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Bladder involvement in spine disorders

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Bladder involvement in spine disorders

  2. 3. NORMAL BLADDER <ul><li>The bladder and urethra are innervated by 3 sets of peripheral nerves arising from the Autonomic nervous system (ANS) and Somatic nervous system. </li></ul><ul><li>Male have considerable advantage over females in both length and additional sphincter mechanism, which contracts the bladder during ejaculation and erection. </li></ul>
  3. 5. <ul><li>The detrusor fibres in males at the bladder neck form a sphincter which is called the Internal sphincter. </li></ul><ul><li>The External sphincter is a muscle which is under voluntary control. </li></ul>
  4. 6. NEURAL CONTROL OF BLADDER <ul><li>Vesico sympathetic reflex – relaxes the detrusor muscle, and tightens the urethra, it has the inhibitory control on the parasympathetic transmission </li></ul><ul><li>Vesico parasympathetic reflex – contracts detrusor and relaxes the urethra </li></ul><ul><li>Vesicopudendal reflex —motor cells of S3 level, controls the striated muscles of the pelvic floor and the external sphincter and is inhibited during the micturition. </li></ul>
  5. 7. <ul><li>There is less afferent activity while lying down than when standing. </li></ul><ul><li>The basic spinal reflex controls micturition during infancy and unconciousness. </li></ul>
  6. 8. <ul><li>During the course of a day, an average person will void approximately 4-8 times. The urinary bladder is in storage mode for most of the day. </li></ul>
  7. 9. Normal Micturition <ul><li>The pressure gradients within the bladder and urethra play an important role. </li></ul><ul><li>As long as the urethral pressure is higher than that of the bladder, patients will remain continent. </li></ul><ul><li>If the urethral pressure is abnormally low or if the intravesical pressure is abnormally high, urinary incontinence will result . </li></ul>
  8. 10. <ul><li>As the bladder initially fills, a small rise in pressure occurs within the bladder (intravesical pressure). </li></ul><ul><li>When the urethral sphincter is closed, the pressure inside the urethra (intraurethral pressure) is higher than the pressure within the bladder. </li></ul><ul><li>While the intraurethral pressure is higher than the intravesical pressure, urinary continence is maintained. </li></ul>
  9. 11. The normal micturition cycle <ul><li>It requires the urinary bladder and the urethral sphincter to work together as a coordinated unit. </li></ul><ul><li>During urinary storage, the bladder acts as a low-pressure receptacle, while the urinary sphincter maintains high resistance to urinary flow to keep the bladder outlet closed. </li></ul><ul><li>During urine elimination, the bladder contracts to expel urine while the urinary sphincter opens (low resistance) to allow unobstructed urinary flow and bladder emptying </li></ul>
  10. 12. <ul><li>During some physical activities and with coughing, sneezing, or laughing, the pressure within the abdomen rises sharply. </li></ul><ul><li>This rise is transmitted to both the bladder and urethra. </li></ul><ul><li>As long as the pressure is evenly transmitted to both the bladder and urethra, urine will not leak. </li></ul><ul><li>When the pressure transmitted to the bladder is greater than urethra, urine will leak out, resulting in stress incontinence </li></ul>
  11. 13. Continence Mechanism <ul><li>As the bladder fills, the Pudendal nerve becomes excited. </li></ul><ul><li>Stimulation of the Pudendal nerve results in contraction of the external urethral sphincter. </li></ul><ul><li>Coupled with the internal sphincter, maintains urethral pressure (resistance) higher than normal bladder pressure. </li></ul>
  12. 14. Sympathetic nerves <ul><li>Sympathetic nerves facilitate urine storage in the following ways: </li></ul><ul><li>Sympathetic nerves inhibit the parasympathetic nerves from triggering bladder contractions. </li></ul><ul><li>Sympathetic nerves directly cause relaxation and expansion of the detrusor muscle. </li></ul><ul><li>Sympathetic nerves close the bladder neck by constricting the internal urethral sphincter. This sympathetic input to the lower urinary tract is constantly active during bladder filling. </li></ul>
