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Urinary Issues Problems and Solutions Rebecca Shaw, BSN, MSN, CRNP, CRRN Objectives After completion of class participant will: Be knowledgeable of basic anatomy and physiology of normal bladder function Be able to identify at least 2 conditions which commonly cause problems with urination Be able to describe treatment plans to address each type of bladder dysfunction Prevalence of Problem Bladder Control long standing problem WHO 1998 reported affects over 200 million people worldwide Affects People of all ages, races and nationalities 2014 CDC statistics affects 25 million people in United States alone Interferes with all aspects of life Physical, emotional and psychological Also impacts lives of caregivers Affects QOL Patient and Caregiver Scope of problem Far reaching and broad scope Goal to discuss causes, management and clinical impact Concentrate discussion on 2 types of bladder management problems Upper motor neuron Lower motor neuron Classification of Bladder Dysfunction Uninhibited Bladder (Splash) Example: Urge incontinence associated with Stroke or brain tumor Upper Motor Neuron bladder (Clash) Example: damage associated with Cervicothoracic spinal cord injury or Multiple sclerosis involving cervicothoracic lesions Classification of Bladder dysfunction Lower Motor Neuron Bladder (Stash) Example: Flaccid overflow associated with sacral cord or nerve root injuries Mixed Type Injury (Mishmash) Sacral cord or nerve root injury with various levels of neurological sparing. Anatomy of urological system Anatomy of Urological system Kidneys Located either side of abdominal cavity Responsible for filtering waste and regulating fluid balance filters blood at rate of 125ml/min Ureters connect kidneys to bladder Propel urine into the bladder by peristalsis Volume triggers movement of urine Normal Anatomy urological system Anatomy of Urological system Bladder Hollow muscular organ Controlled primarily by the Autonomic nervous system Enervated by Parasympathetic and Sympathetic nerve fibers Anatomy of urological system Bladder Stretch receptors line the muscle wall Normal micturition is stimulated at about 250300 ccs of stored urine In a normal individual Volitional control begins to fail at 600-700ccs Anatomy bladder Normal micturition Filling Phase Mediated by sympathetic response Primary receptors in bladder neck (Trigone) alpha receptors Stimulation causes relaxation of the detrusor muscle Contraction of the internal and external sphincters Micturition is delayed Normal Micturition Emptying Phase Mediated by Parasympathetic Stimulation Promotes relaxation of bladder neck Facilitates the micturition process and emptying of bladder Both phases of cycle are balanced by the pontine micturition center and the frontal lobe of the brain Pathophysiology of Bladder Dysfunction Uninhibited Bladder Reduced awareness of bladder fullness Low capacity bladder Loss of inhibitory regulation by pontine micturition center Less risk of high bladder pressures consequent upper urinary tract damage. Pathophysiology of bladder dysfunction Upper Motor Neuron Bladder Detrusor-sphincter-dyssynergia (DSD) Results in simultaneous detrusor and urinary sphincter contractions High pressures/low capacities in the bladder Pathophysiolgy Upper Motor Neuron Bladder Often results in vesicouretreral reflux Quickly results in kidney damage Bladder and sphincters frequently are spastic Incontinence occurs when detrusor pressure exceeds urinary sphincter pressures Upper Motor Neuron Bladder SC damage above sacral voiding center Reflex arc remains intact Voiding is incomplete Bladder exhibits spasticity Lack of coordination micturition process Pathophysiology Bladder dysfunction Lower Motor neuron bladder Sacral micturition center damaged Bladder capacity large Detrusor tone low (detrusor areflexic) Pathophysiology Bladder dysfunction Lower Motor neuron bladder Internal and external Sphincters relaxed Frequent overflow incontinence Urinary tract infections common Lower Motor Neuron Bladder SC damage impairs sacral micturition center Voiding reflex is impaired Occurs in spinal shock Permanently in lower thoracic, lumbar and cauda equina injuries Pathophysiology Mixed Injury Flaccid bladder Either spastic or flaccid sphincters Bladder is large under low pressure Pathophysiology Mixed Injury Less chance of reflux Less resistance to outflow Frequent small volume incontinence Management : Goals Allow regular emptying of bladder With as little lifestyle disruption as possible Promote a functionally independent lifestyle Prevention of physical and psychological complications Management : General Complications Complications associated with Bladder dysfunction