Neurogenic Bladder Disorders Dr Malith Kumarasinghe MBBS (Colombo) Yes, it seems absolutely normal, that we all won’t share our urination habits with our neighbor. Yes, it is even hard to address “peeing problems” to our spouse, best friend or primary care taker. That you can remain keeping this part of your privacy undisclosed, I will step forward today and share my knowledge on the topic of bladder problems with you. FORMAL INTRODUCTION Dear Ladies and gentlemen, My name is Andrea Staack and I am pleased to be here today. I am a Urologist specialized on patients suffering from a large spectrum of voiding dysfunctions.

What will you learn during the 2 hours? Physiology of bladder disfunction? How to evaluate? What are the ways to improve symptoms? Therapy with medication Invasive interventions What can you expect to learn during the next 20 minutes of this talk? What is happing to my bladder? How will I get evaluated? How can I improve my symptoms? Therapy with medication Invasive interventions to treat neurogenic bladder disorders.

Risk increases with age Can “happen out of the blue” or 40-50% in the elderly population will suffer from bladder disease in the U.S. Risk increases with age Can “happen out of the blue” or Can have neurological causes “Your are not alone with bladder problems!” 40-50% in the elderly population will suffer from bladder disease in the US. It is an extremely common problem among women and men. It increases with age. Most people think incontinence is part of normal aging. Bladder problems can start out of the blue. Doctors call it idiopathic, which means for no obvious reason or it can have a neurological cause.

Normal Voiding Cycle Emptying phase Filling & storage phase Bladder pressure Normal desire to void First sensation to void Bladder filling Bladder filling Normal voiding Cycle This diagram shows you a normal voiding cycle. I will walk you through. The normal voiding cycle is comprised of a filling/storage phase and an emptying phase. During the filling phase, the bladder muscle stretches to maintain low pressure. At the same time, the urethral sphincter is under high pressure. Sensation of bladder fullness begins when the bladder is half full at around 250cc. At around 500cc, an individual experiences a strong desire to void and the emptying phase begins. After a person chooses the right place to urinate, the urethral sphincter voluntarily relaxes, the pelvic floor relaxes and the bladder muscles contracts. Urination is happening! After this is done, the cycle resumes with bladder filling, urethral sphincter and pelvic floor tightening and bladder muscle relaxation. Abrams P, Wein AJ. The Overactive Bladder — A Widespread and Treatable Condition. Stockholm, Sweden: Erik-Sparre Medical AB; 1998. 4

Dual control of urination: Autonomic nervous system control Nerve coming from the spinal cord and go directly to the bladder When bladder gets fuller, signals are sent to the brain Central nervous system Voluntary control to choose when to void  Both can be altered by aging or neurological disease Control of urination is dual under the influence of both the autonomic and central nervous systems: The autonomic nervous system control urination by direct nerve innervations to the bladder coming from the spinal cord. Signals are sent back to the brain, when the bladder is getting fuller. The central nervous system controls bladder emptying voluntary, which allows for an appropriate social setting for voiding, is voluntary. The autonomic nervous system control and the central nervous system can be both altered by aging or a neurological disease. 5

neurogenic bladder disorder BLADDER MUSCLE SPHINCTER MUSCLES INCONTINENCE Over activity: Muscles squeezes without warning Too loose: Urethra is not supported URINARY RETENTION Less or none activity: Muscle is too lazy Too tight: Urination is difficult Patients with Friedeich’s ataxia might suffer from bladder disorders with progression of the disease. The exact mechanisms of what will happen is not clear. Degeneration of peripheral nerves and the spinal cord, can have a different impact. It can affect the bladder muscle or the sphincter muscles. Overactive bladder. Damaged nerves may send signals to the bladder at the wrong time, causing its muscles to squeeze without warning. Urine retention. For some people, nerve damage keeps their bladder muscles from getting the message that it is time to urinate or makes the muscles too weak to completely empty the bladder. If the bladder becomes too full, urine may back up and the increasing pressure may damage the kidneys. If urine remains in the body too long, an infection can develop in the kidneys or bladder. Urine retention may also lead to overflow incontinence—leakage of urine when the bladder is full and does not empty properly. Poor control of sphincter muscles. Sphincter muscles surround the urethra—the tube that carries urine from the bladder to the outside of the body—and keep it closed to hold urine in the bladder. If the nerves to the sphincter muscles are damaged, the muscles may become loose and allow leakage or stay tight when a person is trying to release urine.

