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Bladder health and continence care

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VOL: 97, ISSUE: 40, PAGE NO: 55

Ray Addison, RN, FETC, Cert.H.Ed, BSc, is a nurse consultant in bladder and bowel dysfunction, Mayday University Hospital, Croydon, Surrey, and honorary nursing consultant to the UK Continence Foundation

The bladder is a muscular organ that needs to shrink and expand to allow the storage of urine and voiding. For this to happen you need an intact bladder wall with an adequate blood supply and an intact functioning nervous system combined with an effective immune system. Drugs such as caffeine can have many effects, including increasing the intensity of bladder contractions in patients with unstable bladders (detrusor instability) or reducing contractility. Therefore patients with neurological disease, those who are immunosupressed or those who have blood disorders are all likely to have the structure of their bladders compromised, resulting in effects on storage and voiding.

The bladder is a muscular organ that needs to shrink and expand to allow the storage of urine and voiding. For this to happen you need an intact bladder wall with an adequate blood supply and an intact functioning nervous system combined with an effective immune system. Drugs such as caffeine can have many effects, including increasing the intensity of bladder contractions in patients with unstable bladders (detrusor instability) or reducing contractility. Therefore patients with neurological disease, those who are immunosupressed or those who have blood disorders are all likely to have the structure of their bladders compromised, resulting in effects on storage and voiding.

Dynamic bladder function
The bladder has to store urine to be an effective reservoir and allow social function and sleep. It needs to have a day time capacity of between 250-500ml; this may increase during sleep. At night it is normal to void once, and nocturia may increase over the age of 60, with up to four episodes by the age of 90. Making the bladder hold over 600ml may result in over-distention, resulting in dysfunction associated with voiding.

The bladder's other main function is to expel urine, making voiding a voluntary action. We need to empty our bladders completely and regularly every three to four hours during the day and about eight times in 24 hours. If bacteria gains access to the bladder, two defence mechanisms are regular and complete voiding to prevent colonisation. Normally there is no outflow obstruction within the urethra, so voiding will not require straining to empty.

Urine
Urine in itself plays a role in maintaining bladder health. It contains waste products and chemicals not required by the body. These can be toxic - for instance, nicotine may affect bladder health in the long term (increased risk of bladder cancer). Urine is bacteriostatic, that is, it tends to restrain the development or the reproduction of bacteria which can always gain entry to the bladder via the urethra (which is much easier in women). Urine is acidic, which creates a bladder environment where bacteria do not thrive, and a Ph greater than six adversely affects antibacterial activity. A good urinary flow is required to flush out bacteria. This should be over 200ml per void to be effective. Urine production is dependent on fluid intake and affected by health status, temperature and activity levels. A healthy adult should produce over a litre of urine per day, and the osmolarity of the urine is an indication of adequacy.

In applying the theories of bladder health to nursing interventions, there are four common aspects of continence care: intermittent self-catheterisation (ISC), bladder retraining and using a Foley indwelling catheter on free drainage (leg and night bag system) or on intermittent bladder drainage, using a catheter valve. Table 1 compares these four interventions in relation to their effects on bladder health.

Conclusion
Bladder health is a complex issue and needs careful consideration. The bladder structure, dynamic function and urine all contribute to the health of the bladder. Some common nursing interventions maintain bladder health and some do not. Patients on long-term free drainage (that is over six months) may eventually have their bladder health compromised and can experience a wide range of complications associated with this, some of which may not be reversible. Nurse specialists working in continence care, urology, spinal cord injury and multiple sclerosis need to base their nursing care and educational programmes on sound bladder health principles.

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