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4th ICI Lecture Series: Neurogenic patients (Committee 10)

Presented by JJ Wyndaele, MD, et al., at the Fourth International Consultation on Incontinence (ICI) - July 5 - 8, 2008. Palais des Congres, Paris, France.



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Neurogenic patients To include pathophysiology, conservative and surgical management of Urinary and Faecal INCONTINENCENeurogenic patients Committee 10 Wyndaele JJ (Chair) Kovindha A Schurch B Madersbacher H Radziszewski P Ruffion A Sakakibara R consultant Igawa Y consultant Castro D consultant Perkash I consultant Contents/ PART 1 • Pathophysiology • Epidemiology • Diagnostics • Conservative treatment • Surgical treatment • RECOMMENDATIONS Bowel FI Bladder UI Contents/ PART 2 Most prevalent neurologic diseases FI UI Physiology- Pathophysiology S2 S3 S4 Innervation lower urinary (LUT) and gastrointestinal tract (LGIT) T10- L1 Neurological Actions + Pelvic floor + (?) (?) Extern US/AS - + Bladder neck/Intern AS + + - Detrusor Bowel Somatic ParaSympathetic Sympathetic + stimulation - Inhibition ? unknown S2 S3 S4 Neuropathy lower urinary (LUT) and gastrointestinal tract (LGIT) T10- L1 Epidemiology neurogenic LUT - LGIT Prevalence neurogenic LUT / LGIT dysfunction • Limited number publications • Only in specific diseases (separate search). • Data on incontinence not always present in data on e.g. “neurogenic voiding dysfunction” or “sphincter problems”. • No global meta-analysis. 50 % 38 % - 70 % Parkinson 20 % 25 %-78 % Diabetes 11 % - 63 % > 90 % Spinal cord injury 20 % - 73 % 50% - 90 % Multiple sclerosis 9 % - 40 % 20 % - 50 % Cerebrovascular accidents LUT LGIT Pelvic organs neuropathy / incontinence/ retention Recommendations • Many diseases of the nervous system cause pathology of the LUT-LGIT. • • Patients with known Patients with known neurologic neurologic disease disease should be evaluated for such should be evaluated for such dysfunctions (Grade A) dysfunctions (Grade A) LUT LGIT Recommendations • • Evaluation should be made not only Evaluation should be made not only when symptoms occur but also as a when symptoms occur but also as a standard diagnostic approach if standard diagnostic approach if prevalence of LUT/LGIT dysfunction is prevalence of LUT/LGIT dysfunction is known to be high in a specific disease known to be high in a specific disease (Grade A) (Grade A) LUT LGIT Recommendations • • If If “ “idiopathic idiopathic” ” LUT/LGIT dysfunctions LUT/LGIT dysfunctions occur the possibility of an unknown occur the possibility of an unknown neurological cause should be neurological cause should be considered and the necessary considered and the necessary diagnostic steps taken to make a diagnostic steps taken to make a proper diagnosis (Grade A) proper diagnosis (Grade A) LUT LGIT Diagnosis of neurogenic urinary incontinence UI neurogenic urinary incontinence • Preserve renal function: pressure !!!! • Control continence !!!! • Social impact • Degree disability • Quality of life • Cost effectiveness • Technical difficulties • Iatrogenic complications UI Diagnosis Most initial assesments as used in non neurologic patients: • History • Clinical examination • Neurological examination • Urine test • Blood tests • Imaging UI • For a detailed diagnosis of LUT function in neurologic patients, history and clinical examination are not sufficient ! • Urodynamics: cornerstone of the diagnosis and prognosis determination (LOE 2 Grade B) UI Other specialist tests for neurologic LUTD • Ice water test: (LOE 2) • Bethanechol test (LOE 3) • Neurophysiologic testing (LOE 2) • Incontinence in neurologic patients relates not necessarely to the neurologic pathology. Other diseases such as prostate pathology, pelvic organ prolaps etc. might have an influence. These have to be ruled out. UI • Extensive diagnostic workout seems only useful and necessary to tailor an individual treatment based on complete neurofunctional data. • This may not be needed in every patient e.g. patients with suprapontine lesions or in patients where treatment merely will consist of bladder drainage due to bad medical condition or limited life expectancy. Conservative treatment UI Conservative treatment • Mainstay of treatment • No completely new treatment modality has developed since last ICI publication UI Conservative treatment overview • Behavioural therapy B.1 Triggered reflex voiding B.2 Bladder expression (Crede and Valsalva manouver) B.3 Behavioural methods Toiletting assistance • Catheters C.1 Intermittent catheterisation C.2 Indwelling catheterisation C.3 Condom catheter and external appliances • Pharmacotherapy • Electrostimulation E.1 Electrical Neuromodulation E.2 Electrical stimulation of the pelvic floor musculature E.3 Intravesical electrical stimulation (IVES) UI Conservative treatment