Q. I’m in my seventh year as a T4 para. About a year after I was injured I started having bladder accidents. I had a urodynamics test and was told I have a spastic bladder and was prescribed Ditropan. The Ditropan kept me dry, but made me feel like I was wheeling around in a fog and gave me severe dry-mouth. The side effects were so bad that I stopped taking it and started cathing more often. With the extra cathing I was staying dry and figured I had the problem under control.
 
In December I had a urology check-up, which showed my bladder spasms have caused ridges (scarring) on the walls of my bladder. I’m back on the Ditropan, but the side effects are really bugging me. Is there anything out there that will quiet my bladder but not make me feel like I’m spitting sand and lost in a haze?
— Phil

A. Phil, your letter points out a dilemma many wheelers face — a spastic bladder can cause permanent bladder and kidney damage without any noticeable symptoms. Left unchecked, this can lead to kidney failure. Yet, for many wheelers the side effects of oxybutynin chloride (Ditropan’s generic name) can be difficult to live with. And as you found out in your urology check-up, cathing enough to stay dry doesn’t mean you have solved the problem.

In January of this year the FDA approved a topical gel form of oxybutynin choloride. Peer reviewed studies show this topical gel to be as effective as the pill form, but with few side effects. In May, Watson Pharmaceuticals came out with the first and only commercially available version of this gel, called Gelnique.

To understand how the gel works, it is helpful to take a look at how oxybutynin choloride works and what causes the side effects. Oxybutynin chloride is a muscle relaxant that specifically targets smooth muscle tissue; bladder muscle is smooth muscle, hence the drug’s effectiveness in reducing bladder spasms. When the oral (pill) version passes through the system, the stomach and liver turns some of it into N-desethyloxybutynin (N-DEO). Researchers think that N-DEO is the culprit that causes most of the adverse side effects. By applying the drug to the skin in gel form, it bypasses the stomach and liver, they don’t produce N-DEO and you have a delivery system that leaves most of the side effects behind but still relaxes the bladder muscle.

Gelnique comes in individual packets about the size of an alcohol skin prep. Each application lasts for 24 hours. The user rubs the gel onto an area of skin on the stomach, shoulder, or thigh. The gel dries quickly, is colorless, odorless and doesn’t leave any residue. Sunscreen can be applied after half an hour, and swimming and bathing are OK an hour after application.

As far as insurance reimbursement is concerned, as always check with your provider in advance to see if the drug is covered. The manufacturer says Glenique is covered under Medicare part D and many private insurance plans. In California, Gelnique is covered under CCS (California Children’s Services), and Medi-Cal (California Medicaid) will pay for it with a TAR (Treatment Authorization Request). If you are paying cash, a one-month supply costs $115. A four-month “trial card” is available from your doctor (through the company) and the card gives you $25 off each prescription — including “share-of-cost coverage.” Also, since it is a new drug, you may want to ask your urologist if they have any free samples.

For online information: www.gelnique.com.

Q. I’m a T11 para. Recently I’ve had one bladder infection after another. After the last UTI was cleared up with antibiotics, my urologist prescribed a low daily dose of Nitrofurantoin, to stay on indefinitely. So far I haven’t had any more UTIs but the Nitrofurantoin is tearing up my gut and gives me the runs. Are there other antibiotics that will keep the UTIs at bay but be easier on my stomach?
— Dan

A. Dan, Nitrofurantoin (a generic form of Macrodantin) is an antibiotic used to treat UTIs and is used as a prophylaxis (to prevent UTIs) in low doses. Unfortunately, like all medications it has possible side effects, one of the most common is stomach upset and diarrhea.

Paula Wagner, a nurse practitioner in the urology department of U.C. Davis Medical Center in Sacramento, Calif., offers a prophylaxis option without the side effects of an oral antibiotic; putting the antibiotic directly into the bladder. The prescription is a mix of Neosporin Gu (liquid Neosporin antibiotic) and sterile saline. You add 1cc of Neosporin Gu to a 1 liter bottle of sterile saline and shake. Then pour out 40cc’s of the Neosporin into a sterile container, draw it into a 60cc syringe and inject it directly into the bladder. If you manage your bladder by intermittent catheterization, simply empty your bladder with the catheter, then inject the Neosporin mix through the catheter into the bladder, and remove the catheter. The mix stays in the bladder until the next time you cath. If you use a Foley or have a suprapubic, separate the catheter tube, inject the 40cc mix into the bladder and clamp the catheter for 30 minutes. Make sure to set an alarm — you never want to leave a urinary tube clamped off for too long or you could have problems with reflux and/or dysreflexia.

Wagner says in her department they often use the Neosporin mix as a prophylaxis for people with reoccurring bladder infections. The usual course is to use one dose a day for a week, then every other day for as long as your urologist suggests.

As an aside, Wagner says when a person suddenly gets reoccurring bladder infections, one of the things to look for is a bladder stone. The way to check for a stone is with an ultra-sound or x-ray of the bladder. Wagner says the Neosporin Gu treatment is helpful for people that have reoccurring bladder stones — bacteria is an irritant and stones can form around the bacteria — you get rid of the bacteria and there is nothing for stones to surround.