eMedicine Specialties > Physical Medicine and Rehabilitation > Rehabilitation Protocols

Bladder Management

Ramon S Lansang Jr, MD, Consulting Staff, Department of Orthopedics, Charleston Area Medical Center

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.

Differential Diagnoses

Other Problems to Be Considered

Urinary outflow obstruction
Prostatism
Urinary tract infection

Workup

Laboratory Studies

• Urinalysis and urine culture with sensitivity to rule out infection
• Twenty-four–hour creatinine clearance
• Residual urine volume
  • Usually determined by bladder scanning after void; may be measured directly by catheterization if bladder scan is not available
  • Reflects bladder and outlet activity during emptying phase of micturition
  • Acceptable quantity of up to 100 mL of postvoid residual urine with voiding frequency greater than every 2 hours, if patient is not experiencing frequent urinary tract infections

Imaging Studies

• Radiologic studies
  • Plain film of the urinary tract, bladder, and kidneys is indicated to determine presence of radiopaque calculi in conjunction with ultrasonography.
  • Excretory urography or intravenous pyelography can be used for visualization of the collecting system.
  • Isotope studies (eg, technetium Tc 99m dimercaptosuccinic acid [DMSA]) are used for evaluation of function of renal cortex.
• Ultrasonography
  • Used for routine evaluation of the upper urinary tract
  • Evaluate for presence of ureteral obstruction, scarring, masses, and either renal or bladder calculi

Other Tests

• Urodynamics: Evidence for or against the use of urodynamics for assessing bladder function versus other methods is insufficient in poststroke patients with urinary incontinence and bladder dysfunction, but it may be useful as an adjunctive diagnostic tool.
• Cystometry
  • This helps evaluate filling and storage phases of detrusor function by measuring changes in intravesical pressure with increases in bladder volume.
  • Normal adult bladder capacity is around 400-750 mL, with bladder pressures normally not exceeding 15 cm water during filling phase.
  • Bladder volumes can be determined and recorded during first sensation of filling, voiding urgency, and maximal filling.
  • It can assess the voluntary voiding phase after filling and the efficacy of emptying.
  • Cystometry assesses the leak point (ie, the pressure at which voiding occurs).
  • Abnormal findings include decreased bladder compliance with intravesical pressures exceeding 15 cm water with steep rising curve in the cystometrogram, possibly due to bladder inflammation, bladder fibrosis, or detrusor hypertrophy.
  • Involuntary detrusor contraction (ie, phasic increase in intravesical pressures during filling phase) reflects presence of detrusor hyperreflexia in patients with suprapontine lesions (eg, from CVA, Parkinson disease). This phenomenon also is seen in patients with suprasacral spinal cord disease (eg, SCI, MS, spina bifida).
  • A noncompliant bladder with reduced capacity demonstrates steep curve associated with neurogenic lesions, inflammation, or severe outlet obstruction.
  • A leak point in excess of 40 cm water may result in hydronephrosis in children with myelomeningocele.
  • An absence of contractions in attempting to void, as seen in areflexic bladders, may be seen in patients with sacral lesions. Peripheral neuropathy can develop from conditions such as diabetes mellitus.
• Electromyography
  • Electromyography (EMG) is used to measure electrical potentials generated by depolarization of the detrusor muscle and urethral sphincter.
  • Anticipated normal findings include incremental increase in EMG activity in the external sphincter during filling phase secondary to increased recruitment of motor units.
  • Prior to voiding, diminished EMG activity in the external sphincter is expected. Relaxation of the external sphincter is followed by bladder contraction.
  • Abnormal EMG patterns include absence of recruitment and low levels of EMG activity as in patients with complete SCI.
  • Inappropriate increase may be observed in EMG activity of the sphincter, leading to detrusor contraction against a closed sphincter or detrusor sphincter dyssynergia.
  • Some potential findings will include confirmation of detrusor sphincter contraction dyssynergia, increased duration of bladder contractions, and uninhibited bladder contractions.
• Cystoscopy
  • This is indicated in patients with recurrent urinary tract infections, especially those with bladder stones.
  • It is also indicated to investigate the possibility of tumor or with trauma.
  • Finally, this is useful for the evaluation of the bladder outlet and urethra.
• Videourodynamics
  • Evaluation of complex lower urinary tract pathology is performed using videourodynamics.
  • This technique involves EMG studies during 3 phases in conjunction with periodic screening of synchronous cystourethrographic studies of the bladder and outlet.
  • Videourodynamics is particularly useful for the detection of sites of bladder outlet obstruction and detrusor-sphincter dyssynergia.