Uncontrolled Contraction of the Bladder Muscle Normal bladder Patients with urge or frequency Patients with urge incontinence Unstable Contraction of the Detrusor Muscle - In healthy individuals, the urethral pressure is greater than the bladder pressure - In patients with frequency and urgency, unstable detrusor contractions create the feeling of urgency, but incontinence does not occur because the urethral pressure remains greater than the bladder pressure In patients with urge incontinence, detrusor contractions are very strong, resulting in an increase in bladder pressure that exceeds urethral pressure; involuntary urine leakage occurs, often emptying the bladder Overactive Bladder Part of the pathology of overactive bladder is the inappropriate contraction of the detrusor muscle during the filling/storage phase of the micturition cycle. These unpredictable and involuntary detrusor contractions cause increased urinary urgency, or a strong desire to urinate. Because the bladder cannot fill appropriately or completely, bladder capacity is reduced, resulting in urinary frequency, or the need to empty the bladder frequently. The most severe form of overactive bladder occurs when detrusor pressure during these contractions overcomes sphincteric resistance, resulting in urinary incontinence. Urethral resistance Uncontrolled bladder muscle contractions 7

neurogenic bladder disorder: More patients will most likely develop incontinence from bladder overactivity than from difficulties to empty bladder Degenerative disease of nerve tissue in the spinal cord and peripheral nerves Exact mechanism of bladder disorders remains unclear -More patients will most likely develop incontinence from bladder overactivity than from difficulties to empty the bladder. In this talk I will emphasize on on the most common symptoms complex and its management and I will briefly talk about the management with difficulties to empty the bladder. -We know that Friedreich’s ataxia is a degenerative diseases of nerve tissue in the spinal cord and the peripheral nerves. -The exact mechanism of bladder disorders remains unclear at this time.

Overactive Bladder Symptom: “Experiencing a strong urge to go to the bathroom.”  Urinary Urgency You might say: “I am expere….” The symptoms of overactive bladder include urinary urgency—the sudden, strong need to urinate immediately

Overactive Bladder Symptom: “Going to the bathroom frequently.” “Have to go to the bathroom, where the bladder wakes me up at night.”  Urinary Frequency The symptoms of overactive bladder include urinary frequency—urination eight or more times a day or two or more times a night

Overactive Bladder Symptom: “Loosing involuntary urine accompanied with the strong desire to void.”  Urge Urinary Incontinence The symptoms of overactive bladder include urge incontinence—leakage of urine that follows a sudden, strong urge to urinate

2. How to evaluate? “Hello, incontinence helpline – Can you hold?” I hope this won’t happen to you, when you are making your appointment. “Hello, incontinence helpline – Can you hold?”

2. How to evaluate? -History- Fluid intake pattern Number of continent and incontinence episodes Night time urgency Voiding Pattern Quality of stream Incomplete voiding At the beginning, a complete history needs to be obtained. The urologist will ask about -fluid intake -number of continent and incontinent episodes -night time urgency -voiding pattern, such as quality of stream, or a feeling of incomplete voiding Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682. Wyman JF, et al. Obstet Gynecol. 1988;71:812-817.