main points • Behavioural methods Toiletting assistance Grade C • Intermittent catheterisation Grade A • Pharmacotherapy including Botulinum TX Grade A • Electrostimulation Grade C UI Surgery neurogenic urinary incontinence UI Surgery decrease/abolish detrusor overactivity/ lower bladder pressure • Botulinum Toxin in detrusor (LOE 1) Grade A • Enterocystoplasty (LOE 2) Grade B • Autoaugmentation (LOE 4) Grade C UI • Dorsal Rhizotomy (+ SARS) (LOE 2) Grade B – spinal cord injury patients – neurologic overactivity – refractory medical treatment UI Possible alternatives to avoid rhizotomy: still experimental LOE 4 Grade C • Selective anodal block • Cryotherapy deafferentation • SPARSI (anterior + posterior roots) UI Surgery to increase outlet resistance • Artificial urinary sphincter (LOE 3) Grade C • Bladder neck sling procedures (LOE 3) Grade C • (Resorbable or non –resorbable bulking agents) (LOE 4) Grade D UI Diversion • Acceptable treatment in selected cases (LOE 3) Grade C UI Surgery decrease outlet resistance Incontinence ! • TUI sphincter spinal cord injured (LOE 2) Grade B • Intraurethral stents (LOE 2) Grade B • Botulinum in Sphincter (LOE 3) Grade C UI Diagnosis neurogenic faecal incontinence FI Diagnosis • Beside initial assesment, same specialist techniques used as in non neurogenic : Anal manometry, transit time, transrectal ultrasound,expulsion test …… • Most studies small numbers, value in neurogenic not well established • Bowel symptoms related Quality of life assessment (LOE 2). Krogh et al study 2005 FI Diagnosis • Perform electrodiagnostic tests, especially external anal sphincter needle electromyography, in addition to anorectal manometry, to identify or confirm neurogenic cause of faecal incontinence. Grade C FI Conservative treatment FI Measures to restore bowel movement and evacuation • Diet • Regular toiletting • Abdominal massage • Mechanical stimulation including digital stimulation transrectally • Chemical stimulation of colorectal reflex including oral drug, suppositories and enema • Valsalva or Manually generated external pressure • Digital disimpaction FI Conservative Treatment • Small and poor quality studies on –Medication –Cisapride –Psyllium –rectal preparations –mechanical evacuation • No conclusions possible • • Treatment Treatment remains remains so so far far empirical empirical FI Conservative • Biofeedback: limited cases • Perianal electrical stimulation: limited result • • Retrograde Retrograde colonic colonic enema enema highly highly succesfull succesfull in meningomyelocoele (LOE in meningomyelocoele (LOE 3) 3) FI Recommandations for conservative neurologic bowel management • • Intensive patient Intensive patient education education (Grade A) (Grade A) • • Bowel Bowel training training with with regular regular, , consistently consistently timed timed, reflex , reflex triggered triggered bowel bowel evacuation evacuation can can lead lead to social to social faecal faecal continence (Grade B) continence (Grade B) • Percutaneous sacral neuromodulation:More studies are needed FI Surgery FI Surgical treatment modalities • • antegrade continent enema procedure • artificial anal sphincter • dynamic graciloplasty • elective colostomy • sacral nerve stimulation FI RECOMMENDATIONS Surgery • • Sacral nerve stimulation (Grade C). Sacral nerve stimulation (Grade C). –when conservative therapy failed and acute and temporary percutaneous nerve evaluation indicates positive effects • • Antegrade Antegrade continence enema continence enema especially in especially in neuropathic neuropathic children children (Grade C). (Grade C). –Patients selected for appropriate motivation. Some data in adults FI RECOMMENDATIONS Surgery • • Dynamic Dynamic graciloplasty graciloplasty and artificial anal and artificial anal sphincter (Grade C) sphincter (Grade C) –high risk treatment failure –complications requiring re-operation –development evacuation difficulties Very strict patient selection for both Very strict patient selection for both procedures procedures • • Colostomy in some selected SCI patients Colostomy in some selected SCI patients with intractable fecal incontinence who failed with intractable fecal incontinence who failed all other therapy (Grade C) all other therapy (Grade C) FI Described in details in our chapter – Dementia – Multiple system atrophy – Parkinson – Alzheimer – Cerebral lesions-cerebrovascular accidents – Multiple sclerosis – Spinal cord lesion – Spinal stenosis – Guillain Barre – HIV – Lumbar disc prolapse – Meningomyelocoele – Diabetes mellitus – Peripheral neuropathy due to iatrogenic lesions (focal neuropathy) – Systemic lupus erythematosus – Herpes zoster Future • Restoring function by nerve transplants, tissue engineering, ….. ? UI FI Committee 10 thanks you for your attention

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