6 - Bladder Dysfunction Flashcards
Central Pathways of Bladder. 4 marks ππ
1- Frontal Lobe Cortical Micturition Center (CMC)
Inhibits parasympathetic sacral micturition center
Controlling external urethral sphincter
Result in social inhibition and control of micturition
2- Pontine micturition center (PMC)
Coordinates bladder contraction and sphincter relaxation
3- Sacral Micturition Center (Pelvic and pudendal nuclei)
Micturition reflex mediated by parasympathetic sacral pelvic n. (S2βS4)
4- Motor cortex to pudendal nucleus
Voluntary control of external urethral sphincter
Cuccurollo 4th Edition Chapter 7 SCI pg566
Peripheral Efferent Pathways of Bladder. 3 marks ππ
1- SYMPATHETIC
Nerve
Hypogastric nerves (T11βL2)
Receptor & Location
Body of the bladder (Beta-2 adrenergic receptors)
Base of the bladder and prostatic urethra (Alpha-1 adrenergic receptors)
Neurotrasnmitter
Norepinephrine
Function
Beta adrenergic receptors within the body of the bladder causes smooth muscle relaxation (compliance)
Alpha adrenergic receptors within the base of the bladder/prostatic urethra causes smooth muscle contraction (increase outlet resistance)
Goal
Urine storage
2- PARASYMPATHETIC
Nerve
Pelvic nerves (S2βS4)
Receptors & Location
Bladder wall, trigone, bladder neck (Cholinergic muscarinic receptors)
Neurotrasmitter
Acetylcholine (Ach)
Function
Bladder contraction and emptying
3- SOMATIC
Nerve
Pudendal nerve (S2-S4)
Receptor
Cholinergic nicotenic receptors
Neurotrasmitter
Acetylcholine (Ach)
Function
Innervate striated muscle of external urethral sphincter.
Function
Voluntary contraction for preventing leakage or emptying
Cuccurollo 4th Edition Chapter 7 SCI pg566
Afferent Pathways of bladder. ππ
1- Pelvic nerve (parasympathetic)
Detrusor muscle stretch receptors
Bladder wall tension
Bladder mucosal nociception (pain, irretation)
2- Pudendal nerves
External anal and urethral sphincters, perineum, genitalia
Urethral mucosal sensation (pain, tempreture, passage of urine)
Cuccurollo 4th Edition Chapter 7 SCI pg568
Braddom 5th Edition Chapter 20 Bladder
Compare Urethral Sphincters (Nerve - Receptor - Type of Muscle - Function)ππ
INTERNAL SPHINCTER
- T11βL2 hypogastric nerve (sympathetic)
- Alpha-adrenergic receptors (Norepinephrine)
- Smooth muscle, involuntary
- Contracts sphincter for storage
- Thatβs why we use alpha block, omnic!
EXTERNAL SPHINCTER
- Pudendal nerve (S2βS4) (parasympathetic)
- Nicotinic receptor (ACh)
- Skeletal muscle, voluntary
- Voluntary preventing leakage or facilitate emptying
Cuccurollo 4th Edition Chapter 7 SCI pg568
You are meeting a patient with bladder dysfcuntion, explain to his how does the bladder work.
How does the bladder work when the spinal cord is intact? 3 marks. ππ (OSCE)
1- Urine Production
Urine produced by the kidneys passes through the ureters to fill the bladder. When the bladder is not full, the bladder wall muscle is relaxed. The bladder sphincter muscles are tightened so urine does not leak out.
2- Urine Storing
When there is enough urine to stretch the bladder walls, a nerve signal is sent up the spinal cord to tell the brain that the bladder is full. Because the brain controls the external sphincter muscle, urine can be held until an appropriate time to empty.
3- Urine Emptying
When the bladder is to be emptied, signals are sent from the brain down the spinal cord to cause the coordinated squeezing of the bladder wall muscle and relaxation of the bladder sphincter muscles to allow urine to pass through the urethra and out of the body.
