Acute Stroke and Its Managment - Research Paper Example

 INTRODUCTION: WHAT IS STROKE? By definition, the stroke is described as a “sudden diminution or loss of consciousness, sensation and voluntary motion caused by rupture or obstruction (as by a clot) of a blood vessel of the brain – called also apoplexy, brain attack, cerebral accident, cerebrovascular accident.” (1) About 700,000 cases of strokes are recorded to occur in United States alone per year. According to the estimates, about 165,000 of these patients die. Stroke comes out to be the second major cause of death world wide. Bogousslavsky and Caplan (2001) found that stroke is a focal neurologic event which is acute in on set and have a vascular cause. The incidence increases with the advancement of age. (2) With a progress in the medical science, the management of the stroke patients has significantly improved, yet the mortality rate still remains at about 50% chances for the 5-year survival of such patients in some cases. Moreover, the percentage for a risk of stroke following a Transient Ischemic Attack (TIA) lies at about 30%. Out of the factors which lead to the stroke, the most important ones are the age of patient and the severity of stroke at its onset. Shuaib and Goldstein (1999) found that prevalence of stroke can be controlled by controlling some cardiovascular risk factors. Such risk factors include smoking and high blood pressure. Still under study are the roles of controlling diabetes and lipid content for the prevention of stroke. (2) Hankey (2005) found that use of mannitol in certain clinical conditions in some acute strokes becomes very beneficial. Stroke generally occurs in the old age, with predominance in persons having diabetes and hypertension. In the diabetic patients, the blood vessels are already compromised. If such patients are suffering with hypertension as well, a sudden rise of blood pressure often leads to a rupture of the blood vessels in the brain usually the fragile ones. Adams, et al., (2006) found that stroke may lead to the brain hemorrhage because of the rupture of blood vessels in the brain. Also depending upon the amount of the blood leaked from the vessel, a pressure occurs on the surrounding brain tissues. This can lead o a loss of consciousness along with the other symptoms like loss of sensation or voluntary motion depending upon the area of the brain involved etc. The risk factors management is another important issue. There are certain risk factors in the patients of stroke which need an urgent and special attention so as to have a good prognosis. Some of these risk factors include nutrition, thrombosis, position and urinary retention. Hennerici (2003) found that cranial computed tomography can be used as a diagnostic technique for the patients showing acute symptoms. Such therapies should be developed which could really help people in treatment. Davis, et al., (2003) found that the development of therapies for acute stroke is a difficult venture with many potential pitfalls. Bogousslavsky (1997) found that new therapies are being tested for acute strokes in order to find a perfect therapy regarding strokes. Verheugt (2003) found that fibronolytic therapy has made its significance regarding treatment of cardiovascular disease. Thrombolytic therapy also exists which saves both disabilities regarding strokes and also saves money. Lyden (2005) found that thrombolytic stroke therapy can not only save disabilities but also saves dollars. Appropriate and effective therapies must be used for acute care for the purpose of diagnosis of acute disorders and all challenges regarding acute disorders should be given extreme importance. Malone and Lindsay (2006) found that hemodynamic stability is the number one challenge regarding therapies in an acute care setting. In our discussion below, we are going to keep our attention on the problem of urinary retention in the patients of stroke. It is important to prevent the problem of urinary retention in the patients of stroke as if left untreated it can lead to the urinary tract infection and other problems. BRIEF DESCRIPTION: Besides many other complications of stroke, an important one is the bladder dysfunction. The normal function of the bladder is the storage and expulsion of the urine in an organized and co-ordinate manner. Hankey (2002) found that for the normal functioning of bladder, both the central and the peripheral nervous systems are responsible. If this system is disturbed, and the bladder starts to malfunction, then a term is applied, known as the ‘Neurogenic bladder’. This