Bladder Incontinence In Spinal Cord Injuries

BLADDER INCONTINENCE IN SPINAL CORD INJURIES

• Following spinal shock, one of two types of bladder conditions will develop, depending on location of lesions i.e. 1. LMN Bladder 2. UMN Bladder

LMN BLADDER (FLACCID BLADDER) OTHER NAMES: - OVERFLOW INCONTINENCE - NON RELFEX BLADDER - AUTONOMOUS BLADDER

• Lesion - conus medullaris or cauda equina • SCI at the micturation reflex center (S2S4), generally involving T12 vertebral injury or below – results LMN bladder • Hence, the bladder becomes flaccid. • Now due to destruction of sensory nerve fibers from the urinary bladder to SC, overdistention of the bladder takes place.

• So there is no inhibition of pudendal nerve and the external sphincter remains in contracted state. • Hence leads to overflow incontinence. • There is no reflex activity of the detrusor muscle.

LMN BLADDER (FLACCID BLADDER) • In this condition, patients never feel the urge to urinate, the bladder never empties, and small amounts of urine leak continuously.

Symptoms include the following: • • • •

Bladder never feels empty Frequent night time urinate Inability to void, even when the urge is felt Urine dribbles, even after voiding

UMN BLADDER (SPASTIC BLADDER) OTHER NAMES: - URGE INCONTINENCE - REFLEX BLADDER - AUTOMATIC BLADDER

• Lesion - above the conus medullaris or cauda equina • SCI above the micturition reflex center (S2-S4), generally involving T11-T12 vertebral injury or above – results in UMN bladder • Hence, the bladder becomes spastic.

• So even a small amount of urine inside the bladder is oversensitive and sensory impulses are sent from bladder to SC. • Inhibition of pudendal nerve and external sphincter relaxes. Voiding of urine takes place. • Hence leads to urge incontinence. • The reflex arc is intact with this type of injury.

UMN BLADDER (SPASTIC BLADDER) • Urge incontinence is characterized by a sudden uncontrollable urge to urinate and frequent urination. It is often necessary to use a bathroom as frequently as every 2 hours, and bed-wetting is common. • With urge incontinence, the bladder contracts and squeezes out urine involuntarily. Sometimes a large amount of urine is released.

• Accidental urination can be triggered by  sudden change in position or activity,  hearing or touching running water, and  drinking a small amount of liquid.

LMN BLADDER

UMN BLADDER

Lesion – at conus medullaris or cauda equina

Lesion - above the conus medullaris or cauda equina

SCI at the micturation reflex center (S2-S4), generally involving T12 vertebral injury or below.

SCI above the micturition reflex center (S2-S4), generally involving T11-T12 vertebral injury or above.

Hence LMN bladder

Hence UMN bladder

LMN BLADDER Overdistention of bladder - due to destruction of sensory nerve fibers from the urinary bladder

UMN BLADDER Bladder is oversensitive - sensory nerve fibers from bladder to spinal cord intact.

No inhibition of pudendal Inhibition of pudendal nerve and the external nerve and external sphincter remains in sphincter relaxes. contracted state. No reflex activity

The reflex arc is intact

MANAGEMENT FOR LMN BLADDER

Medication • Alpha-1-adrenergic blocking agents • Anticholinergic medication

Intermittent SelfCatheterization • Intermittent self-catheterization is a safe and effective method of completely emptying the bladder every 3 to 8 hours, or as recommended by a physician, to keep urine volume low.

Intermittent Catheter

• It is more important to empty your bladder than to have an absolutely clean catheter. • The risk for infection is greater from a full bladder than from an unwashed catheter.

Physiotherapy Management 1. Stimulation of detrusor contractions •

Some patients, especially those with acquired cord lesions, can induce a useful ‘reflex’ detrusor contraction by suprapubic tapping or by perianal stimulation, and occasionally the external urethral sphincter can be made to relax by similar maneuvers.

• These measures can form part of a comprehensive bladder ‘retraining’ which has been found to be of value in some patients with spinal injury.

2. External compression and abdominal straining • Manual compression of the bladder by suprapubic pressure (Crede’s maneuver) can raise the intravesical pressure to 50 mm H2O or more and empty the bladder in patients who have some degree of sphincter weakness.

