Bladder management in individuals with chronic neurogenic lower urinary tract dysfunction

Heavy moxibustion at Sanyin point ameliorates neurogenic bladder dysfunction in spinal cord injury rats through the PI3 K/mTOR pathway

OBJECTIVE

The present study aims to investigate the effect and mechanism of heavy moxibustion (100 moxa-cone) at Sanyin point (the common point of Yin and kidney) on the function of neurogenic bladder (NB) dysfunction in rats with spinal cord injury (SCI).

METHODS

Twenty-four male Sprague-Dawley rats were divided into four groups (n = 6): control, NB, NB + Moxibustion, and NB + Moxibustion + YS-49 (PI3 K agonist). The rats in control groups accepted a cut open of the skin, fascia, and muscle. The NB model was established using spinal cord transection. Fourteen days later, animals received heavy moxibustion at Sanyin point for three weeks or/and intraperitoneal administration of YS-49 (a PI3 K agonist). Basso, Beattie, and Bresnahan (BBB) scale, urodynamic parameters, bladder size, and weight were measured. The hematoxylin-eosin staining method was used to observe the histology of the bladder mucosa. Moreover, NB dysfunction after SCI could be restored by autophagy activation and autophagy is mediated by the PI3 K/Akt/mTOR pathway. Therefore, the expressions of autophagy factor (LC3 II/I and p62), PI3 K, and p-mTOR in the bladder mucosa were evaluated by western blotting.

RESULTS

Heavy moxibustion treatment relieved the development of NB dysfunction in rats with SCI, with an increase in the bladder voiding efficiency and a decrease in afferent activity during storage in the moxibustion group compared with the NB group. The expression levels of LC3 II/I were markedly elevated by moxibustion, accompanied by a decrease in the levels of p62. YS-49 addition increased the PI3 K and p-mTOR expression which were down-regulated by moxibustion. Importantly, YS-49 reversed the effects of moxibustion on autophagy and bladder function.

CONCLUSION

Heavy moxibustion at Sanyin point exerted its effect on healing-impaired NB dysfunction in rats with SCI, possibly activating autophagy through the PI3 K/mTOR pathway.

An in-vitro model for bacteria-related catheter encrustations

PURPOSE

About 50% of individuals with long-term indwelling catheters are affected by catheter encrustations and bladder stone formation. Therefore, prophylaxis of catheter encrustations is important. Currently, however, neither an established prophylaxis nor a standardized in-vitro model to test different measures exist. We have therefore developed and qualitatively evaluated an in-vitro model of catheter encrustation.

METHODS

Size 14 French suprapubic catheters were incubated under sterile conditions at 37 degrees Celsius in five different media: (1) sterile artificial urine (n = 16), (2) artificial urine with E. coli (n = 8), (3) with Pseudomonas aeruginosa (n = 8), (4) with Proteus mirabilis (n = 8), and (5) with a mix of these three strains (n = 8). Catheter balloons were inflated either a glycerine or a bactericidal solution. After 6 weeks, the catheters were removed from the solution, dried, and weighed, and a photometric determination of the retrieved encrustations was performed.

RESULTS

Most frequently and pronounced encrustations were detected in the Pseudomonas group. The median weight of these encrustations (50% struvite and brushite) was 84.4 mg (47.7 mg / 127.3 mg). Even on catheters stored in sterile urine, encrustations (69.2% struvite) were found. Bacterial growth was not affected by the medium used for catheter blockage.

CONCLUSION

Although in-vitro models appear to be limited because they lack "the human factor", they are valuable for systematically assessing physico-chemical factors affecting encrustations. Therefore, our model, being reliable and cost-effective, may foster further research despite its limitations.

