Bladder Expression

1. Concept

  • Attempted voiding by manual compression of the bladder (Crede Maneuver) or abdominal straining (Valsalva maneuver) to expel the urine 

2. History

  • Origin: unknown
  • Has been recommended since a long time for patients with so-called lower motor neuron lesions
  • For more information, please refer to this.

3. Terminology

  • Bladder expression
  • Passive voiding

4. Purpose of this procedure

  • In order to enable/to facilitate bladder emptying.

5. Possible Indications

  • In patients with a combination of an underactive detrusor (decreased bladder tone, areflexic or hyporeflexic detrusor) with an underactive sphincter (outlet resistance is borderline or decreased due to outlet denervation of smooth or striated sphincter or both) and preferably a flaccid pelvic floor musculature
  • In patients with an surgically created incompetent urethral sphincter mechanism (for example, post-sphincterotomy)
  • Most effective in patients who can generate an intravesical pressure greater than 50cmH2O with this maneuver
  • Abdominal pressure demands function of the upper extremities and are as expected more used by paraplegics than tetraplegics [Hansen 2004]. 
  • The Credé maneuver is more readily performed in a child and it is much easier in a patient with a lean and lax abdominal wall.

6. Contraindications

  • VUR
  • Reflux to the seminal vesicle or vas deferens
  • Genito-rectal prolapse
  • Hernias
  • Recurrent UTIs

7. Procedure

  • Crede maneuver: Compression of suprapubic area downward using both hands in order to press bladder body. This maneuver obviously requires adequate hand control.
  • Valsalva maneuver: A similar increase in intravesical pressure. Sitting and letting the abdomen protrude forward on the thighs and straining. This maneuver obviously requires adequate and voluntary control of the abdominal wall and diaphragmatic muscles.

8. Efficiency

  • These “voiding” methods are unphysiologic and thus are not effective.
    • The Crede and Valsalva maneuvers in the patients studied did not produce voiding. [McGuire 1977]
    • Adaptive funneling of the bladder neck does not develop with these maneuvers.
    • Striated urethral sphincter closure mechanism through reflex may actually occur if the proper reflex arcs are intact.
    • Voiding cystourethrograms during these techniques show a typical bending, deformation and narrowing of the membranous urethra at the level of the pelvic floor. The bladder and its outlet are forced downwards and backwards, while the penile urethra is fixed via the suspensory ligament of penis to the pubic symphysis. Thus the urethra becomes compressed by the pelvic floor musculature. Any further increase of the intraabdominal pressure increases the deformation of the membranous urethra and makes bladder emptying worse [Madersbacher 1977].

9. Clinical Outcomes

  • The prevalence of urologic complications is high among the population having practiced Crede maneuver for more than 20 years to expel urine. Urinary lithiasis in 31.3%, hydronephrosis in 35.1% and renal damage in 16.2%. [Chang 2000]
  • Men are more susceptible to upper urinary tract deterioration than women. [Chang 2000]

10. Advantages

  • Relatively easy procedures for the patients to perform
  • Do not require any additional device

11. Disadvantages

  • Chances of complications:
    • More than 40% of patients showed demonstrable influx into the prostate and the seminal vesicles and other complications, e.g. epididymo-orchitis. [Madersbacher 1977]
    • The high pressures cause reflux into the upper urinary tract with all known complications [Madersbacher 1977]
    • Preexisting VUR is a relative contraindication, especially in patients capable of generating a high intravesical pressure by these maneuvers.
  • If adequate emptying does not take place, other modes of management to decrease outlet resistance should be considered (for example, external sphincterotomy). However, these may cause undesirable urinary continence.

12. Current Significance

  • A case of renal rupture and deterioration of renal function after the Crede” technique in a girl with neurogenic bladder and DSD without VUR [Reinberg 1994].
  • These maneuvers only assure a good quality of life and are cost-effective in long term when the indication is proper and the urodynamic study at initial and regular followup times shows safe throughout the years.

13. Other Comments

  • The intravesical pressure between these voiding maneuvers may be above that associated with upper tract deterioration. Therefore, close follow-up and periodic evaluation are necessary to avoid this complication even though initial urodynamic evaluation showed the upper urinary tract is safe with these maneuvers. For more information, please refer to this.
  • The Crede maneuver is not safe for long-term use in spinal cord injury patients, especially in men [Chang 2000]
  • The most overt misuse in the patient with an areflexic bladder with decreased compliance during filling and storage. In storage phase of such a patient, intravesical pressures may build up silently that are greater enough to cause renal deterioration. These maneuvers under these circumstances obviously aggravate an already dangerous situation.

Key Points of This Section

  • These maneuvers are inefficient methods of bladder empyting.
  • Bladder expression is not safe if urodynamic study prove unsafe.
  • These maneuvers should be replaced by CIC.

References

  • Chang SM, Hou CL, Dong DQ, Zhang H. Urologic status of 74 spinal cord injury patients from the 1976 Tangshan earthquake, and managed for over 20 years using the Crede maneuver. Spinal Cord. 2000 Sep;38(9):552-4.
  • Hansen RB, Biering-Sorensen F, Kristensen JK. Bladder emptying over a period of 10-45 years after a traumatic spinal cord injury. Spinal Cord. 2004 Nov;42(11):631-7. 
  • Madersbacher H. The neuropathic urethra: urethrogram and pathophysiologic aspects. Eur Urol. 1977;3(6):321-32.
  • McGuire EJ. The effects of sacral denervation on bladder and urethral function. Surg Gynecol Obstet. 1977 Mar;144(3):343-6.
  • Reinberg Y, Fleming T, Gonzalez R. Renal rupture after the Crede maneuver. J Pediatr. 1994 Feb;124(2):279-81.

 

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