Bladder Dysfunction Clinical Presentation

In general, patients present with retention, urinary incontinence, or a mixed picture of incomplete emptying and incontinence. Establish the etiology of the patient’s symptoms before initiating pharmacologic treatment.^[7] If a neurologic event has led to symptoms, establish premorbid voiding function and symptoms.

In most patients, a clear neurologic event (eg, traumatic brain injury [TBI], cerebrovascular accident [CVA], spinal cord injury [SCI], or onset of multiple sclerosis [MS]) precedes the urologic symptoms. In others, there is a history of previous pelvic surgery or trauma.

Consider medications that are known to be capable of affecting bladder control and function, such as sedatives, muscle relaxants, opiates, calcium channel blockers, and antihistamines. Review the medical history, particularly paying attention to any endocrine or neurologic conditions. Determine the individual’s ability to perform self-care tasks, such as hygiene, bathing, and dressing. Consider the patient’s fluid intake and level of hydration.

Determine the motor level of the lesion, including the completeness of the lesion in SCI patients. Ascertain the extent of the patient’s hand function and ability to perform transfers and activities of daily living. Hand function is especially important in SCI patients who are to perform self-catheterization.

Conduct sensory testing to determine the sensory level, especially in SCI patients. Include testing with light touch, pinprick, proprioception, and sacral sensation.

Test reflexes, including normally tested muscle stretch reflexes, the bulbocavernosus reflex, cremasteric reflexes, and anal reflexes. Use the bulbocavernosus reflex to test the integrity of the pudendal nerve and the S2-S4 segments.

Determine the condition of the skin in the perianal area. In patients with chronic neurogenic bladder, the skin typically shows areas of chronic irritation manifested by areas of excoriation and redness, usually superseded by fungal infection.

Establish the state of vaginal and bladder supports, particularly in patients with suspected stress incontinence. Relaxation of the bladder neck and weakness of the sphincter mechanism are common in these patients.

Evaluate the status of the prostate, especially in men aged 60 years or older. Prostatic enlargement, which can cause secondary urologic symptoms, usually manifests as urinary retention.

Note the presence of cognitive impairment or dementia. Such patients are at risk for incontinence as a consequence of disinhibited bladder contractions.

Urinary tract infections are a frequent cause of morbidity in patients with neurogenic bladder. Patients who lack sensation do not experience dysuria. Instead, symptoms may include fever, tachycardia, a feeling of uneasiness, signs and symptoms of autonomic dysreflexia, malodorous urine, increase in spasticity (in patients with upper motor neuron lesions), and lethargy.

The main morbid feature of urinary tract infection is that if left untreated, it may lead to urosepsis or pyelonephritis.^{[8, 9]} Pyelonephritis often is associated with reflux, kidney stones, and obstruction. Recurrent pyelonephritis is associated with renal deterioration.

Bladder infections are the most common complication of neurogenic bladder. The use of prophylactic antibiotics in patients on long-term intermittent catheterization is still controversial. Avoid use of prophylactic antibiotics in patients with indwelling Foley catheters.

Vesicoureteral reflux is associated with renal deterioration, especially in the presence of recurrent infection. Most deaths from renal complications in patients with neurogenic bladder are secondary to reflux.

Approximately 8% of patients with SCI develop renal calculi in the form of kidney and bladder stones.^[10] Kidney stones are the leading cause of renal dysfunction in SCI. The incidence of kidney stone formation is highest (up to 8%) in patients with indwelling catheters. Bladder stones usually are associated with indwelling Foley catheters. Struvite stones and calcium phosphate make up more than 90% of cases of stone formation. Nephrolithiasis is indicative of renal deterioration.

The prevalence of bladder cancer is higher in SCI patients who have had an indwelling Foley catheter for 10 years or more than in other patients with SCI or in the general population. Squamous cell carcinoma and transitional cell carcinomas are the types of bladder cancer commonly diagnosed in SCI patients.^[11]