1. NEUROGENIC BLADDER AND BLADDER TRAINING TRI DAMIATI P, M.D..Physiatrist Dept.of Physical Medicine and Rehabilitation School of Medicine, Padjadjaran University Dr.Hasan Sadikin General Hospital

2. anatomy

4. NORMAL VOIDING PHYSIOLOGY TWO PHASES TWO PHASES THE FILLING ( STORAGE )THE FILLING ( STORAGE ) OCCURS WHEN A PERSON IS NOT TRYING TO VOID OCCURS WHEN A PERSON IS NOT TRYING TO VOID THE EMPTYING ( VOIDING )THE EMPTYING ( VOIDING ) OCCURS WHEN A PERSON IS ATTEMPTING TO VOID OR TOLD TO VOID OCCURS WHEN A PERSON IS ATTEMPTING TO VOID OR TOLD TO VOID

5. NORMAL VOIDING PHYSIOLOGY cont… DURING FILLING / STORAGE PHASE DURING FILLING / STORAGE PHASE SHOULD BE VERY LITTLE RISE IN BLADDER PRESSURESHOULD BE VERY LITTLE RISE IN BLADDER PRESSURE PROGRESSIVE INCREASE IN SYMPATHETIC STIMULATION OF THE BETA RECEPTORPROGRESSIVE INCREASE IN SYMPATHETIC STIMULATION OF THE BETA RECEPTOR RELAXATION ALPHA RECEPTORS → CONTRACTION OF THE URETHRARELAXATION ALPHA RECEPTORS → CONTRACTION OF THE URETHRA

6. NORMAL VOIDING PHYSIOLOGY cont… DURING FILLING / STORAGE PHASE cont… DURING FILLING / STORAGE PHASE cont… INHIBITS EXITATORY PARASYMPATHETIC GANGLIONIC TRANSMISSION → SUPRESS BLADDER CONTRACTIONINHIBITS EXITATORY PARASYMPATHETIC GANGLIONIC TRANSMISSION → SUPRESS BLADDER CONTRACTION PROGRESSIVE INCREASE IN URETHRAL SPHINCTER EMG ACTIVITYPROGRESSIVE INCREASE IN URETHRAL SPHINCTER EMG ACTIVITY

7. NORMAL VOIDING PHYSIOLOGY cont… VOIDING / EMPTYING PHASE VOIDING / EMPTYING PHASE SHOULD BE CESSATION OF URETHRAL SPHINCTER ACTIVITYSHOULD BE CESSATION OF URETHRAL SPHINCTER ACTIVITY URETHRAL SPHINCTER PRESSURE DROPURETHRAL SPHINCTER PRESSURE DROP FUNNELING OF THE BLADDER NECKFUNNELING OF THE BLADDER NECK

8. NORMAL VOIDING PHYSIOLOGY cont… VOIDING / EMPTYING PHASE cont… VOIDING / EMPTYING PHASE cont… NO LONGER REFLEX INHIBITION TO THE SACRAL MIXTURITION CENTER FROM THE SPHINCTER MECHANISMNO LONGER REFLEX INHIBITION TO THE SACRAL MIXTURITION CENTER FROM THE SPHINCTER MECHANISM FOLLOWED BY THE BLADDER CONTRACTIONFOLLOWED BY THE BLADDER CONTRACTION THE URETHRAL SPHINCTER REMAIN OPEN THROUGHOUT VOIDINGTHE URETHRAL SPHINCTER REMAIN OPEN THROUGHOUT VOIDING

9. NORMAL VOIDING PHYSIOLOGY cont… VOIDING / EMPTYING PHASE cont… VOIDING / EMPTYING PHASE cont… SHOULD BE NO RISES IN INTRA ABDOMINAL PRESSURE DURING VOIDINGSHOULD BE NO RISES IN INTRA ABDOMINAL PRESSURE DURING VOIDING NO POSTVOID RESIDUAL URINENO POSTVOID RESIDUAL URINE

10. CLASSIFICATION OF VOIDING DYSFUNCTION WIDE VARIETY OF CLASSIFICATIONWIDE VARIETY OF CLASSIFICATION IDEALLY THE SYSTEM SHOULD DISCRIBEIDEALLY THE SYSTEM SHOULD DISCRIBE THE TYPE OF NEUROLOGIC LESION THE TYPE OF NEUROLOGIC LESION CLINICAL SYMPTOMS CLINICAL SYMPTOMS URODYNAMIC DATA URODYNAMIC DATA TREATMENT OPTION TREATMENT OPTION SINGLE CLASSIFICATION FOCUSING ON ALL THESE FACTOR DOES NOT EXISTSINGLE CLASSIFICATION FOCUSING ON ALL THESE FACTOR DOES NOT EXIST

