Rehabilitation Approach to Bladder Dysfunction after Brain Injury 1 ...

Current Concepts in Brain Injury Rehabilitation 

B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury 

Slide 1 

___________________________________ 

___________________________________ 

Rehabilitation Approach to Bladder 

Dysfunction after Brain Injury 

Justin Hong, MD 

Neomi Aladjem, RN, CRRN, CBIS 

May 12, 2012 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 2 

___________________________________ 

Objectives 

• Define the problem of bladder dysfunction and its 

clinical significance 

• Understand bladder anatomy and function 

• Review approach to evaluation and treatment 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 3 

___________________________________ 

Objectives (Continued) 

• Review causes of bladder dysfunction 

• Understand behavioral plans and bladder patterning 

• Questions 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

1



Slide 4 

___________________________________ 

Defining the Problem 

• What is the definition of bladder dysfunction 

• The bladder serves two main functions: 

o Waste storage 

o Waste micturition / voiding 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 5 

___________________________________ 

Defining the Problem (Continued) 

• Bladder function is one of the fundamental activities of daily 

living. 

• Though studies directly examining bladder dysfunction in 

patients with brain injury (BI) are not as numerous as those in 

the stroke literature, there are suggestions that at least 50% 

of patients deal with bladder dysfunction, either urinary 

incontinence (UI) or urinary retention (UR), during the acute 

post-injury inpatient rehabilitation (IPR) period. (Chua 2003) 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 6 

___________________________________ 

Defining the Problem (Continued) 

• One retrospective case series (N = 84, 44.7 ± 17.9 years, 

66 males, 18 females) examining bladder dysfunction during 

post-acute BI IPR showed the following (Chua 2003): 

– UI associated with increased length of stay, decreased 

functional discharge status, and decreased rates of return 

to work. 

– Not associated with admission to long-term care facility, 

BUT… 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

2



Slide 7 

___________________________________ 

Bladder Anatomy and Function 

• Components of the urinary system 

• Lower urinary tract (LUT) 

• Bladder 

• Urethra 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 8 

___________________________________ 


• Detrusor muscle 

(smooth muscle) 

• Internal urethral sphincter 

(smooth muscle) IUS 

• External urethral sphincter 

(skeletal muscle) EUS 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 9 

___________________________________ 


• The bladder serves two main functions: 

o Urine storage (storage reflex) 

o Micturition (voiding reflex) 

• Involves both the central and peripheral nervous system. 

• Coordination mediated not only by neurons in the spinal cord, 

but also in the brainstem and brain (Beckel 2011). 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

3



Slide 10 

___________________________________ 


• During bladder storage 

– 100-200cc first sensation of bladder filling 

– 300-400cc bladder fullness 

– 400-500cc sense of urgency 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 11 

___________________________________ 

Pathways (Storage) 

• Sympathetic pre-ganglionic nucleus (T11-L2, intermediolateral 

gray matter) inferior mesenteric ganglia sympathetic 

post-ganglionic motoneurons body of bladder 

(β-adrenergic receptor (AR) – relaxation) and base of bladder 

/ IUS (α-AR – contraction) 

• Somatic efferents (S2-S4, Onuf’s nucleus (ON)) pudendal 

nerve EUS (α-1 nicotinic receptor – voluntary contraction) 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 12 

___________________________________ 

Storage 

___________________________________ 

___________________________________ 

___________________________________ 

(Beckel 2011) 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

4



Slide 13 

___________________________________ 

Pathways (Voiding) 

• Afferent (detrusor muscle stretch receptors, anal / urethral 

sphincters / perineum / genitalia) myelinated A-δ fibers 

(bladder distention) pelvic and pudendal nerves to Gert’s 

nucleus (sacral) periaqueductal gray (PAG) in midbrain 

– Also, unmyelinated C-fibers that are silent (increased 

activity following spinal cord injury (SCI)) 

• When threshold pressure met, lateral PAG pontine 

micturition center (PMC) parasympathetic pre-ganglionic 

nucleus (S2-S4) and also, sacral GABAergic / glycinergic 

inhibitory inter-neuron 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 14 

___________________________________ 

Pathways (Voiding) 

• Parasympathetic pre-ganglion nucleus (S2-S4, 

intermediolateral gray matter) pelvic nerve major pelvic 

/ intramural ganglia Detrusor (muscarinic M2 receptor 

(mAChR)) – contraction of bladder body) 

• PMC GABAergic / glycinergic interneuron inhibits 

motoneurons of Onuf’s nucleus (EUS relaxation) 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 15 

___________________________________ 

Voiding 

___________________________________ 

___________________________________ 

___________________________________ 

(Beckel 2011) 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

5



Slide 16 

___________________________________ 

Central Pathways 

• In humans, over the age of 2-3 years old, timing of voiding can 

be volitionally controlled. 

