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Bladder Management

Anyone can be affected by bladder dysfunction. Common healthcare issues that are associated with bladder issues are enlarged prostate, hormonal changes in women, obesity, constipation, diabetes issues affecting cognition such as Alzheimer’s disease and other dementia, and neurological diseases and injury for example, spinal cord injury, multiple sclerosis and Parkinson’s disease. Lifestyle factors can affect bladder function such as smoking, inactivity, over consumption of alcohol and sugary drinks, or a protein-based diet. Urinary issues can result as a side effect of certain medications. At times, the reason for bladder dysfunction is unclear.

How the Urinary System Works

Removing waste from the body is an important step in maintaining health. The urinary system consists of organs that complete this process. Removal of liquid waste from the body is a major function but also the urinary system is responsible for regulation of blood volume, blood pressure, and the chemical components of the body.

Elimination of liquid waste from the body begins with the kidneys. These are two organs, one on each side of the body at the back and bottom of the ribcage. Kidneys are in constant motion filtering blood. It does not matter what you are doing, the kidneys are filtering blood. The kidneys do slow their work at night due to certain hormones like vasopressin (antidiuretic hormone, ADH), so you do not have to wake up at night to toilet if you do not have bladder dysfunction.

On a typical day, the kidneys filter about 1,700 liters or about seven cups of blood. The waste collected from blood by the kidneys becomes urine. The kidneys are controlled by the autonomic nervous system which is the part of the nervous system that causes the body to work automatically, or without your conscious control.

From each kidney is a long muscular tube, called a ureter, that extends to the bladder. The ureters transport urine from the kidneys to the bladder. They are designed to work with a one-way flow from a kidney to the bladder using peristalsis or muscular contractions. The ureters are also controlled by autonomic nervous system through the pelvic splanchnic nerves and from the inferior hypogastric plexus. However, the peristalsis action is from pacemaker cells within the ureter.

Once the urine enters the bladder, it is stored there until an appropriate time to release it. The bladder is a single organ at the bottom of the abdomen on the pelvic floor, just above the pubic bone. The bladder is medically called the detrusor muscle. The bladder will stretch as it fills with urine and contract as urine is emptied from it. As urine collects in the bladder, very slight contractions are triggered. These contractions become stronger as the bladder fills. The brain interprets the contractions to signal when it is time to empty the bladder.

Maximum capacity of the adult bladder is between 300-500ccs or 13 to 29 ounces. Overfilling of the bladder can lead to serious issues and consequences. Average amounts of urine in adults should be approximately two cups with slight variations in individuals. In children, bladder capacity is related to age but also affected by the child’s size. Estimation of pediatric bladder capacity is calculated using the formula: child’s age in years plus 2 and then multiple by 30. (AGE + 2)30 = pediatric bladder capacity in ccs. Alternatively, AGE + 2 provides the child’s bladder size in ounces.

The bladder consists of smooth muscle which is controlled by the autonomic nervous system, the sympathetic nerves of L2 and the parasympathetic nerves at S2,3,4. The sympathetic system regulates urine storage. The parasympathetic system controls bladder contractions and storage of urine. The pudendal nerve also exiting the spine at S2,3,4 also plays a part, especially in the external urinary sphincter.

The bladder has three openings, two at the top where the ureters enter to deliver urine from the kidneys and one at the base of the bladder for urine excretion. This opening for urine removal is called the urethra. The urethra is about eight inches long in males as it travels the length of the penis. In women, the urethra is about one and a half inches long.

The urethra contains two sphincters (circular muscles). The internal bladder sphincter is at the opening of the bladder. It is a part of the bladder muscle. It is under the control of the autonomic nervous system which means a person does not have voluntary control over it. When the bladder contractions are strong enough, urine will automatically flow out through the internal bladder sphincter. The second sphincter, the external sphincter is made of skeletal muscle which is under control of the somatic part of the nervous system. Somatic nerves are under your volitional control. You open and close the external sphincter muscle when you choose to empty urine from your bladder. The pudendal nerve also exiting the spine at S2,3,4 is the motor nerve for the external urinary sphincter.