11. CLASSIFICATION OF VOIDING DYSFUNCTION cont… URODYNAMIC AND FUNCTIONAL CLASSIFICATION URODYNAMIC AND FUNCTIONAL CLASSIFICATION INCONTINENCEINCONTINENCE RETENTIONRETENTION RETENTION AN INCONTINENCERETENTION AN INCONTINENCE

12. CLASSIFICATION OF VOIDING DYSFUNCTION cont… INCONTINENCE INCONTINENCE CAUSED BY BLADDERCAUSED BY BLADDER UNHIBITED CONTRACTING UNHIBITED CONTRACTING DECREASE CAPACITY DECREASE CAPACITY LOW COMPLIANCE LOW COMPLIANCE NORMAL ---  COGNITIVE / MOBILITY ISSUE NORMAL ---  COGNITIVE / MOBILITY ISSUE CAUSED BY THE OUTLETCAUSED BY THE OUTLET DECREASE BLADDER NECK PRESSURE DECREASE BLADDER NECK PRESSURE DECREASE EXTERNAL SPHINCTER PRESSURE DECREASE EXTERNAL SPHINCTER PRESSURE

13. CLASSIFICATION OF VOIDING DYSFUNCTION cont… RETENTION RETENTION CAUSED BY THE BLADDERCAUSED BY THE BLADDER DETRUSSOR AREFLEXIA DETRUSSOR AREFLEXIA LARGE CAPACITY / HIGH COMPLIANCE LARGE CAPACITY / HIGH COMPLIANCE NORMAL → COGNITIVE / MOBILITY ISSUE NORMAL → COGNITIVE / MOBILITY ISSUE CAUSED BY THE OUTLETCAUSED BY THE OUTLET HIGH VOIDING PRESSURE WITH LOW FLOW RATE HIGH VOIDING PRESSURE WITH LOW FLOW RATE INTERNAL SPHINCTER DYSINERGIA INTERNAL SPHINCTER DYSINERGIA EXTERNAL SPHINCTER DYSINERGIA EXTERNAL SPHINCTER DYSINERGIA OVERACTIVE SPHINCTER MECHANISM OVERACTIVE SPHINCTER MECHANISM

14. CLASSIFICATION OF VOIDING DYSFUNCTION cont… RETENTION AND INCONTINENCE RETENTION AND INCONTINENCE CAUSED BY THE BLADDERCAUSED BY THE BLADDER UNINHIBITED CONTRACTION WITH UNDER ACTIVE DETRUSOR UNINHIBITED CONTRACTION WITH UNDER ACTIVE DETRUSOR

15. TREATMENT OPTION FOR VOIDING DISORDERS INCONTINENCE CAUSED BY THE BLADDERINCONTINENCE CAUSED BY THE BLADDER SCHEDULED VOIDING SCHEDULED VOIDING INTERMITTENT CATHETERIZATION / INDWELLING CATHETER / EXTERNAL CONDOM / DIAPERS INTERMITTENT CATHETERIZATION / INDWELLING CATHETER / EXTERNAL CONDOM / DIAPERS PHARMACOLOGIC PHARMACOLOGIC SURGICAL SURGICAL

16. TREATMENT OPTION FOR VOIDING DISORDERS cont… INCONTINENCE CAUSED BY THE SPHINCTER INCONTINENCE CAUSED BY THE SPHINCTER SCHEDULED VOIDINGSCHEDULED VOIDING PELVIC FLOOR EXERCISES / BIOFEEDBACK PELVIC FLOOR EXERCISES / BIOFEEDBACK INTERMITTENT CATHETERIZATION / INDWELLING CATHETER / EXETERNAL CONDOM / DIAPERSINTERMITTENT CATHETERIZATION / INDWELLING CATHETER / EXETERNAL CONDOM / DIAPERS PHARMACOLOGICPHARMACOLOGIC SURGICALSURGICAL

17. TREATMENT OPTION FOR VOIDING DISORDERS cont… RETENTION CAUSED BY THE BLADDER RETENTION CAUSED BY THE BLADDER SCHEDULED VOIDING COMBINED WITHSCHEDULED VOIDING COMBINED WITH SUPRA PUBIC TAPPING SUPRA PUBIC TAPPING VALSAVA VALSAVA CREDE CREDE INTERMITTENT CATHETERIZATION / INDWELLING CATHETERINTERMITTENT CATHETERIZATION / INDWELLING CATHETER PHARMACOLOGICPHARMACOLOGIC SURGICALSURGICAL