can be a result of an internal or external trauma, any disease or an injury. Torbey and Salim (2007) found that the neurogenic bladder can be presented both in the forms of either an under activity or an over activity. Also it can be presented as the detrusor muscle depending upon the site of neurological damage. Detrusor muscle is the muscle of the bladder responsible for the contraction of the bladder walls. (3) MICTURITION CONTROL: Micturition is the process of voiding urine occurs as a simple reflex in the new born individuals. With the growth of the child, this reflex gets modified and ultimately results in the form of a voluntary action almost by the age of three. The whole process is controlled by a co-ordination between the sympathetic, the Para sympathetic, the central and the somatic nervous systems. All of them work together in order to carry out a complete voluntary and coordinated emptiness of the bladder. Micturition occurs automatically at some bladder volumes when the total control over voiding is gained by micturition reflex. This is the situation that occurs with babies and some patients who are spinally injured. In case of spinally injured patients, it depends on the levels of lesions. Pontine micturation center gain an interaction with the brain and voiding becomes inhibited. So we can say that for a voluntary control of micturation, the presence of an intact spinal cord becomes essential. When the bladder is in the relaxed state, it is the time for its filling. Adams (1993) found that the bladder steadily gets modified to the filling of urine. This happens because of the activation of the beta-adrenergic receptors. When this process is being carried out, the beta-adrenergic receptors in the smooth muscles of urethra are activated in order to carry out the contraction of the sphincter to prevent urine from getting out of it. The bladder remains relaxed during the process of storage. The urinary bladder has a slow adaptation to the filling process. It occurs as a result of the beta adrenergic receptors. These are activation by the stimulation of the hypo gastric nerve. Along with the activation of these receptors in the bladder wall, there occurs a simultaneous stimulation of the beta adrenergic receptors in the smooth muscles of the urethra. Along with these, the striated muscle of the urethral sphincter contract rapidly in order to prevent the urine from flowing. Now, slowly as the pressure builds up within the bladder due to an increase in the volume of urine leading to an increased vesicle pressure, the expansion receptors become activated. This information is transmitted to the brain via the pelvic nerves. Thus, the whole process of micturition has certain steps. These are given below: 1. The filling sensation is transmitted to the central brain. 2. The voluntary control to initiate the micturition process by the central brain, 3. Simultaneous initial relaxation of the urethral sphincter. 4. Stimulation of the pelvic nerve fibers. 5. The neuromuscular impulses are then rapidly transmitted across the bladder. This leads to the contraction of bladder in a coordinated manner. 6. At the local and spinal levels, the process of inhibition takes place involving the smooth and the striated muscle fibers. This acts upon the internal and the external urethral sphincters in order to facilitate the process of emptying of the bladder. If any of these steps is disturbed, the urinary retention and incomplete emptying of the bladder occurs. (9) ACUTE URINARY RETENTION: DEFINING INDICATORS: Described below are various signs and symptoms which are considered as indicators for defining the condition of the patient as having the urinary retention: 1. Total absence or a decrease (< 30 ml/hr) in the urinary output for complete two hours, 2. Hesitancy, 3. Lower abdominal distention, 4. Abdominal discomfort or 5. Dribbling (8). Acute urinary retention is one of the most common urological emergencies seen in the hospital setup. A person is said to have developed the urinary retention when he becomes unable to void urine voluntarily for many hours, even when the bladder is full. (4) MacWalter and Shirley (2003) found that patients suffering with stroke face bladder and bowel function problems. It happens after recovery from the illness. It can either be in the form of urinary retention, urinary incontinence, constipation, or bowel incontinence. The main reason for such dysfunctions is the damage to that area of brain, which controls the waste removal, or to the area that sends signals for it. Sometimes, the cause may be some infection