The normal function of the urinary bladder is to store and expel urine in a coordinated, controlled fashion.

This coordinated activity is regulated by the central and peripheral nervous systems. Neurogenic bladder is a term applied to a malfunctioning urinary bladder due to neurologic dysfunction or insult emanating from internal or external trauma, disease, or injury. Symptoms of neurogenic bladder range from detrusor underactivity to overactivity, depending on the site of neurologic insult. The urinary sphincter also may be affected, resulting in sphincter underactivity or overactivity and loss of coordination with bladder function. The appropriate therapy and a successful outcome are predicated upon accurate diagnosis through a careful medical and voiding history together with a variety of clinical examinations, including urodynamics and selective radiographic imaging studies.

Neuroanatomy
Normal voiding essentially is a spinal reflex that is modulated by the central nervous system (brain and spinal cord), which coordinates the functions of the bladder and urethra. The bladder and urethra are innervated by 3 sets of peripheral nerves arising from the autonomic nervous system (ANS) and somatic nervous system. The central nervous system is composed of the brain, brain stem, and the spinal cord. Brain The brain is the master control of the entire urinary system. The micturition control center is located in the frontal lobe of the brain. The primary activity of this area is to send tonically inhibitory signals to the detrusor muscle to prevent the bladder from emptying (contracting) until a socially acceptable time and place to urinate is available. Certain lesions or diseases of the brain, including stroke, cancer, or dementia, result in loss of voluntary control of the normal micturition reflex. The signal transmitted by the brain is routed through 2 intermediate stops (the brainstem and the sacral spinal cord) prior to reaching the bladder. Brainstem The brainstem is located at the base of the skull. Within the brainstem is a specialized area known as the pons, a major relay center between the brain and the bladder. The pons is responsible for coordinating the activities of the urinary sphincters and the bladder so that they work in synergy. The mechanical process of urination is coordinated by the pons in the area known as the pontine micturition center (PMC). The PMC coordinates the urethral sphincter relaxation and detrusor contraction to facilitate urination.

The pons is a major relay center between the brain and the bladder. The mechanical process of urination is coordinated by the pons in the area known as the pontine micturition center (PMC).

The conscious sensations associated with bladder activity are transmitted to the pons from the cerebral cortex. The interaction of a variety of excitatory and inhibitory neuronal systems is the function of the PMC, which is characterized by its inborn excitatory nature. The PMC functions as a relay switch in the voiding pathway. Stimulation of the PMC causes the urethral sphincters to open while facilitating the detrusor to contract and expel the urine. The PMC is affected by emotions, which is why some people may experience incontinence when they are excited or scared. The ability of the brain to control the PMC is part of the social training that children experience during growth and development. Usually the brain takes over the control of the pons at age 34 years, which is why most children undergo toilet training at this age. When the bladder becomes full, the stretch receptors of the detrusor muscle send a signal to the pons, which in turn notifies the brain. People perceive this signal (bladder fullness) as a sudden desire to go to the bathroom. Under normal situations, the brain sends an inhibitory signal to the pons to inhibit the bladder from contracting until a bathroom is found. When the PMC is deactivated, the urge to urinate disappears, allowing the patient to delay urination until finding a socially acceptable time and place. When urination is appropriate, the brain sends excitatory signals to the pons, allowing the urinary sphincters to open and the detrusor to empty. Spinal cord The spinal cord extends from the brainstem down to the lumbosacral spine. It is located in the spinal canal and is protected by the cerebrospinal fluid, meninges, and a vertebral column. It is approximately 14 inches long in an adult. Along its course, the spinal cord sprouts off many nerve branches to different parts of the body. The spinal cord functions as a long communication pathway between the brainstem and the sacral spinal cord. When the sacral cord receives the sensory information from the bladder, this signal travels up the spinal cord to the pons and then ultimately to the brain. The brain interprets this signal and sends a reply via the pons that travels down the spinal cord to the sacral cord and, subsequently, to the bladder.

In the normal cycle of bladder filling and emptying, the spinal cord acts as an important intermediary between the pons and the sacral cord. An intact spinal cord is critical for normal micturition. If spinal cord injury has occurred, the patient will demonstrate symptoms of urinary frequency, urgency, and urge incontinence but will be unable to empty his or her bladder completely. This occurs because the urinary bladder and the sphincter are both overactive, a condition termed detrusor sphincter dyssynergia with detrusor hyperreflexia (DSD-DH). The sacral spinal cord is the terminal portion of the spinal cord situated at the lower back in the lumbar area. This is a specialized area of the spinal cord known as the sacral reflex center. It is responsible for bladder contractions. The sacral reflex center is the primitive voiding center. In infants, the higher center of voiding control (the brain) is not mature enough to command the bladder, which is why control of urination in infants and young children comes from signals sent from the sacral cord. When urine fills the infant bladder, an excitatory signal is sent to the sacral cord. When this signal is received by the sacral cord, the spinal reflex center automatically triggers the detrusor to contract. The result is involuntary detrusor contractions with coordinated voiding. A continuous cycle of bladder filling and emptying occurs, which is why infants and young children are dependent on diapers until they are toilet trained. As the child's brain matures and develops, it gradually dominates the control of the bladder and the urinary sphincters to inhibit involuntary voiding until complete control is attained. Voluntary continence usually is attained by age 3-4 years. By this time, control of the voiding process has been relinquished by the sacral reflex center of the sacral cord to the higher center in the brain. If the sacral cord becomes severely injured (eg, spinal tumor, herniated disc), the bladder may not function. Affected patients may develop urinary retention, termed detrusor areflexia. The detrusor will be unable to contract, so the patient will not be able to urinate and urinary retention will occur. Peripheral nerves Peripheral nerves form an intricate network of pathways for sending and receiving information throughout the body. The nerves originate from the main trunk of the spinal cord and branch out in different directions to cover the entire body. Nerves convert the internal and external environmental stimuli to electrical signals so that the human body can understand stimuli as one of the ordinary senses (ie, hearing, sight, smell, touch, taste, equilibrium). The bladder and the urethral sphincters are under the influence of their corresponding nerves. The ANS lies outside of the central nervous system. It regulates the actions of the internal organs (eg, intestines, heart, bladder) under involuntary control. The ANS is divided into the sympathetic and the parasympathetic nervous system. Under normal conditions, the bladder and the internal urethral sphincter primarily are under sympathetic nervous system control. When the sympathetic nervous system is active, it causes the bladder to increase its capacity without increasing detrusor resting pressure (accommodation) and stimulates the internal urinary sphincter to remain tightly closed. The sympathetic activity also inhibits parasympathetic stimulation. When the sympathetic nervous system is active, urinary accommodation occurs and the micturition reflex is inhibited.

The pudendal nerve originates from the nucleus of Onuf and regulates the voluntary actions of the external urinary sphincter and the pelvic diaphragm. Examples of these muscles are the external urinary sphincter and the pelvic diaphragm. while the urinary sphincter maintains high resistance to urinary flow to keep the bladder outlet closed. This sympathetic input to the lower urinary tract is constantly active during bladder filling. Immediately preceding parasympathetic stimulation. Sympathetic nerves also facilitate urine storage in the following ways: • • • Sympathetic nerves inhibit the parasympathetic nerves from triggering bladder contractions. The urinary bladder is in storage mode for most of the day.The parasympathetic nervous system functions in a manner opposite to that of the sympathetic nervous system. During urinary storage. the sympathetic influence on the internal urethral sphincter becomes suppressed so that the internal sphincter relaxes and opens. an average person will void approximately 4-8 times. . Sympathetic nerves close the bladder neck by constricting the internal urethral sphincter. In terms of urinary function. Sympathetic nerves directly cause relaxation and expansion of the detrusor muscle. In addition. The result is facilitation of voluntary urination. bladder filling primarily is a passive event. resulting in urinary retention. Thus. If the bladder pressure is greater than the urethral pressure (resistance). the bladder accumulates increasing volumes of urine while the pressure inside the bladder remains low. Normal bladder function consists of 2 phases—filling and emptying. urine will leak out. Difficult or prolonged vaginal delivery may cause temporary neurapraxia of the pudendal nerve and cause stress urinary incontinence. Conversely. Like the ANS. Activation of the pudendal nerve causes contraction of the external sphincter and the pelvic floor muscles. the somatic nervous system is a part of the nervous system that lies outside of the central spinal cord. allowing an individual to engage in more important activities than urination. During urine elimination. the activity of the pudendal nerve is inhibited to cause the external sphincter to open. The normal micturition cycle requires that the urinary bladder and the urethral sphincter work together as a coordinated unit to store and empty urine. the bladder acts as a low-pressure receptacle. The filling of the urinary bladder depends on the intrinsic viscoelastic properties of the bladder and the inhibition of the parasympathetic nerves. the parasympathetic nerves stimulate the detrusor to contract. The somatic nervous system regulates the actions of the muscles under voluntary control. The pressure within the bladder must be lower than the urethral pressure during the filling phase. Physiology and Pathophysiology Physiology During the course of a day. Filling phase During the filling phase. the bladder contracts to expel urine while the urinary sphincter opens (low resistance) to allow unobstructed urinary flow and bladder emptying. which occurs with activities such as Kegel exercises. suprasacral-infrapontine spinal cord trauma can cause overstimulation of the pudendal nerve.

