Nerve disease and bladder control

National Kidney and Urologic Diseases Information Clearinghouse
For the urinary system to do its job, muscles and nerves must work together to hold urine in the bladder and then release it at the right time. Nerves carry messages from NATIONAL
the bladder to the brain to let it know when INSTITUTES
the bladder is full. They also carry messages OF HEALTH
from the brain to the bladder, telling muscles either to tighten or release. A nerve prob­ lem might affect your bladder control if the nerves that are supposed to carry messages between the brain and the bladder do not work properly. U.S. Department
of Health and
Human Services
What bladder control
problems does nerve
damage cause?
Nerves that work poorly can lead to three
different kinds of bladder control problems. Overactive bladder. Damaged nerves may
send signals to the bladder at the wrong time, causing its muscles to squeeze with­ Nerves carry signals from the brain to the bladder • urinary frequency—defined as urination nerves to the sphincter muscles are dam­ aged, the muscles may become loose and allow leakage or stay tight when you are • urinary urgency—the sudden, strong Urine retention. For some people, nerve
• urge incontinence—leakage of urine not get the message that it is time to release urine or are too weak to completely empty Poor control of sphincter muscles. Sphinc­
ter muscles surround the urethra and keep full, urine may back up and the increasing it closed to hold urine in the bladder. If the pressure may damage the kidneys. Or urine that stays too long may lead to an infection in If nerve damage is suspected, the doctor the kidneys or bladder. Urine retention may may need to test both the bladder itself and the nervous system, including the brain. Three different kinds of tests might be used: What causes nerve damage?
Urodynamics. These tests involve measur­
ing pressure in the bladder while it is being filled to see how much it can hold and then checking to see whether the bladder empties completely and effi ciently. Imaging. The doctor may use different types
• infections of the brain or spinal cord of equipment—x rays, magnetic resonance imaging (MRI), and computerized tomog­raphy (CT) scans—to take pictures of the urinary tract and nervous system, including EEG and EMG. An electroencephalograph
(EEG) is a test in which wires with pads are placed on the forehead to sense any dysfunc­tion in the brain. The doctor may also use an In addition, some children are born with nerve problems that can keep the bladder with pads placed on the lower abdomen to from releasing urine, leading to urinary test the nerves and muscles of the bladder. What are the treatments for
How will the doctor test for
overactive bladder?
nerve damage and bladder
The treatment for a bladder control problem control problems?
depends on the cause of the nerve damage Any evaluation for a health problem begins and the type of voiding dysfunction that with a medical history and a general physical examination. Your doctor can use this infor­ In the case of overactive bladder, your doctor mation to narrow down the possible causes may suggest a number of strategies, including bladder training, electrical stimulation, drug therapy, and, in severe cases where all other treatments have failed, surgery. Bladder training. Your doctor may ask
you to keep a bladder diary—a record of
your fluid intake, trips to the bathroom,
and episodes of urine leakage. This record
may indicate a pattern and suggest ways to
avoid accidents by making a point of using the bathroom at certain times of the day—a practice called timed voiding. As you gain control, you can extend the time between trips to the bathroom. Bladder training also includes Kegel exercises to strengthen the muscles that hold in urine. Electrical stimulation. Mild electrical pulses
can be used to stimulate the nerves that control the bladder and sphincter muscles. Depending on which nerves the doctor plans A device can be placed under your skin to deliver to treat, these pulses can be given through mild electrical pulses to the nerves that control bladder function. the vagina or anus, or by using patches on the skin. Another method is a minor surgi­cal procedure to place the electric wire near Drug therapy. Different drugs can affect the
the tailbone. This procedure involves two nerves and muscles of the urinary tract in steps. First, the wire is placed under the skin and connected to a temporary stimulator, • Drugs that relax bladder muscles and which you carry with you for several days. If your condition improves during this trial period, then the wire is placed next to the tailbone and attached to a permanent stimu­ lator under your skin. The Food and Drug which belong to the class of drugs called device, marketed as the InterStim system, to side effect is dry mouth, although large treat urge incontinence, urgency-frequency syndrome, and urinary retention in patients stipation, a faster heartbeat, and fl ush­ for whom other treatments have not worked. ing. A new patch delivery system for oxybutynin (Oxytrol) may decrease side effects. Ditropan XL and Detrol LA are timed-release formulations that deliver a low level of the drug continuously in the body. These drugs have the advantage of once-a-day administration. In 2004, the FDA approved trospium chloride (Sanctura), darifenacin (Enablex), and solifenacin succinate (VESIcare) for the treatment of overactive bladder. • Drugs for depression that also relax Try not to squeeze other muscles at the same time. Be careful not to tighten your stom­ ach, legs, or buttocks. Squeezing the wrong antidepressant. Side effects may include muscles can put more pressure on your blad­ der control muscles. Just squeeze the pelvic Additional drugs are being evaluated for the At fi rst, find a quiet spot to practice—your bathroom or bedroom—so you can concen­ trate. Pull in the pelvic muscles and hold for a count of 3. Then relax for a count of Surgery. In extreme cases, when incontinence
3. Repeat, but don’t overdo it. Work up to is severe and other treatments have failed, 3 sets of 10 repeats. Start doing your pelvic surgery may be considered. The bladder may muscle exercises lying down. This position is be made larger through an operation known the easiest because the muscles do not need as augmentation cystoplasty, in which a part to work against gravity. When your muscles of the diseased bladder is replaced with a get stronger, do your exercises sitting or section taken from the patient’s bowel. This standing. Working against gravity is like operation may improve the ability to store urine but may make the bladder more diffi ­cult to empty, making regular catheterization Be patient. Don’t give up. It takes just necessary. Additional risks of surgery include 5 minutes a day. You may not feel your blad­ the bladder breaking open and leaking urine der control improve for 3 to 6 weeks. Still, into the body, bladder stones, mucus in the most people do notice an improvement after Some people with nerve damage cannot tell How do you do Kegel
whether they are doing Kegel exercises cor­ exercises?
