What is the role of nonmedical treatment and surgery in the urologic management of neurological disease?

Updated: Dec 27, 2018
  • Author: Frances M Dyro, MD; Chief Editor: Robert A Egan, MD  more...
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Answer

Nonmedical treatment of incontinence involves the use of pelvic floor muscle training, tibial nerve stimulation, biofeedback, pessaries, bladder retraining, and sometimes intermittent catheterization. For mild stress incontinence, Kegel exercises may increase pelvic muscle tone enough to correct the problem.

Inserts around which the muscles can contract can be placed in the vagina. Stimulators, also placed in the vagina, produce tonic contraction of the sphincter and pelvic floor, which both increases outflow resistance and decreases uninhibited contractions. Intractable cases may be treated with implanted sacral nerve stimulators. [42] Sacral neuromodulation can be successful in patients with voiding dysfunction and a history of spinal surgery; however, those with urge incontinence are less likely to report significant improvement. [43]

Various surgical procedures have been developed for managing incontinence, largely stress incontinence in women. In aging postmenopausal women, pelvic floor laxity complicated by pelvic floor neuromuscular damage incurred during labor and delivery predisposes to descent of the bladder neck, cystocele formation, and decreased outflow resistance. All these factors produce a mechanical type of incontinence that is managed by reestablishing the normal relationship of the bladder neck and trigone to the pelvic floor.

Although many women can be treated successfully by inserting a pessary, the highest rate of cure has been reported in those who undergo suprapubic bladder-neck suspension or a pubovaginal sling procedure. Cystoceles are treated with anterior repair of the vagina, often in conjunction with removal of a prolapsed uterus. The use of injectable bulking agents, such as polytetrafluoroethylene (PTFE; Teflon) or collagen, may increase urethral resistance, but long-term results have been poor.

In failure to become dry, especially after pelvic surgery, irradiation, or history of difficult vaginal deliveries, a fistula must be considered.

Stimulators of various sorts have been developed over the past 30 years to attempt to manage voiding dysfunction. These are implanted devices placed on spinal roots.

The incontinence seen in patients with parkinsonism, dementia, cerebrovascular disease, or multiple sclerosis may be a combination of true bladder dysfunction and decreased mobility. About 35% of such patients may have detrusor hyperactivity and decreased bladder capacity. Anticholinergic drugs are helpful, as is timed voiding. When mental function is decreased, behavior modification, frequent toileting, and avoidance of sedatives can decrease the frequency of “accidents.”


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