Abstract
Background
B
Differential Diagnosis
Common etiologies of bladder spasms include a urinary tract infection (UTI), ingestion of chemical irritants such as diet soda or caffeine, constipation, obstruction of the bladder outflow tract (e.g., nonemptying catheter from blood clots), disinhibition from interruption of upper motor neurons, or irritation of the detrusor muscle from a tumor, catheter, or intramural stone. 2 Medications can also lead to spasms either by bladder irritation (e.g., diuretics) or disruption of the detrusor muscle or bladder outlet (e.g., opioids, anticholinergics, benzodiazepines, and NSAIDs).3,4 See Fast Fact #287.
Clinical Evaluation of Bladder Spasms
1. Determine whether the bladder is emptying properly. If not, consider urethral catheterization (see hereunder).
• In the inpatient setting, a portable ultrasound can be used to check the postvoid residual (PVR) urine in the bladder. Of note, PVRs obtained by portable ultrasound can be difficult to interpret. In general, clinicians should look for an acute increase in PVR values (e.g., from 200 to 450 mL) in the setting of acute bladder spasm(s), rather than an arbitrary threshold volume. 5
• In the home or hospice setting, physical examination of the suprapubic area for bladder fullness and patient report can guide the nonhospital clinician in evaluating bladder emptying.
2. Evaluate for easily reversible causes—for example, stop offending agents and treat constipation.
3. Exclude UTI with a urinalysis (UA). If an indwelling catheter is in place, it should be changed, and an urine culture should be sent from the new catheter as soon as it is placed.
Clinical Management
Multiple nonpharmacologic and pharmacologic therapies exist and may be used in combination (Table 1). In general, start with the least invasive approach. Diagnostic imaging and/or a urology referral may be warranted in refractory cases, especially when acute urinary retention is encountered. 6
TID, three times daily; ER, extended release; IR, immediate release; BID, two times daily; QID, four times daily; PO, by mouth.
Urethral catheterization
Most experts prefer intermittent catheterization for ambulatory patients with longer prognoses to minimize infection risk. In moribund patients who are dying, indwelling catheterization is often preferred by patients, clinicians, and caregivers.1,7 Caregivers should be informed of the following catheter management tips:
• Pull gently on the tubing so the tip is not pushing against the bladder wall. • Ensure appropriate catheter drainage by irrigating with saline, elevating and dropping the tubing to minimize airlocks, and avoiding large uphill loops that may impede drainage by gravity. • Consider upsizing catheter to improve drainage. • Palpate the catheter for hardness and consider changing to a softer catheter with a shorter tip. • Use securing devices or tape to prevent pulling of the tubing against the bladder neck.7,8
Interventional procedures
• Onabotulinum toxin injection to the detrusor muscle may improve spasms even in the setting of an indwelling catheter. 13 Urinary retention is a known side effect.
• Surgical resection of bladder tumors or lithotripsy of stones.
• Pelvic physical therapy: consider when hypertonic levator muscle dysfunction is source of discomfort.
• Other: use of intravesical baclofen or bupivacaine infused through an indwelling catheter has been reported, as have nerve blocks. 14 A pessary can be considered if anterior vaginal wall prolapse is present (requires trained fitter).