Neurogenic Bladder Dysfunction Management and Nursing Care

Neurogenic bladder dysfunction can be common in patients suffering from a variety of medical conditions; most commonly, neurological conditions. A person with multiple sclerosis (MS) will have a 40 to 90% chance of developing neurogenic bladder dysfunction, and instances are just as high in people with Parkinson’s disease, spinal cord injuries and strokes (Dorsher & McIntosh 2012). 

What is Neurogenic Bladder Dysfunction?

The term neurogenic bladder dysfunction is the overlying term for a variety of lower urinary tract disorders that are caused by a disease or an injury that has disrupted normal neurological function (Mauk 2012).

Normal bladder function relies on information travelling through neural pathways from the cerebral cortex, through the spinal cord, and on to the bladder to coordinate normal micturition and urinary continence. When this pathway is damaged, it can result in loss of bladder sensation and also the loss of the coordination between urethral sphincter and its muscles. This means that these muscles may not contract even when the bladder fills or the person has the urge to void, leading to bladder dysfunction such as urinary incontinence and retention (Mauk 2012).

 Dependent on the aetiology and classification of the neurogenic bladder dysfunction, the individual may experience a variety of symptoms, which commonly include:

• Urinary urgency and frequency
• Urinary retention; and
• Urinary incontinence.

(Greenwood et al. 2013) 

Classifications of a Neurogenic Bladder

 A neurogenic bladder can be classified in many ways, however, generally classification is based on the location of the neurologic lesion:

• Lesions above the pontine micturition centre: These are seen commonly in patients with strokes and brain tumours and produce an uninhibited bladder. A patient with an uninhibited neurogenic bladder will experience sensation but lack voluntary control, so they may have urgency, frequent bladder contractions, and nocturia.
• Lesions between the pontine micturition centre and sacral spinal cord: This is commonly seen in people with traumatic spinal cord injuries or MS, and produces an upper motor neuron bladder in which there is a reduced bladder capacity. Consequently, the potential high pressures within the bladder have the capacity to produce renal damage. These patients will often lack the sensation to void, which can also result in urinary retention.
• Sacral cord lesions that damage the detrusor nucleus but spare the pudendal nucleus produce a mixed, type A bladder in which patients may experience urinary retention without incontinence.
• Sacral cord lesions that spare the detrusor nucleus but damage the pudendal nucleus produce a mixed, type B bladder in which the patient may experience episodes of incontinence.
• Lower motor neuron bladder form sacral cord or sacral nerve root injuries in which the patient will experience an areflexic bladder.

(Dorsher & McIntosh 2012; Mauk 2012)

Investigations and Bladder Assessment

Diagnosis of neurogenic bladder is essential to ensure effective management strategies are implemented. There are a variety of investigations and assessments that need to be completed in order to diagnose a neurogenic bladder and exclude other possible causes.

Some of these investigations include:

• Analysis of the urine
• Measurement of residual urine
• Urine flow test
• Filling and voiding cystometry
• Ureteroscopy
• Radiological investigations
• Neurophysiological examination of the pelvic floor; and
• Micturition cystourethrography.

(Greenwood et al. 2013)

Potential Complications of Neurogenic Bladder Dysfunction

Not only are there physical complications related to neurogenic bladder dysfunction, there can also be negative psychosocial effects present in the individual. These can include a decrease in the individual’s quality of life, and feelings of embarrassment and depression that can further lead to social isolation – devastating in the case of someone with a progressive neurological condition (Ginsberg 2013).

Some potential complications of neurogenic bladder dysfunction include:

• Urinary tract infections
• Calculi
• Autonomic dysreflexia – this is a medical emergency in which the message that the bladder is full cannot reach the brain. Because the message is blocked it leads to arteriole vasoconstriction and hypertension, which causes vasodilation of the heart and brain, leading to bradycardia and dilation of smaller blood vessels to compensate. If left untreated, the patient can have severe hypertension with systolic BP as high as 300mmHg and stroke, coma or death can occur. The most common cause of this is a distended bladder; and
• Hydronephrosis – when an over-distended bladder causes a reflux of urine into the kidneys.

(Mauk 2012)

Management of Neurogenic Bladder Dysfunction

Management of neurogenic bladder dysfunction needs to be individualised according to the patient, the classification of their bladder dysfunction, the cause of their dysfunction, and their symptoms. Nurses will often be involved in the management of neurogenic bladder dysfunction through patient education and support as they learn techniques and strategies for their management of this condition.

The main focus of management is on patient education. The goal of all bladder management programs is to develop predictable and effective patterns of elimination by emptying the bladder and preventing potential complications. The patient needs to be involved in their own bladder management program to ensure it works for them and fits in with their lifestyle. This may mean a combination of bladder training, behaviour modification and medications, and as a last resort, surgery may be required (Dorsher & McIntosh 2012; Mauk 2012).

Bladder training is an essential component of neurogenic bladder dysfunction management. It ensures regular and adequate emptying of the bladder and may be through the means of a voiding schedule or self-catheterisation (Ginsberg 2013).

Intermittent catheterisation can be used for patients who have complete or partial urinary retention. The use of self-administered intermittent catheterisation has many benefits over an indwelling catheter, including enhancing the patient’s independence and confidence with self care, and reducing potential barriers to sexual function. If the patient has some ability to void, intermittent catheterisation can be used as part of their bladder retraining program. Patient education is critical for patients who are self-administering intermittent catheterisation, with one of the most frequent complications occurring being urinary tract infections (Ginsberg 2013).

An indwelling catheter or suprapubic catheter can also be used, and once again, patient education is essential for catheter care on discharge. This is not the preferred method of bladder management in the long-term for a patient, however, it may be the most effective and practical solution for people with poor hand function, high fluid intake, lack of support and lack of success with other management strategies (Mauk 2012).

Pharmacological therapies can also be used for bladder management; antimuscarinics are commonly used and not only result in an increased bladder capacity, but also delay the urge to void (Ginsberg 2013).

Surgical interventions are generally implemented as a last resort and include procedures such as transurethral sphincterotomies and enterocystoplasties (Ginsberg 2013).
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References

• Dorsher, PT & McIntosh, P 2012, ‘Neurogenic bladder’, Advances in Urology, vol. 2012, doi: http://dx.doi.org/10.1155/2012/816274.
• Ginsberg, D 2013, ‘The epidemiology and pathophysiology of neurogenic bladder’, The American Journal of Managed Care, vol. 19, no. 10, pp. 191–6.
• Ginsberg, D 2013, ‘Optimizing therapy and management of neurogenic bladder’, The American Journal of Managed Care, vol. 19, no. 10, pp. 197-204.
• Greenwood, RJ, Barnes, MP, McMillan, TM & Ward, C (eds.) 2013, Handbook of Neurological Rehabilitation, 2nd edn, Routledge, New York.
•  Mauk, KL 2012, Rehabilitation Nursing: A contemporary approach to practice, Jones & Bartlett Learning, Sudbury.

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