• Based on studies utilizing functional imaging techniques (PET, 

fMRI), there is evidence that the anterior cingulate gyrus 

(ACG) and pre-frontal cortex (both forebrain) are involved 

during storage and voiding. 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 17 

___________________________________ 


___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 18 

___________________________________ 


• ACG multiple connections (amygala, hippocampus, insula, 

thalamic dorsal medial nucleus, caudate nucleus, putamen, 

PAG, etc.) 

– Attention, introspection, executive functions, etc. 

• Pre-frontal cortex multiple connections 9ACG, PAG, 

hypothalamus, thalamus, insula, etc.) 

– Executive function, social behavior, planning, etc. 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

6



Slide 19 

___________________________________ 

Summary 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 20 

___________________________________ 

Bladder Dysfunction Approach 

• When approaching bladder dysfunction, first identify the 

problem: 

– Urinary incontinence, urinary retention, or mixed picture 

• Not always clear. 

• Detailed history including date and mechanism of brain injury 

(location), associated injuries, interventions, medications, 

dietary status, and hydration. 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 21 

___________________________________ 


• Past medical history including neurologic conditions, 

endocrine disorders, benign prostatic hypertrophy (BPH), 

stress incontinence, constipation, prior pelvic / prostate / 

spine surgeries, etc. 

• Pre-injury functional history (dressing, hygiene, toileting, etc.) 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

7



Slide 22 

___________________________________ 

BPH 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 23 

___________________________________ 

Stress Incontinence 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 24 

___________________________________ 


• Thorough physical examination. 

– HEENT 

– Heart 

– Lung 

– Abdomen 

– Extremities 

– Integument 

– Cognitive 

– Sensory, Motor, Reflexes, etc. 

– Consider rectal examination 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

8



Slide 25 

___________________________________ 

Differential Diagnosis 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 26 

___________________________________ 


___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 27 

___________________________________ 


___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

9



Slide 28 

___________________________________ 


Urinary incontinence: 

• Infection (Urinary tract infection, prostatitis, etc.) 

• Constipation 

• Medications (i.e., diuretics) 

• Overhydration 

• Behavioral (disinhibited, psychiatric, etc.) 

• Neurogenic bladder 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 29 

___________________________________ 

Neurogenic Bladder 

Spastic bladder (lesion above sacral micturition center UMN) 

• Difficulty with storage 

• Over-active small bladder 

• No storage 

Flaccid bladder (lesion at sacral micturition center or in 

peripheral innervation of bladder LMN) 

• Large boggy, areflexic bladder with spastic internal sphincter 

• No emptying 

Cuccurullo 2010 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 30 

___________________________________ 

Neurogenic Bladder 

Combination-type, Detrusor Sphincter Dyssynergia (DSD) 

• Injury between PMC and sacral micturition center 

• Small, spastic bladder 

• Spastic internal sphincter 

• May present as retention or incontinence (at high pressures) 

___________________________________ 

___________________________________ 

___________________________________ 


___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

10



Slide 31 

___________________________________ 

Evaluation and Treatment 

• Urinary incontinence, retention, mixed picture 

• If potential causes are identified, address them in a systemic 

fashion. 

• Could start with bladder patterning program with recording 

of post-void residuals (PVR’s) with intermittent straight 

catheterization parameters. 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 32 

___________________________________ 


Proceed with further workup depending on clinical suspicion. 

Could include the following: 

• Bloodwork (BMP, CBCD, Hg1A, PSA, UA, UCx, Urine cytology, 

etc.) 