rectly. If you are not sure, ask your doctor Kegel exercises strengthen the muscles that or nurse to examine you while you try to do them. If you are not squeezing the right muscles, you can still learn proper Kegel The first step in doing Kegel exercises is exercises by doing special training with bio­ to find the right muscles. Imagine you are feedback, electrical stimulation, or both. trying to stop yourself from passing gas. Squeeze the muscles you would use. If you sense a “pulling” feeling, those are the right muscles for pelvic exercises. What are the treatments for
Botox injection. Botulinum toxin type A
lack of coordination between (Botox) is best known as a cosmetic treatment
for facial wrinkles. Doctors have also found the bladder and urethra?
that botulinum toxin is useful in blocking The job of the sphincter muscles is to hold spasms like eye ticks or relaxing muscles in urine in the bladder by squeezing the urethra patients with multiple sclerosis. Urologists shut. If the urethral sphincter fails to stay have found that injecting botulinum toxin into closed, urine may leak out of the bladder. the tissue surrounding the sphincter can help When nerve signals are coordinated properly, it to relax. Although the FDA has approved the sphincter muscles relax to allow urine botulinum toxin only for facial cosmetic to pass through the urethra as the bladder purposes, researchers are studying the safety contracts to push out urine. If the signals are and effectiveness of botulinum toxin injection not coordinated, the bladder and the sphinc­ into the sphincter for possible FDA approval ter may contract at the same time, so urine Drug therapy for an uncoordinated bladder
What are the treatments for
and urethra. Scientists have not yet found
urine retention?
a drug that works selectively on the urethral Urine retention may occur either because sphincter muscles, but drugs used to reduce the bladder wall muscles cannot contract or because the sphincter muscles cannot relax. used to help the sphincter relax. Baclofen (Lioresal) is prescribed for muscle spasms or Catheter. A catheter is a thin tube that can be
cramping in patients with multiple sclerosis inserted through the urethra into the bladder and spinal injuries. Diazepam (Valium) can to allow urine to flow into a collection bag. If be taken as a muscle relaxant or to reduce you are able to place the catheter yourself, you can learn to carry out the procedure at blockers can also be used to relax the sphinc­ regular intervals, a practice called clean inter­ ter. Examples of these drugs are alfuzosin mittent catheterization. Some patients cannot (UroXatral), tamsulosin (Flomax), terazosin (Hytrin), and doxazosin (Cardura). The main damage affects their hand coordination as side effects are low blood pressure, dizziness, well as their voiding function. These patients fainting, and nasal congestion. All of these need to have a caregiver place the catheter for drugs have been used to relax the urethral them at regular intervals. If regular catheter sphincter in people whose sphincter does not placement is not feasible, the patients may need to have an indwelling catheter that can be changed less often. Indwelling catheters have several risks, including infection, blad­der stones, and bladder tumors. However, if the bladder cannot be emptied any other way, then the catheter is the only way to stop the buildup of urine in the bladder that can dam­age the kidneys. Urethral stent. Stents are small tube-like
Hope through Research
devices inserted into the urethra and allowed to expand, like a spring, widening the open­ ing for urine to flow out. Stents can help has many research programs aimed at fi nding prevent urine backup when the bladder wall treatments for urinary disorders, including bladder control problems caused by nerve because of improper nerve signals. However, stents can cause problems if they move or have narrowed the search for a gene that causes neurological problems in bladder, Surgery. Men may consider a surgery that
bowel, and facial muscles. Finding the gene removes the external sphincter—a sphinc­ may lead to greater understanding of how terotomy—or a piece of it—a sphincter nerves and muscles work together and how resection—to prevent urinary retention. nerve damage can cause urination problems. The National Institute of Child Health and through the urethra to deliver electrical or laser energy that burns away sphincter tissue. orative Urological Research in Spinal Cord Possible complications include bleeding that Injury, a program devoted to fi nding novel requires a transfusion and, rarely, problems strategies to treat bladder control problems with erections. This procedure causes loss of urine control and requires the patient to collect urine by wearing an external catheter that fits over the penis like a condom. No external collection device is available for women. Urinary diversion. If other treatments fail
and urine regularly backs up and damages
the kidneys, the doctor may recommend
a urinary diversion, a procedure that may
require an outside collection bag attached to
a stoma, a surgically created opening where
urine passes out of the body. Another form
of urinary diversion replaces the bladder with
a continent urinary reservoir, an internal
pouch made from sections of the bowel or
other tissue. This method allows the person
to store urine inside the body until a catheter
is used to empty it through a stoma.
For More Information
American Urological Association Foundation
1000 Corporate Boulevard
Linthicum, MD 21090
Phone: 1–866–RING–AUA (746–4282)
or
Email: [email protected] Internet: www.auafoundation.org National Association for Continence
P.O. Box 1019
Charleston, SC 29402–1019
Phone: 1–800–BLADDER (252–3337)
or
Email: [email protected] Internet: www.nafc.org You may also find additional information about this National Kidney and
topic by visiting MedlinePlus at www.medlineplus.gov.
Urologic Diseases
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