2. How will I get evaluated? -History- Risk factors: Previous surgeries Back pain History of lumbar disc prolapse History of other urological or gynecological conditions: Bladder prolapse Uterine prolapse Rectal prolapse

2. How to evaluate? -History- Excluding secondary causes: Diabetes Congestive heart failure Bladder cancer Urinary tract infections Pregnancy Medications Secondary causes for bladder disorders need to be excluded: Such as: -diabetes, which causes also peripheral nerve damages -Congestive heart failure, which might cause edema. Can lead to more urination during the night. -bladder cancer or urinary tract infections, can cause irritation -pregnancy can lead to bladder overactivty as well as certain -medications. Raz, S and Rodriguez, LV: Female Urology. 3rd edition. Saunders Elsevier, 2008.

2. How to evaluate? -History- Alterations in bowel habits Changes in sexual function OB/GYN history Medications( details in next slide) Neurologic history Back pain, back surgery Stroke Numbness, weakness, balance problems Further, -alterations in bowel habits will be discussed -changes in sexual function, An OB/GYN history will be obtained and a neurological history, including questions about back pain, back surgery, stroke, numbness, weakness and balance problems.

2. How will I get evaluated? Medications That May Influence Bladder Function: Narcotics Sedatives OTC-Sleep aids and cold remedies Antipsychotics Herbal remedies Anti-water meds (Diuretics) Antidepressants Blood pressure meds Hypnotics Pain meds Medications That May Influence Bladder Function Those medications, which might influence bladder functions and might caus overactive bladder-like symptoms are: diuretics antidepressants antihypertensives hypnotics analgesics narcotics sedatives OTC sleep aids and cold remedies antipsychotics herbal remedies

2. How to evaluate? -Quantification of symptoms- Voiding diary day and night for >24 hours: Document of fluid intake Quantification of urine output with voiding hat Uncontrolled loss of urine at day and night Degree of urge to go to the bathroom Use and number of pads For more an objective quantification through a voiding diary needs to be conducted for at least 24 consecutive hours. In the the voiding diary you will beed to document -the fluid intake, -quantification of urine output with voiding hat -documents uncontrolled loss of urine at day and night -document the degree of urge to go to the bathroom -and the use and number of pads. Raz, S and Rodriguez, LV: Female Urology. 3rd edition. Saunders Elsevier, 2008.

2. How to evaluate? -Quantification of symptoms- Do you have to rush to the toilet to urinate? Does urine leak before you can get to the toilet? How often do you pass urine during the day? During the night, on average, how many times do you have to get up to urinate? Does urine leak after you feel a sudden need to go to the toilet? In order to understand the significance of the problem, the urologist will need to quantify the symptoms. The following questions will be asked through validated questionnaires: Do you have to rush to the toilet to urinate? Does urine leak before you can get to the toilet? How often do you pass urine during the day? During the night, on average, how many times do you have to get up to urinate? Does urine leak after you feel a sudden need to go to the toilet? International Consultation on Incontinence Modular Questionnaire on Overactive Bladder in Raz, S and Rodriguez, LV: Female Urology. 3rd ed., 2008

2. How to evaluate? -Physical examination- General examination Focused neurological examination Genitalia and pelvic floor examination Rectal examination A thorough medical examination is mandated. This includes a focused neurological examination, and A rectal examination to rule out constipation, any growth or rectal prolapse. Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.

2. How to evaluate? -Invasive Tests- Urodynamic studies assess: Uncontrolled bladder contractions Urethral competence during filling Bladder function during voiding Left-over urine after urination Urodynamic studies are very important. They assess: -uncontrolled bladder contractions -urethral competence during filling -Bladder function during voiding -residual urine after urination. Those information are crucial in understanding the pathology of the disease in order to determine the best treatment for each individual patient. Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.

