Bladder Rehabilitation in Spinal Cord Injury

Bladder Rehabilitation in Spinal Cord Injury

                                 BY

                           Dr. A.G.K.Sinha

               Department of Physiotherapy Punjabi University Patiala

Outline:

introduction , neuro-physiology of micturition,  

Bladder in spinal cord injury, technique of balder management , management principles of various types of bladder, long term management and follow up , protocol adopted at SMRC Bhubaneshwar

Introduction

The dysfunction of the lower urinary tract is one of the most hazardous neurological deficits seen in Spinal Cord injury. The embarrassing urinary incontinence not only acts as a major barrier in the social integration of these patients but is also responsible for the high mortality & morbidity due to its life threatening disturbances of the renal function.

Bladder Rehabilitation is an essential component of the comprehensive rehabilitation programme of SCI. Unfortunately this component skill not emphasized in many rehab. Centers in India.

Neuro -Physiology of Micturition

The functions of lower urinary tract are to

1. Store the urine with maintenance of continence
2. To eliminate/evacuate the urine completely at will.

These functions are regulated by the two functional units in Lower urinary tract

1.        Reservoir(the bladder )and

2.        the outlet(consisting of bladder neck, urethra and voluntary muscles of pelvic floor)

The activity of these two units are controlled and mediated by the neural circuits located in the brain, spinal cord and peripheral organs.

                Under normal conditions bladder and sphincter exhibit the reciprocal relationship. During storage phase the outlets are closed and the bladder smooth muscle remain silent [ fig 1 ] allowing the pressure inside the bladder (intravesical pressure) to remain low over the wide range of bladder volume.

 fig 1  storage phase

                During voluntary micturition, there occurs relaxation of the pelvic floor and paraurethral voluntary muscles- to reduce the intraurethral pressure, as a result of which bladder neck opens. This change in few second is followed by a contraction of detrusor muscles[ fig 2 ]  which increase the intravaginal pressure and brings about the elimination of urine.

 fig 2  voiding phase

                These changes are coordinated by the micturition centres situated in the pons and brainstem, and mediated by the following three sets of nerves emerging from thoraco-lumbar (T11- L2) and sacral segment of spinal cord.

1.        Sacral parasympathetic( pelvic nerve)

2.        Sacral somatic( pudendal nerve)

3.        Thoracolumbar sympathetic( hypogastric nerve and sympathetic chain)

Sacral parasympathetic provides major excitatory inputs to the bladder bowel. It consist of several spinal preganglionic neurons which innervates the detrusor muscle.

Pudendal nerve carries somatic efferent to the external uretheral sphincter and to the muscle of pelvic floor from the S3-S4 segment. These muscles are responsible for voluntary initiation and control of micturition.

Sympathetic pathways arising from T11 to L2 provide an EXCITATORY input to the smooth muscles of urethra and bladder and INHIBITORY inputs to the body of bladder.

Afferent activities arising in the bladder is carried to the CNS over both sets of autonomic N..The most important afferent for initiating micturition are those passing in the pelvic  N. to the sacral segments. These afferents consist of small myelinated (Aδ)  and unmyelinated( c) fibres, which conveys impulses from the tension receptors and nociceptors in the bladder wall .Intravesical threshold for activation of afferent ranges from 5- 15 mmHg .

The central pathways controlling LUT function are organized on simple on- off switching circuits which maintains a reciprocal relationship between bladder and sphincter. The accommodation of the bladder to the increasing volume of the urine is primarily a passive phenomenon dependent upon the intrinsic properties of detrusor and quiescence of parasympathetic pathways.

The storage phase of the bladder can be switched to voiding phase either reflexly or voluntarily. The Reflex action is more commonly seen in infants when the volume of urine exceeds the micturition threshold afferent firing from tension receptors reverse the pattern of efferent out flows. These reflexes require an integrative action of various component of neural axis.

Bladder in Spinal Cord Injury

Spinal cord injury proximal to lumbosacral level eliminates voluntarily and supraspinal control of voiding. The reciprocal relationship between bladder and sphincter is abolished .Initially these involve an areflexic bladder with complete retention of urine followed by slow development of different level of activity of detrusor and sphincter. Apart from automatic or cord bladder (spastic bladder) developed after suprasacral lesions  and Autonomous (flaccid bladder)  bladder of sacral lesion .Two other combinations of the bladder sphincter tone is also seen .

