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584 AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

kidney srones) 42 Management that may be specific to urinary calculi

includes extracorporeal shock wave lithotripsy and ureteroscopy.4J

Neurogenic Bladder

A neurogenic bladdet is characterized by bladder paralysis that occurs

with central nervous system disruption (Parkinson's disease, stroke,

brain tumors, multiple sclerosis, or trauma) at the corrical or spinal

cord level, resulting in urinary flow disturbances. Lesions above the

sactal level of the spinal cord result in loss of voluntary control of

voiding; lesions below the sacral level result in the loss of voluntary

and involuntary control of voiding. Neurogenic bladders may lead to

infection, especially when there is associated bladder distention and

urine retention, catheter placemenr, or stone formation, which can be

caused by bone resorption from physical immobility.'·44

Symptoms of neurogenic bladders with infection arc difficult to

assess, because altered sensation from neurologic disturbance often

masks pain or other symptoms. However, the patient may reporr a

burning sensation with voiding.9

Management consists of addressing the primary neurologic disturbance (as able) and providing anti-infective agents for any associated infection.' Anticholinergic agents have also been helpful with this disorder." Table 9-3 provides a summary of the different types of urinary incontinence.

Prostate Disorders

Benign Prostatic Hypertrophy

Bellign prostatic hypertrophy (BPH) is a benign, progressive enlargement of the prostate gland and is the mOSt common benign tumor in men.·s Almost all men older than age 60 develop BPH, which is associated with the normal aging process. Concern arises when enlargement interferes with normal voiding patterns. Acute urinary retention and urinary tract infection are the primary complications of BPH.46

Signs and symptoms of BPH include the following4s•46;

• Palpable prostate gland lobes with digital rectal examination

• Decreased force of urinary stream

• Straining to void

• Postvoid dribble

GENITOURINARY SY$TIM

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Table 9-3. Types of Urinary Incominence

Type

Description

Common Causes

Stress

Loss of urine that occurs

\'Veakness in the bladder outlet

involuntarily in siruations

region, urethral sphincter, or

associated with increased

pelvic floor muscles

intra-abdominal pressure,

such as with laughing,

coughing, or exercise

Urge

Leakage of urine that occurs

Cystitis, urethritis, tumors,

after a sensation of bladstones, outflow obstructions.

der fullness is perccived

strokc, dementia, and parkinsonism

Overflow

Leakage of urine from

Obstruction by prostate, stricmechanical forces or uriture or cystocele

nary retention from an

A noncontractile bladder, as

overdistcnded bladder

occurs in diabetes mellitus or

spinal cord injury

A neurogenic bladder, as occurs

in multiple sclerosis or other

lesions above [he sacral portion of the spinal cord

Functional

The inability to void because

Depression, anger, hostility,

of cognitive or physical

dementia, and other neuroimpairments, psychologilogic disorders

cal unwillingness, or environmental barriers

Source: Adapted (rom Bl Bullock. Disorders o( Micturi[ion and ObS[runion of {he

Genitounn:try Tract. In Bl Bullock (cd), Pathophysiology: Adaptations and Alterations

111 Function (4th cd). Philadelphia: Lippincon, 1996;648.

• Urinary frequency with incomplete emptying

• Nocturia and dysuria

Management of BPH includes any of the following4S.46:

• Alpha,-adrenergic blocking agents (doxazosin [CarduraJ, tamsulosin IFlomaxj, terazosin [Hytrin]) act to relax the smooth muscle in the prostate and neck of the bladder to facilitate voiding.

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ActIrE CARE HANDBOOK FOR PHYSICAL TI-lERAPISTS

• Sa-reductase enzyme inhibitor (finasteride [ProscarJ) inhibits

male hormones to prostate causing the gland to shrink over time.

• Anti-infective agents (if there is associated infection).

• Intermittent self-catheterization.

• Surgical options include transurethral incIsIon of the prostate, transurethral resection of the prostate (TURP), suprapubic or retropubic prostatectomy (open removal of the prostate), and

balloon dilation.

Prostatitis

Prostatitis is an inflammation of the prostate gland. It can be divided

into four categories: (I) acute bacterial, (2) chronic bacterial, (3) nonbacterial, and (4) prostatodynia (presence of prostatitis symptoms without physical findings). Nonbacterial prostatitis and prostatodynia occur more commonly than do acute and chronic bacterial prostatitis. Causative pathogens for acute and chronic bacterial prostatitis can include E. coli, Pseudomonas aeruginosa, Neisseria gonorrhoeae, and Mycobacterium tuberculosis.45

Signs and symptoms of prostatitis include the following42 • .,:

• Fever with rectal, perineal, or low back pain (acute bacterial

prostatitis)

•

Increased urinary frequency or urgency to void

•

Painful urination (dysuria)

• Bladder irritability

• Difficulty initiating a stream

• Nocturia

• Sexual dysfunction

Management of prostatitis includes any of the following42•4s:

•

Dietary modifications (alcohol, chili powder, and other hot

spices can aggravate symptoms)

•

Anti-infective agents (for bacterial prostatitis)

GENITOURINARY SYSTEM

587

• Alphal-adrenergic blocking agents (See Benign Prostatic

H ypenroph y.)

• Nonsteroid anti-inflammarory drugs

• Antipyretics

• Surgery (open resection of the prostate or TURP)

Managemenl

The specific managemenr of various genitourinary disorders is discussed earlier in the respective pathophysiology sections. This section expands on renal replacemenr rherapy and surgical procedures.

Guidelines for physical therapy intervention for patients who have

genitourinary dysfunction are also discussed.

Renal Replacelllent Therapy

The primary method of managing fluid and electrolyte balance in

patients with ARF or CRF is peritoneal dialysis or intermittenr hemodialysis. Both types of dialysis use the principles of diffusion, osmosis, and ultrafiltration to balance fluid and electrolyte levels. Diffusion is

the movemenr of soimes, such as er, urea, or electrolytes, from an

area of higher concentration to an area of lower concentration.