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anatomy

NEUROGENIC BLADDER AND BLADDER TRAINING TRI DAMIATI P , M.D..Physiatrist Dept.of Physical Medicine and Rehabilitation School of Medicine, Padjadjaran University Dr.Hasan Sadikin General Hospital. anatomy. NORMAL VOIDING PHYSIOLOGY. TWO PHASES THE FILLING ( STORAGE )

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anatomy

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  1. NEUROGENIC BLADDER AND BLADDER TRAININGTRI DAMIATI P , M.D..PhysiatristDept.of Physical Medicine and RehabilitationSchool of Medicine, Padjadjaran UniversityDr.Hasan Sadikin General Hospital

  2. anatomy

  3. NORMAL VOIDING PHYSIOLOGY TWO PHASES THE FILLING ( STORAGE ) OCCURS WHEN A PERSON IS NOT TRYING TO VOID THE EMPTYING ( VOIDING ) OCCURS WHEN A PERSON IS ATTEMPTING TO VOID OR TOLD TO VOID

  4. NORMAL VOIDING PHYSIOLOGY cont… DURING FILLING / STORAGE PHASE SHOULD BE VERY LITTLE RISE IN BLADDER PRESSURE PROGRESSIVE INCREASE IN SYMPATHETIC STIMULATION OF THE BETA RECEPTOR RELAXATION ALPHA RECEPTORS → CONTRACTION OF THE URETHRA

  5. NORMAL VOIDING PHYSIOLOGY cont… DURING FILLING / STORAGE PHASE cont… INHIBITS EXITATORY PARASYMPATHETIC GANGLIONIC TRANSMISSION → SUPRESS BLADDER CONTRACTION PROGRESSIVE INCREASE IN URETHRAL SPHINCTER EMG ACTIVITY

  6. NORMAL VOIDING PHYSIOLOGY cont… VOIDING / EMPTYING PHASE SHOULD BE CESSATION OF URETHRAL SPHINCTER ACTIVITY URETHRAL SPHINCTER PRESSURE DROP FUNNELING OF THE BLADDER NECK

  7. NORMAL VOIDING PHYSIOLOGY cont… VOIDING / EMPTYING PHASE cont… NO LONGER REFLEX INHIBITION TO THE SACRAL MIXTURITION CENTER FROM THE SPHINCTER MECHANISM FOLLOWED BY THE BLADDER CONTRACTION THE URETHRAL SPHINCTER REMAIN OPEN THROUGHOUT VOIDING

  8. NORMAL VOIDING PHYSIOLOGY cont… VOIDING / EMPTYING PHASE cont… SHOULD BE NO RISES IN INTRA ABDOMINAL PRESSURE DURING VOIDING NO POSTVOID RESIDUAL URINE

  9. CLASSIFICATION OF VOIDING DYSFUNCTION WIDE VARIETY OF CLASSIFICATION IDEALLY THE SYSTEM SHOULD DISCRIBE THE TYPE OF NEUROLOGIC LESION CLINICAL SYMPTOMS URODYNAMIC DATA TREATMENT OPTION SINGLE CLASSIFICATION FOCUSING ON ALL THESE FACTOR DOES NOT EXIST

  10. CLASSIFICATION OF VOIDING DYSFUNCTION cont… URODYNAMIC AND FUNCTIONAL CLASSIFICATION INCONTINENCE RETENTION RETENTION AN INCONTINENCE

  11. CLASSIFICATION OF VOIDING DYSFUNCTION cont… INCONTINENCE CAUSED BY BLADDER UNHIBITED CONTRACTING DECREASE CAPACITY LOW COMPLIANCE NORMAL --- COGNITIVE / MOBILITY ISSUE CAUSED BY THE OUTLET DECREASE BLADDER NECK PRESSURE DECREASE EXTERNAL SPHINCTER PRESSURE

  12. CLASSIFICATION OF VOIDING DYSFUNCTION cont… RETENTION CAUSED BY THE BLADDER DETRUSSOR AREFLEXIA LARGE CAPACITY / HIGH COMPLIANCE NORMAL → COGNITIVE / MOBILITY ISSUE CAUSED BY THE OUTLET HIGH VOIDING PRESSURE WITH LOW FLOW RATE INTERNAL SPHINCTER DYSINERGIA EXTERNAL SPHINCTER DYSINERGIA OVERACTIVE SPHINCTER MECHANISM

  13. CLASSIFICATION OF VOIDING DYSFUNCTION cont… RETENTION AND INCONTINENCE CAUSED BY THE BLADDER UNINHIBITED CONTRACTION WITH UNDER ACTIVE DETRUSOR

  14. TREATMENT OPTION FOR VOIDING DISORDERS INCONTINENCE CAUSED BY THE BLADDER SCHEDULED VOIDING INTERMITTENT CATHETERIZATION / INDWELLING CATHETER / EXTERNAL CONDOM / DIAPERS PHARMACOLOGIC SURGICAL

  15. TREATMENT OPTION FOR VOIDING DISORDERS cont… INCONTINENCE CAUSED BY THE SPHINCTER SCHEDULED VOIDING PELVIC FLOOR EXERCISES / BIOFEEDBACK INTERMITTENT CATHETERIZATION / INDWELLING CATHETER / EXETERNAL CONDOM / DIAPERS PHARMACOLOGIC SURGICAL

  16. TREATMENT OPTION FOR VOIDING DISORDERS cont… RETENTION CAUSED BY THE BLADDER SCHEDULED VOIDING COMBINED WITH SUPRA PUBIC TAPPING VALSAVA CREDE INTERMITTENT CATHETERIZATION / INDWELLING CATHETER PHARMACOLOGIC SURGICAL

