Bladder Tests

There are some common tests that the urologist may do to see what is going on with the bladder and kidneys.

A valuable resource for different urinary and bladder tests can be found at AboutKidsHealth

The first and least invasive is kidney ultrasound. It allows a view of what the kidneys look like. They look at the size of the kidneys, any scarring, hydronephrosis (dilation of the kidney) and any indication of infection and determine if the kidneys are healthy.

Hydronephrosis is when the kidney swells up (increases in size) because urine is building up in it. It can be caused if there is a blockage and urine cannot drain out, or if urine in the bladder is being pushed back into the kidney (reflux). There are different grades of kidney reflux.
To prevent kidney reflux it is important to relax the bladder.

A VCUG is with an x-ray. VCUG stands to Voiding CystoUrethroGraphy.

You lie down under an x-ray machine. A catheter is put into the bladder and the bladder is filled with contrast. It looks at the bladder capacity (how much urine the bladder can hold) and what happens when the bladder is full. What is the shape of the bladder? Does it leak out? Or does it reflux into the kidney? The contract allows the x-ray to see exactly what urine does. The test takes about 15-20 minutes and gives and understanding of bladder capacity.

The picture shows reflux on one side (http://www.hindawi.com/journals/au/2011/852928.fig.001.jpg)

Urodynamics is another test.
Urodynamics is to evaluate the relationship between pressure in the bladder and flow of urine through the urethra. The test measures and evaluates filling the bladder, emptying the bladder and tries to recreate instances of leaking. All of the information is recorded on a video screen

http://img.medscapestatic.com/pi/meds/ckb/42/13242tn.jpg

This test is a little more involved, it measures filling the bladder with fluid and measuring what the bladder does. A catheter goes into the bladder and the rectum and electrodes measure pressure.
It goes very slow, because it is looking as bladder movement and spasms it is important to stay still for most of the time.

At different times during the test they want to see how the bladder reacts to different movements, so you are asked to cough at specific times. When we went he never wanted to cough when it was time, and it was something we should have practiced ahead of time, but I never thought about it. They looked to see what the bladder would do when it was completely full.
Usually my son doesn't feel it when his bladder is full, but this time when it was very uncomfortable when it got full.

All of these tests helps to give an idea of what is going on with the bladder and kidneys. A neurogenic bladder means that the bladder does not work like it should due to neurologic damage (damage to the nerves that tell them what to do). There is a variety of things that the bladder may due because it doesn't know what to do.
Urology is a very important member of the health care team and helps to provide professional guidance in the care of bladder and kidneys.

Resources:
http://www.aboutkidshealth.ca/En/HealthAZ/TestsAndTreatments/Tests/Pages/UrinaryandBladderTestsHome.aspx

Bladder Plans

We have been having some issues with bladder leaking between cathing.
We had a VCUG and Urodynamics a couple of months ago and left with a plan to increase cathing and record output (volumes cathing and amount of leaking).

The increase in cathing time we were not that great with, but most of the time we were about every 3-4 hours. At school it increased to every 2 hours; which means he is out of class for 45 min a day (3x 15 min). And we were still getting some leaking. Over Christmas break I recorded all output to have some data to bring.

I brought all of our information for our urology appointment and is showed that there is leaking probably about 80-90% of the time.

To try to stop the leaking we discussed options: in medication and urology procedure.

Oxybutynin is the medication of choice for neurogenic bladder. It is an anticholinergic medication and relaxes the smooth muscle of the bladder.

Gelnique is Oxybutynin in gel form. It is topical, which means we put it on his skin and it gets absorbed.  Because it is absorbed in the skin and not in pill form we have noticed a decrease in side effects such as flushing, over heating, constipation.
Because we are currently using this already, the option we discussed is increasing the gelnique. It is expensive, and the more you increase the dose the increased chance of side effects.

Another option is to try oral medication.
We have used Oxybutynin in a liquid form (and ended up with a ton of cavities). And we discussed trying a pill instead of liquid form. But anything taken by mouth has increased side effects. My worry is that we are really good with our bowel routine. And I don't want to mess that up. To take oral oxybutynin he would have to take this medication 3 times a day, and we would have to offset the constipation with medication daily or every other day.
This isn't really something we want to do right now.

Oxybutynin can also be crushed and flushed into the bladder. This would be similar to the oral dosage (3x a day), but with less side effects because it is right at the source. It is time consuming and can be messy. In the end, it was not recommended.

There are other medications called Detrol. I don't know very much about the medication, other than it is used as an alternative to oxybutynin.

The other procedure options are more invasive and now the question is, what is more invasive? Putting a variety of medication in your body on a daily basis at a dose so that it will work. Or trying something else.

The other option (and one we are going forward with) involves general anesthetic in the operating room for the purposes of a cystoscopy. A cystoscopy in adults does not need general anesthetic as it does not involve any actual surgery (like incisions and stuff). But in a child, they do it with the child asleep.

