Assessment

HISTORY. Take a full history of urinary voiding, including night/day patterns, amount of urine voided, and number of urinary emptyings per day. Most patients will describe a history of urinary incontinence and changes in the initiation or interruption of urinary voiding. Elicit an accurate description of the sensations during bladder filling and emptying. In patients with spastic neurogenic bladder, expect the patient to describe a history of involuntary or frequent scanty urination without a sensation of bladder fullness. In patients with flaccid neurogenic bladder, expect overflow urinary incontinence. Also ask patients if they have a history of frequent urinary tract infections, a complication that often accompanies neurogenic bladder.

PHYSICAL EXAMINATION. Evaluate the extent of the patient's CNS involvement by performing a complete neurological assessment, including strength and motion of extremities and levels of sensation on the trunk and extremities. With a spastic neurogenic bladder, the patient may have increased anal sphincter tone so that when you touch the abdomen, thigh, or genitalia, the patient may void spontaneously. Often, the patient will have residual urine in the bladder even after voiding. In patients with a flaccid neurogenic bladder, palpate and percuss the bladder to evaluate for a distended bladder; usually, the patient will not sense bladder fullness in spite of large bladder distension because of sensory deficits. In patients with urinary incontinence, evaluate the groin and perineal area for skin irritation and breakdown.

PSYCHOSOCIAL. The patient will likely view neurogenic bladder dysfunction as one more manifestation of an already uncontrollable situation. Anxiety about voiding will be added to the anxiety about the underlying cause of the dysfunction. Urinary incontinence leads to embarrassment over the lack of control and concern over the odor of urine that often can permeate clothing and linens. Patients who perceive that the only alternative is urinary catheterization have concerns about being normally active with a catheter and may also fear sexual dysfunction.

Diagnostic Highlights

Neurogenic Bladder 665

Test

Normal Result

Abnormality with Condition

Explanation

Uroflowmetry Cystometry

>200 mL, 10-20 mL/sec, depending on age

Absence of residual urine; sensation of fullness at 300-500 mL; urge to void at 150-450 mL

Decreased

Varies with type of dysfunction; may have residual urine and lack of sensation or urge to void

Measures completeness and speed of bladder emptying, which are both reduced

Evaluates detrusor muscle function and tonicity; determines etiology of bladder dysfunction; and differentiates among classifications of bladder dysfunction

Other Tests: Urethral pressure profile, urinalysis, excretory urogram, voiding cystourethrogram, cystourethroscopy, electrocyography of pelvic muscles, ultrasound of bladder, serial sampling of urine for bacterial analysis

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