Neurogenic Bowel and Bladder Dysfunction

The lower abdominal area includes organs carrying out essential functions, like urination, defecation, sexual activity, and fertility. The lower urinary tract (LUT), distal gastrointestinal (GI) tract, and genital system interact under both physiological and pathological conditions. Pelvic physiological function depends on coordinated communication among all organs of the sacral area. The LUT and distal GI tract share a common embryological origin, innervation, and functions of storage and excretion phases of urine and feces, respectively. Pelvic cross-sensitization among pelvic organs is conveyed by neural, endocrine, paracrine, and immune mechanisms. Diseases in one of the pelvic organs may provoke alterations in their cross-talk, subsequently causing clinical comorbidities within a single anatomical structure. Experimental data, from both human and animal studies, suggest different cause-and-effect interactions; for example, chronic intestinal inflammation may provoke changes in detrusor activity with increased frequency of micturition, while neurogenic cystitis may be associated with abdominal hyperalgesia. The understanding of these altered cross-reflexes is mandatory to identify potential targets to plan and perform effective treatments in patients with comorbid disorders like neurogenic bladder and bowel dysfunction.

Neurogenic bladder and bowel dysfunction occur as a consequence of many different diseases or traumatic injuries of the central or peripheral nervous system, for example, spinal cord injury (SCI), spina bifida (SB), multiple sclerosis (MS), Parkinson’s disease (PD), stroke, and traumatic brain injury (TBI). Neurogenic sexual dysfunction is a common comorbidity, but it will be discussed in another chapter.

Neurogenic bladder dysfunction may present with different symptoms. The physiological bladder cycle encompasses two phases. During the filling phase, bladder distention takes place under low pressures and the inner urinary sphincter remains closed due to the influence of the sympathetic nervous system (SNS), via the T10–L2 nerve roots, while the external urinary sphincter remains closed via the pudendal nerves originating from the S2–S4 nerve roots. During the voiding phase, the bladder contracts under the influence of the parasympathetic nervous system (PNS), via the S2–S4 nerve roots, and the urinary sphincter relaxes to allow emptying.

LUT symptoms (LUTS) may be classified into two categories: obstructive LUTS, such as weak and/or intermittent stream, straining, hesitancy, terminal dribbling, incomplete voiding, urinary retention, and overflow incontinence; and voiding or irritative LUTS, such as polyuria, urge incontinence, painful urination, and nocturia.

When the bladder contracts involuntarily before complete filling, the condition is called detrusor overactivity (DO). On the other hand, when the bladder cannot empty urine effectively, the associated condition is defined as detrusor underactivity (DU). Similarly, the sphincter may be either overactive or underactive. Detrusor-sphincter dyssynergia (DSD) happens in case of altered coordination between the overactive detrusor and overactive urinary sphincter, causing a dysfunctional condition, characterized by the persistence of an elevated postvoid residual (PVR) and increased detrusor pressures associated with the risk for vesico-ureteral reflux.

Urinary incontinence (UI) may be classified as urgency urinary incontinence (UUI), complaints of involuntary loss of urine associated with urgency; stress urinary incontinence (SUI), complaints of involuntary loss of urine on effort or physical exertion including sporting activities, sneezing, or coughing; and mixed urinary incontinence (MUI).

Neurogenic bladder dysfunction–related symptoms are predominantly due to the location and the extent of the neurological lesion.

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  Suprapontine lesions:

  
  
  
  
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    Examples: PD, Alzheimer’s disease, stroke, TBI

    
    
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    History: predominantly storage symptoms

    
    
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    Findings: DO, insignificant PVR

  
  
  
  
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  Spinal lesions between the pons and the sacral cord:

  
  
  
  
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    Examples: SCI, SB

    
    
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    History: both storage and voiding symptoms

    
    
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    Findings: DO, DSS, usually raised PVR

  
  
  
  
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  Sacral and infrasacral lesions:

  
  
  
  
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    Examples: lumbar degenerative disc disease, iatrogenic pelvic nerve lesions, peripheral neuropathy (e.g., due to diabetes)

    
    
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    History: predominantly voiding symptoms

    
    
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    Findings: DU, acontractile detrusor, high PVR

  
  
  
  
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  MS is a disseminated disease, so it can present different and overlapping clinical features based on the extent and localization of demyelination plaques.

Neurogenic bowel dysfunction (NBD) comprises both constipation and fecal incontinence. The latter may be due to the altered control of the anal sphincter or, mainly, to loss of liquid stool because of impacted feces in the rectum. Similar to the bladder, the distal GI tract is innervated by the SNS and PNS via the T10–L2 and S2–S4 nerve roots, respectively.