Histologic Findings

Chronic neurogenic bladder dysfunction may lead to thickening of the bladder wall secondary to an increase in collagen and connective tissues, leading to potentially less efficient bladder contractions.

Treatment

Rehabilitation Program

Physical Therapy

Early mobilization and transfer training is recommended to minimize urinary incontinence and other complications such as pressure sores. Pressure sores can easily become infected in patients who are incontinent.

Occupational Therapy

Activities of daily living and self-care training are important to encourage maintenance of hygiene and a more efficient use of hand and upper extremity function.

Medical Issues/Complications

A variety of techniques are used to maintain continence and/or empty the bladder.

• Valsalva or Credé maneuver
  • The Credé maneuver is manual compression of the bladder, used in patients with decreased bladder tone or areflexia and low outlet resistance.
  • Facilitation of the Credé maneuver by an attendant is useful, particularly in individuals who are quadriplegic.
  • Increasing intravesical pressure also may be achieved through the Valsalva maneuver (ie, abdominal straining).
• Initiation of reflex bladder contraction
  • Pinching or stimulating the lumbar and sacral dermatomal levels is used to provoke reflex bladder contraction.
  • Patients with SCI may use this technique if there is no outlet obstruction or detrusor sphincter dyssynergia.
• Timed voiding
  • A program of timed voiding is useful in patients with weak sphincters or in patients with hyperreflexic bladders. These patients are put on a schedule of frequent bladder emptying before actual bladder contraction.
  • Timed voiding should be scheduled every 2-4 hours.
• Clean intermittent catheterization
  • The practice of clean intermittent catheterization (CIC) is used primarily in patients with neurogenic bladder disease such as in cases of SCI.
  • Prerequisites for use include sufficient outflow resistance to maintain continence between catheterizations, bladder with low pressure, and adequate bladder capacity, ideally more than 300 mL.
  • Encourage fluid restriction to limit bladder volumes to less than 600 mL.
  • Schedule catheterization 3-6 times per day.
  • Problems with this technique include urethral trauma and predisposition to bacteriuria and/or urinary tract infections.
  • Usually SCI patients with lesions at C7 and below can manage self-catheterization.
  • To avoid development of latex allergy, use nonlatex catheters for chronic use.
  • Lubrication with 2% lidocaine helps to limit pain and trauma.
  • At times, use of a curved tip (coudé) catheter may be necessary if there is difficulty introducing a standard catheter.
• External condom catheters
  • Men with spinal cord lesions higher than C7 who are unable to perform self-catheterization are the most likely to benefit from the use of external condom catheters. If outlet obstruction is present, a sphincterotomy is needed. The patient must have reflex bladder contractions.
  • Skin breakdown can occur, especially in patients with poor hygiene.
  • Urinary tract infections can occur.
• Indwelling catheters
  • Indwelling catheters are either suprapubic or urethral.
  • Patients frequently choose this option for convenience and as a last resort when all other measures have failed. It is also an option for persons who are unable to catheterize themselves and who prefer not to have the caregiver do CIC.
• Catheter care includes monthly catheter changes, sterilization of collection bags, and irrigation. Urinary colonization and infections are common. Long-term users should have routine cystoscopy to rule out bladder cancer. The pediatric and geriatric populations with adequate bladder emptying use diapers or incontinence pads.

