Frontal lobe –Micturition center –Sends inhibitory signals Pons (Pontine Micturition Center) –Major relay/excitatory center –Coordinates urinary sphincters and the bladder –Affected by emotions Spinal cord –Intermediary between upper and lower control
Peripheral Nervous System Somatic (S2-S4) –Pudendal nerves Excitatory to external sphincter Parasympathetic (S2- S4) –Pelvic nerves Excitatory to bladder, relaxes sphincter Sympathetic (T10-L2) –Hypogastric nerves to pelvic ganglia –Inhibitory to bladder body, excitatory to bladder base/urethra
Normal Voiding SNS primarily controls bladder and the IUS –Bladder increases capacity but not pressure –Internal urinary sphincter to remain tightly closed –Parasympathetic stimulation inhibited PNS –Immediately prior to PNS stimulation, SNS is suppressed –Stimulates detrusor to contract –Pudendal nerve is inhibited external sphincter opens facilitation of voluntary urination
Innervations of the Lower Urinary Tract Function Balance between suprasacral modulating pathways, sacral cord and the pelvic floor Emptying phase: “Voiding Reflex” Series of coordinated events involving outlet relaxation, detrusor contraction Storage phase: “Guarding reflexes” constant afferent input to maintain continence
Management Options Type of ManagementAdvantageDisadvantage Indwelling catheterConvenience Less caregiver assistance Infection ± Urethral damage ± Bladder cancer Intermittent catheter± Reduced infectionNeed anticholinergic ± Urethral damage Assistance Cost Labor
Management Options Type of Management AdvantageDisadvantage Reflex voidingNon-invasive± High pressure ± Continence ± High residuals ± Need for sphincterotomy Electrical stimulation + rhizotomy Improved bowel fxn Reduced labor/cost Cosmetically appealing Significant surgery Side effects- rhizotomy ↓ Reflex erection ↓ Reflex ejaculation
Management Options Type of Management AdvantageDisadvantage Surgical diversionMay produce continence Continent pouch easier for female to cath Significant surgery Committed to collection device/cath Risk of cancer
Bladder Augmentation Procedure that increases bladder capacity using intestinal segments –Ileum, colon, or stomach are used Goals –Decreasing intravesicle pressure –Restore urinary continence –Preserve upper urinary tracts by alleviating reflux and hydronephrosis Can combine with a continent abdominal stoma Consider in patients with –Intractable involuntary bladder contractions causing incontinence –Patients who are able and motivated to perform CIC –Reflex voiders wishing to convert to CIC –Females with paraplegia
Urinary Diversion Diverts the urine flow from the bladder Secondary form of bladder management when primary methods have failed Ureters transected just above the bladder and connected to a segment of intestine (terminal ileum) which is in turn brought to the skin of the lower abdominal wall External appliance used as collection device Considered if: –Lower urinary complications secondary to indwelling catheters –Urethrocutaneous fistulas, perineal decubitus ulcers –Urethral destruction in females –Hydronephrosis secondary to a thickened bladder wall and for hydronephrosis secondary to vesicoureteral reflux or failed reimplant. –Bladder malignancy requiring cystectomy
Recommendations Recommendation 1: Intermittent catheterization is the preferable method for bladder emptying for men and women who have adequate hand function or a willing caregiver to perform the catheterization and have bladders that do not empty adequately. Recommendation 2: Intermittent catheterization should be ideally performed every 4 to 6 hours to keep bladder volumes below 400ccs.
Recommendations from the PVA Guidelines Recommendation 5: Consider sterile catheterization for those individuals with recurrent symptomatic infections occurring with clean intermittent catheterization. Rationale: Lower infection rates can be achieved with sterile techniques and with pre-lubricated self contained catheter sets
Recommendations from the PVA Guidelines Recommendation 5: Risk of symptomatic infection is at least comparable and may be less in individuals with indwelling catheters than those managing their bladders with clean intermittent catheterization.