When the urethral sphincters relax and open. However. Emptying phase The storage phase of the urinary bladder can be switched to the voiding phase either involuntarily (reflexively) or voluntarily. the pudendal nerve causes relaxation of the levator ani so that the pelvic floor muscle relaxes. As the infant brain develops. Stimulation of the pudendal nerve results in contraction of the external urethral sphincter. coupled with that of the internal sphincter. When the infant enters childhood (usually at age 3-4 years). in turn. This rise is transmitted to both the bladder and urethra. Involuntary reflex voiding occurs in an infant when the volume of urine exceeds the voiding threshold. urine will not leak. the PMC also matures and gradually assumes voiding control. urinary continence is maintained. the pudendal nerve becomes excited. When the pressure transmitted to the bladder is greater than urethra. resulting in a lower urethral resistance. urinary incontinence will result. During some physical activities and with coughing. A repetitious cycle of bladder filling and emptying occurs in newborn infants. The sympathetic nerves send a message to the internal sphincter to relax and open. The bladder empties as soon as it fills because the brain of an infant has not matured enough to regulate the urinary system. this primitive voiding reflex may reappear in people with spinal cord injuries. the pressure inside the urethra (intraurethral pressure) is higher than the pressure within the bladder. As long as the pressure is evenly transmitted to both the bladder and urethra. Contraction of the external sphincter. predicting when the infant will urinate is difficult. If the urethral pressure is abnormally low or if the intravesical pressure is abnormally high. At this point. a small rise in pressure occurs within the bladder (intravesical pressure). or laughing. patients will remain continent. The pudendal nerve also signals the external sphincter to open.As the bladder fills. When the bladder is filled to capacity. As long as the urethral pressure is higher than that of the bladder. this primitive voiding reflex becomes suppressed and the brain dominates bladder function. the parasympathetic nerves trigger contraction of the detrusor. Because urination is unregulated by the infant's brain. The combination of both urinary sphincters is known as the continence mechanism. automatic emptying of the urine. The pressure gradients within the bladder and urethra play an important functional role in normal micturition. the stretch receptors within the bladder wall signal the sacral cord. resulting in urinary flow. These coordinated series of events allow unimpeded. When the bladder contracts. When the urethral sphincter is closed. the pressure generated by the bladder overcomes the urethral pressure. resulting in stress incontinence. Delaying voiding or voluntary voiding . urine will leak out. While the intraurethral pressure is higher than the intravesical pressure. which is why toilet training usually is successful at age 3-4 years. sends a message back to the bladder indicating that it is time to empty the bladder. sneezing. As the bladder initially fills. maintains urethral pressure (resistance) higher than normal bladder pressure. the pressure within the abdomen rises sharply. The sacral cord.

modulated by inhibitory and excitatory neurologic influences from the brain. the entire voiding cycle is affected. Urinary incontinence results from a dysfunction of the bladder. At the same time. People who are paraplegic or quadriplegic have lower extremity spasticity. In a healthy adult. Shy-Drager syndrome is a rare condition that also causes the bladder neck to remain open. Any part of the nervous system may be affected. in turn. The normal function of urination means that an individual has the ability to stop and start urination on command. causing a complete loss of voiding control. including the brain. and peripheral nerves. the stretch receptors are activated. or spastic bladder (medically termed detrusor hyperreflexia or overactivity). A dysfunctional voiding condition results in different symptoms. the individual enters a spinal shock phase where the nervous system . When an individual cannot find a bathroom nearby. people with this problem rush to the bathroom and even leak urine before reaching their destination. which signals a need to void. When the bladder is full. Bladder overactivity (spastic bladder) is associated with the symptoms of urge incontinence. In addition. the brain bombards the PMC with a multitude of inhibitory signals to prevent detrusor contractions. Pathophysiology If a problem occurs within the nervous system. with relatively low quantities. and storing urine in the bladder is difficult. and Shy-Drager syndrome also are brain lesions. Hydrocephalus. pons. Typical examples of a brain lesion are stroke. brain tumor. cerebral palsy.Bladder function is automatic but completely governed by the brain. ranging from acute urinary retention to an overactive bladder or to a combination of both. Usually. the individual has the ability to delay urination until a socially acceptable time and place. spinal cord. Brain lesion Lesions of the brain above the pons destroy the master control center. The voiding reflexes of the lower urinary tract—the primitive voiding reflex—remain intact. while sphincter underactivity (decreased resistance) results in symptomatic stress incontinence. the sphincter. which are in turn controlled by the PMC located in the brainstem. Affected individuals show signs of urge incontinence. The individual perceives the activation of the stretch receptors as the bladder being full. sacral cord. the voiding process requires coordination of both the ANS and somatic nervous system. which makes the final decision on whether or not to void. or Parkinson disease. A combination of detrusor overactivity and sphincter underactivity may result in mixed symptoms. The healthy adult is aware of bladder filling and can willfully initiate or delay voiding. or both. The bladder empties too quickly and too often. Thus. They may wake up frequently at night to void. after spinal cord trauma. Spinal cord lesion Diseases or injuries of the spinal cord between the pons and the sacral spinal cord also result in spastic bladder or overactive bladder. an individual may actively contract the levator muscles to keep the external sphincter closed or initiate distracting techniques to suppress urination. the PMC functions as an on-off switch that is activated by stretch receptors in the bladder wall and is. Initially.

Peripheral nerve injury Diabetes mellitus and AIDS are 2 of the conditions causing peripheral neuropathy resulting in urinary retention. Some teenagers suddenly develop an abnormal voiding pattern and often are evaluated for tethered cord syndrome. pernicious anemia. These diseases destroy the nerves to the bladder and may lead to silent. known asoptic neuritis. the affected individual will sense an overwhelming desire to urinate but only a small amount of urine may dribble out. . herniated disc. These individuals have difficulty eliminating urine and experience overflow incontinence. the legs become spastic.shuts down. The bladder empties too quickly and too frequently. When the nervous system becomes reactivated. and injuries that crush the pelvis. a condition known as detrusor areflexia. severe herpes in the genitoanal area. the individual will sense the bladder is full and the detrusor may not contract. Similar to injury to the sacral cord. Ischemic changes of the sacral cord associated with the tethering cause the manifestation of dysfunctional voiding symptoms. Sacral cord injury Selected injuries of the sacral cord and the corresponding nerve roots arising from the sacral cord may prevent the bladder from emptying. In the case of a motor neurogenic bladder. These people experience urge incontinence. some children with myelomeningocele may have a hypocontractile bladder instead of a spastic bladder. The medical term for this is detrusor-sphincter dyssynergia because the bladder and the external sphincter are not in synergy. Children born with myelomeningocele may have spastic bladders and/or an open urethra. If both the bladder and external sphincter become spastic at the same time. Multiple sclerosis (MS) is a common cause of spinal cord disease in young women. The voiding disorder is similar to that of the brain lesion except that the external sphincter may have paradoxical contractions as well. Typical causes are a sacral cord tumor. radical hysterectomy. painless distention of the bladder. a neurologic condition in which the tip of the sacral cord is stuck near the sacrum and cannot stretch as the child grows taller. For example. the affected individual may not be able to sense when the bladder is full. Other diseases manifesting this condition are poliomyelitis. the external sphincter is tightening to prevent urine from leaving. The causes of spinal cord injuries include motor vehicle and diving accidents. Patients with chronic diabetes lose the sensation of bladder filling first. Guillain-Barré syndrome. Conversely. They also may have a hypocontractile bladder. and neurosyphilis (tabes dorsalis). affected individuals will have difficulty urinating. Even though the bladder is trying to force out urine. or abdominoperineal resection. the bladder gradually overdistends until the urine spills out. the nervous system reactivates. Summary of definitions • Neurogenic bladder is a malfunctioning bladder due to any type of neurologic disorder. If a sensory neurogenic bladder is present. it causes hyperstimulation of the affected organs. before the bladder decompensates. After 6-12 weeks. Those with MS also may exhibit visual disturbances. This condition also may occur after a lumbar laminectomy.

The detrusor muscle and the external sphincter function in synergy (in coordination). usually associated with frequency and nocturia. When the bladder becomes hyperreflexic. Detrusor areflexia is complete inability of the detrusor to empty due to a lower motor neuron lesion (eg. sacral cord or peripheral nerves). the urinary bladder will be in retention—detrusor areflexia. They include cerebrovascular accident. Parkinson disease. with or without urge incontinence. Almost 25% of affected individuals develop acute urinary retention after a stroke. o • Brain tumor . Urinary retention is the inability of the urinary bladder to empty. but the detrusor cannot generate enough pressure to allow complete emptying. • • • • • • Types of Neurogenic Bladders Supraspinal lesions Supraspinal lesions refer to those lesions of the central nervous system involving the area above the pons. The cause may be neurologic or nonneurologic. When the patient manifests symptoms of detrusor hyperreflexia. o After the cerebral shock phase wears off. The external sphincter is in synergy with detrusor contraction. institute therapies to facilitate bladder filling and storage with anticholinergic medications. Detrusor instability refers to overactive bladder symptoms without neurologic impairment. Paradoxically. The detrusor is too weak to mount an adequate contraction for proper voiding to occur. the patient is in urinary retention. • Cerebrovascular accident o After a stroke. During this time. External sphincter functions normally. and Shy-Drager syndrome. they are in dyssynergy (lack of coordination).• Detrusor hyperreflexia refers to overactive bladder symptoms due to a suprapontine upper motor neuron neurologic disorder. Both the detrusor and the sphincter are contracting at the same time. but irritating voiding symptoms are prevalent. The cause may be neurologic or nonneurologic. and urge incontinence. External sphincter functions normally. Detrusor hyperreflexia with impaired contractility (DHIC) refers to overactive bladder symptoms. Overactive bladder refers to symptoms of urinary urgency. the bladder demonstrates detrusor hyperreflexia with coordinated urethral sphincter activity. the brain may enter into a temporary acute cerebral shock phase. The condition is similar to urinary retention. the individual will complain of urinary frequency. This occurs because the PMC is released from the cerebral inhibitory center. in synergy. urgency. brain tumor. The treatment for the cerebral shock phase is indwelling Foley catheter or clean intermittent catheterization (CIC). DSD-DH refers to overactive bladder symptoms due to neurologic upper motor neuron disorder of the suprasacral spinal cord.

