BLADDER INVOLVEMENT BLADDER INVOLVEMENT IN SPINE DISORDERSIN SPINE DISORDERS

DR. JAYANT SHARMADR. JAYANT SHARMAM.S.D.N.B., M.N.A.M.SM.S.D.N.B., M.N.A.M.S

CONSULTING ORTHOPAEDIC SURGEON CONSULTING ORTHOPAEDIC SURGEON

NORMAL BLADDERNORMAL BLADDER

The bladder and urethra are innervated by The bladder and urethra are innervated by 3 sets of peripheral nerves arising from the 3 sets of peripheral nerves arising from the Autonomic nervous system (ANS) and Autonomic nervous system (ANS) and Somatic nervous system. Somatic nervous system.

Male have considerable advantage over Male have considerable advantage over females in both length and additional females in both length and additional sphincter mechanism, which contracts the sphincter mechanism, which contracts the bladder during ejaculation and erection.bladder during ejaculation and erection.

The detrusor fibres in males at the bladder The detrusor fibres in males at the bladder neck form a sphincter which is called the neck form a sphincter which is called the Internal sphincter.Internal sphincter.

The The External sphincter External sphincter is a muscle which is a muscle which is under voluntary control.is under voluntary control.

NEURAL CONTROL OF NEURAL CONTROL OF BLADDERBLADDER

Vesico sympathetic reflexVesico sympathetic reflex– relaxes the – relaxes the detrusor muscle, and tightens the urethra, it has detrusor muscle, and tightens the urethra, it has the inhibitory control on the parasympathetic the inhibitory control on the parasympathetic transmissiontransmissionVesico parasympathetic reflexVesico parasympathetic reflex– contracts – contracts detrusor and relaxes the urethradetrusor and relaxes the urethraVesicopudendal reflexVesicopudendal reflex—motor cells of S3 —motor cells of S3 level, controls the striated muscles of the pelvic level, controls the striated muscles of the pelvic floor and the external sphincter and is inhibited floor and the external sphincter and is inhibited during the micturition.during the micturition.

There is less afferent activity while lying There is less afferent activity while lying down than when standing.down than when standing.

The basic spinal reflex controls micturition The basic spinal reflex controls micturition during infancy and unconciousness.during infancy and unconciousness.

During the course of a day, an average During the course of a day, an average person will void approximately 4-8 times. person will void approximately 4-8 times. The urinary bladder is in storage mode for The urinary bladder is in storage mode for most of the day.most of the day.

Normal MicturitionNormal Micturition

The pressure gradients within the bladder The pressure gradients within the bladder and urethra play an important role. and urethra play an important role.

As long as the urethral pressure is higher As long as the urethral pressure is higher than that of the bladder, patients will than that of the bladder, patients will remain continent. remain continent. If the urethral pressure is abnormally low If the urethral pressure is abnormally low or if the intravesical pressure is abnormally or if the intravesical pressure is abnormally high, urinary incontinence will resulthigh, urinary incontinence will result. .

As the bladder initially fills, a small rise in As the bladder initially fills, a small rise in pressure occurs within the bladder pressure occurs within the bladder (intravesical pressure).(intravesical pressure).

When the urethral sphincter is closed, the When the urethral sphincter is closed, the pressure inside the urethra (intraurethral pressure inside the urethra (intraurethral pressure) is higher than the pressure within pressure) is higher than the pressure within the bladder. the bladder.

While the intraurethral pressure is higher than While the intraurethral pressure is higher than the intravesical pressure, urinary continence is the intravesical pressure, urinary continence is maintained. maintained.

The normal micturition cycleThe normal micturition cycleIt requires the urinary bladder and the urethral It requires the urinary bladder and the urethral sphincter to work together as a coordinated unit.sphincter to work together as a coordinated unit.

During urinary storage, the bladder acts as a low-During urinary storage, the bladder acts as a low-pressure receptacle, while the urinary sphincter pressure receptacle, while the urinary sphincter maintains high resistance to urinary flow to keep the maintains high resistance to urinary flow to keep the bladder outlet closed.bladder outlet closed.

