In our country, neurogenic bladder in patients with neurological disorders has not received sufficient attention from doctors of various disciplines, including urologists, until now, a series of problems caused by neurogenic bladder in the recovery and stabilization period of neurological disorders are the main factors affecting the survival and quality of life of patients. The quality of survival of patients is improved. Prior to the 1980s, the leading cause of death after the acute phase of spinal cord injury in the United States was renal failure, whereas Stover et al. in 1987 showed that the leading causes of death thereafter had changed to pneumonia, accidents, and suicide, largely due to the aggressive management of neurogenic bladder in these patients by American urologists after the 1980s, who consistently managed the bladder with various treatments to intravesical pressure below 40 cmH2O, while reducing residual urine and minimizing the occurrence of upper urinary tract fluid.
The Institution of Rehabilitation and Research (TIRR) at Texas Medical Center is currently ranked #2 among the “Top 10 Rehabilitation Hospitals” in the United States, and its spinal cord injury rehabilitation system has been recognized as a model by the U.S. Department of Education. Its spinal cord injury rehabilitation system has been considered a model by the U.S. Department of Education. There are 14 medical units at TIRR in Texas, and the author was fortunate enough to spend six months at one of the major TIRRs in Houston, focusing on the management of neurogenic bladder. Through this study, I feel that the management of neurogenic bladder in China has not yet been given attention, and also have some feelings about how to work in this area in the future, here to communicate with colleagues, aiming to jointly improve the diagnosis and treatment of neurogenic bladder in China.
1, pay attention to the management of neurogenic bladder, making it routine In terms of spinal cord injury, in 1997, DeVivo reported that 10,000 new cases occur each year in the United States. Combined with the aging of our population and the absolute increase in the occurrence of traffic and construction accidents, there must also be a large number of patients with neurological injuries in China, and the number of patients with neurogenic bladder that need to be treated will also increase substantially, which is a serious problem that every urologist will face. However, the management of neurogenic bladder is not yet widely appreciated in China, for example, the West China Hospital of Sichuan University, where the authors work, although it is a large general hospital, few patients with neurogenic bladder come to the urology department for treatment, and even if there are a few cases, they are only simple surgery for urinary tract complications of stones, fistulas and urinary diversions, and basically no preventive and The routine management of neurogenic bladder patients is basically not preventive and targeted. Although the hospital has a large rehabilitation unit, there is very little contact between the two units. I think this is a situation that is not uncommon in medical units across the country. In addition, although there are special hospitals and rehabilitation centers for disabled soldiers for patients with neurological injuries, it is known that all but a few of these centers have specialized urologists, but the rest do not have a urology department, let alone one staffed with physicians who are experienced in dealing with neurogenic bladder.
During my time at TIRR, I had the opportunity to see the full range of patient care from outpatient to inpatient, and my impression is that the rehabilitation process that patients receive at TIRR is a comprehensive, continuous, and complete medical process. “Comprehensive” means that each patient will receive guidance from the rehabilitation doctor from the use of the wheelchair to the training of each functional muscle, including, of course, a consultation with a urologist to deal with bladder problems; “continuous” means that each patient will receive lifelong The “continuum” means that each patient will receive lifelong treatment, with good compliance and notification of follow-up visits, although many of these visits will be done on an outpatient basis; “completeness” means that for each treatment, the physician will try to achieve the desired goal and will rarely stop halfway. , injections, neuromodulation, and urinary drainage to reduce intravesical pressure. In terms of management of neurogenic bladder, on the first day of the patient’s visit (usually 1 to 3 months after the acute onset), in addition to taking a history and developing a detailed weekly rehabilitation plan, another medical priority for the rehabilitation physician is to put the patient in contact with a urologist for management of the neurogenic bladder. The urologist’s first contact with the patient will be a thorough evaluation of the patient’s urinary system, one of the most important of which is the collection of raw urodynamic data, which is usually imaging urodynamic data. Based on the results of the examination, the urologist will immediately treat the patient accordingly. Patients who have received early management are generally followed up after 3 months. If the patient has followed medical advice well (e.g., has mastered intermittent catheterization well), has good control of urinary incontinence, and routine urodynamic testing shows control of bladder lesions, the follow-up period is changed to 6 to 12 months. All patients have a copy of the follow-up schedule, and the rehabilitation physician and urology nurse are there to give reminders. I felt that the management of neurogenic bladder was given considerable attention by both the rehabilitation physician and the urologist at TIRR, who placed great emphasis on improving the patient’s quality of life in addition to preserving renal function, with the ideal goal of being able to remain dry and without a drainage tube in the management of neurogenic bladder. Most of the patients I have seen have been able to meet this standard, and many of them have had a history of more than 10 years, with not a few of the younger patients being able to work.
