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The Unmentionable Symptoms of Arachnoiditis: Bowl, Bladder and Sexual Dysfunction; Pelvic Pain by Dr. Sarah Smith THE NEUROGENIC BLADDER: This
term refers to bladder disorders due to nerve damage, commonly involving
the spine: in spinal cord injury or chronic spinal conditions including
arachnoiditis. There
are 3 main types of neurogenic bladder problem:
1)Spastic
bladder : if the communication between the VRC and the brain is
disrupted by spinal cord damage, then the bladder will be emptied
automatically by a reflex process. This causes dribbling, frequency (the
urge to urinate more often than usual) and/or incontinence. Another
version of this is an irritated
or unstable bladder, which may tell the brain that it is necessary
to empty the bladder when it is only partly full. This may lead to
frequent trips to the toilet, passing only small volumes of urine each
time. If the bladder muscle (detrusor) is overactive, you may experience
sudden urge to void and fail to get to the toilet, resulting in
incontinence. 2)
Flaccid bladder: this is when
the bladder is ‘lazy’ and fails to empty; messages of bladder
fullness are no longer perceived and the bladder overfills, which leads
to stretching and weakness of the bladder muscle. This tends to cause
overfill and overflow incontinence, with some frequency, urgency as well
as dribbling or hesitancy. There
is considerable risk of infection as urine can overflow or be sent back
up (reflux) towards the kidneys, which might cause damage in the longer
term. 3)
Dyssynergic bladder: also
known as ‘conflicting bladder’,
as the bladder and sphincter no longer function in conjunction with each
other, their actions being uncoordinated. The bladder may contract to
empty, but the sphincter also contracts to retain the urine, or both the
bladder and sphincter are relaxed. This type of problem can be seen in
combination with either of the first 2 types. Symptoms include urgency
followed by hesitancy, dribbling or incontinence. One of the important
problems with dyssynergia is that if the bladder contracts but the
sphincter fails to open to allow the bladder to empty, then there may be
urine reflux back up towards the kidneys. Spinal
cord injury: The
level of injury will affect the type of bladder problem. This may also
apply to patients with non-traumatic spinal problems such as
arachnoiditis. If
the level of spinal abnormality is above T12, a spastic or reflex
bladder occurs. Below
T12/L1, a flaccid or non-reflex bladder occurs: there may be loss of
sensation, so that the bladder becomes overfull and distended. This may
also cause urine to reflux up the ureters towards the kidneys. To avoid
such problems, it is important to ensure that not more than about 400cc
of urine collect.
SECONDARY
PROBLEMS:
Investigation: 1.
Urine test (urinalysis): to detect blood/protein/bacteria etc.
Mid-stream sample is usually collected. 2. Urodynamics: test for bladder dysfunction 3. Ultrasound kidneys and bladder 4. Abdominal X-ray to detect bladder/kidney stones 5.
Renal scan (renogram/renal perfusion scintigram) : details
anatomy and function of kidney. MANAGEMENT: A
Bladder Management programme
allows patients to plan for bladder emptying in an acceptable manner at
a convenient time, thus avoiding accidents and reducing the risk of
infection. One
method or a combination of methods may be useful for each individual.
In
more severe cases: 1.
ICP: intermittent catheterisation 2.
INDWELLING CATHETER 3.
CONDOM EXTERNAL CATHETER GENERAL
MEASURES: avoid caffeine(acts as a diuretic: promotes increased urine)in
coffee, tea, cola, chocolate; and carbonated beverages; drink plenty of
water: cranberry juice may be helpful in some people to reduce infection
risk. Citrus juices should be avoided as they reduce the urine acidity,
which can encourage bacterial growth. Restricting
fluid intake prior to certain activities may be prudent. However, it is
vital to maintain an adequate fluid intake overall. Try
to avoid becoming constipated as a loaded bowel can make incontinence
worse. (and painkillers are a major culprit in causing constipation!) GENERAL
TIPS ON MANAGEMENT:
BEHAVIOURAL
TECHNIQUES: These methods can be taught by the healthcare team, and allow the patient to regain some control over bladder function. They are not, however, effective in more severe cases. Kegels: exercises
to strengthen pelvic floor muscles were described by Kegel in 1948. They
are used to regain bladder control, especially if the pelvic floor
muscles or sphincter have been weakened by childbirth, for example. Kegels
improves urethral support and closure mechanisms and will reduce the
incidence of stress incontinence. Biofeedback/Electrical
Stimulation: this
is practised to help people to become aware of, and thus to control,
their urinary tract muscles. Treatment
usually lasts about 20-30 minutes a session. Devices for home use are
also available. Bladder
training/timed voiding: having
filled in a chart of urination and leaking events, the patient is
instructed by the physician as to the best pattern to plan timed
urination. If the patient has frequency, he/she will be encouraged to
gradually increase the times between voiding, learning to resist the
urge to urinate, postponing urination as per an individualised
timetable. Crede manoeuvre: a
technique which uses massage to assist the bladder in emptying. While
sitting on the toilet, the patient places his/her hands on the abdomen,
pressing downward and inwards on the lower abdomen while urinating. This
encourages more complete bladder emptying. However, it must be noted
that this technique should NOT be used in patients with dyssynergic
bladder, as it may cause urine reflux.