In summary, the kidneys create urine, the ureters move the urine from the kidneys to the bladder, the bladder stores urine. When the urine is ready to be eliminated, the internal and external sphincters open, the bladder wall contracts, and urine is expelled. After urination is completed, the sphincters close so the bladder can again store urine. All of this must occur in precision and orderly coordination.

Please note for the following graphic that micturition is another word for urination.

Neural Control of Micturition graphic

Bladder Dysfunction

Issues of the bladder fundamentally appear in two ways, incontinence and retention. Urinary incontinence is an inability to control urine output until a socially acceptable moment. Urinary retention is an inability to empty the bladder either partially or fully. As nothing is simple in body function, a combination of retention and incontinence can occur. The source of urinary dysfunction leads to treatments.

Bladder dysfunction stems from a mismanagement by the body to regulate bladder contractions with sphincter function. This can be a result of many factors including illness and neurological issues. Bladder contractions that overpower the strength of the sphincters or weak sphincters can lead to urinary incontinence. Obstruction can lead to urinary retention. Issues with the central nervous system (CNS) causing miscommunication between the bladder and sphincters can lead to retention or neurogenic bladder.

There are several issues that can result from urinary system dysfunction.

Bladder atrophy is a small bladder that remains contracted. It is a result of not exercising the bladder with its stretch and contract ability. This most often occurs due to long term catheter placement either through the urethra or suprapubic opening which leads to immediate removal of urine rather than allowing bladder filling prior to emptying.

Bladder enlargement (hypertrophy) is thickened bladder muscle wall due to overstretching. Constantly over filling the bladder without emptying causes the muscles of the bladder wall to overstretch causing it to become thicker. The most common cause is obstruction but can be from neurological causes as well. A person with bladder hypertrophy has difficulty emptying the bladder and feels like they need to toilet often and has a slow stream.

Autonomic Dysreflexia (AD) Individuals with spinal cord injury, brain injury and those with medical diagnoses that affect the spinal cord can have disruptions in the autonomic nervous system (ANS). This is a miscommunication from the body below the level of spinal cord injury, usually at T6 or above. The body senses something is wrong but cannot identify the issue. Therefore, it triggers the ‘fight or flight’ response. Issues with the bladder are the primary source of AD. It is a medical emergency where the blood pressure becomes elevated 40 or more in systolic pressure (the top number) of the individual’s average blood pressure. The trigger needs to be found and removed.

Cancer of the Urinary System can develop in anyone. Risk factors include smoking (50% of bladder cancer is caused from smoking), exposure to toxic chemicals, some forms of radiation, and long-term infections. Previously, catheterization was a risk but is no longer since latex was removed from catheterization supplies.

Detrusor Sphincter Dyssynergia (DSD) occurs when the bladder muscle contractions do not work in harmony with the urethral sphincter. Either the bladder muscle will contract while the sphincter remains closed or the sphincter will open without successful bladder contractions for urine expulsion. A contracting bladder and closed sphincter can lead to reflux in the kidneys.

Infection of male anatomy Bacteria can spread from the urinary system to and from male organs as they share a communicating passage. This can include prostatitis, epididymitis and epididymo-orchitis (inflammation of the testis).

Kidney dysfunction and damage is caused when urine backs up in the urinary system, from infection and disease. The flow of urine is from the kidneys through the ureters to the bladder. However, backflow due to high pressure in the bladder or an obstruction that does not allow the natural passage of urine will cause urine to store in the kidneys where there is no capacity to do so. Diseases, such as diabetes and hypertension, also affect the ability of kidneys to function. Keeping the kidneys healthy is a priority in bladder management.

Obstruction can occur as a blockage in the kidneys, ureters, or urethra so that urine cannot pass through that part of the system. This can be from a stone, blood clot, stricture, scarring, enlarged prostate or other body organ or from fecal constipation or impaction.

Sepsis is an infection that travels throughout the body. It can begin in the urinary system or travel to the urinary system from another part of the body. Sepsis is a medical emergency. For more detailed information about sepsis:

Stones are hard masses of crystals that mineralize to form stones. They can appear in any part of the urinary system. In the bladder, they may be small and pass without notice. Larger stones can impede the passage of urine and cause pain. Stones that pass through the ureters can be painful as the ureters are small in diameter. In the kidneys, there is no room for stones which can damage delicate tissues. The rough edges of stones can lead to bleeding. In those with spinal cord injury, stones can lead to episodes of autonomic dysreflexia and increased spasticity.

