Bladder Dysfunction Treatment & Management

Updated: Jan 04, 2019
  • Author: Gregory T Carter, MD, MS; Chief Editor: Elizabeth A Moberg-Wolff, MD  more...
  • Print
Treatment

Rehabilitation

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.

A study by Neville et al indicated that in women over age 65 years with urinary incontinence, individualized physical therapy can significantly decrease symptom severity and improve health-related quality of life. Results were assessed via a series of questionnaires, including the Incontinence Impact Questionnaire-7 and the International Consultation on Incontinence Modular Questionnaire-Urinary Incontinence. [20]

Next:

Facilitative Techniques and Maneuvers

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. This technique may be used in spinal cord injuries (SCIs) 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.

Previous
Next:

Catheterization

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.

A retrospective study by Chaudhry et al indicated that in patients undergoing CIC for neurogenic bladder secondary to spina bifida or tethered cord, the risk of frequent urinary tract infection is greater in younger patients, with the odds of such infection decreasing by 7% per year. [21]

Previous
Next:

Pharmacologic Therapy

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. [22, 23, 24]

A retrospective study, Gutiérrez-Martin et al found that in patients with neurogenic detrusor hyperactivity secondary to SCI, intradetrusor injection of botulinum toxin type A (BoNT-A) produced positive urodynamic results for an extended period. The investigators, who reviewed results from 70 patients, found significant increases in cystomanometric bladder capacities, in bladder volumes of the first involuntary detrusor contraction, and in postvoid residues, with 50% of the patients maintaining increased vesical capacity for over 32 months. Treatment was found to be negatively affected by indwelling urinary catheters. [25]

A study by Komesu et al indicated that in women with refractory urgency urinary incontinence, treatment with onabotulinumtoxinA or sacral neuromodulation is more effective in patients under age 65 years than in those aged 65 years or older. In the study’s onabotulinumtoxinA treatment group, for example, the chance that urgency urinary incontinence episodes would decrease by 75% or more was 3.3-fold higher in women under 65 years than in the older patients. Moreover, for women undergoing either of the two therapies, posttreatment symptom bother scores, as measured with the Overactive Bladder Questionnaire Short Form, were reduced by 7.49 points more in the under-65 patients. In addition, urinary tract infections following onabotulinumtoxinA or neuromodulation treatment were more frequent in the older women. However, no age-related differences were found with regard to quality of life improvement. [26]

A study by Faure Walker et al reported that, while quality-of-life measures improved significantly in men who underwent intradetrusor onabotulinumtoxinA therapy for refractory overactive bladder with idiopathic detrusor overactivity, women appeared to experience even greater improvement. While men’s scores on the Urogenital Distress Inventory-6 and the Incontinence Impact Questionnaire-7 dropped by 4.2 and 6.0, respectively, the women’s scores fell by 6.0 and 11.1, respectively. [27]

Previous
Next:

Surgery on Bladder Outlet

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. [28]

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.

Previous
Next:

Surgery on Bladder

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.

Autoaugmentation

In autoaugmentation, detrusor myectomy or myotomy is performed to create a urothelial diverticulum. The operation takes less time than augmentation with a bowel segment and also has the advantage of not requiring involvement of the gastrointestinal tract. The effectiveness of the procedure, however, is in question, with studies reporting varying results. [29, 30]

The long-term outcome of a Danish study suggested that autoaugmentation is an effective means of increasing bladder capacity and compliance in children. The report involved 25 children (median age 9.3 years) with small bladder capacity, low compliance, and high end filling pressures who underwent detrusor myotomy when treatment with clean intermittent catheterization and anticholinergic drugs proved ineffective. Twenty-two of the children had myelomeningocele; the other associated disorders were congenital partial agenesis (2 patients) and congenital scoliosis (one patient). The patients were followed for a median period of 6.8 years. [31, 32]

Although during the first three months after surgery the median bladder capacity actually decreased in these patients, from 103 mL preoperatively to 95 mL, the median capacity had increased by five months postoperatively to 176 mL. The increase remained significant to the end of the follow-up period. Moreover, after one year, median bladder compliance had doubled to 10 mL/cm H2 O, and by five years postoperatively it had reached 17 mL/cm H2 O. By the end of follow-up, median maximal detrusor pressure in the patients dropped from its preoperative level of 43 cm H2 O to 26 cm H2 O. With clean intermittent catheterization, 18 of the patients became continent. [31, 32]

The results of this study, however, contrast with those of an earlier one, by MacNeily et al, on 17 children with myelomeningocele who underwent autoaugmentation by detrusor myotomy. The patients, none of whom had responded to conservative treatment and medications, were followed for a median postsurgical period of about 6.2 years. The investigators reported that, as a result of upper tract deterioration and/or ongoing incontinence, 12 of the cases were considered clinical failures. In terms of bladder compliance and/or capacity, most of the cases were considered urodynamic failures as well. In addition, five patients developed progressive hydronephrosis, with four of these requiring enterocystoplasty. [33]

Previous
Next:

Other Treatments

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.

A randomized, controlled study by Chen et al found percutaneous tibial nerve stimulation (PTNS) to be as effective as the anticholinergic medication solifenacin succinate in the treatment of neurogenic detrusor overactivity in patients with SCI. In the report, 100 patients were divided between the two treatments, with PTNS administered through adhesive skin surface electrodes. Bladder diaries in both groups showed statistically significant improvement after 2 and 4 weeks of treatment, although the difference in improvement between the groups was not significant. [34]

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.

Previous
Next:

Long-Term Monitoring

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 [35]

  • 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

Previous