According to the neurological state of bladder and sphincter, the bladder of SCI can be grouped under following 4 types:

a.        Detrusor Hyper-reflexia with hyper reflexic sphincter.

b.       Detrusor Hypo-reflexia with hyper reflexic sphincter.

c.        Detrusor Hypo-reflexia with hypo reflexic sphincter.

d.       Detrusor Hyper-reflexia with hypo-reflexic sphincter.

 SPASTIC / AUTONOMIC BLADDER:

1. Detrusor hyper reflexia with sphincter hyperreeflexia: This bladder usually develops in patients with supra-sacral lesions. It is characterized by the uncontrolled, inappropriate detrusor contraction with failure of complete and sustained relaxation of sphincter called D-S-D.[ fig 3 ]  During bladder filling, transient detrusor contraction along with sphincter action occurs which reduces the capacity of bladder.

During voiding detrusor contraction along with non relaxation of sphincter muscles creates very high intervesical pressure which forces the urine back to the ureter and to kidney. This is called vesico-ureteral reflex. In long term this bladder produces severe damage to kidney leading to pylonephritis and renal failure.

fig 3  spastic bladder

2. Detrusor hyporeflexia with spastic sphincter: This type of bladder can result primarily in the supra conal lesion or the lesion disturbing sacral roots with intact T12 L12 segments. It can also develop due to recurrent over distension or frequent UTI in the spastic bladder  .[ fig 4]

This type is less problematic if continence is concerned but it has high risk of UTI and stone formation due to high residual urine.

Fig 4   hyperactive sphincter with flaccid detrusor

3. FLACCID BLADDER:

Detrusor hyporeflexia with hyporeflexic sphincter:  characteristic of conus cauda lesion. in this bladder, urinary incontinence is major problem. Patients complaints of frequent   leakage   . The voiding is entirely a passive phenomenon. Bladder can store large quantity of urine. As soon as intravesical pressure exceeds the resistance of outlet urine comes out. During voiding membranous urethra is compressed but pelvic floor muscle and urine flow stops resulting in incomplete voiding. Abdominal straining/ crede is necessary to create intra vesicle pressure to overcome the resistance and produce complete voiding. [ fig 5]

Fig  5     flaccid bladder

4.        Detrusor hyper reflexia with hyporeflexic sphincter: This bladder can again be seen in the supra conus lesion. Incontinence is of severe degree. Bladder is hyperactive. Capacity is low and governed by the point at which either a reflex contraction of bladder occurs or any other intra vesical pressure goes beyond the outlet resistance. [ fig  6]

Fig  6    hyper dterussor   hypo sphincter

TECHNIQUE OF BLADDER MANAGEMENT:

·         Indwelling  Folley’s catheter

·         Supra pubic catheter.

·         Clean intermittent catheterization

·         Suprapubic Tapping, stimulation.

·         Abdominal straining, crede’s maneuver

·         Drugs

·         Transurethral sphincterotomy

·         Post-sacral root rhizotomy with autonomic root stimulation implant

·         Bladder augmentation

§         Calm-ilio-cystoplasty

§         Auto-augmentation

·         Artificial urinary sphincter

·         Ilium Conduit

·         Intra-vesical electro therapy( Kotana’)

MANAGEMENT AT THE STAGE OF SPINAL SHOCK:

            Initially to relieve bladder retention an indwelling catheter should be applied. This help to monitor urine input and output ratio in poly traumatized patients.

As soon as patient stabilizes, the C-I-C should begin with proper aspectic technique and timing.

 The long term use of indwelling catheter carries several high risks such as UTI, incrustation of catheter ballon with subsequent stone formation and peno-sacral ulcer in male.

These risks can be minimized in the acute stage by tying the penis upto the lower abdomen by meticulous cleaning of meatus and adequate care of uro- bags.

