Urinary Issues Problems and Solutions

Rebecca Shaw, BSN, MSN, Rebecca Shaw, BSN, MSN, CRNP, CRRNCRNP, CRRN

Objectives

After completion of class participant will:

Be knowledgeable of basic anatomy and physiology of normal bladder function

 Be able to identify at least 2 conditions which commonly cause problems with urination  

 Be able to describe treatment plans to address each type of bladder dysfunction

Prevalence of Problem

Bladder Control long standing problemBladder Control long standing problemWHO 1998 reported affects over 200 million people worldwideWHO 1998 reported affects over 200 million people worldwide

Affects People of all ages, races and nationalities Affects People of all ages, races and nationalities 2014 CDC statistics affects 25 million people in United States alone2014 CDC statistics affects 25 million people in United States alone

Interferes with all aspects of life Interferes with all aspects of life Physical, emotional and psychologicalPhysical, emotional and psychologicalAlso impacts lives of caregivers Also impacts lives of caregivers

Affects QOL Patient and Caregiver

Scope of problem

Far reaching and broad scope Far reaching and broad scope

Goal to discuss causes, management and clinical impact Goal to discuss causes, management and clinical impact

Concentrate discussion on 2 types of bladder Concentrate discussion on 2 types of bladder management problemsmanagement problemsUpper motor neuron Upper motor neuron Lower motor neuronLower motor neuron

Classification of Bladder Dysfunction

Uninhibited Bladder (Splash)Uninhibited Bladder (Splash)Example: Urge incontinence associated with Example: Urge incontinence associated with

Stroke or brain tumorStroke or brain tumor

Upper Motor Neuron bladder (Clash) Upper Motor Neuron bladder (Clash) Example: damage associated with Example: damage associated with

Cervicothoracic spinal cord injury or Multiple Cervicothoracic spinal cord injury or Multiple sclerosis involving cervicothoracic lesionssclerosis involving cervicothoracic lesions

Classification ofBladder dysfunction

Lower Motor Neuron Bladder (Stash)Lower Motor Neuron Bladder (Stash)Example: Flaccid overflow associated with Example: Flaccid overflow associated with

sacral cord or nerve root injuries sacral cord or nerve root injuries

Mixed Type Injury (Mishmash) Mixed Type Injury (Mishmash) Sacral cord or nerve root injury with various Sacral cord or nerve root injury with various

levels of neurological sparing. levels of neurological sparing.

Anatomy of urological system

Anatomy of Urological system

KidneysKidneys

Located either side of abdominal cavityLocated either side of abdominal cavity

Responsible for filtering waste and regulating fluid Responsible for filtering waste and regulating fluid balancebalance

filters blood at rate of 125ml/min filters blood at rate of 125ml/min

Ureters Ureters

connect kidneys to bladder connect kidneys to bladder

Propel urine into the bladder by peristalsisPropel urine into the bladder by peristalsis

Volume triggers movement of urine Volume triggers movement of urine

Normal Anatomy urological system

Anatomy of Urological system

Bladder Bladder

Hollow muscular organ Hollow muscular organ

Controlled primarily by the Autonomic nervous Controlled primarily by the Autonomic nervous system system

Enervated by Parasympathetic and Enervated by Parasympathetic and Sympathetic nerve fibersSympathetic nerve fibers

Anatomy of urological system

Bladder Bladder

Stretch receptors line the muscle wall Stretch receptors line the muscle wall

Normal micturition is stimulated at about 250-Normal micturition is stimulated at about 250-300 ccs of stored urine 300 ccs of stored urine

In a normal individual Volitional control begins In a normal individual Volitional control begins to fail at 600-700ccsto fail at 600-700ccs

Anatomy bladder

Normal micturition Filling Phase

Mediated by sympathetic responseMediated by sympathetic response

Primary receptors in bladder neck (Trigone) alpha Primary receptors in bladder neck (Trigone) alpha receptors receptors

Stimulation causes relaxation of the detrusor muscle Stimulation causes relaxation of the detrusor muscle

Contraction of the internal and external sphincters Contraction of the internal and external sphincters