  13. 15. Parasympathetic nerves <ul><li>When the urethral sphincters relax and open, the parasympathetic nerves trigger contraction of the detrusor. </li></ul><ul><li>When the bladder contracts, the pressure generated by the bladder overcomes the urethral pressure, resulting in urinary flow. </li></ul><ul><li>These coordinated series of events allow unimpeded, automatic emptying of the urine. </li></ul>
  14. 17. PATHOPHYSIOLOGY <ul><li>Urinary incontinence results from a dysfunction of the bladder, </li></ul><ul><li>the sphincter, </li></ul><ul><li>or both. </li></ul><ul><li>Bladder overactivity (spastic bladder )- the symptoms of urge incontinence. Sphincter underactivity (decreased resistance ) results in symptomatic stress incontinence. Combination of detrusor overactivity and sphincter underactivity may result in mixed symptoms </li></ul>
  15. 18. CNS LESION Uninhibited Bladder <ul><li>Lesions of the Brain above the Pons , -a complete loss of voiding control. The voiding reflexes of the lower urinary tract—the primitive voiding reflex—remain intact. </li></ul><ul><li>Signs of urge incontinence, or spastic bladder (medically termed detrusor hyperreflexia or overactivity). </li></ul><ul><li>Bladder empties too quickly and too often, with relatively low quantities, and storing urine in the bladder is difficult. </li></ul><ul><li>Always associated with impotence. </li></ul><ul><li>No residual urine therefore little risk of infection. </li></ul>
  16. 19. Spinal Cord Lesion AUTOMATIC BLADDER <ul><li>Also result in Spastic bladder or overactive bladder. </li></ul><ul><li>Paraplegic or quadriplegic have lower extremity spasticity. </li></ul><ul><li>Initially, after spinal cord trauma, the individual enters a spinal shock phase. </li></ul><ul><li>After 6-12 weeks, the nervous system reactivates, it causes hyperstimulation of the affected organs </li></ul>
  17. 20. AUTOMATIC BLADDER <ul><li>These people experience urge incontinence. </li></ul><ul><li>The bladder empties too quickly and too frequently. </li></ul><ul><li>The voiding disorder is similar to that of the brain lesion except that the external sphincter may have paradoxical contractions as well. </li></ul><ul><li>If both the bladder and external sphincter become spastic at the same time, the affected individual will sense an overwhelming desire to urinate but only a small amount of urine may dribble out. </li></ul><ul><li>The term for this is Detrusor-sphincter Dyssynergia because the bladder and the external sphincter are not in synergy. </li></ul><ul><li>Even though the bladder is trying to force out urine, the external sphincter is tightening to prevent urine from leaving. </li></ul>
  18. 21. Sacral cord injury AUTONOMOUS BLADDER <ul><li>If a sensory neurogenic bladder is present, the affected individual may not be able to sense when the bladder is full. </li></ul><ul><li>In the case of a motor neurogenic bladder, the individual will sense the bladder is full and the detrusor may not contract, a condition known as Detrusor Areflexia . </li></ul><ul><li>These individuals have difficulty eliminating urine and experience overflow incontinence; the bladder gradually overdistends until the urine spills out. </li></ul><ul><li>Typical causes are a sacral cord tumor, </li></ul><ul><li>herniated disc, and </li></ul><ul><li>injuries that crush the pelvis. </li></ul><ul><li>This condition also may occur after a lumbar laminectomy. </li></ul>
  19. 22. Diabetes mellitus Tabes and AIDS SENSORY BLADDER <ul><li>The conditions causing peripheral neuropathy resulting in urinary retention. </li></ul><ul><li>May lead to silent, painless distention of the bladder. </li></ul><ul><li>Patients with chronic diabetes lose the sensation of bladder filling first, before the bladder decompensates. </li></ul><ul><li>Similar to injury to the sacral cord, affected individuals will have difficulty urinating. They also may have a hypocontractile bladder. </li></ul><ul><li>They have sensory deafferentation and loss of spinal reflex. </li></ul><ul><li>High residual Urine and infection rates. </li></ul><ul><li>Evacuation is incomplete. </li></ul>