Urethritis is an inflammation or infection of the urethra (the opening in the body to the bladder.) This can occur for many reasons but, in individuals who catheterize, it can occur from leaving soap or cleaning solution on the urethra or surrounding area.

Urinary Reflux is the process of urine flowing backwards, up the ureters into the kidneys. As the kidneys have no capacity for storage, damage occurs which can lead to kidney failure.

Urinary Tract Infection is an infection anywhere in the urinary system. Most often, infections begin in the bladder which can then spread to the kidneys. It is critical to treat an infection as soon as possible to ensure it does not spread. Bacteria can enter the urinary system at any point. Most often, the entry is through the urethra where a large number of bacteria are typically found. Bacteria can invade any part of the urinary system. Treatment for infection should be promptly obtained.

Infections are easier to treat when caught early. Signs of a urinary tract infection are: persistent urge to urinate, burning especially with urination, frequent urination, cloudy, foul smelling, mucus, sediment or bloody urine, pain with urination or in the area of the pubic bone, lower back pain, fever, chills, nausea, headache, tiredness, spontaneous urine loss. Those with decreased sensation in the body may notice autonomic dysreflexia (AD) symptoms, increased spasticity, or referred pain to an area of the body where there is sensation especially the shoulder or jaw.

Medications with Urinary System Side Effects

Some drugs affect the urinary system. An excess or overdose of these medications, fluids and supplements can have side effects leading to a disruption in urinary functioning.

Medication/ Fluid/Supplement Effect on Urinary System
Alcohol Urinary urgency, frequency, and functional incontinence. Decreased awareness of need to toilet.
Anticholinergics Urinary retention and overflow incontinence.
Antidepressants Urinary retention, overflow incontinence and dribbling.
Antipsychotics Urinary retention, overflow incontinence and dribbling.
Antihypertensives Stress incontinence especially in women
Caffeine Urinary urgency, frequency, and incontinence.
Diuretics Urinary urgency and frequency. Incontinence can be controlled by taking the medication early in the day and planned toileting.
Nonsteroidal anti-inflammatory drugs (NSAIDS) Decreased awareness of need to toilet. Urgency, functional incontinence.
Opioids Decreased awareness of need to toilet. Urgency, functional incontinence.
Sugary drinks Urinary urgency and frequency.
Vitamin C, D Frequent urination with overdosing

Urinary Incontinence: Types and Treatments

Some individuals have urinary incontinence due to issues that do not arise necessarily from the central nervous system (CNS) or peripheral nervous system (PNS). The source of urinary system issues can also arise from hormonal changes, poorly toned muscles in the pelvic floor and diseases. Urinary incontinence should be discussed with your healthcare professional to ensure you are addressing and treating the correct issue. Those with spinal cord injury, some individuals with brain injury, and those with certain medical conditions have a neurogenic bladder which is miscommunication of the nerves. Continue below for more information about neurogenic bladder.

Urge Incontinence is a sudden urge to urinate with leakage of urine. This is from abnormal bladder contractions which can overpower the strength of the external sphincter to contain the urine in your body until an appropriate time to eliminate it.

The cause of urge incontinence is most often urinary tract infection but can be from disease such as diabetes, stroke, multiple sclerosis, Parkinson’s disease, bladder irritation or spinal cord damage. Any individual can develop urge incontinence, but it is most often found in the elderly, the obese, women with a history of C-section delivery or pelvic surgery, men with prostate conditions or surgery, or those with cancer of the bladder or prostate. Often the cause is unknown.

Treatment of urge incontinence involves changing behavior by toileting on a schedule which keeps your bladder empty to avoid triggering bladder contractions. Avoid caffeine, sugary drinks and alcohol which increase the urge to urinate. Avoid heavy lifting. Tighten the pelvic floor by performing Kegel exercises or using weighted vaginal inserts to strengthen pelvic muscles. Losing weight also helps reduce abdominal load. Biofeedback can be used to learn to reduce contraction responses.

