neurogenic bladder

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Neurogenic Bladder

 

Definition

Neurogenic bladder is a dysfunction that results from interference with the normal nerve pathways associated with urination.

Description

Normal bladder function is dependent on the nerves that sense the fullness of the bladder (sensory nerves) and on those that trigger the muscle movements that either empty it or retain urine (motor nerves). The reflex to urinate is triggered when the bladder fills to 300-500 ml. The bladder is then emptied when the contraction of the bladder wall muscles forces urine out through the urethra. The bladder, internal sphincters, and external sphincters may all be affected by nerve disorders that create abnormalities in bladder function.
There are two categories of neurogenic bladder dysfunction: overactive (spastic or hyper-reflexive) and underactive (flaccid or hypotonic). An overactive neurogenic bladder is characterized by uncontrolled, frequent expulsion of urine from the bladder. There is reduced bladder capacity and incomplete emptying of urine. An underactive neurogenic bladder has a capacity that is extremely large (up to 2000 ml). Due to a loss of the sensation of bladder filling, the bladder does not contract forcefully, and small amounts of urine dribble from the urethra as the bladder pressure reaches a breakthrough point.

Causes and symptoms

There are numerous causes for neurogenic bladder dysfunction and symptoms vary depending on the cause. An overactive bladder is caused by interruptions in the nerve pathways to the bladder occurring above the sacrum (five fused spinal vertebrae located just above the tailbone or coccyx). This nerve damage results in a loss of sensation and motor control and is often seen in stroke, Parkinson's disease, and most forms of spinal-cord injuries. An underactive bladder is the result of interrupted bladder stimulation at the level of the sacral nerves. This may result from certain types of surgery on the spinal cord, sacral spinal tumors, or congenital defects. It also may be a complication of various diseases, such as syphilis, diabetes mellitus, or polio.

Diagnosis

Neurogenic bladder is diagnosed by carefully recording fluid intake and urinary output and by measuring the quantity of urine remaining in the bladder after voiding (residual urine volume). This measurement is done by draining the bladder with a small rubber tube (catheter) after the person has urinated. Kidney function also is evaluated by regular laboratory testing of the blood and urine. Cystometry may be used to estimate the capacity of the bladder and the pressure changes within it. These measurements can help determine changes in bladder compliance in order to assess the effectiveness of treatment. Doctors may use a cystoscope to look inside the bladder and tubes that lead to it from the kidneys (ureters). Cystoscopy may be used to assess the loss of muscle fibers and elastic tissues and, in some cases, for removing small pieces of tissue for biopsy.

Treatment

Doctors begin treating neurogenic bladder by attempting to reduce bladder stretching (distension) through intermittent or continuous catheterization. In intermittent catheterization, a small rubber catheter is inserted at regular intervals (four to six times per day) to approximate normal bladder function. This avoids the complications that may occur when a catheter remains in the bladder's outside opening (urethra) continuously (an indwelling catheter). Intermittent catheterization should be performed using strict sterile technique (asepsis) by skilled personnel, and hourly fluid intake and output must be recorded. Patients who can use their arms may be taught to catheterize themselves.
Indwelling catheters avoid distension by emptying the bladder continuously into a bedside drainage collector. Individuals with indwelling catheters are encouraged to maintain a high fluid intake in order to prevent bacteria from accumulating and growing in the urine. Increased fluid intake also decreases the concentration of calcium in the urine, minimizing urine crystallization and the subsequent formation of stones. Moving around as much as possible and a low calcium diet also help to reduce stone formation.
Drugs may be used to control the symptoms produced by a neurogenic bladder. The unwanted contractions of an overactive bladder with only small volumes of urine may be suppressed by drugs that relax the bladder (anticholinergics) such as propantheline (Pro-Banthine) and oxybutynin (Ditropan). Contraction of an underactive bladder with normal bladder volumes may be stimulated with parasympathomimetics (drugs that mimic the action resulting from stimulation of the parasympathetic nerves) such as bethanechol (Urecholine).
Long-term management for the individual with an overactive bladder is aimed at establishing an effective spontaneous reflex voiding. The amount of fluid taken in is controlled in measured amounts during the waking hours, with sips only toward bedtime to avoid bladder distension. At regular intervals during the day (every four to six hours when fluid intake is two to three liters per 24 hours), the patient attempts to void using pressure over the bladder (Crede maneuver). The patient may also stimulate reflex voiding by abdominal tapping or stretching of the anal sphincter. The Valsalva maneuver, involving efforts similar to those used when straining to pass stool, produces an increase in intra-abdominal pressure that is sometimes adequate to completely empty the bladder. The amount of urine remaining in the bladder (residual volume) is estimated by a comparison of fluid intake and output. The patient also may be catheterized immediately following the voiding attempt to determine residual urine. Catheterization intervals are lengthened as the residual urine volume decreases and catheterization may be discontinued when urine residuals are at an acceptable level to prevent urinary tract infection.
For an underactive bladder, the patient may be placed on a similar bladder routine with fluid intake and output adjusted to prevent bladder distension. If an adequate voiding reflex cannot be induced, the patient may be maintained on clean intermittent catheterization.
Some individuals who are unable to control urine output (urinary incontinence) due to deficient sphincter tone may benefit from perineal exercises. Although this is a somewhat dated technique, male patients with extensive sphincter damage may be helped by the use of a Cunningham clamp. The clamp is applied in a horizontal fashion behind the glans of the penis and must be removed approximately every four hours for bladder emptying to prevent bacteria from growing in the urine and causing an infection. Alternation of the Cunningham clamp with use of a condom collection device will reduce the skin irritation sometimes caused by the clamp.
Surgery is another treatment option for incontinence. Urinary diversion away from the bladder may involve creation of a urostomy or a continent diversion. The surgical implantation of an inflatable sphincter is another option for certain patients. An indwelling urinary catheter is sometimes used when all other methods of incontinence management have failed. The long-term use of an indwelling catheter almost inevitably leads to some urinary tract infections, and contributes to the formation of urinary stones (calculi). Doctors may prescribe antibiotics preventively to reduce recurrent urinary tract infection.