Normal range of bladder volume and detrusor pressure. ππ (OSCE)
Bladder Sensation
Starts around 200ml up to 500ml where patient starts to feel urgency
Bladder Capacity
( Age + 1 ) x 30mL for < 12 years
500-700ml for 12+ years
Voiding Volume
Each void less than 500
Residual Volum
Less than 100
Detrusor pressure
5-10 mmH2O
> 40 mmH2O may harm the kidney
List the type of bladder dysfcuntion in each lesion site ππ
- Rostral to (above) pons
- Between pons and sacral spinal cord
- Sacral spinal cord
- Cauda equina or peripheral nerves.
Rostral to (above) pons
Detrusor hyperreflexia with coordinated sphincters (UMN Bladder)
Between pons and sacral spinal cord
Detrusor hyperreflexia with sphincter dyssynergia (DSD)
Sacral spinal cord
Detrusor and sphincter areflexia (normal detrusor function with areflexic sphincter).
Cauda equina or peripheral nerves
Detrusor and sphincter areflexia.
UMN bladder. Causes, Lesion site, Presentation & Treatment. ππ
Causes
- Parkinson
- Brain Tumor
- Traumatic Brain Injury
- Subacute CVA (detrusor hyperreflexia)
- Multiple sclerosis
- Transverse myelitis
- Degeneration (cervical spondylosis).
- Thoracolumbar Trauma (SCI)
- Vascular (AVM) (Non-traumatic SCI)
Sacral Reflex
- Lack of inhibition of sacral micturition center
- Result in detrusor overactivity - hyperactive bladder
Presentation
- Reduced or complete loss of bladder sensation
- Failure to store: Small & Overactive, Random emptying (accidents)
- Failure to empty: Spastic bladder neck and sphincter
Treatment
- Behavioral/Life Style
- Timed void
- Scheduled fluid intak
- Routine water intake to minimize urgency, leaks or accidents
- Minimize fluid and caffeinated beverage past 6pm
- Collecting Devices
- Diaper (eldarly or dementia)
- Indwelling catheters (no care giver or poor hand skills)
- External condom catheter (low outlet obstruction)
- Clean intermittent catheterization (good hand skills and adherence)
- Suprapubic cacatheterizationher (problems with previous methods)
- Pharmacological
- Anticholinergics (anti-detrusor) : Oxybutinin, Solifenacin (Vesicare)
- Alpha-adrenergic blockers (anti-sphincter): Tamsulosin (Omnic)
- Botulinum toxin (Botox) injections to relax the bladder muscles
- Intrathecal baclofen (SCI patient with LL spasticity)
- Surgical
- Augmentation
- Diversion (Urostomy)
- Denervation
- Bladder neck incision
- Sphincterotomy incision
- Sphincterotomy
- Prostate resection
- Pudendal neurectomy
Cuccurollo 4th Edition Chapter 7 SCI pg572 Table 7-9
Braddom 5th Edition Chapter 20 pg436 Table 20-4
DeLisa 5th Edition Chapter 7 SCI pg1358 Table 51.3
LMN bladder. 4 Causes (MOCK), Lesion site, Presentation & Treatment. ππ
Causes
- Spinal shock: Reflex arc not functioning
- Acute CVA (detrusor areflexia)
- Conus medullaris syndrome
- Cauda equina syndrome
- Syringomyelia
- Herniated lumbar disk.
- Lumbar spinal stenosis.
