This document outlines plans to establish a Centre for Urinary Incontinence and Neurourology to provide specialized care for patients with neurogenic bladder disorders. The center would offer multidisciplinary services including clinical evaluation, urodynamic testing, physiotherapy, and treatment. It aims to fill a gap, as currently no specialized neurourology services exist in India despite a large patient population. The center would be led by Dr. Shirish Yande and utilize a team of doctors, nurses, and technicians trained in neurourology and urodynamics. It would provide both inpatient and outpatient care targeting underprivileged patients and establishing standards of care for neurogenic bladder conditions.

1. Dr. Shirish Yande www.shirishyande.com
Project - Centre for Urinary Incontinence and Neurourology
A pioneering attempt at providing specialized care to patients of Neurogenic Bladder and Urethral Disorders.

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Introduction ......................................................................................................................... 1
Neurourology ....................................................................................................................... 2
Mechanism .......................................................................................................................... 2
Education ............................................................................................................................. 2
Conditions leading to Neurogenic Disorders ......................................................................... 3
Conditions affecting Brain (Suprapontine) ........................................................................ 3
Conditions affecting Spinal Cord (Suprasacral Spinal Cord) ............................................... 3
Conditions affecting the Peripheral Nervous System (Subsacral Lesions) .......................... 4
Images ................................................................................................................................. 4
Centre for Urinary Incontinence and Neurourology .............................................................. 5
Patients ............................................................................................................................ 5
Neurourology Unit ........................................................................................................... 5
Urodynamic Department .................................................................................................. 6
Space Requirement .......................................................................................................... 7
Conclusion ............................................................................................................................ 7
Introduction
Neurogenic Bladder and Urethral Disorders afflict a surprisingly large number of patients in India. These patients suffer from embarrassing and socially unacceptable conditions like bladder dysfunction, urinary and faecal incontinence. These problems also affect function of kidneys, which in the long term, is a threat to life. The disorder also affects sexual function, which further deteriorates the quality of life. Patients with Neurogenic Bladder and Urethral Disorders require a special Urological focus to their medical care. Currently, despite the large number of patients, no specialized Neurourology services exist in our country. This lack of facilities is not surprising due to the following reasons:
1. Management of Neuropathic Bladders needs intensive work.
2. It demands expertise, knowledge as well as dedication to the field of Neurourology by specially trained personnel.
3. A busy Urology practitioner may not want to spend the prohibitive time needed for implementing the neurological principles and overall rehabilitation of the affected individuals.
The team at the Centre for Advanced Urodynamics plans to launch a dedicated unit for specialized care to patients with Neurogenic Bladder and Urethral Disorders. This unit will offer multidisciplinary services, including:
Contents

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• Comprehensive Clinical Evaluation.
• Laboratory Infrastructure.
• Urodynamic Evaluation.
• Physiotherapy Support.
• Backup of Indoor patient services.
Since majority of patients belong to an underprivileged socioeconomic class, financial assistance and discounts will form a major consideration of this unit.
Neurourology
Neurourology refers to Urological care of patients with bladder and urethral dysfunction caused by relevant neurological conditions. Patient care is vital because:
• Bladder dysfunction produces socially unacceptable effects like urinary and faecal incontinence.
• The afflictions can influence function of kidneys and in turn produce threat to life in the long term.
Neurourological conditions largely include:
• Spinal cord injuries.
• Cord tumors.
• Brain trauma.
• A variety of brain tumors.
• Various peripheral neuropathies including diabetes.
Neurourological conditions also include transient and permanent changes in the bladder function due to surgery of brain and spinal cord for any reason.
Mechanism
Normal bladder cannot function without an intact nerve supply. Despite significant advances in the fields of Neuroanatomy and Neurohistochemistry, Innervation of bladder and urethra is still not completely understood. In any given case, bladder and urethral function may present a package of complex abnormalities. Creating awareness of potential treatment of these conditions is a difficult task. This is because some neurological conditions may produce serious bladder dysfunction without producing appreciable symptoms.
Education
The challenges of educating people about Neurologic conditions are:
1. Creating awareness that neurologic conditions can lead to life threatening urological complications without sufficient warning or symptoms.
2. Creating awareness of commonest symptoms, that would raise suspicion of Neurologic conditions.

