Question

This concept map asks you to organize the pathophysiology of elimination. For urinary dysfunction, include alterations of motility, neuromuscular function, patency, and perfusion. For bowel dysfunction, including motility, neuromuscular function, and patency. You may choose to organize this into more than one map if desired. Please include 1-2 causes for each type of alteration (either from your text or additional sources), a disease process associated with each type of alteration, and include 1-2 examples of treatment for each disease.

Answer 1

Bladder and bowel dysfunction (BBD) describes a spectrum of lower urinary symptoms (LUTS) accompanied by fecal elimination issues that manifest primarily by constipation and/or encopresis. This increasingly common entity is a potential cause of significant physical and psychosocial burden for children and families. BBD is commonly associated with vesicoureteral reflux (VUR) and recurrent urinary tract infections (UTIs), which at its extreme may lead to renal scarring and kidney failure. Additionally, BBD is frequently seen in children diagnosed with behavioural and neuropsychiatric disorders such as attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Patients with concomitant BBD and neuropsychiatric disorders have less favourable treatment outcomes. Early diagnosis and treatment of BBD are critical to avoid secondary comorbidities that can adversely impact children’s kidney and bladder function, and psychosocial well-being. The majority of patients will improve with urotherapy, adequate fluid intake, and constipation treatment. Pharmacological treatment must only be considered if no improvement occurs after intensive adherence to at least six months of urotherapy ± biofeedback and constipation treatment. Anticholinergics remain the mainstay of medical treatment. Selective alpha-blockers appear to be effective for improving bladder emptying in children with non-neurogenic detrusor overactivity (DO), incontinence, recurrent UTIs, and increased post-void residual (PVR) urine volumes. Alpha-1 blockers can also be used in combination with anticholinergics when overactive bladder (OAB) coexists with functional bladder outlet obstruction. Minimally invasive treatment with onabotulinumtoxinA bladder injections, and recently neurostimulation, are promising alternatives for the management of BBD refractory to behavioural and pharmacological treatment.

For the urinary system to do its job, muscles and nerves must work together to hold urine in the bladder and then release it at the right time. Nerves carry messages from the bladder to the brain to let it know when the bladder is full. They also carry messages from the brain to the bladder, telling muscles either to tighten or release. A nerve problem might affect your bladder control if the nerves that are supposed to carry messages between the brain and the bladder do not work properly.

Nerves that work poorly can lead to three different kinds of bladder control problems.
Overactive bladder. Damaged nerves may send signals to the bladder at the wrong time, causing its muscles to squeeze without warning. The symptoms of overactive bladder include

•     urinary frequency—defined as urination eight or more times a day or two or more times at night
•     urinary urgency—the sudden, strong need to urinate immediately
•     urge incontinence—leakage of urine that follows a sudden, strong urge to urinate

Poor control of sphincter muscles. Sphincter muscles surround the urethra and keep it closed to hold urine in the bladder. If the nerves to the sphincter muscles are damaged, the muscles may become loose and allow leakage or stay tight when you are trying to release urine.

Urine retention. For some people, nerve damage means their bladder muscles do not get the message that it is time to release urine or are too weak to completely empty the bladder. If the bladder becomes too full, urine may back up and the increasing pressure may damage the kidneys. Or urine that stays too long may lead to an infection in the kidneys or bladder. Urine retention may also lead to overflow incontinence.

Urinary incontinence is leaking of urine that you can't control. Many American men and women suffer from urinary incontinence. We don't know for sure exactly how many. That's because many people do not tell anyone about their symptoms. They may be embarrassed, or they may think nothing can be done. So they suffer in silence.

Urinary incontinence is not just a medical problem. It can affect emotional, psychological and social life. Many people who have urinary incontinence are afraid to do normal daily activities. They don't want to be too far from a toilet. Urinary incontinence can keep people from enjoying life.

Many people think urinary incontinence is just part of getting older. But it's not. And it can be managed or treated.

Many events or conditions can damage nerves and nerve pathways. Some of the most common causes are

•     normal delivery
•     infections of the brain or spinal cord
•     diabetes
•     stroke
•     accidents that injure the brain or spinal cord
•     multiple sclerosis
•     heavy metal poisoning

In addition, some children are born with nerve problems that can keep the bladder from releasing urine, leading to urinary infections or kidney damage.

Any evaluation for a health problem begins with a medical history and a general physical examination. Your doctor can use this information to narrow down the possible causes for your bladder problem.

If nerve damage is suspected, the doctor may need to test both the bladder itself and the nervous system, including the brain. Three different kinds of tests might be used:

Urodynamics. These tests involve measuring pressure in the bladder while it is being filled to see how much it can hold and then checking to see whether the bladder empties completely and efficiently.

Imaging. The doctor may use different types of equipment—x-rays, magnetic resonance imaging (MRI), and computerized tomography (CT) scans-to take pictures of the urinary tract and nervous system, including the brain.

EEG and EMG. An electroencephalograph (EEG) is a test in which wires with pads are placed on the forehead to sense any dysfunction in the brain. The doctor may also use an electromyograph (EMG), which uses wires with pads placed on the lower abdomen to test the nerves and muscles of the bladder.

The treatment for a bladder control problem depends on the cause of the nerve damage and the type of voiding dysfunction that results.

In the case of overactive bladder, your doctor may suggest a number of strategies, including bladder training, electrical stimulation, drug therapy, and, in severe cases where all other treatments have failed, surgery.

Bladder training. Your doctor may ask you to keep a bladder diary-a record of your fluid intake, trips to the bathroom, and episodes of urine leakage. This record may indicate a pattern and suggest ways to avoid accidents by making a point of using the bathroom at certain times of the day-a practice called timed voiding. As you gain control, you can extend the time between trips to the bathroom. Bladder training also includes Kegel exercises to strengthen the muscles that hold in urine.