- Amyotrophic lateral sclerosis
- Burst Fracture L1
Sacral Reflex
- Absent
Presentation
- Reduced or complete loss of bladder sensation
- Overflow incontinence
- Failure to empty: Large, areflexic, flaccid bladder, urine retention
Treatment
- Behavioral/Lifestyle
- Timed voids
- Pelvic floor exercises (limit stress incontinence)
- Reflex voiding, Valsalva and CredΓ© maneuvers (risk for β reflux )
- Scheduled fluid intake
- Routine water intake to minimize urgency, leaks or accidents
- Minimize fluid and caffeinated beverage past 6pm
- Collecting Devices
- Diaper (eldarly or dementia)
- Indwelling catheters (no care giver or poor hand skills)
- External condom catheter (low outlet obstruction)
- Clean intermittent catheterization (good hand skills and adherence)
- Suprapubic cacatheterizationher (problems with previous methods)
- Pharmacological
- Bethanechol: Stimulate cholinergic receptors (rarely used)
- Ξ±-Agonists
- Surgical
- Artificial sphincter
Cuccurollo 4th Edition Chapter 7 SCI pg572 Table 7-9
Braddom 5th Edition Chapter 20 pg436 Table 20-4
LMN bladder. 4 Causes (MOCK), Lesion site, Presentation & Treatment. ππ
Causes
- Spinal shock: Reflex arc not functioning
- Acute CVA (detrusor areflexia)
- Conus medullaris syndrome
- Cauda equina syndrome
- Syringomyelia
- Herniated lumbar disk.
- Lumbar spinal stenosis.
- Amyotrophic lateral sclerosis
- Burst Fracture L1
Sacral Reflex
- Absent
Presentation
- Reduced or complete loss of bladder sensation
- Overflow incontinence
- Failure to empty: Large, areflexic, flaccid bladder, urine retention
Treatment
- Behavioral/Lifestyle
- Timed voids
- Pelvic floor exercises (limit stress incontinence)
- Reflex voiding, Valsalva and CredΓ© maneuvers (risk for β reflux )
- Scheduled fluid intake
- Routine water intake to minimize urgency, leaks or accidents
- Minimize fluid and caffeinated beverage past 6pm
- Collecting Devices
- Diaper (eldarly or dementia)
- Indwelling catheters (no care giver or poor hand skills)
- External condom catheter (low outlet obstruction)
- Clean intermittent catheterization (good hand skills and adherence)
- Suprapubic cacatheterizationher (problems with previous methods)
- Pharmacological
- Bethanechol: Stimulate cholinergic receptors (rarely used)
- Ξ±-Agonists
- Surgical
- Artificial sphincter
Cuccurollo 4th Edition Chapter 7 SCI pg572 Table 7-9
Braddom 5th Edition Chapter 20 pg436 Table 20-4
In detrusor areflexia (LMN bladder), why do some patients have difficulty emptying?
Internal sphincter tone is usually flaccid with LMN lesion, but may be intact due to sympathetic innervation, causing difficulty with complete emptying.
Ref: http://www.scireproject.com/case-studies/case-6-mr-r-b/neurogenic-bladder
List 8 reversible factors for incontinence ππ
ASIA A C8 increasing incontinence. 4 causes.
List 4 urodynamic and functional causes of incontinence in neurogenic bladder dysfunction
Caused by the bladder
- Detrusor overactivity
- Decreased capacity
- Low bladder wall compliance
- Normal (cognitive/mobility issue)
Caused by the outlet
- Incompetent sphincter
DeLisa 5th Edition Chapter 7 SCI pg1351 Table 51.2
DIAPPERS
- Delirium
- Infection
- Atrophic vaginitis, urethritis
- Pharmaceuticals
- Psychological (Depression)
- Endocrine (Diabetes, Sodium abrnomalities)
- Reduced mobility
- Stool impaction
DeLisa 5th Edition Chapter 51 Neurogenic Bladder & Bowel pg1353
List 4 classes of treatment for enhancing bladder volumes in hyper-reflexic bladder in SCI.
