Cerebral Palsy Neurogenic Bladder, Outcomes of Lifetime Care

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1 Cerebral Palsy Neurogenic, Outcomes of Lifetime Care Kevin P Murphy MD Gillette Lifetime Specialty Healthcare St. Paul Minnesota Cerebral Palsy 1

2 Disclosure Information AACPDM 67 th Annual Meeting, October 16-19, 19, 2013 I have no financial relationships to disclose I I will discuss the following off label use and/or investigational use in my presentation: Clostridium Botulinum Toxin A injections for urinary incontinence in adults with cerebral palsy. Cerebral Palsy 2

3 1. McNeal DM, et al. DMCN 1983; 5: Dector RM, et al. J Urol 1987; 138: Drigo P, et al. Ital J Neurol Sci 1988; 9: Mayo ME. J Urol 1992; 147: Reid CJ, et al. Arch Dis Child 1993; 68: Houle AM, et al. J Urol 1998; 160: Karaman M, et al. IntJ Urol 2005; 12: Silva JA, et al. Urology 2010; 76: Borzyskowski M. Cerebral Palsy and the. DMCN 1989; 31: Many factors involved with bladder control in people with cerebral palsy. Factors include: age, cognition, communication, mobility, UE function, expectations, training, hypertonicity and compatible living environment. Continence more complicated than static CNS pathology & measured bladder function. Cerebral Palsy 3

4 Murphy KP, et al. Cerebral Palsy, Neurogenic & Outcomes of Lifetime Care. DMCN 2012; 54: people with CP seen in sequence through an outpatient Rehabilitation Medicine clinic. 96 females, 118 males. GMFCS levels I V. 52 with hemiplegia,, 42 diplegia,, 117 quadraplegia,, 3 dyskinesia(athetosis athetosis component). Median age for total population 9.6 years (ages 5-66). 5 Special education levels through graduate school. 16.4% (35 individuals) with symptomatic neurogenic bladder (SNB) on urodynamic testing. 91% obtained total continence or major improvement (drops in urinary pads only) with conservative care. Prevalence of males to females with SNB equal. SNB documented across the lifespan, educational spectrum and functional levels. More common in those with bilateral involvement. Cerebral Palsy 4

5 80% with spastic hyper-reflexic reflexictype on urodynamic testing (International Continence Society Criteria 2010). Tendency for urinary retention and hypo-reflexia in the adult over 30 years old (GMFCS Level V). Upper urinary tract pathology infrequent. Small spastic bladder in child may overstretch into larger hypo-reflexive bladder of adult. May be the most common missed diagnosis (associated condition) in the care of people with CP. One of the most easily treated problems in people with CP. A A problem of Lifetime Care- more apparent in the adult but with often undiagnosed roots in childhood. Cerebral Palsy 5

6 Individual Selection Criteria Basic and consistent yes/no communication system in place. Personal desire to be dry, more continent and out of pads if possible. Functional Toileting Environment (FTE), is present or can be created. Functional Toileting Environment (FTE) An environment allowing toileting to occur in a continent & functional manner, including necessary communications, staffing, equipment and motivation. Can involve full medical and surgical team review including Occupational, Physical & Speech therapy, social services, psychology and nursing support. Cerebral Palsy 6

7 Functional Toileting Environment (FTE) Private environment Public environment Friend s s home Family home Outdoors Indoors Upstairs Downstairs FTE- Therapeutic Interventions Augmentive communication device-dynavox Dynavox/IPAD Floor Reaction AFO / L-CrutchesL Grab bars/space to perform transfers ITB/Botox/Phenol: eg hip adductors Adaptive commode/time to sit alone in privacy Staffing assist and education that can be done. Cerebral Palsy 7

8 Treatment Options outside of FTE Anticholinergics Management of pelvic floor hypertonicity including hip adductors. Fluid schedules Catheterization options (ICC, Indwelling) Surgical options Diagnostic Testing Computerized Functional Urodynamic Study Voiding Cysto Urethrogram (VCUG) Renal Ultrasound (RBUS) Urine analysis &/or cultures Metabolic profile (electrolytes, BUN & creatinine) Vitamin B 12 Cerebral Palsy 8

9 Reasons for Failed Treatment Cognitive deficiency Behavioral deficiency Mental Health diagnoses Sexual abuse Psycho-Social issues (eg( parents separated, living in different homes with ongoing discord). Adult who now becomes incontinent Primary Condition (incontinence not in CP defintion) Secondary conditions (over stretched bladder now with retention & leaking; cervical spinal stenosis). Associated conditions (seizures, late onset dystonia). Comorbidities (stress incontinence; interstitial fibrosis; tumors; Alzheimer s/cns degeneration). Cerebral Palsy 9

10 Continence of urine; a part of basic human dignity. Should not be denied anyone within context of patient-centered professional medical/surgical care. Further study & research in the urinary continence of people with CP is hoped & called for at this time. Encouragement is given to facilitate Lifetime Care medical & surgical practices for this problem of young & old. Cerebral Palsy 10

11 Cerebral Palsy 11

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