Voiding dysfunction is a general term to describe the condition where there is a lack of

coordination between the bladder muscle (detrusor) and the urethra. With normal urination, the urethra
relaxes and opens when the bladder muscle contracts allowing urine to pass out of the body freely. In
those voiding dysfunction, the urethra does not relax when the bladder muscle contracts making it
difficult for urine to pass. Both neurogenic and non-neurogenic disorders can cause adult voiding
dysfunction. The micturition (voiding or urination) process involves several highly coordinated
neurologic responses that mediate bladder function. A functional urinary system allows for appropriate
bladder filling and complete bladder emptying. If voiding dysfunction goes undetected and untreated,
the upper urinary system may be compromised. Chronic incomplete bladder emptying from poor
detrusor pressure results in recurrent bladder infection. Incomplete bladder emptying due to bladder
outlet obstruction (such as benign prostatic hyperplasia), causing high-pressure detrusor contractions,
can result in hydronephrosis from the high detrusor pressure that radiates up the ureters to the renal
pelvis.

CAUSES

Voiding dysfunction maybe caused by nerve dysfunction, non-relaxing pelvic floor muscles or both if the
problem stems from a neurological disorder or spinal injury it is called detrusor-sphincter dyssynergia.
If no neurological disorder or injury is present, it is referred to as pseudodyssynergia

SYMPTOMS

Difficulty emptying the bladder

Urinary hesitancy
Slow or weak urine stream
Urinary urgency and frequency
Dribbling urine after urination is complete
NURSING MANAGEMENT
Fluid Management
An adequate daily fluid intake of approximately 50 to 60ounces (1500 to 1600 mL), taken as small
increments
between breakfast and the evening meal, helps to reduce urinary urgency related to concentrated urine
production, decreasesthe risk of urinary tract infection, and maintains bowel functioning. (Constipation,
resulting from inadequate
daily fluid intake, can increase urinary urgency and urine retention.) The best fluid is water. Fluids
containing caffeine,
carbonation, alcohol, or artificial sweetener should be avoided because they irritate the bladder wall,
thus resulting
in urinary urgency. Some patients who have heart failure or end-stage renal disease need to discuss their
daily fluid limit
with their primary health care provider.

Standardized Voiding Frequency

After establishing a patients natural voiding and urinary incontinence tendencies, voiding on a schedule
can be very
effective in those with and without cognitive impairment, although patients with cognitive impairment
may require assistance
with this technique from nursing personnel or family members. The object is to purposely empty the
bladder before the bladder reaches the critical volume that would cause an urge or stress incontinence
episode. This approach
involves the following:

Timed voiding involves establishing a set voiding frequency (such as every 2 hours if incontinent
episodes
tend to occur 2 or more hours after voiding). The individual chooses to void by the clock at the given
interval while
awake, rather than wait until a voiding urge occurs.

Prompted voiding is timed voiding that is carried out by staff or family members when the individual
has cognitive
difficulties that make it difficult to remember to void at set intervals. The caregiver checks the patient to
assess if he
or she has remained dry and, if so, assists the patient to use the bathroom while providing positive
reinforcement
for remaining dry.
 Habit retraining is timed voiding at an interval that is more frequent than the individual would usually
choose. This technique helps to restore the sensation of the need to void in individuals who are
experiencing diminished sensation
of bladder filling due to various medical conditions such as a mild cerebrovascular accident (CVA).

Bladder retraining, also known as bladder drill, incorporates a timed voiding schedule and urinary
urge inhibition exercises to inhibit voiding, or leaking urine, in an attempt to remain dry for a set time.
When the first timing interval
is easily reached on a consistent basis without urinary urgency or incontinence, a new voiding interval,
usually
10 to 15 minutes beyond the last, is established. Again, the individual practices urge inhibition exercises
to delay
voiding or avoid incontinence until the next preset interval arrives. When an acceptable voiding interval
is reached, the patient continues that timed voiding sequence throughout the day.

Pelvic Muscle Exercise (PME)

Also known as Kegel exercises, PME aims to strengthen the voluntary muscles that assist in bladder and
bowel continence in both men and women. Research shows that written or verbal instruction alone is
usually inadequate to
teach an individual how to identify and strengthen the pelvic floor for sufficient bladder and bowel
control. Biofeedbackassisted PME uses either electromyography or manometry to help the individual
identify the pelvic muscles as he or she attempts to learn which muscle group is involved when
performing PME. The biofeedback method also allows assessment of the strength of this muscle area.
PME involves gently tightening the same muscles used to stop flatus or the stream of urine for 5- to 10-
second increments, followed by 10-second resting phases. To be effective, these exercises need to be
performed two or three times a day for at least 6 weeks. Depending on the strength of the pelvic
musculature when initially evaluated, anywhere from 10 to 30 repetitions of PME are prescribed at each
session.
Elderly patients may need to exercise for an even longer time to strengthen the pelvic floor muscles.
Pelvic muscle exercises are helpful for women with stress, urge, or mixed incontinence
and for men who have undergone prostate surgery.

