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Melanie Cole (Host): Neurogenic bladder is a unique problem among disabled patients that has a significant impact on a patient's quality of life, and is very often overlooked within patient communities, such as Ms. Spinal cord injury and other rehab patients. Welcome to GW Doc POD a peer to peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole. And joining me is Dr. Daniel Stein. He's an assistant professor of urology at the George Washington University School of Medicine & Health Sciences, and he's affiliated with The George Washington University Hospital.

Dr. Stein, thank you so much for joining us today. I'd like you to start by telling us a little bit about neurogenic bladder. What is this issue? What conditions is it associated with? I mentioned a few in my intro, but tell us a little bit about the prevalence of it and what you've been seeing?

Dr. Daniel Stein: Sure thanks for having me today. Neurogenic bladder is a pretty broad topic. It's essentially any problem with the bladder that is caused by a neurologic condition, which is pretty broad. When we're thinking about neurogenic bladder, we're often thinking about some of the more common problems such as spinal cord injuries, multiple sclerosis patients transverse myelitis some of the more significant neurologic conditions affecting the spinal cord, which can often affect the function of the bladder.

Melanie Cole (Host): So then speak a little bit about how this affects the quality of life for these patients. What exactly is neurogenic bladder what's happening for them?

Dr. Daniel Stein: Sure. I mean, simply put enough, the bladder has two functions. The bladder has to store urine in a way that will allow the person to not leak the urine out, which can obviously affect their quality of life significantly, and in a way that's safe for their kidneys. And then the second function of the bladder is you've gotta empty the bladder. I mean, it's a pretty simple organ, but, it has to effectively get the bladder completely empty to avoid things like urinary tract infections. And again, in a way that is comfortable for the patient.

When people have a neurogenic condition, both of those can get affected. So they can both have problems with storage in their bladder, and that can lead to things like problems with kidney dysfunction, as well as urinary incontinence, which is a big factor for people's quality of life. Obviously, if they're not able to hold the urine effectively, they might leak that urine and that's gonna affect their quality of life significantly. Secondly, often with neurologic conditions, people can't pee normally, and so they can't empty their bladder efficiently on their own.

And so we have to consider ways to more efficiently, empty their bladder again, to avoid things like urinary tract infections and whatnot. So those are the two main categories that we think about when we're treating people for a neurologic condition affecting their bladder.

Melanie Cole (Host): Well, then what are some of the challenges of finding appropriate therapies and treatment pathways to relieve that urinary incontinence that you mentioned, and other symptoms that are associated with neurogenic bladder while avoiding adverse events and treatment complications to really work on the patient's quality of life?

Dr. Daniel Stein: One of the main factors that comes into play as a barrier is just identifying the patients. Unfortunately, a lot of these patients have a lot of other things going on, understandably, particularly in things like our spinal cord injury patients, where during that acute event, they're dealing with a considerable number of other factors. And it's usually once they've stabilized and they've sort of gotten through their initial event, that people have to really focus and see where the problem lies.

And a lot of that has to do with discussion with the patients. So having that conversation with the patient to really identify, are they having any issues? Is there things that we can improve? So, first and foremost, we think about, bladder storage, right? So there we're worrying about the effects on the kidney. So I talk to my patients and I think sort of in three categories, when I'm talking about my patients, number one is keeping their kidneys safe, avoiding things like renal failure.

If you go back several decades, that was one of the major factors, that contributed to patient's mortality after some of these conditions was renal failure because we didn't have a good understanding of how to manage bladders. So now that's a big factor. We wanna protect their kidneys and that involves putting them on the right medications to reduce the bladder pressures that they have, as well as making sure that they're getting their bladder emptying completely.

The second category that I talk to my patients about is reducing the risk of urinary tract infections. And that's a big issue for a lot of these patients is recurrent urinary tract infections that can lead to current antibiotics and hospitalizations, and all sorts of problems. That often has to do with teaching them how to empty their bladder efficiently. And I'll get to that in just a second. The last thing is quality of life and we think about these three categories all independently. So when I'm first evaluating a patient I'm first gonna start thinking about, are they on medications? Are they able to hold their urine okay?

And often these are medication factors, to get their bladder capacity to a good, level. And that's often things like anticholinergic medications, beta three agonist medications, and sometimes Botox injections in the bladder. Of course, this goes hand in hand with emptying the bladder, which is one of the main factors, they need a referral to a urologist because that's often about teaching them how to either intermittently catheterize themselves or have some form of catheter drainage. Because a lot of the times these patients can't empty their bladder efficiently on their own or at least need monitoring to make sure that they're doing it correctly.

Melanie Cole (Host): Wow. This is such an interesting issue. and as we said, I think it is very underestimated really. It's not something that people often hear about and even patients and their caregivers may not always wanna mention it to their providers. I like that you gave us those three goals of management and why they're so important. Now speak about some of the techniques that you might use, when you might use catheterization, any medications or interventions to relieve some of those bothersome symptom?