Collecting Devices
- Intermittent or indwelling catheter
Pharma
- Oral Anticholinergics (Oxybutynin, Solifenacin) β First line therapy
- Alpha-Adrenergic Blockers
- Botulinum toxin A (BTX-A)
- Intravesical instillations of oxybutinin
- Intrathecal baclofen/clonidine
Surgical
- Surgical Augmentation
- Urinary Diversion
https://scireproject.com/wp-content/uploads/SCIRE_Bladder_V7.pdf
List 4 urodynamic and functional causes of retention in neurogenic bladder dysfunction
Caused by the bladder
- Detrusor areflexia
- Large capacity/high compliance
- Normal (cognitive/mobility issue)
Caused by the outlet
- High voiding pressure with low flow rate
- Internal sphincter dyssynergia
- External sphincter dyssynergia
- Overactive sphincter mechanism (i.e., sphincter or pseudosphincter dyssynergia)
DeLisa 5th Edition Chapter 7 SCI pg1351 Table 51.2
Which drug will best lower urethral resistance?
Alpha-adrenergic antagonists (Omnic 0.4mg OD)
What is Detrusor sphincter dyssynergia (DSD)? When does it happen? π
Successful micturition reflex
- Bladder sphincter must relax just before the onset of a bladder contraction
- Goal is unobstructed voiding
- Itβs coordinated via PMC
Pontine micturition center (PMC)
- Coordination of bladder contraction and sphincter activity
- Disruptions in pathways between the PMC and the sacral outflow to the bladder can lead to detrusor sphincter dyssynergia, a leading cause of obstruction in individuals with suprasacral spinal cord injury (SCI).
Detrusor sphincter dyssynergia (DSD)
- Involuntary urinary sphincter contraction
- Increased activity of detrusor muscle contraction in the same time.
Neurological injury
- Between the sacral micturition center (S2βS4) and pontine micturition centers
Cuccurollo 4th Edition Chapter 7 SCI pg574
Braddom 5th Edition Chapter 20 Bladder pg429
What to monitor for patients with neurogenic bladder?
π‘ Blood - Imaging - Special Tests
- Blood urea nitrogen (BUN) and creatinine.
- Renal ultrasound (at least yearly) to identify reflux or hydronephrosis
- Measurement of a postvoid residual urine volume (PVR)
- Signs and symptoms of AD during voiding.
- Monitored for UTIs
Why SCI patients are at higher risk of developing CKD? 4 marks
π‘ Stone β Obstruct β Reflux β Bacteria
- Nephrolithiasis (stones)
- Obstructive nephropathy (sphincter)
- Reflux nephropathy (hypertrophied bladder wall)
- Chronic pyelonephritis (infections)
List 4 urinary complications seen in SCI
- Bacteriuria & UTIs
- Hypercalciuria and Stones
- Vesicoureteral reflux (VUR)
- Hydronephrosis
- Renal deterioration
- Autonomic Dysreflexia
Cuccurollo 4th Edition Chapter 7 SCI pg576
Mention 4 UTI sign and symptoms in SCI patient
π‘ The symptoms of urinary tract infections are not always easy to recognize.
- More frequent or severe muscle spasms (increased spasticity)
- Autonomic dysreflexia (in people with injuries above T6)
- Fever, chills
- Malasia
- Cloudy urine
- Hematuria
- Bad-smelling urine
- Increased frequency
- Urinary incontinence
- Pain or burning feeling while urinating (if sensation is present)
- Pain in the abdomen or back (if sensation is present)
What test can be employed to differentiate prostatitis from pyelonephritis?
Elevated PSA (prostate-specific antigen) is seen in prostatitis
List 4 risk factors for UTI in SCI patient.
