Disclosure Information AACPDM 67 th Annual Meeting October 16-19, 2013

Neurogenic Bladder Speaker Name: Jenna Katorski RN CNP Disclosure of Relevant Financial Relationships I have no financial relationships to disclose.

JENNA KATORSKI RN CNP Disclosure of Off-Label and/or investigative uses: I will not discuss off label use and/or investigational use in my presentation GILLETTE LIFETIME SPECIALTY HEALTHCARE SAINT PAUL, MINNESOTA

Objectives

ó Identify symptoms of neurogenic bladder Neurogenic Bladder ó Describe how urodynamics are helpful in evaluation of neurogenic bladder ó Describe medical management options for neurogenic bladder ó Describe recommended follow up for patients with previous urologic surgeries/procedures Neurogenic Bladder Symptoms of Neurogenic Bladder

ó Inability to control urination ó Dribbling, straining or inability to ó Loss of normal bladder function caused or urinate or by damage to part of the nervous system ó Resulting in the bladder and or the ó Hydronephrosis on imaging sphincter being: ó Recurrent urinary tract ôUnderactive ôOveractive

Neurogenic Bladder Complications Assessment Tools

ó Renal damage/failure secondary to ó (VUR) high bladder pressures ó Patient History ó Void/cath/leak diary ó Bladder scan (post void residual) ó Renal ó Cystometrogram (urodynamics) ó Renal stones or bladder stones ó Advanced imaging

ó Increased risk for UTIs and pyleonephritis, especially if VUR present What Are Urodynamics?

Urodynamics ó Tests to examine voiding disorders ó Focuses on the bladder’s ability to store and empty CYSTOMETROGRAM (CMG) URODYNAMIC STUDIES (UDS) ó Tests may include Uroflow, CMG, EMG and Voiding pressure study

Detrusor Pressure (Pdet)

ó Pdetrusor=Pves-Pabd ô Pressure of bladder muscle ô Reading should be positive number and less than 10 at start of test ô When filling if Pdet >40cm/H2O, upper tracts are at risk. During Procedure Normal Bladder Function on CMG

ó Patient asked to report ô First sensation ô First desire to void ô Strong desire to void ô Capacity ó Patient asked to perform ô Valsalva ô Cough ô Other activities reported to cause leakage ô Void at end of study

Abnormal CMG EMG

ó Sphincter muscles should relax when a patient voids.

ó There can be a dis-coordination between the sphincter and the bladder in myleodysplasia and CP. ô Destrusor Sphincter Dyssynergia or DSD. Post-Void Residual (PVR) What Can You Learn From UDS?

ó Performed after a uroflow or urination either by ó Sensation bladder scan or catheterization ó Detrusor compliance ó If catheterized, urine is drained and measured ó Detrusor over activity (uninhibited contractions) ó Estimated Bladder Capacity formula ó Leak point pressure ô (age in years x 30) + 30 ó Capacity ˜ (up to age 12 at which EBC is 390ml). ó Sphincter muscle activity ô Adult bladder 400-500ml ó PVR should be < 10% of bladder capacity

Bladder, Outlet or Both Neurogenic Bladder ó Bladder dysfunction ó Outlet dysfunction Classifications ô Overactive ô Low resistance ˜ Uninhibited detrusor ˜ Incontinence contractions ô High resistance ö urgency/frequency/leak ˜ Retention age ó ˜ Non-compliant (low Mixed compliance) ˜ Results in leakage and/or upper tract risk ô Underactive ˜ Retention ˜ What are the Goals? Management of Neurogenic Bladder ó Prevent renal failure (less common in CP compared to patient’s with SB or SCI with neurogenic bladders. ó Maintain low/normal pressure during both filling and emptying ó Minimize UTIs ó Continence ó Means of emptying ó Functional volumes and schedule ó Adequate long term follow up

