Current Concepts in Brain Injury Rehabilitation
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 ___________________________________ ___________________________________ ___________________________________ ___________________________________ 1 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury 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… ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 2 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury Slide 7 ___________________________________ ___________________________________ Bladder Anatomy and Function • Components of the urinary system ___________________________________ • Lower urinary tract (LUT) • Bladder • Urethra ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 8 ___________________________________ ___________________________________ Bladder Anatomy and Function • Detrusor muscle (smooth muscle) • Internal urethral sphincter (smooth muscle) IUS • External urethral sphincter (skeletal muscle) EUS ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 9 ___________________________________ ___________________________________ Bladder Anatomy and Function • 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). ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 3 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury Slide 10 ___________________________________ ___________________________________ Bladder Anatomy and Function • 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) ___________________________________ ___________________________________ ___________________________________ 4 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury 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) ___________________________________ ___________________________________ ___________________________________ 5 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury 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 ___________________________________ ___________________________________ Central Pathways ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 18 ___________________________________ ___________________________________ Central Pathways • 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. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 6 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury 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 ___________________________________ ___________________________________ Bladder Dysfunction Approach • 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.) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 7 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury Slide 22 ___________________________________ ___________________________________ BPH ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 23 ___________________________________ ___________________________________ Stress Incontinence ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 24 ___________________________________ ___________________________________ Bladder Dysfunction Approach • Thorough physical examination. – – – – – – – – – HEENT Heart Lung Abdomen Extremities Integument Cognitive Sensory, Motor, Reflexes, etc. Consider rectal examination ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 8 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury Slide 25 ___________________________________ ___________________________________ Differential Diagnosis ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 26 ___________________________________ ___________________________________ Differential Diagnosis ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 27 ___________________________________ ___________________________________ Differential Diagnosis ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 9 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury Slide 28 ___________________________________ ___________________________________ Differential Diagnosis ___________________________________ 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) ___________________________________ ___________________________________ ___________________________________ Cuccurullo 2010 ___________________________________ ___________________________________ 10 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury 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 ___________________________________ ___________________________________ Bladder Dysfunction Approach 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 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 11 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury Slide 34 ___________________________________ ___________________________________ Urodynamic Study ___________________________________ ___________________________________ ___________________________________ Cuccurullo 2010 ___________________________________ ___________________________________ Slide 35 ___________________________________ ___________________________________ Urodynamic Study ___________________________________ ___________________________________ Cuccurullo 2010 ___________________________________ ___________________________________ ___________________________________ Slide 36 ___________________________________ ___________________________________ Spastic Bladder ___________________________________ ___________________________________ ___________________________________ Cuccurullo 2010 ___________________________________ ___________________________________ 12 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury Slide 37 ___________________________________ ___________________________________ Flaccid Bladder ___________________________________ ___________________________________ ___________________________________ Cuccurullo 2010 ___________________________________ ___________________________________ Slide 38 ___________________________________ ___________________________________ DSD (Detrusor Sphincter Dyssynergia) ___________________________________ ___________________________________ ___________________________________ Cuccurullo 2010 ___________________________________ ___________________________________ Slide 39 ___________________________________ ___________________________________ Pudendal Nerve EMG St. Mark’s Electrode ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 13 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury 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) ___________________________________ ___________________________________ ___________________________________ 14 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury Slide 43 ___________________________________ ___________________________________ Treatments (Medications) • 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 ___________________________________ ___________________________________ Treatments (Medications) • 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? ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 15 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury 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 ___________________________________ ___________________________________ Bladder Dysfunction 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. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 16 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury Slide 49 ___________________________________ ___________________________________ Bladder Dysfunction Non neurological causes include: Fecal impaction Urinary tract infection Medication Increased / decrease fluid intake ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 50 ___________________________________ ___________________________________ Bladder Dysfunction 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 ___________________________________ ___________________________________ Bladder Dysfunction • 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. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 17 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury Slide 52 ___________________________________ ___________________________________ Bladder Dysfunction 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 ___________________________________ ___________________________________ Bladder Dysfunction 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 ___________________________________ ___________________________________ Bladder Dysfunction • 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. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 18 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury Slide 55 ___________________________________ ___________________________________ Bladder Dysfunction ___________________________________ • 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 ___________________________________ ___________________________________ Bladder Dysfunction • 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 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 19 May 12, 2012 Current Concepts in Brain Injury Rehabilitation B1-3: Rehabilitation Approach to Bladder Dysfunction after Brain Injury Slide 58 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 20 May 12, 2012
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