Bladder Management

Triggering-Type or Expression Voiding Methods of Bladder Management

Individuals with SCI undergoing inpatient rehabilitation are sometimes taught various maneuvers in order to initiate or attempt spontaneous voiding, termed “expression voiding” as well as to provide a “trigger” to initiate voiding (Wyndaele et al. 2001). Only one study examining these methods met the criteria for inclusion in the present review.

Table 14. Triggering-Type or Expression Voiding Methods

Author Year Country Research Design Score Total Sample Size	Methods	Outcome
Elmelund et al. 2018 Denmark RCT PEDro=3 NInitial=36 NFinal=26	Population: Pelvic floor muscle training (PFMT): Mean age=47yr; Gender: males=0, females=13; Etiology: SCI=11; Myelomeningocele=2. Time since injury=13yr; Inclusion criteria: Women with incomplete spinal cord injury and urinary incontinence. Pelvic floor muscle training combined with intravaginal electrical stimulation (PFMT+IVES): Mean age=59yr; Gender: males=0, females=13; Etiology: SCI=12; Myelominogocele=1; Time since injury=10yr; Inclusion criteria: Women with incomplete spinal cord injury and urinary incontinence. Intervention: Participants in the PFMT groups were instructed to perform 30 near-maximal contractions of 5-10-s followed by 10 s of pause. Participants in the PFMT+IVES were to perform the same exercises but with the addition of vaginal electrical stimulation during the exercises using an electrical stimulation device. Two stimulation programs were used; intermittent stimulation (40 Hz, 250 microsecond pulse width applied for 7.5-10 min during exercises with 5-10 s of stimulation followed by 10-s breaks), and continuous stimulation (10 Hz, 250 microsecond pulse width applied for 10-20 min). Outcome measures were assessed at baseline, post-intervention (week 12), and follow-up (week 24). Both groups performed the intervention on a daily basis for 12 wk. Outcome Measures: Reflectometry: opening urethral pressure-squeezing (OUP-squeezing); OPU-resting; Self-reported outcomes: daily episodes of urinary incontinence (UI); mean bladder capacity; max bladder capacity; daily voiding episodes (VE).	1. Participants in the PFMT group showed significant decreases in OUP-squeezing, OUP-resting, and a significant increase in IE when comparing baseline to post-intervention (at 12 weeks) (p<0.05). There were no significant differences in participant-reported mean bladder capacity, max bladder capacity, and VE when comparing baseline to post-intervention (p>0.05). 2. Participants in the PFMT+IVES showed no significant differences for any of the variables indicated when comparing baseline to post-intervention (p>0.05). 3. PFMT was only more effective for OUP-resting when comparing baseline to post-intervention (p=0.018). 4. When comparing baseline to follow up (24 weeks), PFMT showed significant increases in UI and max bladder capacity (p<0.05). 5. PFMT+IVES showed no significant differences in outcomes when comparing 24 wk follow-up to baseline (p>0.05). 6. There was no significant difference in the effectiveness of both interventions for all outcomes when comparing baseline to the 24 wk follow-up (p>0.05).
Shendy et al. 2015 Egypt RCT PEDro=6 N=30	Population: Transcutaneous electrical nerve stimulation (TENS group): Mean age=28.1 yr; Pelvic floor biofeedback (PFBFB group): Mean age=28.3 yr. Intervention: Individuals with precipitancy overactive bladder and erectile dysfunction were randomized to 1) TENS, which involved two surface electrodes placed directly over the skin of S2 for 30 min at 50 Hz (n=15) or 2) PFBFB, which involved contraction of the pelvic floor muscles in the fowler lying position while watching the electromyography biofeedback activities (n=15). Both groups performed pelvic floor exercises, 90 contractions per day after training session. Outcome Measures: Bladder volume at first desire to void, maximum bladder capacity, maximum flow rate, detrusor pressure at maximum flow rate, right side amplitude per time (A/T), left side A/T, right side upper centile amplitude (UCA), left side UCA, International Index of Erectile Function Questionnaire (IIEF-5).	1. After treatment, bladder volume at first desire to void (p=0.001), maximum cystometric capacity (p=0.001), detrusor pressure at maximum flow rate (p=0.002), and maximum flow rate (p=0.001) significantly increased in TENS group but only the maximum flow rate (p=0.042) significantly increased in the PFBFB group. There were no significant differences between groups, except for the detrusor pressure at maximum flow rate being significantly higher in the TENS group both before (p=0.008) and after (p=0.001) treatment. 2. Post-treatment, the TENS group had significantly higher right side A/T (p=0.001), left side A/T (p=0.001), right side UCA (p=0.029), left side UCE (p=0.041), and IIEF-5 (p=0.013) compared to PFBFB group. 3. In terms of right side A/T, left side A/T, right side UCA, left side UCA, and IIEF-5, the PFBFB group did not have any significant increases post-treatment while TENS had significant increases post-treatment (p=0.001).
Xia et al. 2014 China RCT PEDro=6 N=42	Population: Neurogenic bladder; Treatment group: Mean age: 37.2 yr, Gender: males=13, females=8; Time post-injury: 2.4 mo; Control group: Mean age: 37.5 yr; Gender: males=14, females=7; Mean time post-injury: 2.6 mo. Intervention: Individuals were randomized to 1) Treatment group (n=21): Acupuncture treatment, consisting of 10 stimulations over 2 weeks or 2) Control group (n=21): Bladder training, including interval water drinking, timed voiding, and intermittent catheterization. Outcome Measures: Bladder capacity, residual urine volume, bladder pressure, rectal pressure, detrusor pressure, bladder compliance, International Prostate Symptom Score (IPSS), and efficacy rate.	1. Compared with control group, the treatment group had significantly increased bladder capacity and compliance, and significantly reduced residual urine volume, bladder pressure, rectal pressure, and detrusor pressure (p<0.05). 2. IPSS values for both groups were significantly lower post-treatment (p<0.05), with treatment group scores significantly lower than control group score (p<0.05). 3. The total efficacy rate in the treatment group was significantly higher than the control group (p=0.043).
Greenstein et al. 1992 USA Case Series N=5	Population: SCI: Age: 29-58 yr; Gender: males=5, females=0; Level of injury: paraplegia, upper motor neuron bladder=3, lower motor neuron bladder=2; Severity of injury: complete=1, incomplete=4; Time post-injury=2.5-34 yr. Intervention: Voiding by Valsalva (n=4) or Crede maneuver (n=1) Outcome Measures: Urodynamics: bladder pressure at end of filling and during voiding, external sphincter activity, renal function/anatomy, and urinary tract infections (UTIs).	1. The Valsalva procedure enabled bladder emptying in 4 and the Crede procedure in 1 people. 2. Max. intravesical pressure during voiding ranged from 95–160cm H2O 3. 2 of 5 people developed significant vesicoureteral reflux. 1 also had impaired renal function and hydronephrosis which resolved when switched to IC 4. 3 had symptomatic UTIs and 1 had an asymptomatic UTI.