2. How to evaluate? -Laboratory tests- Urine tests To rule out blood in the urine, kidney problems, urinary tract infections Blood work as appropriate Blood sugar PSA (prostate cancer) Urinalysis is an essential component of the patient workup and is used to rule out conditions that may be responsible for such urinary symptoms as urinary tract infection, cancer, diabetes, and renal disease. Blood work is also essential. A PSA test should be administered to adequately informed men over 50 years of age in accordance with the AUA guidelines. Assessment of post void residuals needs to be performed. To learn if the patient can empty the bladder. This can be done simply with ultrasound or with catheterization. Fantl JA et al. Agency for Healthcare Policy and Research; 1996; AHCPR Publication No. 96-0686.

2. How to evaluate? -Invasive Tests- Bladder scanning with a camera (Cystoscopy) To rule out any growth, inflammation, or stones inside the bladder Imaging Studies Ultrasound X-ray studies with contrast fluid during MRI More invasive tests include: -bladder scanning with a camera to rule out any growth inside the bladder, inflammations or stones Imaging studies can be obtained using ultrasound, x-ray with contrast fluid, or MRI to evaluate the bladder, urethra and the pelvic floor. Clinical Practice Guidelines: Urinary Incontinence in Adults. 1996. AHCPR publication 96-0682.

How to improve symptoms? After all this extensice work up and testing by your urologist, you will be put to work!

-Dietary changes- Adequate fluid intake: Not too much to avoid too frequency Not too little to avoid bladder irritation and urinary tract infections Reduce evening fluids to manage nighttime urination Fluid intake -Amount of fluid <1500 cc, and in the older patients 1500-2000 cc/day of liquids -too little: smaller amounts of fluid intake results in smaller amounts of urine, which is higher concentrated and irritates the bladder. Patients are also more prone to urinary tract infections. 1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.

-Dietary changes- Certain fluids can irritate the bladder: Carbonated drinks Citrus juices Caffeinated drinks, e.g. soda, tea, coffee Alcoholic beverages It is also important to watch out what to drink. Caffeine: -natural diuretric and bladder irritant -can cause bladder spasms Alcohol: -has an diuretric effect (causes release of anti-diuretic hormone from the pituitary gland) 1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.

-Dietary changes- Dietary adjustments Bowel regulation Fruits Vegetables High fiber intake Bowel regulation Avoid constipation and straining Routine defecation schedule Now, think about foods. Certain foods are high in Vit. D, B, protein and potassium. This has been shown to be bladder protective for overactivity. Other Foods, such as -Artificial sweeteners (e.g. aspartame) -highly spiced foods -chocolare are more likely prone to increase bladder spasms. ---Little scientific evidence exists on certain foods and little research has been done so far- -My goal is to increase awareness in my patients to consider an effect on the bladder with certain foods Bowel regulation: -straining and constipation can induce progressive neuropathy 1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.

-Lifestyle changes- Stop smoking Weight reduction To reduce chronic coughing reduces downward pressure on the pelvic floor Weight reduction Excessive body weight affects bladder pressure, blood flow, and nerves In addition to dietary changes, lifestyle changes have been shown to protect the bladder and to decrease overactive episodes. Quit smoking. This reduces the risk of chronic coughing. Coughing puts on extra downward pressure on the pelvic floor. 2. Weight reduction might be considered. Excessive body weight affects the bladder pressure, blood flow, and nerves. 1. Burgio KL et al. J Am Geriatr Soc. 2000;48:370-374.

-Exercises- Pelvic floor exercise: Helps strengthen the muscles of the pelvic floor – improves bladder stability Helps suppress the feeling of urgency Bladder Relaxation Exercise for the pelvic floor can be very helpful to deal with bladder overactivity. It Helps to strenghten the muscles of the pelvic floor and improves bladder stability It helps to suppress the feeling of urgency. Contraction