Similar to other supraspinal lesions. the patient may become totally incontinent after the TURP procedure. If patients with Parkinson disease exhibit symptoms of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE). the bladder neck (internal sphincter) will be open at rest. the diagnosis of BOO should be confirmed by multichannel urodynamic studies. Patients with Shy-Drager syndrome should avoid undergoing TURP because the risk of total incontinence is high. The striated urethral sphincter often demonstrates poorly sustained contraction. and masked facies. and urge incontinence. and degenerative disease affecting the ANS with multisystem organ atrophy. with striated sphincter denervation. the treatment for Parkinson disease is to facilitate bladder filling and promote urinary storage with anticholinergic agents. The most common cause of postprostatectomy incontinence in the patient with Parkinson disease is detrusor hyperreflexia. First-line treatment for detrusor hyperreflexia includes anticholinergic medication. Degeneration of the nucleus of Onuf results in denervation of the external striated sphincter. progressive. nocturia. urgency. o o o . cerebellar ataxia and autonomic dysfunction are common. Urodynamic evaluation often reveals detrusor hyperreflexia. If transurethral resection of the prostate (TURP) is performed without urodynamic confirmation of obstruction. When the patient manifests symptoms of detrusor hyperreflexia. Patients with Parkinson disease manifest symptoms of bradykinesia. It results in dopamine deficiency and increased cholinergic activity in the corpus striatum. Symptoms specific to the urinary bladder include urinary frequency. cogwheel rigidity. anhidrosis.o Detrusor hyperreflexia with coordinated urethral sphincter is the most common observed urodynamic pattern associated with a brain tumor. urgency. o o o o o • Shy-Drager syndrome o Shy-Drager syndrome is a rare. the individual complains of urinary frequency. In addition to Parkinson-like symptoms. and urinary incontinence. Often. The treatment for Shy-Drager syndrome is to facilitate urinary storage with anticholinergic agents coupled with CIC or indwelling catheter. Typical urodynamic findings for Parkinson disease are most consistent with detrusor hyperreflexia and urethral sphincter bradykinesia. although a few individuals may have detrusor areflexia or poorly sustained bladder contractions. Sympathetic nerve atrophy causes nonfunctional bladder and an open bladder neck. and urge incontinence. o • Parkinson disease o This is a degenerative disorder of pigmented neurons of substantia nigra. Affected individuals demonstrate orthostatic hypotension. skeletal muscle tremor.

striated sphincter dyssynergia. may be used. the individual may develop DSD-DH. A unique complication of T6 injury is autonomic dysreflexia. may be used for prophylactically treating patients with autonomic dysreflexia. and smooth sphincter dyssynergia. o o o o • Spinal cord lesions (above the sixth thoracic vertebrae) o Individuals who sustain a complete cord transection above the sixth thoracic vertebrae (T6) most often will have urodynamic findings of detrusor hyperreflexia. and the individual experiences urinary retention and constipation. hypertension. parenteral ganglionic or adrenergic blocking agents. the initial response from the nervous system is spinal shock. and the somatic reflex activity is either depressed or absent. The internal and external urethral sphincter activities. causing visceral distention. Realizing that suprasacral lesions exhibit detrusor areflexia at initial insult but progress to hyperreflexic state over time is important.Spinal cord lesions • Spinal cord injury o When an individual sustains a spinal cord injury from a diving accident or motor vehicle injury. The spinal shock phase typically lasts 6-12 weeks. Conversely. Autonomic dysreflexia is an exaggerated sympathetic response to any stimuli below the level of the lesion. Symptoms of autonomic dysreflexia include sweating. The autonomic activity is depressed. it may be prolonged in some cases. and periodic urodynamic testing must be performed for this alteration in detrusor behavior. Often. Depending on the level of the lesion. the individual must be monitored for leaking between CIC. During this time. During this spinal shock phase. are normal. the urinary bladder must be drained with CIC or indwelling urethral catheter. When the spinal shock phase wears off. including terazosin. The anal and bulbocavernosus reflex typically is absent. If additional measures are required. Acute management of autonomic dysreflexia is to decompress the rectum or bladder. the inciting event is instrumentation of the urinary bladder or the rectum. Urodynamic findings are consistent with areflexic detrusor and rectum. Oral blocking agents. and reflex bradycardia. o o o . the affected individual experiences flaccid paralysis below the level of injury. spinal anesthetic may be used as a prophylactic measure whenever bladder instrumentation is considered. sacral cord lesions are associated with areflexic bladders that may become hypertonic overtime. During urodynamics. such as chlorpromazine. Thus. headache. Alternatively. This occurs most commonly with lesions of the cervical cord. Decompression usually will reverse the effects of unopposed sympathetic outflow. bladder function returns but the detrusor activity increases in reflex excitability to an overactive state—detrusor hyperreflexia. intravesical instillation of cold saline may indicate return of reflex activity or help better characterize the lesion. however.

long-term indwelling catheterization.• Spinal cord lesions (below T6) o Individuals who sustain spinal cord lesions below T6 level will have urodynamic findings of detrusor hyperreflexia. impaired detrusor contractility. o o • Multiple sclerosis o MS is caused by focal demyelinating lesions of the central nervous system. It most commonly involves the posterior and lateral columns of the cervical spinal cord. Paradoxically. The optimum therapy for a patient with MS and incontinence must be individualized and based on the urodynamic findings. Thus. or urinary diversion. o Peripheral nerve lesions Peripheral nerve lesions due to diabetes mellitus. Treatment of diabetic cystopathy is CIC. As many as 50% of patients will demonstrate DSD-DH. DHIC also has been observed. herpes zoster. o . using urodynamic studies to evaluate patients with MS is critical. The most common urodynamic finding is detrusor hyperreflexia. detrusor areflexia. Affected patients will demonstrate extensor plantar response and positive Babinski sign. decreased bladder sensation. Affected patients experience decreased bladder sensation and increased voiding intervals. Neurogenic bladder occurs because of autonomic and peripheral neuropathy. and smooth sphincter dyssynergia but no autonomic dysreflexia. A metabolic derangement of the Schwann cell results in segmental demyelination and impaired nerve conduction. Neurologic evaluation will reveal skeletal muscle spasticity with hyperreflexic deep tendon reflexes. occurring in as many as 50-90% of patients with MS. These individuals will experience incomplete bladder emptying secondary to detrusor sphincter dyssynergia. • Tabes dorsalis (neurosyphilis) o In tabes dorsalis. eventually. striated sphincter dyssynergia. and radical pelvic surgery result in detrusor areflexia. herniated lumbar disk disease. Usually. central and peripheral nerve conduction is impaired. and. neurogenic bladder dysfunction occurs 10 or more years after the onset of diabetes mellitus. poor correlation exists between the clinical symptoms and urodynamic findings. tabes dorsalis. Classic urodynamic findings associated with this condition are elevated residual urine. Detrusor areflexia occurs in 20-30% of cases. or loss of facilitatory input from higher centers. The most common urodynamic finding associated with neurosyphilis is detrusor areflexia with normal sphincteric function. o The first symptoms of diabetic cystopathy are loss of sensation of bladder filling followed by loss of motor function. • Diabetic cystopathy o Usually. Cornerstone of treatment involves CIC and anticholinergic medications.

The striated sphincter. and urinary retention. proctocolectomy. The early stages of herpes infection are associated with lower urinary tract symptoms of urinary frequency. A typical urodynamic finding of sacral nerve injury is detrusor areflexia with intact bladder sensation. Urinary retention is self-limited and will resolve spontaneously with clearing of the herpes infection. o • Herniated disc o Slow and progressive herniation of the lumbar disc may cause irritation of the sacral nerves and cause detrusor hyperreflexia. o • Pelvic surgery o Patients undergoing major pelvic surgery. Later stages include decreased bladder sensation. • Other tests . increased residual urine. however. abdominoperineal resection.• Herpes zoster o Herpes zoster is a neuropathy associated with painful vesicular eruptions in the distribution of the affected nerve. urgency. Urine cytology: Carcinoma-in-situ of the urinary bladder causes symptoms of urinary frequency and urgency. Conversely. or total exenteration will experience bladder dysfunction postoperatively. and urge incontinence. Most commonly. If the peripheral sympathetic nerves are damaged. Peripheral sympathetic nerve damage often occurs in association with detrusor denervation. postsurgical patients will manifest symptoms of detrusor areflexia. the internal sphincter will be open and nonfunctional. However. is preserved. acute compression of the sacral roots associated with deceleration trauma will prevent nerve conduction and result in detrusor areflexia. o Workup Lab studies • • Urinalysis and urine culture: Urinary tract infection can cause irritative voiding symptoms and urge incontinence. The herpes virus lies dormant in the dorsal root ganglia or the sacral nerves. such as radical hysterectomy. Sacral nerve involvement leads to impairment of detrusor function. Irritative voiding symptoms out of proportion to the overall clinical picture and/or hematuria warrant urine cytology and cystoscopy. Associated internal sphincter denervation may occur. as many as 80% of affected patients will experience spontaneous recovery of function within 6 months after surgery. Chem 7 profile: Blood urea nitrogen (BUN) and creatinine (Cr) are checked if compromised renal function is suspected.

the patient is experiencing urine loss. • Uroflow rate o Uroflow rate is a useful screening test used mainly to evaluate bladder outlet obstruction. provocative maneuvers help to unveil bladder instability. During the test. Pyridium turns the urine color orange. and the presence of phasic contractions (detrusor instability). o Diagnostic procedures • Postvoid residual urine o The postvoid residual urine (PVR) measurement is a part of basic evaluation for urinary incontinence. Both of these conditions will cause urinary retention with overflow incontinence. incontinent episodes. Most commonly. Patients should resume their usual physical activities while wearing a Peri-pad. Intravesical methylene blue test or oral Pyridium or Urised may be used. moisture most likely is a normal vaginal fluid. Pressure-flow studies can be combined with voiding cystogram and videourodynamic study for complicated cases of incontinence. o If the PVR is high. It is an objective documentation of the patient's voiding pattern. Methylene blue and Urised turns the urine color blue. liquid filling medium is used. If the pads remain white.• • Voiding diary: A voiding diary is a daily record of the patient's bladder activity. Uroflow rate is volume of urine voided per unit of time. If the pads turn to orange or blue. o • Voiding cystometrogram (pressure-flow study) o Pressure-flow study simultaneously records the voiding detrusor pressure and the rate of urinary flow. o • Filling cystometrogram o A filling cystometrogram (CMG) assesses the bladder capacity. An average adult bladder holds approximately 50-500 mL of urine. a weak detrusor. Pad test o This is an objective test that documents the urine loss. the bladder may be contractile or the bladder outlet may be obstructed. Low uroflow rate may reflect urethral obstruction. or a combination of both. and inciting events associated with urinary incontinence. This test alone cannot distinguish an obstruction from a contractile detrusor. compliance. o • Cystogram . This is the only test able to assess bladder contractility and the extent of a bladder outlet obstruction.

