The body isn`t very much different from a house.
Every day, almost automatically, things go on in the basement and walls of your home that keep life humming along. So it is with your body. With nary a thought from you, this remarkable mechanism continuously converts fuel to energy, takes in fresh air and distributes the two wherever they are needed. It heats itself and cools itself down. It turns various appliances on and off through a maze of electrical wiring. And it cleans itself, draining the waste out through what is normally an efficient plumbing system.
But problems can develop within the body, just as they can inside a house. Consider that plumbing system. An estimated 10 to 12 million American men, women, and children are victims of an unmentionable disorder known as urinary incontinence. Because of injury, illness or congenital defect, they are unable to control the flow of urine. As a result, their lives are ridden with humiliation, hardship and the danger of serious kidney disease.
Here is where the house analogy breaks down. When the water pipes go on the fritz in your home, you can call in a plumber and have them fixed. Repairs on the body are not so easy to come by. For most of the incontinent population in the U.S., a cure has always been out of reach.
At this moment, however, a research effort is underway at Chicago`s Children`s Memorial Hospital that may soon change all that. If the experiment proves successful, a cure for many incontinent Americans will at last become a reality.
The doctor behind the research is an energetic young urologist named William Kaplan who is dedicated to introducing the treatment–called
”intravesical transurethral electrotherapy,” or, for us less technical folks, ”electrical bladder stimulation”–to this country. The therapy is not new. It originated in Hungary more than a quarter of a century ago and is now in use in a number of places in Europe but it has encountered apathy and resistance from U.S. physicians.
Part of the problem is undoubtedly a bias against medicine as practiced in the Communist bloc nations. It may also have something to do with the nature of the treatment itself; it has Frankensteinian overtones in that the patient is subjected to an electrical current. But the treatment`s lack of acceptance here inspires questions about how many other promising foreign therapies may not be getting a proper hearing from American doctors.
Such questions aside, Kaplan is hoping that if he can demonstrate the treatment`s efficacy, it will generate enthusiasm within the U.S. medical community and, not so coincidentally, loosen up funding to permit large numbers of patients to be helped.
To understand electrical bladder stimulation, it is first necessary to understand why certain people become incontinent.
In normal individuals, the bladder fills up with urine from the kidneys until a sensory impulse is sent, via the nervous system, to what is known as the detrusor center. The impulse tells the detrusor center that the bladder is full and it is time to urinate. At an appropriate opportunity, a signal is then sent back along a parallel neural pathway instructing the smooth, involuntary muscles of the bladder to contract and force urine out. At the same time the sphincter muscles below the bladder–there are two of them–are told to relax and allow the urine to flow.
When the bladder has emptied, more neural impulses are conveyed causing the reverse to occur. The sphincter muscles contract while the bladder simultaneously relaxes. Bladder control is dependent on coordination of all these separate neurological events.
Unfortunately, for a variety of reasons, some people possess what are called ”neurogenic” bladders. Their nerve pathways don`t work. This can be caused by such ailments as multiple sclerosis and stroke. It can be the result of a spinal cord injury or trauma due to spinal surgery. Or it can be inborn, as in the case of children and adults with myelomeningocele, a paralyzing form of spina bifida in which the spinal cord fails to cover over with protective tissue before birth. The cord bulges out of the back in a membraneous sac and the delicate nervous tissue inside is invariably damaged.
Neurogenic bladder can take several forms. A common one is known as
”atonic” or ”areflexive” bladder. The bladder does not respond to fullness by contracting. Instead, it just keeps filling up until the pressure of the liquid inside overcomes the power of the neck of the bladder to withhold it. Such people constantly leak urine. Another condition is called
”spastic” bladder. The bladder is in a continual state of contraction, forcing urine out whenever it is present.
Whatever the cause, the result is the same: extreme public embarrassment, withdrawn social behavior and the ordeal of having to wear and change absorbent pads wherever one goes, as if one were a newborn infant. There is also the potential for kidney damage because of unrelieved high pressure within the bladder.