Recommendations from the PVA Guidelines Recommendation 6: Patient should be advised of long-term complications of indwelling catheterization, including: –Bladder stones –Kidney stones –Urethral erosions –Bladder cancer –Epididymitis –Recurrent symptomatic urinary tract infections
Assessment of Function U/a and c & s BUN & Cr –if compromised renal function is suspected Postvoid residual urine –If high, the bladder may be contractile or the bladder outlet may be obstructed
Renal/Bladder US Advantages –Simple –Eval kidney, parenchymal loss, abnl echogenicity –Eval for hydronephrosis, stones Disadvantages –Low sensitivity for small stones –Ureters not evaluated well n Mainstay of screening in many institutions
Nuclear Renal Scan Advantages –Functional info –No nephrotoxic reactions –Low radiation Disadvantage –Less anatomic info –Cannot detect stones
KUB Historically, routinely used to detect renal and bladder stones Disadvantages –Poorly sensitive to stones –“KUB not justified in routine f/u of urinary tract in SCI” Tins et al. Spinal Cord 2005
Red Rubbers, $.50 Sterile single use catheters $1.00 No-touch kits with collection bags $4.00 No-touch catheters $2.00 “Bitch catheter”
Ultimately, we do what is right for each of our patients, just like we would treat our own family
UTI Indications to treat - No catheter & three of the following present… Fever (increase in temp >2 degrees F (1.1 degrees C) or rectal temperature >99.5 degrees F (37.5 degrees C) or single measurement of temperature >100 degrees F (37.8 degrees C) );14 New or increased burning pain on urination, frequency or urgency; New flank or suprapubic pain or tenderness; Change in character of urine (e.g., new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory (new pyuria or microscopic hematuria); and/or Worsening of mental or functional status (e.g., confusion, decreased appetite, unexplained falls, incontinence of recent onset, lethargy, decreased activity).
UTI Indications to treat – w/ catheter & two of the following Fever or chills; New flank pain or suprapubic pain or tenderness; Change in character of urine (e.g., new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory (new pyuria or microscopic hematuria); and/or Worsening of mental or functional status. Local findings such as obstruction, leakage, or mucosal trauma (hematuria) may also be present.
UTI Follow up Recurrent UTIs Predisposing Factors –structural abnormalities - a referral to a urologist –poor perineal hygiene PRIMARY - reconsider the relative risks and benefits of continuing the use of an indwelling catheter.
Neurogenic Bladder What is a neurogenic bladder? A medical term for overflow incontinence, secondary to a neurologic problem However, this is NOT a type of urinary incontinence
Urinary Catherization Equipment: Straight catheters Box of supplies: foley, 3 way foley, cath kits with sterile gloves, drainage bags with urin Bag, Drape and towel Tape Skin so soft lubricant Overbed table Good lighting
Complication of catheterization 1.Infection- (primary cause) 2.Uretheral tares 3.Ruptured bladder 4.Bladder spasm 5.Possible allergic reaction to tape or latex
Urinary Catherization A.Purposes of catherization: 1. Relief of discomfort due to bladder distention 2. Assess amount of residual urine 3. Obtain a urine specimen 4. Empty bladder prior to procedure 5. Manage incontinence 6. Provide for bladder irrigation 7. Prevent urine coming in contact with wound 8.facilitate accurate measurement of output in critically ill clients 9. Self catherization for management of neurogenic bladder
Types of Equipment: -Catheters 1. Sizes – range from 8 to 18 French indicates diameter. 2. Types a. Straight- single use for intermittent catherization ; has 1 opening b. Foley- inflatable balloon (5cc-30cc), known as indwelling or retention catheters, has 2 openings c. Continuous catheter-3 openings or lumens (1 to drain urine, 1 for filling balloon, and 1 for irrigation), used for periodic or continuous bladder irrigation d. Coude’- curved tip, used on male clients with enlarged prostates or for obstruction
e. Suprapubic-inserted through abdominal wall over suprapubic bone and into bladder. f. Condom catheter- used for incontinence, also known as a sheath or Texas catheter (pg1098) Drainage Bags : 1. Regular 2. Urometer 3. Leg bag Psychological Implications 1.Maintain privacy 2.Anxiety- need for explainition