During urine elimination, the bladder contracts to During urine elimination, the bladder contracts to expel urine while the urinary sphincter opens (low expel urine while the urinary sphincter opens (low resistance) to allow unobstructed urinary flow and resistance) to allow unobstructed urinary flow and bladder emptyingbladder emptying

During some physical activities and with During some physical activities and with coughing, sneezing, or laughing, the pressure coughing, sneezing, or laughing, the pressure within the abdomen rises sharply. within the abdomen rises sharply.

This rise is transmitted to both the bladder and This rise is transmitted to both the bladder and urethra. urethra. As long as the pressure is evenly transmitted to As long as the pressure is evenly transmitted to both the bladder and urethra, urine will not leak.both the bladder and urethra, urine will not leak.

When the pressure transmitted to the bladder When the pressure transmitted to the bladder is greater than urethra, urine will leak out, is greater than urethra, urine will leak out, resulting in stress incontinence resulting in stress incontinence

Continence MechanismContinence Mechanism

As the bladder fills, the Pudendal nerve As the bladder fills, the Pudendal nerve becomes excited. becomes excited. Stimulation of the Pudendal nerve results Stimulation of the Pudendal nerve results in contraction of the external urethral in contraction of the external urethral sphincter. sphincter. Coupled with the internal sphincter, Coupled with the internal sphincter, maintains urethral pressure (resistance) maintains urethral pressure (resistance) higher than normal bladder pressure. higher than normal bladder pressure.

Sympathetic nervesSympathetic nerves

Sympathetic nerves Sympathetic nerves facilitate urine storage in facilitate urine storage in the following ways: the following ways: Sympathetic nerves inhibit the parasympathetic Sympathetic nerves inhibit the parasympathetic nerves from triggering bladder contractions. nerves from triggering bladder contractions. Sympathetic nerves directly cause relaxation Sympathetic nerves directly cause relaxation and expansion of the detrusor muscle. and expansion of the detrusor muscle. Sympathetic nerves close the bladder neck by Sympathetic nerves close the bladder neck by constricting the internal urethral sphincter. This constricting the internal urethral sphincter. This sympathetic input to the lower urinary tract is sympathetic input to the lower urinary tract is constantly active during bladder filling.constantly active during bladder filling.

Parasympathetic nervesParasympathetic nervesWhen the urethral sphincters relax and When the urethral sphincters relax and open, the parasympathetic nerves trigger open, the parasympathetic nerves trigger contraction of the detrusor. contraction of the detrusor.

When the bladder contracts, the pressure When the bladder contracts, the pressure generated by the bladder overcomes the generated by the bladder overcomes the urethral pressure, resulting in urinary flow.urethral pressure, resulting in urinary flow.

These coordinated series of events allow These coordinated series of events allow unimpeded, automatic emptying of the urine. unimpeded, automatic emptying of the urine.

PATHOPHYSIOLOGYPATHOPHYSIOLOGYUrinary incontinence results from a dysfunction Urinary incontinence results from a dysfunction of the bladder,of the bladder, the sphincter, the sphincter, or both. or both. Bladder overactivity (spastic bladderBladder overactivity (spastic bladder)- the )- the symptoms of urge incontinence. symptoms of urge incontinence. Sphincter underactivity (decreased Sphincter underactivity (decreased resistanceresistance) results in symptomatic stress ) results in symptomatic stress incontinence. incontinence. Combination Combination of detrusor overactivity and sphincter of detrusor overactivity and sphincter underactivity may result in mixed symptoms underactivity may result in mixed symptoms

CNS LESIONCNS LESIONUninhibited BladderUninhibited Bladder

Lesions of the Brain above the PonsLesions of the Brain above the Pons, -a complete loss , -a complete loss of voiding control. The voiding reflexes of the lower of voiding control. The voiding reflexes of the lower urinary tract—the primitive voiding reflex—remain intact. urinary tract—the primitive voiding reflex—remain intact. Signs of urge incontinence, or spastic bladder (medically Signs of urge incontinence, or spastic bladder (medically termed detrusor hyperreflexia or overactivity).termed detrusor hyperreflexia or overactivity). Bladder empties too quickly and too often, with relatively Bladder empties too quickly and too often, with relatively low quantities, and storing urine in the bladder is difficult.low quantities, and storing urine in the bladder is difficult.Always associated with impotence.Always associated with impotence.No residual urine therefore little risk of infection.No residual urine therefore little risk of infection.

