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What part of the brain controls the urge to urinate?

the pons The mechanical process of urination is coordinated by the pons in the area known as the pontine micturition center (PMC). The conscious sensations associated with bladder activity are transmitted to the pons from the cerebral cortex.

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Medical Care

Treatment of urinary incontinence varies by type, as follows:

Stress incontinence may be treated with surgical and some non-surgical approaches

Urge incontinence may be treated with behavioral modification, pharmacotherapy, or third-line procedures

Mixed incontinence may require medications as well as surgery

Overflow incontinence is generally treated by emptying the bladder with a catheter

Other forms of incontinence may be resolved by treating the underlying cause (eg, urinary tract infection, constipation) Do not consider anti-incontinence products to be a cure-all for urinary incontinence; however, judicious use of pads and devices to contain urine loss and maintain skin integrity are extremely useful in selected cases. Absorbent pads and internal and external collecting devices have an important role in the management of chronic incontinence. The criteria for use of these products are fairly straightforward, and they are beneficial in certain situations:

Failure of all other treatments and persistent incontinence

Illness or disability that prevents participation in care

Inability to benefit from medications

Incontinence disorders that cannot be corrected by surgery

Awaiting surgery

Absorbent products

Absorbent products are pads or garments designed to absorb urine to protect the skin and clothing. Available in both disposable and reusable forms, they are a temporary means of keeping the patient dry until a more permanent solution becomes available. By reducing wetness and odor, they help maintain the patient's comfort and allow them to function in normal activities. They may be used temporarily until a definitive treatment takes effect or if the treatment yields less-than-perfect results. Absorbent products are helpful during the initial assessment and workup of urinary incontinence. As an adjunct to behavioral and pharmacologic therapies, they play an important role in the care of persons with intractable incontinence. Do not use absorbent products instead of definitive interventions to decrease or eliminate urinary incontinence. Early dependency on absorbent pads may be a deterrent to achieving continence, providing the wearer a false sense of security. The improper use of absorbent products may contribute to skin breakdown and urinary tract infections. Thus, appropriate use, meticulous care, and frequent pad or garment changes are needed when absorbent products are used.

Catheters

Urinary diversion, using various catheters, has been one of the mainstays of anti-incontinence therapy. The use of catheters for bladder drainage has withstood the test of time. Bladder catheterization may be a temporary measure or a permanent solution for urinary incontinence. Different types of bladder catheterization include indwelling urethral catheters, suprapubic tubes, and self-intermittent catheterization. [3]

Indwelling urethral catheters

Commonly known as Foley catheters, indwelling urethral catheters historically have been the mainstay of treatment for bladder dysfunction. If urethral catheters are used for a long-term condition, they must be changed at least monthly. These catheters may be changed at an office, a clinic, or at home by a visiting nurse. The standard catheter size for treating urinary retention is 16F or 18F, with a balloon filled to 10 mL of sterile water. Larger catheters (eg, 22F, 24F) with bigger balloons are used for treating grossly bloody urine found in other urologic conditions or diseases. Proper management of indwelling urethral catheters varies per individual. The usual practice is to replace indwelling catheters and collection bags at least once monthly. However, catheters that develop encrustations and problems with urine drainage must be changed more frequently. All indwelling catheters that remain in the urinary bladder for more than 2 weeks become colonized with bacteria. Bacterial colonization does not mean the patient has clinical bladder infection. Symptoms of bladder infection include foul odor, purulent urine, and hematuria. Fever with flank pain often is present if upper tracts are involved. If bladder infection occurs, change the entire catheter and the drainage system. The urinary drainage bag does not need to be disinfected to prevent infection. Routine irrigation of catheters is not required. However, some authors favor the use of 0.25% acetic acid irrigation because it is bacteriostatic, minimizes catheter encrustation, and diminishes the odor. When this method is used, 30 mL is instilled into the bladder and allowed to freely drain on a twice-daily basis. Continuous antibiotic prophylaxis is not only unnecessary for patients with indwelling catheters, it is contraindicated, because it promotes the generation of bacteria that are resistant to common antibiotics. Use of an indwelling Foley catheter in individuals who are homebound requires close supervision by a visiting nurse and additional personal hygiene care. In spite of its apparent advantages, the use of a Foley catheter for a prolonged period of time (eg, months to years) is strongly discouraged. Long-term use of urethral catheters poses significant health hazards. Indwelling urethral catheters are a significant cause of urinary tract infections that involve the urethra, bladder, and kidneys. Within 2-4 weeks after catheter insertion, bacteria will be present in the bladder of most women. Asymptomatic bacterial colonization is common and does not pose a health hazard. However, untreated symptomatic urinary tract infections may lead to urosepsis and death. The death rate of nursing home residents with urethral catheters has been found to be three times higher than that of residents without catheters; this may be more a reflection of the severity of comorbid conditions that lead to the clinical decision to use chronic bladder drainage than causation from the use of chronic bladder drainage. [4] The use of a urethral catheter is contraindicated in the treatment of urge incontinence. Other problems associated with indwelling urethral catheters include encrustation of the catheter, bladder spasms resulting in urinary leakage, hematuria, and urethritis. More severe complications include formation of bladder stones, development of periurethral abscess, renal damage, and urethral erosion. Another problem of long-term catheterization is bladder contracture, which occurs with urethral catheters as well as suprapubic tubes. Anticholinergic therapy (for patients with significant detrusor hyperreflexia) and intermittent clamping of the catheter in combination have been reported to be beneficial for preserving the bladder integrity with long-term catheter use. [5] Individuals who did not use the medication and daily clamping regimen experienced a decrease in bladder capacity. For this reason, some physicians recommend using anticholinergic medications with intermittent clamping of the catheter if lower urinary tract reconstruction is anticipated in the future.

