BLADDER INCONTINENCE

IN
SPINAL CORD INJURIES
• Following spinal shock, one of two types
of bladder conditions will develop,
depending on location of lesions i.e.

1. LMN Bladder

2. UMN Bladder
 LMN BLADDER
(FLACCID BLADDER)

OTHER NAMES:
- OVERFLOW INCONTINENCE
- NON RELFEX BLADDER
- AUTONOMOUS BLADDER
• Lesion - conus medullaris or cauda equina

• SCI at the micturation reflex center (S2-

S4), generally involving T12 vertebral
injury or below – results LMN bladder

• Hence, the bladder becomes flaccid.

• Now due to destruction of sensory nerve

fibers from the urinary bladder to SC,
overdistention of the bladder takes place.
• So there is no inhibition of pudendal nerve
and the external sphincter remains in
contracted state.

• Hence leads to overflow incontinence.

• There is no reflex activity of the detrusor

muscle.
 LMN BLADDER
(FLACCID BLADDER)
• In this condition, patients never feel the
urge to urinate, the bladder never empties,
and small amounts of urine leak
continuously.
Symptoms include the following:

• Bladder never feels empty

• Frequent night time urinate
• Inability to void, even when the urge is felt
• Urine dribbles, even after voiding
 UMN BLADDER
(SPASTIC BLADDER)

OTHER NAMES:
- URGE INCONTINENCE
- REFLEX BLADDER
- AUTOMATIC BLADDER
• Lesion - above the conus medullaris or
cauda equina

• SCI above the micturition reflex center

(S2-S4), generally involving T11-T12
vertebral injury or above – results in UMN
bladder

• Hence, the bladder becomes spastic.

• So even a small amount of urine inside the
bladder is oversensitive and sensory
impulses are sent from bladder to SC.

• Inhibition of pudendal nerve and external

sphincter relaxes. Voiding of urine takes
place.

• Hence leads to urge incontinence.

• The reflex arc is intact with this type of

injury.
 UMN BLADDER
(SPASTIC BLADDER)
• Urge incontinence is characterized by a
sudden uncontrollable urge to urinate and
frequent urination. It is often necessary to
use a bathroom as frequently as every 2
hours, and bed-wetting is common.

• With urge incontinence, the bladder

contracts and squeezes out urine
involuntarily. Sometimes a large amount of
urine is released.
• Accidental urination can be triggered by
 sudden change in position or
activity,
 hearing or touching running water,
and
 drinking a small amount of liquid.
 LMN BLADDER UMN BLADDER
Lesion – at conus Lesion - above the
medullaris or cauda conus medullaris or
equina cauda equina

SCI at the micturation SCI above the

reflex center (S2-S4), micturition reflex center
generally involving T12 (S2-S4), generally
vertebral injury or below. involving T11-T12
vertebral injury or above.

Hence LMN bladder Hence UMN bladder

 LMN BLADDER UMN BLADDER
Overdistention of Bladder is oversensitive
bladder - due to - sensory nerve fibers
destruction of sensory from bladder to spinal
nerve fibers from the cord intact.
urinary bladder

No inhibition of pudendal Inhibition of pudendal

nerve and the external nerve and external
sphincter remains in sphincter relaxes.
contracted state.

No reflex activity The reflex arc is intact

MANAGEMENT FOR
LMN BLADDER
Medication

• Alpha-1-adrenergic blocking agents

• Anticholinergic medication
Intermittent Self-
Catheterization

• Intermittent self-catheterization is a safe

and effective method of completely
emptying the bladder every 3 to 8 hours,
or as recommended by a physician, to
keep urine volume low.
Intermittent Catheter
• It is more important to empty your bladder
than to have an absolutely clean catheter.

• The risk for infection is greater from a full

bladder than from an unwashed catheter.
Physiotherapy Management

1. Stimulation of detrusor contractions

• Some patients, especially those with

acquired cord lesions, can induce a
useful ‘reflex’ detrusor contraction by
suprapubic tapping or by perianal
stimulation, and occasionally the external
urethral sphincter can be made to relax
by similar maneuvers.
• These measures can form part of a
comprehensive bladder ‘retraining’ which
has been found to be of value in some
patients with spinal injury.
2. External compression and abdominal
straining

• Manual compression of the bladder by

suprapubic pressure (Crede’s maneuver)
can raise the intravesical pressure to 50
mm H2O or more and empty the bladder in
patients who have some degree of
sphincter weakness.
• Similar pressures can also be achieved by
abdominal straining when there is
sufficient control of the muscles of the
anterior abdominal wall.
Surgical Management
Artificial bladder sphincter replacement

Definition

• Artificial sphincter insertion surgery is the

implantation of an artificial valve in the
genitourinary tract to restore continence and
psychological well being to individuals with
urinary sphincter insufficiency that leads to
severe urinary incontinence.
• Implantation surgery related to urinary
sphincter incompetence is also called
artificial sphincter insertion or inflatable
sphincter insertion.