Alternative treatment

The cause of the bladder problem must be determined and treated appropriately. If nerve damage is not permanent, homeopathy and acupuncture may help restore function.

Key terms

Anticholinergic — An agent that blocks certain nerve impulses.
Catheterization — Insertion of a slender, flexible tube into the bladder to drain urine.
Compliance — A term used to describe how well a patient's behavior follows medical advice.
Cystometry — A test of bladder function in which pressure and volume of fluid in the bladder are measured during filling, storage, and voiding.
Cystoscopy — A direct method of bladder study and visualization using a cystoscope (self-contained optical lens system). The cystoscope can be manipulated to view the entire bladder, with a guide system to pass it up into the ureters (tubes leading from the kidneys to the bladder).
Glans penis — The bulbous tip of the penis.
Motor nerves — Nerves that cause movement when stimulated.
Parasympathomimetic — An agent whose effects mimic those resulting from stimulation of the parasympathetic nerves.
Perineal — The diamond-shaped region of the body between the pubic arch and the anus.
Reflex — An involuntary response to a particular stimulus.
Sensory nerves — Nerves that convey impulses from sense organs to the higher parts of the nervous system, including the brain.
Sphincter — A band of muscles that surrounds a natural opening in the body; these muscles can open or close the opening by relaxing or contracting.
Ureter — A tube leading from one of the kidneys to the bladder.
Urethra — The tube that leads from the bladder to the outside of the body.
Urostomy — A diversion of the urinary flow away from the bladder, resulting in output through the abdominal wall. The most common method involves use of a portion of intestine to conduct the urine out through the abdomen and into an external pouch worn for urine collection.

Prognosis

Individuals with an overactive bladder caused by spinal cord lesions at or above the seventh thoracic vertebra, are at risk for sympathetic dysreflexia, a life-threatening condition which can occur when the bladder (and/or rectum) becomes overly full. Initial symptoms include sweating (particularly on the forehead) and headache, with progression to slow heart rate (bradycardia) and high blood pressure (hypertension). Patients should notify their physician promptly if symptoms do not subside after the bladder (or rectum) is emptied, or if the bladder (or rectum) is full and cannot be emptied.

Resources

Organizations

Bladder Health Council, American Foundation for Urologic Disease. 300 West Pratt St., Suite 401, Baltimore, MD 21201. (800) 242-2383 or (410) 727-2908.
National Association for Continence. P.O. Box 8310, Spartanburg, SC 29305-8310. (800) 252-3337. http://www.nafc.org.
Simon Foundation for Continence. Box 835, Wilmette, IL 60091.

neu·ro·path·ic blad·der

any defective functioning of bladder due to impaired innervation, for example, cord bladder, neuropathic bladder.
Synonym(s): neurogenic bladder

neurogenic bladder

dysfunction of the urinary bladder caused by a lesion of the nervous system. Treatment is aimed at preventing infection, controlling incontinence, and preserving kidney function by enabling the bladder to empty completely and regularly. Kinds of neurogenic bladder are flaccid bladder and spastic bladder. Also called neuropathic bladder.

