Wee Answer Wednesday: Neurological Disorders & Incontinence

We’ve talked a lot about spinal cord injuries here but it’s important not to forget, that’s not the only disease that’s strongly associated with incontinence. Incontinence is often caused by other neurologic conditions such as Multiple Sclerosis, Parkinson’s Disease, Stroke and Spina Bifida. In each of these cases incontinence can have a huge economic, physical and psychological impact. So with that in mind, this week we’ve got a few questions from customers with these diagnoses!

1. Why is incontinence associated with these neurological conditions?

Many neurological conditions can cause what is known as neurogenic detrusor overactivity which basically translates to involuntary bladder contractions. There is no physical problem with the bladder or urethra. Instead involuntary muscle contractions and disrupted communication between the brain and bladder make it hard to control urinary frequency or urgency. This can lead to embarrassing accidents and potentially serious medical complications such as urinary tract infections, yeast infections or decubitus ulcers if incorrectly managed.

2. How does incontinence impact quality of life for men with neurological disorders?

Short answer here – it has a huge impact. The exact amount varies by person, by diagnosis and by their stage of illness. However, study after study has concluded that incontinence has a negative impact on health related quality of life assessments.

For example, one study indicated that 96% of individuals with MS reported bladder problems with 41% indicating they were moderately or greatly bothered by it. In addition, 31% reported that urinary problems impacted their emotional health, ability to perform household chores (22%) and physical recreation (28%).

Five different studies have suggested that incontinent stroke patients have impaired functioning, lower life satisfaction and a higher rate of institutionalization compared with stroke patients who are continent. Twelve months after their stroke, 45% of incontinent survivors were institutionalized, compared to 5% of survivors without urinary incontinence.

3. Do all men with these disorders have urinary incontinence?

No. Not everyone will have incontinence; however, a majority will, particularly as degenerative diseases like MS or Parkinson’s develop.

For Spina Bifida sufferers, urinary and fecal incontinence was very common (60.9 and 34.1%, respectively), regardless of the bladder and bowel management they used. The majority of urinary and fecal incontinent patients perceived this as a problem (69.7 and 77.0%, respectively). Spina bifida aperta, hydrocephalus and a level of lesion of L5 or above were associated with patients suffering from urinary and/or fecal incontinence.

4. I have been diagnosed with a neurological disorder which shall remain nameless and thankfully, I’m still fully continent. But I’m concerned about when that will change. How often should I get my urinary function evaluated?

Guidelines for this will vary widely based on diagnosis and the stage of the illness. However, the best guidelines I have are to get evaluated when you start experiencing symptoms or at least every three years, whichever occurs first.

There are several possible urodynamic tests your doctor can consider running to evaluate your bladder and bowel function. I’ve included a brief excerpt below from recommendations from the Agency for Healthcare Research and Quality.

 

Assessment of Lower Urinary Tract Dysfunction in Patients with Neurological Conditions

Assessment applies to new patients, those with changing symptoms, and those requiring periodic reassessment of their urinary tract management. The interval between routine assessments will be dictated by the person’s particular circumstances (for example, their age, diagnosis, and type of management) but should not exceed 3 years.

Clinical Assessment

When assessing lower urinary tract dysfunction in a person with neurological disease, take a clinical history, including information about:

  • Urinary tract symptoms
  • Neurological symptoms and diagnosis (if known)
  • Clinical course of the neurological disease
  • Bowel symptoms
  • Sexual function
  • Comorbidities
  • Use of prescription and other medication and therapies

Assess the impact of the underlying neurological disease on factors that will affect how lower urinary tract dysfunction can be managed, such as:

  • Mobility
  • Hand function
  • Cognitive function
  • Social support
  • Lifestyle

Undertake a general physical examination that includes:

  • Measuring blood pressure
  • An abdominal examination
  • An external genitalia examination
  • A vaginal or rectal examination if clinically indicated (for example, to look for evidence of pelvic floor prolapse, fecal loading, or alterations in anal tone)

Carry out a focused neurological examination, which may need to include assessment of:

  • Cognitive function
  • Ambulation and mobility
  • Hand function
  • Lumbar and sacral spinal segment function

Undertake a urine dipstick test using an appropriately collected sample to test for the presence of blood, glucose, protein, leukocytes, and nitrites. Appropriate urine samples include clean-catch midstream samples, samples taken from a freshly inserted intermittent sterile catheter and samples taken from a catheter port. Do not take samples from leg bags.

If the dipstick test result and person’s symptoms suggest an infection, arrange a urine bacterial culture and antibiotic sensitivity test before starting antibiotic treatment. Treatment need not be delayed but may be adapted when results are available.

Be aware that bacterial colonisation will be present in people using a catheter and so urine dipstick testing and bacterial culture may be unreliable for diagnosing active infection.

Ask people and/or their family members and carergivers to complete a ‘fluid input/urine output chart’ to record fluid intake, frequency of urination and volume of urine passed for a minimum of 3 days.

Consider measuring the urinary flow rate in people who are able to void voluntarily.

Measure the post-void residual urine volume by ultrasound, preferably using a portable scanner, and consider taking further measurements on different occasions to establish how bladder emptying varies at different times and in different circumstances.

Consider making a referral for a renal ultrasound scan in people who are at high risk of renal complications such as those with spina bifida or spinal cord injury.

Refer people for urgent investigation if they have any of the following ‘red flag’ signs and symptoms:

  • Hematuria
  • Recurrent urinary tract infections (for example, three or more infections in the last 6 months)
  • Loin pain
  • Recurrent catheter blockages (for example, catheters blocking within 6 weeks of being changed)
  • Hydronephrosis or kidney stones on imaging
  • Biochemical evidence of renal deterioration

Be aware that unexplained changes in neurological symptoms (for example, confusion or worsening spasticity) can be caused by urinary tract disease, and consider further urinary tract investigation and treatment if this is suspected.

Refer people with changes in urinary function that may be due to new or progressing neurological disease needing specialist investigation (for example, syringomyelia, hydrocephalus, multiple system atrophy, or cauda equina syndrome).

Assess the impact of lower urinary tract symptoms on the person’s family members and carergivers and consider ways of reducing any adverse impact. If it is suspected that severe stress is leading to abuse, follow local safeguarding procedures.

Urodynamic Investigations

Do not offer urodynamic investigations (such as filling cystometry and pressure-flow studies) routinely to people who are known to have a low risk of renal complications (for example, most people with multiple sclerosis).

Offer video-urodynamic investigations to people who are known to have a high risk of renal complications (for example, people with spina bifida, spinal cord injury, or anorectal abnormalities).

Offer urodynamic investigations before performing surgical treatments for neurogenic lower urinary tract dysfunction.

 

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