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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.
586
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
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• 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.