Micturition is delayed Micturition is delayed

Normal Micturition Emptying Phase

Mediated by Parasympathetic Stimulation Mediated by Parasympathetic Stimulation

Promotes relaxation of bladder neck Promotes relaxation of bladder neck

Facilitates the micturition process and emptying of Facilitates the micturition process and emptying of bladder bladder

Both phases of cycle are balanced by the pontine Both phases of cycle are balanced by the pontine micturition center and the frontal lobe of the brainmicturition center and the frontal lobe of the brain

Pathophysiology of Bladder Dysfunction

Uninhibited BladderUninhibited BladderReduced awareness of bladder fullnessReduced awareness of bladder fullnessLow capacity bladder Low capacity bladder Loss of inhibitory regulation by pontine Loss of inhibitory regulation by pontine

micturition center micturition center Less risk of high bladder pressures Less risk of high bladder pressures

consequent upper urinary tract damage. consequent upper urinary tract damage.

Pathophysiology of bladder dysfunction

Upper Motor Neuron Bladder Upper Motor Neuron Bladder

Detrusor-sphincter-dyssynergia (DSD)Detrusor-sphincter-dyssynergia (DSD)

Results in simultaneous detrusor and urinary Results in simultaneous detrusor and urinary sphincter contractions sphincter contractions

High pressures/low capacities in the bladder High pressures/low capacities in the bladder

Pathophysiolgy

Upper Motor Neuron Bladder Upper Motor Neuron Bladder

Often results in vesicouretreral refluxOften results in vesicouretreral reflux

Quickly results in kidney damage Quickly results in kidney damage

Bladder and sphincters frequently are spastic Bladder and sphincters frequently are spastic

Incontinence occurs when detrusor pressure Incontinence occurs when detrusor pressure exceeds urinary sphincter pressures exceeds urinary sphincter pressures

Upper Motor Neuron Bladder

SC damage above sacral voiding center SC damage above sacral voiding center

Reflex arc remains intact Reflex arc remains intact

Voiding is incomplete Voiding is incomplete

Bladder exhibits spasticity Bladder exhibits spasticity

Lack of coordination micturition process Lack of coordination micturition process

Pathophysiology Bladder dysfunction

Lower Motor neuron bladder Lower Motor neuron bladder

Sacral micturition center damagedSacral micturition center damaged

Bladder capacity largeBladder capacity large

Detrusor tone low (detrusor areflexic)Detrusor tone low (detrusor areflexic)

Pathophysiology Bladder dysfunction

Lower Motor neuron bladder Lower Motor neuron bladder

Internal and external Sphincters relaxed Internal and external Sphincters relaxed

Frequent overflow incontinenceFrequent overflow incontinence

Urinary tract infections common Urinary tract infections common

Lower Motor Neuron Bladder

SC damage impairs sacral micturition center SC damage impairs sacral micturition center

Voiding reflex is impaired Voiding reflex is impaired

Occurs in spinal shock Occurs in spinal shock

Permanently in lower thoracic, lumbar and cauda equina Permanently in lower thoracic, lumbar and cauda equina injuries injuries

Pathophysiology

Mixed InjuryMixed Injury

Flaccid bladderFlaccid bladder

Either spastic or Either spastic or

flaccid sphincters flaccid sphincters

Bladder is large under low pressure Bladder is large under low pressure

Pathophysiology

Mixed Injury Mixed Injury

Less chance of reflux Less chance of reflux

Less resistance to outflow Less resistance to outflow

Frequent small volume incontinence Frequent small volume incontinence

Management : Goals

Allow regular emptying of bladder Allow regular emptying of bladder

With as little lifestyle disruption as possible With as little lifestyle disruption as possible

Promote a functionally independent lifestyle Promote a functionally independent lifestyle

Prevention of physical and psychological complications Prevention of physical and psychological complications

Management :General Complications

Complications associated with Bladder Complications associated with Bladder dysfunctiondysfunctionSkin maceration Skin maceration Pressure ulcers Pressure ulcers Renal or bladder calculi Renal or bladder calculi Frequent urinary tract infections Frequent urinary tract infections Increased risk renal and bladder cancer Increased risk renal and bladder cancer Renal damage Renal damage Dialysis Dialysis

