Blaasvolume trainen, hoe doe je dat?

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1 Blaasvolume trainen, hoe doe je dat? Luitzen-Albert GROEN, kinderuroloog UZ Gent 2008 Universitair Ziekenhuis Gent 1

2 Wat is een normale blaascapaciteit Roberto Martınez-GarcıaNeurourology and Urodynamics 33: (2014) Leeftijd +1 x30 2

3 Blaasvolume trainen, hoe doe je dat? Vanaf welke leeftijd Waarom blaasvolume trainen? Hoe blaasvolume trainen Wat als het echt niet lukt? 3

4 Vanaf welke leeftijd? Vanaf welke leeftijd 4j? 5j? Nee! Wanneer het kind er klaar voor is 4

5 Waarom blaasvolume trainen? Incontinentie: Kleine blaas + dagwekker -> droog -> daling blaasvolume -> recidief Kleine blaas + timed voiding/wobl -> droog -> daling blaasvolume -> recidief Daarom: eerst capaciteitstraining, dan pas dagwekker/timedvoiding/wobl Enuresis: Lage blaascapaciteit + plaswekker -> moeilijk Kleine blaas + capaciteitstraining -> droog Capaciteitstraining -> persisteren enuresis Normale blaascapaciteit + plaswekkerer ->easy 5

6 Hoe blaasvolume trainen Drinkschema Max. micties= uitsteloefeningen 6

7 Hoe blaasvolume trainen Drinkschema Max. micties= uitsteloefeningen HEREVALUATIE na 6-12 weken Normale capaciteit? Geen normale capaciteit 7

8 Wat als capaciteitstraining niet lukt? Drinkschema Max. micties= uitsteloefeningen HEREVALUATIE na 6-12 weken Normale capaciteit? -> Geen normale capaciteit Overactieve blaas??? 8

9 Hoe is de blaasfunctie gereguleerd? PONTINE COORDINATION CORTICAL INHIBITION 9

10 Wat is de oorzaak van blaasoveractiviteit? 10

11 Anticholinergica 2008 Universitair Ziekenhuis Gent 11

12 Side effects anticholinergics Dry mouth Constipation Headache Changes behavior Blurred vision Reason: Effect on other organs than bladder Salivary glands, Brains, Intestine, Eye 12

13 Effect Anticholinergics Acetyl Choline (Ach): primary contractile neurotransmitter in bladder Exert effect on Muscarine-receptor (M 1 or M 2 -rec) Anticholinergic medication inhibits binding between Ach and M-rec By doing so: Overactive bladder/detrusor overactivity 13

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16 Organ selective anticholinergics 5 different genes 5 different mrnas 5 different M-rec subtypes M 1 M 2 M 3 M 4 M 5 16

17 Human bladder M 3 bladder contraction in healthy bladder M 2 less important Probably more important in obstructed or neurogenic bladder 17

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19 Side effects anticholinergics Dry mouth M 3 receptor regulates parotid salivary gland secretion Oxybutynin (Ditropan) 17-97%, Propiverine (Mictonorm) 20-47% Tolterodine (Detrusitol) 8-50% Solifenacine (Vesicare) 8-30% 19

20 Side effects anticholinergics Constipation M 3 receptor regulates intestinal smooth muscle contraction More constipation with more selective M 3 antagonist darifenacine Emselex Oxybutynin (Ditropan) 4-50%, Propiverine (Mictonorm) 4-17% Tolterodine (Detrusitol) 3-8% Solifenacine (Vesicare) 3-13% Darifenacine (Emselex) 14-22% 20

21 Side effects anticholinergics Blurred vision M 3 receptor regulates Ciliary and Iris sphincter muscle Incidence: Oxybutynin 15%, Propiverine (Mictonorm) 4% Tolterodine 1-5%, Solifenacine 4-6% 21

22 Side effects anticholinergics Cerebral side effects M 1 M 2 M 3 M 4 M 5 All present in brains M 1 most present Hippocampus and Cortex Oxybutinine: small molecule/stucture passes blood brain barrier easily Moderate selectivity M 1 M 3 Trospium chloride Polarity: doesn t pass BBB 22