Restrict the use of indwelling catheters to the following situations:

As comfort measures for the terminally ill

To avoid contamination or to promote healing of severe pressure sores

In cases of inoperable urethral obstruction that prevents bladder emptying

In individuals who are severely impaired and for whom alternative interventions are not an option When an individual lives alone and a caregiver is unavailable to provide other supportive measures

For acutely ill patients who require accurate monitoring of fluid balance

For severely impaired persons for whom bed and clothing changes are painful or disruptive

Suprapubic catheters

A suprapubic tube is an attractive alternative to long-term urethral catheter use. The most common use of a suprapubic catheter is in individuals with spinal cord injuries and a malfunctioning bladder. Both paraplegic and quadriplegic individuals have benefited from this form of urinary diversion. When suprapubic tubes are needed, usually smaller (eg, 14F, 16F) catheters are placed. [6] Like the urethral catheter, suprapubic tubes should be changed once a month on a regular basis. Suprapubic catheters have many advantages. With a suprapubic catheter, the risk of urethral damage is eliminated. Multiple voiding trials may be performed without having to remove the catheter. Because the catheter comes out of the lower abdomen rather than the genital area, a suprapubic tube is more patient-friendly. Bladder spasms occur less often because the suprapubic catheter does not irritate the trigone as does the urethral catheter. In addition, suprapubic tubes are more sanitary for the individual, and bladder infections are minimized because the tube is away from the perineum. Suprapubic catheters are changed easily by either a nurse or a doctor. Unlike the urethral catheter, a suprapubic tube is less likely to become dislodged because the exit site is so small. When the tube is removed, the hole in the abdomen quickly seals itself with scar formation.

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Indications for suprapubic catheters include short-term use following gynecologic, urologic, and other types of surgery. Suprapubic catheters may be used whenever the clinical situation requires the use of a bladder drainage device; however, suprapubic catheters are contraindicated in persons with chronic unstable bladders or intrinsic sphincter deficiency because involuntary urine loss is not prevented. A suprapubic tube does not prevent bladder spasms from occurring in unstable bladders nor does it improve the urethral closure mechanism in an incompetent urethra. Potential complications of long-term suprapubic catheterization are similar to those associated with indwelling urethral catheters, including leakage around the catheter, bladder stone formation, urinary tract infection, and catheter obstruction. During the initial placement of a suprapubic tube, a potential for bowel injury exists. Although uncommon, bowel perforation is known to occur with first-time placement of suprapubic tubes. Other potential complications include cellulitis around the tube site and hematoma. If the suprapubic tube falls out inadvertently, the exit hole of the tube will seal up and close quickly within 24 hours if the tube is not replaced with a new one. If tube dislodgment is recognized promptly, a new tube can be reinserted quickly and painlessly as long as the tube site remains patent. A suprapubic catheter is an alternative solution to an indwelling urethral catheter in patients who require long-term bladder drainage. Potential problems unique to suprapubic catheters include skin infection, hematoma, bowel injury, and problems with catheter reinsertion. Long-term management of a suprapubic tube also may be problematic if the healthcare provider lacks the knowledge and expertise of suprapubic catheter management or if the homebound individual lacks quick access to a medical center in case of an emergency. Nevertheless, in the appropriate situation, the suprapubic catheter affords many advantages over long-term urethral catheters.

