1, classification of neurogenic bladder
Urinary disorders caused after spinal cord injury are the main clinical manifestations of neurogenic bladder. Depending on the location and degree of post-injury, the type of neurogenic bladder is different, and in the past, our country’s neurogenic bladder, basically according to Nesbit’s classification method, namely
1) reflex bladder ;
2) autonomic bladder;
3) Uninhibited bladder;
4) Sensory nerve palsy bladder;
5) motor nerve palsy bladder. This classification is more difficult to apply in practice.
Bors called the voiding disorder caused by lesions above the spinal urinary center (sacral 2-4) as upper motor neuron bladder, where the conus and sacral 2-4 nerve roots or cauda equina are not damaged and the reflex arc through the pelvic vegetative and pubic nerves is intact; the voiding disorder caused by lesions of the spinal urinary center itself or its peripheral nerves (including parasympathetic and somatic nerves) is called lower motor neuron bladder, where the above reflex arc is absent or diminished.
Each of these two types of neurogenic bladder is classified as complete or incomplete, depending on the degree of damage. Complete upper motor neuron bladder corresponds to reflex bladder, while complete and incomplete lower motor neuron bladder corresponds to autoregulatory bladder. Therefore, for patients who identify the site of their lesion, combined with clinical manifestations, conclusions can be drawn without error and can be used as a basis for treatment.
2.Functional rehabilitation training of neurogenic bladder
The ultimate goal of neurogenic bladder treatment for SCI patients is to establish an autonomous urinary rhythm as soon as possible, without or with less catheterization, eliminating the need to carry a urinary bag and improving the quality of life of patients as much as possible. the process of urinary rehabilitation for SCI patients consists of three stages: indwelling catheterization, primary catheterization and the establishment of a reflex bladder, and finally the establishment of a reflex bladder through training. Therefore, functional rehabilitation of the bladder occupies an important position.
The functional rehabilitation of the neurogenic bladder currently uses manual training: that is, when the bladder is full and the bottom of the bladder reaches two fingers above the umbilicus, manual massage for urination can be performed. The operator uses one hand to massage the patient’s lower abdomen from the outside to the inside, with even force, from light to heavy, when the bladder shrinks into a ball, one hand should hold the bottom of the bladder and squeeze the bladder forward and down. After urination, the operator will put the left hand on the back of the right hand to pressurize the urine, and when the urine no longer flows out, release the hand and pressurize again, trying to drain. For patients with urinary incontinence, the force should be slightly greater and directed toward the perineum; for patients with spastic paralysis, the massage time is about 15 min and the technique should be light.
In 1992, Menon et al. proposed a new method of neurogenic bladder function retraining with suprapubic tapping every 4 h, followed by catheterization. Some authors applied this method to a group of 55 patients with SCI who underwent bladder retraining with catheterization and medication, and 45 (82%) of them achieved voluntary voiding after discharge. However, in 1993, Zhou Guochang et al. found that percussion of the bladder could induce autonomic over-reflex in patients with high-grade SCI, and suggested that SCI patients should look for trigger points on both sides of the lower abdomen when performing bladder function rehabilitation, (using the skin-bladder reflex to stimulate the patient’s inner thigh, penile corpora or perineum to find the site that causes voiding action) to establish a reflex bladder.
In 1995, Zhan Shaoli et al. reported clinical observations of the application of physiotherapy methods for bladder function rehabilitation training. The results showed that out of 38 cases, 26 patients with incomplete paraplegia, 22 recovered the random bladder, 2 recovered the reflex bladder, and 2 were ineffective. All of them who were ineffective received treatment more than 1.5 years after the injury. Of the 12 cases with total paraplegia and conus injury, 9 were good after treatment and 3 were ineffective. 2 of the 3 ineffective cases were spinal cord or nerve root transection. Therefore, some authors believe that neurogenic bladder after SCI is related to the degree and site of spinal cord injury, and if treated with electrical excitation as early as possible within 2 months after injury, it is beneficial for bladder function recovery and establishment of reflex bladder.
However, rehabilitation of bladder function also has certain indications and contraindications, and Menon et al. concluded that the following conditions must be met before retraining of the bladder can be performed
1) Patient’s bladder capacity and compliance continues for 4h without catheterization;
2) Urine microscopy ≤ 10 WBC/HPF;
3) No fever;
4) no persistent bacteriuria present. according to Perkash, vesicoureteral reflux, stone disease and pre-renal failure are contraindications to bladder retraining. Therefore, it is important to perform urodynamics, nuclear scan, renal ultrasound, cystography, urethrography and intravenous pyelogram before bladder retraining.
3. Care during the rehabilitation period
While rehabilitating the neurogenic bladder, it is equally important to know how to perform proper bladder care.
1) Continuous drainage For patients with indwelling catheterization, the traditional method is to leave it open at the very beginning to keep the bladder empty and to avoid overstretching and fatigue of the detrusor muscle in a tension-free state. Usually the catheter is clamped after 1 to 2 weeks and opened every 3 to 4 h to facilitate the maintenance of a certain bladder volume and prevent contractures. The urinary catheter is changed every 1 to 2 weeks and the bladder is flushed with 1:5000 furacilin solution once or twice a day. 1995 Zhu Jianying et al, proposed a treatment method of continuous drainage in which the indwelling urinary catheter is clamped closed on the next day and urine is released every 2h for infusion and every 4h for non-infusion, without changing the urinary catheter or flushing the bladder during the indwelling period, and the urinary catheter is removed after 3 weeks. The authors applied this method compared to the traditional method and the infection rate was 19.35%, which was significantly lower than the 85.29% in the traditional group. Therefore, the authors concluded that this improved nursing method, which significantly reduced the rate of urinary tract infection and followed the developmental pattern of neurogenic bladder formation, is an easy, effective and feasible nursing method for early urinary tract management in patients with paraplegia due to spinal cord injury.
(2) Intermittent catheterization (IC) This method was first proposed by Stromeyer in 1844, who recommended that urine could be removed from the bladder by periodic flushing, and Guttmann proposed aseptic intermittent catheterization for SCI patients. He argued that IC allows the patient to remain relatively uncatheterized in order to stimulate recovery of bladder function by periodic bladder dilation. In a study of a group of cases, the authors found that 77% of patients were discharged from the hospital free of catheters and that most patients were intra-urinary sterile.Bennett et al. analyzed the results of bladder treatment in 70 women with SCI and concluded that IC was the best option.
As a result, it is now the most common method of bladder management in patients with acute and chronic SCI. Catheterization is performed every 2 to 4 h without indwelling catheters. A slightly thinner catheter is preferred for catheterization, and a sufficient amount of paraffin oil must lubricate the tube during insertion to avoid damage to the urethra or edema of the urethral mucosa due to repeated intubation. Patients are instructed to urinate on their own between intubations, while other methods are used to stimulate urination, such as tapping on the suprapubic area and patting the thighs. Fang Yumei et al. explored intermittent catheterization positions in SCI patients, and the results suggested that the better catheterization position to empty the urine in the bladder is the lateral position, and concluded that the lateral position can reduce pain and discomfort in patients undergoing abdominal and iliac surgery, is convenient for patients, reduces embarrassment and anxiety in female patients, and is suitable for all types of bladders.