and vesicoureteral reflux. and tumor. A voiding cystogram can identify a urethral diverticulum. bladder cancer. o • Electromyography o Electromyography (EMG) helps to ascertain the presence of coordinated or uncoordinated voiding. Failure of urethral relaxation during bladder contraction results in uncoordinated voiding (detrusor sphincter dyssynergia). EMG allows accurate diagnosis of detrusor sphincter dyssynergia common in spinal cord injuries. o • Videourodynamics o Videourodynamics is the criterion standard for evaluation of a patient with incontinence. Mixed incontinence may require medications as well as surgery. bladder stone) that would remain undiagnosed by urodynamics alone. Intrinsic sphincter deficiency will be evident by an open bladder neck. o • Cystoscopy o The precise role of cystoscopy in the evaluation of neurogenic bladder allows discovery of bladder lesions (eg. stone. easily. such as vesicoureteral reflux and bladder diverticulum. A voiding cystogram can assess bladder neck and urethral function (internal and external sphincter) during filling and voiding phases. as well as the functional pressure-flow relationship between the bladder and the urethra. and the presence of a cystocele. Videourodynamics enables documentation of lower urinary tract anatomy. Presence of a vesicovaginal fistula or bladder diverticulum also may be noted. . General agreement is that cystoscopy is indicated for people complaining of persistent irritative voiding symptoms or hematuria.o A static cystogram (anteroposterior and lateral) helps to confirm the presence of stress incontinence. Overflow incontinence may be treated with some type of catheter regimen. Urge incontinence may be treated with behavioral modification or with bladder-relaxing agents. o Treatment Medical care Stress incontinence may be treated with surgical and nonsurgical means. urethral obstruction. This information is important in determining the etiology of the incontinence and may influence treatment decisions. such as cystitis. Videourodynamics combines the radiographic findings of voiding cystourethrogram (VCUG) and multichannel urodynamics. the degree of urethral motion. The physician can diagnose obvious causes of bladder overactivity.

providing the wearer a false sense of security. these absorbent products are specially designed to trap urine.  For occasional minimal urine loss. however. they play an important role in the care of persons with intractable incontinence. which removes the motivation to seek evaluation and treatment. disposable diapers or reusable pad and pant systems are used. they are a temporary means of keeping the patient dry until a more permanent solution becomes available. Unlike sanitary napkins. and special bed pads. (3) women who cannot be helped by medications. In addition. pant guards. (4) women with incontinence disorders that cannot be corrected by surgery. Early dependency on absorbent pads may be a deterrent to achieving continence. Thus. Absorbent pads and internal and external collecting devices have an important role in the management of chronic incontinence. and (5) women who are awaiting surgery. As an adjunct to behavioral and pharmacologic therapies. They may be used temporarily until a definitive treatment takes effect or if the treatment yields less-than-perfect results. appropriate use. o Do not use absorbent products instead of definitive interventions to decrease or eliminate urinary incontinence. (2) women who are too ill or disabled to participate in behavioral programs. urinary tract infection. adult diaper garments. By reducing wetness and odor. o o . pant liners (shields and guards). and they are beneficial for women who meet the following conditions: (1) women who fail all other treatments and remain incontinent. • Absorbent products o Absorbent products are pads or garments designed to absorb urine to protect the skin and clothing. and keep the patient dry. a variety of washable pants and disposable pad systems. combination pad-pant systems. and frequent pad or garment changes are needed when absorbent products are used. Different types of products with varying degrees of absorbency exist. adult diapers (briefs). depending on the brand and the absorbent material of the product. panty shields (small absorbent inserts) may be used. Available in both disposable and reusable forms. Absorbent products are helpful during the initial assessment and workup of urinary incontinence. Absorbent products used include underpads. In addition. 47% of elderly men and women use some type of absorbent product. they help maintain the patient's comfort and allow her to function in normal activities. constipation) or by simply changing a few medications. undergarments. In nursing homes. These products may absorb 20-300 mL. Chronic use of absorbent products may lead to inevitable acceptance of the incontinence condition. The criteria for use of these products are fairly straightforward. meticulous care. judicious use of pads and devices to contain urine loss and maintain skin integrity are extremely useful in selected cases. minimize odor. Absorbent pads and garments that are available include panty shields. improper use of absorbent products may contribute to skin breakdown and urinary tract infections. or combinations of these products.Functional incontinence may be resolved by treating the underlying cause (eg. More than 50% of members in Help for Incontinent People (HIP) use some form of protective garment to remain dry. Do not consider anti-incontinence products to be a cure-all for urinary incontinence.

Urethral occlusive devices must be removed after several hours or after each voiding. With device manipulation. Adult undergarments (full-length pads) are bulkier and more absorbent than guards. 22F. o • Catheters o Urinary diversion. Unlike pads. The catheter and bag are replaced on a monthly basis. indwelling urethral catheters historically have been the mainstay of treatment for bladder dysfunction. The usual practice is to change indwelling catheters once every month. Absorbent bed pads also are available to protect the bed sheets and mattresses at night.   • Urethral occlusive devices o Urethral occlusive devices are artificial devices that may be inserted into the urethra or placed over the urethral meatus to prevent urinary leakage. All indwelling catheters in the urinary bladder for more than 2 weeks o  . offering the highest level of absorbency. they may be more difficult and expensive to use than pads. Indwelling urethral catheters  Commonly known as Foley catheters. Proper management of indwelling urethral catheters varies per individual. Urethral occlusive devices. 24F) with bigger balloons are used for treating grossly bloody urine found in other urologic conditions or diseases. however. Different types of bladder catheterization include indwelling urethral catheters. they must be changed monthly. The use of catheters for bladder drainage has withstood the test of time. guards (close-fitting pads) may be more appropriate. These catheters may be changed at an office. If urethral catheters are used for a long-term condition. For light incontinence. and are secured in place with self-adhesive tape. patients may soil their hands. Bladder catheterization may be a temporary measure or a permanent solution for urinary incontinence. Adult briefs are the bulkiest type of protection. with a 5mL balloon filled with 10 mL of sterile water. catheters that develop encrustations and problems with urine drainage must be changed more frequently. a clinic. suprapubic tubes. are best suited for an active woman with incontinence who does not desire surgery. or at home by a visiting nurse. They are available in different sizes and absorbencies. however. Urethral occlusive devices are more attractive than absorbent pads because they tend to keep the patient drier. Larger catheters (eg. has been one of the mainstays of antiincontinence therapy. Absorbent guards are attached to the underwear and can be worn under normal clothing. using various catheters. The risk that a urethral plug may fall into the bladder or fall off the urethra always exists. and self-intermittent catheterization. these devices may be more difficult to change. These devices are palliative measures to prevent involuntary urine loss. perhaps. The standard catheter size for treating urinary retention is 16F or 18F. They may be held in place by waist straps or snug underwear.

and kidneys. Chronic dependence on these catheters is extremely risky because long-term use of urethral catheters poses significant health hazards. The urinary drainage bag does not need to be disinfected to prevent infection. However. hematuria. Another problem of long-term catheterization is bladder contracture. bladder spasms resulting in urinary leakage. bladder.     . and urethritis. Indwelling urethral catheters are a significant cause of urinary tract infections that involve the urethra. Within 2-4 weeks after catheter insertion. untreated symptomatic urinary tract infections may lead to urosepsis and death. Bacterial colonization does not mean the patient has clinical bladder infection. change the entire catheter and the drainage system. and hematuria. renal damage. Asymptomatic bacterial colonization is common and does not pose a health hazard. Patients do not have to take continuous antibiotics while using the catheter. continuous antibiotic therapy is contraindicated while a catheter is used. Individuals who did not use the medication and daily clamping regimen experienced a decrease in bladder capacity and vesicoureteral reflux. Fever with flank pain often is present if upper tracts are involved. 30 mL is instilled into the bladder and allowed to freely drain on a twice daily basis. development of periurethral abscess. Symptoms of bladder infection include foul odor. In fact. some physicians recommend using anticholinergic medications with intermittent clamping of the catheter if lower urinary tract reconstruction is anticipated in the future. Other problems associated with indwelling urethral catheters include encrustation of the catheter. the use of a Foley catheter for a prolonged period of time (eg. The use of a urethral catheter is contraindicated in the treatment of urge incontinence. In spite of its apparent advantages. some authors favor the use of 0.become colonized with bacteria. Indwelling use of a Foley catheter in individuals who are homebound requires close supervision by a visiting nurse and additional personal hygiene care. Anticholinergic therapy and intermittent clamping of the catheter in combination have been reported to be beneficial for preserving the bladder integrity with long-term catheter use. and diminishes the odor. minimizes catheter encrustation. this may be more a reflection of the severity of comorbid conditions that lead to the clinical decision to use chronic bladder drainage than causation from the use of chronic bladder drainage.  Routine irrigation of catheters is not required. The death rate of nursing home residents with urethral catheters has been found to be 3 times higher than that of residents without catheters. months to years) is strongly discouraged. For this reason. which occurs with urethral catheters as well as suprapubic tubes. and urethral erosion. bacteria will be present in the bladder of most women. If bladder infection occurs. Prolonged use of antibiotics to prevent infection actually may cause paradoxical generation of bacteria that are resistant to common antibiotics. More severe complications include formation of bladder stones. When used. However. purulent urine.25% acetic acid irrigation because it is bacteriostatic.

