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

NEUROGENIC BLADDER NEUROGENIC BLADDER AND BLADDER TRAININGAND BLADDER TRAINING

TRI DAMIATI P , M.D..PhysiatristTRI DAMIATI P , M.D..PhysiatristDept.of Physical Medicine and Dept.of Physical Medicine and

RehabilitationRehabilitationSchool of Medicine, Padjadjaran School of Medicine, Padjadjaran

UniversityUniversityDr.Hasan Sadikin General HospitalDr.Hasan Sadikin General Hospital

anatomyanatomy

NORMAL VOIDING PHYSIOLOGYNORMAL VOIDING PHYSIOLOGY

TWO PHASESTWO PHASES

• THE FILLING ( STORAGE )THE FILLING ( STORAGE ) OCCURS WHEN A PERSON IS NOT TRYING TO OCCURS WHEN A PERSON IS NOT TRYING TO

VOIDVOID

• THE EMPTYING ( VOIDING )THE EMPTYING ( VOIDING ) OCCURS WHEN A PERSON IS ATTEMPTING OCCURS WHEN A PERSON IS ATTEMPTING

TO VOID OR TOLD TO VOIDTO VOID OR TOLD TO VOID

NORMAL VOIDING PHYSIOLOGY cont…NORMAL VOIDING PHYSIOLOGY cont…

DURING FILLING / STORAGE PHASEDURING FILLING / STORAGE PHASE

• SHOULD BE VERY LITTLE RISE IN BLADDER SHOULD BE VERY LITTLE RISE IN BLADDER PRESSUREPRESSURE

• PROGRESSIVE INCREASE IN SYMPATHETIC PROGRESSIVE INCREASE IN SYMPATHETIC STIMULATION OF THE BETA RECEPTOR STIMULATION OF THE BETA RECEPTOR

• RELAXATION ALPHA RECEPTORS → RELAXATION ALPHA RECEPTORS → CONTRACTION OF THE URETHRACONTRACTION OF THE URETHRA


DURING FILLING / STORAGE PHASE cont…DURING FILLING / STORAGE PHASE cont…

• INHIBITS EXITATORY PARASYMPATHETIC INHIBITS EXITATORY PARASYMPATHETIC GANGLIONIC TRANSMISSION → SUPRESS GANGLIONIC TRANSMISSION → SUPRESS BLADDER CONTRACTIONBLADDER CONTRACTION

• PROGRESSIVE INCREASE IN URETHRAL PROGRESSIVE INCREASE IN URETHRAL SPHINCTER EMG ACTIVITYSPHINCTER EMG ACTIVITY


VOIDING / EMPTYING PHASEVOIDING / EMPTYING PHASE

• SHOULD BE CESSATION OF URETHRAL SHOULD BE CESSATION OF URETHRAL SPHINCTER ACTIVITY SPHINCTER ACTIVITY

• URETHRAL SPHINCTER PRESSURE DROPURETHRAL SPHINCTER PRESSURE DROP

• FUNNELING OF THE BLADDER NECKFUNNELING OF THE BLADDER NECK


VOIDING / EMPTYING PHASE cont…VOIDING / EMPTYING PHASE cont…

• NO LONGER REFLEX INHIBITION TO THE NO LONGER REFLEX INHIBITION TO THE SACRAL MIXTURITION CENTER FROM THE SACRAL MIXTURITION CENTER FROM THE SPHINCTER MECHANISMSPHINCTER MECHANISM

• FOLLOWED BY THE BLADDER CONTRACTIONFOLLOWED BY THE BLADDER CONTRACTION

• THE URETHRAL SPHINCTER REMAIN OPEN THE URETHRAL SPHINCTER REMAIN OPEN THROUGHOUT VOIDINGTHROUGHOUT VOIDING


VOIDING / EMPTYING PHASE cont…VOIDING / EMPTYING PHASE cont…

• SHOULD BE NO RISES IN INTRA ABDOMINAL SHOULD BE NO RISES IN INTRA ABDOMINAL PRESSURE DURING VOIDINGPRESSURE DURING VOIDING