2. Accelerate the training of urologists engaged in neurogenic subspecialties The physicians who deal with neurogenic bladder should be urologists who have received specialized training in neurology, because the management of neurogenic bladder is very complex. Firstly, there is a diversity of bladder dysfunction due to neurological injury, and the combination of abnormalities in the activity of the bladder’s detrusor muscle, detrusor compliance, internal and external sphincter coordination, and bladder sensation is even more complex after neurological injury. Secondly, there is no specific treatment for neurogenic bladder, and it is necessary to adjust the treatment plan according to the changes in the condition, such as the increase and change of medication, the adjustment of the number and duration of intermittent catheterization, the management of dysfunction of the forced urinary sphincter (DSD), and the timing of bladder enlargement and urinary drainage. Finally, these patients have different treatment expectations, and some of them have psychiatric factors, which require doctors to understand the thoughts of these patients and be prepared to fully communicate with them and to accurately evaluate the effectiveness of the treatment methods used.
At TIRR, I have seen a number of urology residents from the University of Texas Medical School at Houston attending the urology clinic and urodynamic unit and being directly involved in the management of patients, including surgical treatment. There are also a number of fellows at TIRR (generally referred to as graduates receiving funding within the establishment of a British or American research institution or university, as distinguished from master’s or doctoral students who pay their own tuition or apply for grants, and as distinct from postdocs; sometimes referred to as members of senior groups within the institution. Here it should refer to the former. Editor’s note) specializing in neurourinary work.
Currently, there is no urology residency training system in China, and few existing urologists have had the opportunity to receive training in the management of neurogenic bladder. In our country, the management of such patients is mostly performed by urologists who are involved in urinary control. The current urological control group in China is only 7 years old and there are very few physicians who actually have more experience in the management of neurogenic bladder, so the training of urologists in the neurourinary subspecialty should be accelerated. This task is best undertaken by academic organizations such as the Urological Control Group of the Chinese Urological Association.
3. The hospital should have professional staff and basic equipment Although TIRR is a hospital engaged in rehabilitation and does not have a urology department, it has a urology clinic 2 days a week with sitting physicians from other medical units in Houston, all of whom are professors engaged in neurourinary and urinary control specialties. It also does not have an operating room, and all surgical patients can be operated on by the sitting professors at their hospital before returning to the rehabilitation hospital. However, the TIRR provides good imaging urodynamic equipment for the professors who come to the clinic, with urodynamic technicians and radiologists, as well as a dedicated office and case room.
Although urodynamic testing has made great progress in our country thanks to the efforts of the Urogynecology Group, its use is mostly limited to routine examination of bladder outlet obstruction and screening of patients with outpatient voiding abnormalities, and fewer hospitals are able to routinely perform imaging urodynamic testing, which is the key to the management of patients with neurogenic bladder. Therefore, I feel that the imaging urodynamic examination should be routinely carried out as soon as possible in the rehabilitation centers and hospitals that are in a position to do so, and to allocate specialized examination technicians and urologists to work on the diagnosis and treatment of neurogenic bladder.
4, social and family concerns and sound insurance system TIRR in the United States is a non-profit public hospital, its development is mostly from social and individual donations, which can reflect the concern of American society for people with disabilities. The current situation in China is that most patients with neurological disorders are a burden to their families and the society has the idea that “paralysis is waste”, so few patients request treatment for neurogenic bladder, and even if they have the desire to be treated, it is difficult to find a competent hospital and neurologist. The cost of medical care is also an insurmountable difficulty for patients. The authors have worked with a large number of these patients, who are characterized by “urinary odor” due to incontinence, have little or no social activity, and most die of renal failure.
The management of neurogenic bladder is a long-term process, and regular follow-up examinations, medications and possible surgical treatment will be a major medical expense. In the United States, the insurance system is relatively well developed and patients seeking treatment can be treated largely without regard to medical costs. In contrast, most patients with neurological impairment in China have more financial difficulties, and it is crucial for society to give these patients comprehensive insurance to improve the overall treatment of neurogenic bladder and improve the quality of survival.