- Female (anatomy increases the risk)
- Use of urinary catheters
- Reusing catheters or unclean environments
- Incomplete emptying
- Obstruction of the urinary tract (kidney or bladder stone, enlarged prostate, or narrowing of the urethra)
- Bladder overfilling
- Reflux
- Poor hygiene
SCIRE
How do manage patient with positive urine culture? ππ (OSCE)
Asymptomatic UTIs
- Not a true infection but instead is colonization of the bladder
- Continue indwelling catheter or IC
- Adequate hydration
Exceptions
- Patients undergoing invasive procedures
- Urease-producing organisms
Symptomatic UTIs
- Fever, malaise, increased spasticity or neurogenic pain
- Pyuria: >10 leukocytes per cubic millimeter
- Clean catch midstream urine specimen: >100,000 organisms per milliliter
- 7 days of antibiotics + probiotic
Medication
- Fluorquinolones (such as Ciprofloxacin and Ofloxacin)
- Nitrofurantoin
Duration
- 7 days of antibiotics + probiotic
- For catheter-related UTIs, the typical duration is about 2 weeks
Cuccurollo 4th Edition Chapter 7 SCI pg576
SCIRE
List 5 Urease-producing organisms ππ Dr. Abdulrazaq
- Escherichia coli
- Staphylococcus epidermidis
- Proteus
- Pseudomonas
- Klebsiella
Types of urinary incontinence π
Explain Stress Urinary incontinence
Two important reflexes to check in SCI patient in regard bladder dysfunction. ππ
- Bulbocavernosus reflex (S2βS4)
- Anal reflex (wink; S2βS4)
Cuccurollo 4th Edition Chapter 7 SCI pg569
List 3 investigations for neurogenic bladder on admission and follow up in T8 complete. π
π‘ Any investigations: Blood - Radiology - Special, repeat those on follow up!
Admission
- CrCl, 24-hour urine
- Urinalysis
- Urine culture and sensitivity
- Renal and bladder ultrasound
- PVR
- Urodynamic
Follow up
- Annual CrCl, 24-hour urine
- Annual Renal US and KUB
- Repeat urodynamic after 1 year
Ref: SCI Principles and practice textbook, p301
Braddom 5th Edition Chapter 20 Bladder pg442 Box 20.1
List 4 indications for urodynamic study in SCI pt. ππ
FAILURE TO PASS
- Large postvoid residuals (i.e., retention)
FAILURE TO STORE
- Urinary incontinence
- Urinary frequency
COMPLICATIONS
- Recurrent UTIs in a patient with neurogenic bladder
- Deterioration of the upper tracts
- Bladder or kidney stones.
MONITOR & FOLLOW
- Monitoring of voiding pressures
- Evaluation and monitoring of pharmacotherapy
- Unexplained autonomic dysreflexia.
DeLisa 5th Edition Chpater 51 Neurogenic Bowel & Bladder pg1355
SCI principles and practice textbook, pg 301.
What time period after SCI should urodynamic testing be done? ππ
What are the phases in a urodynamic study? ππ (MOCK 2022)
What variables are measured/assessed during each phase?
π‘ In those who have the potential for autonomic dysreflexia, changes in blood pressure before, during, and after voiding can also be evaluated.
Filling (storage) phase, during which water is being infused into the bladder.
1- Bladder sensation
First sensation 100 to 200 mL
Sense of fullness 300 to 400 mL
Sense of urgency 400 to 500 mL
2- Bladder capacity
Normal between 400 and 700 mL
3- Bladder wall compliance
4- Bladder stability
Whether or not there are uninhibited contractions
Voiding (emptying) phase, when a person is told to void.
- Leak-point pressure (bladder pressure at which voiding begins)
- Maximum voiding pressure
- Urethral sphincter activity (EMG or actual pressure)
- Flow rate
- Voided volume
- Postvoid residual.
DeLisa 5th Edition Chapter 51 Neurogenic Bowel & Bladder pg1357
Answer
Areflexic LMN bladder dysfunction.
- Absent bulbocavernosus reflex.
- Major detrusor contractions are absent.
- No pelvic floor muscle activity external urethral sphincter.
- Large bladder capacity.
Answer
Uninhibited neurogenic bladder dysfunction.
- Brisk bulbocavernosus reflex.
- Spontaneous detrusor contraction at reduced bladder capacity.
- Silence of pelvic floor muscles external urethral sphincter.
Answer
Hyperreflexic UMN bladder dysfunction
- Brisk bulbocavernosus reflex.
- Bladder capacity is reduced.
- High intravesical pressure during detrusor contraction.
- Detrusor/external urethral sphincter dyssynergia with marked electrical activity of the pelvic floor muscles during detrusor contraction.