change the suprapubic tube once a month on a regular basis. Suprapubic catheters have many advantages. urinary tract infection. bladder stone formation. (2) to avoid contamination or to promote healing of severe pressure sores. In addition. The most common use of a suprapubic catheter is in individuals with spinal cord injuries and a malfunctioning bladder. and (7) for severely impaired persons for whom bed and clothing changes are painful or disruptive. Potential complications with chronic suprapubic catheterization are similar to those associated with indwelling urethral catheters. Because the catheter comes out of the lower abdomen rather than the vaginal area. (5) when an individual lives alone and a caregiver is unavailable to provide other supportive measures. 16F) catheters are placed. When the tube is removed. A suprapubic tube does not prevent bladder spasms from occurring in unstable bladders nor does it improve the urethral closure mechanism in an incompetent urethra. and catheter obstruction. the risk of urethral damage is eliminated. and other types of surgery. Suprapubic catheters may be used whenever the clinical situation requires the use of a bladder drainage device. Both people who are paraplegic and people who are quadriplegic have benefited from this form of urinary diversion. Indications for suprapubic catheters include short-term use following gynecologic. (3) in case of inoperable urethral obstruction that prevents bladder emptying. Multiple voiding trials may be performed without having to remove the catheter. Unlike the urethral catheter. Suprapubic catheters are changed easily by either a nurse or a doctor. when long-term use of a urethral catheter is anticipated. However. including leakage around the catheter. urologic. With a suprapubic catheter. however. suprapubic catheters are contraindicated in persons with chronic unstable bladders or intrinsic sphincter deficiency because involuntary urine loss is not prevented. usually smaller (eg. a suprapubic tube is less likely to become dislodged because the exit site is so small. Restrict the use of indwelling catheters to the following situations: (1) as comfort measures for the terminally ill. suprapubic tubes are more sanitary for the individual. Although uncommon. a suprapubic tube is more patientfriendly. a potential for bowel injury exists. During the initial placement of a suprapubic tube. When suprapubic tubes are needed. (6) for acutely ill persons in whom accurate fluid balance must be monitored. a suprapubic catheter is an attractive alternative. o Suprapubic catheters  A suprapubic tube is an attractive alternative to long-term urethral catheter use. 14F. Like the urethral catheter. (4) in individuals who are severely impaired and for whom alternative interventions are not an option. and bladder infections are minimized because the tube is away from the perineum. the hole in the abdomen quickly seals itself within 1-2 days. Bladder spasms occur less often because the suprapubic catheter does not irritate the trigone as does the urethral catheter. bowel perforation is known to occur     .

o Intermittent catheterization  Intermittent catheterization or self-catheterization is a mode of draining the bladder at timed intervals. Ideally. Long-term management of a suprapubic tube also may be problematic if the health care provider lacks the knowledge and expertise of suprapubic catheters or if the homebound individual lacks quick access to a medical center in case of an emergency. a caregiver or health professional can perform intermittent catheterization for the patient. Other potential complications include cellulitis around the tube site and hematoma. the suprapubic catheter affords many advantages over long-term urethral catheters. a new tube can be reinserted quickly and painlessly as long as the tube site remains patent. however.  A suprapubic catheter is an alternative solution to an indwelling urethral catheter in women who require chronic bladder drainage. The bladder must be drained on a regular basis. suprapubic tube) for both men and women. In addition. and before bed) or based on bladder volume. Intermittent catheterization may be performed using a soft. the amount drained each time should not exceed 400-500 mL.with first-time placement of suprapubic tubes. rubber catheter or a short. every 3-6 hours during the day. In the appropriate situation. intermittent catheterization is the best solution for bladder decompression of a motivated individual who is not physically handicapped or mentally impaired. or a nonfunctioning bladder. Intermittent catheterization has become a healthy alternative to indwelling catheters for individuals with chronic urinary retention due to an obstructed bladder. bowel injury. self-catheterization is recommended by some surgeons for women during the acute healing process after anti-incontinence surgery. either based on a timed interval (eg. the exit hole of the tube will seal up and close quickly within 24 hours if the tube is not replaced with a new one. on awakening. A prerequisite for self-catheterization is the patients' ability to use their hands and arms. suprapubic tube. The use of plastic catheters is preferable to red rubber catheters because they are easier to clean and last longer. If catheterization is performed every    . urethral catheter. plastic catheter. rigid. as opposed to continuous bladder drainage. If the suprapubic tube falls out inadvertently. urethral catheter. a weak bladder. Remember that the average adult bladder holds approximately 400-500 mL of urine. intermittent catheterization). hematoma. and problems with catheter reinsertion. Many studies of young individuals with spinal cord injuries have shown that intermittent catheterization is preferable to indwelling catheters (ie. This drainage limit may require decreasing the fluid intake or increasing the frequency of catheterizations. Of all 3 possible options (ie. red. If tube dislodgment is recognized promptly. in a situation in which a patient is physically or mentally impaired. Potential problems unique to suprapubic catheters include skin infection. Young children with myelomeningocele have benefited from the use of intermittent catheterization.

artificial hip) or patients who are immunosuppressed because of age or disease. such as patients with an internal prosthesis (eg. For the older population and individuals with a weak immune system. individual catheterization schedules may vary. For individuals who are impaired. Intermittent catheterization may be performed using either a sterile catheter or a nonsterile clean catheter. sterile intermittent catheterization appears to be the safest method for this high-risk population. is recommended for young individuals with a bladder that cannot empty and without any other available options. determine whether to use antibiotic therapy for asymptomatic bacteriuria on individual merits. Young children and the older population are able to do this everyday without problems. freedom from indwelling catheter and bags. Furthermore. and unimpeded sexual relations. Usually. the sterile technique of intermittent catheterization has been recommended. The use of chronic suppressive antibiotic therapy in people regularly using clean intermittent catheterization is undesirable because it may result in the emergence of resistant bacterial strains. a home caregiver or a visiting nurse can be instructed to perform intermittent catheterization. using a clean technique. Anyone who has good use of her hands and arms can perform self-catheterization. Persons who are older are at higher risk than younger persons for developing bacteriuria and other complications caused by intermittent catheterization because they do not have a strong defense system against infection. catheterization should occur 4-5 times a day. increase the frequency of catheterization to. Sterile gloves are not necessary. the infections that do occur usually are managed without complications. In general. routine use of long-term suppressive therapy with antibiotics in patients with chronic clean intermittent catheterization is not recommended. the average adult empties the bladder 4-5 times a day. Although the incidence of infection and other complications for older patients who are using sterile versus clean intermittent catheterization is not well established. every 4 hours to maintain the volume drained at 400500 mL. Potential complications of intermittent catheterization include bladder      .6 hours and the amount drained is 700 mL. Thus. Candidates for intermittent catheterization must have motivation and intact physical and cognitive abilities. depending on the amount of fluid taken in during the day. Studies show that in patients with spinal cord injuries. at work— anywhere. Patients should wash their hands with soap and water. Potential advantages of performing intermittent catheterization include patient autonomy. Clean intermittent catheterization results in lower rates of infection than the rates noted with indwelling catheters. In high-risk populations. artificial heart valve. however. Intermittent catheterization. the incidence of bacteria in the bladder is 1-3% per catheterization and 1-4 episodes of bacteriuria occur per 100 days of intermittent catheterization performed 4 times a day. perhaps.  Intermittent catheterization is designed to simulate normal voiding. Self-catheterization may be performed at home.

and artificial urinary sphincter. An average American adult requires a daily allowance of approximately 6-8 glasses of fluids. and dietary experimentation should be instituted on an individual basis. unwanted bladder symptoms can be improved or possibly cured. • Diet The fact that certain foods in a daily diet can worsen symptoms of urinary frequency and urge incontinence is well known. Dietary stimulants are substances contained in the food or drink that either cause or exacerbate irritative voiding symptoms. Chocolate snacks and treats contain caffeine. A third food group that may worsen urinary bladder incontinence is chocolate-containing sweets. If a patient's diet contains dietary stimulants.infection. Concurrent use of anticholinergic therapy will maintain acceptable intravesical pressures and prevent bladder contracture. Caffeine is a bladder-unfriendly agent.sling procedures. cayenne pepper. Examples of fruits that have significant potassium include grapefruits and oranges. and stricture. By eliminating or minimizing the intake of dietary stimulants. changes in her diet may help ameliorate incontinence symptoms. Avoidance of dietary stimulants begins with consumer awareness through careful label reading and maintaining a daily diet diary. Excessive intake of chocolate confectioneries worsens irritative bladder symptoms. including . chili pepper. • Food o Foods that contain heavy or hot spices may contribute to urge incontinence. Some examples of hot spices include curry. botulinum toxin injections. A second food group that may worsen irritative voiding symptoms is citrus fruit. o o • Beverages o The quantity and quality of refreshments consumed will influence urinary voiding symptoms. these include sacral neuromodulation. Fluids refer to all the beverages a person consumes in a day. Studies have demonstrated that long-term use of intermittent catheterization appears to be preferable to indwelling catheterization (ie. Experimenting with dietary changes is not appropriate for everyone.2 detrusor myomectomy. urethral inflammation. suprapubic tube) with respect to urinary tract infections and the development of stones within the bladder or kidneys. Surgical care for urge incontinence involves procedures that improve bladder compliance or bladder capacity. urethral trauma. and dry mustard. andbladder augmentation. Certain food products exacerbate symptoms of urge incontinence. 1. Fruits and juices that have a high potassium concentration may worsen preexisting urge incontinence. A few medical reports have alluded to the fact that avoiding spicy foods may have a beneficial effect on urinary incontinence. Surgical care • Surgical care for stress incontinence involves procedures that increase urethral outlet resistance. urethral catheter. periurethral bulking therapy. Operations that increase urethral resistance include bladder neck suspension.