neurogenic bladder

Urology A urinary bladder with loss or impairment of voluntary control of micturition. The two types are Spastic, due to lesions of the spinal cord, accompanied by urgency, ↑ frequency, ↓ functional capacity, spastic contractions, and poor voluntary control; or Flaccid, due to segmental lesions at S2 to S4, interfering with voluntary and reflex control, ↓ of sensation of bladder fullness, causing 'overflow' incontinence, when the bladder contains 2+ liters

neu·ro·path·ic blad·der

(nūr'ō-path'ik blad'ĕr)
Any defective functioning of bladder due to impaired innervation.
Synonym(s): neurogenic bladder.

neurogenic bladder

A disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder. Voluntary control is lost but the bladder may empty itself automatically after filling.

Neurogenic Bladder

DRG Category:669
Mean LOS:4.2 days
Description:SURGICAL: Transurethral Procedures With CC
DRG Category:700
Mean LOS:3.3 days
Description:MEDICAL: Other Kidney and Urinary Tract Diagnoses Without CC or Major CC

Neurogenic bladder is defined as an interruption of normal bladder innervation because of lesions on or insults to the nervous system. Neurogenic bladder dysfunctions have been categorized in two ways: according to the response of the bladder to the insult (classification I) or according to the lesion’s level (classification II) (Table 1).

Classifications of Neurogenic Bladder
Table 1. Classifications of Neurogenic Bladder
CLASSIFICATIONTYPECAUSESRESPONSE
Classification IUninhibitedStroke, multiple sclerosis; lesions in corticoregulatory tractsCan void spontaneously when bladder is full
Sensory paralyticLesions in lateral spinal tract from diabetic peripheral neuropathy, pernicious anemiaCannot sense a full bladder and has chronic retention and overflow incontinence
Motor paralyticSpinal cord lesions at or above sacral level (S2–S4; upper motor neuron lesion)Unable to initiate voiding even when bladder is full and causing extreme pain
AutonomousRetention and incontinence occur when a condition such as cancer, trauma, or infection causes destruction of nerve connections between the bladder and the central nervous system (CNS) (lower motor neuron lesion)Cannot perceive bladder fullness or cannot initiate voiding without assistance such as abdominal pressure
ReflexUpper neuron lesions above T12Cannot perceive bladder filling; bladder contracts on reflex but often does not empty completely, leading to an increased potential for bladder infection
Classification IIUpper motor neuron damageDamage to corticospinal or pyramidal tract in brain or spinal cord at or above the level of the sacral vertebrae (S2–S4)Bladder tends to respond in a spastic, hypertonic, or hyperreflexic manner; nerve impulses are not transmitted from spinal area to cerebral cortex; no sensation of urge to void; lower cord is unaffected so bladder reflexively empties, resulting in urinary incontinence
Lower motor neuron damageDamage to anterior horn cells, nerve roots, or peripheral nervous system below the sacral vertebraeBladder tends to respond in a flaccid, atonic, or hyporeflexic manner; messages related to bladder filling do not reach cerebral cortex, resulting in residual urinary retention

Many complications can result in patients with neurogenic bladder, such as bladder infection and skin breakdown related to incontinence. In addition, urolithiasis (stones in the urinary tract) is a common complication. Patients with spinal lesions above T7 are also at risk for autonomic dysreflexia, a life-threatening complication. Autonomic reflexia results from the body’s abnormal response to stimuli such as a full bladder or a distended colon. It results in severely elevated blood pressure, flushing, diaphoresis, decreased pulse, and a pounding headache. Chronic renal failure (CRF) can also result from chronic overfilling of the bladder, causing backup pressures throughout the renal system.

Causes

See Table 1.

Genetic considerations

No clear genetic contributions to susceptibility have been defined.

Gender, ethnic/racial, and life span considerations

The incidence and manifestations of neurogenic bladder dysfunction do not change with age, except that older people of both sexes are more at risk for strokes. They also may have had neurological diseases longer, resulting in more sequelae such as neurogenic bladder dysfunction. The treatment plan is unmodified for elderly patients, except that self-catheterization may need to be modified or not used at all depending on the ability of the individual. There are no known specific racial or ethnic considerations.

Global health considerations

While no international data are available, neurogenic bladder likely exists as a condition in all regions of the world.

Assessment

History

Take a full history of urinary voiding, including night/day patterns, amount of urine voided, and number of urinary emptyings per day. Most patients will describe a history of urinary incontinence and changes in the initiation or interruption of urinary voiding. Elicit an accurate description of the sensations during bladder filling and emptying. In patients with spastic neurogenic bladder, expect the patient to describe a history of involuntary or frequent scanty urination without a sensation of bladder fullness. In patients with flaccid neurogenic bladder, expect overflow urinary incontinence. Also ask patients if they have a history of frequent urinary tract infections, a complication that often accompanies neurogenic bladder.

