Bladder dysfunction in ALD and AMN Sara Simeoni, MD Department of Uro-Neurology National Hospital for Neurology and Neurosurgery Queen Square, London

Bladder dysfunction is unfortunately very common in both men and women! -overactive bladder (urinary urgency, frequency, nocturia and incontinence)  MOST COMMON -stress urinary incontinence (involuntary leakage on effort or exertion, or on sneezing or coughing) -low stream Significant impact on quality of life but frequently under-reported and under-treated!

Severity of bladder symptoms in AMN 67% of patients reported symptoms to be of moderate or severe grade and having a significant impact on the quality of life  Despite this high figure, only a third of patients receive treatment for managing bladder symptoms

What happens during the assessment? Ask a few questions Keep a diary of visits to the toilet Test the urine for an infection See if the bladder is emptying after urination Urodynamics? Talk about treatments

Measuring the post void residual

Urgency Frequency Nocturia Incontinence Storage symptoms Hesitancy Straining Interrupted stream Double voiding Voiding symptoms

Lifestyle modifications Fluid intake of around 1–2 l a day, although this should be individualized. Drinks that CAN irritate the bladder Caffeinated tea and coffee Green tea Hot chocolate Fizzy drinks, especially Cola Caffeinated energy drinks Fresh acidic drinks Drinks that DON’T irritate the bladder Decaffeinated tea and coffee Water All types of diluted fruit juices Non-acidic fresh drinks Herbal tea Red bush tea

Bladder training Bladder training involves training yourself to voluntarily ‘hold on’ for increasingly longer periods You begin with small delays, such as 30 minutes, and gradually work your way up to urinating every three to four hours.

Pelvic floor muscles exercises They help strengthen your pelvic floor muscles and urinary sphincter. These strengthened muscles can help you stop the bladder's involuntary contractions. A physiotherapist can help you learn how to do the exercises correctly. Useful especially if you have involuntary leakage on effort or exertion, or on sneezing or coughing.

Medications that relax the bladder Antimuscarinics (e.g. tolterodine, oxybutinin, trospium, solifenacin, darifenacin, fesoterodine)  possible side effects are dry eyes, dry mouth and constipation Mirabegron  possible side effects are hypertension and palpitations

Percutaneous tibial nerve stimulation to relax the bladder -Treatment option for overactive bladder (frequency, urgency, nocturia, incontinence) -A nerve in the leg called the posterior tibial nerve is stimulated near the ankle -It modulates the nerve that control bladder function -No major safety concerns -60-80% of patients benefit from this treatment -12 weeks of treatment

Percutaneous Tibial Nerve Stimulation (PTNS) A 34-gauge stainless steel needle is inserted approximately 3–4cm about three fingerbreadths cephalad to the medial malleolus, 9V stimulator (Urgent PC®, Uroplasty Inc., US) with an adjustable pulse intensity of 01–10mA, a fixed pulse width of 200 microseconds and a frequency of 20Hz. Courtesy Uroplasty

Botulinum toxin injections to relax the bladder Botulinum toxin type A injected into the detrusor muscle under cystoscopic guidance appears to be a highly promising treatment for intractable detrusor overactivity. Duration < 15 minutes Discomfort score 3.4 (0.5 – 9) Effect lasts 9-13 months Often need to perform catheterisation afterwards. It significantly improves frequency, urgency and nocturia and quality of life. Fewer urinary tract infections and reduced urethral leakage when using an indwelling catheter (catheter bypassing).

How to manage difficulties in emptying the bladder Complete bladder emptying is important for avoiding recurrent urinary tract infections and maintaining renal function. As there are no effective medications for improving voiding, catheterisation is usually the best option.

Catheterisation Clean intermittent self-catheterisation is preferred as it avoids the long term complications associated with a permanent indwelling catheter. Frequency of catheterization depends on the postvoid residual volume and fluid intake. If the symptoms become refractory to all treatments a long term indwelling catheter may be an option This should be a suprapubic rather than a urethral catheter because of the impact of the latter on urethral integrity, perineal hygiene and sexuality.

Urine infections -Urine should not be routinely tested unless there are symptoms suggesting infection. -Antibiotics should be limited to symptomatic urinary tract infections. -Unrestricted use of prophylactic antibiotics can lead to drug resistance; however, in individuals with proven recurrent urinary tract infections it is sometimes reasonable to start prophylactic low dose antibiotics; this decision should be taken in consultation with a urology specialist team. -Cranberry extract tablets and D-Mannose may be helpful to prevent infections due to E.Coli

To recap Bladder dysfunction is frequent in ALD/AMN Check to see if the bladder is emptying or not Treatments- Fluids Exercise Tablets Electrical stimulation of nerves (PTNS) Botox

Get in touch Primary care- community continence team Uro-Neurology department- we are here to help National Hospital for Neurology and Neurosurgery Queen Square, London WC1N 3BG

Thanks for your attention! Questions?