• NO POSTVOID RESIDUAL URINENO POSTVOID RESIDUAL URINE

CLASSIFICATION OF VOIDING CLASSIFICATION OF VOIDING DYSFUNCTIONDYSFUNCTION

• WIDE VARIETY OF CLASSIFICATIONWIDE VARIETY OF CLASSIFICATION

• IDEALLY THE SYSTEM SHOULD DISCRIBEIDEALLY THE SYSTEM SHOULD DISCRIBE THE TYPE OF NEUROLOGIC LESIONTHE TYPE OF NEUROLOGIC LESION CLINICAL SYMPTOMSCLINICAL SYMPTOMS URODYNAMIC DATA URODYNAMIC DATA TREATMENT OPTIONTREATMENT OPTION

• SINGLE CLASSIFICATION FOCUSING ON ALL SINGLE CLASSIFICATION FOCUSING ON ALL THESE FACTOR DOES NOT EXISTTHESE FACTOR DOES NOT EXIST

CLASSIFICATION OF VOIDING CLASSIFICATION OF VOIDING DYSFUNCTION cont…DYSFUNCTION cont…

URODYNAMIC AND FUNCTIONAL URODYNAMIC AND FUNCTIONAL CLASSIFICATION CLASSIFICATION

• INCONTINENCEINCONTINENCE

• RETENTIONRETENTION

• RETENTION AN INCONTINENCERETENTION AN INCONTINENCE


INCONTINENCEINCONTINENCE• CAUSED BY BLADDERCAUSED BY BLADDER

UNHIBITED CONTRACTINGUNHIBITED CONTRACTING DECREASE CAPACITYDECREASE CAPACITY LOW COMPLIANCELOW COMPLIANCE NORMAL ---NORMAL --- COGNITIVE / MOBILITY ISSUE COGNITIVE / MOBILITY ISSUE

• CAUSED BY THE OUTLETCAUSED BY THE OUTLET DECREASE BLADDER NECK PRESSUREDECREASE BLADDER NECK PRESSURE DECREASE EXTERNAL SPHINCTER PRESSUREDECREASE EXTERNAL SPHINCTER PRESSURE


RETENTIONRETENTION

• CAUSED BY THE BLADDERCAUSED BY THE BLADDER DETRUSSOR AREFLEXIADETRUSSOR AREFLEXIA LARGE CAPACITY / HIGH COMPLIANCELARGE CAPACITY / HIGH COMPLIANCE NORMAL → COGNITIVE / MOBILITY ISSUENORMAL → COGNITIVE / MOBILITY ISSUE

• CAUSED BY THE OUTLETCAUSED BY THE OUTLET HIGH VOIDING PRESSURE WITH LOW FLOW RATEHIGH VOIDING PRESSURE WITH LOW FLOW RATE INTERNAL SPHINCTER DYSINERGIAINTERNAL SPHINCTER DYSINERGIA EXTERNAL SPHINCTER DYSINERGIAEXTERNAL SPHINCTER DYSINERGIA OVERACTIVE SPHINCTER MECHANISMOVERACTIVE SPHINCTER MECHANISM