Spinal Cord LesionSpinal Cord LesionAUTOMATIC BLADDER AUTOMATIC BLADDER

Also result in Also result in Spastic bladder Spastic bladder or overactive or overactive bladder. bladder. Paraplegic or quadriplegic have lower extremity Paraplegic or quadriplegic have lower extremity spasticity. spasticity. Initially, after spinal cord trauma, the individual Initially, after spinal cord trauma, the individual enters a spinal shock phase.enters a spinal shock phase.After 6-12 weeks, the nervous system After 6-12 weeks, the nervous system reactivates, it causes hyperstimulation of the reactivates, it causes hyperstimulation of the affected organs affected organs

AUTOMATIC BLADDERAUTOMATIC BLADDERThese people experience urge incontinence. These people experience urge incontinence. The bladder empties too quickly and too frequently. The bladder empties too quickly and too frequently. The voiding disorder is similar to that of the brain lesion The voiding disorder is similar to that of the brain lesion except that the external sphincter may have paradoxical except that the external sphincter may have paradoxical contractions as well. contractions as well. If both the bladder and external sphincter become spastic at If both the bladder and external sphincter become spastic at the same time, the affected individual will sense an the same time, the affected individual will sense an overwhelming desire to urinate but only a small amount of overwhelming desire to urinate but only a small amount of urine may dribble out. urine may dribble out. The term for this is The term for this is Detrusor-sphincter DyssynergiaDetrusor-sphincter Dyssynergia because the bladder and the external sphincter are not in because the bladder and the external sphincter are not in synergy.synergy. Even though the bladder is trying to force out urine, the Even though the bladder is trying to force out urine, the external sphincter is tightening to prevent urine from leaving. external sphincter is tightening to prevent urine from leaving.

Sacral cord injurySacral cord injuryAUTONOMOUS BLADDER AUTONOMOUS BLADDER

If a sensory neurogenic bladder is present, the affected If a sensory neurogenic bladder is present, the affected individual may not be able to sense when the bladder is individual may not be able to sense when the bladder is full. full. In the case of a motor neurogenic bladder, the individual In the case of a motor neurogenic bladder, the individual will sense the bladder is full and the detrusor may not will sense the bladder is full and the detrusor may not contract, a condition known as contract, a condition known as Detrusor AreflexiaDetrusor Areflexia. . These individuals have difficulty eliminating urine and These individuals have difficulty eliminating urine and experience overflow incontinence; the bladder gradually experience overflow incontinence; the bladder gradually overdistends until the urine spills out. overdistends until the urine spills out. Typical causes are a sacral cord tumor,Typical causes are a sacral cord tumor, herniated disc, and herniated disc, and injuries that crush the pelvis. injuries that crush the pelvis. This condition also may occur after a lumbar laminectomy. This condition also may occur after a lumbar laminectomy.

Diabetes mellitus Tabes and AIDSDiabetes mellitus Tabes and AIDSSENSORY BLADDERSENSORY BLADDER

The conditions causing peripheral neuropathy resulting in The conditions causing peripheral neuropathy resulting in urinary retention.urinary retention. May lead to silent, painless distention of the bladder. May lead to silent, painless distention of the bladder. Patients with chronic diabetes lose the sensation of bladder Patients with chronic diabetes lose the sensation of bladder filling first, before the bladder decompensates. filling first, before the bladder decompensates. Similar to injury to the sacral cord, affected individuals will Similar to injury to the sacral cord, affected individuals will have difficulty urinating. They also may have a have difficulty urinating. They also may have a hypocontractile bladder.hypocontractile bladder. They have sensory deafferentation and loss of spinal reflex.They have sensory deafferentation and loss of spinal reflex. High residual Urine and infection rates.High residual Urine and infection rates. Evacuation is incomplete.Evacuation is incomplete.