Electrical stimulation. Mild electrical pulses can be used to stimulate the nerves that control the bladder and sphincter muscles. Depending on which nerves the doctor plans to treat, these pulses can be given through the genital parts, or by using patches on the skin. Another method is a minor surgical procedure to place the electric wire near the tailbone. This procedure involves two steps. First, the wire is placed under the skin and connected to a temporary stimulator, which you carry with you for several days. If your condition improves during this trial period, then the wire is placed next to the tailbone and attached to a permanent stimulator under your skin. The Food and Drug Administration (FDA) has approved this device, marketed as the InterStim system, to treat urge incontinence, urgency-frequency syndrome, and urinary retention in patients for whom other treatments have not worked.

Drug therapy. Different drugs can affect the nerves and muscles of the urinary tract in different ways.

    Drugs that relax bladder muscles and prevent bladder spasms include oxybutynin chloride (Ditropan), tolterodine (Detrol), hyoscyamine (Levsin), and propantheline bromide (Pro-Banthine), which belong to the class of drugs called anticholinergics. Their most common side effect is dry mouth, although large doses may cause blurred vision, constipation, a faster heartbeat, and flushing. A new patch delivery system for oxybutynin (Oxytrol) may decrease side effects. Ditropan XL and Detrol LA are timed-release formulations that deliver a low level of the drug continuously in the body. These drugs have the advantage of once-a-day administration. In 2004, the FDA approved trospium chloride (Sanctura), darifenacin (Enablex), and solifenacin succinate (VESIcare) for the treatment of overactive bladder.
    Drugs for depression that also relax bladder muscles include imipramine hydrochloride (Tofranil), a tricyclic antidepressant. Side effects may include fatigue, dry mouth, dizziness, blurred vision, nausea, and insomnia.

Additional drugs are being evaluated for the treatment of overactive bladder and may soon receive FDA approval.

Surgery. In extreme cases, when incontinence is severe and other treatments have failed, surgery may be considered. The bladder may be made larger through an operation known as augmentation cystoplasty, in which a part of the diseased bladder is replaced with a section taken from the patient's bowel. This operation may improve the ability to store urine but may make the bladder more difficult to empty, making regular catheterization necessary. Additional risks of surgery include the bladder breaking open and leaking urine into the body, bladder stones, mucus in the bladder, and infection.

Kegel exercises strengthen the muscles that hold up the bladder and keep it closed.

The first step in doing Kegel exercises is to find the right muscles. Imagine you are trying to stop yourself from passing gas. Squeeze the muscles you would use. If you sense a "pulling" feeling, those are the right muscles for pelvic exercises.

Try not to squeeze other muscles at the same time. Be careful not to tighten your stomach, legs, or buttocks. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Just squeeze the pelvic muscles. Don't hold your breath.

At first, find a quiet spot to practice-your bathroom or bedroom-so you can concentrate. Pull in the pelvic muscles and hold for a count of 3. Then relax for a count of 3. Repeat, but don't overdo it. Work up to 3 sets of 10 repeats. Start doing your pelvic muscle exercises lying down. This position is the easiest because the muscles do not need to work against gravity. When your muscles get stronger, do your exercises sitting or standing. Working against gravity is like adding more weight.

Be patient. Don't give up. It takes just 5 minutes a day. You may not feel your bladder control improve for 3 to 6 weeks. Still, most people do notice an improvement after a few weeks.

Some people with nerve damage cannot tell whether they are doing Kegel exercises correctly. If you are not sure, ask your doctor or nurse to examine you while you try to do them. If you are not squeezing the right muscles, you can still learn proper Kegel exercises by doing special training with biofeedback, electrical stimulation, or both.

Urine retention may occur either because the bladder wall muscles cannot contract or because the sphincter muscles cannot relax.

Catheter. A catheter is a thin tube that can be inserted through the urethra into the bladder to allow urine to flow into a collection bag. If you are able to place the catheter yourself, you can learn to carry out the procedure at regular intervals, a practice called clean intermittent catheterization. Some patients cannot place their own catheters because nerve damage affects their hand coordination as well as their voiding function. These patients need to have a caregiver place the catheter for them at regular intervals. If regular catheter placement is not feasible, the patients may need to have an indwelling catheter that can be changed less often. Indwelling catheters have several risks, including infection, bladder stones, and bladder tumors. However, if the bladder cannot be emptied any other way, then the catheter is the only way to stop the buildup of urine in the bladder that can damage the kidneys.

Urethral stent. Stents are small tube-like devices inserted into the urethra and allowed to expand, like a spring, widening the opening for urine to flow out. Stents can help prevent urine backup when the bladder wall and sphincter contract at the same time because of improper nerve signals. However, stents can cause problems if they move or lead to infection.

Surgery. Men may consider a surgery that removes the external sphincter-a sphincterotomy-or a piece of it-a sphincter resection-to prevent urinary retention. The surgeon will pass a thin instrument through the urethra to deliver electrical or laser energy that burns away sphincter tissue. Possible complications include bleeding that requires a transfusion and, rarely, problems with erections. This procedure causes loss of urine control and requires the patient to collect urine by wearing an external catheter that fits over the penis like a condom. No external collection device is available for women.

Urinary diversion. If other treatments fail and urine regularly backs up and damages the kidneys, the doctor may recommend a urinary diversion, a procedure that may require an outside collection bag attached to a stoma, a surgically created opening where urine passes out of the body. Another form of urinary diversion replaces the bladder with a continent urinary reservoir, an internal pouch made from sections of the bowel or other tissue. This method allows the person to store urine inside the body until a catheter is used to empty it through a stoma.