Related eMedicine topics:
Incontinence, Urinary: Nonsurgical Therapies
Incontinence, Urinary: Comprehensive Review of Medical and Surgical Aspects
Injectable Bulking Agents for Incontinence

Surgical Intervention

• Surgery on the bladder outlet
  • Transurethral resection of the bladder neck is indicated in patients with obstruction at the bladder neck when medical therapy has failed to produce satisfactory results.
  • External sphincterotomy is indicated in patients with suprasacral lesions causing failure to empty when other therapeutic modalities have not been successful. Candidates for this procedure should have adequate detrusor contractions.
  • Stenting makes use of removable stents inserted into the urethra via cystoscopy. Indications are similar to those for sphincterectomy.
  • Urethral overdilation is performed only in females and has the same objective as sphincterotomy.
  • External compressive procedure involves creation of a fascial sling around the bladder neck, using a fascial strip from either the abdominal rectus muscle or tensor fascia lata.
  • Implantation of an artificial sphincter is used most commonly in children with myelomeningocele who have an incompetent sphincter mechanism.
• Surgery on the bladder
  • Bladder augmentation is used primarily in patients with refractory hyperreflexic bladders when medical treatment has failed to alleviate symptoms. In this procedure, the bladder is opened and patched using a reconfigured segment of bowel. Augmentation also is used to achieve a normal bladder capacity in children and adolescents, often in conjunction with the artificial sphincter.
  • The Mitrofanoff procedure uses the appendix to create a channel between the abdominal wall and the bladder. This procedure is particularly useful in patients who are unable to reach the urethra for CIC or in patients with limited hand function due to SCI. In general, it is easier to manipulate clothing and pass the catheter through the umbilicus than to transfer, remove lower extremity garments, and perform urethral CIC.

Related eMedicine topic:
Incontinence, Urinary: Surgical Therapies

Consultations

Consult with a urologist for diagnostic and therapeutic management of new and complicated cases.

Other Treatment

• Several studies have investigated the efficacy of intravesical administration of capsaicin, a neurotoxin for C-afferent fibers, for treatment of detrusor hyperreflexia. The results of one study showed improvement in manifestations of bladder disorders, including decreased voiding frequency, fewer leakages, and increased cystometric capacity. In a similar fashion, resinferatoxin, acts on C-afferent fibers to limit detrusor muscle hyperactivity with less pain as an adverse effect because both are administered intravesically. Both agents are still in the experimental stages, but they clearly have the advantage of having fewer adverse systemic effects compared with more traditional oral agents.
• Electrical stimulation involves use of electrodes driven by an implanted receiver to stimulate detrusor contractions. Electrodes usually are placed in the anterior sacral roots. Bilateral S2-S4 rhizotomies are usually a prerequisite to prevent spontaneous hyperreflexic contractions. This technique may be useful for patients who can transfer independently but who have incontinence between catheterizations.
• Some medical institutions have been successful using injections of bovine collagen into the urethra and bladder neck to increase tissue bulk around the bladder neck in patients with decreased outlet resistance.

Medication

Cholinergic agonists are used in patients with detrusor areflexia; these agents include bethanechol chloride, which may mimic effects of acetylcholine and cause detrusor contractions.

Alpha-adrenergic blocking agents include phenoxybenzamine and prazosin. Phenoxybenzamine is useful in reducing bladder outlet resistance in SCI, as long as detrusor bladder contractions are present. This medication is not helpful in areflexic bladders. Phenoxybenzamine is helpful in patients with detrusor sphincter dyssynergia.

Anticholinergic agents may help to alleviate symptoms in patients with urinary incontinence due to uninhibited bladder contractions secondary to suprasacral lesions. This group of drugs includes propantheline bromide, oxybutynin, and tolterodine tartrate, which competitively block acetylcholine receptors at postganglionic autonomic receptor sites, suppressing uninhibited bladder contractions.

Tricyclic antidepressants (TCAs) may (1) have peripheral alpha-adrenergic and central anticholinergic effects, (2) suppress bladder contractions, and (3) enhance bladder neck resistance. Alpha-adrenergic agents are used to enhance bladder neck resistance in patients with stress incontinence or denervation of the bladder neck.