Summary of definitions Summary of definitions

Neurogenic bladder Neurogenic bladder is a malfunctioning bladder due to is a malfunctioning bladder due to any type of neurologic disorder. any type of neurologic disorder. Detrusor hyperreflexia Detrusor hyperreflexia refers to overactive bladder refers to overactive bladder symptoms due to a suprapontine upper motor neuron symptoms due to a suprapontine upper motor neuron neurologic disorder. External sphincter functions neurologic disorder. External sphincter functions normally. The detrusor muscle and the external sphincter normally. The detrusor muscle and the external sphincter function in synergy (in coordination). function in synergy (in coordination). DSD-DHDSD-DH refers to overactive bladder symptoms due to refers to overactive bladder symptoms due to neurologic upper motor neuron disorder of the neurologic upper motor neuron disorder of the suprasacral spinal cord.suprasacral spinal cord. Paradoxically, the patient is in urinary retention. Both Paradoxically, the patient is in urinary retention. Both the detrusor and the sphincter are contracting at the the detrusor and the sphincter are contracting at the same time; they are in dyssynergy (lack of coordination). same time; they are in dyssynergy (lack of coordination).

Detrusor hyperreflexia with impaired Detrusor hyperreflexia with impaired contractility (DHIC) contractility (DHIC) refers to overactive bladder refers to overactive bladder symptoms,symptoms,

but the detrusor cannot generate enough but the detrusor cannot generate enough pressure to allow complete emptying. pressure to allow complete emptying.

The external sphincter is in synergy with detrusor The external sphincter is in synergy with detrusor contraction. contraction.

The detrusor is too weak to mount an adequate The detrusor is too weak to mount an adequate contraction for proper voiding to occur.contraction for proper voiding to occur.

The condition is similar to urinary retention, but The condition is similar to urinary retention, but irritating voiding symptoms are prevalent. irritating voiding symptoms are prevalent.

Overactive bladder Overactive bladder refers to symptoms of refers to symptoms of urinary urgency, with or without urge urinary urgency, with or without urge incontinence, usually associated with incontinence, usually associated with frequency and nocturia. The cause may be frequency and nocturia. The cause may be neurologic or nonneurologic. neurologic or nonneurologic. Detrusor areflexia Detrusor areflexia is complete inability of is complete inability of the detrusor to empty due to a lower motor the detrusor to empty due to a lower motor neuron lesion (eg, sacral cord or neuron lesion (eg, sacral cord or peripheral nerves). peripheral nerves).

Detrusor instability Detrusor instability refers to overactive refers to overactive bladder symptoms without neurologic bladder symptoms without neurologic impairment. External sphincter functions impairment. External sphincter functions normally, in synergy. normally, in synergy.

TREATMENT OF SUPRASPINAL TREATMENT OF SUPRASPINAL LESIONSLESIONS

The treatment for the cerebral shock The treatment for the cerebral shock phase is indwelling Foley catheter or clean phase is indwelling Foley catheter or clean intermittent catheterization (CIC). When intermittent catheterization (CIC). When the bladder becomes hyperreflexic, the bladder becomes hyperreflexic, institute therapies to facilitate bladder institute therapies to facilitate bladder filling and storage with anticholinergic filling and storage with anticholinergic medications medications

Spinal cord injury Spinal cord injury

The spinal shock phase typically lasts 6-12 The spinal shock phase typically lasts 6-12 weeks; it may be prolonged in some weeks; it may be prolonged in some cases. During this time, the urinary cases. During this time, the urinary bladder must be drained with indwelling bladder must be drained with indwelling urethral catheter. urethral catheter.

Spinal cord lesions (above the Spinal cord lesions (above the sixth thoracic vertebrae) sixth thoracic vertebrae)

A unique complication of T6 injury is A unique complication of T6 injury is Autonomic Autonomic dysreflexia dysreflexia Symptoms of autonomic dysreflexia include Symptoms of autonomic dysreflexia include sweating, sweating, headache, headache, hypertension, hypertension, and reflex bradycardia. and reflex bradycardia.