RETENTION AND INCONTINENCERETENTION AND INCONTINENCE

• CAUSED BY THE BLADDERCAUSED BY THE BLADDER

UNINUNINHHIBITED CONTRACTION WITH UNDER ACTIVE IBITED CONTRACTION WITH UNDER ACTIVE DETRUSORDETRUSOR

TREATMENT OPTION FOR TREATMENT OPTION FOR VOIDING DISORDERSVOIDING DISORDERS

• INCONTINENCE CAUSED BY THE BLADDERINCONTINENCE CAUSED BY THE BLADDER

SCHEDULED VOIDINGSCHEDULED VOIDING INTERMITTENT CATHETERIZATION / INDWELLING INTERMITTENT CATHETERIZATION / INDWELLING

CATHETER / EXTERNAL CONDOM / DIAPERSCATHETER / EXTERNAL CONDOM / DIAPERS PHARMACOLOGICPHARMACOLOGIC SURGICALSURGICAL

TREATMENT OPTION FOR VOIDING TREATMENT OPTION FOR VOIDING DISORDERS cont…DISORDERS cont…

INCONTINENCE CAUSED BY THE SPHINCTERINCONTINENCE CAUSED BY THE SPHINCTER

• SCHEDULED VOIDINGSCHEDULED VOIDING

• PELVIC FLOOR EXERCISES / BIOFEEDBACKPELVIC FLOOR EXERCISES / BIOFEEDBACK

• INTERMITTENT CATHETERIZATION / INDWELLING INTERMITTENT CATHETERIZATION / INDWELLING CATHETER / EXETERNAL CONDOM / DIAPERSCATHETER / EXETERNAL CONDOM / DIAPERS

• PHARMACOLOGICPHARMACOLOGIC

• SURGICALSURGICAL

TREATMENT OPTION FOR VOIDING TREATMENT OPTION FOR VOIDING DISORDERS cont…DISORDERS cont… RETENTION CAUSED BY THE BLADDERRETENTION CAUSED BY THE BLADDER

• SCHEDULED VOIDING COMBINED WITHSCHEDULED VOIDING COMBINED WITH SUPRA PUBIC TAPPINGSUPRA PUBIC TAPPING VALSAVAVALSAVA CREDECREDE

• INTERMITTENT CATHETERIZATION / INDWELLING INTERMITTENT CATHETERIZATION / INDWELLING CATHETER CATHETER



TREATMENT OPTION FOR VOIDING TREATMENT OPTION FOR VOIDING DISORDERS cont…DISORDERS cont…

RETENTION CAUSED BY SPHINCTER / RETENTION CAUSED BY SPHINCTER / OUTLETOUTLET

• SUPRAPUBIC TAPPING / BIOFEEDBACKSUPRAPUBIC TAPPING / BIOFEEDBACK

• INTERMITTENT CATHETERIZATION / INTERMITTENT CATHETERIZATION / INDWELLING CATHETERINDWELLING CATHETER



TRAUMATIC SCI (SPINAL CORD TRAUMATIC SCI (SPINAL CORD INJURY)INJURY)

• THE MOST SCI IS SUPRA SACRAL LESIONTHE MOST SCI IS SUPRA SACRAL LESION• TYPE UPPER MOTORNEURON TYPE UPPER MOTORNEURON • CAN BE A DETRUSOR HYPERREFLEXIA CAN BE A DETRUSOR HYPERREFLEXIA

WITH DETRUSOR SPHINCTER WITH DETRUSOR SPHINCTER DYSINNERGIADYSINNERGIA

• INITIAL PERIOD OF SCI IS SPINAL SHOCKINITIAL PERIOD OF SCI IS SPINAL SHOCK HYPOREFLEXIA OF SOMATIC SYSTEMHYPOREFLEXIA OF SOMATIC SYSTEM DETRUSOR AREFLEXIADETRUSOR AREFLEXIA

TRAUMATIC SCI (SPINAL CORD INJURY) TRAUMATIC SCI (SPINAL CORD INJURY) cont…cont…

• RECOVERY OF BLADDER FUNCTION USUALLY RECOVERY OF BLADDER FUNCTION USUALLY FOLLWS RECOVERY OF SKELETAL MUSCLE FOLLWS RECOVERY OF SKELETAL MUSCLE REFLEXESREFLEXES

• UNHIBITED BLADDER CONTRATION UNHIBITED BLADDER CONTRATION GRADUALLY RETURN AFTER 6 – 8 WEEKSGRADUALLY RETURN AFTER 6 – 8 WEEKS

BLADDER TRAININGBLADDER TRAINING

CONSIST OF:CONSIST OF:

• SCHEDULED VOIDINGSCHEDULED VOIDING

• PELVIC FLOOR EXERCISEPELVIC FLOOR EXERCISE

• SUPRA PUBIC TAPPING , VALSAVA , SUPRA PUBIC TAPPING , VALSAVA , CREDECREDE

• INTERMITTENT CATHETERIZATIONINTERMITTENT CATHETERIZATION

BLADDER TRAINING cont…BLADDER TRAINING cont…

SCHEDULED VOIDINGSCHEDULED VOIDING

• TIMED VOIDING, THEY ARE TOUHGT TO VOID BEFORE TIMED VOIDING, THEY ARE TOUHGT TO VOID BEFORE REACHING THEIR FULL CAPACITY -REACHING THEIR FULL CAPACITY - UNHIBITED UNHIBITED BLADDERBLADDER

• PROGRESSIVELY INCREASING THE TIME BETWEEN PROGRESSIVELY INCREASING THE TIME BETWEEN VOIDING VOIDING


PELVIC FLOOR MUSCLES EXERCISES / KEGEL PELVIC FLOOR MUSCLES EXERCISES / KEGEL EXERCISESEXERCISES

OBJECTIVE :OBJECTIVE :• TO STRENGTHEN THE PELVIC FLOOR MUSCLESTO STRENGTHEN THE PELVIC FLOOR MUSCLES

PELVIC FLOOR MUSCLES CONSIST OF:PELVIC FLOOR MUSCLES CONSIST OF:• PUBOCOCCYGEUSPUBOCOCCYGEUS• ILIOCOCCYGEUSILIOCOCCYGEUS• ISCHIOCOCCYGEUSISCHIOCOCCYGEUS

BLADDER TRAINING cont…BLADDER TRAINING cont… - -

PELVIC FLOOR MUSCLES EXERCISESPELVIC FLOOR MUSCLES EXERCISES

THE FUNCTION OF PELVIC FLOOR MUSCLES:THE FUNCTION OF PELVIC FLOOR MUSCLES:

• PROVIDE SUPPORT FOR THE PELVIC VISCERA AS WE STAND PROVIDE SUPPORT FOR THE PELVIC VISCERA AS WE STAND UPRIGHT, AND SUPPURT FOR THE BLADDER NECK AND THE UPRIGHT, AND SUPPURT FOR THE BLADDER NECK AND THE URETHROVESICULAR ANGLE WHICH IS VITAL IMPORTANCE FOR URETHROVESICULAR ANGLE WHICH IS VITAL IMPORTANCE FOR CONTINENCECONTINENCE

• CLOSING FORCE ALONG URETHRAL WALL ESPECIALLY CLOSING FORCE ALONG URETHRAL WALL ESPECIALLY WHENEVER THERE IS AN INCREASE IN INTRA ABDOMINAL WHENEVER THERE IS AN INCREASE IN INTRA ABDOMINAL PRESSUREPRESSURE

• THE SEXUAL FUNCTION THE SEXUAL FUNCTION CORRELATION BETWEEN CORRELATION BETWEEN STRENGHT AND ACHIEVES ORGASMSTRENGHT AND ACHIEVES ORGASM



HOW TO DO KEGEL EXERCISE:HOW TO DO KEGEL EXERCISE:

• FIND THE RIGHT MUSCLES, by:FIND THE RIGHT MUSCLES, by: TRY TO STOP THE FLOW OF URINE TRY TO STOP THE FLOW OF URINE INSERT A FINGER INSIDE YOUR VAGINA AND TRY TO INSERT A FINGER INSIDE YOUR VAGINA AND TRY TO

SQUEEZESQUEEZE USING THE BIOFEEDBACK TECHNIQUEUSING THE BIOFEEDBACK TECHNIQUE IMAGINE THAT YOU ARE TRYING TO STOP PASSING GASIMAGINE THAT YOU ARE TRYING TO STOP PASSING GAS



THE TECHNIQUE OF EXERCISETHE TECHNIQUE OF EXERCISE• THE PATIENTS HAVE TO BE ABLE TO CONSISTENLY ISOLATE THE PATIENTS HAVE TO BE ABLE TO CONSISTENLY ISOLATE