Consider When Discussing Management Options Non-invasive incontinence products

ó Patient’s goals Pads Briefs ó Mobility ó Hand function ó Spasticity and tone management ó Communication ó Availability/scope of care of PCAs/staff ó Environment/Schedule (home, school, day program, work, respite, camp, etc) ó Executive function/memory External Indwelling Catheters

Male External Female External Catheter

Intermittent Catheterization (IC) Intermittent Catheterization Techniques

ó Clean technique & re-use catheter ó Clean technique with single use catheter ó Sterile technique with single use catheter Complications of Catheterization

ó Positioning Catheters ó Urethral Events ó Scrotal Events ó Bladder Events ó Pain ó Urinary Tract Infections

Open vs Closed Catheters for IC Catheter Tips

ó Open ó Closed System ó Straight ó Coude ô Sterile catheter is packed ô Catheter drainage bag is separately connected in one entire sterile system

ó Olive Catheter Options Catheter Sizes

ó Coating: ó Sized in French (FR) ó Lengths ô Uncoated latex free ô FR=diameter (mm) * 3 ô 14”-16” ô Silicone (Latex free) ô Small FR number=small ô 6” = Female ô Uncoated Red rubber diameter ó Foley balloon size Latex ó Pediatric ô 5-30ml ô Hydrophilic ô 5FR-10FR ô Antibiotic ó Adult ô 8FR-18FR

Timed Toileting

Medical Management Options ó Schedule time to toilet to routinely empty bladder Functional Toileting Evaluation Medications

ó Environmental ó Anticholinergic Medications: ó Communication ô Reduce uninhibited bladder contractions; improves bladder storage and pressures. ó Spasticity and tone management ô Routes: oral or topical (patch & gel) ó Equipment ó Bracing

Considerations When Prescribing Common Antimuscarinics: Receptor

ó Side Effects ó Frequency/Route ó Darifenacin (Enablex): M3 ó Solifenacin (Vesicare): M2 & M3 ó Fesoterodine (Toviaz): M2 & M3 ó Tolterodine (Detrol): M2 & M3 ô Safety vs tolerability ô Memory/executive ô Detrol IR ô Worsening conditions function concerns ó Oxybutynin (Ditropan) M2 & M3 ô Detrol LA ô Ditropan IR ô Dexterity ô Ditropan XL ó Trospium (Sanctura): M2 & M3 ô Oxytrol patch ô Sanctura IR ô Gelnique 10% transdermal gel ô Sanctura XR

ó Mirabegron (Myrbetriq) Beta 3 Agonist

Older Antimuscarinics ó Propantheline ó Hyoscyamine Common Side Effects

Dry Mouth Flushing Hypertension GI Effects - Headache Other Constipation

Darifenacin 19-35% <1% 15-21% 7% (Enablex): Fesoterodine 19-35% 4-6% (Toviaz): Oxybutynin Oral: 29-71% Oral 1-5% Oral 1-<5% Oral 7-15% Oral: 6-10% Topical and transdermal site (Ditropan) Topical 2-12% Topical 1% Topical 2% reaction 4-17% Transdermal 4- Transdermal 3% 10% Solifenacin 11-28% <1% 5-13% Case reports with QT interval (Vesicare): prolongation Tolterodine 23-35% 6-7% Individual cases of tachycardia, (Detrol): peripheral edema and palpations reported, no case of torsade de pointes linked to drug.

Trospium 9-22% 9-10% 4-7% Increase HR with escalating dose, no (Sanctura): prolongation Mirabegron 3% 9-11% 2-3% 4% (Myrbetriq)

Purpose

Screening & Surveillance ó Evaluation and management of NGB in adults is complex due to their past urologic history and surgeries. GILLETTE LIFETIME SPECIALTY HEALTHCARE ó Identify patients at risk of upper tract damage and ADULT connect with appropriate urology resources. Background Methods

ó GLSHC provides services for adults with childhood ó Review of literature and recommendations from onset disabilities. urologic surgeons who specialize in NGB. ó Majority of patients have transitioned from Gillette ó Resulted in a guideline outlining recommended Children’s Specialty Healthcare. urology services based on past medical/surgical history. ó Urologic services at GLSHC include: ô Research is lacking to support some screening/surveillance for ô Urologist patient increased risk of ô Medical Urology (PM&R physician & NP) ô RN ô Imaging ô Urodynamics