Acute management of autonomic Acute management of autonomic dysreflexia is to decompress the rectum or dysreflexia is to decompress the rectum or bladder.bladder.

Decompression usually will reverse the Decompression usually will reverse the effects of unopposed sympathetic outflow. effects of unopposed sympathetic outflow. If additional measures are required, If additional measures are required, parenteral ganglionic or adrenergic parenteral ganglionic or adrenergic blocking agents, such as chlorpromazine, blocking agents, such as chlorpromazine, may be used may be used

Spinal cord lesions (below T6) Spinal cord lesions (below T6)

Individuals who sustain spinal cord lesions Individuals who sustain spinal cord lesions below T6 level will have urodynamic findings below T6 level will have urodynamic findings of of

Detrusor HyperreflexiaDetrusor Hyperreflexia, ,

Striated sphincter dyssynergiaStriated sphincter dyssynergia, and, and

Smooth sphincter dyssynergia Smooth sphincter dyssynergia

but no Autonomic dysreflexia but no Autonomic dysreflexia

Cornerstone of treatment involves CIC and Cornerstone of treatment involves CIC and anticholinergic medications anticholinergic medications

OTHER CONDITIONSOTHER CONDITIONS

Multiple sclerosis -Detrusor Hyperreflexia Multiple sclerosis -Detrusor Hyperreflexia

Diabetic cystopathy -Detrusor Areflexia Diabetic cystopathy -Detrusor Areflexia

Herniated disc -Detrusor Areflexia with Herniated disc -Detrusor Areflexia with intact bladder sensation. Associated intact bladder sensation. Associated internal sphincter denervation internal sphincter denervation

Lab studiesLab studies

Urinalysis and urine cultureUrinalysis and urine culture: Urinary tract infection can : Urinary tract infection can cause irritative voiding symptoms and urge incontinence. cause irritative voiding symptoms and urge incontinence. Urine cytologyUrine cytology: Carcinoma-in-situ of the urinary bladder : Carcinoma-in-situ of the urinary bladder causes symptoms of urinary frequency and urgency. causes symptoms of urinary frequency and urgency. Irritative voiding symptoms out of proportion to the Irritative voiding symptoms out of proportion to the overall clinical picture and/or hematuria warrant urine overall clinical picture and/or hematuria warrant urine cytology and cystoscopy. cytology and cystoscopy. Chem profileChem profile: Blood urea nitrogen (BUN) and creatinine : Blood urea nitrogen (BUN) and creatinine (Cr) are checked if compromised renal function is (Cr) are checked if compromised renal function is suspectedsuspected

PVRPVR

The postvoid residual urine (PVR) The postvoid residual urine (PVR) measurement is a part of basic evaluation measurement is a part of basic evaluation for urinary incontinence. for urinary incontinence.

If the PVR is high, the bladder may be If the PVR is high, the bladder may be contractile or the bladder outlet may be contractile or the bladder outlet may be obstructed. Both of these conditions will obstructed. Both of these conditions will cause urinary retention with overflow cause urinary retention with overflow incontinence. incontinence.

INVESTIGATIONSINVESTIGATIONS

Low uroflow rate may reflect urethral Low uroflow rate may reflect urethral obstruction, a weak detrusor, or a obstruction, a weak detrusor, or a combination of both. This test alone combination of both. This test alone cannot distinguish an obstruction from a cannot distinguish an obstruction from a contractile detrusor. contractile detrusor.

EMG allows accurate diagnosis of EMG allows accurate diagnosis of detrusor sphincter dyssynergia common in detrusor sphincter dyssynergia common in spinal cord injuries. spinal cord injuries.