Intermittent catheterization

Intermittent catheterization or self-catheterization is a mode of draining the bladder at timed intervals, as opposed to continuous bladder drainage. A prerequisite for self-catheterization is patients' ability to use their hands and arms; however, in a situation in which a patient is physically or mentally impaired, a caregiver or health professional can perform intermittent catheterization for the patient. Of all 3 possible options (ie, urethral catheter, suprapubic tube, intermittent catheterization), intermittent catheterization is the best solution for bladder decompression of motivated individuals who can physically and cognitively participate in their care. Many studies of young patients with spinal cord injuries have shown that intermittent catheterization is preferable to indwelling catheters (ie, urethral catheter, suprapubic tube) for both men and women. Intermittent catheterization has become a healthy alternative to indwelling catheters for individuals with chronic urinary retention due to an obstructed, weak, or nonfunctioning bladder. Young children with myelomeningocele have also benefited from the use of intermittent catheterization. For those children, antibiotic prophylaxis (low-dose chemoprophylaxis) has commonly been prescribed for urinary tract infections. A study by Zegers et al found that this practice can be safely discontinued, especially in boys, patients with low urinary tract infection rates, and patients without vesicoureteral reflux. [7] Intermittent catheterization may be performed using a soft, red, rubber catheter or a short, rigid, plastic catheter. Plastic catheters are preferable to red rubber catheters because they are easier to clean and last longer. The bladder must be drained on a regular basis, either based on a timed interval (eg, on awakening, every 3-6 hours during the day, and before bed) or based on bladder volume. Remember that the average adult bladder holds approximately 400-500 mL of urine. Ideally, the amount drained each time should not exceed 400-500 mL. This drainage limit may require decreasing the patient's fluid intake or increasing the frequency of catheterizations. For example, if catheterization is performed every 6 hours and the amount drained is 700 mL, increase the frequency of catheterization to, perhaps, every 4 hours to maintain the volume drained at 400-500 mL. Intermittent catheterization is designed to simulate normal voiding. Usually, the average adult empties the bladder four to five times a day. Thus, catheterization should be done four to five times a day; however, individual catheterization schedules may vary, depending on the amount of fluid taken in during the day. Candidates for intermittent catheterization must have motivation and intact physical and cognitive abilities. Anyone with good manual dexterity and an accessible urethra, including young children and older adults, can perform self-catheterization every day without problems. For individuals who are unable to self-catheterize, a home caregiver or a visiting nurse can be instructed to perform intermittent catheterization. Self-catheterization may be performed almost anywhere, including at home and at work. Intermittent catheterization may be performed using either a sterile catheter or a nonsterile clean catheter. Intermittent catheterization, using a clean technique, is recommended for young individuals with a bladder that cannot empty and without any other available options. Patients should wash their hands with soap and water. Sterile gloves are not necessary. Clean intermittent catheterization results in lower rates of infection than the rates noted with indwelling catheters. Studies show that in patients with spinal cord injuries, the incidence of bacteria in the bladder is 1-3% per catheterization, and one to four episodes of bacteriuria occur per 100 days of intermittent catheterization performed four times a day. Furthermore, the infections that do occur usually are managed without complications. In general, routine use of long-term suppressive therapy with antibiotics in patients regularly using clean intermittent catheterization is not recommended, because it may result in the emergence of resistant bacterial strains. A study of a patients with acute spinal cord injury at 15 North American centers revealed that using a hydrophilic-coated catheter for intermittent catheterization delayed the onset of first antibiotic-treated symptomatic urinary tract infections. In addition, a reduction in incidence of symptomatic urinary tract infection was noted during inpatient rehabilitation for these patients. [8] For older individuals and those with a weak immune system, the use of sterile technique for intermittent catheterization has been recommended. Older persons are at higher risk than younger persons for developing bacteriuria and other complications of intermittent catheterization because they do not have a strong defense system against infection. Although the incidence of infection and other complications for older patients using sterile versus clean intermittent catheterization is not well established, sterile intermittent catheterization appears to be the safest method for this high-risk population. Potential advantages of performing intermittent catheterization include patient autonomy, freedom from indwelling catheter and bags, and unimpeded sexual relations. Potential complications of intermittent catheterization include bladder infection, urethral trauma, urethral inflammation, and stricture. Concurrent use of anticholinergic therapy will maintain acceptable intravesical pressures and prevent bladder contracture. Studies have demonstrated that long-term use of intermittent catheterization appears to be preferable to indwelling catheterization (ie, urethral catheter, suprapubic tube) with respect to urinary tract infections and the development of stones within the bladder or kidneys. Overall, the management of infections in the setting of catheters and drainage tubes is challenging. Experimental use of bacterial interference (bladder colonization with low-virulence bacteria, such as Escherichia coli HU2117) represents a novel and perhaps effective method at the prevention of infections; however, at the present time, it is difficult to do clinically outside of the research setting. Further studies may prove this modality more clinically useful in practice environments. [9, 10]