Cultural Considerations 1.Gender. 2.Explain the procedure to client 3.Meticulous hygiene observed (Muslims use left hand for unclean procedures) 4.Strict Sterile procedure need to be observed
A.In and Out Catherization (no ballon) 1. After client voids, I&O cath to determine amount of residual urine after a foley catheter has been removed 2.Use straight catheter 3. If over 200 cc obtained then physician may order retention catheter (foley catheter) B. Indwelling catherization (Foley) has ballon 1. Need for extra lighting 2.Follow procedure as outlined during practice 3.Discuss taping for male and female- pressure on penile-scrotal angle can lead to necrosis 4.Collection of specimen from port on drainage bag tubing 5. If getting no urine, insert catheter a little more 6. After getting urine, insert catheter another inch
7. Catheter care- once every 8 hours as outlined by policy (peri-care with soap, water, rinse- for uncircumsized males remember to pull back foreskin for cleaning and return to previous position) 8. Encourage fluid intake 2000cc-3000cc per day ( if not on fluid restriction) in order to maintain catheter patency 9. Removal of indwelling catheter- clean gloves, towel, chux, and syringe to accommodate removal of saline in balloon ( never cut)- instruct client to bear down. Note amount of voiding & time after removal of catheter. 10. Equipment changes- foleys should be changed every 10 to 30 days in order to prevent bladder neck necrosis- change bags as needed.
Documentation 1.Size of catheter and balloon 2.Amount,color, odor and consistency of urine 3.How client tolerated procedure
Complications 1.Infection a. Most common b. Sources- identify sites on catheter system 2. Uretheral Trauma 1. Not frequent 2. After catheter removal edema may interfere with urine flow. 3.Obstructed catheter 1. Medications- some may cause precipitation of uric acid crystals 2. Clots- post prostatecomy. May run CBI at a rate so as to reduce clots 3. Tubing kinked- reposition client
Bladder Irrigation 1.Open- disconnect catheter from drainage bag and instill irrigating solution or medication (pg 1096) 2.Closed intermittent- need to clamp drainage tubing below port and instill irrigant through port 3.Closed Continuous (CBI)- use 3 way foley catheter, hang irrigating solution on IV pole ( usually NSS for post prostatecomy clients) and adjust flow rate; if catheter clogs during CBI, no drainage will flow but irrigation will continue to run in; How to calculate true urine output- subtract amount of irrigation which has infused from the amount of drainage from the catheter= urine output. (pg 1095)
Self catherization Indication: 1.Spinal cord injury- neurogenic bladder Procedure: 1.Knowledge of clean versus sterile 2.Knowledge of anatomy and physiology 3.Children can be taught as young as 6 years 4.Performed every 6-8 hours 5.Controlled fluid intake regimen 6.May reuse catheter if washed and bagged properly
Things to Remember 1.Know signs of dehydration and fluid overload 2.Usual output is 30cc/hour;if acutely ill need to measure more frequently 3.Measure output every 8 hours or more if needed 4. Encourage fluid intake of 2000ml/day if not restricted 5. Check most recent serum electrolyte 6.Foley of males to tape on abdomen; females to legs 7.When taping provide slack to more around in bed 8.Foley drainage bag below level of bladder and OFF FLOOR 9.Make sure cleanse uncircumcised males before insertion of catheter 10. Check allergies of client relating to tape, latex, llubricant, Betadine, shell fish
11.Do not drain more than 500 to 1000 cc at one 12.Do Catheter care daily on all clients who have foley catheters 13.Make sure catheter tubing does not kink 15.When aspirating the balloon, if the balloon says 5cc there maybe 10cc in the balloon 16.Check old adults for atypical signs and symptoms of UTI 17.If client is unable to void 6-8 hrs after catheter removal notify MD
18. If client voiding around catheter may to have a larger catheter 19NEVER cut the tubing on the balloon to remove a foley catheter 20NEVER force the catheter in a child if met resistance wait 20 seconds until sphincter relaxes and then try again 21.If patient has a foley for a long period of time, may have to retrain bladder, this is sometimes done with orthopedic trauma patients 22.Patients who have long term use of foley’s are prone to kidney stones because of small amounts of fluid intake