Medical careMedical care

Stress incontinence Stress incontinence may be treated with surgical and may be treated with surgical and nonsurgical means. nonsurgical means. Urge incontinence Urge incontinence may be treated with behavioral may be treated with behavioral modification or with bladder-relaxing agents. modification or with bladder-relaxing agents. Mixed incontinence Mixed incontinence may require medications as well as may require medications as well as surgery. surgery. Overflow incontinence Overflow incontinence may be treated with some type may be treated with some type of catheter regimen. of catheter regimen. Functional incontinence Functional incontinence may be resolved by treating may be resolved by treating the underlying cause, such as urinary tract infection, the underlying cause, such as urinary tract infection, constipation, or by simply changing a few medications. constipation, or by simply changing a few medications.

Do not consider anti-incontinence products Do not consider anti-incontinence products to be a cure-all for urinary incontinence.to be a cure-all for urinary incontinence.

Use of pads and devices to contain urine Use of pads and devices to contain urine loss and maintain skin integrity.loss and maintain skin integrity.

Absorbent pads and internal and external Absorbent pads and internal and external collecting devices have a role in the collecting devices have a role in the management of chronic incontinence.management of chronic incontinence.

CathetersCatheters

Urinary diversion, using various catheters, Urinary diversion, using various catheters, has been one of the mainstays of anti-has been one of the mainstays of anti-incontinence therapy. incontinence therapy.

The use of catheters for bladder drainage The use of catheters for bladder drainage has withstood the test of time. has withstood the test of time.

Bladder catheterization may be a Bladder catheterization may be a temporary measure or a permanent temporary measure or a permanent solution for urinary incontinence. solution for urinary incontinence.

Types of Bladder CatheterizationTypes of Bladder Catheterization

Indwelling urethral catheters.Indwelling urethral catheters.

Suprapubic tubes.Suprapubic tubes.

Self-intermittent catheterizationSelf-intermittent catheterization

Indwelling urethral cathetersIndwelling urethral catheters

Commonly known as Commonly known as Foley CathetersFoley Catheters, indwelling , indwelling urethral catheters have been the mainstay of urethral catheters have been the mainstay of treatment for bladder dysfunction. treatment for bladder dysfunction. They must be changed monthly. They must be changed monthly. The standard catheter size for treating urinary The standard catheter size for treating urinary retention is 16F or 18F, with a 5-mL balloon filled retention is 16F or 18F, with a 5-mL balloon filled with 10 ml. of sterile water.with 10 ml. of sterile water. Larger catheters ( 22F, 24F) with bigger balloons Larger catheters ( 22F, 24F) with bigger balloons are used for treating grossly bloody urine found in are used for treating grossly bloody urine found in other urologic conditions or diseases. other urologic conditions or diseases.

The catheter and bag are replaced on a monthly The catheter and bag are replaced on a monthly basis.basis.

Catheters that develop encrustations and problems Catheters that develop encrustations and problems with urine drainage must be changed more with urine drainage must be changed more frequently.frequently.

All indwelling catheters in the urinary bladder for All indwelling catheters in the urinary bladder for more than 2 weeks become colonized with bacteria. more than 2 weeks become colonized with bacteria.

Bacterial colonization does not mean the patient has Bacterial colonization does not mean the patient has clinical bladder infection. clinical bladder infection.

Symptoms of bladder infection include foul Symptoms of bladder infection include foul odour, purulent urine, and hematuria. odour, purulent urine, and hematuria. Fever with flank pain often present. Fever with flank pain often present.

If bladder infection occurs, change the If bladder infection occurs, change the entire catheter and the drainage system.entire catheter and the drainage system.

The urinary drainage bag does not need The urinary drainage bag does not need to be disinfected to prevent infectionto be disinfected to prevent infection

CATHETER CARECATHETER CARE

Routine irrigation of catheters is not Routine irrigation of catheters is not required. use of 0.25% acetic acid.required. use of 0.25% acetic acid.

Irrigation because it is bacteriostatic, Irrigation because it is bacteriostatic, minimizes catheter encrustation, and minimizes catheter encrustation, and diminishes the odor. diminishes the odor.

