Bladder distention

Bladder distention—abnormal enlargement of the bladder—results from an inability to excrete urine, which then accumulates in the bladder. Distention can be caused by a mechanical or anatomic obstruction, a neuromuscular disorder, or the use of certain drugs. 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 it occasionally has a sudden onset. Gradual distention usually causes no symptoms 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. (See Bladder distention: Causes and associated findings, pages 100 and 101.)

Emergency interventions

History and physical examination

If distention isn’t severe, begin by reviewing the patient’s voiding patterns. Find out the time and amount of the patient’s last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva’s or Credé’s maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.

Explore the patient’s history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Ask about his drug history, including his use of over-the-counter drugs.

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, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.

Medical causes

Benign prostatic hyperplasia (BPH)

In BPH, bladder distention develops gradually as the prostate enlarges. Occasionally, its onset is acute. Initially, the patient experiences urinary hesitancy, straining, and frequency; reduced force of and 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 pain is usually the 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’s usually most severe when micturition ceases. The pain may be accompanied by urinary frequency and urgency, terminal hematuria, and dysuria.

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.

Cultural Cue: Bladder cancer is twice as common in Whites as in Blacks. It’s relatively uncommon among Asians, Hispanics, and Native Americans.

Multiple sclerosis

In this neuromuscular disorder, 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. In some patients, urine retention and bladder distention are the only signs.

Cultural Cue: Prostate cancer is more common in Blacks than in other ethnic groups.

Prostatitis

In acute prostatitis, bladder distention occurs rapidly along with perineal discomfort and a sensation of suprapubic fullness. Other signs and symptoms include perineal pain; tense, 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.

Bladder distention is rare in chronic prostatitis, which may be accompanied by perineal discomfort, a sensation of 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 often 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

In urethral calculi, urethral obstruction leads to interrupted urine flow and bladder distention. 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 due to 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.

Special considerations

Monitor the patient’s vital signs and the extent of bladder distention. Encourage the patient to change positions to alleviate discomfort. Provide an analgesic if necessary.

Prepare the patient for diagnostic tests (such as endoscopy and radiologic studies) to determine the cause of bladder distention. You may need to prepare him for surgery if interventions fail to relieve bladder distention and obstruction prevents catheterization.

Pediatric pointers

Look for urine retention and bladder distention in any infant who fails to void normal amounts. (In the first 48 hours of life, an infant excretes about 60 ml of urine; during the next 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.

Patient counseling

If the patient doesn’t require immediate urinary catheterization, provide privacy and suggest that he assume the normal voiding position. Teach him to perform Valsalva’s maneuver, or gently perform Credé’s maneuver. You can also stroke or intermittently apply ice to the inner thigh, or help him relax in a warm tub or sitz bath. 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.

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Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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