Katie S. Murray, DO
Tomas L. Griebling, MD, MPH, FACS
BASICS
DESCRIPTION
• Stroke (CVA-cerebovascular accident) is the 3rd leading cause of death, and the leading cause of chronic morbidity in the United States
• Stroke can be ischemic or hemorrhagic
• Stroke can lead to urinary tract disturbances
• Initially, transient (occasionally permanent) urinary retention ± overflow incontinence
• Likelihood of voiding disturbances is directly associated with stroke severity
• May eventually develop bladder overactivity and urgency with or without incontinence
• Urinary symptoms post-CVA are very common
– 25% of people have urinary incontinence at time of discharge and 15% have these issues at 1 yr post-CVA (1)[A]
EPIDEMIOLOGY
• 270/100,000 Americans experience a stroke each year
• Mean age 72 yr
RISK FACTORS
• Urinary disturbances after stroke are common, the risk factor is stroke and extent of hemorrhage or ischemia
– Those with dysphagia, >75 yr, motor weakness, and visual field defects were more likely to have long-term incontinence issues (2)[A]
Genetics
N/A
PATHOPHYSIOLOGY
• Urinary retention due to cerebral shock and detrusor areflexia
• Incontinence-multifactorial (4)[B]
– Overflow urinary incontinence from retention
– Detrusor overactivity (DO) with urge urinary incontinence (UUI)
– Functional incontinence due to mobility and/or cognitive impairment
ASSOCIATED CONDITIONS
• Prostatic hyperplasia
• Underlying urinary incontinence
• Fecal incontinence and/or constipation
• Depression
• See also Differential Diagnosis
GENERAL PREVENTION
• Stroke prevention measures
– Smoking cessation
– Blood pressure control
– Cholesterol control
– Diabetic control
– Avoid hormonal replacement therapy in older women
– Identify and control atrial fibrillation
– Balanced diet and exercise
– Low-dose aspirin if appropriate
DIAGNOSIS
HISTORY
• Based on diagnosis of CVA
• Evaluate for previous or underlying urologic issues or complaints
• Obtain medication history
• Detailed past surgical history
PHYSICAL EXAM
• Abdominal exam for bladder distention
• Neurologic exam (usually already done by primary team during initial diagnosis)
• Digital rectal exam (DRE) to evaluate rectal tone and prostate size in males
• Pelvic exam in females
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis with or without urine culture as clinically appropriate
• Creatinine to evaluate renal function
Imaging
• Postvoid residual bladder scan
• Abdominal imaging
– Renal/bladder ultrasound
– KUB
Diagnostic Procedures/Surgery
• Voiding/fluid intake diaries
– Bladder capacity
– Daily/nightly trends
• Urodynamic studies: Should not be performed until after stability in neurologic symptoms following stroke (not immediately)
– Typically 3–6 mo following stroke
– Evaluate bladder function and detrusor function vs. bladder outlet obstruction
– May be used for surgical guidance and management if necessary
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Urinary Retention (see Section I “Urinary Retention, Adult Male,” “Urinary Retention, Adult Female”)
• Urge incontinence
– Loss of urine accompanied by urgency; often related to triggers such as sounds of running water, cold weather, passing a restroom
• Stress incontinence
– Urinary leakage associated with exertion, lifting, coughing, sneezing
• Mixed incontinence
– Urinary leakage associated with both stress and urge incontinence
• Low bladder compliance resulting in overflow incontinence
• Continuous urinary incontinence is the continuous loss of urine
• Postmicturition dribble
– The involuntary loss of urine immediately after passing urine, usually after leaving the toilet
• Mobility or cognitive impairment post stroke
TREATMENT
GENERAL MEASURES
• General stroke rehabilitation interventions (3)
– Physical therapy
– Occupational therapy
• Initially and short term
– Ensure bladder drainage with Foley catheter vs. clean intermittent catheterization (CIC)
• Long term
– CIC, Foley or suprapubic catheter for urinary retention and elevated post void residuals