or any other complication in such patients. Gorelick and Alter (2002) found that the urinary retention occurs when the patient becomes powerless to void the urine. Or we can say that when the patient becomes unable to completely empty the bladder. This condition has to be treated effectively, because if left untreated, it can lead to bladder stones, reflux (when the urine flows back to the kidneys due to excessive pressure), or urinary tract infection (UTI). Out of these outcomes, the UTI needs an urgent medical attention; otherwise it can lead to foul smelling, cloudy urine, urine having blood or deposits, burning micturation, fever and chills, lower abdominal cramps, lower back ache, feeling of incomplete evacuation of the bladder even after passing the urine. (5) SELECTED CAUSES OF URINARY RETENTION: Given below are some of the causes of urinary retention: Cause Men Women Both Obstructive Benign prostatic hyperplasia; meatal stenosis; paraphimosis; penile constricting bands; phimosis; prostate cancer Organ prolapse (cystocele, rectocele, uterine prolapse); pelvic mass (gynecologic malignancy, uterine fibroid, ovarian cyst); retroverted impacted gravid uterus Aneurismal dilation; bladder calculi; bladder neoplasm; fecal impaction; gastrointestinal or retroperitoneal malignancy/mass; urethral strictures, foreign bodies, stones, edema Infectious and inflammatory Balanitis; prostatic abscess; prostatitis Acute vulvovaginitis; vaginal lichen planus; vaginal lichen sclerosis; vaginal pemphigus Bilharzias; cystitis; echinococcosis; Guillain-Barré syndrome; herpes simplex virus; Lyme disease; periurethral abscess; transverses myelitis; tubercular cystitis; urethritis; varicella-zoster virus Other Penile trauma, fracture, or laceration Postpartum complication; urethral sphincter dysfunction (Fowler's syndrome) Disruption of posterior urethra and bladder neck in pelvic trauma; postoperative complication; psychogenic (8) PATHOPHYSIOLOGY OF URINARY RETENTION: The process of urinary excretion is controlled by both the sympathetic and parasympathetic nervous systems of our body. Gonzalez, et al., (2006) found that the sympathetic nervous system is responsible for the regulation of the process of urine storage in the bladder. While the parasympathetic nervous system controls the bladder contraction and the passage of urine. These parasympathetic nerve impulses travel from the S1 to S4 of the ventral grey matter of the spinal cord. They travel through the pelvic nerves to the ganglia near the bladder wall. (6) The sympathetic efferent nerve fibers cover the spinal areas from T11 to L2. These are present in the lateral grey columns of the spinal cord. The sympathetic pathway for the control of the bladder function comprises of a long post ganglionic chain, which takes its path along with the hypo gastric nerve. Their ultimate destination is to synapse with the alpha and the beta receptors in the bladder wall and bladder neck or the internal sphincter. Of these two types of receptors, the beta receptors carry out the function of relaxation of the bladder in order to accommodate the filling. The alpha receptors are responsible for a controlled tonic contraction of the internal sphincter during the filling process. The external periurethral sphincter comes under the voluntary control of our body. It contracts normally during the process of coughing or the Valsalva maneuver. It also contracts under a condition when a person deliberately tries to stop the urine from flowing. (6) Now, after understanding some of the pathophysiology of the bladder control, we shall discuss about the central nervous control for the urinary excretion. Let us now discuss some of the pathological conditions which can lead to the detrusor problems. If there is any lesion of the peripheral nerve, or the sacral micturition center, it can lead to the detrusor areflexia. It is represented as the distended bladder with overflow incontinence. If the lesion is in the spinal cord, or below the pontine micturition center in the brain stem, but still above the sacral micturition center, the result is an uninhibited bladder contraction along with an associated uncoordinated sphincter activity. In such a condition, the external sphincter can contract reflexively during the contraction of the bladder. This condition is called as the ‘detrusor sphincter dyssynergia’. The lesions above the pontine micturition center result in an inability of the cerebral cortex to carry out inhibition. This results in the uninhibited bladder contractions. But in such a case, the voluntary relaxation