| Bladder Dysfunction |
- Normal voiding requires coordination of detrusor (smooth muscle of bladder) contraction with internal and external urinary sphincter relaxation.
- Upper Motor Neuron bladder dysfunction is characterized by high pressure from simultaneous detrusor and urinary sphincter contractions, leading to vesicoureteral reflux that can produce renal damage. The spinal cord damage renders the bladder and sphincters spastic.
- Lower Motor Neuron bladder dysfunction is characterized by a large bladder capacity (due to low bladder muscle tone) with intact internal urinary sphincter innervation. The patient is as risk for overflow urinary incontinence and UTIs.
- Urodynamic studies are used to determine abnormalities in the bladder and urethra in the filling/storage phase as well as voiding phase in neurogenic bladder dysfunction. These studies are typically completed at 3 months post injury (Patient must be out of spinal shock).
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| Neurogenic Bladder Care |
- Goals: Preserve renal function, prevent life-threatening complications such as autonomic dysreflexia, and promote continence (Dry between catheterizations).
- Foley
- Foley placement is recommended acutely.
- Discontinue if hemodynamically stable and strict I&Os not required.
- CIC Goal
- Clean intermittent catheterization (CIC) is the standard of care for Upper Motor Neuron neurogenic bladder but may also be indicated in patients with lower motor neuron neurogenic bladder and urinary retention.
- Begin CIC q 4 hours
- Adult sized patient GOAL: < 350-400 mL with each catheterization
- Pediatric patient GOAL: < maximum bladder capacity
- Pediatric Bladder Capacity: (Age (years) +2) x 30 = X mL
- Spontaneous Voiding
- Perform bladder scan for post-void residual (PVR) and every 6 hours without void.
- PVR Goal:
- Adult sized patient: < 100 mL
- Pediatric patient: < 20% bladder capacity
- Straight catheterization recommended if:
- Adult sized patient: PVR > 150 mL or bladder scan > 400 mL
- Pediatric patient: PVR > 25% bladder capacity or bladder scan > 75% bladder capacity
- May discontinue bladder scans when:
- Patient with three true PVR < PVR goal
- Patient without need for straight catheterization in 7 days (If unable to determine timing of void and completing random bladder scans)
- Note: Should continue to monitor and bladder scan for no void in 8 hours
- Troubleshooting
- Note: If incontinent between catheterizations, must determine if due to true void, incomplete void due to spasticity, or leakage due to overflow incontinence or flaccid sphincter. A voiding diary may be helpful.
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Incontinent
Wet between episodes |
PVR |
Management |
| True Void |
No |
0-Very low |
Timed voids |
| Incomplete Void |
No/Yes |
Moderate-high |
CIC +/-
Adjunct Medications |
| Flaccid Sphincter |
Yes |
Low |
Timed voids +/- Maneuvers |
| Overflow Incontinence |
Yes |
Moderate-high |
CIC |
- Adjunct Medications
- Anticholinergics: Oxybutynin (Ditropan)
- MOA – Reduce spastic detrusor muscle to provide bladder relaxation
- Side effects – Dry mouth and eyes, constipation, headache, and tachycardia
- Alpha adrenergic antagonists: Tamsulosin (Flomax)
- MOA – Relax the bladder neck and decrease outflow resistance to decrease incontinence, increase bladder capacity, improve bladder emptying
- Side effects – Postural hypotension and dizziness
- Maneuvers for Flaccid Bladders
- Crede – Manual pressure over suprapubic region to increase vesicular pressure and promote bladder emptying
- Tapping – Tapping over suprapubic region to trigger detrusor contraction
- Valsalva Maneuver – Bearing down to increase vesicular pressure – May also trigger detrusor contraction
- Persistent Incontinence
- Utilize 3-day voiding diary to characterize incontinence
- May require placement of Condom Cath (Males) or Foley Catheter (Male or Females) with persistent incontinence as temporary measure to maintain dry skin and protect against breakdown.
- Other needs for foley or condom cath:
- Significant agitation with CIC
- Urinary abnormalities, consult Urology
- Bladder Management for the Patient with a Neurogenic Bladder
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| Neurogenic Bowel Care |
- Goal: Bowel movement every evening (It may take 21 days or more to establish a reliable bowel program).
- Can be categorized into hyperreflexic or hyporreflexic neurogenic bowel.
- Colonic transit time is doubled (80.7 +/- 11 hours vs 39 +/- 5 hours).
- 80% of children will ultimately require either oral, rectal, or combination medication regimens.
- 3-2-1 Protocol for Upper Motor Neuron Neurogenic Bowel
- An advantage of hyperreflexic NBD is that defecation can be initiated by stimulating the defecatory reflex activity with digital stimulation, rectal stimulant medication, enemas, or electrical stimulation. Rectal medications are used to initiate and maintain reflex defecation. The medication is introduced into the rectum 30 min prior to the intended NB program/care, followed by digital rectal stimulation.
- Softener: Colace TID, BID if loose stool
- Motility: Senna at noon
- Evacuation: Dulcolax suppository (or equivalent polyethylene glycol bisect bisacodyl (i.e., Magic Bullet) and glycerine. Other options include docusate mini-enema (i.e., Enemeez) every evening
- Technique for Suppository Administration
- If prone to autonomic dysreflexia, apply lidocaine jelly onto the rectum 5 minutes prior to digital stimulation and/or insertion of suppository
- For injuries above L1, AFTER resolution of spinal shock, use digital stimulation with slow, gentle rotation of the finger for 15-60 seconds — repeat every 5-10 minutes until stool evacuation complete
- Patient to be sitting on toilet/commode or positioned on left side if completing in bed
- Lower Motor Neuron Neurogenic Bowel Management
- Includes digital evacuation, disimpaction, and/or stool bulking agents. Hyporeflexic NB is exceptionally difficult to manage due to the lack of both PNS and somatic reflex activity.
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