Living With a Spinal Cord Injury

Bladder Care

You may not have control of your bladder after a spinal cord injury (SCI). You may not realize that your bladder is full and you need to urinate, or you may not be able to use the muscles that control your ability to urinate. Good bladder management can improve your quality of life and prevent bladder problems, which are one of the biggest concerns for people with SCIs.

Poor bladder management can lead to urinary tract infections (UTIs), kidney and bladder problems, sepsis (a bloodstream infection), and in rare cases, kidney failure. For information on testing for, treating, and preventing UTIs, see the topic Urinary Tract Infections in Teens and Adults.

Normal voiding

Your kidneys and bladder work together to make urine and remove it from your body. The kidneys filter waste products and water from the blood to form urine. The urine moves from the kidneys through tubes called ureters to the bladder, which stores the urine until it is full. The bladder is made of muscle (detrusor muscle) and can stretch to hold about 2 cups [16 fl oz (475 ml) ] of urine. From the bladder, urine leaves the body through another thin tube, the urethra. Sphincter muscles at the top of the urethra control the flow of urine from the bladder. See a picture of the male and female urinary systems.

In normal urination, when the bladder is full, a message is sent from the bladder to the brain. The brain sends a message back to the bladder to squeeze (contract) the detrusor muscle and relax the sphincter muscles so you can urinate. After the bladder starts to empty, it normally empties all of the urine.

What an SCI does

After an SCI, the kidneys usually continue to filter waste, and urine is stored in the bladder. But messages may not be able to move between your bladder and sphincter muscles and your brain. This can result in the:

• Inability to store urine. You cannot control when your bladder empties (reflex incontinence). This is known as reflex or spastic bladder.
• Inability to empty the bladder. Your bladder is full but you cannot empty it. It stretches as it continues to fill with urine, which can cause damage to the bladder and kidneys. This is known as a flaccid bladder.

Bladder management

A bladder management program lets you or a caregiver empty your bladder when it is easy for you and helps you avoid bladder accidents and prevent UTIs. You and your rehabilitation team decide which bladder management program is best for you. You need to consider where your spinal cord is injured and how it has affected your bladder function. You also need to consider your lifestyle, how likely you are to get bladder infections (susceptibility), and whether you or a caregiver is able to use a catheter .

Your doctor may do a number of tests to help find out about your bladder function. These may include:

• Urinalysis, blood urea nitrogen (BUN), and creatinine clearance, which provide information on how well your kidneys are working.
• Urine culture, which provides information on bacteria growing in your urinary tract.
• Cystoscopy, which looks inside your bladder, ureters, and urethra to see if they are normal and to check for kidney stones.
• Cystometrogram, which is a test of the pressure inside the bladder. This can help your doctor find out how well your bladder is contracting (squeezing).
• Ultrasound, which uses reflected sound waves to produce a picture of your bladder and kidneys.

Common ways to manage bladder function include the following:

• Intermittent catheterization programs (ICPs) are often used when you have the ability to use a catheter yourself or someone can do it for you. You insert the catheter—a thin, flexible, hollow tube—through the urethra into the bladder and allow the urine to drain out. It is done at scheduled times, and the catheter is not permanent. For more information, see:

  Using a catheter for men.

  Using a catheter for women.

  You may also hear this called intermittent self-catheterization (ISC), clean intermittent catheterization (CIC), or clean intermittent self-catheterization (CISC).
• If you cannot use intermittent catheterization, you can use a permanent catheter known as an indwelling Foley catheter . This type of catheter is inserted through the urethra into the bladder and has a balloon on the end that is inflated with sterile water after the end is inside the bladder. The inflated balloon prevents the catheter from slipping out. Urinary tract infections are more likely to occur with long-term use of an indwelling catheter than with an ICP. Caring for the catheter is important to avoid infections.
• If you use an indwelling Foley catheter, after a period of time you may be able to change to a suprapubic indwelling catheter. This is a permanent catheter that is surgically inserted above the pubic bone directly into the bladder. It does not go through the urethra.
• For men, a condom catheter can also be used. A catheter and collection bag are attached to a condom. When you urinate, the urine goes through the condom and catheter to the bag. Condom catheters are only for short-term use, because long-term use increases the risk of urinary tract infections, damage to the penis from friction with the condom, and a block in the urethra.
• If you have a spastic bladder, you may be able to "trigger" the bladder to contract and avoid having to use a catheter. To do this, you can try tapping on the bladder area, stroking your thigh, doing push-ups in your wheelchair, or using Valsalva maneuvers, which are efforts to breathe out without letting air escape through the nose or mouth.
• It is also possible to use absorbent products, such as adult diapers. But these can result in recurring skin irritations.

You may use just one program or a combination of methods. In general, any of the first three methods can be used if you cannot store urine (spastic bladder), and an ICP is used if you cannot empty your bladder (flaccid bladder).

The most important factors in bladder management are monitoring the amount of fluids you drink, following a regular schedule for emptying your bladder, and being sure that you empty your bladder completely. Your rehab team will help you set up a schedule based on your needs and the amount of fluids you generally drink.

Medicines

A number of medicines are available to help you manage your bladder. These include:

• Anticholinergics, such as oxybutynin and propantheline, which calm the bladder muscles. They may prevent uncontrollable bladder contractions (spasms) that force urine out of the bladder.
• Cholinergics, such as bethanechol, which can help the bladder to squeeze, forcing out urine.

Research continues on bladder management. New methods include surgically implanted components that stimulate the bladder through a radio control.

Note: Bladder problems can trigger autonomic dysreflexia, a syndrome in which there is a sudden onset of very high blood pressure and headaches. If not treated promptly and correctly, it may lead to seizures, stroke, and even death. Although autonomic dysreflexia rarely leads to these more serious complications, it is important to know the symptoms and watch for them. Autonomic dysreflexia is more common in people with an injury to the thoracic nerves of the spine or above (T6 or above).

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Author:	Shannon Erstad, MBA/MPH	Last Updated: February 18, 2009
Medical Review:	William M. Green, MD - Emergency Medicine Nancy Greenwald, MD - Physical Medicine and Rehabilitation
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