Author Year

Country

Research Design

Score

Total Sample Size

Methods

Outcome

Elmelund et al. 2018

Denmark

RCT

PEDro=3

NInitial=36

NFinal=26

Population: Pelvic floor muscle training (PFMT): Mean age=47yr; Gender: males=0, females=13; Etiology: SCI=11; Myelomeningocele=2. Time since injury=13yr; Inclusion criteria: Women with incomplete spinal cord injury and urinary incontinence.

Pelvic floor muscle training combined with intravaginal electrical stimulation (PFMT+IVES): Mean age=59yr; Gender: males=0, females=13; Etiology: SCI=12; Myelominogocele=1; Time since injury=10yr; Inclusion criteria: Women with incomplete spinal cord injury and urinary incontinence.

Intervention: Participants in the PFMT groups were instructed to perform 30 near-maximal contractions of 5-10-s followed by 10 s of pause. Participants in the PFMT+IVES were to perform the same exercises but with the addition of vaginal electrical stimulation during the exercises using an electrical stimulation device. Two stimulation programs were used; intermittent stimulation (40 Hz, 250 microsecond pulse width applied for 7.5-10 min during exercises with 5-10 s of stimulation followed by 10-s breaks), and continuous stimulation (10 Hz, 250 microsecond pulse width applied for 10-20 min). Outcome measures were assessed at baseline, post-intervention (week 12), and follow-up (week 24). Both groups performed the intervention on a daily basis for 12 wk.

Outcome Measures: Reflectometry: opening urethral pressure-squeezing (OUP-squeezing); OPU-resting; Self-reported outcomes: daily episodes of urinary incontinence (UI); mean bladder capacity; max bladder capacity; daily voiding episodes (VE).

1. Participants in the PFMT group showed significant decreases in OUP-squeezing, OUP-resting, and a significant increase in IE when comparing baseline to post-intervention (at 12 weeks) (p<0.05). There were no significant differences in participant-reported mean bladder capacity, max bladder capacity, and VE when comparing baseline to post-intervention (p>0.05).

2. Participants in the PFMT+IVES showed no significant differences for any of the variables indicated when comparing baseline to post-intervention (p>0.05).

3. PFMT was only more effective for OUP-resting when comparing baseline to post-intervention (p=0.018).

4. When comparing baseline to follow up (24 weeks), PFMT showed significant increases in UI and max bladder capacity (p<0.05). 5. PFMT+IVES showed no significant differences in outcomes when comparing 24 wk follow-up to baseline (p>0.05).

6. There was no significant difference in the effectiveness of both interventions for all outcomes when comparing baseline to the 24 wk follow-up (p>0.05).

Shendy et al. 2015

Egypt

RCT

PEDro=6

N=30

Population: Transcutaneous electrical nerve stimulation (TENS group): Mean age=28.1 yr; Pelvic floor biofeedback (PFBFB group): Mean age=28.3 yr.

