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Causes and symptoms
neurogenic bladderUrology 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)
Synonym(s): neurogenic bladder.
neurogenic bladderA 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.
|Mean LOS:||4.2 days|
|Description:||SURGICAL: Transurethral Procedures With CC|
|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).
|Classification I||Uninhibited||Stroke, multiple sclerosis; lesions in corticoregulatory tracts||Can void spontaneously when bladder is full|
|Sensory paralytic||Lesions in lateral spinal tract from diabetic peripheral neuropathy, pernicious anemia||Cannot sense a full bladder and has chronic retention and overflow incontinence|
|Motor paralytic||Spinal 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|
|Autonomous||Retention 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|
|Reflex||Upper neuron lesions above T12||Cannot perceive bladder filling; bladder contracts on reflex but often does not empty completely, leading to an increased potential for bladder infection|
|Classification II||Upper motor neuron damage||Damage 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 damage||Damage to anterior horn cells, nerve roots, or peripheral nervous system below the sacral vertebrae||Bladder 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.
See Table 1.
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.
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.
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.
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.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Uroflowmetry||> 200 mL, 10–20 mL/sec, depending on age||Decreased||Measures completeness and speed of bladder emptying, which are both reduced|
|Cystometry||Absence of residual urine; sensation of fullness at 300–500 mL; urge to void at 150–450 mL||Varies with type of dysfunction; may have residual urine and lack of sensation or urge to void||Evaluates 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
DiagnosisAltered urinary elimination related to incontinence or retention secondary to trauma or CNS dysfunction
OutcomesUrinary continence; Urinary elimination; Infection status; Knowledge: Disease process, medication, treatment regimen; Symptom control behavior
InterventionsUrinary retention care; Fluid management; Fluid monitoring; Urinary catheterization; Urinary elimination management
Planning and implementation
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.
|Medication or Drug Class||Dosage||Description||Rationale|
|Alpha-adrenergic drugs||Varies with drug||Pseudoephedrine hydrochloride||Contracts bladder neck and thereby increases bladder outlet resistance|
|Antimuscarinic (anticholinergic) drugs||Varies with drug||Atropine; 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.
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.
- 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.