Physical examination

Evaluate the extent of the patient’s CNS involvement by performing a complete neurological assessment, including strength and motion of extremities and levels of sensation on the trunk and extremities. With a spastic neurogenic bladder, the patient may have increased anal sphincter tone so that when you touch the abdomen, thigh, or genitalia, the patient may void spontaneously. Often, the patient will have residual urine in the bladder even after voiding. In patients with a flaccid neurogenic bladder, palpate and percuss the bladder to evaluate for a distended bladder; usually, the patient will not sense bladder fullness in spite of large bladder distention because of sensory deficits. In patients with urinary incontinence, evaluate the groin and perineal area for skin irritation and breakdown.

Psychosocial

The patient will likely view neurogenic bladder dysfunction as one more manifestation of an already uncontrollable situation. Anxiety about voiding will be added to the anxiety about the underlying cause of the dysfunction. Urinary incontinence leads to embarrassment over the lack of control and concern over the odor of urine that often can permeate clothing and linens. Patients who perceive that the only alternative is urinary catheterization have concerns about being normally active with a catheter and may also fear sexual dysfunction.

Diagnostic highlights

TestNormal ResultAbnormality With ConditionExplanation
Uroflowmetry> 200 mL, 10–20 mL/sec, depending on ageDecreasedMeasures completeness and speed of bladder emptying, which are both reduced
CystometryAbsence of residual urine; sensation of fullness at 300–500 mL; urge to void at 150–450 mLVaries with type of dysfunction; may have residual urine and lack of sensation or urge to voidEvaluates detrusor muscle function and tonicity, determines etiology of bladder dysfunction, and differentiates among classifications of bladder dysfunction

Other Tests: Urethral pressure profile, urinalysis, urine cytology, excretory urogram, voiding cystourethrogram, cystourethroscopy, electromyography of pelvic muscles, ultrasound of bladder, serial sampling of urine for bacterial analysis

Primary nursing diagnosis

Diagnosis

Altered urinary elimination related to incontinence or retention secondary to trauma or CNS dysfunction

Outcomes

Urinary continence; Urinary elimination; Infection status; Knowledge: Disease process, medication, treatment regimen; Symptom control behavior

Interventions

Urinary retention care; Fluid management; Fluid monitoring; Urinary catheterization; Urinary elimination management

Planning and implementation

Collaborative

The goals for the medical management of patients include maintaining the integrity of the urinary tract, controlling or preventing infection, and preventing urinary incontinence. Many of the nonsurgical approaches to managing neurogenic bladder depend on independent nursing interventions such as the Credé method, Valsalva’s maneuver, or intermittent catheterization (see below).

If all attempts at bladder retraining or catheterization have failed, a surgeon may perform a reconstructive procedure, such as correction of bladder neck contractures, creation of access for pelvic catheterization, or other urinary diversion procedures. Some surgeons may recommend implantation of an artificial urinary sphincter if urinary incontinence continues after surgery.

Pharmacologic highlights

Medication or Drug ClassDosageDescriptionRationale
Alpha-adrenergic drugsVaries with drugPseudoephedrine hydrochlorideContracts bladder neck and thereby increases bladder outlet resistance
Antimuscarinic (anticholinergic) drugsVaries with drugAtropine; propantheline (Pro-Banthine); darifenacin (Enablex); Solifenacin succinate (VESIcare); dicyclomine hydrochloride (Bentyl)Decrease spasticity and incontinence in spastic neurogenic bladder disorders

Other Drugs: Estrogen derivatives; estrogen increases tone of urethral muscle and enhances urethral support; antispasmodic drugs; tricyclic antidepressant drugs increase norepinephrine and serotonin levels and also have a direct muscle relaxant effect on the urinary bladder.

Independent

Focus on bladder training. The patient may notice bladder dysfunction initially during the acute phase of the underlying disorder, such as during recovery from a spinal cord injury. During this time, an indwelling urinary catheter is frequently in place. Ensure that the tubing is patent to prevent urine backflow and that it is taped laterally to the thigh (in men) to prevent pressure to the penoscrotal angle. Clean the catheter insertion site with soap and water at least two times a day. Before transferring the patient to a wheelchair or bedside chair, empty the urine bag and clamp the tubing to prevent reflux of urine. Encourage a high fluid intake (2 to 3 L/day) unless contraindicated by the patient’s condition.