of the urethral sphincter remains intact. The lesions below the pontine micuturition center represent both with the detrusor hyperreflexia and sphincter-detrusor muscle dyssynergia. This occurs commonly in the patients suffering with SCIs, MS and transverse myelitis. (6) MANAGEMENT OF ACUTE URINARY RETENTION: The acute urinary retention due to any reason is a painful condition. The patients suffering with the urinary retention present either with an overflow incontinence, or recurrent urinary tract infections. The physician should also rule out any change in the baseline neurological condition of the patient. In such patients a detailed neurological examination is mandatory. This includes both a general evaluation of the neurological status, as well as the examination procedures specified to assess the bladder function. These procedures include the bulbocavernosus reflex, anal reflex, voluntary contractions of the pelvic floor, anal sphincter tone and sensations in the S2 to S5 dermatological distributions. This area from S2 to S5 is the ‘perianal’ and ‘saddle’ area respectively. Furthermore, the imaging studies are also required in order to rule out any lesion in the brain and spinal cord. (8) INITIAL MANAGEMENT OF URINARY RETENTION: The main problem is the inability to void urine, which then leads to a number of complications including urinary tract infections. Decompression of the bladder has some side effects. These complications are independent of the speed of decompression, so it does not make any difference if the decompression is carried out rapidly or slowly. Therefore, the recommended process is to carry out decompression in a rapid way. These complications include hematuria, hypotension, post obstructive diuresis and potential complications of decompression. (7) Urinary tract infection (UTI) is itself a major complication of the catheterization. So, it should be looked upon very seriously after catheterization whether the patient is fine, or is showing the signs and symptoms of the urinary tract infection, because it will then require the removal of the catheter as a first step to cure the problem. It is shown from another study done on the abdominal surgery patients that the suprapubic catheters decrease the bactiriuria and discomfort and were preferred by the patients. (7). Such patients are usually advised to use the clean intermittent self-catheterization. This technique is known to be the first line treatment in the management of urinary retention. This is also known to have a less frequency of complications like renal failure, upper urinary tract deterioration and urosepsis. Other managements of urinary retention depend upon the etiology, leading either to the medical or surgical treatment (7). Given below are the possible neurological causes of urinary retention: NEUROLIGICAL CAUSES OF URINARY RETENTION AND VOIDING DYSFUNCTION: Lesion Type Causes Autonomic or peripheral nerve Autonomic neuropathy; diabetes mellitus; Guillain-Barré syndrome; herpes zoster virus; Lyme disease; pernicious anemia; poliomyelitis; radical pelvic surgery; sacral agenesis; spinal cord trauma; tabes dorsalis Brain Cerebrovascular disease; concussion; multiple sclerosis; neoplasm or tumor; normal pressure hydrocephalus; Parkinson's disease; Shy-Drager syndrome Spinal cord Dysraphic lesions; invertebral disk disease; meningomyelocele; multiple sclerosis; spina bifida occulta; spinal cord hematoma or abscess; spinal cord trauma; spinal stenosis; spinovascular disease; transverse myelitis; tumors or masses of conus medullaris or cauda equine (7) STEP BY STEP MANAGEMENT: Given below a table describing some of the tests required in patients with the urinary retention. DIAGNOSTIC TESTS IN THE PATIENTS WITH URINARY RETENTION: Test type Diagnostic test Rationale Laboratory Urinalysis Evaluate for infection, hematuria, proteinuria, glucosuria Serum blood urea nitrogen, creatinine, electrolytes Evaluate for renal failure from lower urinary tract obstruction Serum blood glucose Evaluate for undiagnosed or uncontrolled diabetes mellitus in neurogenic bladder Prostate-specific antigen Elevated in prostate cancer; may be elevated in benign prostatic hyperplasia, prostatitis, and in the setting of acute urinary retention Imaging studies Renal and bladder ultrasonography Measure post void residual urine; evaluate for bladder and urethral stones, hydronephrosis, and upper urinary tract disease Pelvic ultrasonography; CT of abdomen and pelvis Evaluate for suspected pelvic, abdominal, or retroperitoneal mass or malignancy causing extrinsic bladder neck