Intravesical agents such as oxybutynin have been used with fewer adverse systemic effects; however, they have a more time-consuming and inconvenient manner of administration. Experimental agents capsaicin and resinferatoxin are effective in early investigative studies.

Cholinergic agents

Stimulate cholinergic receptors in the smooth muscle of the urinary bladder and GI tract, resulting in increased peristalsis.

Bethanechol hydrochloride (Duvoid, Urecholine)

Used for selective stimulation of the bladder to produce contraction to initiate micturition and empty the bladder. Found to be most useful in patients who have bladder hypocontractility, provided they have functional and coordinated sphincters. Rarely used due to difficulty in timing effect and because of GI stimulation.

Dosing

Adult

10-50 mg PO tid/qid

Pediatric

Not established

Interactions

Concurrent administration with ganglion-blocking compounds may cause drop of blood pressure to critical levels

Contraindications

Documented hypersensitivity; peptic ulcer disease, obstructive pulmonary disease, bradycardia, vasomotor instability, hypotension, atrioventricular conduction defects, hyperthyroidism, epilepsy, and mechanically obstructed GI or GU tract

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Urinary retention secondary to possible reflux of urine into kidneys may occur

Alpha-adrenergic blockers

Have been used to decrease bladder overactivity.

Prazosin (Minipress)

Improves urine flow rates by relaxing smooth muscle. This relaxation is produced by blocking alpha1-adrenoceptors in the bladder neck and prostate.
When increasing dosages, give first dose of each increment hs to reduce syncopal episodes.
Although doses >20 mg/d usually do not increase efficacy, some patients may benefit from up to 40 mg/d.

Dosing

Adult

Initial dose: 10 mg PO qd; can be increased by 10 mg PO q5d, given at intervals of 8-12h

Pediatric

Not established

Interactions

Acute postural hypotensive reaction from beta-blockers may worsen; indomethacin may decrease antihypertensive activity; verapamil may increase serum levels and may increase patient's sensitivity to prazosin-induced postural hypotension; may decrease antihypertensive effects of clonidine

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Drowsiness and dizziness may occur after first dose of this drug; caution in renal insufficiency and when driving or handling machinery

Phenoxybenzamine (Dibenzyline)

Decreases bladder contractions through long-lasting noncompetitive alpha-adrenergic blockade of the postganglionic synapses at the smooth muscle and exocrine glands.

Dosing

Adult

Initial dose: 10 mg PO qd; can be increased by 10 mg PO q5d q8-12h

Pediatric

Not established

Interactions

May interact with compounds that stimulate both alpha-adrenergic and beta-adrenergic blocking agents to produce exaggerated hypotensive effect

Contraindications

Documented hypersensitivity; those in whom a fall in blood pressure would be undesirable; orthostatic hypotension

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in cerebral or coronary arteriosclerosis and renal impairment; can worsen symptoms of respiratory tract infections

Anticholinergic drugs

These drugs inhibit the binding of acetylcholine to the cholinergic receptor, thereby suppressing involuntary bladder contraction of any etiology. In addition, they increase the volume of the first involuntary bladder contraction, decrease the amplitude of the involuntary bladder contraction, and may increase bladder capacity.

Propantheline bromide (Pro-Banthine)

Used for anticholinergic effect to control symptoms of urinary incontinence secondary to uninhibited bladder contractions related to upper motor neuron lesions.

Dosing

Adult

7.5-15 mg PO q6h

Pediatric

Not established

Interactions

Effects decrease when administered concurrently with antacids; toxicity increases when administered concurrently with disopyramide, TCAs, phenothiazines, corticosteroids, and bretylium

Contraindications

Documented hypersensitivity; bowel obstruction, myasthenia gravis, intestinal atony, obstructive uropathy, severe ulcerative colitis, and narrow-angle glaucoma

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in elderly patients with autonomic neuropathy, congestive heart failure (CHF), and renal or hepatic disease

Oxybutynin (Ditropan)

Commonly used drug in bladder disorder and is known for anticholinergic-antispasmodic effects. Has a smooth muscle relaxing effect distal to the cholinergic receptor site. Also available in long-acting form for qd dosing.