Surgical Care

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Surgical care for stress incontinence involves procedures that increase urethral outlet resistance, which include the following: Surgical care for urge incontinence involves procedures that improve bladder compliance or bladder capacity, which include the following:

Sacral neuromodulation

Botulinum toxin injections [11, 12]

Bladder augmentation

The US Food and Drug Administration (FDA) has approved botulinum toxin A for neurogenic detrusor overactivity in adults who have an inadequate response to or are intolerant of an anticholinergic drug. However, a Cochrane review that included four randomized controlled trials of botulinum A toxin injection as a treatment for detrusor-sphincter dyssynergia (DSD) found that intraurethral injections might improve some urodynamic measures after 30 days, but the studies had a high risk of bias, the quality of the evidence was limited, and the need for reinjection is a significant drawback. The authors advised that more study of effectiveness needed; optimal dose and mode of injection remain to be determined, and sphincterotomy might be a more effective option for long-term treatment. [13]

Fluid Intake

The quantity and quality of fluids consumed will influence urinary voiding symptoms. Fluids refer to all the beverages a person consumes in a day, including water, soda, and milk. The human body receives water from beverages consumed and from food eaten. The recommended amount of fluids consumed (all types) in 24 hours totals 6-8 glasses. The benefits of adequate fluid intake include prevention of dehydration, constipation, urinary tract infection, and kidney stone formation. Some patients tend to drink water excessively. Others take medication that makes their mouths dry, so they drink more water. Some patients who are trying to lose weight are on a diet that requires consuming abundant amounts of water. Excessive water intake worsens irritative bladder symptoms. The exact amount of fluid needed per day is calculated on the basis of the patient's lean body mass. Thus, the amount of fluid requirement will vary per individual. Some older patients do not drink enough fluids to keep themselves well hydrated. They minimize their fluid intake to unacceptable levels, thinking that if they drink less, they will experience less incontinence. Trying to prevent incontinence by restricting fluids excessively may lead to bladder irritation and actually worsen urge incontinence. In addition, dehydration contributes to constipation. If a patient has a problem with constipation, recommend eating a high-fiber diet, receiving adequate hydration, and administering laxatives. Many drinks contain caffeine. Caffeine is a natural diuretic, and it has a direct excitatory effect on bladder smooth muscle. Thus, caffeine-containing products produce excessive urine and exacerbate symptoms of urinary frequency and urgency. Caffeine-containing products include coffee, tea, hot chocolate, and sodas. Even chocolate milk and many over-the-counter medications contain caffeine. Of caffeine-containing products, coffee contains the most caffeine. Drip coffee contains the most caffeine, followed by percolated coffee and then instant coffee. Even decaffeinated coffee contains a small amount of caffeine. Decaffeinated coffee contains an amount of caffeine similar to the amount in chocolate milk. Persons who consume a large amount of caffeine should slowly decrease the amount of caffeine consumed to avoid significant withdrawal responses such as headache and depression. Studies have shown that drinking carbonated beverages, citrus fruits drinks, and acidic juices may worsen irritative voiding or urge symptoms. Consumption of artificial sweeteners also has been theorized to contribute to urge incontinence. Nighttime voiding and incontinence are major problems in the older population. Women who have nocturia more than twice a night or experience nighttime bed-wetting may benefit from fluid restriction and the elimination of caffeine-containing beverages from their diet in the evening. Patients should restrict fluids after dinnertime so they can sleep uninterrupted through the night.