Whatever be the method of in acute stage, the recurrent UTI , overdistension of bladder and uretheral damage during catherisation must be avoided, as these complication retard the neurological recovery of bladder. For these many center also  use suprapubic catheter in the period of spinal shock.

fig  7 :  the catheter should be tied over the abdomen to prevent kink  and to avoid  penile pressure sore

SUB ACUTE STAGE:

 At the end of spinal shock different neurological type will develop. The line of management depends upon the thorough evaluation of bladder status.

UROLOGICAL EVALUATION:

Assessment  of bladder function involves obtaining information about :Frequency, urgency, sensation of bladder filling, volume control, social need, perirectal examination to note the tone and control of bladder and sphincter, neurological examination of T12- S5 segment including BC and Anal wink reflexes, Abdominal palpation. It also include urine analysis (volume, culture and sensitivity), measurement of post voiding residual urine, ultrasound and urodynamic studies are also helpful if available.

Principle of Management in different Bladder type

1.         Spastic Bladder(Detrusor Hyperreflexia with Hyperreflexic sphincter  )

   

   Aim- a)To eliminate/diminish outflow abstraction

                b) To decrease the detractor hyperactively

Method I               Drugs + C.I.C. with suprapubic tapping and stinulation .

The smooth much relaxant (Prabathim) is used to decrease the over activity of detrusor   and wake the bladder hyperflexic  or Areflexic. This increase the capacity of bladder and decrease the changes of backward flow of urine. Unbalanced bladder can then be accomplished by sporadic tapping and stimulation followed to C.I.C. to check residual urine and to prevent stasis of urine. The combination of week bladder with spastic sphincter mostly points dry period between catheterization.

 Method-II             Sphincterotomy

This surgical technique aims at eliminating the outflow resistance of severly spastic sphincter (which prevent C.I.C).. This operation is destructive and irresponsible. The urinary incontinence persists. Good for male who may use condom drainage but not suitable for female.

Method III:            Post sacral Rhizotomy with Ant. Sacral stimulation.

These surgical techniques abolishes the detrusor hyperreflexia by interruption of sacral arc by cutting the post sacral root and obtain voluntary voiding by implantation of sacral root stimulation. The device consists of platinum electrode implanted on the spinal nerve of sacrum. The electodes are connected by cable to a silicon rubber covered Radioreciever, implanted beneath the skin. To empty the bladder the receiver is stimulated either by radiotrasmitter or by simple tapping. The urine flow commences within seconds. It gives good option for females.

2   Detrussor hyporeflexia with hypreflexic sphincter.

            With this bladder the problem of incontinence is rare. The aim of management is to prevent stasis of urine. The C.I.C. is the method of choice. If this is not possible surgical procedures has to be considered which includes sphincterotomy with bladder neck incision.

3   Flaccid Bladder: Hyporeflexic  Detrusor with Hyporeflexic sphinctor.

The aim of management is to prevent incontinence and to provide adequate emptying. Initially passive voiding by abdominal straining or crede movements is recommended. These maneuvers creates unphysiological high intravesical pressure.If the  vesico ureteric  reffex  is present , it is contraindicated. If there persists residual urine of more than 50 ml. than C.I.C. at regular interval with adequate fluid intake combined with condom drainage in male and diapers in female is a safe and satisfactory procedure.

4.   Detruosor Hyper-reflexia with sphincter hypo-reflexia.

The capacity of bladder is very low. Incontinence is a major problem. Aim is to maintain continence.

 Method I: Drugs to decrease spasticity of bladder (Probanthine) combined with controlled fluid intake and regular bladder emptying is a non surgical technique of management. Male pt. has to wear condom for drainage and female has to wear diapers all the time.

Method II:  Posterior Rhizotomy- This decreases the tone of detrusor and converts this bladder into areflexic bladder, which has to be managed by C.I.C.

Method III : Bladder augmentation - The different surgical procedure aims at increasing the capacity of bladder by splinting it.

Patients Education

Irrespective of the type of drainage, there are certain basics which must be taught to each patient & his family.

1 Cleanliness: The hygiene of perineal areas must be maintained on a daily basis.

                - Follow correct technique of C.I.C.

                - Clean patients after bowel program

                - In female never clean from back to front

                - Wash daily urobags with detergent & fresh water

2.   Maintenance of Appliances

                Each patient should be instructed about preparation about condom drainage, urobags, irrigation of catheter & urobags with acetic acid etc.