compression MRI or CT of brain Evaluate for intracranial lesion, including tumor, stroke, multiple sclerosis (MRI preferred in multiple sclerosis) MRI of spine Evaluate for lumbosacral disk herniation, cauda equina syndrome, spinal tumors, spinal cord compression, multiple sclerosis Other Cystoscopy, retrograde cystourethrography Evaluate for suspected bladder tumor and bladder or urethral stones or strictures Urodynamic studies (e.g., uroflowmetry, cystometry, electromyography, urethral pressure profile, video urodynamics, pressure flow studies of micturition) Evaluate bladder function (detrusor muscle and sphincter) in patients with neurogenic bladder to help guide management note: Imaging studies and diagnostic procedures are guided by the clinical context and suspected diagnoses. CT = computed tomography; MRI = magnetic resonance imaging. (8) Bhatt and Flather (2003) found that a vital step regarding management of urinary retention is to evaluate the amount and frequency of the urine that is collected. Character should also be evaluated which includes the assessment of color, odor and specific gravity of urine. A step that confirms the urinary retention is to measure the amount of the intake and output. The intake-output chart is assessed. If the intake is greater than the output, then urinary retention is diagnosed. THERAPEUTIC INTERVENTIONS: As an initial management an increased fluid intake should be recommended. It should not be less than 1500 ml/ 24 hrs. An increased intake of cranberry juice daily is recommended. This keeps the urine acidic. The cranberry juice metabolizes to hippuric acid. The hippuric acid helps to maintain the acidity of urine. The benefit lies in the fact that the acidic urine is less likely to be infected. For the bedridden patients, the equipment like bed pan orinal should be kept within the reach of patient. The patient should be provided privacy. The patient should be encouraged to void urine almost every four hours. Sometimes little useful tips are also helpful. CREDE’S METHOD: The crede’s method performed over bladder is another useful step in the management of urinary retention. This method requires applying pressure over bladder, using hands, by pressing down on the bladder. This procedure is very likely to stimulate the relaxation of the bladder sphincter, thereby allow urination. The Bathanicole causes the stimulation of the parasympathetic nervous system to release the acetylcholine at nerve endings. It also causes an increase in the tone and amplitude of contraction of the smooth muscles of urinary bladder. This drug is good in a way that it has fewer side effects after oral administration. However, some of the side effects include abdominal cramps, sweating and flushing. These side effects are recorded under the therapeutic dose, while an increased dosage results in side effects like malaise, headache, diarrhea, nausea, vomiting, asthmatic attacks, bradycardia, hypotension, atrio-ventricular block and cardiac arrest. Introducing intermittent catheterization is another option for management in such patients. For an indwelling (Foley) catheter, certain protocols should be observed, like: In males, applying a tape with the catheter to secure it with the abdomen prevents the development of a urethral fistula. While in females, the catheter should be secured with a tape attached with the thighs in order to prevent the displacement of the catheter. KEY RECOMMENDATIONS FOR PRACTICE: Clinical recommendation Evidence rating In men with benign prostatic hyperplasia, initiation of treatment with alpha blockers at the time of catheter insertion improves the success rate of trial of voiding without catheter. B Men with urinary retention from benign prostatic hyperplasia should undergo at least one trial of voiding without catheter before surgical intervention is considered. C Prevention of acute urinary retention in men with benign prostatic hyperplasia may be achieved by long-term treatment with 5-alpha reductase inhibitors. B Silver alloy-impregnated urethral catheters reduce the incidence of urinary tract infections in hospitalized patients requiring catheterization for up to 14 days. A Suprapubic catheters improve patient comfort and decrease bacteriuria and recatheterization in patients requiring catheterization for up to 14 days. A Low-friction, hydrophilic-coated catheters increased patient satisfaction and decreased urinary tract infection and hematuria in patients with neurogenic bladder who practice clean, intermittent self-catheterization. A A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion. (8) TWO