coffee contains the most caffeine. and administering laxatives. The exact amount of fluid needed per day is calculated based on the patient's lean body mass. Studies have shown that drinking carbonated beverages. tea. Trying to prevent incontinence by restricting fluids excessively may lead to bladder irritation and actually worsen urge incontinence. so they drink more water. They minimize their fluid intake to unacceptable levels. dehydration contributes to constipation. Support hose (Jobst) or intermittent. Decaffeinated coffee contains an amount of caffeine similar to the amount in chocolate milk. constipation. Some women drink water because they enjoy the taste. Caffeine-containing products include coffee. The human body receives water from beverages consumed. they will experience less incontinence. This problem may be treated with a behavior technique. Thus. soda. Even chocolate milk and many over-the-counter medications contain caffeine. and/or medications. Drinking water excessively actually worsens irritative bladder symptoms. the amount of fluid requirement will vary per individual. and milk. Patients should restrict fluids after dinnertime so they can sleep uninterrupted through the night. If a patient has a problem with constipation. and water metabolized from food eaten. water contained in the food ingested. and sodas. Consumption of artificial sweeteners also has been theorized to contribute to urge incontinence. Advise these individuals to elevate their lower extremities several hours during the late afternoon or evening to stimulate a natural diuresis and limit the amount of edema present at bedtime. o Some patients tend to drink water excessively. Women who have nocturia more than twice a night or experience nighttime bed-wetting may benefit from fluid restriction and the elimination of caffeine-containing beverages from their diet in the evening. Some older women do not drink enough fluids to keep themselves well hydrated. receiving adequate hydration. hot chocolate. and kidney stone formation. Thus. Persons who consume a large amount of caffeine should slowly decrease the amount of caffeine consumed to avoid significant withdrawal responses such as headache and depression. Many drinks contain caffeine. Others take medication that makes their mouths dry. sequential o o o o o . The recommended amount of fluids consumed (all types) in 24 hours totals 6-8 glasses. Nighttime voiding and incontinence are major problems in the older population. Drip coffee contains the most caffeine. caffeine-containing products produce excessive urine and exacerbate symptoms of urinary frequency and urgency. Of caffeine-containing products. Some women who are trying to lose weight are on a diet that requires consuming abundant amounts of water. The benefits of adequate fluid intake include prevention of dehydration. Even decaffeinated coffee contains a small amount of caffeine. Individuals who develop edema of the lower extremities during the day experience nighttime voiding because the excess fluid from the lower extremities returns to the heart in a recumbent position. thinking that if they drink less. In addition. and it has a direct excitatory effect on bladder smooth muscle. recommend eating a high-fiber diet. followed by percolated coffee and then instant coffee. and acidic juices may worsen irritative voiding or urge symptoms. Caffeine is a natural diuretic. urinary tract infection.water. citrus fruits drinks. support hose.

are a rehabilitation technique used to tighten and tone the pelvic floor muscles (ie. Behavioral treatment. they are not doing these exercises properly. or reinforced with biofeedback therapy or with electrical stimulation. surgery is warranted. An anatomic defect of the levator ani musculature requires physical rehabilitation. Depending on other medical conditions. including pelvic muscle exercises and educated use. Pelvic floor muscles also are known as levator ani muscles. If the patient is using abdominal muscles or contracting their buttocks. Pelvic floor muscle exercises are performed by drawing in or lifting up the levator ani muscles as if to control urination or defecation with minimal contraction of abdominal. They are named levator muscles because they function to levitate or elevate the pelvic organs into their proper place. If aggressive physical therapy does not work. If patients have difficulty identifying the levator muscles. When levator muscles weaken and fail. o Individuals who benefit the most from pelvic floor exercises tend to be young healthy women who can identify the levator muscles accurately. sometimes called Kegel exercises. These rehabilitation exercises may be used for urge incontinence as well as mixed incontinence. buttock. Pelvic floor exercises work best in mild cases of stress incontinence associated with urethral hypermobility but not intrinsic sphincter deficiency. electrical stimulation further enhances pelvic muscle rehabilitation therapy. Contraction of the external urinary sphincter induces reflex bladder relaxation. changing the time of administration of the diuretic to the morning may prevent large nighttime volumes of voiding. Pelvic floor exercises. thus improving sleep.compression devices (SCDs) used briefly at the end of the day can reduce lower extremity edema and minimize nighttime diuresis. augmented with vaginal cones. o Judicious use of diuretics has been associated with a decrease in lower-extremity edema and lower nighttime urine volumes. • Pelvic floor exercise o Pelvic floor exercise refers to strengthening the levator muscles lining the floor of the bony pelvis. Older adults with weak pelvic tone or women who have difficulty recognizing the right muscles will need adjunct therapy such as biofeedback or electrical stimulation. These exercises empower the external urinary sphincter to prevent stress incontinence and build up the pelvic floor muscles to avert impending pelvic prolapse. o . They also benefit men who develop urinary incontinence following prostate surgery. pelvic prolapse and stress incontinence result. biofeedback therapy may be instituted. For selected individuals. Pelvic muscle exercises may be used alone. Pelvic floor muscle rehabilitation may be used to reprogram the urinary bladder to decrease the frequency of incontinence episodes. The first step in pelvic muscle rehabilitation is to establish a better awareness of the levator muscle function. Kegel exercises may be performed to eliminate urge incontinence. levator ani) that have become weak over time. is a safe and effective intervention that should be used as a first-line treatment for urge and mixed incontinence. Activity Anti-incontinence exercises emphasize rehabilitating and strengthening the pelvic floor muscles that are critical in maintaining urinary continence. or inner thigh muscles. In addition.

The best results are achieved when standard pelvic muscle exercises (Kegel exercises) are performed with intravaginal weights. vaginal weights (identical shape and volume) come in a set of 5. As part of a progressive resistive exercise program. These steps will provide the patient more time to walk slowly to the bathroom with urinary control. By making this maneuver a habit. This exercise is performed twice daily. the exercise may be increased to 30 minutes. Pelvic floor exercises are effective. The sustained contraction required to retain the weight within the vagina increases the strength of the pelvic floor muscles. This is known as the guarding reflex. the subjective cure or improved continence status was approximately 70- o o . the sensation of impending bladder contraction will dissipate.5. patients should not contract their abdominal muscles. By regularly training the external sphincter. patients will develop a protective mechanism against stress and urge incontinence. patients can gradually increase the time between urination from 1-3 hours. Strong contractions of the pelvic floor muscles will suppress bladder contractions.o For urge incontinence. Contracting the abdominal muscles is counterproductive and merely worsens urinary incontinence. the involuntary urine loss is thwarted. this technique may be used for urge symptoms. the bladder automatically relaxes. tailor a regimented program of exercises and repetitions to each individual so that the muscle strength increases progressively. Thus. As the levator ani muscles become stronger. 60. 20. Whenever patients feel urinary urgency. o o o o • Vaginal weights o Vaginal weight training is an effective form of pelvic floor muscle rehabilitation for stress incontinence in premenopausal women. Patients should practice contracting the levator ani muscles immediately before and during situations when leakage may occur. 32. and mixed incontinence (stress and urge incontinence). with increasing weights (ie. even after multiple antiincontinence surgeries. When performing these drills. When the patient contracts the external urethral sphincter. Vaginal weights are tamponlike special help aids used to enhance pelvic floor muscle exercises. By squeezing the levator ani muscles when the patient feels the sense of urgency. pelvic floor muscle exercises are used to retrain the bladder. In general. Some patients may need more intensive training than others. a single weight is inserted into the vagina and held in place by tightening the perivaginal muscles (levator ani muscles) for as many as 15 minutes. and 75 g). When the patient tightens the external urinary sphincter just as a sneeze is about to occur. The beneficial effects of pelvic floor muscle exercises alone have been well documented in medical literature. 45. urge incontinence. so the urge to urinate eventually subsides. Successful reduction in urinary incontinence has been reported to range from 56-95%. they may try to stop the feeling by contracting the pelvic floor muscles. In premenopausal women with stress incontinence. The intravaginal weight provides the sensory feedback for the desired pelvic muscle contraction. Patients should begin to see improvement in 3-4 weeks. This will condition the external sphincter instinctively to contract with increases in abdominal pressure or when the need to urinate is imminent. Shaped like a small cone.

Biofeedback allows the patient to correctly identify the pelvic muscles that need rehabilitation. and mixed incontinence. Biofeedback therapy is recommended for treatment of stress incontinence. Overall. Biofeedback is an intensive therapy. urge incontinence. awareness of levator ani muscle contraction can be achieved more efficiently using biofeedback than vaginal palpation alone. During a biofeedback therapy. The best biofeedback protocol is one that reinforces levator ani muscle contraction with inhibition of abdominal and bladder contraction. with weekly sessions performed in an office or a hospital by a trained professional. Therefore. Combining bladder and urinary sphincter biofeedback allows the patient to regulate the pelvic muscle contraction in response to increasing bladder volumes and to monitor the bladder activity. When the exercises are performed properly. Biofeedback. Biofeedback produces a greater reduction in female urinary incontinence compared to pelvic muscle exercises alone. Biofeedback also has been used successfully in treatment of men with urge incontinence and intermittent stress incontinence after prostate surgery. The patient is instructed to contract and relax the pelvic floor muscles upon command. and it often is followed by a regimen of pelvic floor muscle exercises at home. Vaginal weight training also may be useful for women who are postmenopausal with stress incontinence. the medical literature indicates that pelvic muscle o o o o o . Studies on biofeedback combined with pelvic floor exercises show a 54-87% improvement with incontinence. using multi-measurement recording. displays the simultaneous measurement of pelvic and abdominal muscle activity on the computer monitor. These devices allow the patient to receive immediate visual feedback on the activity of the pelvic floor muscles. Biofeedback therapy uses a computer and electronic instruments to relay auditory or visual information to the patient about the status of pelvic muscle activity. These sensors detect electrical signals from the pelvic floor muscles. Medical studies have demonstrated significant improvement in urinary incontinence in women with neurologic disease and in the frail older population when a combination of biofeedback and bladder training is used. The benefit of biofeedback therapy is that it provides the patient with minute-by-minute feedback on the quality and intensity of her pelvic floor contraction.80% after 4-6 weeks of treatment. the electric signals from the pelvic floor muscles are registered on a computer screen. Reports using this method show a 76-82% reduction in urinary incontinence. Biofeedback is best used in conjunction with pelvic floor muscle exercises and bladder training. vaginal weights are not effective in the treatment of pelvic organ prolapse. a special tampon-shaped sensor is inserted in the patient's vagina or rectum and a second sensor is placed on her abdomen. • Biofeedback o Biofeedback therapy is a form of pelvic floor muscle rehabilitation using an electronic device for individuals having difficulty identifying levator ani muscles. however. Biofeedback provides a specific reinforcement for pelvic muscle contraction that is isolated from the counterproductive abdominal contraction.

