Bladder Dysfunction Treatment & Management

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

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

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

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

Various techniques are used to maintain continence or empty the bladder.

The Credé maneuver involves manual compression of the bladder; it is 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).

Reflex bladder contraction may be provoked by pinching or stimulating the lumbar and sacral dermatomal levels. Spinal cord injuries (SCIs) may use this technique if there is no outlet obstruction or detrusor-sphincter dyssynergia.

A program of timed voiding is useful in patients with weak sphincters or 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.

The practice of clean intermittent catheterization (CIC) is used primarily in patients with neurogenic bladder disease such as is seen in cases of SCI. Usually, SCI patients with lesions at C7 and below can manage self-catheterization. Prerequisites for CIC include the following:

• Sufficient outflow resistance to maintain continence between catheterizations
• Low pressure within the bladder with
• Adequate bladder capacity (ideally, >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 or urinary tract infections. To prevent latex allergy, use nonlatex catheters for long-term CIC. Lubrication with 2% lidocaine helps limit pain and trauma. At times, use of a curved tip (coudé) catheter may be necessary if introduction of a standard catheter proves difficult.

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 necessary. The patient must have reflex bladder contractions. Skin breakdown can occur, especially in patients with poor hygiene. Urinary tract infections can occur.

Indwelling catheters, either suprapubic or urethral, may be employed. 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 perform CIC.

Catheter care includes monthly catheter changes, sterilization of collection bags, and irrigation. Urinary colonization and infections are common. Long-term users should undergo routine cystoscopy to rule out bladder cancer. Pediatric and geriatric patients with adequate bladder emptying may use diapers or incontinence pads.

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 for reducing bladder outlet resistance in patients with SCIs, as long as detrusor bladder contractions are present; however, it is not useful in patients with areflexic bladders. Phenoxybenzamine is helpful in patients with detrusor-sphincter dyssynergia.

Anticholinergic agents may help alleviate symptoms in patients with urinary incontinence that is 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. They appear to cause fewer adverse systemic effects; however, the manner in which they are administered is more time-consuming and inconvenient.

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 1 study showed improvement in manifestations of bladder disorders, including decreased voiding frequency, fewer leakages, and increased cystometric capacity. Similarly, resiniferatoxin acts on C-afferent fibers to limit detrusor muscle hyperactivity. Like capsaicin, it is administered intravesically and thus tends to cause less pain as an adverse effect.

At present, both capsaicin and resiniferatoxin are still considered experimental agents in this setting. Nevertheless, it is already clear that they have the advantage of causing fewer adverse systemic effects than the more traditional oral agents do.^{[13, 14, 15]}

Transurethral resection of the bladder neck is indicated in patients who have obstruction at the bladder neck when medical therapy has failed to produce satisfactory results.

External sphincterotomy is indicated in patients who have suprasacral lesions that cause 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 sphincterotomy.

Urethral overdilation is performed only in females and has the same objective as sphincterotomy.

An external compressive procedure involves the creation of a fascial sling around the bladder neck, using a fascial strip from either the rectus abdominis or tensor fasciae latae.

Implantation of an artificial sphincter is most commonly performed in children with myelomeningocele who have an incompetent sphincter mechanism.

Bladder augmentation is performed primarily in patients with refractory hyperreflexic bladders when medical treatment has failed to alleviate symptoms. In this procedure, the bladder is opened and patched with 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 as a result of 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.

Electrical stimulation involves the 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 for preventing spontaneous hyperreflexic contractions. This technique may be useful for patients who can transfer independently but who experience incontinence between catheterizations.

Some medical institutions have successfully used injections of bovine collagen into the urethra and bladder neck to increase tissue bulk around the bladder neck in patients with decreased outlet resistance.

An outpatient visit 1 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 should include the following measures:

• In patients with indwelling catheters, perform cystoscopy annually to look for bladder tumors, because these patients are at increased risk for squamous cell and transitional cell carcinoma if they have had indwelling catheters for more than 10 years; perform cystoscopy more frequently if further risk factors (eg, smoking or a history of recurrent urinary tract infections) are present^[16]
• Perform ultrasonographic examinations of the kidneys and bladder annually
• Perform voiding cystourethrography as needed
• Schedule dimercaptosuccinic acid scanning as indicated
• Determine the glomerular filtration rate as necessary
• Order urinalysis and urine culture with sensitivity at least annually and as needed