1. Urinary Issues Problems and Solutions Rebecca Shaw, BSN, MSN, CRNP, CRRN

3. 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

4. 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

5. Affects QOL Patient and Caregiver

6. 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

7. 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

8. 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.

9. Anatomy of urological system

10. 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

11.  Ureters  connect kidneys to bladder  Propel urine into the bladder by peristalsis  Volume triggers movement of urine

12. Normal Anatomy urological system

13. Anatomy of Urological system  Bladder  Hollow muscular organ  Controlled primarily by the Autonomic nervous system  Enervated by Parasympathetic and Sympathetic nerve fibers

14. Anatomy of urological system  Bladder  Stretch receptors line the muscle wall  Normal micturition is stimulated at about 250- 300 ccs of stored urine  In a normal individual Volitional control begins to fail at 600-700ccs

15. Anatomy bladder

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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

22. Pathophysiology in SCI  Communication between the bladder and the brain is interrupted  The two systems work separately without central control  Where injury is located affects how the system performs afterward  Upper motor neuron (clash)  Lower motor neuron (stash)

24. Pathophysiology Bladder dysfunction  Lower Motor neuron bladder  Sacral micturition center damaged  Bladder capacity large  Detrusor tone low (detrusor areflexic)

25. Pathophysiology Bladder dysfunction  Lower Motor neuron bladder  Internal and external Sphincters relaxed  Frequent overflow incontinence  Urinary tract infections common

26. 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

27. Pathophysiology  Mixed Injury  Flaccid bladder  Either spastic or  flaccid sphincters  Bladder is large under low pressure

28. Pathophysiology  Mixed Injury  Less chance of reflux  Less resistance to outflow  Frequent small volume incontinence

29. 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

30. 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

31. Management : Evaluation  Full patient history  Previous history  Comorbidities  Current complaints  Medications

32. 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

33. 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

34. 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

35. 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

36. Management Intermittent Catherization

37. 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

38. 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

39. 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

40. 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

41. 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

42. Management UMN Additional treatment options  Indwelling catheters  Foley  Suprapubic  Medications  Cholinergic Agonists-Urecholine

43. LMN Complications  Large volume residuals (low pressure)  Frequent UTIs exacerbated by stagnant urine  Urinary stones (bladder and kidneys)

44. LMN complications  Scarring of urological structures  Polynephritis  Increased risk bladder cancer  Associated with chronic bladder irritation

45. 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

46. 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

47. 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

48. Successful Bladder Management is Cause for Celebration ANY EXCUSE FOR A PARTY!

49. Questions?

50. 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  Urinary Incontinence in Adults. 2014;. Last full review/revision August 2014  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. www.pva.org