18. TREATMENT OPTION FOR VOIDING DISORDERS cont… RETENTION CAUSED BY SPHINCTER / OUTLET RETENTION CAUSED BY SPHINCTER / OUTLET SUPRAPUBIC TAPPING / BIOFEEDBACKSUPRAPUBIC TAPPING / BIOFEEDBACK INTERMITTENT CATHETERIZATION / INDWELLING CATHETERINTERMITTENT CATHETERIZATION / INDWELLING CATHETER PHARMACOLOGICPHARMACOLOGIC SURGICALSURGICAL

19. TRAUMATIC SCI (SPINAL CORD INJURY) THE MOST SCI IS SUPRA SACRAL LESIONTHE MOST SCI IS SUPRA SACRAL LESION TYPE UPPER MOTORNEURONTYPE UPPER MOTORNEURON CAN BE A DETRUSOR HYPERREFLEXIA WITH DETRUSOR SPHINCTER DYSINNERGIACAN BE A DETRUSOR HYPERREFLEXIA WITH DETRUSOR SPHINCTER DYSINNERGIA INITIAL PERIOD OF SCI IS SPINAL SHOCKINITIAL PERIOD OF SCI IS SPINAL SHOCK HYPOREFLEXIA OF SOMATIC SYSTEM HYPOREFLEXIA OF SOMATIC SYSTEM DETRUSOR AREFLEXIA DETRUSOR AREFLEXIA

20. TRAUMATIC SCI (SPINAL CORD INJURY) cont… RECOVERY OF BLADDER FUNCTION USUALLY FOLLWS RECOVERY OF SKELETAL MUSCLE REFLEXESRECOVERY OF BLADDER FUNCTION USUALLY FOLLWS RECOVERY OF SKELETAL MUSCLE REFLEXES UNHIBITED BLADDER CONTRATION GRADUALLY RETURN AFTER 6 – 8 WEEKSUNHIBITED BLADDER CONTRATION GRADUALLY RETURN AFTER 6 – 8 WEEKS

21. BLADDER TRAINING CONSIST OF: SCHEDULED VOIDINGSCHEDULED VOIDING PELVIC FLOOR EXERCISEPELVIC FLOOR EXERCISE SUPRA PUBIC TAPPING, VALSAVA, CREDESUPRA PUBIC TAPPING, VALSAVA, CREDE INTERMITTENT CATHETERIZATIONINTERMITTENT CATHETERIZATION

22. BLADDER TRAINING cont… SCHEDULED VOIDING SCHEDULED VOIDING TIMED VOIDING, THEY ARE TOUHGT TO VOID BEFORE REACHING THEIR FULL CAPACITY -  UNHIBITED BLADDERTIMED VOIDING, THEY ARE TOUHGT TO VOID BEFORE REACHING THEIR FULL CAPACITY -  UNHIBITED BLADDER PROGRESSIVELY INCREASING THE TIME BETWEEN VOIDINGPROGRESSIVELY INCREASING THE TIME BETWEEN VOIDING

23. BLADDER TRAINING cont… PELVIC FLOOR MUSCLES EXERCISES / KEGEL EXERCISES PELVIC FLOOR MUSCLES EXERCISES / KEGEL EXERCISES OBJECTIVE : OBJECTIVE : TO STRENGTHEN THE PELVIC FLOOR MUSCLESTO STRENGTHEN THE PELVIC FLOOR MUSCLES PELVIC FLOOR MUSCLES CONSIST OF: PELVIC FLOOR MUSCLES CONSIST OF: PUBOCOCCYGEUSPUBOCOCCYGEUS ILIOCOCCYGEUSILIOCOCCYGEUS ISCHIOCOCCYGEUSISCHIOCOCCYGEUS

24. BLADDER TRAINING cont… - PELVIC FLOOR MUSCLES EXERCISES THE FUNCTION OF PELVIC FLOOR MUSCLES: THE FUNCTION OF PELVIC FLOOR MUSCLES: PROVIDE SUPPORT FOR THE PELVIC VISCERA AS WE STAND UPRIGHT, AND SUPPURT FOR THE BLADDER NECK AND THE URETHROVESICULAR ANGLE WHICH IS VITAL IMPORTANCE FOR CONTINENCEPROVIDE SUPPORT FOR THE PELVIC VISCERA AS WE STAND UPRIGHT, AND SUPPURT FOR THE BLADDER NECK AND THE URETHROVESICULAR ANGLE WHICH IS VITAL IMPORTANCE FOR CONTINENCE CLOSING FORCE ALONG URETHRAL WALL ESPECIALLY WHENEVER THERE IS AN INCREASE IN INTRA ABDOMINAL PRESSURECLOSING FORCE ALONG URETHRAL WALL ESPECIALLY WHENEVER THERE IS AN INCREASE IN INTRA ABDOMINAL PRESSURE THE SEXUAL FUNCTION  CORRELATION BETWEEN STRENGHT AND ACHIEVES ORGASMTHE SEXUAL FUNCTION  CORRELATION BETWEEN STRENGHT AND ACHIEVES ORGASM