23 Wat als het echt niet lukt? 2008 Universitair Ziekenhuis Gent 23

24 Denk aan andere oorzaken van OAB I Idiopathic detrusor overactivity delay in maturation of CNS? II Neurogenic detrusor overactivity Supraspinal neurological lesions: e.g. CP Suprasacral spinal lesions: e.g. MMC Diabetes mellitus III Non-neurogenic detrusor overactivity Bladder infection Bladder outlet obstruction Bladder tumor: RMS Bladder stones Foreign body J Kreder, K., & R Dmochowski, R. (2007). The overactive bladder: evaluation and management (p. 6). 24

25 DOE (video)-urodynamica 25

26 Meatal anomalies in girls Controversial Easy to identify DV Anterior deflection of the urinary stream Easy to observe Easy to treat Vaginal micturition Hoebeke, P., et al., Anomalies of the external urethral meatus in girls with non-neurogenic bladder sphincter dysfunction. BJU Int, (3): p

27 Minivalves in boys Controversial Might cause incontinence Might cause enuresis Cause of therapy resistance Mallouh, C., Urethral valves: unusual presentation in 14-year-old boy. Int Urol Nephrol, (3): p Bomalaski, M.D., et al., Delayed presentation of posterior urethral valves: a not so benign condition. J Urol, (6): p Schober, J.M., L.M. Dulabon, and C.R. Woodhouse, Outcome of valve ablation in latepresenting posterior urethral valves. BJU Int, (4): p

28 Radiological and endoscopic appearance of congenital urethral obstructive lesions: (A,B) Ablation of posterior urethral valves 28

29 Botox Cystoscopic injection Off-label treatment 29

30 Implantatie neuromodulatie D 2008 Universitair Ziekenhuis Gent 30

31 Blaasvolume trainen, hoe doe je dat? Vanaf welke leeftijd Waarom blaasvolume trainen? Hoe blaasvolume trainen Drinkschema Max. micties= uitsteloefeningen TENS Anticholinergica Wat als het echt niet lukt? Psycholoog Video-urodynamica MRI Cystoscopie? Psycholoog 31

32 Anticholinergica 2008 Universitair Ziekenhuis Gent 32

33 Side effects anticholinergics Dry mouth Constipation Headache Changes behavior Blurred vision Reason: Effect on other organs than bladder Salivary glands, Brains, Intestine, Eye 33

34 Effect Anticholinergics Acetyl Choline (Ach): primary contractile neurotransmitter in bladder Exert effect on Muscarine-receptor (M 1 or M 2 -rec) Anticholinergic medication inhibits binding between Ach and M-rec By doing so: Overactive bladder/detrusor overactivity 34

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37 Organ selective anticholinergics 5 different genes 5 different mrnas 5 different M-rec subtypes M 1 M 2 M 3 M 4 M 5 37

38 Human bladder M 3 bladder contraction in healthy bladder M 2 less important Probably more important in obstructed or neurogenic bladder 38

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40 Side effects anticholinergics Dry mouth M 3 receptor regulates parotid salivary gland secretion Oxybutynin (Ditropan) 17-97%, Propiverine (Mictonorm) 20-47% Tolterodine (Detrusitol) 8-50% Solifenacine (Vesicare) 8-30% 40

41 Side effects anticholinergics Constipation M 3 receptor regulates intestinal smooth muscle contraction More constipation with more selective M 3 antagonist darifenacine Emselex Oxybutynin (Ditropan) 4-50%, Propiverine (Mictonorm) 4-17% Tolterodine (Detrusitol) 3-8% Solifenacine (Vesicare) 3-13% Darifenacine (Emselex) 14-22% 41

42 Side effects anticholinergics Blurred vision M 3 receptor regulates Ciliary and Iris sphincter muscle Incidence: Oxybutynin 15%, Propiverine (Mictonorm) 4% Tolterodine 1-5%, Solifenacine 4-6% 42

43 Side effects anticholinergics Cerebral side effects M 1 M 2 M 3 M 4 M 5 All present in brains M 1 most present Hippocampus and Cortex Oxybutinine: small molecule/stucture passes blood brain barrier easily Moderate selectivity M 1 M 3 Trospium chloride Polarity: doesn t pass BBB 43