Bladder distention
Bladder distention: Excerpt from Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
Bladder distention is an abnormal enlargement of the bladder due to the accumulation of urine arising from an inability to excrete urine. Distention can be caused by a mechanical or anatomic obstruction, neuromuscular disorder, or the use of certain drugs. Although it’s relatively common in all ages and both sexes, it’s most common in older men with prostate disorders that cause urine retention.
Distention usually develops gradually, but the onset can also be sudden. Gradual distention usually remains asymptomatic until stretching of the bladder produces discomfort. Acute distention produces suprapubic fullness, pressure, and pain. If severe distention isn’t corrected promptly by catheterization or massage, the bladder rises within the abdomen, its walls become thin, and renal function can be impaired.
Bladder distention is aggravated by the intake of caffeine, alcohol, large quantities of fluid, and diuretics.
Act Now: If the patient has severe distention, insert an indwelling urinary catheter to help relieve discomfort and prevent bladder rupture. If greater than 700 ml is emptied from the bladder, compressed blood vessels dilate and may make the patient feel faint. Typically, the indwelling catheter is clamped for 30 to 60 minutes to permit vessel compensation.
Assessment
History
Ask the patient about voiding patterns, the time and amount of the last voiding, and the amount of fluid he consumed since the last voiding. Does he have a history of difficulty when urinating? Ask whether Valsalva’s maneuver or Credé’s maneuver is required to initiate urination. Does he experience an urgent need to urinate? Does the urge to urinate arise without warning? Is urination painful or irritating? Ask about the force and continuity of the urine stream and whether the bladder is empty after voiding.
Assess the patient’s history for the presence of a urinary tract obstruction or infections, venereal disease, lower abdominal or urinary tract trauma, systemic or neurologic disorders, and neurologic, intestinal, or pelvic surgery. Note medication history, including the use of over-the-counter or recreational drugs.
Physical examination
Take the patient’s vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can’t be palpated through the abdominal wall.) Inspect the urethral meatus. Document the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
Pediatric pointers
Look for urine retention and bladder distention in an infant who fails to void normal amounts. (In the first 48 hours of life, an infant excretes about 60 ml of urine; during the following week, he excretes about 300 ml of urine daily.) In males, posterior urethral valves, meatal stenosis, phimosis, spinal cord anomalies, bladder diverticula, and other congenital defects may cause urinary obstruction and resultant bladder distention.
Geriatric pointers
Pre-existing disease states may hamper adequate assessment of bladder distention in elderly patients.
Medical causes
See Bladder distention: Causes and associated findings, pages 46 and 47.
Benign prostatic hyperplasia (BPH)
With BPH, bladder distention gradually develops as the prostate enlarges. Occasionally, its onset is acute. Initially, the patient experiences urinary hesitancy, straining, and frequency; reduced force of and the inability to stop the urine stream; nocturia; and postvoiding dribbling. As the disorder progresses, it produces prostate enlargement, sensations of suprapubic fullness and incomplete bladder emptying, perineal pain, constipation, and hematuria.
Bladder calculi
Bladder calculi may produce bladder distention, but more commonly it produces pain as its only symptom. The pain is usually referred to the tip of the penis, the vulvar area, the lower back, or the heel. It worsens during walking or exercise and abates when the patient lies down. It can be accompanied by urinary frequency and urgency, terminal hematuria, and dysuria. Pain is usually most severe when micturition ceases.
Bladder cancer
By blocking the urethral orifice, neoplasms can cause bladder distention. Associated signs and symptoms include hematuria (most common sign); urinary frequency and urgency; nocturia; dysuria; pyuria; pain in the bladder, rectum, pelvis, flank, back, or legs; vomiting; diarrhea; and sleeplessness. A mass may be palpable on bimanual examination.
Multiple sclerosis (MS)
With MS, urine retention and bladder distention result from interruption of upper motor neuron control of the bladder. Associated signs and symptoms include optic neuritis, paresthesia, impaired position and vibratory senses, diplopia, nystagmus, dizziness, abnormal reflexes, dysarthria, muscle weakness, emotional lability, Lhermitte’s sign (transient, electric-like shocks that spread down the body when the head is flexed), Babinski’s sign, and ataxia.
Prostate cancer
Prostate cancer eventually causes bladder distention in about 25% of patients. Usual signs and symptoms include dysuria, urinary frequency and urgency, nocturia, weight loss, fatigue, perineal pain, constipation, and induration of the prostate or a rigid, irregular prostate on digital rectal examination. For some patients, urine retention and bladder distention are the only signs.
Prostatitis
With acute prostatitis, bladder distention occurs rapidly along with perineal discomfort and suprapubic fullness. Other signs and symptoms include perineal pain; tense, a boggy, tender, and warm enlarged prostate; decreased libido; impotence; decreased force of the urine stream; dysuria; hematuria; and urinary frequency and urgency. Additional signs and symptoms include fatigue, malaise, myalgia, fever, chills, nausea, and vomiting.
With chronic prostatitis, bladder distention is rare. However, it may be accompanied by sensations of perineal discomfort and suprapubic fullness, prostatic tenderness, decreased libido, urinary frequency and urgency, dysuria, pyuria, hematuria, persistent urethral discharge, ejaculatory pain, and dull pain radiating to the lower back, buttocks, penis, or perineum.
Spinal neoplasms
Disrupting upper neuron control of the bladder, spinal neoplasms cause neurogenic bladder and resultant distention. Associated signs and symptoms include a sense of pelvic fullness, continuous overflow dribbling, back pain that usually mimics sciatica pain, constipation, tender vertebral processes, sensory deficits, and muscle weakness, flaccidity, and atrophy. Signs and symptoms of urinary tract infection (dysuria, urinary frequency and urgency, nocturia, tenesmus, hematuria, and weakness) may also occur.
Urethral calculi
With urethral calculi, urethral obstruction leads to bladder distention. The patient experiences interrupted urine flow. The obstruction causes pain radiating to the penis or vulva and referred to the perineum or rectum. It may also produce a palpable stone and urethral discharge.
Urethral stricture
Urethral stricture results in urine retention and bladder distention with chronic urethral discharge (most common sign), urinary frequency (also common), dysuria, urgency, decreased force and diameter of the urine stream, and pyuria. Urinoma and urosepsis may also develop.
Other causes
Catheterization
Using an indwelling urinary catheter can result in urine retention and bladder distention. While the catheter is in place, inadequate drainage due to kinked tubing or an occluded lumen may lead to urine retention. In addition, a misplaced urinary catheter or irritation with catheter removal may cause edema, thereby blocking urine outflow.
Drugs
Parasympatholytics, anticholinergics, ganglionic blockers, sedatives, anesthetics, and opiates can produce urine retention and bladder distention.
Nursing considerations
Monitor the patient’s vital signs and the extent of bladder distention. Obtain bladder urinary volume with a bladder scanner. Encourage the patient to change positions to alleviate discomfort. Administer medications for pain relief.
Prepare the patient for diagnostic tests, such as endoscopy and radiologic studies, to determine the cause of bladder distention. Withhold fluids and food if surgery is indicated.
Patient teaching
If the patient doesn’t require immediate urinary catheterization, provide privacy and suggest that a normal voiding position be assumed. Teach Valsalva’s maneuver, or gently perform Credé’s maneuver. Use the power of suggestion to stimulate voiding. For example, run water in the sink, pour warm water over his perineum, place his hands in warm water, or play tapes of aquatic sounds.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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