Management : Evaluation

Full patient history Full patient history

Previous history Previous history

Comorbidities Comorbidities

Current complaints Current complaints

Medications Medications

Management: Evaluation

Physical Exam Physical Exam AnatomyAnatomyNeurological exam Neurological exam

Mental status and cognition Mental status and cognition ReflexesReflexesSensation including sacral dermatomesSensation including sacral dermatomesSpinal cord injury Full AIS exam including Spinal cord injury Full AIS exam including

rectal tone/sensationrectal tone/sensation

Management: Evaluation

Labs and special tests Labs and special tests Urinalysis Urinalysis Urine culture Urine culture Serum BUN/CR Serum BUN/CR Creatinine Clearance Creatinine Clearance Post void residual (cath or bladder scan) Post void residual (cath or bladder scan) Urodynamic testing Urodynamic testing Annual renal ultrasound and KUB Annual renal ultrasound and KUB

Management: Uninhibited Bladder

Remove environmental barriersRemove environmental barriers Timed voids Timed voids

Every 2-4 hours Every 2-4 hours Awaken once at night Awaken once at night

Initiate fluid scheduleInitiate fluid scheduleLimit Limit Spread throughout the day Spread throughout the day Only small sips after 6PM Only small sips after 6PM No fluids after bedtime No fluids after bedtime

Management:UMN Bladder

Intermittent Catherization Program (ICP)Intermittent Catherization Program (ICP)

Limit daily intake of fluids to 2 liters Limit daily intake of fluids to 2 liters Decrease fluids after supper to prevent over distension of Decrease fluids after supper to prevent over distension of

bladder at nightbladder at night

Cath every 6 hours 6AM-12Noon-6PM and bedtime Cath every 6 hours 6AM-12Noon-6PM and bedtime

Keep residuals below 400ccs for females and 500 ccs Keep residuals below 400ccs for females and 500 ccs

for males for males Increase cath schedule to every 4 hours for high residuals Increase cath schedule to every 4 hours for high residuals

Management Intermittent Catherization

Additional Treatment options UMN bladder

Indwelling catheter (Foley, suprapubic)Indwelling catheter (Foley, suprapubic) MedicationsMedications

Tricyclic Antidepressants-ImipramineTricyclic Antidepressants-ImipramineAnticholinergic- OxybutyninAnticholinergic- OxybutyninCholinergic agonists-Urecholine Cholinergic agonists-Urecholine Alpha 1 Adrenergic Antagonists-Tamsulosin Alpha 1 Adrenergic Antagonists-Tamsulosin

Botulism injectionsBotulism injections Surgical interventions Surgical interventions

SphincterotomySphincterotomyEnterocystoplastyEnterocystoplastyArtificial urinary sphincter devicesArtificial urinary sphincter devices

Complications Upper Motor Neuron Bladder

High pressure reflux leading to kidney damageHigh pressure reflux leading to kidney damage

Frequent Urinary Tract Infections Frequent Urinary Tract Infections

Renal calculi and bladder stones Renal calculi and bladder stones

Increased risk of bladder cancer Increased risk of bladder cancer

Autonomic dysreflexia Autonomic dysreflexia

Management: Complications

Autonomic Dysreflxia Occurs UMN injuries T6 and above Autonomic Dysreflxia Occurs UMN injuries T6 and above Symptoms Symptoms

Percipitious rise in blood pressure Percipitious rise in blood pressure Bradycardia Bradycardia HeadacheHeadacheNasal congestion, red splotching and goose bumps Nasal congestion, red splotching and goose bumps

Causes Causes Bladder distension Bladder distension Constipation Constipation Skin irritation Skin irritation Unknown causes Unknown causes

Management : Autonomic dysreflexia

Treat the cause Treat the cause Unkink catheter or Straight cathUnkink catheter or Straight cathCheck for impaction and remove/treat Check for impaction and remove/treat Check for skin irritation and remove source Check for skin irritation and remove source If unable to find cause quickly use meds If unable to find cause quickly use meds

Nitrol paste, Procardia or other BP medications Nitrol paste, Procardia or other BP medications

Management :LMN bladder

Intermittent Catherization Program (IC)Intermittent Catherization Program (IC)

Limit daily intake of fluids to 2 liters Limit daily intake of fluids to 2 liters

Decrease fluids after supper to prevent over distension of Decrease fluids after supper to prevent over distension of bladder at nightbladder at night

