6 - Bladder Dysfunction Flashcards

Question

Types of urinary incontinence 🔑 Explain Stress Urinary incontinence

Answer 1

1. Bulbocavernosus reflex (S2–S4) 2. Anal reflex (wink; S2–S4) Cuccurollo 4th Edition Chapter 7 SCI pg569

Answer 2

💡 **Any investigations: Blood - Radiology - Special, repeat those on follow up!** **Admission** 1. CrCl, 24-hour urine 2. Urinalysis 3. Urine culture and sensitivity 4. Renal and bladder ultrasound 5. PVR 6. Urodynamic **Follow up** 1. Annual CrCl, 24-hour urine 2. Annual Renal US and KUB 3. Repeat urodynamic after 1 year Ref: SCI Principles and practice textbook, p301 Braddom 5th Edition Chapter 20 Bladder pg442 Box 20.1

Answer 3

**FAILURE TO PASS** 1. Large postvoid residuals (i.e., retention) **FAILURE TO STORE** 1. Urinary incontinence 2. Urinary frequency **COMPLICATIONS** 1. Recurrent UTIs in a patient with neurogenic bladder 2. Deterioration of the upper tracts 3. Bladder or kidney stones. **MONITOR & FOLLOW** 1. Monitoring of voiding pressures 2. Evaluation and monitoring of pharmacotherapy 3. Unexplained autonomic dysreflexia. DeLisa 5th Edition Chpater 51 Neurogenic Bowel & Bladder pg1355 SCI principles and practice textbook, pg 301.

Answer 4

💡 In those who have the potential for autonomic dysreflexia, changes in blood pressure before, during, and after voiding can also be evaluated. **Filling (storage) phase, during which water is being infused into the bladder.** **1- Bladder sensation** First sensation 100 to 200 mL Sense of fullness 300 to 400 mL Sense of urgency 400 to 500 mL **2- Bladder capacity** Normal between 400 and 700 mL **3- Bladder wall compliance** **4- Bladder stability** Whether or not there are uninhibited contractions **Voiding (emptying) phase, when a person is told to void.** 1. **Leak-point pressure (bladder pressure at which voiding begins)** 2. **Maximum voiding pressure** 3. **Urethral sphincter activity (EMG or actual pressure)** 4. **Flow rate** 5. **Voided volume** 6. **Postvoid residual.** DeLisa 5th Edition Chapter 51 Neurogenic Bowel & Bladder pg1357

Answer 5

**Areflexic LMN bladder dysfunction.** 1. Absent bulbocavernosus reflex. 2. Major detrusor contractions are absent. 3. No pelvic floor muscle activity external urethral sphincter. 4. Large bladder capacity.

Answer 6

**Uninhibited neurogenic bladder dysfunction.** 1. Brisk bulbocavernosus reflex. 2. Spontaneous detrusor contraction at reduced bladder capacity. 3. Silence of pelvic floor muscles external urethral sphincter.

Answer 7

**Hyperreflexic UMN bladder dysfunction** 1. Brisk bulbocavernosus reflex. 2. Bladder capacity is reduced. 3. High intravesical pressure during detrusor contraction. 4. Detrusor/external urethral sphincter dyssynergia with marked electrical activity of the pelvic floor muscles during detrusor contraction.

Answer 8

(A) **Normal pattern.** No contractions occur during filling. Voiding is initiated by relaxation of the sphincter before the bladder contracts. Low pressure emptying occurs (B) **Suprapontine neurologic lesion**: Contractions occur during filling, which the patient tries to suppress. Coordinated sphincteric relaxation occurs, leading to incontinence. (C) **Infrapontine/suprasacral neurologic lesion**: Contractions occur during filling and sphincteric cocontraction (**detrusor sphincter dyssynergia**) occurs, leading to high detrusor pressure. (D) **Sacral or infrasacral neurologic lesion**: Minimal or no bladder contraction or sphincteric activity is present.

Answer 9

40 mm H2O. Hence, must determine LPP (leak point pressure) – if greater than 40 mm H2O, then problems will occur. Ref: 1996 – Watanabe. Urodynamics of SCI.

Answer 10

Leak point pressure: Lowest detrusor pressure at which urine leakage occurs in the absence of either a detrusor contraction or an increase in abdominal pressure.