Answer
(A) Normal pattern. No contractions occur during filling. Voiding is initiated by relaxation of the sphincter before the bladder contracts. Low pressure emptying occurs
(B) Suprapontine neurologic lesion: Contractions occur during filling, which the patient tries to suppress. Coordinated sphincteric relaxation occurs, leading to incontinence.
(C) Infrapontine/suprasacral neurologic lesion: Contractions occur during filling and sphincteric cocontraction (detrusor sphincter dyssynergia) occurs, leading to high detrusor pressure.
(D) Sacral or infrasacral neurologic lesion: Minimal or no bladder contraction or sphincteric activity is present.
Above what intravesicular pressure predisposes a patient to upper tract dysfunction (eg. Hydronephrosis)?
40 mm H2O. Hence, must determine LPP (leak point pressure) β if greater than 40 mm H2O, then problems will occur.
Ref: 1996 β Watanabe. Urodynamics of SCI.
Which parameter will best identify the patients who are at risk for upper urinary tract abnormality?
Leak point pressure:
Lowest detrusor pressure at which urine leakage occurs in the absence of either a detrusor contraction or an increase in abdominal pressure.
Advice patient on how to manage his fluid intake and CIC ππ (OSCE)
ADULT
- Start CIC 4-6 times daily with target of <500ml of urine each voiding session
- Timed voiding before sleep and after waking up
- Fluid intake 2-3 L per day on divided times, 250-500ml each time
- Avoid caffeinated beverages past 6pm
- Have set of routine for both CIC and fluid intake (limiting accidents, leaks, retension)
- Post-void residual <100 mL
PEDIATRIC
- First 10 kg the daily fluid requirement is 100 mL/kg
- 11-20 kg the daily fluid requirement is 1000 mL + 50 mL/kg for every kg over 10.
- <20 kg the daily fluid requirement is 1500 mL + 20 mL/kg for every kg over 20
- Capacity <12 yo = (age +2) x 30 mL
- Post-void residual <20 mL
List 3 goals of bladder routine. ππ (OSCE)
- Regularly empty the bladder
- Prevent leaks
- Avoid serious complications long-term.
- Upper tract complications (hydronephrosis, pyelonephritis)
- Lower tract complications (cystitis, vesicoureteral reflux)
Cuccurollo 4th Edition Chapter 7 SCI pg571 & SCIRE
Which type of reflex voiding is advised? which is not? π
Reflex voiding
Technique that can be used by some people with spastic bladder to cause urination.
Safe
Tapping over the bladder lightly and repeatedly with the fingertips or the side of the hand to stimulate reflex muscle contractions in the bladder that cause urination.
This technique can be used to help improve bladder emptying during intermittent catheterization and when using condom catheters.
Unsafe
Older techniques for reflex voiding such as the Valsalva maneuver (increasing abdominal pressure by holding the breath and bracing) and the Crede technique (applying manual pressure onto the bladder through the abdomen) are NO longer used because they can cause too much pressure in the bladder, which can damage the kidneys.
https://community.scireproject.com/topic/bladder/#reflex-voiding
Which type of reflex voiding is advised? which is not? π
Reflex voiding
Technique that can be used by some people with spastic bladder to cause urination.
Safe
Tapping over the bladder lightly and repeatedly with the fingertips or the side of the hand to stimulate reflex muscle contractions in the bladder that cause urination.
This technique can be used to help improve bladder emptying during intermittent catheterization and when using condom catheters.
Unsafe
Older techniques for reflex voiding such as the Valsalva maneuver (increasing abdominal pressure by holding the breath and bracing) and the Crede technique (applying manual pressure onto the bladder through the abdomen) are NO longer used because they can cause too much pressure in the bladder, which can damage the kidneys.
https://community.scireproject.com/topic/bladder/#reflex-voiding
What are the 2 indications and 4 contraindications of crede and valsalva maneuver for bladder emptying? ππ
Indications:
- LMN bladder with low outlet resistance.
- sphincterotomy.
