NEUROGENIC BLADDER AND BLADDER TRAINING TRI DAMIATI P

NEUROGENIC BLADDER AND BLADDER TRAINING TRI DAMIATI P , M. D. . Physiatrist Dept. of Physical Medicine and Rehabilitation School of Medicine, Padjadjaran University Dr. Hasan Sadikin General Hospital

anatomy

NORMAL VOIDING PHYSIOLOGY n TWO PHASES • THE FILLING ( STORAGE ) n OCCURS WHEN A PERSON IS NOT TRYING TO VOID • THE EMPTYING ( VOIDING ) n OCCURS WHEN A PERSON IS ATTEMPTING TO VOID OR TOLD TO VOID

NORMAL VOIDING PHYSIOLOGY cont… n DURING FILLING / STORAGE PHASE • SHOULD BE VERY LITTLE RISE IN BLADDER PRESSURE • PROGRESSIVE INCREASE IN SYMPATHETIC STIMULATION OF THE BETA RECEPTOR • RELAXATION ALPHA RECEPTORS → CONTRACTION OF THE URETHRA

NORMAL VOIDING PHYSIOLOGY cont… n DURING FILLING / STORAGE PHASE cont… • INHIBITS EXITATORY PARASYMPATHETIC GANGLIONIC TRANSMISSION → SUPRESS BLADDER CONTRACTION • PROGRESSIVE INCREASE IN URETHRAL SPHINCTER EMG ACTIVITY

NORMAL VOIDING PHYSIOLOGY cont… n VOIDING / EMPTYING PHASE • SHOULD BE CESSATION OF URETHRAL SPHINCTER ACTIVITY • URETHRAL SPHINCTER PRESSURE DROP • FUNNELING OF THE BLADDER NECK

NORMAL VOIDING PHYSIOLOGY cont… n VOIDING / EMPTYING PHASE cont… • NO LONGER REFLEX INHIBITION TO THE SACRAL MIXTURITION CENTER FROM THE SPHINCTER MECHANISM • FOLLOWED BY THE BLADDER CONTRACTION • THE URETHRAL SPHINCTER REMAIN OPEN THROUGHOUT VOIDING

NORMAL VOIDING PHYSIOLOGY cont… n VOIDING / EMPTYING PHASE cont… • SHOULD BE NO RISES IN INTRA ABDOMINAL PRESSURE DURING VOIDING • NO POSTVOID RESIDUAL URINE

CLASSIFICATION OF VOIDING DYSFUNCTION • WIDE VARIETY OF CLASSIFICATION • IDEALLY THE SYSTEM SHOULD DISCRIBE n n THE TYPE OF NEUROLOGIC LESION CLINICAL SYMPTOMS URODYNAMIC DATA TREATMENT OPTION • SINGLE CLASSIFICATION FOCUSING ON ALL THESE FACTOR DOES NOT EXIST

CLASSIFICATION OF VOIDING DYSFUNCTION cont… n URODYNAMIC AND FUNCTIONAL CLASSIFICATION • INCONTINENCE • RETENTION AN INCONTINENCE

CLASSIFICATION OF VOIDING DYSFUNCTION cont… n INCONTINENCE • CAUSED BY BLADDER n n UNHIBITED CONTRACTING DECREASE CAPACITY LOW COMPLIANCE NORMAL --- COGNITIVE / MOBILITY ISSUE • CAUSED BY THE OUTLET n n DECREASE BLADDER NECK PRESSURE DECREASE EXTERNAL SPHINCTER PRESSURE

CLASSIFICATION OF VOIDING DYSFUNCTION cont… n RETENTION • CAUSED BY THE BLADDER n n n DETRUSSOR AREFLEXIA LARGE CAPACITY / HIGH COMPLIANCE NORMAL → COGNITIVE / MOBILITY ISSUE • CAUSED BY THE OUTLET n n HIGH VOIDING PRESSURE WITH LOW FLOW RATE INTERNAL SPHINCTER DYSINERGIA EXTERNAL SPHINCTER DYSINERGIA OVERACTIVE SPHINCTER MECHANISM

CLASSIFICATION OF VOIDING DYSFUNCTION cont… n RETENTION AND INCONTINENCE • CAUSED BY THE BLADDER n UNINHIBITED CONTRACTION WITH UNDER ACTIVE DETRUSOR

TREATMENT OPTION FOR VOIDING DISORDERS • INCONTINENCE CAUSED BY THE BLADDER n n SCHEDULED VOIDING INTERMITTENT CATHETERIZATION / INDWELLING CATHETER / EXTERNAL CONDOM / DIAPERS PHARMACOLOGIC SURGICAL

TREATMENT OPTION FOR VOIDING DISORDERS cont… n INCONTINENCE CAUSED BY THE SPHINCTER • SCHEDULED VOIDING • PELVIC FLOOR EXERCISES / BIOFEEDBACK • INTERMITTENT CATHETERIZATION / INDWELLING CATHETER / EXETERNAL CONDOM / DIAPERS • PHARMACOLOGIC • SURGICAL

TREATMENT OPTION FOR VOIDING DISORDERS cont… n RETENTION CAUSED BY THE BLADDER • SCHEDULED VOIDING COMBINED WITH n n n SUPRA PUBIC TAPPING VALSAVA CREDE • INTERMITTENT CATHETERIZATION / INDWELLING CATHETER • PHARMACOLOGIC • SURGICAL

TREATMENT OPTION FOR VOIDING DISORDERS cont… n RETENTION CAUSED BY SPHINCTER / OUTLET • SUPRAPUBIC TAPPING / BIOFEEDBACK • INTERMITTENT CATHETERIZATION / INDWELLING CATHETER • PHARMACOLOGIC • SURGICAL

