eMedicine Specialties > Physical Medicine and Rehabilitation > Rehabilitation Protocols
Bladder Management
Updated: Jan 26, 2009
Introduction
Background
In the practice of physical medicine and rehabilitation, voiding disorders are usually a result of neurologic conditions, such as spinal cord injury (SCI) or disease, cerebrovascular accident (CVA), traumatic brain injury (TBI), multiple sclerosis (MS), or dementia. Incontinence and urinary retention can cause social embarrassment and added morbidity, such as infections, stones, or renal injury.
Related eMedicine topics:
Urinary Incontinence
Voiding Dysfunction
Pathophysiology
The sympathetic nervous system regulates the process of urine storage in the bladder. In contrast, the parasympathetic nervous system controls bladder contractions and the passage of urine. Parasympathetic nerve impulses travel from S2-S4 ventral gray matter via the pelvic nerves to the ganglia near the bladder wall. Postganglionic nerve impulses then travel to the smooth muscle cholinergic receptors to produce bladder contraction.
Sympathetic efferent nerve fibers originate from the lateral gray column of the spinal cord from T11-L2. The sympathetic system has a long postganglionic chain that runs with the hypogastric nerve to synapse with alpha-receptors and beta-receptors in the bladder wall and bladder neck or internal sphincter. Beta-receptors are responsible for mediating relaxation of the bladder with filling. Alpha-receptors are responsible for tonically contracting the internal sphincter during bladder filling.
The somatic efferent nerve fibers originate from the pudendal nucleus of S2-S4 and supply the external periurethral sphincter. The external sphincter is under voluntary control and normally contracts in response to coughing or the Valsalva maneuver or when a person actively tries to prevent or halt urine flow.
Three areas of the CNS (ie, the sacral micturition center, the pontine micturition center, the cerebral cortex) control bladder function. The sacral micturition center is located at the S2-S4 levels and is responsible for bladder contraction. The pontine micturition center may play a role in coordinating relaxation of the external sphincter with bladder contractions while the cerebral cortex plays an inhibitory role in relation to the sacral micturition center.
Lesions of the peripheral nerves or the sacral micturition center cause detrusor areflexia that manifests as distended bladder with overflow incontinence. Lesions of the spinal cord or brainstem below the pontine micturition center, but above the sacral micturition center, lead to uninhibited bladder contractions with uncoordinated sphincter activity. The external sphincter may contract reflexively when the bladder contracts, a problem known as detrusor sphincter dyssynergia. Lesions above the pontine micturition center lead to lack of inhibition from the cerebral cortex and result in uninhibited bladder contractions, but voluntary relaxation of the urethral sphincter remains intact. This problem is encountered commonly in patients with CVA, TBI, or dementia.
Individuals with lesions below the pontine micturition center have both detrusor hyperreflexia and sphincter-detrusor muscle dyssynergia. These are the patients with SCIs, MS, and transverse myelitis.
Frequency
United States
Incidence of neurogenic bladder dysfunction depends on the primary cause. Etiology and level of central or peripheral nervous system injury correlate with different causes and classifications of bladder dysfunction. Bladder disorders are reported in 40-90% of patients with MS. Estimates of incidence of urologic symptoms in patients who have sustained a CVA vary, ranging from 33-60% in the acute setting and persisting in 15% at 6 months to 1 year.
The rate of urologic dysfunction in patients with Parkinson disease has been reported to be 37-72%. The rate of urinary incontinence is higher in patients with dementia and other types of cognitive impairment (eg, TBI, CVA, Parkinson disease) than in the general population. Bladder disorders are nearly universal in children with myelomeningocele and in patients with SCI.
Mortality/Morbidity
- Urinary tract infections are a frequent cause of morbidity in patients with neurogenic bladder. Patients with neurogenic bladder 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 and/or pyelonephritis.