Contraindications:
- DESD (detrusor external sphincter dyssynergia).
- bladder outlet obstruction.
- vesicoureteral reflux.
- hydronephrosis.
PVA Guidelines, bladder, pg1.
Compare the different types of Urine Collection Devices 4 marks ππ (OSCE)
DIAPERS
Incontinent patients with dementia
Advantages: Ease of care
Disadvantages: Risk of infection and ulcer can result from poor hygiene
Caution: Test PVR for adequate bladder emptying
EXTERNAL CONDOM CATHETER
Unable to perform self-catheterization
Advantages: Continues negative pressure
Disadvantages: Skin breakdown - Urethral damage - Risk of UTI can result from poor hygiene
Caution: Can be too tight or loose
INDWELLING CATHETER
Unable to perform self-catheterization
Advantages: Continues negative pressure
Disadvantages: Traction - Traumatic hypospadias - Squamous cell carcinoma
Caution: Monthly catheter changes
CLEAN INTERMITTENT CATHETERIZATION
SCI lesions at C6
Advantages: Social integration - Quality of Life
Disadvantages: Symptomatic bacteriuria - Urethral trauma - Incontinence
Caution: Restrict fluid intake - Timed schedule (four times a day)
Braddom 5th Edition Chapter 20 Bladder Dysfunction pg436-437
List 4 Indications of Indwelling Urethral Catheterization
Indications of Indwelling catheterization
- Limited assistance from a caregiver
- Poor hand skills
- High fluid intake
- Need for temporary management of vesicoureteral reflux
- Elevated detrusor pressures
- Failure of other less invasive methods (eg. IC)
- Cognitive impairment or active substance abuse
Indications to continue for 14+ days
- Documented PVR are in a range over 200 mL
- Persistent overflow incontinence
- Inability to manage the incontinence/retention with IC
- Symptomatic infections, and/or renal dysfunction
- Contamination of stage 3 or 4 pressure ulcers with urine that has impeded healing
- Terminal illness or severe impairment that limits positioning or clothing changes
DeLisa 5th Edition Chapter 51 Neurogenic Bowel & Bladder pg1363
List 4 Complications of indwelling urinary catheterization ππ Dr. Salem
π‘ Urethra - Stagnated urine - Foreign body - Attached to leg
- Pain and discomfort
- Urethral injury
- Urethral strictures
- Hematuria
- Allergic reaction to the catheter material (often latex)
- UTI, cystitis
- Bladder cancer is associated with long term use of catheterization
- Bladder stones, kidney stones
- Epididymo-orchitis
- Impaired quality of life: Limits movement and activities, Inconvenience, Embarrassing
SCIRE
Tan p 583
What factors increase the risk of bladder cancer in SCI patients?
- Stones - bladder stones
- Infection - chronic infection
- Catheter - indwelling
- Smoking β unclear association
Ref: 2010 β urologic complications of neurogenic bladder. Gormley et al.
List 4 Indications & Contraindications for Clean Intermittent Catheterization (CIC) ππ
Contraindications
- Inability to catheterize themselves or a caregiver who is unable to perform catheterization
- Poor cognition
- Unwillingness to adhere to the catheterization time schedule or the fluid intake regimen
- Abnormal urethral anatomy such as stricture and bladder neck obstruction
- Bladder capacity less than 200 mL
- Adverse reaction toward having to pass the catheter into the genital area multiple times a day (repeated hematuria)
- Tendency to develop autonomic dysreflexia with bladder filling despite treatment
DeLisa 5th Edition Chapter 51 Neurogenic Bowel & Bladder pg1364
Indications
- Good hand function
- Good cognition
- Good vision
- Pt welling / compliance
- Available of equipment
Dr. Salem Academic Day
What can be done to limit complications from intermittent catheterization? π
π‘ To Follow proper bladder care 1) Technique 2) Complete emptying
- Use of hydrophilic catheter
- Washing your hands thoroughly with soap and hot water before catheterization
- Single use catheters
- Single use lubricant
- Genital hygiene
- Collect less than 500mL of urine each time, if more consider more frequency.
