Bladder Voiding Disorder Urinary Dysfunction

What Are Bladder Voiding Disorders?

The characteristic of the clinical picture of bladder emptying disorder is urinary retention, i.e., the inability to urinate. The patient loses the feeling for the degree of filling of the bladder, and the functional capacity of the bladder muscle decreases. Therefore, incomplete bladder emptying occurs, and residual urine remains in the bladder. The bladder emptying disorders arise due to defective communication between the brain and the bladder.

Typically, adults excrete about 1-2l of urine daily, depending on the amount of fluid they drink—nerves control bladder emptying in the spinal cord. The bladder consists of three muscle layers, which form the "detrusor," responsible for contracting during urination. From a bladder filling of about 250ml, a stretching signal is sent out, which triggers the bladder's reflexive emptying. During micturition, only the external sphincter on the urethra can be controlled voluntarily; the other processes cannot be influenced consciously.

Which Bladder Voiding Disorders Are Known?

A distinction is made between an acute and a chronic clinical picture. Acute voiding dysfunction is characterized by sudden painful or painless urinary retention lasting more than 24 hours. In this case, bladder catheterization becomes necessary to reduce the volume of urine.

Chronic voiding dysfunction develops unnoticed, and insidiously, a residual amount of urine of at least 50% of the maximum bladder capacity remains in the bladder during urination. The maximum bladder capacity is the filling volume at which the maximum urge to urinate occurs. In men, this is about 400-600ml; in women, 300-400ml. However, these values can vary significantly from person to person and can increase in particular in the case of chronically increased residual urine volume ("bladder leaks").

Initially, the patient notices that micturition is difficult but can achieve complete emptying of the bladder by conscious pressing. In advanced stages of the disease, uncontrolled voiding occurs, and overflow incontinence develops (see: urinary incontinence). The danger of bladder voiding disorders is the threat of secondary damage such as severe urinary tract infections that patients often develop.

The interaction between the bladder and the sphincter muscle is disturbed in this disorder (detrusor-sphincter dyssynergia, DSD). When the volume of urine increases, the urinary bladder's pressure does too, and urine can flow back into the ureters incorrectly. As urine backs up from the full bladder into the ureters and kidneys, long-term kidney damage occurs.

What Are Symptoms of Bladder Voiding Disorders?

Affected patients suffer from abdominal pain when the bladder fills more, which can become very severe. The voiding disorders can occur as:

• Problem with urine retention: increased urge to urinate, loss of urine, frequent urination, or
• As disturbed urination: weak urine stream, delayed onset of micturition, residual urine, abdominal press necessary to assist urination.

As a result of chronic residual urine in the bladder, urinary tract infections and even pyelonephritis occur consistently. Impaired urination can lead to severe kidney damage.

What Causes Bladder Voiding Disorders?

The causes for the development of bladder voiding disorders are manifold. They can be roughly divided into neurological, mechanical, or even psychogenic causes. For example, they often occur after radical surgeries in the small pelvis (cancer surgeries, where damage to or intermediate disturbance of the bladder nerves (pelvic plexus) is unavoidable. This is followed by a disturbing feeling of filling or emptying and disturbed bladder emptying due to loss of mobility of the bladder muscle.

After many years of diabetes mellitus, up to 50% of the patients develop voiding disorder, a so-called "diabetic cystopathy." For this reason, the urinary bladder function of people with diabetes must constantly be monitored as well. Various neurological diseases, such as multiple sclerosis, Parkinson's disease, stroke, herniated disc, etc., are regularly associated with impaired bladder function.

Other risk factors include vaginal surgical delivery, medication use, or chronic alcohol abuse. Mechanical causes are urethral strictures, distinct phimosis, bladder stones, prostate enlargement, or prostate carcinoma.

Diagnosis of Bladder Voiding Disorders

To diagnose bladder voiding disorders, the patient must be questioned in detail by a specialist in urology or neuro-urology about his or her symptoms. The external genital organs, urinary bladder, and renal pelvis are examined during a thorough physical examination. The bladder, kidneys, ureters, and prostate can be assessed in more detail in an ultrasound examination.

A urine examination is also essential in diagnosing, as an acute urinary tract infection must always be excluded. A urodynamic examination, which means bladder pressure measurement, examines the urinary tract's functional processes and allows an assessment of the urinary storage and voiding function. Besides, a cystoscopy may help detect the disease.

Treatment of Bladder Voiding Disorder

The goal of treatment for bladder dysfunction is to restore regular and complete bladder emptying. The method used here depends on the cause of the disease.

In the case of temporary voiding disorders, e.g., after childbirth, parasympathomimetic drugs help very well. These are drugs that stimulate the nervous system that supplies the bladder. Bladder training is also a very successful therapy method, which involves consciously emptying the bladder at least every 4 hours; the patient must take a lot of time and possibly use the abdominal press for complete emptying. The abdominal press is a conscious tightening of the abdominal muscles, which supports emptying the bladder.

In cases of complete micturition incapacity, urinary diversion through a catheter is necessary. If it is possible for the patient, self-catheterization is the best method. Otherwise, permanent diversion with a permanent catheter is available, which is not ideal, however, because a permanent catheter carries a significant risk of urinary tract infections. In some cases, electrical stimulation of the bladder brings back the lost bladder-filling sensation. It makes spontaneous urination possible again, or implantation of a bladder pacemaker can reactivate the bladder muscle.

Sources:

Gynäkologie und Geburtshilfe; Thomas Weyerstahl, Manfred Stauber; Duale Reihe; 4. Auflage, 2013

http://www.glenwood.de/cms/deutsch/erkrankungen/blasenentleerungsstoerungen/ (03.10.2015)

http://www.das-kontinenzzentrum.de/blasenentleerungsstoerungen.html (03.10.2015)