• Similar pressures can also be achieved by abdominal straining when there is sufficient control of the muscles of the anterior abdominal wall.

Surgical Management Artificial bladder sphincter replacement Definition

• Artificial sphincter insertion surgery is the implantation of an artificial valve in the genitourinary tract to restore continence and psychological well being to individuals with urinary sphincter insufficiency that leads to severe urinary incontinence.

• Implantation surgery related to urinary sphincter incompetence is also called artificial sphincter insertion or inflatable sphincter insertion. • The artificial urinary sphincter (AUS) is a small device placed under the skin that keeps pressure on the urethra until there is a decision to urinate, at which point a pump allows the urethra to open and urination commences.

MANAGEMENT FOR UMN BLADDER • Avoid over consumption of diuretics, antidepressants, antihistamines, and cough-cold preparations. • Eat fruits, vegetables, and whole grains daily to prevent constipation. • Stop smoking (nicotine irritates the bladder).

Medication •

The various drugs used are: a. Anticholinergic Agents a. Propantheline bromide c. Oxybutynin chloride

d. Muscarinic receptor antagonist e. Oxybutynin transdermal system f. Antispasmodic Medications g. Tricyclic Antidepressants h. Alpha-1-adrenergic blocking agents

• A number of protective devices are available to help manage accidental urination, including the following:  Bed pads  Combination pad-pant systems  Disposable or reusable adult diapers  Full-length absorbent undergarments

Bed Pad

Disposable Adult Diapers

Physiotherapy Management 1. Bladder Training with Timed Voiding • The patient keeps a voiding diary of all episodes of urination and leaking, and the physician analyzes the chart and identifies the pattern of urination.

• The patient uses this timetable to plan when to empty the bladder to avoid accidental leakage. • In bladder training, biofeedback and Kegel exercise help the patient resist the sensation of urgency, postpone urination, and urinate according to the timetable.

• Such measures involve the imposition of a regime of micturation by the clock with increasing gaps between voids. • To be successful, in demands a high degree of patient compliance as well as expert supervision.

2. Kegel exercises • Kegel exercises strengthen the pelvic floor muscles to help improve bladder control for people suffering from urinary incontinence. • The name of the muscle group strengthened through Kegel exercises is the pubococcygeous muscle group.

• These muscles relax under your command, to control the opening and closing of your urethral sphincter: in other words, they are the muscles that give you urinary control. • When they are weak, leakage occurs. Through regular exercise, however, you can build up their strength and endurance and, in many cases, regain control.

• The first step is to properly identify the muscle group to be exercised. a. As you begin urinating, try to stop the flow of urine without tensing the muscles of your legs. It is very important not to use these other muscles, because only the pelvic floor muscles help with bladder control.

b. When you are able to slow or stop the stream of urine you have located the correct muscles. Feel the sensation of the muscles pulling inward and upward.

• Helpful hint . . . If you squeeze the rectal area as if not to pass gas, you will be using the correct muscles. • Now you are ready to begin exercising regularly. • Once you have located the correct muscle, set aside two times each day for exercising.

• Set 1: Quick Contractions (QC) -- tighten and relax the sphincter muscle as rapidly as you can. • Set 2: Slow Contractions (SC) -- contract the sphincter muscle and hold to a count of 3 (gradually work at increasing the count to 10). Make sure you relax completely between contractions.

• In the beginning you should check yourself frequently by placing a hand over your abdomen and buttocks during your exercises. • You should not feel the muscles of your abdomen, buttocks, or thighs tighten. If there is movement of these muscles you should continue experimenting until you are able to isolate the pelvic floor muscles.

• You should see improvement of your bladder control in 3 to 6 weeks. Keep a record of urine leakage to monitor your progress. • Make pelvic exercises a part of your daily routine. • Use daily routines such as watching TV, reading, waiting at stoplights and waiting in the grocery store checkout line as cues to perform a few exercises.

REFERENCES • www.urologychannel.com • www.surgeryencyclopedia.com • Susan B O’Sullivan

By: Dr. Suketu Shah Content Owner – www.findphysio.com Srinivas College Of Physiotherapy

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