After a Spinal Cord Injury (SCI) the nerves to and from your bladder are affected. The connection from the spinal cord to the brain is interrupted and the bladder can no longer empty on demand. You may not be able to feel when your bladder is full.
Management of your bladder after SCI is possible with a proper bladder routine and good planning/habits.
- How the urinary system works
- What Do I Need to Know?
- Neurogenic bladder
- Spastic/Reflexic bladder
- Flaccid/Areflexic bladder
- Common complications of neurogenic bladder
- What Can I Do?
- Preventing complications
- The importance of a bladder management program
- Who Can Help Me?
- Conclusion & Resources
INTRODUCTION TO THE URINARY SYSTEM
How the urinary system works
The function of the kidneys is to filter the blood and remove excess water and waste materials, turning them into urine. From the kidneys, the urine flows down small tubes called ureters into the bladder.
The bladder is a sac lined with muscle; called the detrusor muscle that stores urine until it can be eliminated from the body. At the exit from the bladder, a circular outlet muscle called the sphincter acts as a gate; when the sphincter muscle contracts, it tightens and prevents urine from flowing; when the sphincter relaxes, it allows urine to flow out through the urethra.
Normally, the process of urination requires coordination between different sets of nerves and muscles. First, sensory messages tell your brain that your bladder is full. Then, when you want to urinate, you can open the sphincter and allow the muscle lining the bladder wall to contract, squeezing the urine out of the bladder.
WHAT DO I NEED TO KNOW?
A spinal cord injury can interrupt the coordination between the brain and bladder causing changes to urination. When the functioning of the urinary system is affected by spinal cord injury, the result is a condition called neurogenic bladder. Everyone’s situation is different and requires individual evaluation and management.
Types of neurogenic bladder
Spastic bladder (reflexic): A spastic or reflexic bladder is from an Upper Motor Neuron (UMN) spinal cord injury at or above T12.
The bladder and sphincter muscles become tight and spastic. The partial or total loss of communication from the brain can limit ability to feel bladder fullness and control the sphincter muscle to hold the urine in. The bladder is spastic (overactive) causing involuntary reflex voiding and incontinence. There can also be loss of coordination between the bladder and sphincter muscle called detrusor sphincter dyssynergia (DSD). This is where the bladder contracts to empty but the sphincter muscle stays tight. When this happens the urine can be forced back up the ureters to the kidneys (called reflux), possibly causing kidney damage.
Flaccid bladder (areflexic): A flaccid or areflexic bladder is from a Lower Motor Neuron (LMN) spinal cord injury below T12.
The partial or total loss of communication from the brain limits the ability to feel bladder fullness. The bladder muscle cannot contract to empty the bladder causing it to overfill (urinary retention); this can cause urine to be forced back up the ureters to the kidneys (called reflux), possibly causing kidney damage. The sphincter muscle may also be relaxed causing urine to leak out when the bladder overfills or with coughing, sneezing and activities such as transfers, lifting and playing sports.
People with spinal cord injury need to be aware of possible complications so they can take steps to prevent them. See below for the most common recurring complications of living with a neurogenic bladder:
Urinary Tract Infections (UTI)
Urinary Tract Infection (UTI): Typically, bacteria enter the urinary tract at the urethra. Bacteria can then migrate to the bladder and multiply. It is important to note that the presence of bacteria in the bladder does not necessarily mean treatment with antibiotics is needed. If you use a catheter, it is highly likely that you have bacteria present in your urine but bacteria alone does not indicate an infection.
However, growth of a new bacteria in your bladder or in a place that you don’t usually have bacteria could be a serious infection in need of proper treatment. Early signs of an infection include cloudy, foul-smelling urine and/or sediment (gritty particles) or mucus in the urine (or in your catheter tube or drainage bag), a need to urinate more often, and more urgently.
More serious symptoms may include blood or pus in the urine, fever, chills, nausea, headache, increase of muscle spasms, and autonomic dysreflexia (injuries above T6). If you experience these symptoms you should see a doctor immediately.
Urinary stones can cause recurring UTI’s, fever, chills and blood in the urine.
Your health care provider (family doctor, physiatrist, etc.) can help determine whether you have urinary stones and how to treat them. Treatment often requires a cystoscopy by a urologist.
Wetting/Leakage: Can be caused by UTI, bladder stones or overfilling of bladder.