Bladder retraining should stimulate normal bladder function. For the patient with a spastic bladder, the objective of the training is to increase the control over bladder function. Encourage the patient to attempt to void at specific times. Various methods of stimulating urination include applying manual pressure to the bladder (Credé’s maneuver), stimulating the skin of the abdomen or thighs to initiate bladder contraction, or stretching the anal sphincter with a gloved, lubricated finger. If the patient is successful, measure the voided urine and determine the residual volume by performing a temporary urinary catheterization. The goal is to increase the times between voidings and to have a concurrent decrease in residual urine amounts. Teach the patient to assess the need to void and to respond to the body’s response to a full bladder, as the usual urge to void may be absent. When the residual urine amounts are routinely less than 50 mL, catheterization is usually discontinued.

If bladder training is not feasible (this is more frequently experienced when the dysfunction is related to a flaccid bladder), intermittent straight catheterization is necessary. Begin the catheterizations at specific times and measure the urine obtained. Institutions and agencies have varied policies on the maximum amount of urine that may be removed through catheterization at any one time. Self-catheterization may be taught to the patient when she or he is physically and cognitively able to learn the procedure. If this procedure is not possible, a family member may be taught the procedure for home care. Sterile technique is important in the hospital to prevent infection, although home catheterization may be accomplished with the clean technique.

If the patient demonstrates signs and symptoms of autonomic dysreflexia, place the patient in semi-Fowler’s position, check for any kinking or other obstruction in the urinary catheter and tubing, and initiate steps to relieve bladder pressure. These interventions may include using the bladder retraining methods to stimulate evacuation or catheterizing the patient. The anus should be checked to ascertain if constipation is causing the problem, but perform fecal assessment or evacuation cautiously to prevent further stimulation that might result in increased autonomic dysreflexia. Monitor the vital signs every 5 minutes and seek medical assistance if immediate interventions do not relieve the symptoms.

The patient’s psychosocial state is essential for health maintenance. Teaching may not be effective if there are other problems that the patient believes have a higher priority. The need for a family member to perform catheterization may be highly embarrassing for both the patient and the family. Because anxiety may cause the patient to have great difficulty in performing catheterization, a relaxed, private environment is necessary. Some institutions have patient support groups for people who have neurogenic bladders; if a support group is available, suggest to the patient and significant other that they might attend. If the patient has more than the normal amount of anxiety or has ineffective coping, refer the patient for counseling.

Evidence-Based Practice and Health Policy

Hansen, E.L., Hvistendahl, G.M., Rawashdeh, Y.F., & Olsen, L.H. (2013). Promising long-term outcome of bladder autoaugmentation in children with neurogenic bladder dysfunction. The Journal of Urology, 190(5), 1869–1875.

  • Investigators examined the long-term outcomes over a median period of 6.8 years (range, 0.1 to 15.6 years) among 25 children (median age, 9.3 years) treated with autoaugmentation for neurogenic bladder dysfunction. Median bladder capacity increased significantly from 103 mL (range, 14 to 250 mL) preoperatively to 176 mL (range, 70 to 420 mL) postoperatively (p < 0.01).
  • Compared to preoperative levels, median bladder compliance doubled to 10 mL/cm water at the 1-year follow-up and increased to 17 mL/cm water by 5 years (p < 0.05). Vesicourethral reflux, which was present in 36% of children, was relieved in 77.8% of those children postoperatively.
  • Underlying conditions in this sample included myelomeningocele in 88% of the children, congenital partial agenesis of the sacrum in 8% the children, and congenital scoliosis in 4% of the children.

Documentation guidelines

  • Physical findings related to intake, output, residual urine measures, presence of edema or dehydration, incontinence, autonomic dysreflexia, infection
  • Response to cholinergic or anticholinergic medications
  • Response to treatment, including patient perceptions of comfort, control of bodily functions, and ability to perform bladder evacuation procedures

Discharge and home healthcare guidelines

The patient and significant others need to understand that although they have achieved a bladder program in the hospital, their daily rhythm may be quite different at home. They need to be encouraged to adapt the pattern of bladder evacuation to the family schedule. Teach the patient the medication dosage, action, side effects, and route of all prescribed medications.

Discuss potential complications, particularly urinary tract infection, and encourage the patient to report signs of infection to the physician immediately. Teach the patient and significant others preventive strategies, such as keeping equipment clean, good hand-washing techniques, and adequate fluid intake to limit the risk of infection. Refer the patient to an appropriate source for catheterization supplies if appropriate or refer the patient to social service for help in obtaining supplies. Discuss the potential for sexual activity with the patient; if possible, have a nurse of the same gender talk with the patient to answer questions and provide support.