5Neuroanatomy of Voiding Frontal lobeMicturition centerSends inhibitory signalsPons (Pontine Micturition Center)Major relay/excitatory centerCoordinates urinary sphincters and the bladderAffected by emotionsSpinal cordIntermediary between upper and lower control
6Peripheral Nervous System Somatic (S2-S4)Pudendal nervesExcitatory to external sphincterParasympathetic (S2-S4)Pelvic nervesExcitatory to bladder, relaxes sphincterSympathetic (T10-L2)Hypogastric nerves to pelvic gangliaInhibitory to bladder body, excitatory to bladder base/urethra
7Normal Voiding SNS primarily controls bladder and the IUS PNS Bladder increases capacity but not pressureInternal urinary sphincter to remain tightly closedParasympathetic stimulation inhibitedPNSImmediately prior to PNS stimulation, SNS is suppressedStimulates detrusor to contractPudendal nerve is inhibited external sphincter opens facilitation of voluntary urination
17Management Options Type of Management Advantage Disadvantage Indwelling catheterConvenienceLess caregiver assistanceInfection± Urethral damage± Bladder cancerIntermittent catheter± Reduced infectionNeed anticholinergicAssistanceCostLabor
18Management Options Type of Management Advantage Disadvantage Reflex voidingNon-invasive± High pressure± Continence± High residuals± Need for sphincterotomyElectrical stimulation + rhizotomyImproved bowel fxnReduced labor/costCosmetically appealingSignificant surgerySide effects- rhizotomy↓ Reflex erection↓ Reflex ejaculation
19Management Options Type of Management Advantage Disadvantage Surgical diversionMay produce continenceContinent pouch easier for female to cathSignificant surgeryCommitted to collection device/cathRisk of cancer
21Bladder AugmentationProcedure that increases bladder capacity using intestinal segmentsIleum, colon, or stomach are usedGoalsDecreasing intravesicle pressureRestore urinary continencePreserve upper urinary tracts by alleviating reflux and hydronephrosisCan combine with a continent abdominal stomaConsider in patients withIntractable involuntary bladder contractions causing incontinencePatients who are able and motivated to perform CICReflex voiders wishing to convert to CICFemales with paraplegia
22Urinary Diversion Diverts the urine flow from the bladder Secondary form of bladder management when primary methods have failedUreters 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 wallExternal appliance used as collection deviceConsidered if:Lower urinary complications secondary to indwelling cathetersUrethrocutaneous fistulas, perineal decubitus ulcersUrethral destruction in femalesHydronephrosis secondary to a thickened bladder wall and for hydronephrosis secondary to vesicoureteral reflux or failed reimplant.Bladder malignancy requiring cystectomy
24RecommendationsRecommendation 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.
25Recommendations 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
26Recommendations 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.
27Recommendations from the PVA Guidelines Recommendation 6: Patient should be advised of long-term complications of indwelling catheterization, including:Bladder stonesKidney stonesUrethral erosionsBladder cancerEpididymitisRecurrent symptomatic urinary tract infections
29Assessment of Function U/a and c & sBUN & Crif compromised renal function is suspectedPostvoid residual urineIf high, the bladder may be contractile or the bladder outlet may be obstructed
30Renal/Bladder US Mainstay of screening in many institutions Advantages SimpleEval kidney, parenchymal loss, abnl echogenicityEval for hydronephrosis, stonesDisadvantagesLow sensitivity for small stonesUreters not evaluated well
31Nuclear Renal Scan Advantages Disadvantage Functional info No nephrotoxic reactionsLow radiationDisadvantageLess anatomic infoCannot detect stones
32KUB Historically, routinely used to detect renal and bladder stones DisadvantagesPoorly sensitive to stones“KUB not justified in routine f/u of urinary tract in SCI”Tins et al. Spinal Cord 2005
33Secondary Conditions Increased risk of Bladder infection Kidney infectionHydronephrosisUrethral trauma/laxity
34Urinary Stones and SCI Higher incidence, especially in first 6 mos 3-6% upper tract11-15% bladderEtiologyStasisCalcium metabolismInfectionDiagnosisCT is gold standard
36Red Rubbers, $.50 No-touch catheters $2.00 “Bitch catheter” Sterile single use catheters $1.00No-touch kits with collection bags $4.00No-touch catheters $2.00“Bitch catheter”
37Ultimately, we do what is right for each of our patients, just like we would treat our own family
38UTIIndications 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) );14New 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/orWorsening of mental or functional status (e.g., confusion, decreased appetite, unexplained falls, incontinence of recent onset, lethargy, decreased activity).
39UTI 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/orWorsening of mental or functional status.Local findings such as obstruction, leakage, or mucosal trauma (hematuria) may also be present.
