- See:
-
Autonomic Dysfunction:
-
Management of the Spine Injured Patient:
-
UTI:
- Discussion:
- it is rare to find a patient who has a single bladder dysfunction,
nevertheless, somem generalizations can be made;
- traumatic cord lesions above T12 usually result in a reflex neurogenic
bladder (upper motor neuron) and lesions below that level, in
mixed or lower motor neuron lesion;
- Acute Phase of Spinal Shock: (see
spinal shock)
- this variable period, which is manifested by a hypotonic, paresthetic
areflexxic bladder, usually lasts approximately 6-12 weeks;
- more rapid recovery occurs with incomplete lesions;
- treatment goal in the acute phase is simply the prevention of UTI
and urosepsis;
- intermittent sterile catheterization, small caliber (12-14 Fr) catheter
is used every 4-6 hours to maintain a bladder volume < 500 ml;
- in the chronic phase bladder volumes should be < 100 ml;
- consider ascorbic acid and mandelamine
- when used institutionally, intermittent catheterization requires
strict sterile techniques, whereas outpatient intermittent
catheterization only requires a clean technique;
- Failure of Bladder Emptying:
- failure to maintain continence in patients with neurogenic bladder
dysfunction may be due to uninhibited bladder contractions, decreased
outlet resistance, overflow incontinence or iatrogenic causes
related to pharmacologic or surgical intervention;
- lower motor neuron bladder results in hypotonic detrussor function and
failure to generate enough intravesical pressure for adequate emptying;
- increased outlet resistance due to bladder neck hypertrophy, prostatic
obstruction or increased resistance of external sphincter leads to
incomplete emptying;
- methods available to increase the intravesical pressure include
external compression (Crede) and increased intra-abdominal pressure;
- these methods require a low outet resistance and a patient who
is physically able to perform these maneuvers;
- application is usuaally limited to lower motor neuron bladders;
- attempt to reduce bladder neck and external sphincter resistance using
medications have met with some success;
- alpha adrenergic agents (dibenzyline) and skeletal muscle relaxants
(ie, diazepam,
baclofen, dantrolene) have been used alone or in
combination;
- if increased outlet resistance is secondary to physical obstruction or
fails to respond to pharmacologic methods, surgery may be indicated;
- unless adequate drainage can be maintained, a neurologic bladder may
become very large;
- Treatment:
- persistent outlet obstruction can eventually decrease renal function
and predispose to urinary infection;
- consequently these patients are often left with urinary catheters;
- vesical calcifications are not uncommon in paraplegic patients
because stone formation is favored by urinary stasis;
- in alkaline urine, calcification is favored and may even occur
around foreign body;
- any sold materal may become nidus for calcium salt encrustation;
- oxbutynin chloride (ditropan):
- may be effective in patients with upper motor neuron lesions;
- Bethanechol
- parasympathomimetic agent that has a direct stimulating effect on the
detrussor, causing increased intravesicular pressure;
- in doses of 5-10 mg SC or in oral doses of 50 mg or more, it may be
of use in treating some pts with neurogenic bladder dysfunction;
- this med may cause sphincter detrussor dyssynergia;
- impairment of bladder storage function:
- pharmacologic manipulation using agents to competitviely block
acetyl- choline receptors have been tried;
- these agents, having an atropine like effect, act primarily at
post ganglionic autonomic effector sites;
- prophantheline bromide (Pro banthine) has been used to block
unihibited contractions;
- 15 mg PO q4-6 hrs in the adult;
- side effects include dry mouth, blurred vision, constipation;
- Management of Post Void Residual:
- in patients who void by reflex, the volume of residual urine after
voiding should be less than 100 ml to confirm adequate emptying;
- high-pressure reflex voiding can sometimes be improved by combination
of alpha-adrenergic blockers and antispasticity agents to relax
internal and external sphincters or by surgery;
- intermittent catheterization, however, can be used in men or women
and in patients with flaccid or reflex bladders;
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Undetected genito-urinary dysfunction in vertebral fractures.