  20. 23. Summary of definitions <ul><li>Neurogenic bladder is a malfunctioning bladder due to any type of neurologic disorder. </li></ul><ul><li>Detrusor hyperreflexia refers to overactive bladder symptoms due to a suprapontine upper motor neuron neurologic disorder. External sphincter functions normally. The detrusor muscle and the external sphincter function in synergy (in coordination). </li></ul><ul><li>DSD-DH refers to overactive bladder symptoms due to neurologic upper motor neuron disorder of the suprasacral spinal cord. </li></ul><ul><li>Paradoxically, the patient is in urinary retention. Both the detrusor and the sphincter are contracting at the same time; they are in dyssynergy (lack of coordination). </li></ul>
  21. 24. <ul><li>Detrusor hyperreflexia with impaired contractility (DHIC) refers to overactive bladder symptoms, </li></ul><ul><li>but the detrusor cannot generate enough pressure to allow complete emptying. </li></ul><ul><li>The external sphincter is in synergy with detrusor contraction. </li></ul><ul><li>The detrusor is too weak to mount an adequate contraction for proper voiding to occur. </li></ul><ul><li>The condition is similar to urinary retention, but irritating voiding symptoms are prevalent. </li></ul>
  22. 25. <ul><li>Overactive bladder refers to symptoms of urinary urgency, with or without urge incontinence, usually associated with frequency and nocturia. The cause may be neurologic or nonneurologic. </li></ul><ul><li>Detrusor areflexia is complete inability of the detrusor to empty due to a lower motor neuron lesion (eg, sacral cord or peripheral nerves). </li></ul>
  23. 26. <ul><li>Detrusor instability refers to overactive bladder symptoms without neurologic impairment. External sphincter functions normally, in synergy. </li></ul>
  24. 27. TREATMENT OF SUPRASPINAL LESIONS <ul><li>The treatment for the cerebral shock phase is indwelling Foley catheter or clean intermittent catheterization (CIC). When the bladder becomes hyperreflexic, institute therapies to facilitate bladder filling and storage with anticholinergic medications </li></ul>
  25. 28. Spinal cord injury <ul><li>The spinal shock phase typically lasts 6-12 weeks; it may be prolonged in some cases. During this time, the urinary bladder must be drained with indwelling urethral catheter. </li></ul>
  26. 29. Spinal cord lesions (above the sixth thoracic vertebrae) <ul><li>A unique complication of T6 injury is Autonomic dysreflexia </li></ul><ul><li>Symptoms of autonomic dysreflexia include sweating, </li></ul><ul><li>headache, </li></ul><ul><li>hypertension, </li></ul><ul><li>and reflex bradycardia. </li></ul>
  27. 30. <ul><li>Acute management of autonomic dysreflexia is to decompress the rectum or bladder. </li></ul><ul><li>Decompression usually will reverse the effects of unopposed sympathetic outflow. If additional measures are required, parenteral ganglionic or adrenergic blocking agents, such as chlorpromazine, may be used </li></ul>
  28. 31. Spinal cord lesions (below T6) <ul><li>Individuals who sustain spinal cord lesions below T6 level will have urodynamic findings of </li></ul><ul><li>Detrusor Hyperreflexia , </li></ul><ul><li>Striated sphincter dyssynergia , and </li></ul><ul><li>Smooth sphincter dyssynergia </li></ul><ul><li>but no Autonomic dysreflexia </li></ul><ul><li>Cornerstone of treatment involves CIC and anticholinergic medications </li></ul>
  29. 32. OTHER CONDITIONS <ul><li>Multiple sclerosis -Detrusor Hyperreflexia </li></ul><ul><li>Diabetic cystopathy -Detrusor Areflexia </li></ul><ul><li>Herniated disc -Detrusor Areflexia with intact bladder sensation. Associated internal sphincter denervation </li></ul>
  30. 33. Lab studies <ul><li>Urinalysis and urine culture : Urinary tract infection can cause irritative voiding symptoms and urge incontinence. </li></ul><ul><li>Urine cytology : Carcinoma-in-situ of the urinary bladder causes symptoms of urinary frequency and urgency. Irritative voiding symptoms out of proportion to the overall clinical picture and/or hematuria warrant urine cytology and cystoscopy. </li></ul><ul><li>Chem profile : Blood urea nitrogen (BUN) and creatinine (Cr) are checked if compromised renal function is suspected </li></ul>
  31. 34. PVR <ul><li>The postvoid residual urine (PVR) measurement is a part of basic evaluation for urinary incontinence. </li></ul><ul><li>If the PVR is high, the bladder may be contractile or the bladder outlet may be obstructed. Both of these conditions will cause urinary retention with overflow incontinence. </li></ul>