Skin maceration Pressure ulcers Renal or bladder calculi Frequent urinary tract infections Increased risk renal and bladder cancer Renal damage Dialysis Management : Evaluation Full patient history Previous history Comorbidities Current complaints Medications Management: Evaluation Physical Exam Anatomy Neurological exam Mental status and cognition Reflexes Sensation including sacral dermatomes Spinal cord injury Full AIS exam including rectal tone/sensation Management: Evaluation Labs and special tests Urinalysis Urine culture Serum BUN/CR Creatinine Clearance Post void residual (cath or bladder scan) Urodynamic testing Annual renal ultrasound and KUB Management: Uninhibited Bladder Remove environmental barriers Timed voids Every 2-4 hours Awaken once at night Initiate fluid schedule Limit Spread throughout the day Only small sips after 6PM No fluids after bedtime Management: UMN Bladder Intermittent Catherization Program (ICP) Limit daily intake of fluids to 2 liters Decrease fluids after supper to prevent over distension of bladder at night Cath every 6 hours 6AM-12Noon-6PM and bedtime Keep residuals below 400ccs for females and 500 ccs for males Increase cath schedule to every 4 hours for high residuals Management Intermittent Catherization Additional Treatment options UMN bladder Indwelling catheter (Foley, suprapubic) Medications Tricyclic Antidepressants-Imipramine Anticholinergic- Oxybutynin Cholinergic agonists-Urecholine Alpha 1 Adrenergic Antagonists-Tamsulosin Botulism injections Surgical interventions Sphincterotomy Enterocystoplasty Artificial urinary sphincter devices Complications Upper Motor Neuron Bladder High pressure reflux leading to kidney damage Frequent Urinary Tract Infections Renal calculi and bladder stones Increased risk of bladder cancer Autonomic dysreflexia Management: Complications Autonomic Dysreflxia Occurs UMN injuries T6 and above Symptoms Percipitious rise in blood pressure Bradycardia Headache Nasal congestion, red splotching and goose bumps Causes Bladder distension Constipation Skin irritation Unknown causes Management : Autonomic dysreflexia Treat the cause Unkink catheter or Straight cath Check for impaction and remove/treat Check for skin irritation and remove source If unable to find cause quickly use meds Nitrol paste, Procardia or other BP medications Management : LMN bladder Intermittent Catherization Program (IC) Limit daily intake of fluids to 2 liters Decrease fluids after supper to prevent over distension of bladder at night Cath every 6 hours 6AM-12Noon-6PM and bedtime Keep residuals below 400ccs for females and 500 ccs for males Cath more often if necessary Management UMN Additional treatment options Indwelling catheters Foley Suprapubic Medications Cholinergic Agonists-Urecholine LMN Complications Large volume residuals (low pressure) Frequent UTIs exacerbated by stagnant urine Urinary stones (bladder and kidneys) LMN complications Scarring of urological structures Polynephritis Increased risk bladder cancer Associated with chronic bladder irritation Management: Mixed Injury type Highly individualized Based on presentation of injury May be combination of interventions May take several adjustments before satisfactory treatment plan is achieved Make one change at a time based on patient/caregiver feedback Summary Bladder dysfunction is complex, broad spectrum condition Affects all aspects of patient life A comprehensive evaluation is needed to correctly identify pathophysiology A comprehensive multidisciplinary approach is needed to adequately address problems Summary Patient education is primary cornerstone of success Can be treated successfully treated Satisfactory management from patient, caregiver and provider standpoint Prevention of long term complications Successful Bladder Management is Cause for Celebration ANY EXCUSE FOR A PARTY! Questions? References Cited University of Kansas, and spokesman, American Urology Association; June 25, 2014, Vital and Health Statistics, U.S. Centers for Disease Control and Prevention, National Center for Health Statistics report, Prevalence of Incontinence Among Older Americans World Health Organization calls First International Consultation on Incontinence http\\.www.who/int-pr-1998/en/pr-98-49 Shenot, Patrick J. Urinary Incontinence in Adults. The Merck Manual Professional Edition 2014;. Last full review/revision August 2014 Dorsher, Peter McIntosh, Peter. Neurogenic Bladder. Advances in Urology. (2) 2012 Jeong SF, Cho Sy, Of Ll. Spinal cord/brain injury and neurogenic bladder. Urol. Clin North Am. 2010;37 537-546. Consortium for Spinal Cord Medicine. (2006). Bladder Management for Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Paralyzed Veterans of America. www.pva.org.