Exercises- Kegel exercise for men and women: Find your pelvic floor muscles. Squeeze your pelvic floor muscles as hard as you can and hold them (squeeze 3-5 sec and relax for 5 sec). Do sets of repetitions of squeezing (start with 5 repetitions: squeeze, hold, relax). Increase lengths, intensity, and repetitions every couple of days. Perform Kegel exercises 3-4x during the day. How can I do pelvic floor exercise. You might have heard about Kegel exercise. It is very effective for women AND men. Now, I will put you to work. Everybody is asked, because people, who haven’t found tehmself from having bladder problems, might will from this exercise, since it is preventative Start by locating your PC muscle. Many people begin doing kegel exercises but are actually squeezing the wrong muscle. Before you start the exercises, find your PC muscle, make sure you know where your PC muscle is and what it feels like. Squeezing kegel exercises: start slow, find your baseline. The basic exercise can be done anytime and anywhere. Just squeeze your PC muscles as hard as you can, and hold them. This is doing a kegel exercise. Start by squeezing and holding for a count of 3-5 seconds, then release and relax for 5 seconds. When you release, notice how your muscles feel. The first time you do a kegel exercise see how many times you can do it before you feel your muscles getting tired. Squeezing kegel exercises: use sets of repetitions Your kegel exercises will be most efficient and have the most impact if you get into doing sets of repetitions of the squeezing. Once you’ve found your baseline, you can work from there. If you can, start with doing 5 repetitions (squeeze/hold/release). Judge for yourself how long you can hold the squeeze for, but don’t push yourself too much at first. Building up strength with kegel exercises. Once you've found your baseline, do your exercises, and every couple of days increase both the length of time you hold the squeeze for, and the number of exercises per set. As a guideline, try to work up to a point where you can hold the squeeze for ten seconds. And try to work up to doing ten reps of kegel exercises per set. So you squeeze, hold for ten second, release, relax for ten seconds, and repeat ten times. Do your kegel exercises three or four times a day. Try to take three or four times in the day to do kegel exercises. Again, everyone is different, but as a guideline try to do ten reps per session, holding for ten seconds on each exercise. Vary the intensity and time in kegel exercises. You can also try to vary the intensity of your squeezing and the amount of time you hold the squeeze in a set. Once you’re comfortable that you're doing the exercises properly try a set where you do rapid squeeze and release. Experiment with how long you can comfortably hold a squeeze. Remember not to push yourself to the point of pain or discomfort. Using products for resistance kegel exercises. Some people will use a toy or kegel exercising device to add resistance to kegel exercises. This is not necessary, and while some sex educators suggest it increases the usefulness of the exercise, doing them on your own is still a great way to develop your PC muscle. If you are interested in purchasing a product for kegel exercises, make sure it isn’t too large, as this may get in the way of kegel exercises more than it will help them. Do kegels while masturbating and having partner sex. Once you're comfortable, incorporate kegel exercises in your masturbation. Do them while you’re getting warmed up, doing them before you have an orgasm, and even try to do them while having an orgasm. You may notice that kegels change the way your sexual excitement and your experience of orgasm feels. Tips: Isolate the PC muscle when doing your kegel exercises. At the beginning, remember to regularly check that you are exercising your PC muscle, and not other muscles. Avoid contracting your abdominal, thigh, or buttocks muscles. This is something many people do, but it reduces the effectiveness of the kegel exercise Concentrate on breathing and trying to keep yourself relaxed, and only tense the PC muscles you are using. Try not to tense up your whole body. Finding time to do your kegel exercises. You don’t need to set aside a big chunk of time to do kegel exercises. Do a few reps while waiting for a stop light to turn green. In the last ten minutes before lunch, when you’re sitting at a desk, do a few reps. Do them while you’re waiting for the movie to start, or a commercial break to be over. Don’t overdo your kegel exercises.Like any exercise, it’s important to build up slowly, and pay attention to your body. If you are experiencing pain or discomfort, you are pushing yourself too hard. It is possible that you could strain the muscles and aggravate a current problem, when you are trying to resolve it. Kegel exercise products can be fun and helpful but they aren’t necessary.There are more and more products, often called “kegelcisors” on the market. While some of these can genuinely increase the strengthening exercises, and some of them double as fun sex toys, remember that they are not necessary. You don’t need any special work out clothes or paraphernalia to do kegel exercises properly.