All members of the rehabilitation team take part in neurogenic bladder and bowel management through their different roles during all phases of rehabilitation. However, rehabilitation does not end after in-patient hospitalization. In people with disabilities due to nervous system diseases, outpatient services are needed for longer periods to reach the highest level of functional capacity and performance, and later to sustain abilities gained from the initial rehabilitation program throughout life.

The impact of neurogenic bladder and bowel on health-related quality of life (HRQoL) is well documented in the literature. After SCI, persons with paraplegia prefer optimal function of bladder and bowel to ambulation, or at least both seem to be of equal importance. With this in mind, good quality long-life management of neurogenic bladder and bowel is a high priority for the rehabilitation team.

Information and communication technology (ICT) has expanded greatly over the past decade and is now available to the majority of the world’s population. Telerehabilitation services previously demanded expensive technology, special rooms, and special precautions for keeping personal information safe. At present, however, simplification has addressed many technical problems pertinent to bladder and bowel management via telerehabilitation and future improvements are a logical expectation.

In this chapter we will provide an overview of current knowledge and practice related to using telerehabilitation for bladder and bowel management along with reviewing areas that warrant further research and development.

Methodology

In order to determine the state of the science with regard to the use of telerehabilitation for neurogenic bladder and bowel management, the authors performed an extensive narrative research using PubMed, Scopus, and Web of Science, without finding significant original studies involving telehealth in the fields of neurogenic bladder and bowel dysfunction, but mainly expert opinions. We accessed ClinicalTrials.gov on November 10, 2020, and found a recruiting study assessing the efficiency and satisfaction with telephone consultation in neuro-urology. The following search strategy took place (last update on November 15, 2020): (telerehabilitation OR telehealth OR telemedicine OR televisit OR teleconsultation) AND (bladder OR bowel OR incontinence OR continence OR urology OR gastroenterology OR coloproctology). We found 837 articles and, finally, included 23 articles ( Fig. 16.1 ). We observed an exponential increase in the number of papers in the year 2020 ( Fig. 16.2 ) after the COVID-19 pandemic. Most articles dealt with general interventions in urology, views, expert opinions, and guidance on telehealth. Fewer studies involved GI diseases. Most papers presented pilot studies in bladder and bowel remote management of persons with neurological diseases, presenting mainly educational/observational data on the telehealth services provided ( Table 16.1 ).

Flow chart of our search, performed on November 15, 2020, using PubMed, Scopus, and Web of Science, and typing the following keywords: (Telerehabilitation OR telehealth OR telemedicine OR televisit OR teleconsultation) AND (bladder OR bowel OR incontinence OR continence OR urology OR gastroenterology OR coloproctology).

The picture depicts the number of papers per year, obtained by typing the following terms in PubMed on November 15, 2020: (Telerehabilitation) OR (telehealth) OR (telemedicine) OR (televisit) OR (teleconsultation) AND (bladder) OR (bowel) OR (incontinence) OR (continence) OR (urology) OR (gastroenterology) OR (coloproctology). An exponential growth occurred in the year 2020, after the COVID-19 pandemic.

Nonneurogenic Bowel and Bladder Dysfunction

A recent systematic review by Novara et al. looked for urological applications of telehealth and identified 45 studies, concerning UI (n = 14), prostate cancer (n = 11), urolithiasis (n = 6), hematuria management (n = 3), urinary tract infections (UTIs; n = 5), general urology (n = 2), LUTS (n = 2), and male sexual dysfunction (n = 2). The methodological quality of most studies was estimated as “good,” reporting 12 studies involving randomized controlled trials (RCTs).

A vital part of telehealth interventions is represented by smartphone applications. Although most data are on nonneurogenic UI management, results can be transferable. A systematic review in urology applications, in 2015, revealed 150 applications, with one-third of them focused on calculators, diaries, and patient information, while the need for scientific approval and peer-review application validation was recognized. In chronic GI disorders, another review in self-monitoring presented several applications controlling GI symptoms. Comparing electronic and paper micturition charts, the same level of accuracy was documented, possibly with better adherence to electronic ones.

A plethora of such interventions has been created and validated for pelvic floor muscle training, with 73 studies reported by Latorre et al. Applications such as iPelvis, Kegel Trainer Pro, Tät application, and MyHealtheBladder are available, even if most of them have been not validated. Bernard et al. highlighted the role and importance of conservative UI self-management through mobile technologies, identifying the features of data extraction, educational features, reinforcements, reminder systems, social media features, self-monitoring options, and biofeedback.