– Caution to avoid long-term indwelling urethral catheter to avoid risk of bladder neck erosion or urethral injury
– Bladder overactivity
Behavioral modifications regarding voiding habits and fluid intake
See medication therapy below
MEDICATION
First Line
• Antimuscarinics or β3-agonists: Decrease detrusor overactivity (DO) that is demonstrated as urinary frequency and urgency
(± incontinence)
– Side effects
Dry mouth, constipation, blurred vision, confusion
Use cautiously in geriatric patients secondary to potential central nervous system effects
Second Line
• α-Blockers for prostatic hyperplasia and retention related to BPH if necessary
• 5α-reductase inhibitors for BPH especially in those men with large prostate glands
SURGERY/OTHER PROCEDURES
• Suprapubic catheter placement if long-term urinary retention
• Intravesical botulinum toxin injections for DO
– Temporary effect and may require patients to perform CIC
• Neuromodulation
• Transurethral resection of prostate if concomitant BPH with clinical obstruction
• Urinary diversion
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
Psychological support and re-enforcement
Complementary & Alternative Therapies
• Absorbent pads and products
• Pelvic floor physical therapy with or without biofeedback
• Acupuncture
ONGOING CARE
PROGNOSIS
• Health-related quality of life is impaired in general in those with urgency incontinence post neurologic event (4)[B]
• Urinary symptom outcome is proportional to the extent of resolution of other stroke sequelae
– Those who resolve cognitive and/or motor function often resolve urinary issues
COMPLICATIONS
• Short term
– Acute renal failure if acute urinary retention
– Urinary tract infection if not draining bladder appropriately
– Urinary incontinence because of overflow incontinence in retention
– Depression
• Long term
– Renal dysfunction and possible renal failure
– Urinary tract infections—recurrent
– Decreased quality of life
– Depression
FOLLOW-UP
Patient Monitoring
• Detrusor overactivity (DO): yearly checkups, medicine monitoring
• Neurogenic bladder and performing CIC
– Evaluate renal function with yearly (or more often if clinically indicated) creatinine and renal ultrasound
– Urodynamic evaluation for significant change in clinical symptoms
– If indwelling catheter dependent, needs regular cystoscopy to visualize bladder and monitor for cancer or stones
Increased risk of bladder cancer is secondary to chronic foreign body in urinary tract
Patient Resources
www.stroke.org/site/DocServer/NSAFactSheet_BowelandBladder.pdf?docID=984 (National STROKE Association)
REFERENCES
1. Thomas LH, Cross S, Barrett J, et al. Treatment of urinary incontinence after stroke in adults. Cochrane Database Syst Rev. 2008;(1):CD004462.
2. Patel M, Coshall C, Rudd AG, et al. Natural history and effects on a 2-year outcomes of urinary incontinence after stroke. Stroke. 2001;32:122–127.
3. Brittain KR, Peet SM, Castleden CM. Stroke and incontinence: Review.Stroke. 1998;29:524–528.
4. Tapia CL, Khalaf K, Berenson K, et al. Health-related quality of life and economic impact of urinary incontinence due to detrusor overactivity associated with a neurological condition: A systematic review. Health Qual Life Outcomes. 2013;11:13.
ADDITIONAL READING
www.stroke.org (National Stroke Association)
See Also (Topic, Algorithm, Media)
• Detrusor Overactivity
• Neurogenic Bladder, General Considerations
• Urinary Retention, Adult Female
• Urinary Retention, Adult Male
• Urinary Retention, Pediatric
CODES
ICD9
• 434.91 Cerebral artery occlusion, unspecified with cerebral infarction
• 788.29 Other specified retention of urine
• 788.38 Overflow incontinence
ICD10
• I63.9 Cerebral infarction, unspecified
• R33.8 Other retention of urine
• N39.490 Overflow incontinence
CLINICAL/SURGICAL PEARLS
• Important to determine residual urinary effects after near full recovery from stroke.
• Prior to operation, ensure stability of urinary function.