3. How to improve symptoms? Biofeedback therapy: Monitors correct muscular contraction to develop conscious control of pelvic musculature Voluntary contraction of the pelvic floor muscles controls urge to urinate In case you feel lost practicing KEGEL exercise or finding the right muscles to contract, you might consider Biofeedback. IT Biofeedback therapy monitors the correct muscluar contraction to develop conscious control of pelvic musculature. If you are able to perform a voluntary contraction of the pelvic floor muscles, you might be better in controling the urge to urinate. -------- -Outpatient clinic, 4-8 hours/week -relaxing environment -Measurment of bladder pressure, anal sphincter pressure and vaginal EMG plust measurment of abdominal activity -rectal ballon for intra-abdominal pressure -First step is to make the patient understanding to identify the PFM when instructed to squeeze around the examiners fingers, lifting up (some patients bear down, which is counter productive, it increases intra-abdominal pressure -Patients are instructed to breath evenly and to relax abdominal muscles -Place one hand on the abdomen to notice faulty abdominal contractions PFM

Bladder training: Scheduled voiding at set times during the day Active use of muscles to prevent urine loss Increase voiding intervals after the initial goal is achieved Keep own input and output chart Reward increasing volumes of urinary output By training your pelvic floor muscles you have already excelled. Now it is time to train your bladder. This is the way you can do it: Schedule voiding at set times during the day Use actively your trained pelvic floor msucles to prevent urine leakges Increase your voding intervals after the nital goal is achieved. Keep your own input and output chart Reward yourself, when you noticed that you urinated more but less frequently.

Alternative therapies: Hypnotherapy Yoga Acupuncture Hypnosis -Form of cognitive therapy -Hypnotherapy teaches patients through relaxation and suggestion to regain the executive function of the brain over the bladder’s afferent signals to urinate. -Provides relaxations techniques Yoga: -also provides relaxation techniques and strengthen the pelvic floor Acupuncture -Inhibits uncontrolled bladder contractions -studies have shown that acupuncture effects the PFM

4. How to improve symptoms? -Summary- 6 steps for continence: Drink less than 5 glasses/day (40 oz) Stop drinking after dinner Elevate legs Timed voiding Regular pelvic floor exercises Voiding diary Behavioral modification plus exercise provides plus bladder training are excellent treatments with minimal side effects to control bladder overactivity. Patients should be instructed to implement the following program at home: regular pelvic floor muscle exercises specified voiding schedule aimed at expanding voiding intervals guidelines for controlling urgency active use of muscles to prevent urine loss Program to train yourself at home: Regular pelvic floor muscle exercises Set up voiding schedule aiming to expanding voiding intervals guidelines for controlling urgency Active use of muscles to prevent urine loss Dietary changes

What will you learn during the next 20 min? What is happening to my bladder? How will I get evaluated? How can I improve my symptoms? Therapy with medication Forms of interventions If those measurements are not sufficient to improve symptoms, there are some forms of medical therapy. However, if possible, I recommend medication only in conjunction with life style changes, dietary changes, and the exercises.

“Each capsule contains your medication plus a treatment for each of its side effects.” Those pills are not on the market yet, since nobody is able to swallow them.

