Neurogenic bladder is not the name of a single disease, but a general term for a group of diseases in which a neurological lesion causes malfunction of the bladder and urethra and a series of complications as a result. It involves a variety of neurological disorders, including central disorders, peripheral neuropathy, neurological damage from surgery and trauma, and some infectious diseases that involve the nervous system. The effects of alterations in bladder and urethral function vary widely, and accurate evaluation and timely and correct management can effectively avoid adverse complications such as damage to renal function and improve the quality of life of patients.
Principles of rehabilitation treatment for neurogenic bladder
1, the concept of “balanced bladder” and the purpose of neurogenic bladder treatment
In the management of neurogenic bladder, preservation of upper urinary tract function is the main focus of treatment, of which the establishment and maintenance of a “balanced bladder” with no threat of damage to the upper urinary tract is the main goal of treatment. In many cases, patients with neurogenic bladder cannot regain normal urinary function, but it is necessary to establish a “balanced bladder” based on treatment, which basically means that a new functional balance of the vesicourethra can be achieved through adjustment, with the basic requirement that the bladder can store urine at low pressure and has a large bladder capacity, and can empty the bladder without a urinary catheter. The basic requirements are that the bladder can store urine at low pressure and have a large bladder capacity, that the bladder can be emptied without a urinary catheter, that there is no incontinence and that the function of the upper urinary tract is not impaired. Unlike restoring the function of the vesicourethra, “balancing the bladder” does not necessarily mean restoring the physiological balance, but rather emphasizes the functional balance, such as reducing the urethral resistance to accommodate the contractile weakness of the detrusor muscle to obtain bladder emptying; replacing an incomplete or hyperfunctional urethral sphincter with an artificial urethral sphincter, etc.
2. Urodynamic findings as a basis for selecting treatment options
Although the clinical manifestations of neurogenic bladder are all voiding dysfunction, the pathological changes in the anatomy and function of the bladder urethra are very different depending on the site of nerve injury and the course of the disease. Therefore, in the management of neurogenic bladder, we cannot base our treatment exclusively on the history, physical examination and imaging of the nerve injury. Urodynamic examination is an examination of the functional changes in the vesicourethra, and the addition of simultaneous imaging can also reveal anatomical abnormalities of the vesicourethra, such as vesicoureteral reflux, bladder diverticula, and internal sphincter dysfunction. The results of urodynamic examination are also an important basis for the classification of neurogenic bladder, and the management of neurogenic bladder must be based on the findings of urodynamic examination, rather than just referring to the neurological history and examination.
3.Actively treat the primary disease and follow up regularly
For those with curable and recoverable primary neuropathy, the primary disease can be treated to ensure that the bladder is in a relatively safe “equilibrium bladder” state, and then to promote recovery of bladder-urethral function.
Because the neurological disorders that cause neurogenic bladder tend to be dynamic, the direction of change is not constant, with some disorders improving or even healing on their own, and more neurological lesions progressing in a worsening direction. This trend dictates that the state of neurogenic bladder is also dynamic and therefore requires rigorous follow-up of each patient with neurogenic bladder to determine if the patient needs to change the treatment plan accordingly based on the patient’s prevailing condition or to know if there are any emerging complications that require treatment.
4. Prevention and treatment of complications to improve the patient’s quality of life
Protect the function of the forced urinary muscle, actively prevent and treat upper urinary tract complications such as hydronephrosis and vesicoureteral reflux, treat common urinary tract infections, urinary stones and other complications, and use reasonable auxiliary devices such as voiding or urine collection to maintain a normal personal and social life, reduce pain and improve the patient’s quality of life.
Rehabilitation treatment for neurogenic bladder
Rehabilitation of neurogenic bladder is a very important treatment tool with the advantages of economy, effectiveness and few side effects. Various conservative treatment tools and concepts should be used throughout the life of patients with neurogenic bladder at all stages of disposition, but the indications should be strictly controlled.
1.Behavioral therapy
Behavioral Therapy (Behavioral Therapy) is to improve the bladder’s urinary storage and voiding function through the patient’s subjective conscious activity or functional exercise, so as to achieve partial restoration of lower urinary tract function in order to reduce the damage of lower urinary tract dysfunction on the body’s function. Behavioral therapies include pelvic floor exercises, biofeedback and bladder training.