PHARMACOLOGICAL
TREATMENT Overactive
bladder: 1)
anticholinergic
drugs:
such as Oxybutinin: Cystrin/ Ditropan Note that antidepressants such as
amitriptyline and imipramine, which may be prescribed as adjuvant
analgesics or for depression, have anticholinergic properties, so may be
beneficial in reducing bladder instability. Side-effects: dry mouth,
constipation, blurred vision, nausea, drowsiness, confusion and weight
gain. These drugs are not suitable for patients with cardiac problems, 2)
Tolterodine
(Detrusitol) is a new drug. Side-effects include, as expected, dry
mouth; the drug cannot be used in people with urinary retention, gastric
retention or glaucoma. However, the drug is more bladder-selective than
other similar drugs, and whilst it is as effective as oxybutinin, the
incidence of severe dry mouth is lower. 3)
Hyoscyamine
sulfate (Levbid, Cytospaz) : an
anticholinergic; contra-indicated for obstructive disorders, in patients
with glaucoma and ulcerative colitis. 4)
Dicyclomine
hydrochloride (Bentyl) has a direct
relaxant effect on smooth muscle as well as antimuscarinic action. This
drug increases bladder capacity in patients with detrusor hyperreflexia. 5)
Flavoxate
hydrochloride (Urispas): direct
inhibitory action on smooth muscle as well as anticholinergic and local
analgesic (painkilling) properties. (US guidelines (AHCPR) do not
recommend its use.) 6)
Other
drugs used have included:
prostaglandin inhibitors, scopolamine and bromocriptine.
Stress
incontinence: 1)
Alpha
adrenergic drugs:
phenylpropanolamine hydrochloride. It should not be used in patients
with obstructive incontinence. Caution is necessary in patients with
high blood pressure, overactive thyroid, and heart conditions. 2) Pseudoephedrine hydrochloride 3)
Hormonal
replacement therapy (HRT) /Oestrogen:
this helps to maintain and restore
urethral tissue health in post-menopausal women. Oestrogen appears to
reduce stress incontinence, heightening bladder outlet resistance by
increasing blood flow, tone and nerve response in the urethral muscle.
However, its exact mechanism of action
remains unknown. To avoid build-up of the lining of the womb
(endometrium), progesterone should be given with oestrogen. Various
doses are used. Oestradiol is available as a skin-patch (Femapak,
Estrapak, Evorel) and as a vaginal ring. 4)
Combined
oestrogen/alpha-adrenergic agonist therapy
: may be beneficial in post-menopausal women who have malfunction of the
urethral sphincter muscles. Phenylpropanolamine (PPA: found in OTC
preparations such as Dimetapp and Robitussin-CF) 25-100mg twice a day
plus oestrogen tablets(dose varies). Emptying
dysfunction: Baclofen
may be of some help in emptying dysfunction. It is a muscle relaxant
drug, which quite a few arachnoiditis patients take to combat muscle
cramps. Parasympathetic
nerve stimulation may be helpful in patients with an upper motor neurone
neurogenic bladder, i.e. an under-active bladder which fails to empty
properly. Dyssynergic bladder: Alpha blockers: dybenzyline, Clonidine, Hytrin.
Note that clonidine is sometimes used as an adjuvant analgesic
(painkiller in conjunction with morphine or related drugs). Obstructive urinary problems: Alpha-blockers:
useful for urge incontinence and in cases of prostate enlargement; they
reduce the tone of smooth muscles in the urethra, decreasing urethral
resistance and relieving symptoms of obstruction. Examples include:
Doxazosin (Cardura), Terazosin (Hytrin), Tamsulosin (Flomax).
Side-effects include: drowsiness, dizziness, postural hypotension (drop
in blood pressure on standing up), depression, headache, dry mouth,
nausea, rhinitis (runny nose), urinary
frequency and incontinence, erectile disorders, palpitations. They
should not be used in patients with low blood pressure and micturition
syncope (fainting when passing urine).