Detrusor/Sphincter Dyssynergia (DSD)
Detrusor/Sphincter Dyssynergia (DSD): Occurs when the sphincter muscle does not relax when the bladder muscle contracts. When these uncoordinated muscle contractions happen, the urine cannot flow through the urethra or the flow is interrupted. This results in the urine backing up into the kidneys, which is called “reflux” and can be a long-term risk to your kidney health. This condition is often monitored by regular ultrasound of the kidneys.
Often with dyssynergia the bladder may not empty completely resulting in residual urine left which can increase risk for UTI.
Autonomic Dysreflexia (AD): AD is a sudden rise in blood pressure in response to an irritating stimulus below the level of injury, typically for someone who has an injury at T6 and above.
It can be a complication of bladder management, commonly due to a full bladder. It is a medical emergency if not treated immediately.
Kidney Damage: Caused by a high pressure bladder and reflux.
Bladder Cancer: Evidence shows a potential increased risk of developing bladder cancers with long time use of indwelling catheters.
WHAT CAN I DO?
What you can do to manage your bladder health
Over time you may come to recognize patterns of symptoms that are typical for you. When you know the signs of a urinary tract infection, you should contact your family doctor who can help you with advice and treatment. Make sure you follow their advice carefully, and take all your medication if prescribed.
If you have more serious symptoms such as a high fever, back pain and AD, seek more immediate help. If you have problems with repeated UTIs over time, this may indicate a problem with your bladder program.
As a person with a spinal cord injury, you are at risk for a number of potential urinary system complications. Healthy habits and proper bladder care is the best way to prevent problems and maintain your short and long term health.
For the health of your urinary system here are some basic recommendations:
DID YOU KNOW?
High fever and back pain are serious symptoms of UTI. Seek more immediate help!
A recommended amount for fluid intake for those on intermittent catheters or spontaneous voiding is 2000 mL in a 24 hour period. For people with foley catheters the recommendation is to drink between 2000-3000 mL of fluids. Caffeinated and alcoholic beverages are not a part of this recommended daily fluid intake. Drink adequate healthy fluids (e.g. water and juices) and space them throughout the day.
Empty your bladder regularly
If you use intermittent catheterization: keep your urine output volumes below 500 mL each time to ensure your bladder is emptied on a regular basis.
If you use a collection bag, ensure the bag is emptied when it is 1/2 to 3/4 full so that your bladder can drain adequately.
Follow your bladder schedule
Adhere to your bladder management routine.
Review technique regularly
Review your catheter technique regularly with an outpatient nurse clinician, a urologist or physiatrist. Urological health can change over time, and tools and supplies change and improve. It’s useful to periodically review your technique to ensure you are reducing your risk of infections and preventing complications.
Regular follow-up is essential
Remember to keep annual follow ups with a urologist once a year and ensure you get the recommended periodic tests of neurogenic bladder health: renal (kidney) ultrasound, cystoscopy, and urodynamics.
Limit the use of antibiotics
Antibiotics are a crucial tool for infection, but routine use can result in antibiotic-resistant infection and require more involved treatment and higher risks. Antibiotics are also very hard on your intestinal flora which can affect your bowel management. Take antibiotics only when prescribed and recommended to you by a physician, and always take the full course of antibiotics when they are prescribed.
Keep a bladder diary
Bladder Diaries are a helpful tool in looking at volumes of intake; types of fluids and when they are consumed. It measures urine volumes, night time voiding, frequency, leaking or incontinence. This information is baseline information that helps a clinician approach treatment and recommendations.
Understand the importance of a Bladder Management Program
A bladder management program will allow you to empty your bladder in a way that is suitable to you. Depending on your level of injury, there will be different methods to empty your bladder and keep your urinary system healthy. You’ll work with your health care team to develop, monitor and change your bladder management program.
The method you use depends on the needs of your urinary system and other circumstances like your ability to perform your own self-care or to get assistance.
Method Options are:
- Intermittent catheterization(IC) – this involves inserting a catheter into the bladder on a regular schedule to empty the bladder. It is important to use good technique and proper cleanliness when you use IC, in order to reduce the risk of infections.
- Indwelling catheters – also known as a Foley catheter. In this case, the catheter stays in the bladder and continually drains into a collection bag and is usually changed once per month. The indwelling catheter may be inserted into the bladder via the urethra or into the lower abdomen; called a supra pubic catheter. Since indwelling catheters have the most long-term complications, your health care team will only use them as a last resort when other methods are not an option.
- External Condom Catheters – a condom connected to a urine drainage bag, used for males only.