Answer 11

**ADULT** 1. Start CIC 4-6 times daily with target of \<500ml of urine each voiding session 2. Timed voiding before sleep and after waking up 3. Fluid intake 2-3 L per day on divided times, 250-500ml each time 4. Avoid caffeinated beverages past 6pm 5. Have set of routine for both CIC and fluid intake (limiting accidents, leaks, retension) 6. Post-void residual \<100 mL **PEDIATRIC** * First 10 kg the daily fluid requirement is 100 mL/kg * 11-20 kg the daily fluid requirement is 1000 mL + 50 mL/kg for every kg over 10. * \<20 kg the daily fluid requirement is 1500 mL + 20 mL/kg for every kg over 20 * Capacity \<12 yo = (age +2) x 30 mL * Post-void residual \<20 mL

Answer 12

1. Regularly empty the bladder 2. Prevent leaks 3. Avoid serious complications long-term. * Upper tract complications (hydronephrosis, pyelonephritis) * Lower tract complications (cystitis, vesicoureteral reflux) Cuccurollo 4th Edition Chapter 7 SCI pg571 & SCIRE

Answer 13

**Reflex voiding** Technique that can be used by some people with spastic bladder to cause urination. **Safe** Tapping over the bladder lightly and repeatedly with the fingertips or the side of the hand to stimulate reflex muscle contractions in the bladder that cause urination. This technique can be used to help improve bladder emptying during intermittent catheterization and when using condom catheters. **Unsafe** Older techniques for reflex voiding such as the Valsalva maneuver (increasing abdominal pressure by holding the breath and bracing) and the Crede technique (applying manual pressure onto the bladder through the abdomen) are NO longer used because they can cause too much pressure in the bladder, which can damage the kidneys. [https://community.scireproject.com/topic/bladder/#reflex-voiding](https://community.scireproject.com/topic/bladder/#reflex-voiding)

Answer 14

**Reflex voiding** Technique that can be used by some people with spastic bladder to cause urination. **Safe** Tapping over the bladder lightly and repeatedly with the fingertips or the side of the hand to stimulate reflex muscle contractions in the bladder that cause urination. This technique can be used to help improve bladder emptying during intermittent catheterization and when using condom catheters. **Unsafe** Older techniques for reflex voiding such as the Valsalva maneuver (increasing abdominal pressure by holding the breath and bracing) and the Crede technique (applying manual pressure onto the bladder through the abdomen) are NO longer used because they can cause too much pressure in the bladder, which can damage the kidneys. [https://community.scireproject.com/topic/bladder/#reflex-voiding](https://community.scireproject.com/topic/bladder/#reflex-voiding)

Answer 15

**Indications:** 1. LMN bladder with low outlet resistance. 2. sphincterotomy. **Contraindications:** 1. DESD (detrusor external sphincter dyssynergia). 2. bladder outlet obstruction. 3. vesicoureteral reflux. 4. hydronephrosis. PVA Guidelines, bladder, pg1.

Answer 16

**DIAPERS** Incontinent patients with dementia Advantages: Ease of care Disadvantages: Risk of infection and ulcer can result from poor hygiene Caution: Test PVR for adequate bladder emptying **EXTERNAL CONDOM CATHETER** Unable to perform self-catheterization Advantages: Continues negative pressure Disadvantages: Skin breakdown - Urethral damage - Risk of UTI can result from poor hygiene Caution: Can be too tight or loose **INDWELLING CATHETER** Unable to perform self-catheterization Advantages: Continues negative pressure Disadvantages: Traction - Traumatic hypospadias - Squamous cell carcinoma Caution: Monthly catheter changes **CLEAN INTERMITTENT CATHETERIZATION** SCI lesions at C6 Advantages: Social integration - Quality of Life Disadvantages: Symptomatic bacteriuria - Urethral trauma - Incontinence Caution: Restrict fluid intake - Timed schedule (four times a day) Braddom 5th Edition Chapter 20 Bladder Dysfunction pg436-437

Answer 17

**Indications of Indwelling catheterization** 1. Limited assistance from a caregiver 2. Poor hand skills 3. High fluid intake 4. Need for temporary management of vesicoureteral reflux 5. Elevated detrusor pressures 6. Failure of other less invasive methods (eg. IC) 7. Cognitive impairment or active substance abuse **Indications to continue for 14+ days** 1. Documented PVR are in a range over 200 mL 2. Persistent overflow incontinence 3. Inability to manage the incontinence/retention with IC 4. Symptomatic infections, and/or renal dysfunction 5. Contamination of stage 3 or 4 pressure ulcers with urine that has impeded healing 6. Terminal illness or severe impairment that limits positioning or clothing changes DeLisa 5th Edition Chapter 51 Neurogenic Bowel & Bladder pg1363

Answer 18

💡 Urethra - Stagnated urine - Foreign body - Attached to leg 1. Pain and discomfort 2. Urethral injury 3. Urethral strictures 4. Hematuria 5. Allergic reaction to the catheter material (often latex) 6. UTI, cystitis 7. Bladder cancer is associated with long term use of catheterization 8. Bladder stones, kidney stones 9. Epididymo-orchitis 10. Impaired quality of life: Limits movement and activities, Inconvenience, Embarrassing SCIRE Tan p 583

Answer 19

1. Stones - bladder stones 2. Infection - chronic infection 3. Catheter - indwelling 4. Smoking – unclear association Ref: 2010 – urologic complications of neurogenic bladder. Gormley et al.