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Urinary Incontinence is one such common but important symptom. Management of Urinary Incontinence is an important and mandatory part of the project. Cure for Urinary Incontinence is similar to Neurourology. Clinical information and imaging offer only clues about the nature of Incontinence. However, an objective evaluation method such as Urodynamics helps reveal the details helping in focused treatment. Urinary Incontinence or “Leakage of Urine” is a medical condition resulting in inability to hold back urine. Despite the large number of patients suffering from this disorder, the condition receives poor public attention and education. While most of the patients are women, poor education results in ignorance about the various treatments and their potentials. Constant advances in the medical knowledge has ensured that the condition is now completely curable. Women patients must now realize that they need not suffer from this embarrassing and debilitating condition anymore. Today, with so many treatment options, this condition can be controlled, leading to a marked improvement in the quality of life. (Vide Article in the Annexure 1) One can conclude that Urological care of a neurologically affected bladder demands a very careful and elaborate evaluation, followed by a precise management as well as monitoring in the long term. Dr. Shirish Yande and the Centre for Advanced Urodynamics plans to establish such a specialist unit a well established Urodynamic Clinic is conveniently complemented by a comprehensive clinical set up.
Conditions leading to Neurogenic Disorders
These are some of the conditions that affect the nervous system leading to various levels of neurological lesions.
Conditions affecting Brain (Suprapontine)
• Cerebrovascular Accident
• Cerebral tumors
• Cerebral palsy
• Dementia
• Head Injuries
• Cerebral ataxia
• Shy-Drager Syndrome
• Multiple Systems Atrophy (MSA)
• Parkinson’s Disease
Conditions affecting Spinal Cord (Suprasacral Spinal Cord)
• Spinal Cord Injury
• Disc lesions
• Spinal surgery
• Ankylosing Spondylosis

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• Guillain-Barre syndrome
• Tabes Dorsalis
• Multiple Sclerosis (MS)
• Pernicious Anemia
• Tropical Spastic Paraparesis
Conditions affecting the Peripheral Nervous System (Subsacral Lesions)
• Complex pelvic surgery
• Radical hysterectomy
• Guillain-Barre syndrome
• Acquired Immune Deficiency Syndrome (AIDS)
• Herpes Zoster
• Systemic Lupus Erythematosus
• Diabetic Neuropathy
• Pelvic Trauma
• Herpes Zoster
• Poliomyelitis
• Myelomeningocele
• Transverse myelitis
• Tethered cord Syndrome
• Short Filum Terminale
• Alcohol Neuropathy
• Chickun Gunya
Images
Bladder with Neurologic Disorder Spinal Cord Injury

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Centre for Urinary Incontinence and Neurourology
Patients
There will be two sources of patients.
1. Indoors patients: These patients can be examined and specifically referred to the Neurourology services, as required.
2. Outdoor patients can be examined by a dedicated OPD on a regular basis, preferably by specific appointments.
Mobile Indoor patients also could use the OPD facilities. All interrogations and investigations are to be performed using set protocols. The Frequency Volume Charts and other informational charts will be handed over to patients, free of charge. Urodynamic evaluation will be done, wherever indicated.
Neurourology Unit
This unit consists of the following functions or equipment:
1) The Reception: Can be shared with other OPD departments.
2) Incontinence Nurse: Should be a full-time trained Nurse who can handle handle Urodynamics as well as the Intermittent Catheterization Program.
3) Technician : Should be fully trained to run and maintain the Urodynamics Equipment. They should also assist in completion of investigation protocol and in Intermittent Catheterization Program.
4) Junior Doctor : Should be specifically trained for the specialized service. They will perform initial interrogation of all patients visiting the Centre. They will collect the complete clinical history, conduct physical examination and complete the values in a database. Junior Doctor will supervise Incontinence Nurse. They will be completely responsible for conducting the Urodynamic investigations of the service.
Urodynamic Tracing in Neurogenic Bladder Dysfunction

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5) Consultant : After completion of interrogation and examination by the Junior Doctor, the patient meets the Consultant. The Consultant perform several roles:
a) conduct regular OPDs every day
b) See all recruited patient and identify them for general and specific investigations.
c) Advise the Junior Doctor on a number of relevant issues.
d) Visit indoor patients for evaluating specific requirements of ancillary services.
e) Seek opinions of ancillary services such as Neurophysician and Physiotherapist after evaluating case of Indoor patients.
f) Perform final counseling of the patient based on all the investigations and ancillary consultations.
g) Plan the entire course of action and follow up for the patient.
6) Urodynamics Equipment: This dedicated equipment, catering only to the needs of the center, is an integral part of the service. The equipment includes a comprehensive multichannel system with Video, EMG and a Bladder Scanner. It will cater for the needs of the Centre. If possible, the center should have another Urodynamics equipment to meet specific requirements of referring Physicians for Urodynamic Investigation.
7) Other Services:
• Clinical laboratory.
• MRI.
• CT Scan.
• Neurophysiology laboratory.
• Physiotherapy.
• Counseling room for Intermittent Catheterization Program.
Urodynamic Department
1) Receptionist - 1
2) Consultant - 1
3) Junior Doctor - 1
4) Technician - 1
5) Incontinence Nurse - 1

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Space Requirement
The Center requires approximately 500 square feet carpet area. The tentative arrangement is shown in the image below.
Conclusion
Dr. Shirish Yande and the team at Centre for Advanced Urodynamics have long and varied experience stretching over two decades in treating Urinary Incontinence. Dr. Yande is uniquely qualified and experienced to head the proposed Centre for Urinary Incontinence and Neurourology. His altruistic leanings will help this center achieve their declared social service oriented aims of alleviating sufferings of patients, especially from the socially weaker sector. Dr. Shirish Yande Urologist & Urodynamicist shirishdyande@gmail.com Mobile +91-98220-38848. 13 April 2014
Tentative Floor Plan of Centre for Urinary Incontinence and Neurourology