The primary treatment of neurogenic bladder is to protect the kidney function from pyelonephritis, hydronephrosis leading to chronic renal failure; secondly, to improve urinary symptoms to reduce their life pain. The specific measures of treatment are to reduce the amount of residual urine using various non-surgical or surgical methods, which can reduce urinary complications after the residual urine volume is eliminated or reduced to very little (less than 50 ml). However, it must be noted that in a few patients, complications such as pelvic effusion, pyelonephritis, and decreased renal function occur even though the residual volume is minimal or even completely absent. Because of the strong contraction of the detrusor muscle during urination in these patients, the intravesical pressure can be as high as 19.72 kPa (200 cmH2O) or more (normal should be 6.9 kPa or less than 7 cmH2O). These patients should be treated early to relieve lower urinary tract obstruction. Several commonly used treatment methods are described as follows.
1.Non-surgical treatment
(1) Intermittent catheterization or continuous drainage During the spinal shock period after spinal cord injury or in patients with large amounts of residual urine or urinary retention, intermittent catheterization can be used if the renal function is normal. Initially, it is operated by medical personnel. If the patient is in good general condition, the patient can be trained to self-catheterize. Intermittent catheterization is more appropriate in women. If all surgical therapies are ineffective, home-based intermittent catheterization can be performed for life. If the patient is in poor general condition or has impaired renal function, an indwelling catheter should be used for continuous drainage.
(2) Pharmacological treatment Any patient with high residual bladder urine volume, regardless of whether there are symptoms of reflex hyperactivity of the detrusor muscle such as urinary frequency, urinary urgency and urge incontinence, should first apply alpha-blockers to reduce residual urine. If alpha-blockers alone are not effective, drugs that increase bladder contraction such as uratine and neostigmine can be applied simultaneously. For patients with symptoms of hyperreflexia of the detrusor muscle (urinary frequency, urgency, and enuresis) without residual urine or with little residual can apply drugs that inhibit bladder contraction such as urinary dorin, isoproterenol, and prulbenecid. For patients with mild stress urinary incontinence without residual urine can apply drugs that promote bladder neck and posterior urethra contraction such as ephedrine and insulin. For patients with impaired energy function, measures should be taken first to make urine drainage smooth, rather than applying drugs to improve urinary symptoms.
(3) Acupuncture therapy Acupuncture has a good effect in treating sensory paralysis of the bladder due to diabetes mellitus, and is particularly effective for early lesions.
(4) Closure therapy This method is advocated by Bors for upper motor neuron lesions (hyperreflexia of the detrusor muscle). It is not effective for motor neuron lesions (no reflexes in the forced urinary muscles). In patients with good results after closure, there is a significant reduction in residual urine volume and a marked improvement in voiding symptoms. In a small number of patients, the effect is maintained for several months to as long as 1 year after 1 closure. These patients require only regular earthworks and do not need to resort to surgery. Closure therapy is performed in the following order: ① Mucocutaneous closure: the bladder is emptied with a catheter and 90 ml of 0.25% pantocaine solution is injected and expelled after 10 to 20 minutes. ②Bilateral pubic nerve block. ③Selective sacral nerve block: block one pair of sacral nerves from S2 to 4 at a time. If there is no effect, a combined block of S2 and S4 and S4 can be performed.
(5) Bladder training and dilation This method can be used for those with severe symptoms of urinary frequency and urgency and no residual urine or very little residual volume. Ask the patient to drink water regularly during the day, 200ml per hour. try to extend the interval between urination, so that the bladder can be easily and gradually expanded.
2.Surgical treatment
Surgical treatment is usually performed after the non-surgical treatment is ineffective and after the neuropathy is stabilized. If you have a 4-channel or 6-channel urodynamic checker, you can perform surgery to release the obstruction after the site and nature of functional lower urinary tract obstruction is clarified through the examination results.
(1) Principles of surgery
(1) In patients with mechanical obstruction in the urinary tract (such as prostatic hyperplasia), the mechanical obstruction should be removed first.
(ii) In patients with no reflex of the forced urinary muscle, transurethral bladder neck dissection should be considered first.
③In patients with hyperreflexia of the forced urinary muscles or those with synergistic dysfunction of the forced urinary sphincter, transurethral external sphincterotomy or resection can be performed if the pubic nerve block has only a transient effect.
④In patients with hyperreflexia of the detrusor muscle, if selective sacral nerve block has a transient effect, the corresponding sacral nerve anhydrous alcohol injection or the corresponding sacral nerve rhizotomy is feasible.
⑤ Patients with severe symptoms of urinary frequency and urgency (urgent voiding syndrome), no residual urine or very little residual urine, and no effect of medication, closure therapy, bladder training and dilation can be considered for cystic nerve stripping or cystoscopic injection of the pelvic nerve on both sides of the bladder base with anhydrous alcohol or 6% petrolatum.
(6) In patients with hyperreflexia of the detrusor muscle, if various closure therapies are ineffective, a cervical cystotomy is performed.
(7) Full-length posterior urethrotomy: this procedure is only applicable to men, so that the patient’s internal urethral sphincter all lose the function of controlling the outflow of urine from the bladder, resulting in unresisted urinary incontinence and unobstructed urinary drainage. Patients are required to use a penile sleeve and urine collection bag to collect urine for life. With this procedure, complications such as urinary tract infections are reduced to less than 1%. The disadvantage is that it is less convenient for the patient in terms of life.
(2) Indications for full-length posterior urethrotomy and urinary diversion
(1) Progressive renal hypofunction, hydronephrosis or uncontrollable renal nephritis even after non-surgical and surgical treatment.
②Severe urinary symptoms even after non-surgical and surgical treatment.
(③) Those who already have severe impairment of renal function or chronic renal failure.
In the above cases, urethral retention leading to a tube is a good management method for female patients.
(3) Treatment of non-resistant incontinence (severe incontinence without residual urine) Male patients can be treated with penile clamps or urinary collection bags, and female patients can be treated with urethral clamps or urinary flow diversion surgery. An artificial urethral sphincter device can be considered if available. Patients with neurogenic bladder need to be followed up regularly for a long time after treatment to achieve better results. Residual urine measurement, urine culture, renal function tests and intravenous urography should be performed once or twice a year to observe the presence of hypovolemia and urinary tract complications.