Intervention: Individuals with precipitancy overactive bladder and erectile dysfunction were randomized to 1) TENS, which involved two surface electrodes placed directly over the skin of S2 for 30 min at 50 Hz (n=15) or 2) PFBFB, which involved contraction of the pelvic floor muscles in the fowler lying position while watching the electromyography biofeedback activities (n=15). Both groups performed pelvic floor exercises, 90 contractions per day after training session.

Outcome Measures: Bladder volume at first desire to void, maximum bladder capacity, maximum flow rate, detrusor pressure at maximum flow rate, right side amplitude per time (A/T), left side A/T, right side upper centile amplitude (UCA), left side UCA, International Index of Erectile Function Questionnaire (IIEF-5).

1. After treatment, bladder volume at first desire to void (p=0.001), maximum cystometric capacity (p=0.001), detrusor pressure at maximum flow rate (p=0.002), and maximum flow rate (p=0.001) significantly increased in TENS group but only the maximum flow rate (p=0.042) significantly increased in the PFBFB group. There were no significant differences between groups, except for the detrusor pressure at maximum flow rate being significantly higher in the TENS group both before (p=0.008) and after (p=0.001) treatment.

2. Post-treatment, the TENS group had significantly higher right side A/T (p=0.001), left side A/T (p=0.001), right side UCA (p=0.029), left side UCE (p=0.041), and IIEF-5 (p=0.013) compared to PFBFB group.

3. In terms of right side A/T, left side A/T, right side UCA, left side UCA, and IIEF-5, the PFBFB group did not have any significant increases post-treatment while TENS had significant increases post-treatment (p=0.001).

Xia et al. 2014

China

RCT

PEDro=6

N=42

Population: Neurogenic bladder; Treatment group: Mean age: 37.2 yr, Gender: males=13, females=8; Time post-injury: 2.4 mo; Control group: Mean age: 37.5 yr; Gender: males=14, females=7; Mean time post-injury: 2.6 mo.

Intervention: Individuals were randomized to 1) Treatment group (n=21): Acupuncture treatment, consisting of 10 stimulations over 2 weeks or 2) Control group (n=21): Bladder training, including interval water drinking, timed voiding, and intermittent catheterization.

Outcome Measures: Bladder capacity, residual urine volume, bladder pressure, rectal pressure, detrusor pressure, bladder compliance, International Prostate Symptom Score (IPSS), and efficacy rate.

1. Compared with control group, the treatment group had significantly increased bladder capacity and compliance, and significantly reduced residual urine volume, bladder pressure, rectal pressure, and detrusor pressure (p<0.05).

2. IPSS values for both groups were significantly lower post-treatment (p<0.05), with treatment group scores significantly lower than control group score (p<0.05).

3. The total efficacy rate in the treatment group was significantly higher than the control group (p=0.043).

Greenstein et al. 1992

USA

Case Series

N=5

Population: SCI: Age: 29-58 yr; Gender: males=5, females=0; Level of injury: paraplegia, upper motor neuron bladder=3, lower motor neuron bladder=2; Severity of injury: complete=1, incomplete=4; Time post-injury=2.5-34 yr.

Intervention: Voiding by Valsalva (n=4) or Crede maneuver (n=1)

Outcome Measures: Urodynamics: bladder pressure at end of filling and during voiding, external sphincter activity, renal function/anatomy, and urinary tract infections (UTIs).

1. The Valsalva procedure enabled bladder emptying in 4 and the Crede procedure in 1 people.

2. Max. intravesical pressure during voiding ranged from 95–160cm H2O

3. 2 of 5 people developed significant vesicoureteral reflux. 1 also had impaired renal function and hydronephrosis which resolved when switched to IC

4. 3 had symptomatic UTIs and 1 had an asymptomatic UTI.

Note: IC=Intermittent Catheters; UTI=Urinary Tract Infection

Discussion

Greenstein et al. (1992) documented the use of Valsalva (n=4) and Crede (n=1) maneuvers to initiate spontaneous voiding in a small case series of five males with paraplegia (upper motor neuron bladder=3, lower motor neuron bladder=2). Greenstein et al. (1992) note that “Valsalva is defined as increased abdominal pressure using the diaphragm and/or abdominal musculature. The Crede maneuver is suprapubic manual pressure applied over the bladder” (p. 254). Greenstein et al. (1992) intended to examine the potential for long-term complications in those who employed these techniques over an extended period of time. High intravesical pressure was documented during voiding. The authors suggested that long-term monitoring for these individuals is advisable and intermittent catheterization should replace these methods in the event of urological complications. Triggered voiding and use of the Crede maneuver to initiate “voiding” should only be considered in patients with normal upper tracts, provided that urodynamic studies demonstrate low pressure storage and “voiding”, and that there is a low incidence of UTI.

Conclusion

There is level 4 evidence (from one case series study: Greenstein et al. 1992) that triggering mechanisms such as the Valsalva or Crede maneuvers may assist some individuals with neurogenic bladder in emptying their bladders without catheterization; however, high intra-vesical voiding pressures can occur which can lead to renal complications.

Valsalva or Crede maneuver may assist some individuals to void spontaneously but produce high intra-vesical pressure, increasing the risk for long-term complications.

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