Bladder Managment for Adults with Spinal Cord Injury - 37

CLINICAL PRACTICE GUIDELINE

Postoperative. The focus is on maintenance of homeostasis through adequate hydration and fluid elimination. Timed voiding and fluid regulation will prevent overdistention of the bladder (which can reduce bladder contractility and emptying). This practice will afford efficient use of the sacral reflex arc and adequate emptying of the bladder. Bladder contractility will usually recover if further overdistention is prevented through temporary catheterization. The device should not be dropped on a hard surface or in water. Equipment failure and other difficulties, such as fatigue of the detrusor muscle, may arise. Assistance required. The type of assistance needed will be determined based on the individual’s functional ability, specifically on hand function (with and without assistive devices), and on the ability to transfer independently to a toilet and access the genital area. A caregiver can assist with care. Cosmesis. Transfer to the toilet and use of the device mimic normal toileting. If hand function is limited, occupational therapy can devise a holder for the transmitter that will allow the individual to hang it from the neck or waist in a pouch for easy access. The transmitter coil can be taped to the receiver site on the abdomen. For males, a condom can be worn to collect urine (see Nursing Considerations for Reflex Voiding for proper use and care of condom catheters and equipment). It is possible to turn the device on and off using gross motor movement. Interference with social/sexual function. A complete posterior rhizotomy will prevent reflex erection. Other methods of producing erection can be used, and the stimulator can produce erection in some males. Medications. Some individuals may be placed on alpha-adrenergic medication to tighten the bladder neck and assist with continence. Males may be placed on an alpha-blocker to facilitate opening of the bladder neck. After rhizotomy, anticholinergic medication is no longer needed for the bladder. Reversibility. Individuals can stop using the device at any time. Internal components are usually left in place, unless contaminated. The rhizotomy is not reversible. Other. See Nursing Considerations for Reflex Voiding.
Adapted from Joseph, A.C., A. Hixon, J. Giroux, D. Briggs, M. Gardenhire, D. Diaz, and J. Wells. Nursing clinical practice guideline: neurogenic bladder management. Spinal Cord Injury Nursing 15 (2) (1998): 21–56.

Bladder Augmentation
Bladder augmentation, or augmentation cystoplasty, is a surgical procedure that increases bladder capacity by augmenting the bladder using intestinal segments. These segments, which include the ileum, colon, or stomach, are used to create a low-pressure intraabdominal reservoir free of disturbing shifts of fluid and electrolytes. The scientific principle of Laplace’s Law (T=PR/2), which states that the larger the vessel radius, the larger the wall tension required to withstand a given internal fluid pressure, is used to detubularize these intestinal segments, thereby converting a cylinder into a sphere, which decreases the pressure by increasing the radius. Detubularization improves reservoir capacity and compliance. The specific goals of decreasing intravesical pressure are to restore urinary continence and preserve upper urinary tracts by alleviating reflux and hydronephrosis. Bladder augmentation can be combined with a continent abdominal stoma using a tapered or intussuscepted segment of bowel. 1. Consider bladder augmentation for individuals who have: Intractable involuntary bladder contractions causing incontinence. The ability and motivation to perform intermittent catheterization. The desire to convert from reflex voiding to an intermittent catheterization program. A high risk for upper tract deterioration secondary to hydronephrosis and/or ureterovesical reflux as a result of highpressure detrusor sphincter dyssynergia.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Following bladder augmentation, individuals with SCI with incontinence secondary to intractable detrusor hyperreflexia have demonstrated long-term success in their ability to preserve continence. Bladder augmentation increases bladder capacity and bladder wall compliance. The findings are supported by urodynamic data that demonstrate increased maximal cystometric capacity and decreased detrusor pressures (ChartierKastler et al., 2000).

Bladder Managment for Adults with Spinal Cord Injury

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