Neurogenic Bowel and Bladder Dysfunction

In 2018 a narrative review of eHealth technologies for MS analyzed data from 28 eHealth solutions, finding “MS monitor” as an interactive, internet-based program for self-monitoring, self-management, and multidisciplinary care of individuals with MS. Inventories to capture urological symptom data and diaries in parallel with an e-consultation were included. It was shown that through repeated use, HRQoL was increased and the quality of nursing care was improved. TaDiMuS (Tablet-based Data capture in Multiple Sclerosis), a tablet-based platform tool, which included the Bladder Control Scale and the Bowel Control Scale, proved to be an efficient, sensitive, and feasible method of screening patients for bladder and bowel dysfunction.

Another population, where these interventions have been studied, is represented by SB. A nurse-led continence clinic assisted users through Skype to improve their self-care skills in a small qualitative study. Glowing Stars is an Android-based application, which includes an educational module on bladder and bowel management, and an opportunity to record health indicators for self-monitoring of voiding, defecation, skin care, taking medication, and mood status. In SCI, a telerehabilitation intervention using FaceTime with an iPad (Apple Inc., Cupertino, USA) was tested in 62 individuals, dealing with—amongst other concerns—bowel and bladder issues, revealing high levels of satisfaction.

Benefits and Barriers

Telehealth visits, apart from being less time-consuming, can also reduce the number of in-person visits of low acuity patients. Patients value them because of savings of time and money. People are willing to participate in virtual visits (VVs) for their bladder care, specifically individuals who are more confident with internet-based communication, as well as individuals who take an active role in their own health. Even if an in-person examination is required, this can still be offered following a VV.

Barriers in adopting telehealth services are multifactorial. There can be aversion to change in providers and health care systems, concerns about patient privacy, and specific issues with reimbursement. Moreover, one can ask the ethical question: “What if face-to-face visits become available or affordable only for patients with adequate resources, leaving the rest treated through telemedical consultants?”

With a focus on technical adjustment, patient-related barriers include concerns about security and data protection, lack of familiarity with ICT, and difficulty with accessing a high-speed internet connection. Technological failure may significantly undermine the safety and efficacy of telehealth applications. Therefore it is important to give the patient enough time to prepare for the televisit, organize a technical service for troubleshooting, and have a backup plan in case of failure.

From a similar viewpoint, provider-related barriers include technological proficiency of doctors. As every novel health technology, it may require specific training. Although telerehabilitation-related changes may appear small, they may require a significant amount of training, as they involve significant structural changes in work organization. Clinical staff may resist the adoption of telehealth for different reasons: alteration of the roles of staff members, change of the established routine clinical practice, and perceived risk of breaking down the patient-provider relationship.

Introduction

Often, compliance with therapeutic and regular follow-up care for people with a long-standing illness or health problem is unsatisfactory. Many patients face difficulties in accessing rehabilitation services, regardless of the economic situation of different countries. Various factors—such as the lack of specialized services in remote geographical areas, transportation difficulties, increased traveling risk under extreme weather conditions or natural disasters, and conditions such as the COVID-19 pandemic—increase these difficulties and make access to specialized rehabilitation services almost impossible. The provision of remote health services has fortunately been simplified with the development of technology in the decade of 2010–2019, and the COVID-19 pandemic has boosted the widespread adoption of telehealth.

Remote rehabilitation services concerning neurogenic bladder and bowel dysfunction may refer to:

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  Communication between specialized physicians, continence nurses, and therapists and patients at their home for reevaluation and assurance of patients’ compliance and continuation of the rehabilitation program and management of neurogenic bladder and bowel ( Fig. 16.3A );

  
  

  
  

  
  

  

  
  

  
  

  Remote rehabilitation services for neurogenic bladder and bowel management. (a) Specialized health practitioner to/from patient and caregiver; (b) health practitioner to/from health practitioner; (c) nonspecialized health practitioner to/from patient and caregiver with in-person consultation or telecommunication.

  
  
  
  
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  Communication between health professionals in different geographical areas and provision of specialized knowledge to general practitioners (GPs) and other health professionals (nurses, occupational therapists, physiotherapists) in the same region as the patient and assurance of continued rehabilitation of neurogenic bladder and bowel ( Fig. 16.3B );

  
  
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  The communication between GPs, nurses, and therapists and patients at their home for reevaluation and assurance of patients’ compliance and continuation of the rehabilitation program and management of neurogenic bladder and bowel either in person or with telecommunication ( Fig. 16.3C ).

Remote health services for neurogenic bladder and bowel could reduce the cost of health care, by minimizing the number of in-person visits at specialized health care facilities, hospital readmissions, complications, and use of medication that could be avoided (e.g., use of antibiotics in misdiagnosed UTIs).