Dr. Daniel Stein: Sure. Bladder emptying catheterization in a lot of our neurogenic bladder patients, catheterization is our mainstay. There's essentially three concepts. There you're either peeing without any form of catheter and you're managing to get your bladder empty. Or you have two forms of a catheter, either what we call an indwelling catheter, which is some form of catheter that sits in the bladder all the time. That would either be a uretal catheter or super pubic catheter. And then lastly would be intermittent catheterization, and that's where a patient or their caregiver on occasion would be catheterizing the patient in order to empty their bladder on a regular interval.

Usually about every four hours during the day. Now, obviously that's a challenge for patients to think about, but usually if we sit down with patients and work with them, we can actually teach them how to do it themselves efficiently. And it really gives them the independence to be able to empty their bladder regularly. Which is sometimes the mainstay in order to maintain incontinence and independence, which again, if you're a wheelchair patient or a disabled patient, independence is a big factor.

And having that self control to be able to empty their bladder on their own is quite important. so when it comes to catheterization, there's a variety of different types of catheters and methods of catheterization, and it all gets tailored to the patient themselves, how much flexibility they have, how much mobility they have, whether they can move to a toilet or not. So that gets complicated, but it's really that first step when they're being evaluated and being seen.

It's really to identify who needs to be referred and who needs to be seen because a lot of these patients, as you rightfully said, don't bring these issues up or just get complacent and say, well, this is the way I've always been. So I guess this is the way I'm going to have to live rather than that conversation to say, well, there might be a better way that you can get through this and get more independent.

Melanie Cole (Host): Well, I think one of the most important things that you've mentioned a few times, Dr. Stein, is education and for providers that are working with these patients on a regular basis, how important is patient education as a key component for any management plan for Neurogenic bladder? And what would you like them to know? What would you like to tell them about counseling, their patients? Some of the most important factors when they're working about keeping clean and anything you wanna talk about for caregivers and patients?

Dr. Daniel Stein: I think the first and foremost thing for caregivers and patients and what I see more often than not is that the conversation hasn't been had, no one has brought up their bowel or bladder health with them. And for that matter sexual health, which could be a separate discussion, with a lot of these patients. And because they get a little distracted with all the other things that are going on. So the first thing is just to have that conversation, just to ask the patients, Hey, how are you emptying your bladder? How are things going? Are you having any bowel issues? Where are the problems that you run into? And I think once you've started that conversation, it's much easier to figure out where to go with it.

The other thing is to understand that there are options for patients. And that just because a patient, is in a wheelchair or has a high level spon cord injury doesn't mean that they have to be living in a diaper and in incontinent all the time, there are a lot of options for patients and for their quality of life and for the generalized health. And so I think just identifying the problem with patients, talking to patients about it, prompting that conversation and then getting them referred to the right specialist, I think is the real key from the evaluation perspective, at least from primary care providers or rehab providers, in general.

Melanie Cole (Host): This is a very important and under discussed topic today, Dr. Stein, and I'm so glad we were able to do this before we wrap up. Are there any exciting advances in urology, in the research world, any clinical trials or investigational medicine, you'd like other providers to know. And while you're telling us that, speak about the unique areas that set you apart at the George Washington University Hospital, and why you feel early referral is important?

Dr. Daniel Stein: Sure. Well, I'll address each of those separately. So as for what's on the horizon, one of the big advantages we've made in the last few decades has been medical management of the bladder itself. We've sort of started with just Oxy Butin or some of the basic anticholinergics. Now there's probably six or seven different anti anticholinergics, some better than others. There's two other classes of medications that we can give in conjunction with the anticholinergics that would be beta three agonists and Botox injections.

And that's really changed the landscape when it comes to bladder management. At least moving away from things like surgical management, which we did more of in the past, down the horizon, there are some things that are promising in terms of bladder installations with probiotics to try to reduce, bacterial colonization for patients, who catheterize on their own. As well as some of the other advances, just in technical aspects of some of the catheters that are coming out now.

In terms of where we advance here at GW, I think just having a dedicated, neurogenic bladder clinic and staff that understand having the facilities where we can really allow patients who do have, wheelchairs or other accessibility issues to get in, to see us. We work with a variety of staff, including our physician assistants and nursing staff who had expertise in teaching our patients, how to catheterize and how to work with their unique problems.

And having a multidisciplinary team where we can also refer patients to neurologists and sexual medicine specialists and nephrologists, and a variety of different specialists. I think really having that all under one roof is really a good key to getting good care for some of these more complex problems.

Melanie Cole (Host): Thank you so much, Dr. Stein for joining us today. This was an interesting topic and I'm so glad we were able to discuss it.

And to refer your patient for management of neurogenic bladder, please call 1-888-4GW-DOCS. If you have questions for one of our specialists, please email This email address is being protected from spambots. You need JavaScript enabled to view it..

That concludes this episode of GW Doc POD, a peer-to-peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole. Thanks so much for tuning in today.

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