Urinary Elimination: Catheters, Bladder Training, Incontinence & UTIs

Home Self-Catheterization vs. Hospital Technique

• • Patients with spinal cord injuries or neurologic disorders often perform intermittent self-catheterization at home.
  • ◦ Home setting → allegedly ↓ cross-contamination risk compared with hospital environment.
• • In hospital: strict surgical asepsis is required to minimize hospital-acquired infections (HAIs).
• • Cost issues: some patients re-use single-use catheters → ↑ infection risk (educate on single use & replacement frequency).

Bladder Training & Catheter Clamping

• • Purpose: strengthen detrusor & peri-urethral muscles before catheter removal.
• • Ordered “clamp / unclamp” schedule:
  • ◦ Doctor specifies on/off intervals (e.g., clamp 2 h, unclamp 30 min) to restore tone.
  • ◦ Gradual lengthening of clamped time encourages bladder filling & contraction.
• • Evaluate post-removal voiding; many patients struggle if tone not re-established.

Pelvic-Floor (Kegel) Exercises

• • Indication: stress incontinence, post-partum, post-catheter removal.
• • Technique teaching:
  • ◦ Identify correct muscle by attempting to stop mid-stream; if only dribbling stops → incorrect.
  • ◦ Tighten perineal muscles 10\,\text{s} → relax 10\,\text{s}.
  • ◦ Start with 10 reps/session, build to 20 reps.
  • ◦ Frequency: ≥ 4 sessions/day.
  • ◦ Mastery & continence control may take 4{-}6 weeks.

Scheduled Voiding

• • Establish individualized schedule (often q2h) for:
  • ◦ Hospitalized pts, LTC residents, cognitive/functional limitations.
• • After several days:
  • ◦ Evaluate continence; adjust schedule, fluid timing, meds that ↑ diuresis (e.g., diuretics, caffeine).

Urinary Retention

• • Definition: inability to empty bladder despite urge → pooled urine.
• • Complications: stasis → infection, bladder distension, overflow incontinence.
• • Forms:
  • ◦ Acute: complete inability to void.
  • ◦ Chronic: incomplete emptying, high post-void residual (PVR).
• • Causes: neuro disorders, meds (e.g., diphenhydramine), tumors, obstruction.

Incontinence: Types & Mechanisms

• • Stress: sneeze/cough/laugh ↑ intra-abdominal pressure → leakage.
• • Urge: sudden strong urge → involuntary loss (Parkinson, Alzheimer).
• • Overflow: bladder over-filled → dribbling/“spillover.”
• • Mixed: combination stress + urge.
• • Functional: external factors (arthritis, confusion) hinder timely toileting.

Management of Incontinence

• • Non-surgical
  • ◦ Fluid modulation (adequate but ↓ evening intake).
  • ◦ Avoid bladder irritants: caffeine, alcohol, spicy foods, chocolate, carbonated sodas.
  • ◦ Bladder training (void q2h), Kegels, scheduled prompts.
  • ◦ Absorbent pads/undergarments (various absorbencies; mail delivery for privacy).
  • ◦ Medications: anticholinergics (oxybutynin transdermal), topical estrogen, mirabegron.
  • ◦ Bulking injections around urethra; intradetrusor Botox → ↑ tone, ↓ OAB symptoms.
• • Surgical
  • ◦ Sling procedure (U-shaped support under urethra).
  • ◦ Pessary for uterine prolapse-related pressure.
  • ◦ Diversions (indwelling catheter, suprapubic tube) when conservative fails.

Neurogenic Bladder

• • Loss of voluntary control due to nervous-system lesion.
  • ◦ Congenital: spina bifida.
  • ◦ Disease: MS, diabetes.
  • ◦ Trauma: spinal cord injury.
• • Types
  • ◦ Spastic (upper motor neuron): reflex emptying, no conscious control.
  • ◦ Flaccid (lower motor neuron): over-distended, large residual, absent sensation.
• • Diagnostics: bladder scan (no order needed), urodynamics, cystoscopy, CT/MRI.
• • Management
  • ◦ Scheduled voiding q2h.
  • ◦ Intermittent/self-catheterization; measure residuals.
  • ◦ Meds: anticholinergics (↓ urgency), cholinergics (bethanechol) to stimulate contraction in flaccid type, botulinum toxin.
  • ◦ Sacral nerve stimulation implant.
  • ◦ Teach signs of distension; distended bladder = urgent evaluation.

Catheter Types & Care

• • Foley (indwelling) standard.
• • Coude catheter: curved tip for prostatic obstruction (male BPH).
• • Suprapubic catheter: surgically inserted above symphysis; use T-gauze, monitor site for infection, avoid fraying gauze.
• • Specimen collection from Foley:
  • ◦ Clamp tubing 30 min.
  • ◦ Scrub port with antiseptic.
  • ◦ Aspirate 10{-}30 mL using sterile syringe.
  • ◦ Unclamp; send to lab within 10 min.

Urinary Tract Infection (UTI)

• • Pathogens: bacteria > viruses/fungi; \textit{E. coli} most common (poor perineal hygiene, front-to-back wiping).
• • Risk factors: catheterization, diaphragm/condom use, urine retention, diabetes, MS, SCI, HTN, renal disease, immunosuppressants.
• • S/S lower UTI: dysuria (burning), frequency, urgency.
• • Upper tract (pyelonephritis): flank/low back pain, fever, malaise.
• • Diagnostics: UA, C&S.
• • Pharmacology
  • ◦ Uncomplicated: 3-day Bactrim (TMP-SMX) or ciprofloxacin.
  • ◦ Complicated/recurrent: 7{-}10 days amoxicillin, ampicillin, nitrofurantoin, levofloxacin.
  • ◦ Phenazopyridine (OTC Azo) for analgesia → bright orange urine (harmless; teach).
  • ◦ Complete full course even if symptoms resolve 24{-}48 h.
• • Hydration: \ge 2000\,\text{mL/day} (≈ 30\,\text{mL/kg}) unless contraindicated.
• • Prevention: wipe front→back, void after intercourse, avoid holding urine, avoid irritants.
• • Complication: Urosepsis → sepsis (HR ↑, BP ↓, Temp ↑ or ↓, altered mentation) — medical emergency.

Diagnostic / Imaging Studies (Quick Review)

• • KUB (Kidney-Ureter-Bladder x-ray): size, shape, position of urinary organs.
• • IVP (Intravenous Pyelogram): iodine dye; prep includes bowel prep, check iodine/seafood allergy; expect hot flash.
• • Voiding cystourethrogram (VCUG): catheter inserted; dye fills lower tract; images during voiding.
• • Cystoscopy: lithotomy position.

Diuretics & Lab Monitoring (bonus pharmacology discussion)

• • Thiazides (e.g., hydrochlorothiazide) act on distal convoluted tubule → impair Na^+ /Cl^- reabsorption.
• • Potassium-sparing (spironolactone) inhibit Na^+ reabsorption & K^+ secretion in distal tubule.
• • Labs: monitor electrolytes; hold dose if K^+ elevated.

General Nursing Education Points

• • Encourage reporting of new incontinence, urgency, burning, suprapubic pain.
• • Teach sepsis signs (↑HR, ↓BP, chills, fever/low temp) & seek care promptly.
• • Remind healthcare staff: nurses often neglect own care → avoid delaying treatment.