THE PELVIC MUSCLETHE PELVIC MUSCLE

• ESTABLISH THE INDIVIDUALIZED EXERCISE PROGRAM BASE ESTABLISH THE INDIVIDUALIZED EXERCISE PROGRAM BASE ON THE PATIENT’S INITIAL STRENGTH AND ENDURANCEON THE PATIENT’S INITIAL STRENGTH AND ENDURANCE

• AS THE PATIENT’S CONTRACTILITY AND ENDURANCE AS THE PATIENT’S CONTRACTILITY AND ENDURANCE PROGRESS, THE NUMBER OF REPETIONS IS INCREASEDPROGRESS, THE NUMBER OF REPETIONS IS INCREASED

• MOST CLINICIANS RECOMMEND A TARGET RANGE OF 30 TO 45 MOST CLINICIANS RECOMMEND A TARGET RANGE OF 30 TO 45 REPETITIONS PER DAY AND ARE DIVIDED INTO 3 TIMES AND REPETITIONS PER DAY AND ARE DIVIDED INTO 3 TIMES AND PERFORM IN RECLINING , SITTING AND STANDING POSITIONPERFORM IN RECLINING , SITTING AND STANDING POSITION


INTERMITTENT CATHETERIZATIONINTERMITTENT CATHETERIZATION

STERIL INTERMITTENT CATHETERIZATIONSTERIL INTERMITTENT CATHETERIZATION

CLEAN INTERMITTENT CATHETERIZATION CLEAN INTERMITTENT CATHETERIZATION (CIC)(CIC)


CLEAN INTERMITTENT CATHETERIZATION (CIC)CLEAN INTERMITTENT CATHETERIZATION (CIC)

- IS CONDUCTED FROM 6.00 – 22.00IS CONDUCTED FROM 6.00 – 22.00

- INTAKE OF FLUIDS 100 CC – 125 CC /HOUR LAST INTAKE OF FLUIDS 100 CC – 125 CC /HOUR LAST INTAKE AT DINNER TIME ABOUT 19.00INTAKE AT DINNER TIME ABOUT 19.00

- ATTEMP TO VOID SPONTANEOUSLYATTEMP TO VOID SPONTANEOUSLY

- POST VOID RESIDUALS (PVR) IS MEASURED POST VOID RESIDUALS (PVR) IS MEASURED THROUGH CATHETERIZATION WITH A NELATON THROUGH CATHETERIZATION WITH A NELATON CATHETER CATHETER


CLEAN INTERMITTENT CATHETERIZATION CLEAN INTERMITTENT CATHETERIZATION (CIC)(CIC)• VOLUME OF PVR WILL DETERMINE THE VOLUME OF PVR WILL DETERMINE THE

FREQUENCY OF CATETERIZATION DURING DAY FREQUENCY OF CATETERIZATION DURING DAY TIMETIME

• CATHETERIZATION AT NIGHT IS SITUATIONALCATHETERIZATION AT NIGHT IS SITUATIONAL

• DO THE CATHETERIZATION AS IN MODUL SKILL DO THE CATHETERIZATION AS IN MODUL SKILL LABLAB

• USING THE SURGICAL GLOVES IS OPTIONALUSING THE SURGICAL GLOVES IS OPTIONAL


CLEAN INTERMITTENT CATHETERIZATION CLEAN INTERMITTENT CATHETERIZATION (CIC)(CIC)

PVR MONITORING CHARTPVR MONITORING CHART

PVRPVR CATHETERIZATIONCATHETERIZATION

> 200cc> 200cc Every 4 HrsEvery 4 Hrs

100 – 200cc100 – 200cc Every 6 HrsEvery 6 Hrs

50 – 100cc50 – 100cc Every 8 HrsEvery 8 Hrs

< 50cc< 50cc FreeFree


THE GOALS OF INTERMITTENT THE GOALS OF INTERMITTENT CATHETERIZATIONCATHETERIZATION

Completely and regularly emptying of Completely and regularly emptying of the bladderthe bladder

Avoiding impairment of the kidneys, Avoiding impairment of the kidneys, caused by urine refluxcaused by urine reflux

Free of indwelling or intermittent Free of indwelling or intermittent catheterizationcatheterization

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