Cath every 6 hours 6AM-12Noon-6PM and bedtimeCath every 6 hours 6AM-12Noon-6PM and bedtime

Keep residuals below 400ccs for females and 500 ccs for Keep residuals below 400ccs for females and 500 ccs for

males males Cath more often if necessary Cath more often if necessary

Management UMN Additional treatment options

Indwelling catheters Indwelling catheters Foley Foley Suprapubic Suprapubic

MedicationsMedicationsCholinergic Agonists-Urecholine Cholinergic Agonists-Urecholine

LMN Complications

Large volume residuals (low pressure)Large volume residuals (low pressure)

Frequent UTIs exacerbated by stagnant urine Frequent UTIs exacerbated by stagnant urine

Urinary stones (bladder and kidneys)Urinary stones (bladder and kidneys)

LMN complications

Scarring of urological structures Scarring of urological structures

PolynephritisPolynephritis

Increased risk bladder cancerIncreased risk bladder cancerAssociated with chronic bladder irritation Associated with chronic bladder irritation

Management: Mixed Injury type

Highly individualized Highly individualized

Based on presentation of injury Based on presentation of injury

May be combination of interventions May be combination of interventions

May take several adjustments before satisfactory May take several adjustments before satisfactory treatment plan is achievedtreatment plan is achieved

Make one change at a time based on patient/caregiver Make one change at a time based on patient/caregiver feedbackfeedback

Summary

Bladder dysfunction is complex, broad spectrum Bladder dysfunction is complex, broad spectrum condition condition

Affects all aspects of patient lifeAffects all aspects of patient life

A comprehensive evaluation is needed to correctly A comprehensive evaluation is needed to correctly identify pathophysiology identify pathophysiology

A comprehensive multidisciplinary approach is A comprehensive multidisciplinary approach is needed to adequately address problems needed to adequately address problems

Summary

Patient education is primary cornerstone of Patient education is primary cornerstone of successsuccess

Can be treated successfully treated Can be treated successfully treated Satisfactory management from patient, Satisfactory management from patient,

caregiver and provider standpoint caregiver and provider standpoint Prevention of long term complications Prevention of long term complications

Successful Bladder Management is Cause for Celebration

ANY EXCUSE FOR A PARTY!ANY EXCUSE FOR A PARTY!

Questions?

References Cited

University of Kansas, and spokesman, American Urology Association; June 25, 2014, University of Kansas, and spokesman, American Urology Association; June 25, 2014, Vital and Health StatisticsVital and Health Statistics, U.S. , U.S. Centers for Disease Control and Prevention, National Center for Health Statistics report, Centers for Disease Control and Prevention, National Center for Health Statistics report, Prevalence of Incontinence Among Prevalence of Incontinence Among Older AmericansOlder Americans

World Health Organization calls First International Consultation on Incontinence http\\.www.who/int-pr-1998/en/pr-98-49World Health Organization calls First International Consultation on Incontinence http\\.www.who/int-pr-1998/en/pr-98-49 Shenot, Patrick J. Urinary Incontinence in Adults. Urinary Incontinence in Adults. The Merck Manual Professional Edition 2014 2014;;. Last full review/revision . Last full review/revision

August 2014August 2014 Dorsher, Peter McIntosh, Peter. Neurogenic Bladder. Dorsher, Peter McIntosh, Peter. Neurogenic Bladder. Advances in Urology. (2) 2012Advances in Urology. (2) 2012 Jeong SF, Cho Sy, Of Ll. Spinal cord/brain injury and neurogenic bladder. Jeong SF, Cho Sy, Of Ll. Spinal cord/brain injury and neurogenic bladder. Urol. Clin North AmUrol. Clin North Am. 2010;37 537-546. . 2010;37 537-546. Consortium for Spinal Cord Medicine. (2006). Consortium for Spinal Cord Medicine. (2006). Bladder Management for Adults with Spinal Cord Injury: A Clinical Practice Bladder Management for Adults with Spinal Cord Injury: A Clinical Practice

Guideline for Health-Care Professionals.Guideline for Health-Care Professionals. Paralyzed Veterans of America. Paralyzed Veterans of America. www.pva.org. .