Answer 20

**Contraindications** 1. Inability to catheterize themselves or a caregiver who is unable to perform catheterization 2. Poor cognition 3. Unwillingness to adhere to the catheterization time schedule or the fluid intake regimen 4. Abnormal urethral anatomy such as stricture and bladder neck obstruction 5. Bladder capacity less than 200 mL 6. Adverse reaction toward having to pass the catheter into the genital area multiple times a day (repeated hematuria) 7. Tendency to develop autonomic dysreflexia with bladder filling despite treatment DeLisa 5th Edition Chapter 51 Neurogenic Bowel & Bladder pg1364 **Indications** 1. Good hand function 2. Good cognition 3. Good vision 4. Pt welling / compliance 5. Available of equipment Dr. Salem Academic Day

Answer 21

💡 **To Follow proper bladder care 1) Technique 2) Complete emptying** 1. Use of hydrophilic catheter 2. Washing your hands thoroughly with soap and hot water before catheterization 3. Single use catheters 4. Single use lubricant 5. Genital hygiene 6. Collect less than 500mL of urine each time, if more consider more frequency. 7. Complete emptiness of bladder SCIRE

Answer 22

1. UTI. 2. Bladder overdistention (low adherence) 3. Urinary incontinence. 4. Urethral trauma with hematuria. 5. Urethral false passages. 6. Urethral stricture. 7. Autonomic dysreflexia (if level above T6). 8. Bladder stones. PVA bladder guidelines, pg1.

Answer 23

1. rule out infection (UTI) 2. increase frequency of IC. 3. adjust fluid intake. PVA Guidelines – bladder, pg 1.

Answer 24

1. Desire to improve sexual genital function 2. Difficulty with urethral catheter insertion 3. Leakage secondary to urethral incompetence 4. Perineal skin breakdown 5. Urethral discomfort 6. Urethral abnormalities, such as stricture, false passages, bladder neck obstruction, or urethral fistula 7. Recurrent urethral catheter obstruction 8. Prostatitis, urethritis, or epididymo-orchitis DeLisa 5th Edition Chapter 51 Neurogenic Bowel & Bladder pg1364

Answer 25

1. Tubing is less likely to be sat on or kinked between a person’s legs 2. More comfortable 3. Less likely to interfere with sexual activity (especially men) 4. Much easier to clean around (especially woman) 5. Completely reversible because once the suprapubic catheter is removed, the tract closes, usually within 1 to 2 days 6. Decreases the risk of epididymitis, urethral stricture disease, and urethral irritation DeLisa 5th Edition Chapter 51 Neurogenic Bowel & Bladder pg1364

Answer 26

**Treat low capacity** 1. Bladder Augmentation 2. Bladder Augmentation with Stoma 3. Denervation Procedures 4. Artificial Sphincter 5. Botulinum toxin injections to bladder wall **Treat obstruction** 1. Sphincterotomy 2. Urethral Stents 3. Urinary Diversion 4. Botulinum toxin injections to sphincter 5. Balloon dilation Braddom 5th Edition Chpater 20 Bladder Dysfunction pg438 DeLisa 5th Edition Chapter 51 Neurogenic Bowel & Bladder pg1358 Table 51.3

Answer 27

1. Involuntary bladder contractions causing incontinence. 2. The ability and motivation to perform intermittent catheterizations. 3. The desire to convert from reflex voiding to an intermittent catheterization program. 4. High risk of upper tract deterioration due to hydronephrosis and/or ureterovesical reflux from high pressure detrusor-sphincter dyssnergia.

Answer 28

**Oxybutynin [Ditropan]** **Benefits** 1. Exerts antispasmodic and antimuscarinic effects on smooth muscle 2. Increases bladder capacity 3. Decreases uninhibited contraction 4. Delays desire to void 5. Decreases frequency and urgency **Immediate-release** 5 mg PO twice/three times daily Not to exceed 5 mg PO four times daily **Extended-release** 5-10 mg/day PO; may be increased by 5 mg/day at weekly intervals Not to exceed 30 mg/day **S/E** 1. Dry mouth (21-71%) 2. Constipation (7-15%) 3. Somnolence (2-14%) 4. Nausea (2-12%) [https://reference.medscape.com/drug/ditropan-xl-oxybutynin-343066#0](https://reference.medscape.com/drug/ditropan-xl-oxybutynin-343066#0) **Tamsulosin [Omnic]** **Benefits** 1. Blocks alpha1a adrenergic receptor in smooth muscle of prostate 2. Decreasing bladder neck and urethral resistance **Dose** 0.4 mg PO qDay; take 30 minutes after same meal each day **S/E** 1. Headache (19-21%) 2. Orthostatic hypotension (6-19%) 3. Dizziness (15-17%) 4. Abnormal ejaculation (8-18%) [https://reference.medscape.com/drug/flomax-tamsulosin-342839#10](https://reference.medscape.com/drug/flomax-tamsulosin-342839#10)

6 - Bladder Dysfunction Flashcards

(54 cards)