A Cystoscope is a tube that goes into the urethra and into the bladder, the tube has a light and a camera and things (like a needle) can be passed through the tube to inject into the bladder. 

The cystoscope allows the doctor to inject Botox into spots in the bladder. Botox is also known as botulinum toxin, a name that makes you take a step back. We are giving our child a toxin?! It is of course known most commonly for cosmetic reasons, by weakening facial muscles and smoothing wrinkles. But that is exactly what we want to do to the bladder.
Botox treatment for urinary incontinence due to neurogenic bladder in children is an approved use. It does exactly what it says it does. It paralyzes (relaxes the spasms of) the bladder muscles by injecting into the bladder in multiple places. This is done through the cystoscope.

The effects of the Botox is temporary and will need to be repeated about every 6 months. But as the effects of the botox starts wearing off then we can start looking at medications again. The botox injections means that all other medications can be stopped while the botox is working. I personally used Botox injections to treat my hyperhydrosis (excessive sweating) and found that it worked perfectly for 6 months, and the following 6 months it still worked but not perfectly. And by a year I was back to where I was.
Most of the side effects of the botox (difficulty urinating) we already cath, so it is not an issue. But infection is the most common side effect. I have seen some studies that recommended antibiotics.

The other option that we discussed was a Bulking agent. This means an injection (through the cystoscope) of a bulking agent, such as collagen at the bladder neck to make the bladder neck tighter. This means that by moving around and being more active (like at school) the bladder won't leak. If it looks like the bladder neck is open a lot, then they will do the bulking agent. This isn't something that would need to be repeated. If it isn't open and leaking, then they won't do the bulking agent.

I would hate to do it, and inject something and then not be able to advance the catheter. Because we still need enough space in the bladder neck to advance a catheter.

Originally posted at www.riddingfamily.blogspot.com

Learning About SB: Getting things out - part 1

When you learn about Spina bifida from the doctors you are told that there are a couple of different issues you will be looking at because of the damage to the nerves; mobility and bladder/bowel. Depending on what doctors you are talking to, they will spin it 2 different ways. Your child will be in diapers forever, or this is manageable. Manageable means cathing and an assortment of different poop strategies.

The nerves that go to the bladder and bowels are at the sacral level of the spinal cord. A lesion or damage that is above this area means that the nerve supply to the bladder and bowels are usually affected.

The nerve damage to the bladder leads to something called a neurogenic bladder. But really, what does this mean? The nerves can affect the bladder, the sphincter (the door to the bladder) and pressure.

The neurogenic bladder can do 2 different things. One is that the bladder is ‘lazy’ (this is my term), the bladder is limp and cannot squeeze urine out – like an elastic band that is stretched and can’t tighten up any more. This is where Nickolas is. When I cath Nickolas I can get anywhere from 5mL to 100 mL of urine. Pretty big for one little kid. What we worry about is urine that stays in the bladder because it doesn’t empty. The other is that the bladder is spastic or ‘hyper’. Urine isn’t stored at all and the bladder, but it is always emptying.

Catheterizing (for those who don’t know, and are interested) means that a small flexible tube goes through the urethra and into the bladder. There is a hole at the end of the tube that allows the urine to drain from the bladder. This is one of many things that seem to bother the parents a lot more than the kids. We’ve been doing it since Nickolas was born and it doesn’t look like we are going to be stopping anytime soon (but I can still hope). Nickolas doesn’t care, half of the time he laughs, plays kicks – hopefully missing my hand that is holding the catheter, and hopefully missing the bowl of urine.

The sphincter is a muscle that is the door to the bladder, it can be too tight or too loose, when it is tight you have problems opening up the door, and when it is too loose the door is always opening unannounced.

Pressure is the last thing that affects how kids pee. (If the bladder is a room, the sphincter is the door, than pressure if the wind from the window). Low pressure means that the bladder doesn’t completely empty, and high pressure means that urine can be forced into other ‘rooms of the house’, specifically the ureters and the kidneys.

Pretty much with a neurogenic bladder we want to make sure that the bladder is healthy. We want it to be emptied regularly and not get any infections or damage the kidneys. Incontinence, not being able to control your bladder emptying, we will tackle in the future, but right now, with 2 kids in diapers I am not even close to considering an approach. But there is a combination of ways that we can deal with this.

The main concerns about this way to ‘get things out’ are infections and kidneys. A urologist is our very own pee doctor and helps to monitor how everything is doing.

I was originally going to outline neurogenic bladder and bowels at the same time; but I think it’s too much. So stay tuned for Getting Things Out – Part 2

Most of this information came from my Spina bifida resource manual from Bloorview Children's rehab as well as 
 from http://www.mydr.com.au/babies-pregnancy/continence-in-spina-bifida-bladder-and-bowel


Pictures came from www.apparelyzed.com/bladder-function.html and http://www.aqavic.org.au/sci_facts/neurogenic_bowel.html