When used, 30 ml. is instilled into the When used, 30 ml. is instilled into the bladder and allowed to freely drain on a bladder and allowed to freely drain on a twice daily basis twice daily basis

Patients do not have to take continuous Patients do not have to take continuous antibiotics while using the catheter. antibiotics while using the catheter. Continuous antibiotic therapy is Continuous antibiotic therapy is contraindicated while a catheter is used. contraindicated while a catheter is used. that are resistant to common antibiotics.that are resistant to common antibiotics. Indwelling use of a Foley catheter in Indwelling use of a Foley catheter in individuals who are homebound requires individuals who are homebound requires close supervision by a visiting nurse and close supervision by a visiting nurse and additional personal hygiene care. additional personal hygiene care.

Chronic dependence on these catheters is Chronic dependence on these catheters is extremely risky.extremely risky.

Indwelling urethral catheters are a significant Indwelling urethral catheters are a significant cause of urinary tract infections that involve the cause of urinary tract infections that involve the urethra, bladder, and kidneys.urethra, bladder, and kidneys.

Within 2-4 weeks after catheter insertion, bacteria Within 2-4 weeks after catheter insertion, bacteria will be present in the bladder of most women.will be present in the bladder of most women.

Asymptomatic bacterial colonization is common Asymptomatic bacterial colonization is common and does not pose a health hazard.and does not pose a health hazard.

Untreated symptomatic urinary tract infections Untreated symptomatic urinary tract infections may lead to urosepsis and death. may lead to urosepsis and death.

PROBLEMS OF CATHETERPROBLEMS OF CATHETER

Other problems associated with indwelling Other problems associated with indwelling urethral catheters include encrustation of urethral catheters include encrustation of the catheter, bladder spasms resulting in the catheter, bladder spasms resulting in urinary leakage, hematuria, and urethritis. urinary leakage, hematuria, and urethritis.

More severe complications include More severe complications include formation of bladder stones, development formation of bladder stones, development of periurethral abscess, renal damage, of periurethral abscess, renal damage, and urethral erosion. and urethral erosion.

Suprapubic CathetersSuprapubic Catheters

A suprapubic tube is an alternative to long-A suprapubic tube is an alternative to long-term urethral catheter use. term urethral catheter use. In paraplegic and quadriplegic in the form of In paraplegic and quadriplegic in the form of urinary diversion. urinary diversion. When suprapubic tubes are needed, usually When suprapubic tubes are needed, usually smaller (eg, 14F, 16F) catheters are placed.smaller (eg, 14F, 16F) catheters are placed. Like the urethral catheter, change the Like the urethral catheter, change the suprapubic tube once a month on a regular suprapubic tube once a month on a regular basis. basis.

Indications for suprapubic Indications for suprapubic catheterscatheters

Short-term use-Short-term use-- - Gynecologic, Gynecologic, Urologic, Urologic, other types of surgery. other types of surgery. A suprapubic tube does A suprapubic tube does not prevent bladder spasms from not prevent bladder spasms from occurring in unstable bladders nor does it occurring in unstable bladders nor does it improve the urethral closure mechanism in improve the urethral closure mechanism in an incompetent urethra. an incompetent urethra.

CONTRAINDICATIONSCONTRAINDICATIONS

Chronic unstable bladders.Chronic unstable bladders.

Intrinsic sphincter deficiency because Intrinsic sphincter deficiency because involuntary urine loss is not prevented.involuntary urine loss is not prevented.

Mode of draining the bladder at timed Mode of draining the bladder at timed intervals. intervals. A prerequisite for self-catheterization A prerequisite for self-catheterization is the patients' ability to use their hands is the patients' ability to use their hands and arms.and arms.

The best solution for bladder The best solution for bladder decompression of a motivated individual.decompression of a motivated individual.

INTERMITTENT INTERMITTENT CATHETERIZATIONCATHETERIZATION

Many studies with spinal cord injuries have Many studies with spinal cord injuries have shown that intermittent catheterization is shown that intermittent catheterization is preferable to indwelling catheters. preferable to indwelling catheters. Intermittent catheterization has become a Intermittent catheterization has become a healthy alternative with chronic urinary healthy alternative with chronic urinary retention due to-- retention due to-- obstructed bladder, obstructed bladder, a weak bladder, a weak bladder, a nonfunctioning bladder. a nonfunctioning bladder. Young children with myelomeningocele Young children with myelomeningocele

Intermittent catheterization may be Intermittent catheterization may be performed by: performed by:

using a soft, red, rubber catheter or a using a soft, red, rubber catheter or a short, rigid, plastic catheter. short, rigid, plastic catheter.