Pelvic floor exercise

Anti-incontinence exercises emphasize rehabilitating and strengthening the pelvic floor muscles that are critical in maintaining urinary continence. Pelvic floor muscles also are known as levator ani muscles because they function to levitate or elevate the pelvic organs into their proper place. When levator muscles weaken and fail, pelvic prolapse and stress incontinence result. An anatomic defect of the levator ani musculature requires physical rehabilitation. If aggressive physical therapy does not work, surgery is warranted. Pelvic floor exercises, sometimes called Kegel exercises, are a rehabilitation technique used to tighten and tone the pelvic floor muscles. Kegel exercises may be performed to eliminate urge incontinence. Contraction of the external urinary sphincter induces reflex bladder relaxation. Pelvic floor muscle rehabilitation may be used to reprogram the urinary bladder to decrease the frequency of incontinence episodes. [14, 15] Individuals who benefit the most from pelvic floor exercises tend to be young, healthy, and able to identify the levator muscles accurately. These rehabilitation exercises may be used for urge incontinence as well as mixed incontinence. For urge incontinence, pelvic floor muscle exercises are used to retrain the bladder. When the patient contracts the external urethral sphincter, the bladder automatically relaxes, so the urge to urinate eventually subsides. Strong contractions of the pelvic floor muscles will suppress bladder contractions. Whenever patients feel urinary urgency, they may try to stop the feeling by contracting the pelvic floor muscles. These steps will provide the patient more time to walk slowly to the bathroom with urinary control. By regularly training the external sphincter, patients can gradually increase the time between urination from 1-3 hours. Patients should begin to see improvement in 3-4 weeks. Thus, this technique may be used for urge symptoms, urge incontinence, and mixed incontinence (stress and urge incontinence). Patients should practice contracting the levator ani muscles immediately before and during situations when leakage may occur. This will condition the external sphincter instinctively to contract with increases in abdominal pressure or when the need to urinate is imminent. This is known as the guarding reflex. When the patient tightens the external urinary sphincter just as a sneeze is about to occur, the involuntary urine loss is thwarted. By squeezing the levator ani muscles when the sense of urgency arises, the sensation of impending bladder contraction will dissipate. By making this maneuver a habit, patients will develop a protective mechanism against stress and urge incontinence. The beneficial effects of pelvic floor muscle exercises alone have been well documented in medical literature. [16] Successful reduction in urinary incontinence has been reported to range from 56-95%. Pelvic floor exercises are effective, even after multiple anti-incontinence surgeries.

Electrical stimulation

Electrical stimulation is an area of active research in treating neurogenic bladder. It has been successfully applied to the genital nerve with overactive bladder and shown to decrease detrusor contractions and improve bladder capacity. [17] Furthermore, this treatment was deemed effective and tolerable by the patients who participated in the study. [18] It remains unclear whether sacral neuromodulation has a role in treating neurogenic detrusor overactivity, but this is an area of ongoing study. [19] Overall, electrical stimulation has notable potential as a treatment for neurogenic bladder.

Stem Cell Therapy

A number of clinical trials (mainly phase I and II) on the effects and safety of stem cell therapy for neurogenic bladder after SCI have shown promising results. However, most were not randomized trials, did not have a control group, and included a small number of patients. High-quality randomized trials are still needed before stem cell therapy can be considered for use in clinical settings. [20]

emedicine.medscape.com - Neurogenic Bladder: Overview, Neuroanatomy, Physiology and ...

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