- Predisposition to bladder stone formation is noted at 4 weeks in patients with SCI as a result of hypercalcemia and hypercalciuria and may persist 12-15 months or even longer. Incidence of kidney stone formation is highest in patients with indwelling catheters, up to 8%. Kidney stones are the leading cause of renal dysfunction in SCI.
- 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. Squamous cell carcinoma and transitional cell carcinomas are the types of bladder cancer commonly diagnosed in SCI patients.
Related eMedicine topics:
Neurogenic Bladder
Urinary Tract Infection
Urinary Tract Infection, Female
Urinary Tract Infection, Females
Urinary Tract Infection, Male
Urinary Tract Infection, Males
Urinary Tract Infections in Pregnancy
Race
This condition has no racial predilection.
Sex
The male-to-female ratio varies greatly between disease entities causing neurogenic bladder dysfunction. One study reported the male-to-female ratio as 1.6:8.5 in patients aged 15-64 years without consideration of etiology. Incidence of urinary incontinence, regardless of etiology, has been reported in 8.5% of females aged 15-64 years. In the same age group, only 1.6% of the male population report being affected with urinary incontinence.
Age
Age of occurrence of bladder disorders is related to age of onset of the neurologic disorder.
Clinical
History
- 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 instigation of pharmacologic treatment. If a neurologic event has led to symptomatology, establish premorbid voiding function and symptoms.
- In most patients, a clear neurologic event precedes the urologic symptoms (eg, TBI, CVA, SCI, onset of MS). Other patients have a history of prior pelvic surgery or trauma.
- Consider medications that may have an impact in terms of bladder control and function. Some of the medications frequently encountered include sedatives, muscle relaxants, opiates, calcium channel blockers, and antihistamines.
- Review the medical history, particularly paying attention to any endocrine or neurological conditions.
- Determine the individual's ability to perform self-care tasks such as hygiene, bathing, and dressing.
- Consider patient's fluid intake and level of hydration.
Physical
- Determine the motor level of the lesion, including completeness of 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 sensory level, especially in SCI patients. Include testing with light touch, pinprick, proprioception, and sacral sensation.
- Test reflexes and include normally tested muscle stretch reflexes, the bulbocavernosus reflex, cremasteric, and anal reflexes. Use the bulbocavernosus reflex to test 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 due to disinhibited bladder contractions.
Causes
- Neuropathic causes leading to the need for bladder management include the following:
- Suprapontine lesions (eg, due to CVA, MS, dementia, brain tumors, TBI) lead to uninhibited bladder contractions possibly secondary to loss of cerebral cortex inhibition at the sacral micturition center. Facilitation of the spinobulbospinal reflex also is affected.
- Suprasacral lesions are associated with the group of neurogenic bladder problems caused by spinal cord lesion from trauma, tumors, or spina bifida. These lesions cause interruption of the spinobulbospinal reflex, which leads acutely to areflexia, then usually to detrusor hyperreflexia and uncoordinated micturition with detrusor sphincter dyssynergia.
- Sacral lesions include lesions affecting the conus medullaris, the cauda equina, and S2-S4 peripheral nerves. Common causes of sacral lesions are trauma, stenosis, tumors, peripheral neuropathy, and infection. In general, lesions of this type lead to variable loss of parasympathetic and somatic nerve function. Detrusor areflexia, bladder neck incompetence, and/or loss of external sphincter function may occur.
More on Bladder Management |
 Overview: Bladder Management |
| Differential Diagnoses & Workup: Bladder Management |
| Treatment & Medication: Bladder Management |
| Follow-up: Bladder Management |
| References |
| Next Page » |
References
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Further Reading
Keywords
bladder management, urine, bladder, urination, urinary tract, urinary tract infection, incontinence, bladder problems, urinary tract infections, urinary incontinence, urinary problems, bladder control, urinary retention, neurogenic bladder dysfunction, voiding disorders, neurologic conditions, spinal cord injury, SCI, spinal cord disease, cerebrovascular accident, CVA, stroke, traumatic brain injury, TBI, multiple sclerosis, MS, dementia, social embarrassment