4. Therapy with medication Drug Treatment for Overactive Bladder: Targets bladder nerves to block uncontrolled contractions Anticholinergics  Not very bladder specific Drug treatment for overactive bladder symptoms is problematic. It focuses on blocking receptor sides at the bladder, but is not very bladder specific. Blocking those receptors creates side-effects, and additional, not pleasant drug interactions can occur, if you are on medications for ataxia. 37

4. Therapy with medication Side effects: Dry mouth • Tachycardia Constipation • Fatique Blurred vision • Dizziness Slow thinking Therefore, side effects are common: -The clinical usefulness of previous therapies for OAB was limited by anticholinergic side effects in other body systems because these agents are not selective for the bladder. -The most bothersome side effects of the class of anticholinergics include dry mouth, constipation, blurred vision, tachycardia, and impaired cognitive function. These side effects are more pronounced in elderly patients. 38

4. Therapy with medication Drug interactions between anticholinergics and: Beta-blocker Drowsiness Dizziness Confusion Blurred vision Amantadine Urinary retention Dry skim Watch out, when your take other medications . -The clinical usefulness of previous therapies for OAB was limited by anticholinergic side effects in other body systems because these agents are not selective for the bladder. -The most bothersome side effects of the class of anticholinergics include dry mouth, constipation, blurred vision, tachycardia, and impaired cognitive function. These side effects are more pronounced in elderly patients. -Thus, the ideal antimuscarinic agent for the treatment of OAB would be one that acted specifically on the detrusor muscarinic receptors. 39

Interventions If behavioral changes and medications don’t work, there are some alternatives. They are more or less invasive.

5. Interventions -Botox®- Neurotoxin, Clostridium botulinum Injections into the bladder under direct vision Blocks chemically nerve ends As early as 2 days after injections it improves urgency and frequency You might have heard about Botulinum toxin or Botox. It is pretty effectful to treat wrinkles, but it can also do good for your bladder. First of all, your urologist needs to rule out that you suffer from urinary retention, because Botox could makes things worse. If this is not the case, than it gets directely injected into your bladder. It works like a chemical denervations, and starts already improving symptoms as early as 2 days after injections. ---- BTX - neurotoxin produced by Clostridium botulinum and is a potent presynaptic inhibitor of acetylcholine release at the neuromuscular junction It is applied directly by cystoscopic injection into the detrusor muscle, producing a chemical denervation that is reversible after approximately 6 months (up to 9) The mode of administration allows high concentrations of the agent to reach the bladder tissue without systemic administration and resultant unsuitable levels in other organs BTX is not approved for the treatment of OAB but is now widely used in patients who are refractory to conventional antimuscarinic therapy or who do not tolerate it due to systemic side effects.

5. Interventions -Botox®- Duration between 3-6 months Not FDA-approved for neurogenic bladder, but is widely used for failure of medical therapy Not indicated in patients with difficulties to empty their bladders Botox lasts between 3-6 months. It is not FDA-approved for neurogenic bladder disorders, but widely used worldwide, when medications fails But watch out, if you are having difficulties emptying your bladder.

5. Interventions -Botox®- Local side effects: Excessive bladder muscle relaxation can cause urinary retention Pain Infections Bleeding General side effects: Muscular weakness Less effective during prolonged time Some people build up a resistance Botulinum toxin The local side effects are: -Excessive bladder muscle relaxation, what can cause urinary retnetion -Pain -Infections -Bleedings General: Muscluar weakness I might become less effective using it for a long time Building up a resistance

5. Interventions -Electrical stimulation of the tibial nerve- Objective alternative to medical therapy Least invasive form of neuromodulation Indirect stimulation of bladder nerves using a nerve at the lower leg Recommended treatment is 12 weekly sessions of 30 minutes each Peters KM, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. J Urol. 2009;182:1055–61 least invasive forms of neuromodulation used to treat overactive bladder (OAB) and the associated symptoms of urinary urgency, urinary frequency and urge incontinence The needle electrode is then connected to an external pulse generator which delivers an adjustable electrical pulse that travels to the sacral plexus via the tibial nerve. Among other functions, the sacral nerve plexus regulates bladder and pelvic floor function. Percutaneous tibial nerve stimulation (PTNS) -Non-invasive way of modulating pelvic reflexes via projections from the posterior tibial nerve -is used to deliver stimulation to the posterior tibial nerve using a very thin needle like used for acupuncture The recommended course of treatment is 12 weekly sessions of 30 minutes each