Functional mapping of the lower urinary tract by epidural electrical stimulation of the spinal cord in decerebrated cat model

Several neurologic diseases including spinal cord injury, Parkinson's disease or multiple sclerosis are accompanied by disturbances of the lower urinary tract functions. Clinical data indicates that chronic spinal cord stimulation can improve not only motor function but also ability to store urine and control micturition. Decoding the spinal mechanisms that regulate the functioning of detrusor (Detr) and external urethral sphincter (EUS) muscles is essential for effective neuromodulation therapy in patients with disturbances of micturition. In the present work we performed a mapping of Detr and EUS activity by applying epidural electrical stimulation (EES) at different levels of the spinal cord in decerebrated cat model. The study was performed in 5 adult male cats, evoked potentials were generated by EES aiming to recruit various spinal pathways responsible for LUT and hindlimbs control. Recruitment of Detr occurred mainly with stimulation of the lower thoracic and upper lumbar spinal cord (T13-L1 spinal segments). Responses in the EUS, in general, occurred with stimulation of all the studied sites of the spinal cord, however, a pronounced specificity was noted for the lower lumbar/upper sacral sections (L7-S1 spinal segments). These features were confirmed by comparing the normalized values of the slope angles used to approximate the recruitment curve data by the linear regression method. Thus, these findings are in accordance with our previous data obtained in rats and could be used for development of novel site-specific neuromodulation therapeutic approaches.

Aging with spinal cord injury: A narrative review of consequences and challenges

Given the increase in life expectancy, aging with a pre-existing spinal cord injury (SCI) is becoming more common. This condition is challenging as compromised health status and functional independence can worsen. We aimed to provide an updated overview of the consequences of aging with SCI, highlighting the main challenges facing this population in a narrative review of the current literature we retrieved from the PubMed database from 2000 to 2022 on any aspect related to aging in persons with SCI. Here we address adverse circumstances that increase disability and hinder an active lifestyle, such as progressive physical deterioration, secondary health conditions, limitations in personal activity, changes in family and social support structures, aging of caregivers, and depletion of economic resources. Favorable changes are also observed, including psychosocial adjustments that improve quality of life. Additionally, various interventions are discussed to promote well-being, health, and social participation. Due to the relevance of this issue, people with SCI and all those who take care of them must have up-to-date information to carry out the necessary measures to promote healthy aging in a more inclusive social environment.

A cost-effectiveness analysis of bladder management strategies in neurogenic lower urinary tract dysfunction after spinal cord injury: A publicly funded health care perspective

STUDY DESIGN

Economic evaluation study.

OBJECTIVES

To investigate the long-term cost-effectiveness of clean intermittent catheterization (CIC) compared with suprapubic catheters (SPC) and indwelling urethral catheters (UC) among individuals with neurogenic lower urinary tract dysfunction (NLUTD) related to spinal cord injury (SCI) from a public healthcare perspective.

SETTING

University affiliated hospital in Montreal, Canada.

METHODS

A Markov model with Monte Carlo simulation was developed with a cycle length of 1 year and lifetime horizon to estimate the incremental cost per quality-adjusted life years (QALYs). Participants were assigned to treatment with either CIC or SPC or UC. Transition probabilities, efficacy data, and utility values were derived from literature and expert opinion. Costs were obtained from provincial health system and hospital data in Canadian Dollars. The primary outcome was cost per QALY. Probabilistic and one-way deterministic sensitivity analyses were performed.

RESULTS

CIC had a lifetime mean total cost of $ 29,161 for 20.91 QALYs. The model predicted that a 40-year-old person with SCI would gain an additional 1.77 QALYs and 1.72 discounted life-years gained if CIC were utilized instead of SPC at an incremental cost savings of $330. CIC confer 1.96 QALYs and 3 discounted life-years gained compared to UC with an incremental cost savings of $2496. A limitation of our analysis is the lack of direct long-term comparisons between different catheter modalities.

CONCLUSIONS

CIC appears to be a dominant and more economically attractive bladder management strategy for NLUTD compared with SPC and/or UC from the public payer perspective over a lifetime horizon.

Comparative evaluation of selected serum and urine biomarkers in cats with interstitial and bacterial cystitis

BACKGROUND

Although feline urine is increasingly submitted for bacterial culture and susceptibility testing in veterinary practice, bacterial cystitis (BC) is relatively uncommon compared with feline interstitial cystitis (FIC), which shares similar clinical manifestations. Therefore, an investigation of certain urothelial (glycosaminoglycan [GAG], tissue inhibition metalloproteinase-2 [TIMP-2]), cytokine (interleukin 12 [IL-12]), and neurotrophic factor (nerve growth factor [NGF]) markers may aid diagnosis.

OBJECTIVES

We aimed to evaluate the diagnostic effectiveness of selected serum/urine biomarkers in the diagnosis of cats with FIC and BC.

