What is the treatment for bowel and bladder dysfunction in a patient with a cerebral vascular accident (CVA) or stroke?

From the Guidelines

To treat bowel and bladder dysfunction in a patient with a cerebral vascular accident (CVA) or stroke, a comprehensive approach involving both medical and supportive care is essential, starting with the removal of the Foley catheter within 24 hours after admission and implementing a bladder-training program with timed and prompted toileting on a consistent schedule, as well as a bowel management program for persistent constipation or bowel incontinence. For urinary incontinence, assessment of bladder function and cognitive awareness of the need to void is crucial 1. Scheduled toileting every 2-3 hours during waking hours can help manage urinary incontinence, and medications such as oxybutynin or tolterodine may be considered for overactive bladder symptoms 1. Urinary retention may require intermittent catheterization or an indwelling catheter temporarily, with the use of a portable ultrasound machine recommended for assessing post-void residual 1. For bowel management, establishing a regular toileting schedule, preferably after meals to take advantage of the gastrocolic reflex, and ensuring adequate fluid intake and fiber consumption are key 1. Consideration of stool softeners like docusate sodium for constipation or loperamide for diarrhea may also be necessary, with physical therapy focusing on pelvic floor exercises helping to improve muscle control for both functions 1. Regular reassessment is important as recovery progresses, with the goal of transitioning to more independent management as the patient's condition improves, and addressing the neurological disruption to normal bladder and bowel control pathways caused by the stroke to prevent complications like urinary tract infections or fecal impaction 1.

Some key points to consider in the management of bowel and bladder dysfunction in stroke patients include:

• Removal of the Foley catheter within 24 hours after admission to prevent catheter-associated urinary tract infections 1
• Assessment of bladder function and cognitive awareness of the need to void 1
• Implementation of a bladder-training program with timed and prompted toileting on a consistent schedule 1
• Establishment of a regular toileting schedule for bowel management, preferably after meals 1
• Ensuring adequate fluid intake and fiber consumption for bowel management 1
• Consideration of medications and physical therapy to improve muscle control for both functions 1

From the Research

Treatment Options for Bowel and Bladder Dysfunction

• The treatment for bowel and bladder dysfunction in patients with cerebral vascular accident (CVA) or stroke is tailored to the individual patient's needs and goals 2.
• Behavioral techniques, lifestyle interventions, and anticholinergic medication are commonly used treatment options 3.
• Other therapeutic choices include alternative drugs, intradetrusor injection of botulinum toxin, and spinal neuromodulation 3.
• A bladder rehabilitation program is essential for improving post-stroke lower urinary symptoms and depends on the patient's awareness, cooperation, and independence 3.

Diagnosis and Assessment

• Medical history, including voiding diary, physical examination, and urodynamic studies are useful in establishing a diagnosis of bladder dysfunction following stroke 3.
• Urodynamic studies can reveal bladder hyper- or hyporeflexia, detrusor overactivity with impaired contractility or detrusor-sphincter dyssynergia, or even no abnormalities at all 3.
• Assessment-guided therapy, including distinction of stress or urge urinary incontinence and the assessment of different forms of urinary incontinence, can help manage urinary incontinence after stroke 4.

Effectiveness of Interventions

• Scheduled voiding is a useful first-line treatment in many cases of incontinence 5.
• Professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence and related symptoms after stroke 6.
• Acupuncture therapy has been reported to reduce urinary incontinence, but the quality of the studies is a concern 6.
• Pharmacotherapy and hormonal interventions, such as meclofenoxate, oxybutinin, and oestrogen, have been studied, but the evidence is limited and inconclusive 6.