40UTI Follow up Recurrent UTIs Predisposing Factors structural abnormalities - a referral to a urologistpoor perineal hygienePRIMARY - reconsider the relative risks and benefits of continuing the use of an indwelling catheter.(2 or more in 6 months) in a noncatheterized individual may warrant additional evaluationabnormal post void residual (PVR) urine volume) to rule out such as enlarged prostate, prolapsed bladder, periurethral abscess, strictures, bladder calculi, polyps and tumors
41Neurogenic Bladder What is a neurogenic bladder? A medical term for overflow incontinence, secondary to a neurologic problemHowever, this is NOT a type of urinary incontinence
42Urinary Catherization Equipment:Straight cathetersBox of supplies: foley, 3 way foley, cath kits with sterile gloves, drainage bags with urin Bag, Drape and towelTapeSkin so soft lubricantOverbed tableGood lighting
43Complication of catheterization 1. Infection- (primary cause) 2. Uretheral tares3. Ruptured bladder4. Bladder spasm5. Possible allergic reaction to tape or latex
44Urinary Catherization Purposes of catherization:1. Relief of discomfort due to bladder distention2. Assess amount of residual urine3. Obtain a urine specimen4. Empty bladder prior to procedure5. Manage incontinence6. Provide for bladder irrigation7. Prevent urine coming in contact with wound8.facilitate accurate measurement of output in critically ill clients9. Self catherization for management of neurogenic bladder
45Types of Equipment: Catheters 2. Types 1. Sizes – range from 8 to 18 French indicates diameter.2. Typesa. Straight- single use for intermittent catherization ; has 1 openingb. Foley- inflatable balloon (5cc-30cc), known as indwelling or retention catheters, has 2 openingsc. Continuous catheter-3 openings or lumens (1 to drain urine, 1 for filling balloon, and 1 for irrigation), used for periodic or continuous bladder irrigationd. Coude’- curved tip, used on male clients with enlarged prostates or for obstruction
46e. 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. Regular2. Urometer3. Leg bagPsychological ImplicationsMaintain privacyAnxiety- need for explainition
47Cultural Considerations Gender.Explain the procedure to clientMeticulous hygiene observed (Muslims use left hand for unclean procedures)Strict Sterile procedure need to be observed
481. After client voids, I&O cath to determine amount of A. In and Out Catherization (no ballon)1. After client voids, I&O cath to determine amount ofresidual urine after a foley catheter has been removed2. Use straight catheter3. If over 200 cc obtained then physician may orderretention catheter (foley catheter)B. Indwelling catherization (Foley) has ballon1. Need for extra lighting2. Follow procedure as outlined during practice3. Discuss taping for male and female- pressure onpenile- scrotal angle can lead to necrosis4. Collection of specimen from port on drainage bagtubing5. If getting no urine, insert catheter a little more6. After getting urine, insert catheter another inch
497. 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 patency9. 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.
50Documentation Size of catheter and balloon Amount ,color, odor and consistency of urineHow client tolerated procedure
511. Medications- some may cause precipitation of uric ComplicationsInfectiona. Most commonb. Sources- identify sites on catheter system2. Uretheral Trauma1. Not frequent2. After catheter removal edema may interfere withurine flow.Obstructed catheter1. Medications- some may cause precipitation of uricacid crystals2. Clots- post prostatecomy. May run CBI at a rate soas to reduce clots3. Tubing kinked- reposition client
52Bladder IrrigationOpen- disconnect catheter from drainage bag and instill irrigating solution or medication (pg 1096)Closed intermittent- need to clamp drainage tubing below port and instill irrigant through portClosed 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)
53Self catherization Indication: Procedure: Spinal cord injury- neurogenic bladderProcedure:Knowledge of clean versus sterileKnowledge of anatomy and physiologyChildren can be taught as young as 6 yearsPerformed every 6-8 hoursControlled fluid intake regimenMay reuse catheter if washed and bagged properly
541. Know signs of dehydration and fluid overload Things to Remember1. Know signs of dehydration and fluid overload2. Usual output is 30cc/hour;if acutely ill need to measure more frequently3. Measure output every 8 hours or more if needed4. Encourage fluid intake of 2000ml/day if not restricted5. Check most recent serum electrolyte6. Foley of males to tape on abdomen; females to legs7. When taping provide slack to more around in bed8. Foley drainage bag below level of bladder and OFF FLOOR9. Make sure cleanse uncircumcised males before insertion of catheter10. Check allergies of client relating to tape, latex, l lubricant, Betadine, shell fish
5511. Do not drain more than 500 to 1000 cc at one 12. Do Catheter care daily on all clients who have foley catheters13. Make sure catheter tubing does not kink15. When aspirating the balloon, if the balloon says 5cc there maybe 10cc in the balloon16. Check old adults for atypical signs and symptoms of UTI17. If client is unable to void 6-8 hrs after catheter removal notify MD
5618. If client voiding around catheter may to have a larger catheter 19 NEVER cut the tubing on the balloon to remove a foley catheter20 NEVER force the catheter in a child if met resistance wait 20 seconds until sphincter relaxes and then try again21. If patient has a foley for a long period of time, mayhave to retrain bladder, this is sometimes done withorthopedic trauma patients22. Patients who have long term use of foley’s are prone to kidney stones because of small amounts of fluid intake