CATHETERISATION: No
doubt the very idea of using a catheter is unpleasant, but be assured
that the majority of people who do use one find that it is far more
manageable than the previous problems with constant spasms, frequent,
possibly painful urge and loss of urine at inconvenient and embarrassing
times. The procedure should not be painful if done correctly. Hygiene is
absolutely vital. Lubricant jelly (K-Y) may be helpful in both men and
women. Continence
advisors in your area are the best people to see about advice on
details. (see below for contact addresses for national organisations). PADS
ETC. Naturally,
the notion of having to wear incontinence pads is one which may be
difficult and distressing. However, these days there is a wide range of
products available, many from chemists or even supermarkets. Tenaform
pads are specifically designed for women with incontinence, and come in
different thicknesses according to the volume of urine lost. There are underpants which have inbuilt pads (Marsupial system) either external or internal. There are also washable underwear items for men and women. (see below for details of where you can find out more about these products). ALTERNATIVE
APPROACHES: For menopausal problems, when the urethral sphincter becomes
less elastic, due to hormonal changes, the addition of phytohormones helps reduce the tissue atrophy. It
is easy to add food containing these plant hormones to the diet. Soy
isoflavones have also been found to be helpful: they contain
phyto-oestrogens that bind to oestrogen receptors, thus creating an
oestrogenic effect. 50-100mg
Soy isoflavones should be taken daily: they are available in capsules
and soy-based foods such as soy protein powder, tofu, roasted soy nuts,
soy milk and tempeh. There
are also several phyto-oestrogenic and progesterone creams that can be
applied directly to the vagina. If
neurogenic bladder problems, poor muscle tone and hormone changes are
excluded, there is the possibility that the problem lies in food
“allergies”, sensitivity to certain food types. Herbal
remedies may be considered, but please ensure that you check this out
for interaction with any prescribed medication. Cleavers is a
traditional urinary tonic. Marshmallow root is
soothing: best taken as a cold infusion; after soaking the herb for
several hours in cold water, strain and drink. Buchu :soothing
diuretic (promotes urine) and antiseptic Corn silk (Zea Mays) soothing,
diuretic Horsetail: astringent,
tissue-healing properties, mild diuretic Usnea lichen soothing
and antiseptic Anti-inflammatory
support: Vitamin C: 500mg
two-three times a day, or slow release 1000mg Bromelain :400mg or Wobenzyme 5 tablets, three times a day (not at mealtimes) Vitamin E : 400IU
daily. Homoeopathic
measures: Note
that homoeopathy should really be used in the context of an in-depth
consultation with a trained homoeopath, as a ‘constitutional’ remedy
is a highly individual treatment. Note
that most remedies are delivered in a lactose pellet, so if you are
lactose intolerant, you would be better with a liquid preparation. Causticum: may help
with stress incontinence with frequent urge and difficulty urinating. Natrum muriaticum for
stress incontinence associated with menopausal symptoms, vaginal
dryness, painful intercourse. Pareira: for difficulty
urinating due to prostate enlargement Sepia: for stress
incontinence with sudden urging, especially associated with vaginitis or
prolapsed uterus. Zincum for difficulty urinating standing up (needs to sit to initiate flow), prostate problems. SURGICAL
TECHNIQUES It
is important to assess fully to ascertain that incontinence is truly
stress incontinence rather than detrusor instability: the former can be
improved with surgery whereas the latter cannot. It
is somewhat difficult to fully assess the success of any particular
surgical technique, as pressure flow data in normal women is scarce, so
that one can only make before- and after- comparisons of patients. Iatrogenic
incontinence may actually arise following anti-incontinence surgery. 1.
SNS:
Sacral nerve stimulation: placement of
a temporary stimulation unit (termed the percutaneous nerve evaluation
PNE) is used as a trial procedure to ascertain the potential benefit
from implantation of a permanent unit. The aim is to stimulate the
sacral nerves thereby improving the nerve input into the spinal cord and
inhibiting the hyperactivity of the bladder. The procedure is minimally
invasive, easy to perform, reversible and associated with fewer adverse
effects than other surgical treatments. If it fails to work, it is
unlikely to cause permanent damage and does not prevent other forms of
treatment being undertaken. It is recommended for patients with
intractable urgency and urge incontinence that has failed to respond to
other therapy. It is also successful in improving urination in patients
with urinary retention of unknown cause which is thought to come about
through overactivity of the guarding reflexes, spasticity of the pelvic
floor muscles and sphincter dyssynergia. SNS allows pelvic floor
relaxation and subsequent ability to initiate urination. 2.
Older techniques such as denervation
(rendering the nerve ‘dead’) myomectomy
(removing part of the bladder muscle), diversion (sending the urine out
into a bag for example) and rhizotomy
(nerve root ablation) are no longer considered to be viable treatments
for the overactive bladder. Often when bladder muscle instability was
relieved, normal contractions were no longer possible so that normal
function was also sacrificed. Subsequently, bladder emptying requires
abdominal straining or intermittent self-catheterisation. Abdominal
straining may result in day and nightime frequency and stress
incontinence. Before irreversible surgery is undertaken, patients need
to be made aware that there may be a need for permanent intermittent
self-catheterisation. 3.
Surgical
correction of stress incontinence : the
aim is to provide a ‘sling’ which supports the pelvic floor in such
a way that the neck of the bladder is held in the normal anatomical
position and thus prevents leakage on coughing/straining etc. Various
materials have been used to create this sling. This technique has also
been used to treat urge incontinence. Complication: if it is too tight,
the patient will be unable to void. Note that one important side effect
of this type of pelvic surgery is temporary loss of vaginal sensation
(most cases resolve within a year post-op.) 4. Major bladder surgery: for the most severe cases, in the past, an indwelling suprapubic catheter has been surgically inserted into the bladder through the lower abdomen.(just above the pubic symphysis). However, it is now recognised that permanent indwelling latex catheters carry a risk of bladder stones and even bladder cancer. Nowadays, a technique known as an ileovesicostomy , in which the bladder drains out through the small bowel, is used instead. |