Dosing

Adult

5 mg PO tid

Pediatric

2.5 mg PO tid

Interactions

Coadministration with other anticholinergic agents may exacerbate anticholinergic adverse effects, including dry mouth, drowsiness, and constipation; CNS effects increase when administered concurrently with other CNS depressants

Contraindications

Documented hypersensitivity; patients diagnosed with glaucoma, partial or complete GI obstruction, myasthenia gravis, ulcerative colitis, and toxic megacolon

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Caution in urinary tract obstruction, reflux esophagitis, and heart disease

Tolterodine tartrate (Detrol)

Competitive muscarinic receptor antagonist for overactive bladder; however, it differs from other anticholinergic types in that it has selectivity for urinary bladder over salivary glands. Exhibits a high specificity for muscarinic receptors, has minimal activity or affinity for other neurotransmitter receptors and other potential targets, such as calcium channels.

Dosing

Adult

2 mg PO bid; can be adjusted to 1 mg PO bid

Pediatric

Not established

Interactions

Patients being treated with macrolide antibiotics or antifungal agents should not receive doses of tolterodine higher than 1.0 mg PO bid

Contraindications

Documented hypersensitivity; urinary retention, gastric retention, or uncontrolled narrow-angle glaucoma

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Do not give doses >1.0 mg PO bid to patients with significantly reduced hepatic function; caution in renal impairment

Trospium (Sanctura)

Quaternary ammonium compound that elicits antispasmodic and antimuscarinic effects. Antagonizes acetylcholine effect on muscarinic receptors. Parasympathetic effect reduces smooth muscle tone in bladder. Indicated for overactive bladder (eg, urinary incontinence, urgency, frequency).

Dosing

Adult

20 mg PO bid; on empty stomach at least 1 h before meals
CrCl <30 mL/min: 20 mg PO hs
>75 years: May titrate dose downward to 20 mg PO qd based on tolerability

Pediatric

Not established

Interactions

High-fat meals decrease absorption; coadministration with drugs that compete for tubular secretion (eg, digoxin, procainamide, pancuronium, morphine, vancomycin, metformin, tenofovir) may decrease elimination; coadministration with other drugs that elicit anticholinergic effects (eg, antihistamines, antispasmodics) may increase adverse effects

Contraindications

Documented hypersensitivity; urinary retention; gastric retention; uncontrolled narrow-angle glaucoma

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Anticholinergic effects may occur (eg, dry mouth, constipation, dry eyes, blurred vision); increased anticholinergic effects may occur in individuals >75 y; decrease dose with severe renal impairment (ie, CrCl <30 mL/min)

Solifenacin succinate (VESIcare)

Elicits competitive muscarinic receptor antagonist, which results in anticholinergic effect and inhibition of bladder smooth muscle contraction. Indicated for overactive bladder with symptoms of urgency, frequency, and urge incontinence.

Dosing

Adult

5 mg PO qd; if tolerated, may be increased to 10 mg PO qd prn

Pediatric

Not established

Interactions

CYP-3A4 substrate; because of decreased clearance, do not exceed 5 mg/dose when coadministered with CYP-3A4 inhibitors (eg, ketoconazole, erythromycin); CYP-3A4 inducers (eg, rifampin, carbamazepine) may increase clearance; may increase risk of QT prolongation when coadministered with drugs known to prolong QT interval (eg, sotalol, thioridazine, moxifloxacin)

Contraindications

Documented hypersensitivity, severe hepatic impairment (Child-Pugh class C), uncontrolled narrow-angle glaucoma, urinary retention, gastric retention

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution with renal or hepatic impairment (do not exceed 5 mg with CrCl <30 mL/min or moderate hepatic impairment [Child-Pugh class B]); caution with controlled narrow-angle glaucoma, history of prolonged QT interval, bladder outflow obstruction, or decreased GI motility; tab must be swallowed whole (not crushed) with liquid

Darifenacin (Enablex)

Extended-release product eliciting competitive muscarinic receptor antagonistic activity. Reduces bladder smooth muscle contractions. Has high affinity for M₃ receptors involved in bladder and GI smooth muscle contraction, saliva production, and iris sphincter function. Indicated for overactive bladder with symptoms of urge incontinence, urgency, and frequency. Swallow whole; do not chew, divide, or crush.