however. this treatment does not appear to benefit cognitively impaired patients. scheduled voiding with conscious delay of voiding. Bladder training generally consists of self-education. as well as urge and mixed incontinence. This method of rehabilitation most often is used for active women with urge incontinence and sensory urge symptoms. This form of muscle rehabilitation is similar to the biofeedback therapy. Electrical stimulation appears to be most effective when augmented with pelvic floor exercises. Long-term data report that with electrical stimulation the rate of cured or improved patients ranged from 54-77%. Research indicates that pelvic floor electrical stimulation can reduce urinary incontinence significantly in women with stress incontinence and may be effective in men and women with urge and mixed incontinence. Electrical stimulation may be most beneficial when stress incontinence and very weak or damaged pelvic floor muscles coexist. in order to derive significant benefit. Although bladder training is used primarily o . or surface electrodes. and positive reinforcement. For women with urge incontinence. Like biofeedback. such as biofeedback therapy. Nonimplantable pelvic floor electrical stimulation uses vaginal sensors. patients find that when they respond to symptoms of urge and return to the bathroom soon after they have voided. anal sensors. A regimented program of electrical stimulation will help these weakened pelvic muscles contract so they can become stronger. • Electrical stimulation o Electrical stimulation is a more sophisticated form of biofeedback used for pelvic floor muscle rehabilitation. Electrical stimulation of pelvic floor muscles produces a contraction of the levator ani muscles and external urethral sphincter while inhibiting bladder contraction.exercises and other behavioral strategies. This treatment involves stimulation of levator ani muscles using painless electric shocks. Often. are provided. Patients must continue pelvic floor exercises after the treatment. However. the maximum benefit is derived from any pelvic muscle rehabilitation and education program when ongoing reinforcement and guidance. Incidence of urge incontinence secondary to neurologic diseases may be decreased with this therapy. it is signaling that it is time to void. Adverse reactions are minimal. perform stimulation for a minimum of 4 weeks. Like biofeedback. pelvic floor muscle electrical stimulation has been shown to be effective in treating female stress incontinence. can cure or reduce incontinence. Electrical stimulation therapy requires a similar type of probe and equipment as those used for biofeedback. except small electric shocks are used. o o o • Bladder training o Bladder training involves relearning how to urinate. with or without biofeedback. electrical stimulation may help the bladder relax and prevent it from contracting involuntarily. though the bladder is not full. In other words. they do not expel significant urine. Unfortunately. electrical stimulation can be performed at the office or at home. This therapy depends on a preserved reflex arc through the intact sacral micturition center. Electrical stimulation can be used in conjunction with biofeedback or pelvic floor muscle exercises.

The urethra is normal. o Bladder training uses dietary tactics such as adjustment of fluid intake and avoidance of dietary stimulants. Another method of bladder training is to maintain the prearranged schedule and disregard the unscheduled voids. o o o Medications Stress incontinence results from a weak urinary sphincter. it also may be used for stress and mixed incontinence. Bladder training may not be successful in frail women who are older. Pharmacologic therapy for stress incontinence and an overactive bladder may be most effective when combined with a pelvic exercise regimen. The 3 main categories of drugs used to treat urge incontinence include anticholinergic drugs. The interval goal between each void usually is set between 2 and 3 hours and may be set further apart if desired. Activation of the alpha-receptors results in contraction of the internal urethral sphincter and increases the urethral resistance to urinary flow. patients need to continue to maintain the prearranged voiding times. the interval goal is determined by the patient's current voiding habits and is not enforced at night. In addition. a portable bladder scanner may be used. By using these strategies. patients can induce the bladder to accommodate progressively larger voiding volumes. and tricyclic agents increase bladder outlet resistance to improve symptoms of stress urinary incontinence. . Bladder training has been used primarily to manage urge incontinence. they can check the bladder using the scanner to see how much urine is present. Alternatively. Patients urinate according to a scheduled timetable rather than the symptoms of urge. antispasmodics. As the bladder becomes accustomed to this delay in voiding. however. Initially. When patients feel the need to void. patients can void when their bladder fills to a certain volume rather than responding to the sensation of needing to go to the bathroom. However. patients should ignore the sensation of needing to go to the bathroom. the first voiding interval may be increased by 15to 30-minute increments. while the improvement rate was 75% after 6 months. and tricyclic antidepressant agents. With bladder training. If patients need an objective demonstration that their bladder is relatively empty. With this device. The internal sphincter contains high concentrations of alpha-adrenergic receptors. Medical conditions that cause urge incontinence may be neurologic or nonneurologic.for urge incontinence. This form of training is useful in young women but is difficult to implement in cognitively impaired persons. with simultaneous distraction or relaxation techniques and dietary modification. the rate of patients with mixed incontinence that have been cured is reported to be 12%. bladder ultrasound may be employed. If the bladder is empty. Sympathomimetic drugs. but the bladder is hyperactive or overactive. distraction and relaxation techniques allow delayed voiding to help distend the urinary bladder. estrogen. this program may be used for simple stress incontinence and mixed incontinence. Bladder training requires the patient to resist or inhibit the sensation of urgency and postpone voiding. the interval between mandatory voids is increased progressively. Regardless of the initial voiding pattern. Medical reports demonstrate that bladder training is effective in reducing urinary incontinence. A bladder scanner is a portable ultrasound machine that measures the amount of urine present in a patient's bladder. They will need to continue this program for several months.

Potential anticholinergic adverse effects may be additive because both drugs have similar adverse reactions. myasthenia gravis. Result is an improved mucosal seal effect. Mucosal turgor of periurethral tissue from proper nourishment enhances urethral mucosal coaptation. sedatives. addition of progestin therapy is recommended to prevent endometrial hyperplasia in women with an intact uterus.All drugs with anticholinergic adverse effects are contraindicated if patients have documented narrowangle glaucoma. bowel obstruction. Thus. with mild-to-moderate incontinence. Oxybutynin causes direct smooth muscle relaxation of the urinary bladder and has local anesthetic properties. Each g contains 0. Use medication in women who are postmenopausal and incontinent and who have had a hysterectomy. Other potential beneficial effects of estrogen use include decreased bone loss and resolution of hot flashes during menopause.5 g of conjugated estrogens. and severe heart diseases are contraindications for anticholinergic use. imipramine also increases the bladder outlet resistance at the level of the bladder neck. Routinely prescribing conjugated estrogens to premenopausal women is not recommended. Estrogen supplementation appears to be the most effective in women who are postmenopausal. These agents may impair the patient's ability to perform hazardous activities. Urinary retention. Estrogen derivatives Conjugated estrogen increases the tone of urethral muscle by up-regulating the alpha-adrenergic receptors in the surrounding area and enhances alpha-adrenergic contractile response to strengthen pelvic muscles. such as oxybutynin (Ditropan) and imipramine (Tofranil) may be used. Although their mechanism of action differs. Oral or vaginal form of estrogen may be used. cautiously recommend a short-term low-dose regimen of Premarin with frequent monitoring. When estrogen is used long term. oxybutynin and imipramine work together to improve urge incontinence.625 mg of conjugated estrogens. Wide-angle glaucoma is not a contraindication to their use. which is important in urethral support (prevents urethral hypermobility). combination therapy. which is important in urethral function (prevents intrinsic sphincter deficiency). . For postmenopausal women with an intact uterus. like oxybutynin. Premarin vaginal cream is available in a package with a plastic applicator and a tube that contains 42. Progestin may be administered continuously or intermittently. Limited evidence suggests that oral or vaginal estrogen therapy may benefit some women with stress and mixed urinary incontinence.5-10 mg/d) is needed for 10-13 d to provide maximum maturation of endometrium and to eliminate any hyperplastic changes. Estrogen cream is readily absorbed through the skin and mucous membranes. the combination of these drugs produces a synergistic effect to relax the unstable bladder to hold in urine and prevent urge incontinence. Both types of stress incontinence will benefit from estrogen fortification. ulcerative colitis. however. medroxyprogesterone 2. or hypnotic drugs. When a single drug treatment does not work. Pharmacologic therapy using estrogen derivatives results in few cures (0-14%) but may cause subjective improvement in 29-66% of women. Imipramine has a direct inhibitory and local anesthetic effect on the bladder smooth muscle. such as driving or operating heavy machinery. Progestin (eg. Anticholinergic drugs should not be taken in combination with alcohol. because of the potential for drowsiness. Conjugated estrogen (Premarin) Conjugated estrogen may be used as an adjunctive pharmacologic agent for women who are postmenopausal with stress or mixed incontinence.

repeat regimen prn and taper off or discontinue at 3. Also useful in treating urinary incontinence associated with urinary frequency. • • • • Adult Dosing Interactions Contraindications Precautions 15 mg PO tid/qid Pediatric Not established Dicyclomine hydrochloride (Bentyl) Anticholinergic agent with smooth muscle relaxant properties. 3 wk on and 1 wk off). Effective in treating urge incontinence because they inhibit involuntary bladder contractions. subjective improvement was reported by 62% of the subjects while taking dicyclomine hydrochloride 10 mg tid.625 mg PO qd for 21 consecutive d. When anticholinergic drugs are used in excess. Potential adverse effects of all anticholinergic agents include blurred vision.5-1 applicator) of cream may be administered intravaginally qd in usual cyclic regimen Pediatric Not established Anticholinergic drugs First line of medicinal therapy for women with urge incontinence. • • Dosing Interactions . Blocks the action of acetylcholine at parasympathetic sites in secretory glands and smooth muscle. and facial flushing. urgency. Blocks action of acetylcholine at postganglionic parasympathetic receptor sites.• • • • Adult Dosing Interactions Contraindications Precautions 0. When stronger doses were used (60 mg qid). drowsiness. The reported cure rate was 90%. All anticholinergic drugs have similar performance profiles and toxicity. propantheline bromide was shown to decrease incidence of urge incontinence by 13-17% when 30 mg were used qid.to 6-mo intervals 2-4 g (0. heart palpitations. followed by 7 d without the drug (eg. In a medical study. acute urinary retention in the bladder may occur. In a medical study. dry mouth. cure rate was reported to be over 90%. and nocturnal enuresis. Propantheline bromide (Pro Banthine) Typical prototype for all anticholinergic agents.