Pelvic Floor Exercises (PFEs), also known as “Kegel exercises”, refer to the voluntary contraction of the pelvic floor muscles, mainly the levator muscle, by the patient consciously in order to strengthen the urinary control ability, and can be used as a basic exercise method or as an adjunct to other treatments. Biofeedback is a method that uses simulated sound or visual signals to indicate the normal and abnormal pelvic floor muscle activity, so that patients or doctors can understand the correctness of pelvic floor exercises, which can strengthen the effect of pelvic floor exercises.
2.Management of urinary function
For patients with neurogenic bladder with severe voiding dysfunction, such as those with spinal cord injury, urinary incontinence or urinary retention after pelvic surgery, reasonable means are needed to help patients empty their bladders and minimize the occurrence of urinary incontinence under the premise of a “balanced bladder” to provide patients with a better quality of life.
(1) Manipulation-assisted voiding
The most commonly used techniques are the Valsalva method (abdominal tension) and the Crede method (manual pressure on the lower abdomen). These two methods have been used clinically for many years, but clinical experience has shown that although many patients can facilitate bladder emptying with abdominal compressions, the majority of them fail to empty. Imaging urodynamics can reveal that although these maneuvers increase the pressure in the bladder, the urinary flow rate is small and there is residual urine. The difficulty in bladder emptying is due to the inability to contract and open the internal and external sphincters. Especially in patients with complete flaccid paralysis of the pelvic floor muscles, these maneuvers can induce mechanical obstruction, and images during voiding show distortion, deformation, and stricture of the urethral membrane at the level of the pelvic floor during pushing from above downward. This stricture cannot be detected by retrograde urography, cannot be felt by catheter insertion, and cannot be detected by endoscopy. Prolonged Valsalva or Crede maneuver urination may also lead to increased pressure in the posterior urethra and the inflow of urine into the prostate and seminal vesicles inducing prostatitis or epididymitis and other complications. These non-physiologically high pressures can also cause reflux in the upper urinary tract and should be carefully indicated.
Bladder compressions should only be used in patients with reduced sphincter function associated with decreased activity of the detrusor muscle. It should be emphasized that bladder compression is contraindicated in patients with hyperreflexia of the sphincter and dyscoordination of the detrusor-sphincter. In addition, bladder-uretero-renal reflux, male adnexal reflux, various hernias and hemorrhoids, symptomatic urinary tract infections, and urethral anomalies are also contraindicated. For patients with increased alpha receptor excitability in the bladder neck and proximal urethra, alpha blockers may be considered or internal bladder neck incision may be performed to reduce urethral resistance and decrease residual urine volume.
(2) Reflex-triggered voiding
Reflex triggering of the bladder involves stimulation of the extrapyramidal receptors by the patient and the companion to induce contraction of the detrusor muscle by various techniques. The purpose of periodic triggered voiding is to restore control of the reflex bladder, i.e., the patient can trigger bladder contractions when he or she needs to urinate. This treatment is mostly used in patients with spinal cord injuries above the sacral medulla, but the clinical results are not very satisfactory. This is because bladder contraction by evoking sacral reflexes to urinate is non-physiological, bladder contraction is involuntary and intermittent, and more than 90% of patients have a synergistic dysfunction of both the bladder forceps and the urethral sphincter, which prevents urine output or interrupts urine flow. Moreover, reflex voiding is a nonphysiological reflex of the sacral medulla that must be triggered several times a day to be induced, and is potentially dangerous, with reports of bladder morphologic changes, hypofunction, pelvic effusion, and destruction of renal function.
Therefore, urodynamic and other relevant tests should be performed both at the initiation and during the performance of triggered voiding. The following conditions must be met for this training to be performed.
(i) The patient maintains bladder capacity and compliance for 4 hours without catheterization;
(ii) Urine microscopy ≤ 10 WBC/HPF;
③No fever;
④ no persistent bacteriuria present. This method is most suitable for patients with supraspinal spinal cord injury in the sacral medulla after sphincter or cystotomy to maintain and improve spontaneous reflex urination. Triggered voiding is contraindicated in patients with the following conditions: poor contraction of the detrusor muscle (contraction too weak, too strong, contraction too short, too long), triggered uncoordinated voiding, bladder-ureteral-pelvic reflux, flow to the seminal vesicles and vas deferens in male patients, uncontrollable spontaneous reflex disorder or persistence of recurrent urinary tract infection.
3.Electrical and magnetic stimulation treatment
Electrical stimulation also has some efficacy in the treatment of neurogenic bladder. It is mainly by stimulating the pelvic tissues and organs or the nerve fibers and nerve centers innervating them, thus producing a direct effect on the effector or influencing the activity of the nerve pathways, ultimately changing the functional state of the bladder urethra and improving urinary storage or voiding function.