History
In general, patients present with retention, urinary incontinence, or a mixed picture of incomplete emptying and incontinence. During the interview, try to establish the etiology of the patient’s symptoms before initiating pharmacologic treatment. [13]
Review the medical history, paying particular attention to any endocrine or neurologic conditions. 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. If a neurologic event has led to symptoms, establish premorbid voiding function and symptoms.
Consider medications known to be capable of affecting bladder control and function, such as sedatives, muscle relaxants, opiates, calcium channel blockers, and antihistamines. Consider the patient’s fluid intake and level of hydration. Finally, administer a functional assessment and determine the individual’s ability to perform self-care tasks, such as hygiene, bathing, and dressing.
Physical Examination
Physical examination of a patient for incontinence includes cognitive, neural, musculoskeletal, and pelvic assessment. This is because both voluntary and involuntary control of voiding involve the central and peripheral nervous systems as well as the renal and genitourinary systems. Finally, look at the perianal and pudendal skin for incontinence-associated dermatitis and infection.
While engaging with the patient and taking a history, note the presence of cognitive impairment or dementia. Such patients are at risk for incontinence as a consequence of disinhibited bladder contractions.
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.
Perform pelvic, genitourinary examinations on both male and female patients. For male patients, evaluate the status of the prostate, especially in men aged 60 years or older, as this can cause secondary urologic symptoms such as urinary retention. For female patients, investigate 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.
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.
Complications
Bladder dysfunction harbors complications associated with urine retention as well as incontinence. Complications of incontinence are infective in nature and include cystitis and pyelonephritis. Complications associated with urine retention include vesicoureteral reflux and renal calculi. For those patients who benefit from the use of indwelling catheters, increased risk of cystic cancer is a complication.
Urinary tract infections are a frequent cause of morbidity in patients with neurogenic bladder, because 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.
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.
A study by Welk et al indicated that in patients on intermittent catheterization, those with neurogenic lower urinary tract dysfunction (LUTD) have a higher rate of urinary tract infection than do patients with non-neurogenic LUTD. The annualized incidences of such infections were 54.9% and 38.9%, respectively, the patients having been kept track of for 1 year following the start of intermittent catheterization. For the general population (with no intermittent catheterization), the incidence of urinary tract infection was 9.8%. The rates of hospitalization for urinary tract infection in the three groups were 11.3%, 4.0%, and 1.0%, respectively. [14]
A Korean study, by Sung et al, indicated that the risk of chronic kidney disease (CKD) is three times higher in patients with neurogenic bladder. The prevalence of CKD in these patients was reported to be 8.0% and 22.4%, as measured using serum creatinine– and serum cystatin-c–based estimated glomerular filtration rate, respectively. [15]
The chief concern with urinary tract infection is that if left untreated, it may lead to urosepsis or pyelonephritis. [16, 17] Pyelonephritis is also associated with reflux, kidney stones, and obstruction and can lead to renal deterioration.
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.
Kidney stones are the leading cause of renal dysfunction in SCI, with approximately 8% of SCI patients developing renal calculi in the form of kidney and bladder stones. [18] The highest incidence (up to 8%) is in those patients with indwelling catheters. Bladder stones are associated with indwelling Foley catheters. Struvite stones and calcium phosphate make up more than 90% of cases of stone formation. Nephrolithiasis is also an indicator for 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. [19]
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Pons is major relay center between brain and bladder. Mechanical process of urination is coordinated by pons in area known as pontine micturition center (PMC).
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Large stellate urinary bladder stone. Image courtesy of Wikimedia Commons.