Vaginal Cone Retention Exercises

Vaginal cone retention exercises are an adjunct to the Kegel exercises. Vaginal cones of varying weight
are inserted
intravaginally twice a day. The patient tries to retain the cone for 15 minutes by contracting the pelvic
muscles.

Transvaginal or Transrectal Electrical Stimulation

Commonly used to treat urinary incontinence, electrical stimulation is known to elicit a passive
contraction of the pelvic
floor musculature, thus re-educating these muscles to provide enhanced levels of continence. This
modality is often used with biofeedback-assisted pelvic muscle exercise training and voiding schedules.
At high frequencies, it is effective for stress incontinence. At low frequencies, electrical stimulation can
also relieve symptoms of urinary urgency, Frequency, and urge incontinence. Intermediate ranges are
used for mixed incontinence.

Neuromodulation
Neuromodulation via transvaginal or transrectal nerve stimulation of the pelvic floor inhibits detrusor
overactivity and hypersensory bladder signals and strengthens weak sphincter muscles.
SURGICAL MANAGEMENT
Surgical correction may be indicated in patients who have not achieved continence using
behavioral and pharmacologic therapy. Surgical options vary according to the underlying anatomy and
the physiologic problem. Most procedures involve lifting and stabilizing the bladder or urethra to restore
the normal urethrovesical angle or to lengthen the urethra. Women with stress incontinence may
undergo an anterior vaginal repair, retropubic suspension, or needle suspension to reposition the
urethra. Procedures to compress the urethra and increase resistance to urine flow include sling
procedures and placement of periurethral bulking agents such as artificial collagen.
Periurethral bulking is a semipermanent procedure in which small amounts of artificial collagen
are placed within the walls of the urethra to enhance the closing pressure of the urethra. This procedure
takes only 10 to 20 minutes and may be performed under local anesthesia or moderate sedation.
A cystoscope is inserted into the urethra. An instrument is inserted through the cystoscope to deliver a
small amount of collagen into the urethral wall at locations selected by the urologist. The patient is
usually discharged home after voiding. There are no restrictions following the procedure, although
occasionally more than one collagen bulking session may be necessary if the initial procedure did not
halt stress incontinence. Collagen placement anywhere in the body is considered semipermanent
because its durability averages between 12 and 24 months, until the body absorbs the material.
Periurethral bulking with collagen offers an alternative to surgery, as in a frail, elderly person.
It is also an option for people who are seeking help with stress incontinence who prefer to avoid
surgery and who do not have access to behavioral therapies. An artificial urinary sphincter can be used
to close the urethra and promote continence. Two types of artificial sphincters are a periurethral cuff
and a cuff inflation pump. Men with overflow and stress incontinence may undergo a transurethral
resection to relieve symptoms of prostatic enlargement. An artificial sphincter can be used after prostatic
surgery for sphincter impotence. After surgery, periurethral bulking agents can be injected into the
periurethral area to increase compression of the urethra.

Surgical Procedures:
Implanting a suburethral sling
Implanting an artificial sphincter device
Cryoplasty
Reconstructing and lifting the bladder when it has fallen
Closing the bladder neck

Pharmacologic Therapy

Pharmacologic therapy works best when used as an adjunct to behavioral

interventions. Anticholinergic agents inhibit bladder contraction and are considered first-line
medications for urge incontinence. Several tricyclic antidepressant medications (eg,
amitriptyline [Endep], amoxapine [Asendin]) can also decrease bladder contractions as well
as increase bladder neck resistance (Karch, 2008). Pseudoephedrine sulfate (Sudafed),
which acts on alpha-adrenergic receptors, causing urinary retention, may be used to treat
stress incontinence; it needs to be used with caution in men with prostatic hyperplasia.
Hormone therapy (eg, estrogen) taken orally, transdermally, or topically was once the
treatment of choice for urinary incontinence in postmenopausal women because it restores
the mucosal, vascular, and muscular integrity of the urethra. However, the results of the
Womens Health Initiative showed that after 1 year of therapy, incontinence had increased,
especially in women taking estrogen alone compared to placebo (Mennick, 2005). More
research is needed in this area.

Other medications that treat bladder control problems include

Musculotropic relaxants
Potassium channel openers
Prostaglandin inhibitors
Beta-adrenergic agonists
Alpha-adrenergic agonists
Tricyclic antidepressants
Dimethyl sulfoxide or DMSO
Polysynaptic inhibitors
Ephedrine or pseudoephedrine
Phenylpropanolamine
Imipramine
Estrogens