The use of plastic catheters is preferable The use of plastic catheters is preferable to red rubber catheters because they are to red rubber catheters because they are easier to clean and last longer. easier to clean and last longer.

PRINCIPLES OF SELF PRINCIPLES OF SELF CATHETERIZATIONCATHETERIZATION

The bladder must be drained on a regular basis, The bladder must be drained on a regular basis, either based on a timed interval. (eg, on either based on a timed interval. (eg, on awakening, every 3-6 hours during the day, and awakening, every 3-6 hours during the day, and before bed) or based on bladder volume.before bed) or based on bladder volume.

Ideally the amount drained each time should not Ideally the amount drained each time should not exceed 400-500 mL. exceed 400-500 mL.

If catheterization is performed every 6 hours and If catheterization is performed every 6 hours and the amount drained is 700 mL, the amount drained is 700 mL, Ideal is to drain every 4 hours to maintain the Ideal is to drain every 4 hours to maintain the volume drained at 400-500 mL. volume drained at 400-500 mL.

Studies show that in patients with spinal Studies show that in patients with spinal cord injuries, the incidence of bacteria in cord injuries, the incidence of bacteria in the bladder is 1-3% per catheterization the bladder is 1-3% per catheterization and 1-4 episodes of bacteriuria occur per and 1-4 episodes of bacteriuria occur per 100 days of intermittent catheterization 100 days of intermittent catheterization performed 4 times a day. performed 4 times a day.

For the older population and individuals For the older population and individuals with a weak immune system, the sterile with a weak immune system, the sterile technique of intermittent catheterization technique of intermittent catheterization has been recommended. has been recommended.

ComplicationsComplications

Bladder infection,Bladder infection,

Urethral trauma, Urethral trauma,

Urethral inflammation, Urethral inflammation, and and

Stricture. Stricture. Concurrent use of anticholinergic therapy Concurrent use of anticholinergic therapy will maintain acceptable intravesical will maintain acceptable intravesical pressures and prevent bladder contracture. pressures and prevent bladder contracture.

Surgical careSurgical care

Surgical care for stress incontinence involves Surgical care for stress incontinence involves procedures that increase urethral outlet procedures that increase urethral outlet resistance. resistance. Operations that increase urethral resistance Operations that increase urethral resistance include bladder neck suspension, periurethral include bladder neck suspension, periurethral bulking therapy, sling procedures, and artificial bulking therapy, sling procedures, and artificial urinary sphincter. urinary sphincter. Surgical care for urge incontinence involves Surgical care for urge incontinence involves procedures that improve bladder compliance or procedures that improve bladder compliance or bladder capacity; these include sacral bladder capacity; these include sacral neuromodulation, botulinum toxin injections, neuromodulation, botulinum toxin injections, detrusor myomectomy, and bladder detrusor myomectomy, and bladder augmentation.augmentation.

Pelvic muscle exercises Pelvic muscle exercises

Pelvic floor muscle exercises are performed by drawing Pelvic floor muscle exercises are performed by drawing in or lifting up the levator ani muscles as if to control in or lifting up the levator ani muscles as if to control urination or defecation with minimal contraction of urination or defecation with minimal contraction of abdominal, buttock, or inner thigh muscles abdominal, buttock, or inner thigh muscles Biofeedback therapy Biofeedback therapy is a form of pelvic floor muscle is a form of pelvic floor muscle rehabilitation using an electronic device for individuals rehabilitation using an electronic device for individuals having difficulty identifying levator ani muscles having difficulty identifying levator ani muscles Studies on biofeedback combined with pelvic floor Studies on biofeedback combined with pelvic floor exercises show a 54-87% improvement with exercises show a 54-87% improvement with incontinence incontinence