METHODS

Twelve healthy cats (Control group) and 24 cats with feline lower urinary tract disease (FLUTD) were used, and the cats with FLUTD were divided into FIC and BC groups.

RESULTS

When comparing the three groups, serum GAG, IL-12, NGF, and TIMP-2 concentrations were highest in the FIC group; urine GAG, IL-12, NGF, and TIMP-2 concentrations were higher in the FIC and BC groups than those in the Control group. Serum NGF concentrations were higher in the FIC group than in all other groups. Also, serum GAG, IL-12, NGF, and TIMP-2 concentrations were found to be effective in the differential diagnosis of FIC vs BC.

CONCLUSIONS

We showed that serum NGF is a candidate biomarker that could be used in the diagnosis and differentiation of FIC. Urine GAG, IL-12, NGF, and TIMP-2 concentrations might be helpful in determining urinary bladder inflammation and/or damage in cats with FIC and BC. ROC analyses revealed that serum and urine biomarkers were effective for diagnosing FIC and that serum biomarkers rather than urine biomarkers were effective for the differential diagnosis of FIC and feline BC.

Usefulness of Hydrastis for the prevention of encrustation of long-term indwelling catheters in persons with neurogenic bladder dysfunction: a case series

INTRODUCTION

Virtually every person with a spinal cord injury (SCI) suffers from a neurogenic lower urinary tract dysfunction (NLUTD). In the long term, about 15% of persons with SCI depend on indwelling (suprapubic or transurethral) catheters for bladder management. About 50% of these patients suffer from catheter encrustation and blockage, which may become a vital threat for persons with SCI, as it can lead to septicemia or autonomic dysreflexia. Until today, no prophylaxis of catheter encrustations with an evidence-based proof of efficacy exists.

CASE PRESENTATION

The homeopathic remedy Hydrastis, made from the goldenseal root, is used for the treatment of thick, mucous urine sediment. In four patients with tetraplegia (three female, one male) who managed NLUTD by suprapubic catheters, recurrent encrustations and catheter blockage occurred despite irrigation and medical treatment. Surgical urinary diversion was envisioned. Applying Hydrastis C30 once weekly as a long-term medication, in three of the four patients, catheter obstructions ceased, with a follow-up for at least 1 year. One patient is awaiting ileal conduit surgery.

DISCUSSION

According to the results of our case series, the application of Hydrastis seems to be beneficial in the prevention of encrustations of indwelling catheters in patients with SCI. As the treatment was effective and well tolerated, the problem is frequent, and effective solutions are scarce, a prospective trial seems justified.

Restoring both continence and micturition after chronic spinal cord injury by pudendal neuromodulation

Neurogenic bladder management after spinal cord injury (SCI) is very challenging. Daily urethral catheterization is most commonly used to empty the bladder, which causes frequent infections of the lower urinary tract. This study reports a novel idea to restore both continence and micturition after SCI by an implantable pudendal nerve stimulator (PNS). The PNS was surgically implanted in four cats with complete SCI at T9-T10 spinal level and tested weekly for 13-14 weeks under awake conditions. These chronic SCI cats consistently exhibited large residual bladder volumes (average 40-50 ml) due to their inability to void efficiently, while urine leakage also occurred frequently. The PNS which consisted of stimulating the pudendal nerve at 20-30 Hz to trigger a spinal reflex bladder contraction and at the same time blocking the pudendal nerves bilaterally with 10 kHz stimulation to relax the external urethral sphincter and reduce the urethral outlet resistance successfully induced highly efficient (average 80-100%), low pressure (<50 cmH₂O) voiding. The PNS at 5 Hz also promoted urine storage by inhibiting reflex bladder activity and increasing bladder capacity. At the end of 14-week chronic testing, low pressure efficient voiding induced by PNS was further confirmed under anesthesia by directly measuring voiding pressure using a bladder catheter inserted through the bladder dome. This study demonstrated the efficacy and safety of the PNS in awake chronic SCI cats, suggesting that a novel neuroprosthesis can be developed for humans to restore bladder function after SCI by stimulating and/or blocking the pudendal nerves.