3    Detection of Lower Urinary Tract deterioration

                The early sign and symptom of urinary tract infection is physical examination of urine involving detailed sedimentation & pH level.He should also be instructed about its  line of management.

4    Detection & First Aid of Grave complication.

                Autonomic Dysreflexia  is a serious condition occurring mostly in patients , with lesion above T6. Over distended bladder is one of the most common cause for this. If not managed properly in the early stage it may kill the patient.Each patient must be informed about its signs and symptoms i.e. sudden onset of  headache, sweating , shivering, flush, double vision , giddiness and rise in B.P. Its first aid i.e. to sit up the patient immediately, identify and removal of the cause. It should be done and explained and if possible such patients should be given a card containing information about AD and its line of management. This card helps general medical practioners who do not come in contact with these patients and to save the patients during emergency.

Long Term Care

Each Spinal injured must be reviewed periodically through out his life time, even after successful management at early stage. These patients have increase tendency to develop urinary infection and their bladder function does not remain static but changes over time.

These potential problems are known to compromise renal function severely yet  asymptomatically, so periodical assessment of bladder function which include clinical examination, urine analysis & estimation of residual urine by an urologist , is an essential part of the correct bladder rehabilitation program. 

  

Bladder Rehabilitation At Spinal Injury Unit Of SMRC 

During Aug 95 and Oct 96 we have rehabilitated 56 spinal cord injured. All the patients come to us in different stages and we could see all clinical type of bladder, mostly we received patient with indwelling catheter. Our management protocol is as follows:

A.           First 24 hrs of arrival, the input and output of urine is closely monitored.

B.            If patient was  with indwelling catether, next day catheter was removed – the urine and tip of catheter (if applied for more than 7 days) send for routine microscopy and culture and sensitivity.

C.             Patient was then given 500ml of fluid to drink. His bladder was evaluated in term of

               Sensation of filling

               Urge to void

               Voluntary control

               Frequency of micturition

               Output

Every half hourly abdominal tapping was done to elicit response. If no urine came out within first four hours and the bladder filled nearly up to 500ml (clinically can be known by tapping between umbilicus and symphysis pubis) – CIC was  done.

D.            Based on the evaluation a detailed programe was charted out under the following headings

1.          Method of drainage –mostly c.i.c; sometimes condom drainage ;rarely indwelling.

2.          Frequency of voiding – 4 hourly,6 hourly, 8 hourly

          3.   Water intake – amount and timing.not exceeding 1500ml with CIC                                                                     -

          E. Bladder rehab. Program was  conducted in 3 distinct phases

I. The nursing personal initiate and demonstrate the bladder program to the patient in their caretaker. They are explained the importance of such procedure and are being encouraged to clarify their queries.

II. In this stage patient and carer physically participate in the program. They are practically trained in the different technique. Nursing Personal supervise them and make necessary correction so that the program remain risk free.

III. In this last stage the whole program was managed by patient himself or if unable than by their carer. Nursing staff monitored the program and assesses the attitude of carer and patient toward the program. After successful completion of this phase patient is declared fit for discharge.

F  Education : It was  mandatory to all patient and their carer to learn

-          The tech. of c.i.c

-          Preparation and maintenance of c.i.c kit

-          Prep. of condom drainage tubing, its application and maintenance .

-          Physical examination of urine

-          PH testing of urine

-          Sedimentation deposition detection by vinegar test.

-          Sign, symptoms of UTI

-          Possible danger of each tech.

                  - peno scrotal ulcer

                  - urethral damage

                  - penile pressure sore.

- Methods of cleanliness of perineal areas .

- Signs and first aid of autonomic  dysreflexia    .

This education was imparted by the bed side demonstration and in the group education classes for patient and relative conducted once in a week

We had  also prepared land outs of these information in local language which was given to the patients.

G. Post Discharge Follow up

        After every 3 months (sometimes monthly) patient was evaluated either in the centre or in his house. Evaluation included, subjective and objective examination of bladder status, urine analysis, ultrasound of kidney, ureter and bladder and renal function. Depending on the evaluation finding his bladder program was modified.