Understanding how to manage your bladder after a spinal cord injury is a very important part of staying healthy. Over time, you will adapt your bladder program to changes in your body and your lifestyle, and as you learn more, you will become more skilled in your self-care.
From time to time, you may encounter problems with your bladder program. Leaks and incontinence, UTIs and other complications can have a major impact on your daily life.
When you’re having a problem and you’re not sure what to do, the best option is to use this problem-solving approach to tackle it:
Step 1: Identify the problem. Start by getting a clear picture of what’s wrong. If you’re having problems with urinary tract infections, pay attention to when they happen and what seems to cause them.
Step 2: Gather information. Try to get a better understanding of what may be causing your problem, and some different ways you might try to solve it. This may involve doing research or consulting health care providers. You may also find it helpful to speak with peers, people who have had similar experiences. Make sure you evaluate the reliability of the information you find, and try not to rely on information from only one source.
Step 3: List possible solutions. Based on the information you find, list some things you might try. For example, to deal with recurring UTIs, you might want to drink more water, take cranberry supplements, and pay special attention to hygiene.
Step 4: Try one & evaluate the results. Using your list of solutions, choose the one that seems best and give it a try. It’s important to make only one change at a time so you can tell whether it works or not. Make sure you keep track of what you do and what the results are. If you solve the problem, that’s great! If not, you may want to go back to step 3 and choose another option. Problem-solving can involve lots of trial and error.
Step 5: Know when to ask for help. Don’t try to take everything on by yourself. You can ask your health care team for information and help with your problem-solving, as your needs change over time.
WHO CAN HELP ME?
Taking care of your urinary health is a life-long priority for people with a spinal cord injury. Many of your spinal cord injury care team may help you in managing your bladder and responding to concerns.
Clinical Resource Nurse (Outpatient)
GF Strong Rehabilitation Centre has a Clinical Resource Nurse who is an expert in techniques and tools for managing neurogenic bladder. You can get a referral to GF Strong through your family physician to see the Clinical Resource Nurse for support with your bladder management. After discharge, the nurse can help trouble-shoot bladder concerns and answer questions about routines and products.
Your family physician is your primary partner in looking after your everyday medical needs after SCI. Physicians can help identify and treat complications such as UTIs early and help determine whether your symptoms are more serious and warrant more medical attention. They can prescribe medications that might help support your bowel management, screen for UTIs, and refer you for more specialized help from GF Strong Rehabilitation Centre with your concerns.
Physiatrist (Rehabilitation Medicine Specialist)
Physiatrists, or rehabilitation medicine specialists, are most familiar with how your spinal cord injury affects your body systems, including your urinary system. Most recommend that individuals with SCI see their Physiatrist at least every 1-2 years. If you are struggling with your bladder management routine or it is affecting other aspects of managing your SCI, it’s important to consult your Physiatrist.
Make sure you have regular follow-up appointments with an urologist to evaluate your health and monitor your bladder program. It’s recommended to follow up with Urologist once a year or as directed by your Urologist.
Urology visits may include bladder procedures/tests such as:
- Cystoscopy – a procedure that looks at the inside of your urethra and bladder through a special camera. VCH urology clinic information and instructions.
- Urodynamics – a procedure that shows how your urinary system is working as your bladder is filled with saline and emptied. This procedure also indicates what your bladder pressures are, an indicator of reflux and some other complications.
Your Family Physician can give you a standing requisition for urinalysis and several extra urine collection bottles to keep at home, so you won’t need to see the doctor first just to rule out a UTI.
The key to a healthy urinary system is learning healthy bladder management techniques and developing good habits of cleanliness, drinking adequate healthy fluids and regular bladder assessments. Be aware of physical signs and symptoms that might be telling you something is wrong with your bladder function or that something has changed. Sometimes your bladder will physically change over time, which may require a change in your bladder management program.
- Bladder Management – An infographic on all matters related to the bladder.
- Condom Catheters – Further information on the use of condom catheters, and possible issues.
- Foley Catheters – Further information on the use of a foley catheter, how to take of your foley catheter, and possible issues.
- Intermittent Catheterization For Women – Further information on the use and procedures of intermittent catheterization for females.
- Intermittent Catheterization For Men – Further information on the use and procedures of intermittent catheterization for males.
Be sure to check out the Video Playlist for this chapter!
This website contains general information about medical conditions and treatments. All information, content, and material of this website is for informational purposes only and are not intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified physician or healthcare provider. (c) 2018 Spinal Cord Injury BC