubic tube also may be
problematic if the health care provider lacks the knowledge and
expertise of suprapubic catheters or if the homebound individual lacks
quick access to a medical center in case of an emergency. In the
appropriate situation, the suprapubic catheter affords many advantages
over long-term urethral catheters.
3) Intermittent catheterization
Intermittent catheterization or self-catheterization is a mode of
draining the bladder at timed intervals, as opposed to continuous
bladder drainage. A prerequisite for self-catheterization is the
patients’ ability to use their hands and arms; however, in a situation
in which a patient is physically or mentally impaired, a caregiver or
health professional can perform intermittent catheterization for the
patient. Of all 3 possible options (ie, urethral catheter, suprapubic
tube, intermittent catheterization), intermittent catheterization is
the best solution for bladder decompression of a motivated individual
who is not physically handicapped or mentally impaired.
Intermittent catheterization is designed to simulate normal voiding.
Usually, the average adult empties the bladder 4-5 times a day. Thus,
catheterization should occur 4-5 times a day; however, individual
catheterization schedules may vary, depending on the amount of fluid
taken in during the day.
Potential advantages of performing intermittent catheterization
include patient autonomy, freedom from indwelling catheter and bags,
and unimpeded sexual relations. Potential complications of
intermittent catheterization include bladder infection, urethral
trauma, urethral inflammation, and stricture. Concurrent use of
anticholinergic therapy will maintain acceptable intravesical
pressures and prevent bladder contracture. Studies have demonstrated
that long-term use of intermittent catheterization appears to be
preferable to indwelling catheterization (ie, urethral catheter,
suprapubic tube) with respect to urinary tract infections and the
development of stones within the bladder or kidneys."
http://www.emedicine.com/med/topic3176.htm#section~types_of_neurogenic_bladders
For surgical options, augmentation cystoplasty is the procedure of
choice for neurogenic bladder. Full details of this procedure can be
found on the eMedicine site:
"Any patient with marked reduction in bladder capacity or compliance
may be a candidate for augmentation cystoplasty. Augmentation
cystoplasty is considered when a patient has symptoms so severe that,
despite medical treatment, the person’s lifestyle is limited or when a
person has such high-pressure urinary storage that the upper urinary
tracts are at risk. Both neuropathic and nonneuropathic causes for
bladder dysfunction exist in pediatric and adult populations."
http://www.emedicine.com/med/topic3020.htm
There have been studies suggesting that it has been an effective
therapy. Quek (2003) describes one of them:
"PURPOSE: Augmentation enterocystoplasty is well tolerated by patients
with neurogenic bladder in whom conservative therapy has failed.
However, few studies exist on long-term urodynamic evaluation of these
patients. We assessed the clinical and urodynamic outcomes of patients
with neurogenic bladder treated with augmentation enterocystoplasty
with at least 4 years of followup. MATERIALS AND METHODS: A total of
26 patients with neurogenic voiding dysfunction underwent augmentation
enterocystoplasty alone or in conjunction with various continence or
antireflux techniques. Clinical outcomes regarding incontinence,
medications, catheterization schedule, subsequent interventions, bowel
function and patient satisfaction were addressed. Urodynamic
evaluation was performed to assess the long-term durability of bladder
augmentation. RESULTS: Mean followup was 8.0 years (range 4 to 13).
All but 1 patient (96%) in our series had near or complete resolution
of urinary incontinence. Mean total bladder capacity +/- SD increased
from 201 +/- 106 to 615 +/- 204 ml. (p <0.001) and mean maximum
detrusor pressure decreased from 81 +/- 43 to 20 +/- 12 cm. H O (p
<0.01). Mean interval between catheterizations was 5 hours, with
volumes ranging from 314 to 743 ml. Only 2 patients (8%) needed a low
dose of oxybutynin postoperatively to maintain continence
consistently. Of the 26 patients 23 (88%) reported no significant
change in bowel function and nearly all patients expressed extreme
satisfaction with urological management. A subsequent urological
procedure was required in 12 patients (46%) at a mean of 4.4 years
after initial surgery.(2)CONCLUSIONS: Bladder augmentation provides
durable clinical and urodynamic improvement for patients with
neurogenic bladder dysfunction refractory to conservative therapy.
Furthermore, there is a high level of patient satisfaction with
bladder augmentation." (2)
Nomura et al. (2002) discusses a second procedure, augmentation
ileocystoplasty, and notes that it is effective for neurogenic bladder
that has failed conservative therapy:
"Study design: Retrospective analysis of augmentation ileocystoplasty
for neurogenic bladder.
Objectives: To analyze the effects and complications of augmentation
ileocystoplasty in patients with neurogenic bladder due to spinal cord
injury (SCI) or spina bifida retrospectively.
Setting: Department of Urology, Kanagawa Rehabilitation Hospital,
Japan.