- Complete emptiness of bladder
SCIRE
List 5 potential complications of intermittent catheterization. ππ
- UTI.
- Bladder overdistention (low adherence)
- Urinary incontinence.
- Urethral trauma with hematuria.
- Urethral false passages.
- Urethral stricture.
- Autonomic dysreflexia (if level above T6).
- Bladder stones.
PVA bladder guidelines, pg1.
In SCI, if bladder volumes consistently exceed 500 mL
What are 3 potential management options? ππ
- rule out infection (UTI)
- increase frequency of IC.
- adjust fluid intake.
PVA Guidelines β bladder, pg 1.
List 4 Indications for suprapubic catheter? ππ
- Desire to improve sexual genital function
- Difficulty with urethral catheter insertion
- Leakage secondary to urethral incompetence
- Perineal skin breakdown
- Urethral discomfort
- Urethral abnormalities, such as stricture, false passages, bladder neck obstruction, or urethral fistula
- Recurrent urethral catheter obstruction
- Prostatitis, urethritis, or epididymo-orchitis
DeLisa 5th Edition Chapter 51 Neurogenic Bowel & Bladder pg1364
List 4 Advantages of Indwelling Suprapubic Catheterization π
- Tubing is less likely to be sat on or kinked between a personβs legs
- More comfortable
- Less likely to interfere with sexual activity (especially men)
- Much easier to clean around (especially woman)
- Completely reversible because once the suprapubic catheter is removed, the tract closes, usually within 1 to 2 days
- Decreases the risk of epididymitis, urethral stricture disease, and urethral irritation
DeLisa 5th Edition Chapter 51 Neurogenic Bowel & Bladder pg1364
Name 5 surgical interventions directed to improve bladder care/functioning π
Treat low capacity
- Bladder Augmentation
- Bladder Augmentation with Stoma
- Denervation Procedures
- Artificial Sphincter
- Botulinum toxin injections to bladder wall
Treat obstruction
- Sphincterotomy
- Urethral Stents
- Urinary Diversion
- Botulinum toxin injections to sphincter
- Balloon dilation
Braddom 5th Edition Chpater 20 Bladder Dysfunction pg438
DeLisa 5th Edition Chapter 51 Neurogenic Bowel & Bladder pg1358 Table 51.3
Indications or pre-requisites for bladder augmentation surgery?
- Involuntary bladder contractions causing incontinence.
- The ability and motivation to perform intermittent catheterizations.
- The desire to convert from reflex voiding to an intermittent catheterization program.
- High risk of upper tract deterioration due to hydronephrosis and/or ureterovesical reflux from high pressure detrusor-sphincter dyssnergia.
MOA of Oxybutynin & Tamsulosin ππ EXAM
Oxybutynin [Ditropan]
Benefits
- Exerts antispasmodic and antimuscarinic effects on smooth muscle
- Increases bladder capacity
- Decreases uninhibited contraction
- Delays desire to void
- Decreases frequency and urgency
Immediate-release
5 mg PO twice/three times daily
Not to exceed 5 mg PO four times daily
Extended-release
5-10 mg/day PO; may be increased by 5 mg/day at weekly intervals
Not to exceed 30 mg/day
S/E
- Dry mouth (21-71%)
- Constipation (7-15%)
- Somnolence (2-14%)
- Nausea (2-12%)
https://reference.medscape.com/drug/ditropan-xl-oxybutynin-343066#0
Tamsulosin [Omnic]
Benefits
- Blocks alpha1a adrenergic receptor in smooth muscle of prostate
- Decreasing bladder neck and urethral resistance
Dose
0.4 mg PO qDay; take 30 minutes after same meal each day
S/E
- Headache (19-21%)
- Orthostatic hypotension (6-19%)
- Dizziness (15-17%)
- Abnormal ejaculation (8-18%)
https://reference.medscape.com/drug/flomax-tamsulosin-342839#10