TRAUMATIC SCI (SPINAL CORD INJURY) • THE MOST SCI IS SUPRA SACRAL LESION • TYPE UPPER MOTORNEURON • CAN BE A DETRUSOR HYPERREFLEXIA WITH DETRUSOR SPHINCTER DYSINNERGIA • INITIAL PERIOD OF SCI IS SPINAL SHOCK HYPOREFLEXIA OF SOMATIC SYSTEM n DETRUSOR AREFLEXIA n

TRAUMATIC SCI (SPINAL CORD INJURY) cont… • RECOVERY OF BLADDER FUNCTION USUALLY FOLLWS RECOVERY OF SKELETAL MUSCLE REFLEXES • UNHIBITED BLADDER CONTRATION GRADUALLY RETURN AFTER 6 – 8 WEEKS

BLADDER TRAINING CONSIST OF: • SCHEDULED VOIDING • PELVIC FLOOR EXERCISE • SUPRA PUBIC TAPPING , VALSAVA , CREDE • INTERMITTENT CATHETERIZATION

BLADDER TRAINING cont… n SCHEDULED VOIDING • TIMED VOIDING, THEY ARE TOUHGT TO VOID BEFORE REACHING THEIR FULL CAPACITY - UNHIBITED BLADDER • PROGRESSIVELY INCREASING THE TIME BETWEEN VOIDING

BLADDER TRAINING cont… n n PELVIC FLOOR MUSCLES EXERCISES / KEGEL EXERCISES OBJECTIVE : • TO STRENGTHEN THE PELVIC FLOOR MUSCLES n PELVIC FLOOR MUSCLES CONSIST OF: • • • PUBOCOCCYGEUS ILIOCOCCYGEUS ISCHIOCOCCYGEUS

BLADDER TRAINING cont… PELVIC FLOOR MUSCLES EXERCISES n THE FUNCTION OF PELVIC FLOOR MUSCLES: • PROVIDE SUPPORT FOR THE PELVIC VISCERA AS WE STAND UPRIGHT, AND SUPPURT FOR THE BLADDER NECK AND THE URETHROVESICULAR ANGLE WHICH IS VITAL IMPORTANCE FOR CONTINENCE • CLOSING FORCE ALONG URETHRAL WALL ESPECIALLY WHENEVER THERE IS AN INCREASE IN INTRA ABDOMINAL PRESSURE • THE SEXUAL FUNCTION CORRELATION BETWEEN STRENGHT AND ACHIEVES ORGASM

BLADDER TRAINING cont… PELVIC FLOOR MUSCLES EXERCISES n HOW TO DO KEGEL EXERCISE: • FIND THE RIGHT MUSCLES, by: n n TRY TO STOP THE FLOW OF URINE INSERT A FINGER INSIDE YOUR VAGINA AND TRY TO SQUEEZE USING THE BIOFEEDBACK TECHNIQUE IMAGINE THAT YOU ARE TRYING TO STOP PASSING GAS

BLADDER TRAINING cont… PELVIC FLOOR MUSCLES EXERCISES n THE TECHNIQUE OF EXERCISE • THE PATIENTS HAVE TO BE ABLE TO CONSISTENLY ISOLATE THE PELVIC MUSCLE • ESTABLISH THE INDIVIDUALIZED EXERCISE PROGRAM BASE ON THE PATIENT’S INITIAL STRENGTH AND ENDURANCE • AS THE PATIENT’S CONTRACTILITY AND ENDURANCE PROGRESS, THE NUMBER OF REPETIONS IS INCREASED • MOST CLINICIANS RECOMMEND A TARGET RANGE OF 30 TO 45 REPETITIONS PER DAY AND ARE DIVIDED INTO 3 TIMES AND PERFORM IN RECLINING , SITTING AND STANDING POSITION

BLADDER TRAINING cont… INTERMITTENT CATHETERIZATION n n STERIL INTERMITTENT CATHETERIZATION CLEAN INTERMITTENT CATHETERIZATION (CIC)

BLADDER TRAINING cont… CLEAN INTERMITTENT CATHETERIZATION (CIC) - IS CONDUCTED FROM 6. 00 – 22. 00 - INTAKE OF FLUIDS 100 CC – 125 CC /HOUR LAST INTAKE AT DINNER TIME ABOUT 19. 00 - ATTEMP TO VOID SPONTANEOUSLY - POST VOID RESIDUALS (PVR) IS MEASURED THROUGH CATHETERIZATION WITH A NELATON CATHETER

BLADDER TRAINING cont… CLEAN INTERMITTENT CATHETERIZATION (CIC) • VOLUME OF PVR WILL DETERMINE THE FREQUENCY OF CATETERIZATION DURING DAY TIME • CATHETERIZATION AT NIGHT IS SITUATIONAL • DO THE CATHETERIZATION AS IN MODUL SKILL LAB • USING THE SURGICAL GLOVES IS OPTIONAL

BLADDER TRAINING cont… CLEAN INTERMITTENT CATHETERIZATION (CIC) PVR MONITORING CHART PVR CATHETERIZATION > 200 cc Every 4 Hrs 100 – 200 cc Every 6 Hrs 50 – 100 cc Every 8 Hrs < 50 cc Free

BLADDER TRAINING cont… THE GOALS OF INTERMITTENT CATHETERIZATION n Completely and regularly emptying of the bladder n Avoiding impairment of the kidneys, caused by urine reflux n Free of indwelling or intermittent catheterization