Methods: We have treated 11 patients with neurogenic bladder due to
SCI and 10 patients with spinal bifida with augmentation
ileocystoplasty since 1989. The purpose of the treatment was to stop
vesicoureteral reflux (VUR) and/or amelioration of urinary
incontinence. In 17 of 21 cases, the antireflux operation was received
simultaneously. All cases performed clean intermittent self
catheterization postoperatively.
Results: Urinary incontinence improved in all cases and only transient
recurrence of VUR was observed in the follow-up term. Complications
occurred in patients with SCI, but they could be treated
conservatively.
Conclusion: Augmentation ileocystoplasty is a good treatment option
for contracted bladder or VUR, which occurs in patients with
neurogenic bladder."
http://www.nature.com/cgi-taf/DynaPage.taf?file=/sc/journal/v40/n1/full/3101249a.html
Burns et. al (2001) overviews the medical and surgical management of
neurogenic bladder in his review article:
"The presence of neurogenic bladder requires intervention to prevent
long-term complications such as ureteral reflux. Management strategies
focus on achieving adequate drainage, low-pressure urine storage, and
low-pressure voiding. After any therapeutic intervention, follow-up
testing should be performed to confirm that bladder pressures have
been effectively lowered. In women and men, reflexive contractions can
be suppressed with anticholinergic agents such as oxybutynin chloride
and tolterodine tartrate. In some cases, anticholinergic suppression
has been further augmented by the addition of tricyclic
antidepressants . . . If medications alone fail to work, bladder
augmentation can facilitate low-pressure storage. Bladder emptying can
then safely be accomplished with intermittent catheterization. Many
patients with motor levels of C7 and below can be taught to perform
self-catheterization. Bladder augmentation procedures with urinary
diversion can sometimes facilitate intermittent catheterization via an
easier to reach abdominal stoma.
Alternatively, outlet obstruction can be reduced by transurethral
sphincterotomy or placement of a urethral stent. Surgical and other
invasive procedures should be viewed as irreversible, and patients
should be counseled accordingly. Afterwards, reflexive voiding can
then be managed by wearing a condom (external) catheter.
Another increasingly popular approach to the management of UMN bladder
dysfunction is the use of electric stimulation. The NeuroControl
VOCARE Bladder System (NeuroControl Corp., Valley View, OH) is an
implantable device currently available in the United States. First, a
posterior rhizotomy of the sacral nerve roots is performed to prevent
reflex incontinence. Electrodes are then attached to the anterior
nerve roots. Electrical stimulation of these roots causes simultaneous
contraction of the detrusor and sphincters. Because the
striated-muscle external sphincter fatigues before the smooth-muscle
detrusor, voiding occurs in short spurts when the sphincter
intermittently relaxes. The device can also improve rectal evacuation
and has been approved by the Federal Drug Administration for bowel
management alone.
Long-term management with an indwelling catheter should be the choice
of last resort. It can increase the risk for recurrent bladder
infections and bladder stones. Nevertheless, it is sometimes indicated
in the patient who lacks the manual dexterity to perform intermittent
catheterization and does not have additional assistance available.
This is more commonly an issue in women because the option of an
external catheter is unavailable and intermittent catheterization is
made more difficult by anatomic considerations. In men who will
require a long-term indwelling catheter, consideration should be given
to converting to a suprapubic catheter to prevent complications such
as improper insertion and placement, urethral strictures and fistulas,
and urethral erosions. Indwelling catheters should be replaced every
3–4 weeks." (1)
Finally, the American and Canadian Spinal Research Organization
discusses the use of capsaicin for neurogenic bladder in this article:
http://www.csro.com/3-7.html
I stress that this answer is not intended as and does not substitute
for medical advice - please see your primary care physician for
further evaluation of your individual case.
Please use any answer clarification before rating this answer. I will
be happy to explain or expand on any issue you may have.
Thanks,
Kevin, M.D.
Medline search:
neurogenic bladder restricted to full-text articles
neurogenic bladder and surgery
FAST, Google, Teoma and Inktomi search:
neurogenic bladder
augmentation cystoplasty
treatment of neurogenic bladder
Bibliography:
1) Burns AS. Rivas DA. Ditunno JF. The management of neurogenic
bladder and sexual dysfunction after spinal cord injury. [Review] [82
refs] Spine. 26(24 Suppl):S129-36, 2001 Dec 15.
2) Quek ML. Ginsberg DA. Long-term urodynamics followup of bladder
augmentation for neurogenic bladder. Journal of Urology. 169(1):195-8,
2003 Jan.
Links:
NIDDK - Neurogenic Bladder
http://www.niddk.nih.gov/health/urolog/summary/neuro/
Merck Manual - Neurogenic Bladder
http://www.merck.com/pubs/mmanual_home/sec11/129.htm
Thomas Jefferson Hospital - Neurogenic Bladder
http://www.jeffersonhospital.org/e3front.dll?durki=5292
eMedicine - Neurogenic Bladder
http://www.emedicine.com/med/topic3176.htm#section~types_of_neurogenic_bladders |