Use of medications can reduce bladder contractions. There are many choices including: darifenacin (Enablex), fesoterodine (Toviaz), mirabegron (Myrbetriq), oxybutynin (Ditropan, Ditropan XL, Gelnique, Oxytrol), solifenacin (VESIcare), tolterodine (Detrol, Detrol LA), trospium (Sanctura), hyoscyamine (Anaspaz, Cystospaz, Hyosol, Hyospaz, Levbid, Levsin) or dicyclomine (Antispas, Bentyl, Byclomine, Di-Spaz, Dibent, Or-Tyl, Spasmoject).

Botox injections can be used in the bladder to reduce the frequency and severity of bladder contractions or spasms (tone). These injections will need to be repeated to maintain effectiveness.

Other treatments might include electrical stimulation to strengthen the urinary sphincters. There are also surgical techniques and implants that can increase sphincter compliance.

Overactive Bladder (OAB) is overactive bladder contractions that are often more continuous than episodic as in urge incontinence. Signs of OAB include the frequent urge to urinate and urinating more than 8-10 times during the day or two times at night. OAB may or may not be in addition to leakage of urine (urge incontinence). OAB and urge incontinence can be a mix of issues.

Overactive bladder can occur in anyone but can be a consequence of medical conditions such as multiple sclerosis, diabetes, hormonal changes during menopause, tumors, bladder stones, enlarged prostate, constipations, or as a result of surgery to treat other forms of urinary incontinence. Those with cognitive decline such as stroke, Alzheimer’s disease or other dementia are at risk for OAB. Urinary tract infections mimic the symptoms of OAB.

Behavioral changes can help OAB. These include urinating on a schedule. Practice holding or delaying urination for a short time eventually building to longer times. Changing fluids to decrease or eliminate caffeine, sugary drinks and alcohol will help decrease the urge to urinate. Tighten the pelvic floor with Kegel exercises and general body exercise. Maintain a healthy weight. Stop smoking to eliminate the bladder irritant nicotine. Biofeedback can be used to learn to reduce contraction responses.

In OAB, the bladder may not be able to be completely emptied when urinating. This triggers more contractions that are felt but not able to push out urine. If incomplete emptying of the bladder occurs, intermittent catheterization may be initiated.

If OAB is from hormonal changes in women, estrogen may be added to strengthen tissues. Medication may be used to help empty the bladder. These include tolterodine (Detrol), oxybutynin in pill form (Ditropan XL) or used as a skin patch (Oxytrol) or gel (Gelnique), trospium, solifenacin (VESIcare), darifenacin (Enablex), fesoterodine (Toviaz), or mirabegron (Myrbetriq).

Botox injections into the bladder can calm contractions. Electrical stimulation through the skin or as an implant in your body may be used to interrupt the bladder contraction signals. Surgery for more complicated OAB may be done such as bladder augmentation or enlargement or bladder removal.

Stress Incontinence is uncontrolled leakage of urine due to high intra-abdominal pressure. Typically, stress incontinence occurs with movement, heavy lifting, bending over, running, coughing, laughing, or sneezing. It is more common in women who have had multiple vaginal deliveries, hysterectomy or are post-menopausal. In men, it occurs more often after prostate surgery. Risk factors for both genders are aging, smoking or other medical issues resulting in heavy coughing, obesity, constipation, sexual intercourse and excessive caffeine and alcohol use.

Currently, there are no approved medications for treatment of stress incontinence. Estrogen may help reduce stress incontinence in women. The antidepressant drug duloxetine (Cymbalta) is being tested for treatment of stress incontinence with promising results. There are many over the counter products that are offered but outcomes vary.

Treatments for stress incontinence include pelvic floor exercises to strengthen muscles. Lifestyle changes of weight control, stopping smoking to reduce coughing, and curbing caffeine and alcohol intake are recommended. More advanced treatments are Botox injections, electrical stimulation, and surgically reconstructing the pelvic floor or gynecological surgery.

Overflow Incontinence results in dribbling of urine due to an inability to completely empty the bladder. The urge to empty the bladder is not felt. It is caused by an obstruction anywhere in the bladder outlet area from prostate issues or other narrowing or constriction of the urethra, a weak bladder muscle that cannot fully expel urine or nerve damage. The causes can be specific or a combination of issues.