  32. 35. INVESTIGATIONS <ul><li>Low uroflow rate may reflect urethral obstruction, a weak detrusor, or a combination of both. This test alone cannot distinguish an obstruction from a contractile detrusor. </li></ul><ul><li>EMG allows accurate diagnosis of detrusor sphincter dyssynergia common in spinal cord injuries. </li></ul>
  33. 36. Medical care <ul><li>Stress incontinence may be treated with surgical and nonsurgical means. </li></ul><ul><li>Urge incontinence may be treated with behavioral modification or with bladder-relaxing agents. </li></ul><ul><li>Mixed incontinence may require medications as well as surgery. </li></ul><ul><li>Overflow incontinence may be treated with some type of catheter regimen. </li></ul><ul><li>Functional incontinence may be resolved by treating the underlying cause, such as urinary tract infection, constipation, or by simply changing a few medications. </li></ul>
  34. 37. <ul><li>Do not consider anti-incontinence products to be a cure-all for urinary incontinence. </li></ul><ul><li>Use of pads and devices to contain urine loss and maintain skin integrity. </li></ul><ul><li>Absorbent pads and internal and external collecting devices have a role in the management of chronic incontinence. </li></ul>
  35. 38. Catheters <ul><li>Urinary diversion, using various catheters, has been one of the mainstays of anti-incontinence therapy. </li></ul><ul><li>The use of catheters for bladder drainage has withstood the test of time. </li></ul><ul><li>Bladder catheterization may be a temporary measure or a permanent solution for urinary incontinence. </li></ul>
  36. 40. Types of Bladder Catheterization <ul><li>Indwelling urethral catheters. </li></ul><ul><li>Suprapubic tubes. </li></ul><ul><li>Self-intermittent catheterization </li></ul>
  37. 41. Indwelling urethral catheters <ul><li>Commonly known as Foley Catheters , indwelling urethral catheters have been the mainstay of treatment for bladder dysfunction. </li></ul><ul><li>They must be changed monthly. </li></ul><ul><li>The standard catheter size for treating urinary retention is 16F or 18F, with a 5-mL balloon filled with 10 ml. of sterile water. </li></ul><ul><li>Larger catheters ( 22F, 24F) with bigger balloons are used for treating grossly bloody urine found in other urologic conditions or diseases. </li></ul>
  38. 42. <ul><li>The catheter and bag are replaced on a monthly basis. </li></ul><ul><li>Catheters that develop encrustations and problems with urine drainage must be changed more frequently. </li></ul><ul><li>All indwelling catheters in the urinary bladder for more than 2 weeks become colonized with bacteria. </li></ul><ul><li>Bacterial colonization does not mean the patient has clinical bladder infection. </li></ul>
  39. 43. <ul><li>Symptoms of bladder infection include foul odour, purulent urine, and hematuria. Fever with flank pain often present. </li></ul><ul><li>If bladder infection occurs, change the entire catheter and the drainage system. </li></ul><ul><li>The urinary drainage bag does not need to be disinfected to prevent infection </li></ul>
  40. 44. CATHETER CARE <ul><li>Routine irrigation of catheters is not required. use of 0.25% acetic acid. </li></ul><ul><li>Irrigation because it is bacteriostatic, minimizes catheter encrustation, and diminishes the odor. </li></ul><ul><li>When used, 30 ml. is instilled into the bladder and allowed to freely drain on a twice daily basis </li></ul>
  41. 45. <ul><li>Patients do not have to take continuous antibiotics while using the catheter. </li></ul><ul><li>Continuous antibiotic therapy is contraindicated while a catheter is used. that are resistant to common antibiotics. </li></ul><ul><li>Indwelling use of a Foley catheter in individuals who are homebound requires close supervision by a visiting nurse and additional personal hygiene care. </li></ul>
  42. 46. <ul><li>Chronic dependence on these catheters is extremely risky. </li></ul><ul><li>Indwelling urethral catheters are a significant cause of urinary tract infections that involve the urethra, bladder, and kidneys. </li></ul><ul><li>Within 2-4 weeks after catheter insertion, bacteria will be present in the bladder of most women. </li></ul><ul><li>Asymptomatic bacterial colonization is common and does not pose a health hazard. </li></ul><ul><li>Untreated symptomatic urinary tract infections may lead to urosepsis and death. </li></ul>