Dosing

Adult

7.5 mg PO qd initially; after 2 wk may increase to 15 mg PO qd based on response
Moderate hepatic impairment (Child-Pugh class B) or potent CYP-450 3A4 inhibitors: Do not exceed 7.5 mg PO qd

Pediatric

Not established

Interactions

CYP-450 2D6 and 3A4 substrate; potent CYP-450 3A4 inhibitors (eg, ketoconazole, itraconazole, ritonavir, nelfinavir, clarithromycin, nefazodone) decrease clearance (do not exceed 7.5 mg/d); may cause additive toxicity with other anticholinergics (eg, antihistamines); coadministration with CYP-2D6 substrates that have a narrow therapeutic index (eg, flecainide, thioridazine, TCA [imipramine]) may cause toxicity of these other substrates; may increase midazolam or digoxin levels

Contraindications

Documented hypersensitivity; urinary retention; gastric retention; severe hepatic impairment; uncontrolled narrow-angle glaucoma

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Common adverse effects include xerostomia, constipation, and blurred vision; caution with significant bladder outflow obstruction, decreased GI motility, controlled narrow-angle glaucoma, or moderate hepatic impairment; may cause heat prostration due to decreased ability to sweat

Fesoterodine (Toviaz)

Competitive muscarinic receptor antagonist. Antagonistic effect results in decreased bladder smooth muscle contractions. Indicated for symptoms of overactive bladder (eg, urinary urge incontinence, urgency, and frequency). Available as 4- or 8-mg extended-release tab.

Dosing

Adult

4 mg PO qd; may increase to 8 mg/d; not to exceed 4 mg PO qd in severe renal dysfunction (ie, CrCl <30 mL/min) or with coadministration of drugs that decrease fesoterodine's metabolism (eg, ketoconazole, itraconazole, clarithromycin)

Pediatric

Not established

Interactions

Coadministration with other drugs that cause antimuscarinic or anticholinergic effects may exacerbate adverse effects (eg, xerostomia, constipation); coadministration with strong CYP3A4 inhibitors (eg, ketoconazole, itraconazole, clarithromycin) increases maximum concentration and AUC of fesoterodine

Contraindications

Documented hypersensitivity; urinary or gastric retention; uncontrolled narrow-angle glaucoma; severe liver impairment

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effects include xerostomia and constipation; caution in myasthenia gravis, hepatic or renal impairment, controlled narrow-angle glaucoma, and decreased gastrointestinal motility; may cause anticholinergic effects (eg, dry eyes, dry throat, urinary retention); may increase heart rate

Tricyclic antidepressants

Have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin. The exact mechanisms by which these drugs act in the treatment of incontinence, however, are not understood fully. The Agency for Health Care Policy and Research (AHCPR) guidelines caution that TCAs should be reserved for use in carefully evaluated patients.

Imipramine hydrochloride (Tofranil)

Facilitates urine storage by decreasing bladder contractility and increasing outlet resistance.
Inhibits reuptake of norepinephrine or serotonin (5-hydroxytryptamine, 5-HT) at presynaptic neuron.

Dosing

Adult

10-25 mg PO bid/qid

Pediatric

<6 years: Not established
>6 years: 25 mg PO hs; may be increased to 50 mg PO hs after 1 wk if results are unsatisfactory with initial dosage

Interactions

Increases toxicity of sympathomimetic agents such as isoproterenol and epinephrine by potentiating effects and inhibiting antihypertensive effects of clonidine

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; in acute recovery phase following myocardial infarction; avoid in patients taking MAOIs or fluoxetine or who took them in previous 2 wks

Precautions

Pregnancy

D - Unsafe in pregnancy

Precautions

May impair mental or physical abilities required for performance of potentially hazardous tasks; caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, or receiving thyroid replacement

Sympathomimetic drugs

Increase urethral pressure.