Changes in Bacterial Spectrum and Resistance Patterns Over Time in the Urine of Patients with Neurogenic Lower Urinary Tract Dysfunction Due to Spinal Cord Injury

INTRODUCTION

Urinary tract infections (UTI) are among the most common complications in persons with neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI). As both asymptomatic bacteriuria and UTI are frequently treated with antibiotics, concerns about multidrug resistance arise. Therefore, we analyzed the bacterial spectrum in the urine and the resistance patterns of the strains over time in patients with NLUTD due to SCI.

METHODS

In a systematic chart review, we identified all microbiologic urine test results including resistance patterns of persons with SCI in a tertiary referral hospital at 2 time periods (2010-2011 and 2017-2018). We assessed the frequency of the bacterial strains, the resistance patterns of the 5 most frequent bacteria, and the use of antibiotics for in- as well as for outpatients.

RESULTS

From 2010 to 2011, 1,308 (outpatients) and 2,479 (inpatients) bacterial strains were detected in the urinalyses performed; these numbers rose to 3,162 and 6,112 during 2017-2018, respectively. The most frequently detected bacteria during both time periods were Escherichia coli, Enterococcus faecalis, Klebsiella pneumoniae/variicola, Streptococcus viridans, Pseudomonas aeruginosa, and coagulase negative Staphylococci. Fluoroquinolones were the most frequently used antibiotics during both time periods. Despite its frequent use, no relevant increase in resistance against fluoroquinolones was detected. The most prominent increase in resistance appeared in E. coli against amocixillin/clavulanic acid in inpatients (from 26.0 to 38.5%).

DISCUSSION AND CONCLUSIONS

Although fluoroquinolones were used frequently, we did not observe an increased resistance against these antibiotics over time in the urine of patients with SCI.

Urological malignancies in neurogenic patients

PURPOSE OF REVIEW

To review recent literature related to urologic malignancies in patients with neurogenic lower urinary tract dysfunction (NLUTD). We performed a literature search of electronic databases (PubMed, ScienceDirect, Scopus, and CIANHL), with a focus on articles published between January 2015 and December 2019.

RECENT FINDINGS

Recent reports demonstrate a lower incidence of bladder cancer in the NLUTD population than previously found, although still significantly higher than the general population. Bladder cancer in patients with NLUTD is usually diagnosed at a younger age, and is associated with higher rates of squamous cell cancer, a higher stage at presentation, and increased mortality. Evidence for screening for bladder cancer in NLUTD is conflicting, with no formal protocols proven for general use. NLUTD has been shown to have a lower rate of prostate cancer, and may be associated with an earlier diagnosis of renal cancer.

SUMMARY

Genitourinary malignancies, although still rare, are an important source of morbidity and mortality in patients with NLUTD. Physicians should recognize that bladder cancer in NLUTD is often a lethal disease. Further research is needed to assist physicians with early recognition of these malignancies to improve patient outcomes.

Spinal cord stimulation for the restoration of bladder function after spinal cord injury

Spinal cord injury (SCI) results in the inability to empty the bladder voluntarily, and neurogenic detrusor overactivity (NDO) and detrusor sphincter dyssynergia (DSD) negatively impact both the health and quality of life of persons with SCI. Current approaches to treat bladder dysfunction in persons with SCI, including self-catheterisation and anticholinergic medications, are inadequate, and novel approaches are required to restore continence with increased bladder capacity, as well as to provide predictable and efficient on-demand voiding. Improvements in bladder function following SCI have been documented using a number of different modalities of spinal cord stimulation (SCS) in both persons with SCI and animal models, including SCS alone or SCS with concomitant activity-based training. Improvements include increased volitional voiding, voided volumes, bladder capacity, and quality of life, as well as decreases in NDO and DSD. Further, SCS is a well-developed therapy for chronic pain, and existing Food And Drug Administration (FDA)-approved devices provide a clear pathway to sustainable commercial availability and impact. However, the effective stimulation parameters and the appropriate timing and location of stimulation for SCS-mediated restoration of bladder function require further study, and studies are needed to determine underlying mechanisms of action.

The Real Daily Need for Incontinence Aids and Appliances in Patients with Neurogenic Bladder Dysfunction in a Community Setting in Germany

Purpose

For successful long-term rehabilitation of patients with neurogenic lower urinary tract dysfunction (NLUTD), it is necessary to define the objective requirement for urological aids based on a scientifically validated basis.

