Pharmacological Treatment

At one month post injury, Mr. RB developed urinary incontinence between catheterizations. It is small volume incontinence, and usually comes just before catheterizations when the bladder is relatively full. It does not dribble out, but instead forms a strong short stream with a urinary tract infection ruled out. He is interested in discussing treatment options with you.
Q18. What is the evidence for pharmacological methods of enhancing bladder volume while lowering bladder filling pressures?

A. Anticholinergic Therapy
1. There is strong evidence that propiverine, oxybutynin, tolterodine and trospium chloride are efficacious anticholinergic agents for the treatment of SCI neurogenic bladder.
2. Tolterodine likely results in less dry mouth but is similar in efficacy to oxybutynin.
3. Although not tested in SCI, M3 receptor specific anticholinergics have been shown useful in other types of overactive bladder.

B. De-innervation Therapy
1. There is strong evidence that botulinum toxin A injections into the detrusor muscle provide targeted treatment for detrusor hyperreflexia, and urge incontinence resistant to high-dose oral anticholinergic treatments with intermittent self-catheterization in SCI.

C. Detrusor Muscle Therapy
1. Strong (level 1) evidence supports the use of vanillanoid compounds such as capsaicin or resinoferotoxinto increase maximum bladder capacity and decrease urinary frequency and leakages in neurogenic detrusor overactivity of spinal origin.
2. Limited (level 4) evidence exists to suggest that intravesical capsaicin instillation in bladders of SCI individuals does not increase the rate of common bladder cancers after 5 years of use.

D. Intravesical Instillations
1. Limited (level 4) evidence states that intravesical instillations with oxybutinun or propantheline are ineffective for treating neurogenic bladder in people with SCI.

E. Other Pharmaceutical Treatments
1. Intrathecal baclofen or clonidine may be beneficial for bladder function improvement but invasive and would not be used primarily for this, but rather for spasticity, although a secondary benefit may be less bladder spasticity.

For more information, please see: Anticholinergic Therapy and Toxin Therapy