How are bladder spasms managed?

Management of Bladder Spasms

Bladder spasms should be managed with a stepwise approach beginning with behavioral therapies as first-line treatment, followed by pharmacological interventions including anticholinergics/antimuscarinics, and progressing to more invasive options for refractory cases. 1, 2

Initial Assessment

• Evaluate for underlying causes:
  • Urinary tract infection
  • Bladder outlet obstruction
  • Recent bladder instrumentation or surgery
  • Neurological conditions
  • Medication side effects
• Diagnostic tools:
  • Urinalysis and urine culture to rule out infection
  • Post-void residual (PVR) measurement (values >200-300 mL indicate significant dysfunction) 2
  • Frequency-volume chart/bladder diary to document timing and severity 2

First-Line Management

Behavioral Therapies

• Regular, timed voiding schedule (every 2-3 hours) 2
• Fluid management:
  • Adequate hydration during morning and early afternoon
  • Limiting evening fluid intake
  • Avoiding bladder irritants (caffeine, alcohol, spicy foods) 2
• Pelvic floor muscle exercises (PFMEs) to improve control 2
• Bladder training techniques to increase capacity and control urgency 1

Pharmacological Management

For Mild Bladder Spasms

• Drugs for relieving bladder irritation (e.g., phenazopyridine) 1
• Non-steroidal anti-inflammatory drugs (NSAIDs) 1

For Moderate to Severe Spasms

• Anticholinergic/antimuscarinic medications:
  • Oxybutynin (immediate or extended-release)
  • Tolterodine (immediate or extended-release)
  • Solifenacin
  • Darifenacin
  • Trospium
  • Fesoterodine 1, 3

Important considerations for anticholinergics:

• Contraindicated in narrow-angle glaucoma unless approved by ophthalmologist 1
• Use with extreme caution in patients with impaired gastric emptying or history of urinary retention 1
• Common side effects include dry mouth, constipation, dry eyes, blurred vision 1
• Transdermal preparations (e.g., oxybutynin patch) may be used if dry mouth is a concern 1

For Neurogenic Bladder Spasms

• Alpha-blockers (e.g., terazosin, doxazosin, prazosin) may help with outflow obstruction 1, 2
• Baclofen may be effective for spasms due to spinal cord lesions 4
• For severe cases in spinal cord injury patients, intrathecal baclofen can provide relief 5

Advanced Interventions for Refractory Cases

Botulinum Toxin A (Botox)

• Intravesical injection for detrusor overactivity 6, 3
• Effective when conservative measures and medications fail 3
• Requires specialized administration and monitoring

Nerve Stimulation Techniques

• Sacral nerve stimulation
• Posterior tibial nerve stimulation 3

Regional Anesthetic Techniques

• Lumbar sympathetic blockade at L4 has shown success in managing malignancy-related bladder spasms 7

Special Situations

BCG-Induced Bladder Spasms

For patients receiving BCG treatment for bladder cancer:

1. If symptoms are mild: Continue instillations when symptoms improve within a few days
2. If symptoms persist (>48h) or worsen:
   • Postpone instillation or reduce BCG dose
   • Perform urine culture
   • Start empirical antibiotic treatment (e.g., oral quinolones) 1

Bladder Distention

• Bladder decompression via catheterization if significant distention is present
• Keep bladder volume below 300 mL to improve control 2

Follow-up and Monitoring

• Reassess symptoms using voiding diaries to track improvement
• Follow-up PVR measurements to ensure adequate emptying
• Success defined as ≥50% improvement in symptoms 2

Pitfalls and Caveats

• Anticholinergics should be used with caution in elderly patients due to risk of cognitive impairment
• Rapid decompression of severely distended bladder can lead to complications including post-obstructive diuresis and hematuria 2
• New nighttime symptoms may indicate medical conditions beyond bladder dysfunction requiring further evaluation 2
• Untreated bladder spasms can lead to complications such as urinary tract infections, reduced quality of life, and in severe cases, upper urinary tract damage