• The artificial urinary sphincter (AUS) is a

small device placed under the skin that
keeps pressure on the urethra until there
is a decision to urinate, at which point a
pump allows the urethra to open and
urination commences.
 MANAGEMENT FOR
UMN BLADDER

• Avoid over consumption of diuretics,

antidepressants, antihistamines, and
cough-cold preparations.

• Eat fruits, vegetables, and whole grains

daily to prevent constipation.

• Stop smoking (nicotine irritates the

bladder).
Medication

• The various drugs used are:

a. Anticholinergic Agents

a. Propantheline bromide

c. Oxybutynin chloride
d. Muscarinic receptor antagonist

e. Oxybutynin transdermal system

f. Antispasmodic Medications

g. Tricyclic Antidepressants

h. Alpha-1-adrenergic blocking agents

• A number of protective devices are
available to help manage accidental
urination, including the following:

 Bed pads
 Combination pad-pant systems
 Disposable or reusable adult
diapers
 Full-length absorbent
undergarments
Bed Pad
Disposable
Adult Diapers
Physiotherapy
Management

1. Bladder Training with Timed Voiding

• The patient keeps a voiding diary of all

episodes of urination and leaking, and the
physician analyzes the chart and identifies
the pattern of urination.
• The patient uses this timetable to plan
when to empty the bladder to avoid
accidental leakage.

• In bladder training, biofeedback and Kegel

exercise help the patient resist the
sensation of urgency, postpone urination,
and urinate according to the timetable.
• Such measures involve the imposition of a
regime of micturation by the clock with
increasing gaps between voids.

• To be successful, in demands a high

degree of patient compliance as well as
expert supervision.
2. Kegel exercises

• Kegel exercises strengthen the pelvic floor

muscles to help improve bladder control
for people suffering from urinary
incontinence.

• The name of the muscle group

strengthened through Kegel exercises is
the pubococcygeous muscle group.
• These muscles relax under your
command, to control the opening and
closing of your urethral sphincter: in other
words, they are the muscles that give you
urinary control.

• When they are weak, leakage occurs.

Through regular exercise, however, you
can build up their strength and endurance
and, in many cases, regain control.
• The first step is to properly identify the
muscle group to be exercised.

a. As you begin urinating, try to stop the

flow of urine without tensing the muscles
of your legs. It is very important not to
use these other muscles, because only
the pelvic floor muscles help with bladder
control.
b. When you are able to slow or stop the
stream of urine you have located the
correct muscles. Feel the sensation of
the muscles pulling inward and upward.
• Helpful hint . . . If you squeeze the rectal
area as if not to pass gas, you will be
using the correct muscles.

• Now you are ready to begin exercising

regularly.

• Once you have located the correct

muscle, set aside two times each day for
exercising.
• Set 1: Quick Contractions (QC) -- tighten
and relax the sphincter muscle as rapidly
as you can.

• Set 2: Slow Contractions (SC) -- contract

the sphincter muscle and hold to a count
of 3 (gradually work at increasing the
count to 10). Make sure you relax
completely between contractions.
• In the beginning you should check yourself
frequently by placing a hand over your
abdomen and buttocks during your
exercises.

• You should not feel the muscles of your

abdomen, buttocks, or thighs tighten. If
there is movement of these muscles you
should continue experimenting until you
are able to isolate the pelvic floor muscles.
• You should see improvement of your
bladder control in 3 to 6 weeks. Keep a
record of urine leakage to monitor your
progress.

• Make pelvic exercises a part of your daily

routine.

• Use daily routines such as watching TV,

reading, waiting at stoplights and waiting
in the grocery store checkout line as cues
to perform a few exercises.
 REFERENCES
• www.urologychannel.com

• www.surgeryencyclopedia.com

• Susan B O’Sullivan
 By:
Dr. Suketu Shah

Content Owner –
www.findphysio.com

Srinivas College Of Physiotherapy

Thank you