Methods

This was a cross-sectional multicenter study, based on a questionnaire. Data concerning bladder management and daily consumption of urological appliances for patients with NLUTD in a community setting were collected through a standardized survey.

Results

Seven hundred and sixty-seven records were analyzed: 543 males, 221 females (N/A = 3). Patients using intermittent catheterization (n= 608) required 5.06 (mean) single-use catheters per day. Out of them, 94 (15.5%) required additional pads (mean: 2.29 per day), 34 patients (5.6%) additionally used pants (mean: 2.55 per day) and 46 patients (7.6%) utilized condom catheters (mean: 3.81 per day) between catheterizations. Among all, 126 patients (16.4%) used pads (mean: 5.03 per day), and 51 patients (6.6%) used pants (mean: 3.03 per day). Women needed both pads (p < 0.0001) and diapers (p = 0.0084) significantly more frequently than men. Eighty-two of the male patients (15.1%) applied condom catheters (mean: 2.8 per day). The target value of the objective daily requirement of incontinence aids for adult patients with NLUTD (based on the upper twofold standard deviation from the mean value) was defined as follows: up to nine single-use catheters, seven condom catheters, nine pads and/or seven pants. A “mixed supply” of different incontinence aids is part of the daily supply for many patients.

Conclusion

For the first time, these results allow a reasonable regulation of urological aids and appliances based on scientific data for patients with neurogenic bladder.

Transvaginal bladder-neck closure: a step-by-step video for female pelvic surgeons

INTRODUCTION AND HYPOTHESIS

Transvaginal bladder-neck closure is a definitive surgical option for urethral erosion due chronic bladder catheterization in patients with neurogenic bladder. Surgeons who perform female pelvic reconstructive surgery have limited exposure to this procedure in their training. The purpose of this video is to demonstrate a transvaginal bladder-neck closure due to urethral erosion in a patient with neurogenic bladder due to persistent neuropathy from Guillain-Barré syndrome managed with prolonged catheter drainage.

METHODS

We used a live-action surgical demonstration to describe transvaginal bladder-neck closure with urinary diversion.

RESULTS

This video provides a step-by-step approach to transvaginal bladder-neck closure as treatment for urethral erosion from chronic catheterization. This video can be used to educate and train those performing female pelvic reconstructive surgery.

CONCLUSIONS

Surgeons who perform female pelvic surgery should be familiar with the complications of chronic Foley catheterization and treatment options that include transvaginal bladder-neck closure. This video may be used to facilitate reproducibility and comprehension of this procedure.

Bladder emptying method is the primary determinant of urinary tract infections in patients with spinal cord injury: results from a prospective rehabilitation cohort study

OBJECTIVE

To understand the occurrence of and risk factors for urinary tract infections (UTIs) in patients with spinal cord injury (SCI) undergoing specialized SCI rehabilitation in Switzerland.

PATIENTS AND METHODS

This study used data collected from 369 patients, who participated in a nationwide rehabilitation cohort for SCI in Switzerland between 2013 and 2017. Information on UTIs as well as their potential determinants, including demographics, lesion characteristics, and time-updated data on functional independence and bladder management, was used. Multivariable regression methods were applied to perform a time-updated evaluation of determinants of UTI risk.

RESULTS

The crude incidence rate (IR) of UTIs was 0.55 UTIs per 100 person-days (95% confidence interval [CI] 0.49-0.62), the cumulative IR was 43%, and the median length of stay was 122 days. The bladder emptying method at discharge was largely determined by 28 days after admission. Among those using indwelling or assisted intermittent catheterization (IC), the likelihood of self-IC at discharge was positively related to the level of self-care independence, negatively related to age at injury, and lower in women than men. Catheter users consistently had higher adjusted IRs for UTI than spontaneous voiders. The IR ratios were: indwelling catheter: 5.97 (95% CI 2.63-13.57); assisted IC: 6.05 (95% CI 2.63-13.94); self-IC: 5.16 (95% CI 2.31-11.52); test for differences across catheter groups: P = 0.82. Lesion severity and previous UTI had additional but smaller effect sizes.

CONCLUSIONS

Bladder emptying method was identified as the main risk factor for UTI in patients with SCI. As spontaneous voiders had the lowest UTI rate, further research is warranted to reduce voiding dysfunction, for instance using neuromodulation procedures.