25. BLADDER TRAINING cont… PELVIC FLOOR MUSCLES EXERCISES HOW TO DO KEGEL EXERCISE: HOW TO DO KEGEL EXERCISE: FIND THE RIGHT MUSCLES, by:FIND THE RIGHT MUSCLES, by: TRY TO STOP THE FLOW OF URINE TRY TO STOP THE FLOW OF URINE INSERT A FINGER INSIDE YOUR VAGINA AND TRY TO SQUEEZE INSERT A FINGER INSIDE YOUR VAGINA AND TRY TO SQUEEZE USING THE BIOFEEDBACK TECHNIQUE USING THE BIOFEEDBACK TECHNIQUE IMAGINE THAT YOU ARE TRYING TO STOP PASSING GAS IMAGINE THAT YOU ARE TRYING TO STOP PASSING GAS

26. BLADDER TRAINING cont… PELVIC FLOOR MUSCLES EXERCISES THE TECHNIQUE OF EXERCISE THE TECHNIQUE OF EXERCISE THE PATIENTS HAVE TO BE ABLE TO CONSISTENLY ISOLATE THE PELVIC MUSCLETHE PATIENTS HAVE TO BE ABLE TO CONSISTENLY ISOLATE THE PELVIC MUSCLE ESTABLISH THE INDIVIDUALIZED EXERCISE PROGRAM BASE ON THE PATIENT’S INITIAL STRENGTH AND ENDURANCEESTABLISH THE INDIVIDUALIZED EXERCISE PROGRAM BASE ON THE PATIENT’S INITIAL STRENGTH AND ENDURANCE AS THE PATIENT’S CONTRACTILITY AND ENDURANCE PROGRESS, THE NUMBER OF REPETIONS IS INCREASEDAS THE PATIENT’S CONTRACTILITY AND ENDURANCE PROGRESS, THE NUMBER OF REPETIONS IS INCREASED MOST CLINICIANS RECOMMEND A TARGET RANGE OF 30 TO 45 REPETITIONS PER DAY AND ARE DIVIDED INTO 3 TIMES AND PERFORM IN RECLINING, SITTING AND STANDING POSITIONMOST CLINICIANS RECOMMEND A TARGET RANGE OF 30 TO 45 REPETITIONS PER DAY AND ARE DIVIDED INTO 3 TIMES AND PERFORM IN RECLINING, SITTING AND STANDING POSITION

27. BLADDER TRAINING cont… INTERMITTENT CATHETERIZATION STERIL INTERMITTENT CATHETERIZATION STERIL INTERMITTENT CATHETERIZATION CLEAN INTERMITTENT CATHETERIZATION (CIC) CLEAN INTERMITTENT CATHETERIZATION (CIC)

28. BLADDER TRAINING cont… CLEAN INTERMITTENT CATHETERIZATION (CIC) -IS CONDUCTED FROM 6.00 – 22.00 -INTAKE OF FLUIDS 100 CC – 125 CC /HOUR LAST INTAKE AT DINNER TIME ABOUT 19.00 -ATTEMP TO VOID SPONTANEOUSLY -POST VOID RESIDUALS (PVR) IS MEASURED THROUGH CATHETERIZATION WITH A NELATON CATHETER

29. BLADDER TRAINING cont… CLEAN INTERMITTENT CATHETERIZATION (CIC) VOLUME OF PVR WILL DETERMINE THE FREQUENCY OF CATETERIZATION DURING DAY TIMEVOLUME OF PVR WILL DETERMINE THE FREQUENCY OF CATETERIZATION DURING DAY TIME CATHETERIZATION AT NIGHT IS SITUATIONALCATHETERIZATION AT NIGHT IS SITUATIONAL DO THE CATHETERIZATION AS IN MODUL SKILL LABDO THE CATHETERIZATION AS IN MODUL SKILL LAB USING THE SURGICAL GLOVES IS OPTIONALUSING THE SURGICAL GLOVES IS OPTIONAL

30. BLADDER TRAINING cont… CLEAN INTERMITTENT CATHETERIZATION (CIC) PVR MONITORING CHART PVR PVRCATHETERIZATION > 200cc Every 4 Hrs 100 – 200cc Every 6 Hrs 50 – 100cc Every 8 Hrs < 50cc Free

31. BLADDER TRAINING cont… THE GOALS OF INTERMITTENT CATHETERIZATION Completely and regularly emptying of the bladder Completely and regularly emptying of the bladder Avoiding impairment of the kidneys, caused by urine reflux Avoiding impairment of the kidneys, caused by urine reflux Free of indwelling or intermittent catheterization Free of indwelling or intermittent catheterization