5. Interventions -Sacral Neuromodulation- “Pacemaker for the bladder” Treatment for urgency, frequency, urge incontinence, and urinary retention Proven efficacy in patients for whom more conventional therapy has been unsatisfactory Over 14 years FDA-approved Neurologic diseases -like MS, Parkinson's disease and SCI injuries- are undergoing sacral neuromodulation with good success Sacral neuromodulation is well established as a treatment for urgency, frequency, urge UI, and urinary retention The complete mechanism of action remains unknown but theories include modulation of spinal cord reflexes and brain networks primarily via somatic sensory afferent fibers In addition, previously excluded patients such as those with neurologic diseases like multiple sclerosis or Parkinson's disease and patients with incomplete spinal cord injuries are now undergoing SNM with good success. There are no data on patients with ataxia, who underwent sacral neuromodulation.

5. Interventions -Sacral Neuromodulation- How does it work? Leads float next to bladder nerves Leads are connected to a battery placed at the buttocks Leads sent mild electrical impulses out to the sacral nerves Can be discontinued at any time Sacral neuromodulation is well established as a treatment for urgency, frequency, urge UI, and urinary retention The complete mechanism of action remains unknown but theories include modulation of spinal cord reflexes and brain networks primarily via somatic sensory afferent fibers In addition, previously excluded patients such as those with neurologic diseases like multiple sclerosis or Parkinson's disease and patients with incomplete spinal cord injuries are now undergoing SNM with good success. There are no data on patients with ataxia, who underwent sacral neuromodulation.

5. Interventions -Sacral Neuromodulation- Side effects: Skin irritation Pain Wire movement Device problems Interaction with other devices MRI exam not possible Sacral neuromodulation is well established as a treatment for urgency, frequency, urge UI, and urinary retention The complete mechanism of action remains unknown but theories include modulation of spinal cord reflexes and brain networks primarily via somatic sensory afferent fibers In addition, previously excluded patients such as those with neurologic diseases like multiple sclerosis or Parkinson's disease and patients with incomplete spinal cord injuries are now undergoing SNM with good success. There are no data on patients with ataxia, who underwent sacral neuromodulation.

5. Interventions Surgery: Bladder denervation Bladder augmentation Bladder becomes enlarged with an extension made out of bowel Larger reservoir with lower bladder pressures The last resort is surgery. In very severe cases the Bladder can become disconnected from their nerves, It can get augmented. That means with own bowel a cap or pouch can be created and can enlarge the bladder. A larger reservoir will be made this way with lower pressures

“I’ve reached that age where I’ve given up on Mind Over Matter and am concentrating on Mind Over Bladder.” “I’ve reached that age where I’ve given up on Mind Over Matter and am concentrating on Mind over Bladder.”

3. How to improve symptoms? Summary Program to train yourself at home: Regular Kegel exercise Set up voiding schedule aiming to expanding voiding intervals Active use of muscles to prevent urine loss Dietary changes How can you change your bladder symptoms yourself. Here are some tips on a program to train yourself at home: Perform regular Kegel exercise to train your pelvic floor muscles Set up a voiding schedule to aim to expand voiding intervals. If you were able to hold urine for 40 min, than start to hold for 5 min longer for a couple of days and increase it. After 2 weeks you might see yourself being able to hold urine for longer than 60 mins and so on. Use actively your pelvic floor muscles to prevent urine loss. Apply dietary changes. Watch out for caffeinated drinks or excessive fluid intake!

Your bladder matters! Last but not least, your bladder matters! I want to increase awareness of neurogenic bladder disorders in you as patients and want you to understand how the diagnosis made and how to mange those bladder problems. If there is anything wrong with your bladder; you know, now, that You are not alone with this problem, You can feel less embarrassed to address it and You have learned that you can change the way it is. I am happy to answer your questions in a little bit. Your bladder matters!

Thank You!