Up until about 10 years ago, treatment consisted of the creation of an artificial urinary opening to allow urine to collect in a bag outside the body. Later, a major breakthrough was made with the introduction of ”clean intermittent catheterization,” a self-administered procedure in which incontinent patients catheterize themselves every three or four hours to drain urine from the bladder. The procedure is very effective in keeping people dry and it has been hailed as one of the greatest strides in recent urological practice.
Nevertheless, the prospect of not only managing incontinence but actually curing it is what drives William Kaplan to explore electrical bladder stimulation.
The new technique was the brainchild of Dr. Francis Katona, of the Institute of Neurosurgery in Budapest, who first employed it in 1958. Katona reasoned that it might be possible to reawaken the supposedly dead
neurological pathways by using an electrical stimulus. Earlier attempts to apply electricity directly to the exterior bladder wall had failed, but Katona had another idea in mind–indirect stimulation.
What he did was fill the bladder partway with a saline solution, by means of a catheter. Then he passed a very mild electrical current of between 2 and 8 milliamps–a level so low that, if it is felt at all, it is perceived as only a tiny buzz–into the saline solution via a slender wire running through the middle of the catheter. The saline solution was to convey the electrical charge to the walls of the bladder.
His results? Of 420 incontinent patients treated over the next 15 years, 314 of them, or 75 percent, acquired or regained the ability to consciously control their urination. Not only could they sense when their bladders were full, but they could induce contractions at the apppropriate time and, even more important, stop them at will.
Later Katona began accepting a wider range of incontinent patients
–including some extremely difficult cases–and his success rate dropped correspondingly. But it still stands at 50 percent.
No one is quite sure why the technique works. For one thing, the exact location of the detrusor center remains unknown. Most experts believe it is in the midbrain, but a few respected researchers insist it is in the lower spinal cord. Aside from this uncertainty about where the neural impulses go, there is also disagreement about which nerves carry the transmissions. Some believe the technique merely revitalizes damaged nerves; but others speculate that it somehow reawakens alternative pathways left over from fetal times, pathways that have long since shut down. The only thing that appears certain is that the technique is successful.
As a consequence of Katona`s labors, electrotherapy of the bladder has spread to other medical centers in Europe. Clinics in Switzerland and Austria now offer the treatment. Yet Katona`s research findings have seldom been published in the U.S. and most American urologists are unaware of his accomplishments. Those few who do know about it, seem to consider it so much mumbo jumbo.
Kaplan learned of the treatment two years ago from Dr. Marianne Berenyi, a disciple of Katona`s who was in Chicago for a medical conference. Excited, Kaplan invited her to return and help him set up an electrotherapy clinic at Children`s Memorial. Berenyi arrived last November and stayed for a month.
Since that time, Kaplan has tested 10 myelomeningocele children to determine who would be most likely to benefit from the experimental program. Virtually all myelomeningocele victims, besides having at least some degree of paralysis, are incontinent.
Kaplan settled on two children, a 6-year-old boy named Joey and a 2-year- old boy named P.J.
Electrical bladder stimulation is entirely safe and painless, but it is essentially a long-term training procedure. You are training the bladder and its inactive nerve network to respond to impulses–and as such it requires a considerable investment of time. Joey and P.J. must come at least three days a week–five days is preferable–and spend an hour and a half rigged up to the electrical stimulator and a large polygraph machine that registers bladder contractions. The process may take anywhere from three months to a year before patients learn to control their urinary functions.
One recent morning P.J. lay on a palette while urodynamics nurse coordinator Ingrid Richards first filled his bladder with the sodium chloride solution, then flipped a switch to begin the bladder stimulation. P.J.`s mother sat at his side reading to him from a Sesame Street book.
It was only P.J.`s 10th session, but already he is having several brief bladder contractions per visit, where a few months ago he had none.