Sources of overflow incontinence include temporary issues such as post-operative anesthesia or post-delivery. Diseases can lead to overflow incontinence including nerve damage from diabetes, alcoholism, Parkinson’s disease, multiple sclerosis, back problems/back surgery, or spina bifida. The side effects of some medications can lead to overactive bladder including certain anticonvulsants and antidepressants, that affect nerve signals to the bladder.

Treatment includes behavior changes such as scheduling bladder management and waiting 30 seconds after urinating and attempting to urinate again. Overflow incontinence can be treated with intermittent catheterization. Also, treating the underlying condition that is causing it will be necessary.

One medication for overflow incontinence is bethanechol, a cholinergic medication related to acetylcholine. It is available as Duvoid, Myotonachol, Urecholine, and Urocarb. For men, urinating with an enlarged prostate may be treated with alpha-adrenergic blockers such as doxazosin (Cardura), alfuzosin (Uroxatal), prazosin (Minipress), tamsulosin (Flomax), silodosin (Rapaflo), and terazosin (Hytrin).

Functional Incontinence is an issue where a person has recognition of the urge to urinate but simply cannot get to the toilet in time. The issue could be an inability to move their body fast enough, difficulty in removing their clothes, a physical impairment either in the body or from equipment or a thinking (cognitive) issue where the process is too complicated to work out.

Treatment for functional incontinence is to make the process easier through adjustments in clothing or physical surroundings. Toileting on a schedule can help as the urgency is reduced. If the source of the issue is a physical impairment that can be rectified, that should be a goal.

Mixed Incontinence is a combination of any of the above issues. A combination of the treatments may be required to address mixed incontinence.

Urinary Retention

Obstruction of the Urinary System occurs when something is blocking urine from fully or partially leaving the body. This occurs with enlarged prostate, constipation, bladder cancer, tumors, fibrosis, endometriosis, kidney stones and blood clots. It can be any issue that blocks any part of the urinary system from working or allowing urine to flow through the system or out of the body. Obstruction of the urinary system can occur pre-birth which is detected by blood tests of the mother and ultrasound.

Symptoms of obstruction include difficulty passing urine, slowed stream (dribble), frequency, decreased urine output, blood, or just feeling like your bladder is not empty.

Treatment is to remove or open the obstruction. If urine does not flow out of the body through the urethra, it will back up the ureters into the kidneys. Action must be taken quickly to prevent damage to the kidneys.

Treatment may include a temporary placement of an indwelling catheter, if possible, to open the urethra to allow urine to flow out. A stent may be placed in the ureter or urethra depending on the location of the blockage to open the flow. Surgery to correct the blockage issue is needed if the source of the blockage is an enlarged prostate, tumor or other obstruction.

Neurogenic Bladder (Neurogenic Bladder Dysfunction): Types and Treatments Neurogenic bladder occurs when there is an issue with the nerves and muscles that control bladder function. The parts of the urinary system need to work in coordination for effective urine elimination. Neurogenic means there is a difficulty with nerve transmission. When messages are impaired from being sent to and from the brain, a neurogenic bladder is diagnosed. This can be caused from disease or injury to the central nervous system (brain and spinal cord) or peripheral nervous system (nerves in the body). Examples of causes of neurogenic bladder include these and others:

  • Medical issues affecting the brain or spinal cord
  • Birth defects that effect the spinal cord
  • Accidents to the brain or spinal cord
  • Peripheral nerve damage
  • Genetic nerve problems
  • Infection in the urinary system or body
  • Heavy metal poisoning
  • Brain or spinal cord tumors
  • Cerebral Vascular Accident (CVA) or stroke in
  • the brain or spinal cord
  • Diabetes
  • Multiple Sclerosis
  • Parkinson’s Disease
  • Spina Bifida
  • Cerebral Palsy

Types of neurogenic bladder are uninhibited, hyper-reflexive (spastic), flaccid and mixed.

Uninhibited neurogenic bladder is a reduced sensation or recognition that the bladder is full. Urinary incontinence (involuntary expelling of urine) occurs because the individual does not recognize the urge to void. It is associated with brain injuries, stroke, dementia, and multiple sclerosis.

An uninhibited neurogenic bladder may be treated by behavioral changes such as scheduling bladder management times with slowly stretching the time between voiding. Monitoring fluid intake and the type of fluids can avoid sudden accidents. Medications to tighten the sphincter muscles or relax bladder contractions (anticholinergics) may be used. Also, it may be necessary to begin an intermittent catheterization program (IMC) which is scheduled times of inserting a catheter to drain urine from the bladder.

