Transcript Rebecca Shaw–Urinary issues problems and solutions 2015

Urinary Issues Problems and Solutions
Rebecca Shaw, BSN, MSN,
CRNP, CRRN
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
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
Affects QOL Patient and Caregiver
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
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
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.
Anatomy of urological system
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
 Ureters
connect kidneys to bladder
Propel urine into the bladder by peristalsis
Volume triggers movement of urine
Normal Anatomy urological system
Anatomy of Urological system
 Bladder
Hollow muscular organ
Controlled primarily by the Autonomic nervous
system
Enervated by Parasympathetic and
Sympathetic nerve fibers
Anatomy of urological system
Bladder
Stretch receptors line the muscle wall
Normal micturition is stimulated at about 250300 ccs of stored urine
In a normal individual Volitional control begins
to fail at 600-700ccs
Anatomy bladder
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
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
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.
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
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
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
Pathophysiology Bladder dysfunction
 Lower Motor neuron bladder
Sacral micturition center damaged
Bladder capacity large
Detrusor tone low (detrusor areflexic)
Pathophysiology Bladder dysfunction
 Lower Motor neuron bladder
Internal and external Sphincters relaxed
Frequent overflow incontinence
Urinary tract infections common
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
Pathophysiology
Mixed Injury
Flaccid bladder
Either spastic or
flaccid sphincters
Bladder is large under low pressure
Pathophysiology
Mixed Injury
Less chance of reflux
Less resistance to outflow
Frequent small volume incontinence
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
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
Management :
Evaluation
 Full patient history
Previous history
Comorbidities
Current complaints
Medications
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
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
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
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
Management Intermittent Catherization
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
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
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
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
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
Management UMN
Additional treatment options
 Indwelling catheters
 Foley
 Suprapubic
 Medications
 Cholinergic Agonists-Urecholine
LMN Complications
 Large volume residuals (low pressure)
 Frequent UTIs exacerbated by stagnant urine
 Urinary stones (bladder and kidneys)
LMN complications
 Scarring of urological structures
 Polynephritis
 Increased risk bladder cancer
Associated with chronic bladder irritation
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
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
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
Successful Bladder Management is Cause
for Celebration
ANY EXCUSE FOR A PARTY!
Questions?
References Cited
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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
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.