Diagnosis/Previous Surgery Why surveillance? Diagnosis/Previous Surgery Screening/Evaluation Neurogenic Bladder: Risk of hydronephrosis and upper tract damage. With/without retention, and/or on Neurogenic Bladder: Annual : Renal/Bladder US (RBUS) cath program, and/or on With/without retention, and/or on cath program, medications for bladder spasms, and/or on medications for bladder spasms , and/or and/or recurrent UTIs recurrent UTIs. Indewelling catheter > 10 yr Used for >10years increases risk of squamous cell carcinoma. Suprapubic catheter > 10 yr Bladder Augmentation Annual : RBUS, Cr, BUN, Electrolytes Indewelling catheter > 10 yr Annual after 10 yrs : RBUS, Cr, BUN, Electrolytes, & Urine Cytology Bladder Augmentation Risk of transitional cell carcinoma, formation, metabolic acidosis. Suprapubic catheter > 10 yr Bladder Augmentation-Ileal Used Annual : RBUS, Cr, BUN, Electrolytes & Vitamin B12 Bladder Augmentation-Ileal Risk of transitional cell carcinoma, bladder stone formation, metabolic acidosis Annual after 10 yrs : RBUS, Cr, BUN, Electrolytes, Vitamin B12, Cystoscopy & Urine Used and Vitamin B12 deficiency. Cytology

Indiana Pouch Risk of transitional cell carcinoma, stone formation, metabolic acidosis, vitamin Indiana Pouch Annual : RBUS, KUB X-ray, Cr, BUN, Electrolytes, & Vitamin B12 (Continent Cutaneous Pouch) B12 deficiency (Continent Cutaneous Pouch) Annual after 10 yrs : RBUS, KUB X-ray, Cr, BUN, Electrolytes, Vitamin B12 & Urine Cytology Ileal Conduit Risk of transitional cell carcinoma, stone formation, metabolic acidosis, vitamin B12 deficency. Ileal Conduit Annual : RBUS, KUB X-ray & Vitamin B12 Annual after 10 yrs : RBUS, KUB X-ray, Vitamin B12 & Urine cytology Nephrectomy , Solitary or Require close monitoring of remaining renal function for hydronephrosis, stone Horseshoe formation. Nephrectomy , Solitary or Horseshoe Annual : RBUS & Cr

New Hydronephrosis Need to evaluate for cause of hydronephrosis to reduce poor outcome of renal New Hydronephrosis RBUS, CMG & Cr failure.

Incontinent between catheterization or voids UA/UC, RBUS & CMG (if UA/UC negative) Incontinent between Need to evaluate for cause of leakage: UTI vs high pressure bladder vs catheterization or voids incompetent sphincter. Results Discussion/Conclusion

Distribution and implementation of the guideline: ó Recommendations will change based on new research óIncreased awareness developments and individual patient óProvided structure to annual follow up presentation/symptoms/needs. óHelped nursing staff prepare patients for upcoming visits ó The tool helped providers to identify patients who require óCoordinate services: imaging, labs, and records close urologic follow up óIdentified patients who need to re-establish adult urologic care ó Adult patients benefit from learning the potential risks they ô (2011-2012) increased from 106 to 154 out of a total of 178 adults with SB receiving other services at GLSH. face based on their past surgeries and medical histories. óGuided a patient education resource comparison and gap analysis ó May increase their understanding of the importance of ô creation of eight new urology patient education pieces ongoing urologic follow up and increase adherence to the guidelines in medical management and self-care.

Thank you!

PLEASE WELCOME DR. CHARLES DURKEE

ASSOCIATE PROFESSOR, PEDIATRIC UROLOGY CHILDREN'S HOSPITAL OF WISCONSIN MEDICAL COLLEGE OF WISCONSIN