• Imaging (US of renal / bladder / pelvis, CT abdomen / pelvis, 

CT / MRI of brain, spine) 

• Cystoscopy / retrograde cysto-urethrography 

• Urodynamic studies to assess for neurogenic bladder 

• EMG study of pudendal nerve 

• Consult Urology for assistance 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 33 

___________________________________ 

Cystoscopy / Cystourethrography 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

11



Slide 34 

___________________________________ 

Urodynamic Study 

___________________________________ 

___________________________________ 

___________________________________ 


___________________________________ 

___________________________________ 

___________________________________ 

Slide 35 

___________________________________ 

Urodynamic Study 

___________________________________ 

___________________________________ 

___________________________________ 


___________________________________ 

___________________________________ 

___________________________________ 

Slide 36 

___________________________________ 

Spastic Bladder 

___________________________________ 

___________________________________ 

___________________________________ 


___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

12



Slide 37 

___________________________________ 

Flaccid Bladder 

___________________________________ 

___________________________________ 

___________________________________ 


___________________________________ 

___________________________________ 

___________________________________ 

Slide 38 

___________________________________ 

DSD (Detrusor Sphincter Dyssynergia) 

___________________________________ 

___________________________________ 

___________________________________ 


___________________________________ 

___________________________________ 

___________________________________ 

Slide 39 

___________________________________ 

Pudendal Nerve EMG 

St. Mark’s Electrode 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

13



Slide 40 

___________________________________ 

Treatments (Diet) 

Diet 

– Fluid intake 

– Spicy food, citrus fruit, chocolate / caffeine 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 41 

___________________________________ 

Treatment (Catheterization) 

• Intermittent catheterization 

– Requires cognitive capacity, dexterity, or assistant 

– Option of ileal conduit diversion 

• Indwelling foley catheter 

– Consider risk of traumatic self-discontinuation, change Qmonth 

– Increased cancer of bladder cancer with chronic foley 

• Suprapubic catheter 

– No risk of urethral damage 

– Contraindicated with unstable bladder, sphincter deficiency 

• Texas catheter 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 42 

___________________________________ 

Treatments (Medications) 

• Medications 

– Review current meds before starting new ones 

– Consider potential side effects 

• Alpha-receptor blockers (relax IUS) 

– Flomax, Minipress, Dibenzyline, Hytrin, Cardura (watch for 

orthostatic hypotension) 

• Cholinergics 

– Bethanechol (lowers seizure threshold, can worsen asthma, 

coronary insufficiency, peptic ulcers, lower GI obstruction) 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

14



Slide 43 

___________________________________ 


• Anticholinergics 

– Detrol, Pro-Banthine, Ditropan, Tofranil (TCA) 

• Use with caution in elderly (delirium, dry mouth, blurry 

vision, constipation) 

• Baclofen (GABA-B agonist) oral 

– Some studies showing potential benefit from intrathecal 

Baclofen pump 

• Capsaicin (derived from chili peppers) intravesiculal 

– Affects C-fibers, release / depletion of substance P, for spastic 

bladder 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 44 

___________________________________ 


• Resiniferatoxin (derived from cactus plants) intravesicular 

– Spastic bladder 

• Botulinum toxin therapy for spastic bladder 

– Repeated every 3 months 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 45 

___________________________________ 

Treatments (Procedures) 

• Sacral nerve stimulators 

– Possibly by blocking C-afferent fibers 

• Detrusor myomectomy 

• Sphincterotomy 

• Urethral stenting 

• Urethral dilation (females) 

• Artificial sphincter implantation (children with SB) 

• Bladder augmentation 

• In the future, stem cell therapy for neurogenic bladder 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

15



Slide 46 

___________________________________ 

___________________________________ 

___________________________________ 

Neomi Aladjem, RN, CRRN, CBIS 

___________________________________ 

May 12, 2012 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 47 

___________________________________ 

Bladder Dysfunction 

• Various studies show difference in outcome of bladder dysfunction in TBI 

patients regarding discharge to community. 

• Urinary incontinence is a common consequence after brain injury- up to 

60% in stroke survivors for example. 

• Incontinence plays a huge role in rehabilitation outcomes such as: 

- Decreased activity of daily living 

- Decreased quality of life for patient and care giver 

- Decreased self esteem 

- Embarrassment, shame, isolation 

- Depression 

• Greater chance of admission to a skilled facility versus discharge home 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 48 

___________________________________ 


The bladder is sending signals to the sacral area that it is filling 

up at about: 100-200cc 

you start to feel full: 300-400cc 

urgency to void felt: 400-500cc 

A typical physician order will be to straight cath for greater 

than 400cc. 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

16



Slide 49 

___________________________________ 


Non neurological causes include: 

Fecal impaction 

Urinary tract infection 

Medication 

Increased / decrease fluid intake 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 50 

___________________________________ 


Bladder scan - if the patient has not voided in 6-8 hour a 

scan is needed to see if urine is retained in large amount, MD 

should be notified. If the scan shows a small amount and pt is 

cathed, the sensation of a bladder getting full will not happen. 