Telerehabilitation services concerning neurogenic bladder and bowel dysfunction should only be provided by a health care team that knows and regularly cares for the specific patient. This team can also supervise and continue their therapeutic and educational program and follow-up remotely. Moreover, they can improve the patient’s compliance and lessen complications with or without the collaboration of professionals of primary health services.

A web-based survey evaluated patient demographics, perceptions before use, and acceptance of VVs within an ambulatory urology setting. In total, 1378 patients completed the survey. Compared with those who were “unlikely,” patients “likely” (63%) to participate in VV were younger (62 vs. 65 years), had a college education (77% vs. 65%), had previous exposure to videoconference technology (57% vs. 38%), were more comfortable discussing new symptoms (56% vs. 30%) and sensitive information (48% vs. 27%), played an active role in their health care (65% vs. 54%), traveled larger distances (>90 minutes; 69% vs. 58%), missed more work days (>1 day; 39% vs. 29%), and incurred greater expenses for their care (>$250; 52% vs. 25%).

Many studies have shown the implementation of telerehabilitation in different settings both in urology and gastroenterology. Most studies approached telehealth adopting phone consultations and televisits, that is, digital office visits with the urologist and the patient seeing each other remotely via webcam. Another validated application involves teleconsultations, that is, electronic communication between two health care providers regarding the patient’s diagnosis and/or treatment. Few studies evaluated other approaches, like telementoring, telesurgery, telerounding, or teleimaging.

Telephone Consultations

Safir et al. had 150 patients with hematuria undergoing a 20- to 25-minute long structured interview and consultation via telephone. Later, these patients underwent a cystoscopy and, during this examination, they filled in a 29-question survey regarding their overall acceptance and satisfaction with the telephone consultation. The median time from consult request to appointment was 12 days, and thereafter to cystoscopy was 16 days. The patients reported high acceptance and satisfaction with the telephone consultations in terms of overall satisfaction, efficiency, convenience, friendliness, care quality, understandability, privacy, and professionalism. It was found that 98% of patients preferred phone consultation to face-to-face visits. Transportation-related issues (97%) and logistical clinic issues (65%) were identified as factors responsible for patients’ preferences toward phone consultations.

Televisits

Televisits provide face-to-face communication at distance better than phone calls. Video can allow evaluation of the patient’s environment, physical status, and the observation of some procedures, like urinary catheterization. Most doctors perform telehealth without even realizing it, including phone calls and asynchronous messages via email or fax. These practices are usually not reimbursed, while synchronous VVs are beginning to be reimbursed by many payers. In the United States, Veterans Affairs hospitals pioneered the application of telerehabilitation with the initial attempt to deliver high-quality care in rural areas. Rastogi et al. performed a cross-sectional observational study including 20,600 patients using direct-to-consumer telerehabilitation. Most patients (96%) were female. Up to 84% of encounters were for UTI. In this cluster, 94% received an antibiotic, and receiving the prescription was associated with higher satisfaction with care ( P < 0.001). The management of UTIs via telerehabilitation proved to be feasible and cost-effective, considering the lower cost of televisits compared to traditional outpatient or urgent care.

Teleconsultations

Teleconsultation has been used for decades to link tertiary-referral academic centers to smaller rural centers. This concept is particularly interesting in niche subspecialties with a dearth of centers, like neuro-urology, neuro-gastroenterology, and fetal urology. The Arkansas statewide telerehabilitation service allowed patients to combine maternal-fetal medicine and urological prenatal consultations in one visit, saving time and effort and ultimately, for most patients, providing reassurance that delivery could be accomplished locally with postnatal follow-up already arranged.

Other Telehealth Applications

Sterbis et al. reported the first use of the robotic da Vinci Surgical System (Intuitive Surgical, Sunnyvale, USA) in urological telesurgery and the first successful telesurgical nephrectomy in an animal model. They performed four right nephrectomies in porcine models using both telementoring and telesurgical approaches. Resident surgeons operated a console adjacent to the swine, while attending surgeons simultaneously operated a second console at distances of 1300 and 2400 miles from the operating room. All four procedures and both telementoring and telesurgical models were successful. Kaczmarek et al. successfully used an iPad (Apple, Cupertino, USA) for telerounding on postoperative patients, while a study by Johnston et al. showed the transmission of computed tomography images of patients with renal colic to mobile devices. The solutions described earlier, especially telementoring, could be an optimal way to overcome the shortage of doctors specialized in neurogenic bladder and bowel. Indeed, only few urologists are able to perform infrequent surgical procedures, like augmentation cystoplasty or creation of catheterizable cutaneous channels, so general urologists could be telementored remotely by expert ones.