Ephedrine (Predz D)

Use in neurogenic bladder based on increasing urethral pressure that would help patients with mild-to-moderate stress incontinence by directly stimulating alpha- and beta-adrenergic receptors.

Dosing

Adult

25 mg PO qid

Pediatric

Not established

Interactions

Theophylline, atropine, or MAOIs may increase toxicity; alpha- and beta-blockers decrease vasopressor effects; cardiac glycosides and general anesthetics increase cardiac stimulation

Contraindications

Documented hypersensitivity; angle-closure glaucoma; cardiac arrhythmias; hyperthyroidism

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in elderly patients or those with diabetes mellitus, hyperthyroidism, hypertension, cardiovascular disease, prostatic hypertrophy, or cerebrovascular insufficiency

Follow-up

Further Outpatient Care

• An outpatient visit one month after discharge is recommended.
• Provide support for patients with SCI who are unable to meet their needs independently by arranging for nursing services and attendants for home care.
• Diagnostic follow-up
  • Patients with indwelling catheters must undergo annual cystoscopy for detection of bladder tumors since they have increased risk for squamous cell and transitional cell carcinoma if they have had indwelling catheters for more than 10 years. Recommend cystoscopy more frequently if patient has increased risk factors (eg, smoking, history of recurrent urinary tract infections).
  • Annual renal and bladder ultrasounds are recommended.
  • Perform voiding cystourethrogram as needed.
  • Schedule dimercaptosuccinic acid scanning as indicated.
  • Determine glomerular filtration rate as needed.
  • Order urinalysis and urine culture with sensitivity at least once a year and as needed.

Complications

• Bladder infections are the most common complication of neurogenic bladder. Use of prophylactic antibiotics on patients on chronic intermittent catheterization still is 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.
• Pyelonephritis often is associated with reflux, kidney stones, and obstruction. Recurrent pyelonephritis is associated with renal deterioration.
• Approximately 8% of patients with SCI develop renal calculi in the form of kidney and bladder stones. 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.
• Patients with SCI and more than 10 years with an indwelling catheter have higher incidence of squamous and transitional cell carcinomas compared with the general population.

Prognosis

• The prognosis for recovery depends on the type, severity, and location of the lesion causing the bladder problem. Most patients with SCI with complete lesions remain on intermittent or indwelling catheterization for the rest of their lives.
• Some reversible causes, such as polyneuropathy secondary to vitamin B deficiency, improve with metabolic correction.
• Surgical correction of bladder problems secondary to anatomic derangements, such as prostatic hypertrophy and pelvic floor weakness, improves symptoms in most cases.
• Patients with upper motor neuron lesions such as strokes, MS, and spinal cord pathology may have to depend on medications for the rest of their lives, although some recovery may be expected.

Patient Education

• Proper techniques of intermittent self-catheterizations to include the timing and frequency of such techniques
• The effects of oral medications on bladder function
• The effectiveness and techniques of facilitative bladder emptying maneuvers, such as the Credé and Valsalva maneuvers
• Efficient use of assistive devices used in bladder care
• Possible long-term comorbidities and complications
• Management of some emergencies, such as absence of urine output secondary to kinked catheter
• Prevention of potential complications such as urinary tract infection, bladder cancer, and urolithiasis
• For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center and Cancer and Tumors Center. Also, see eMedicine's patient education articles Bladder Control Problems, Bladder Cancer, and Understanding Bladder Control Medications.

Miscellaneous

Medicolegal Pitfalls

• Failure to identify urinary tract infections could lead to urosepsis.
• Failure to identify reflux could lead to renal failure.
• Failure to identify abnormal bladder mechanics such as dyssynergia could lead to inappropriate management.
• Failure to perform cystoscopy for patients who have had long-term indwelling catheters may lead to missing a diagnosis of bladder cancer.