IMPORTANT PRINCIPLES FOR MANAGING URINARY RETENTION: The patients having urinary retention are at risk of developing certain abnormalities, or complications, which even sometimes can prove to be fatal. Such complications include post renal azotemia, hyperkalemia and metabolic acidosis. In order to avoid such metabolic complications, an appropriate therapy for the fluid balance should be started. Also, the antibiotic therapy should be started side by side. (8) SUMMARY AND CONCLUSION: Management of a patient with stroke demands a serious approach towards the patient. A patient suffering with stroke can present with a number of complications ranging from posture problems like bed sores to infections created by the problem of urinary retention. In addition to urinary retention, such patients can also suffer with the bowel problems including the constipation or diarrhea etc. The treatment of urinary retention is important in a way that if left untreated, it can lead to a number of further complications. This can be understood by the fact that the urine retained in the bladder, due to any reason, like detrusor problem or nerve injury behaves as a stagnant pool of water. This provides a perfect medium of growth for the development multiple organisms. Therefore this result in an ultimate production of bacterial overgrowth, and it can end up as urinary tract infection. In a bed ridden patient like a patient with stroke, such an infection can not be ignored, as the patient already is unable to move, and has a risk of other infections as well, like bed sores, and posture problems. So, the careful management of urinary retention in a patient with stroke is important. There are different approaches for the management of such a patient. Starting from the beginning, a step by step approach can save both the patient from a developing complication, and the physician from the risk of developing any further difficulties. The early management includes the careful monitoring of the urinary voiding pattern. A 48 hourly chart is helpful in this condition. It gives an idea about the amount and frequency of the urine voided by the patient every time. Secondly, if the patient has a feeling of an incomplete voiding, then the amount of the residual urine is measured. It also is an indication for an immediate placement of the urinary catheter, in order to get rid of any residual amount of urine kept in the bladder as it can prone to the development of infections. Tests like urinary culture are performed in order to be sure about the absence of any urinary tract infection. The placement of the urinary catheter demands a need to keep an eye upon the problems like the kinking and patency. BUN and creatinine measurement helps to rule out the difference between the renal failure and urinary tract infection. Increasing the water intake of patient also helps to improve the condition. Offering cranberry juice has proven to be helpful as it helps to keep the urine acidic by converting into hippuric acid, thereby keeping the chances of infection as less as possible. If the catheterization is done, it requires a careful assessment of the hygiene and patency of the catheter. Sometimes Credes method is helpful. It requires the application of slight pressure over the bladder, using hands, thereby allowing the stimulation of the bladder sphincter thus relaxing it and voiding the urine. Therapeutic intervention includes the use of Bathenicol, also called as the Uricholine. Bathenicol acts by increasing the tone and contraction of the urinary smooth muscles. In order to prevent the complications in the patients with urinary retention, the use of antibiotics and the maintenance of the fluid balance prove to be helpful. Thus, urinary retention should be managed carefully, because if left ignored, it can worsen the condition of the patient. REFERENCES: 1. Medical dictionary. Medline plus. [online] 2003 [cited December 14th, 2009]. Available from: http://www2.merriam-webster.com/cgi-bin/mwmednlm?book=Medical&va=stroke 2. Stroke – incidence, mortality, morbidity and risk. PubMed.gov [online] 2004 [cited December 22nd, 2009]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15301227 3. Neurogenic Bladder. eMedicine. [online] 2009 [cited December 24th, 2009]. Available from: http://emedicine.medscape.com/article/453539-overview 4. Urological emergencies – causes, symptoms and management. [online] 2007 [cited December 25th, 2009]. Available from: http://www.pharmj.com/pdf/hp/200711/hp_200711_causes.pdf 5. 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