Reflexive (hyper-reflexive) neurogenic bladder is typically found in individuals with injury to the upper motor neurons (UMNs) of the nervous system. Upper motor neurons (UMNs) are the primary source of movement in humans. The cell bodies of UMNs are in the upper part of the central nervous system, the brain and brainstem. UMNs connect to lower motor neurons (LMNs) through junctions called interneurons. Messages for movement follow this pathway unless disrupted by injury or disease. The results of UMN injury typically are seen in individuals with cervical and thoracic disease or injury. The reflexive neurogenic bladder occurs in individuals with spinal cord injury above T10.

When messages for movement are sent from the brain but the UMNs are damaged, the message is misinterpreted or not able to pass through. Damage to UMNs results in reflexive or spastic bladder. This might be seen outwardly in the body or have effects within the body.

One of the ways UMN injury is displayed is through a reflexive (spastic or tone) bladder. This bladder will fill with urine but will trigger an automatic emptying. The amount of urine expelled can be all the urine in the bladder or just a small amount. This is because the muscle of the bladder will contract as the sphincters do as well. This discoordination leads to urine being retained in the bladder creating high pressures which can cause urine to backflow up the ureters into the kidneys. As the kidneys do not store urine, damage is done. Treatments can prevent kidney damage.

Treatment for reflexive neurogenic bladder is approached depending on the individual’s needs. Men with higher level injuries where hand function is limited and have high pressure in the bladder may have a sphincterotomy performed. This is a surgical procedure where a small cut is made in the external sphincter muscle resulting in a free flow of urine out of the bladder. An external catheter is then used to collect and contain urine. This reduces the risk of urine flow back into the kidneys.

Due to women’s anatomy, a urine collection system is not available (although many are working towards one) so alternatives are used. For men or women, alternatives include suprapubic catheter, which is placed in a surgically created opening in the abdomen just above the pubic bone. A catheter is placed in this opening for free flow of urine. An alternative is use of an indwelling catheter through the urethra.

If hand function is sufficient, self-intermittent catheterization is initiated. This is a process where urine is drained from the bladder through a temporary catheter placement. Once the urine is drained, the catheter is removed. Fluids need to be monitored to avoid overfilling the bladder.

Flaccid neurogenic bladder The cell body of lower motor neurons (LMNs) are in the lower central nervous system in the spinal cord, nerve roots, cranial nerve nuclei of the brainstem and cranial nerves with motor function. LMNs receive messages from UMNs for movement. They connect directly with skeletal muscles for voluntary movement. Messages are sent from the brain to the body to move quickly, move slowly or stay as you are.

When the LMNs are damaged, messages from the brain are misinterpreted or not transmitted to the body. The result is flaccidity. LMN injury is most often seen in individuals with lumbar and sacral disease or injury. Nerves of the central nervous system (CNS) and possibly also the peripheral nervous system (PNS) are typically affected.

Below the level of injury, your body is also flaccid, including the bladder, which will fill with urine but not expel it. The bladder does not contract in the usual manner. Urine just continues to fill the bladder to overcapacity. At times, there might be an automatic expelling or incontinence of urine because the internal sphincter which is a part of the bladder muscle does not contract. Due to paralysis, the individual may not have voluntary control of the external urinary sphincter. Typically, the full amount of urine in the bladder is not eliminated. Residual urine remains in the bladder. It is possible that the bladder can become so full that it ruptures, or the person becomes incontinent (involuntary expelling of urine).

If the reflex arcs are preserved, stretching the rectal opening may result in expulsion of urine. This must be done on a timed basis as sensation signals of a full bladder are not received by the brain. Tapping over the area of the bladder can also stimulate urination for some. Treatment of flaccid neurogenic bladder can also be managed with intermittent catheterization.

Individuals with flaccid neurogenic bladder may be using Credé’s maneuver (rolling the hand down the skin over the bladder) or Valsalva maneuver (bearing down) as triggers for urination. To utilize these methods of voiding, you must ensure that you have low sphincter resistance so urine can easily flow out of the urethra. If your sphincter is tight, these activities build pres

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