Bladder Managment for Adults with Spinal Cord Injury - 13

CLINICAL PRACTICE GUIDELINE

Introduction
More than 200,000 people in the United States live with a spinal cord injury (SCI) as a result of trauma. Each year approximately 10,000 new injuries occur. The average age of injury is 30.7. At the time of discharge from acute rehabilitation centers, 53 percent have tetraplegia, 46 percent have paraplegia, and less than 1 percent experience complete neurologic recovery; 48 percent have complete injuries, and 52 percent have incomplete injuries. When considering treatment options, it is important to note that 11 percent of individuals with SCI have an associated head injury, which may make it more difficult for them to comply with certain bladder management programs. The vast majority of those with SCI and neurologic impairment also have voiding dysfunctions. Even those who are able to ambulate and who have very incomplete injuries may have abnormalities in bladder function, causing social issues, such as urinary incontinence. This can be extremely embarrassing, particularly for young adults, who may be single and involved in social activities, such as dating. Additionally, these voiding dysfunctions may cause upper and lower tract complications. Three important goals when deciding on a bladder management program are to: (1) preserve the upper tract, (2) minimize lower tract complications, and (3) be compatible with the person’s lifestyle. delay drainage proximal to that point. This can result in further dilatation and over time lead to hydronephrosis. Beginning at the place where the ureters connect to the bladder (ureterovesical junction), the ureters tunnel obliquely between the muscular and submucosal layers of the bladder wall 1 to 2 cm before opening into the bladder at the ureteral orifices. This submucosal tunnel is designed to allow urine to flow into the bladder and to prevent reflux into the ureter. Any increase in intravesical pressure simultaneously compresses the submucosal ureter and effectively creates a one-way valve. This configuration is important in preventing reflux. Unfortunately, this same configuration can inhibit urine drainage from the kidneys if there are sustained high intravesical (bladder wall) pressures.

L o w e r U r i n a r y Tr a c t
Anatomically, the bladder is divided into the detrusor and the trigone. The detrusor is composed of smooth muscle bundles that freely crisscross and interlace with each other. Near the bladder neck, the muscle fibers assume three distinct layers. The circular arrangement of the smooth muscles at the bladder neck allows them to act as a functional sphincter. The trigone is located at the inferior base of the bladder and extends from the ureteral orifices to the bladder neck. Traditionally, the urethra has been thought to have two distinct sphincters, the internal and the external, or rhabdosphincter. The internal sphincter is not a true anatomic sphincter. Instead, in both males and females, the term refers to the junction of the bladder neck and proximal urethra, formed from the circular arrangement of connective tissue and smooth muscle fibers that extend from the bladder. This area is considered to be a functional sphincter because there is a progressive increase in tone with bladder filling so that the urethral pressure is greater than the intravesical pressure. These smooth muscle fibers also extend submucosally down the urethra and lie above the external sphincter. The internal urethral sphincter has been described as being under the control of the autonomic system. This area has a large number of sympathetic alpha-receptors, which cause closure when stimulated. The external urethral sphincter has somatic innervation from the sacral region (S2–S4) via the pudendal nerve, allowing the sphincter to be closed at will. In males, the external sphincter has

Anatomy and Physiology of the U p p e r a n d L o w e r U r i n a r y Tr a c t s
When considering the various types of bladder management, it is important to understand the neuroanatomy and neurophysiology of the urinary tract. Discussions often focus on a person’s “neurogenic bladder.” However, changes in the lower tract, such as poor drainage or high bladder pressures, often have a direct impact on the kidneys. Therefore, even though this discussion will treat the kidneys and bladder separately as part of the upper and lower urinary tracts, one needs to consider them as a single unit.

U p p e r U r i n a r y Tr a c t
The kidney consists of two parts, the renal parenchyma and the collecting system. The renal parenchyma secretes, concentrates, and excretes urine into the collecting system. Peristaltic waves propel urine down the ureters to the bladder. Ureteral dilatation for any reason results in inefficient propulsion of the urine bolus, which can

Bladder Managment for Adults with Spinal Cord Injury

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