  17. TREATMENT OPTION FOR VOIDING DISORDERS cont… RETENTION CAUSED BY SPHINCTER / OUTLET SUPRAPUBIC TAPPING / BIOFEEDBACK INTERMITTENT CATHETERIZATION / INDWELLING CATHETER PHARMACOLOGIC SURGICAL

  18. TRAUMATIC SCI (SPINAL CORD INJURY) THE MOST SCI IS SUPRA SACRAL LESION TYPE UPPER MOTORNEURON CAN BE A DETRUSOR HYPERREFLEXIA WITH DETRUSOR SPHINCTER DYSINNERGIA INITIAL PERIOD OF SCI IS SPINAL SHOCK HYPOREFLEXIA OF SOMATIC SYSTEM DETRUSOR AREFLEXIA

  19. TRAUMATIC SCI (SPINAL CORD INJURY) cont… RECOVERY OF BLADDER FUNCTION USUALLY FOLLWS RECOVERY OF SKELETAL MUSCLE REFLEXES UNHIBITED BLADDER CONTRATION GRADUALLY RETURN AFTER 6 – 8 WEEKS

  20. BLADDER TRAINING CONSIST OF: SCHEDULED VOIDING PELVIC FLOOR EXERCISE SUPRA PUBIC TAPPING , VALSAVA , CREDE INTERMITTENT CATHETERIZATION

  21. BLADDER TRAINING cont… SCHEDULED VOIDING TIMED VOIDING, THEY ARE TOUHGT TO VOID BEFORE REACHING THEIR FULL CAPACITY - UNHIBITED BLADDER PROGRESSIVELY INCREASING THE TIME BETWEEN VOIDING

  22. BLADDER TRAINING cont… PELVIC FLOOR MUSCLES EXERCISES / KEGEL EXERCISES OBJECTIVE : TO STRENGTHEN THE PELVIC FLOOR MUSCLES PELVIC FLOOR MUSCLES CONSIST OF: PUBOCOCCYGEUS ILIOCOCCYGEUS ISCHIOCOCCYGEUS

  23. BLADDER TRAINING cont… - PELVIC FLOOR MUSCLES EXERCISES THE FUNCTION OF PELVIC FLOOR MUSCLES: PROVIDE SUPPORT FOR THE PELVIC VISCERA AS WE STAND UPRIGHT, AND SUPPURT FOR THE BLADDER NECK AND THE URETHROVESICULAR ANGLE WHICH IS VITAL IMPORTANCE FOR CONTINENCE CLOSING FORCE ALONG URETHRAL WALL ESPECIALLY WHENEVER THERE IS AN INCREASE IN INTRA ABDOMINAL PRESSURE THE SEXUAL FUNCTION  CORRELATION BETWEEN STRENGHT AND ACHIEVES ORGASM

  24. BLADDER TRAINING cont… PELVIC FLOOR MUSCLES EXERCISES HOW TO DO KEGEL EXERCISE: FIND THE RIGHT MUSCLES, by: TRY TO STOP THE FLOW OF URINE INSERT A FINGER INSIDE YOUR VAGINA AND TRY TO SQUEEZE USING THE BIOFEEDBACK TECHNIQUE IMAGINE THAT YOU ARE TRYING TO STOP PASSING GAS

  25. BLADDER TRAINING cont… PELVIC FLOOR MUSCLES EXERCISES THE TECHNIQUE OF EXERCISE THE PATIENTS HAVE TO BE ABLE TO CONSISTENLY ISOLATE THE PELVIC MUSCLE ESTABLISH THE INDIVIDUALIZED EXERCISE PROGRAM BASE ON THE PATIENT’S INITIAL STRENGTH AND ENDURANCE AS THE PATIENT’S CONTRACTILITY AND ENDURANCE PROGRESS, THE NUMBER OF REPETIONS IS INCREASED MOST CLINICIANS RECOMMEND A TARGET RANGE OF 30 TO 45 REPETITIONS PER DAY AND ARE DIVIDED INTO 3 TIMES AND PERFORM IN RECLINING , SITTING AND STANDING POSITION

  26. BLADDER TRAINING cont… INTERMITTENT CATHETERIZATION STERIL INTERMITTENT CATHETERIZATION CLEAN INTERMITTENT CATHETERIZATION (CIC)

  27. BLADDER TRAINING cont… CLEAN INTERMITTENT CATHETERIZATION (CIC) IS CONDUCTED FROM 6.00 – 22.00 INTAKE OF FLUIDS 100 CC – 125 CC /HOUR LAST INTAKE AT DINNER TIME ABOUT 19.00 ATTEMP TO VOID SPONTANEOUSLY POST VOID RESIDUALS (PVR) IS MEASURED THROUGH CATHETERIZATION WITH A NELATON CATHETER

  28. BLADDER TRAINING cont… CLEAN INTERMITTENT CATHETERIZATION (CIC) VOLUME OF PVR WILL DETERMINE THE FREQUENCY OF CATETERIZATION DURING DAY TIME CATHETERIZATION AT NIGHT IS SITUATIONAL DO THE CATHETERIZATION AS IN MODUL SKILL LAB USING THE SURGICAL GLOVES IS OPTIONAL

  29. BLADDER TRAINING cont… CLEAN INTERMITTENT CATHETERIZATION (CIC)

  30. BLADDER TRAINING cont… THE GOALS OF INTERMITTENT CATHETERIZATION Completely and regularly emptying of the bladder Avoiding impairment of the kidneys, caused by urine reflux Free of indwelling or intermittent catheterization

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