The goal is to teach the pt to sense the fullness and respond 

correctly. 

PVR (post void residual) - The patient is voiding but maybe only 

small amounts each time. These patients may dribble often. If 

the problem is not corrected, more serious problems can 

occur such as urine backing up into the kidneys. 

Bowel Training – Reduce bladder incontinence due to 

constipation 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 51 

___________________________________ 


• Causes for high PVRs include: 

Poor bladder contraction 

A urinary obstruction such as an enlarged prostate. 

Pts with high PVRs may present with frequency, nocturia, slow 

stream of urine during void, urinary tract infections. 

Noturia 

The frequent trips to the BR will interfere with pt’s sleep 

causing inability to stay awake during the day, inability to 

concentrate and take part in the rehab program, therefore a 

delay in achieving the goals can occur. 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

17



Slide 52 

___________________________________ 


Treatment plan: 

Various medications can be used to improve under and over 

active bladder, retention, urge incontinence. 

Multi discipline physical and behavioral plan is tailored for 

each individual patient. 

Family education and training. 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 53 

___________________________________ 


Everyone in the team which includes the Physicians, Nurses, 

PCTs, PT, OT,SLP has a vital role in achieving the rehabilitation 

and the best outcome for the patients. This can best be 

achieved by everyone adhering to the plan, correct, timely 

and precise communication, correct, timely and precise 

documentation. 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 54 

___________________________________ 


• Team decides within 48 hours if patient should be on a 

bladder program. 

• The nurse caring for the pt will initiate the folder and put a 

sign on the door stating how often toileting should be done. 

• A folder with pt’s name and room number, times of toileting 

and voids, is kept on pt’s w/chair. 

• Toileting and documentation is done by nursing stuff and by 

therapists during therapy hours. 

• A hand off from nurse to therapist should occur on day 1 of 

program initiation. 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

18



Slide 55 

___________________________________ 


• The physicians rely on this information to examine the voiding 

patterns and adjust medical treatment for best outcome. 

• The bladder pattern folders, documentation, precise 

communication between team members, staffing days, 

huddles, promptly alerting the physician if a change for the 

worse occurs, all contribute to patient safety, family resilience, 

pt and family satisfaction, pt and family education for easy 

transition to home. 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 56 

___________________________________ 


• Additional treatment for incontinence: 

- restricted fluid intake specially after 6pm. 

- caffeine restriction ( it is a stimulant) 

- bowel management 

- teds during the day for better fluid flow ( blood, 

lymph). 

- bed pans are NOT used in rehab!!! it is about 

teaching and practicing transfers and bladder control 

so the goal of maximum independence at home can 

be achieved. 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

Slide 57 

___________________________________ 

References 

• Cuccurullo SJ, Physical Medicine and Rehabilitation Board Review Second Edition. 2010. 

• Beckel JM, Holstege G. Neurophysiology of the lower urinary tract. Handb Exp Pharmacol. 2011; (202):149-69. 

• Moiyadi AV, Devi BI, Nair KP. Urinary disturbances following traumatic brain injury: clinical and urodynamic 

evaluation. 2007; 22(2):93-98. 

• http://emedicine.medscape.com/article/453539-overview#a1 

• http://www.aafp.org/afp/2008/0301/p643.html 

Pictures/Tables 

• Slide 1: http://health.yahoo.net/vp/body/graphics/fullsize/bladder.jpg 

• Slide 7: http://www.baileybio.com/plogger/thumbs/lrg-846-urinary_system_2.jpg 

• Slide 18: http://en.wikipedia.org/wiki/File:Gray727_anterior_cingulate_cortex.png 

• Slide 22: http://trialx.com/curetalk/wp-content/blogs.dir/7/files/2011/07/BPH.jpg 

• Slide 23: http://kidney.niddk.nih.gov/kudiseases/pubs/uiwomen/ 

• Slide 25-27: http://www.aafp.org/afp/2008/0301/p643.html 

• Slide 34-38: Cuccurullo SJ, Physical Medicine and Rehabilitation Board Review Second Edition. 2010. 

• Slide 39: http://www.cppc.gr/images/St_Marks_electrode.jpg 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

19



Slide 58 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

___________________________________ 

May 12, 2012 

20

Rehabilitation Approach to Bladder Dysfunction after Brain Injury 1 ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?