References

1. Barrett DM, Wein AJ. Voiding dysfunction. Diagnosis, classification, and management. In: Gillenwater JY, et al, eds. Adult and Pediatric Urology. 2nd ed. St Louis:. Mosby Year Book;1991:1001-99.

2. Braddom RL. Physical Medicine and Rehabilitation. Philadelphia:. WB Saunders Co;1996:555-79.

3. Bradley WE. Physiology of the urinary bladder: Campbell's Urology. Philadelphia:. WB Saunders Co;1986.

4. Brindley GS, Rushton DN. Long-term follow-up of patients with sacral anterior root stimulator implants. Paraplegia. Oct 1990;28(8):469-75. [Medline].

5. Cardenas DD, Hooton TM. Urinary tract infection in persons with spinal cord injury. Arch Phys Med Rehabil. Mar 1995;76(3):272-80. [Medline].

6. DeVivo MJ, Fine PR, Cutter GR, Maetz HM. The risk of renal calculi in spinal cord injury patients. J Urol. May 1984;131(5):857-60. [Medline].

7. Duncan PW, Zorowitz R, Bates B, et al. Management of Adult Stroke Rehabilitation Care: a clinical practice guideline. Stroke. Sep 2005;36(9):e100-43.

8. Giannantoni A, Di Stasi SM, Stephen RL, et al. Intravesical capsaicin versus resiniferatoxin in patients with detrusor hyperreflexia: a prospective randomized study. J Urol. Apr 2002;167(4):1710-4. [Medline].

9. Hoffman BB, Lefkowitz RT. Adrenergic receptor antagonists: The Pharmacologic Basis of Therapeutics. New York:. Pergamon Press;1990.

10. Kaufman JM, Fam B, Jacobs SC, et al. Bladder cancer and squamous metaplasia in spinal cord injury patients. J Urol. Dec 1977;118(6):967-71. [Medline].

11. Kuhlemeier KV, Lloyd LK, Stover SL. Long-term followup of renal function after spinal cord injury. J Urol. Sep 1985;134(3):510-3. [Medline].

12. Linsenmeyer TA, Culkin D. APS recommendations for the urological evaluation of patients with spinal cord injury. J Spinal Cord Med. 1999;22(2):139-42. [Medline].

13. Lisenmeyer TA, Stone JM. Neurogenic bladder and bowel dysfunction. In: De Lisa J, ed. Rehabilitation Medicine. Philadelphia:. Lippincott-Raven Publishing;1998:1073-106.

14. Thomas TM, Plymat KR, Blannin J, Meade TW. Prevalence of urinary incontinence. Br Med J. Nov 8 1980;281(6250):1243-5. [Medline].

15. Wein AJ. Lower urinary tract function and pharmacologic management of lower urinary tract dysfunction. Urol Clin North Am. May 1987;14(2):273-96. [Medline].

16. de Sèze M, Wiart L, Joseph PA, et al. Capsaicin and neurogenic detrusor hyperreflexia: a double-blind placebo-controlled study in 20 patients with spinal cord lesions. Neurourol Urodyn. 1998;17(5):513-23. [Medline].

17. de Sèze M, Wiart L, de Sèze MP, et al. Intravesical capsaicin versus resiniferatoxin for the treatment of detrusor hyperreflexia in spinal cord injured patients: a double-blind, randomized, controlled study. J Urol. Jan 2004;171(1):251-5.

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

Contributor Information and Disclosures

Author

Ramon S Lansang Jr, MD, Consulting Staff, Department of Orthopedics, Charleston Area Medical Center
Ramon S Lansang Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Academy of Physical Medicine and Rehabilitation, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Teresa L Massagli, MD, Residency Director, Professor, Department of Rehabilitation Medicine and Pediatrics, University of Washington School of Medicine
Teresa L Massagli, MD is a member of the following medical societies: American Academy of Pediatrics, American Academy of Physical Medicine and Rehabilitation, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Richard Salcido, MD, Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine
Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Medical Association, and American Paraplegia Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

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