”I really think this program is very exciting,” said his mother, Tricia Flaherty. ”They told me it could take as long as a year. But I don`t mind. It will be worth it in the long run if he`ll be able to void by himself. He`s going to have so many difficulties when he enters school. This will be one aspect of his life where he`ll be like everybody else.”
She grinned at her blond-haired son, who was born with a moderately severe case of spina bifida and hydrocephalus (swelling of the head) that required the implanting of a brain shunt. Doctors are hopeful that he will one day walk with braces.
Joey, meanwhile, has temporarily had to stop the program because he is in a body cast, designed to correct another complication of myelomingocele
–curvature of the spine. But before the layoff began he had attained the ability to contract his bladder for up to 2 1/2 minutes–more than enough time to void the bladder. When he returns to the program in a few weeks, he will have lost none of this new ability, as one of the benefits of electrotherapy is that the bladder never forgets its lessons, once learned.
While P.J. is too young to be taught how to stop contractions at will, an older child such as Joey is not. His catheter is rigged to a graduated tube. When his bladder contracts, he can actually see the column of excreted liquid (a blue dye is added to the sodium chloride solution) rising in the tube. Through a biofeedback technique, he then learns to associate sensation with results, and ultimately can master voluntary bladder control.
”This program is 100 percent beneficial,” says nurse Richards. ”If I were funding it, I`d pour $1 million into it. But others might not see it that way.”
Indeed, so far they have not. This has intensified one of the drawbacks of electrical bladder stimulation, which is that only a few patients can be helped at a time. Children`s Memorial has only one electrical stimulator and one part-time technician; thus it can, at best, help only two or three children a week.
Kaplan estimates that he will need four of the $800 machines and four full-time technicians before he is able to handle even a modest 40 children a year. Even then he will be making only a slight dent in Children`s Memorial`s huge population of 1,000 myelomeningocele patients.
”At first I was put off by only being able to help a handful,” says Kaplan. ”But then I decided, better to help 40 than none.
”What I`m trying to do is demonstrate scientifically the value of this procedure. Then my next step is to write it up and hopefully get some financial support from corporations and other private donors. You see it doesn`t matter that this has been published everywhere else in the world. It has to be proven in the United States for it to be accepted here.”
Kaplan cautions that even if bladder stimulation is found to be effective, it must be remembered that it has only a 50 percent success rate. Moreover, there are a number of kinds of incontinence that it won`t alleviate. It is worthless in treating people with a complete severing of the spinal cord, for example, because even if you succeed in reawakening sleeping neural pathways, the nerve impulses still cannot get to the detrusor center, whether it`s in the brain or the spinal cord. The technique is also useless in treating people who have some physiological weakness of the sphincter, such as women who have undergone multiple childbirths. Finally, it seems ineffective in the treatment of retarded individuals, because they are not able to grasp the necessary biofeedback signals.
Nevertheless, bladder electrotherapy seems to hold out enormous promise to a multitude of incontinent children and adults. Those who can be helped
–spina bifida patients, spinal cord injury victims, and those whose spinal cords have been traumatized during tumor surgery–constitute up to a half of all incontinent people.
As David McLone, director of Children`s Memorial`s spina bifida clinic, says: ”If we can increase the bladder control of myelomeningocele patients, we`ve solved their single most difficult social problem. Seven years ago, Bill Kaplan started the clean intermittent catheterization program here, and he has dramatically turned children`s lives around, allowing them to go to normal schools for the first time. If he can improve on that with bladder
stimulation, it can only be of greater benefit.”
Cheryle Gartley, president of the Simon Foundation, an educational and counseling organization for incontinence sufferers, is even more enthusiastic. ”I`m damn excited about it,” says Gartley, herself a victim of neurogenic bladder.
Gartley only recently learned of the existence of the technique, underscoring how it has eluded the U.S. medical establishment for many years. ”There are millions of people afflicted with incontinence,” she says.
”It`s a closet problem that needs to be brought to the fore by everyone, and Bill Kaplan deserves all dollars, volunteers and medical encouragement to look into this.”