  43. 47. PROBLEMS OF CATHETER <ul><li>Other problems associated with indwelling urethral catheters include encrustation of the catheter, bladder spasms resulting in urinary leakage, hematuria, and urethritis. </li></ul><ul><li>More severe complications include formation of bladder stones, development of periurethral abscess, renal damage, and urethral erosion. </li></ul>
  44. 48. Suprapubic Catheters <ul><li>A suprapubic tube is an alternative to long-term urethral catheter use. </li></ul><ul><li>In paraplegic and quadriplegic in the form of urinary diversion. </li></ul><ul><li>When suprapubic tubes are needed, usually smaller (eg, 14F, 16F) catheters are placed. </li></ul><ul><li>Like the urethral catheter, change the suprapubic tube once a month on a regular basis. </li></ul>
  45. 50. Indications for suprapubic catheters <ul><li>Short-term use- - Gynecologic, Urologic, other types of surgery. A suprapubic tube does not prevent bladder spasms from occurring in unstable bladders nor does it improve the urethral closure mechanism in an incompetent urethra. </li></ul>
  46. 51. CONTRAINDICATIONS <ul><li>Chronic unstable bladders. </li></ul><ul><li>Intrinsic sphincter deficiency because involuntary urine loss is not prevented. </li></ul>
  47. 52. <ul><li>Mode of draining the bladder at timed intervals. A prerequisite for self-catheterization is the patients' ability to use their hands and arms. </li></ul><ul><li>The best solution for bladder decompression of a motivated individual. </li></ul>INTERMITTENT CATHETERIZATION
  48. 53. <ul><li>Many studies with spinal cord injuries have shown that intermittent catheterization is preferable to indwelling catheters. Intermittent catheterization has become a healthy alternative with chronic urinary retention due to-- obstructed bladder, a weak bladder, a nonfunctioning bladder. Young children with myelomeningocele </li></ul>
  49. 54. <ul><li>Intermittent catheterization may be performed by: </li></ul><ul><li>using a soft, red, rubber catheter or a short, rigid, plastic catheter. </li></ul><ul><li>The use of plastic catheters is preferable to red rubber catheters because they are easier to clean and last longer. </li></ul>
  50. 55. PRINCIPLES OF SELF CATHETERIZATION <ul><li>The bladder must be drained on a regular basis, either based on a timed interval. (eg, on awakening, every 3-6 hours during the day, and before bed) or based on bladder volume. </li></ul><ul><li>Ideally the amount drained each time should not exceed 400-500 mL. </li></ul><ul><li>If catheterization is performed every 6 hours and the amount drained is 700 mL, Ideal is to drain every 4 hours to maintain the volume drained at 400-500 mL. </li></ul>
  51. 56. <ul><li>Studies show that in patients with spinal cord injuries, the incidence of bacteria in the bladder is 1-3% per catheterization and 1-4 episodes of bacteriuria occur per 100 days of intermittent catheterization performed 4 times a day. </li></ul>
  52. 57. <ul><li>For the older population and individuals with a weak immune system, the sterile technique of intermittent catheterization has been recommended. </li></ul>
  53. 58. Complications <ul><li>Bladder infection, </li></ul><ul><li>Urethral trauma, </li></ul><ul><li>Urethral inflammation, and </li></ul><ul><li>Stricture. Concurrent use of anticholinergic therapy will maintain acceptable intravesical pressures and prevent bladder contracture. </li></ul>
  54. 59. Surgical care <ul><li>Surgical care for stress incontinence involves procedures that increase urethral outlet resistance. </li></ul><ul><li>Operations that increase urethral resistance include bladder neck suspension, periurethral bulking therapy, sling procedures, and artificial urinary sphincter. </li></ul><ul><li>Surgical care for urge incontinence involves procedures that improve bladder compliance or bladder capacity; these include sacral neuromodulation, botulinum toxin injections, detrusor myomectomy, and bladder augmentation. </li></ul>
  55. 60. Pelvic muscle exercises <ul><li>Pelvic floor muscle exercises are performed by drawing in or lifting up the levator ani muscles as if to control urination or defecation with minimal contraction of abdominal, buttock, or inner thigh muscles </li></ul><ul><li>Biofeedback therapy is a form of pelvic floor muscle rehabilitation using an electronic device for individuals having difficulty identifying levator ani muscles </li></ul><ul><li>Studies on biofeedback combined with pelvic floor exercises show a 54-87% improvement with incontinence </li></ul>