these medications have been reported to increase the bladder capacity and effectively decrease or eliminate urge incontinence. extended-release capsules (Levsinex Timecaps. if tolerated. Food does not affect absorption. which in turn has antispasmodic effects. Absorbed well by the GI tract. Cystospaz-M). Blocks action of acetylcholine at parasympathetic sites in smooth muscle. Cystospaz M. for severe symptoms. and extended-release tablets (Levbid). Adverse effect profile of antispasmodic drugs is similar to that of anticholinergic agents. 0. secretory glands. By exerting a direct spasmolytic action on the smooth muscle of the bladder. Drinking alcohol and using sedatives in combination with these antispasmodic drugs is contraindicated. 0. and the CNS. which results in anticholinergic effect and inhibition of bladder smooth muscle contraction.375 mg PO bid. • • • • Adult Dosing Interactions Contraindications Precautions 0. Levsinex. Solifenacin succinate (VESIcare) Elicits competitive muscarinic receptor antagonist activity. Levbid) Anticholinergic agents with antispasmodic properties used for the treatment of urge incontinence.375 mg PO tid Pediatric Not established Antispasmodic drugs These relax the smooth muscles of the urinary bladder. and urge incontinence.125 mg PO q4h. • • • • Adult Dosing Interactions Contraindications Precautions 5 mg PO qd. alternatively. may be increased to 10 mg PO qd . Indicated for overactive bladder with symptoms of urgency. These drugs may impair the patient's ability to perform activities requiring mental alertness and physical coordination.• • Adult Contraindications Precautions 10-20 mg PO tid Pediatric Not established Hyoscyamine sulfate (Levsin/SL. frequency. Levsin. conventional tablets (Levsin). Available in sublingual form (Levsin SL).

Ditropan XL achieves steady-state levels over a 24-h period. Has high affinity for M 3 receptors involved in bladder and GI smooth muscle contraction. divide. Provides local anesthetic effect on irritable bladder.5 mg PO qd initially. or crush. aqueous environment in GI tract causes water to enter tablet via semipermeable membrane at constant rate. Outer tablet is composed of a semipermeable membrane with a precision laser-drilled hole that allows the drug to be released at a constant rate. • • • Dosing Interactions Contraindications . it forces the drug suspension out of the hole at a constant rate over a 24-h period. saliva production. Ditropan XL) Has both anticholinergic and direct smooth muscle relaxant effects on urinary bladder. Mean reduction in urinary frequency was 23%. Ditropan XL tablet has a bilayer core that contains a drug layer and a push layer that contains osmotic components. Has excellent efficacy with minimal adverse effects. do not chew. • • • • Adult Dosing Interactions Contraindications Precautions 7. Reduces bladder smooth muscle contractions. and delays initial desire to void. As the push layer swells. Total continence rate has been reported to be 41-50%. only 1% stopped taking Ditropan XL due to dry mouth and less than 1% stopped taking Ditropan XL due to CNS adverse effects. Swallow whole. Urodynamic studies have shown oxybutynin increases bladder size. Avoids first pass metabolism of liver and upper GI tract to avoid cytochrome P450 enzymes. urgency. after 2 wk may increase to 15 mg PO qd based on response Moderate hepatic impairment (Child-Pugh class B) or potent CYP-450 3A4 inhibitors: Do not exceed 7. In clinical trials. Indicated for overactive bladder with symptoms of urge incontinence.5 mg PO qd Pediatric Not established Oxybutynin chloride (Ditropan IR. When drug is ingested. and frequency. and iris sphincter function. Ditropan XL has an innovative drug delivery system—oral osmotic delivery system (OROS).Pediatric Not established Darifenacin (Enablex) Extended-release product eliciting competitive muscarinic receptor antagonistic activity. Medical studies have shown that oxybutynin chloride reduces incontinence episodes by 83-90%. Introduction of water inside tablet liquifies drug and causes push layer to swell osmotically. decreases frequency of symptoms.

5 mg PO tid. Antagonizes acetylcholine effect on muscarinic receptors. Differs from other anticholinergic types in that it has selectivity for urinary bladder over salivary glands. urgency. frequency). Exhibits high specificity for muscarinic receptors. • • • • Adult Dosing Interactions Contraindications Precautions Detrol: 2 mg PO bid Detrol LA: 4 mg PO qd Pediatric Not established Trospium (Sanctura) Quaternary ammonium compound that elicits antispasmodic and antimuscarinic effects. titrate prn to 5 mg bid/tid/qid Ditropan XL: 5-15 mg PO qd Pediatric Not established Tolterodine L-tartrate (Detrol and Detrol LA) Competitive muscarinic receptor antagonist for overactive bladder. Parasympathetic effect reduces smooth muscle tone in the bladder. take on empty stomach at least 1 h before meals CrCl <30 mL/min: 20 mg PO hs >75 years: May titrate dose downward to 20 mg PO qd based on tolerability Pediatric Not established . urinary incontinence. Has minimal activity or affinity for other neurotransmitter receptors and other potential targets such as calcium channels. • • • • Adult Dosing Interactions Contraindications Precautions 20 mg PO bid. In clinical studies. mean decrease in urge incontinence episodes was 50% and the mean decrease in urinary frequency was 17%.• Adult Precautions Ditropan IR: 2. Indicated to treat symptoms of overactive bladder (eg.

They function to increase norepinephrine and serotonin levels. range is 25-100 mg qd Pediatric Not established Amitriptyline hydrochloride (Elavil) Tricyclic antidepressant with sedative properties. and frequency). these drugs were used to treat major depression. Facilitates urine storage by decreasing bladder contractility and increasing outlet resistance. Has alpha-adrenergic effect on the bladder neck and antispasmodic effect on detrusor muscle. Indicated for symptoms of overactive bladder (eg. • • • • Adult Dosing Interactions Contraindications Precautions 10-50 mg PO qd/tid. urinary urge incontinence. however. it is extremely effective in decreasing symptoms of urinary frequency in women with pelvic floor . urgency.or 8-mg extended-release tab. Imipramine hydrochloride has local anesthetic effect on bladder mucosa.Fesoterodine (Toviaz) Competitive muscarinic receptor antagonist. • • • • Adult Dosing Interactions Contraindications Precautions 4 mg PO qd. clarithromycin) Pediatric Not established Tricyclic antidepressant drugs Historically. Increases circulating levels of norepinephrine and serotonin by blocking their reuptake at nerve endings and is ineffective for use in urge incontinence. Antagonistic effect results in decreased bladder smooth muscle contractions. Available as 4. In addition. However. Imipramine hydrochloride (Tofranil) Typical tricyclic antidepressant. not to exceed 4 mg PO qd in severe renal dysfunction (ie. they have an additional use that is not FDA approved—treatment of bladder dysfunction. CrCl <30 mL/min) or with coadministration of drugs that decrease fesoterodine's metabolism (eg. itraconazole. ketoconazole. may increase to 8 mg/d. they exhibit anticholinergic and direct muscle relaxant effects on the urinary bladder.

and urethral erosion. bowel injury. Patient education For excellent patient education resources. Chronic suprapubic tubes may result in bladder spasms. visit eMedicine's Kidneys and Urinary System Center and Procedures Center. ascending pyelonephritis. Untreated urinary tract infections may lead to urosepsis and death. titrate prn by 10 mg/wk until maximum dose of 150 mg is reached. With improvement in information technology. bladder stones. hematoma. • • • • • Prognosis Prognosis of a patient with incontinence is excellent with modern health care. these skin disorders may lead to pressure sores and ulcers.muscle dysfunction. well-trained medical staff. patients who are incontinent should not experience the morbidity and mortality of the past. see eMedicine's patient education articles Bladder Control . Although the ultimate well being of a patient who is incontinent depends on the underlying condition that has precipitated urinary incontinence. and advances in modern medical knowledge. Also. and bladder infection. bladder stone formation. the postvoid residual urine can lead to overgrowth of bacteria and subsequent urinary tract infection. For individuals with a decompensated bladder that does not empty well. • • • • Adult Dosing Interactions Contraindications Precautions 10 mg/d PO. Well-tolerated and effective in most women with urinary frequency. and problems with catheter reinsertion. Potential problems unique to suprapubic catheters include skin infection. urinary symptoms disappear. possibly resulting in secondary infections. If left untreated. Chronic indwelling catheters may cause recurrent bladder infection. or adverse effects become intolerable Pediatric Not established Follow-up Complications • Prolonged contact of urine with unprotected skin causes contact dermatitis and skin breakdown. Restores serotonin levels and helps break the cycle of pelvic floor muscle spasms. The use of intermittent catheterization may result in bladder infections or urethral injury. urinary incontinence itself is easily treated and prevented by properly trained health care individuals.

The mechanical process of urination is coordinated by the pons in the area known as the pontine micturition center (PMC). Understanding Bladder Control Medications . (Enlarge Image) . Inability to Urinate. and Foley Catheter. When patients are taking anticholinergic agents. Rule out narrow-angle glaucoma prior to prescribing an anticholinergic agent.Problems. Narrow-angle glaucoma may be converted to open-angle glaucoma by an experienced ophthalmologist. Multimedia Media file 1: The pons is a major relay center between the brain and the bladder. monitor these patients to prevent pharmacologically induced urinary retention. Medical/legal pitfalls • • • Failure to diagnose and treat urinary retention may result in adverse consequences.

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