Bladder management

What is the relationship between the spinal cord and the bladder?

A spinal cord injury (SCI) will always affect the control you have over your bladder at any stage. During post-injury rehabilitation, you will learn techniques to empty your bladder. These strategies will be tailored to your individual needs and will take into account your activity and skill level.

It is important to understand how your body works

The urinary system consists of the kidneys, two ureters, the bladder, and the urethra.

Kidneys work 24/7 to remove waste from your body through your bloodstream. This waste becomes urine. Urine is a mixture of excess salts and water that exits the kidneys through the ureters, one from each kidney into the bladder. The ureters allow urine to flow in one direction and are connected to the bladder

How does the bladder work?

The bladder is a muscular sac that stores urine until it is convenient to empty it. Once the bladder is full, nerves send a message to the brain via the spinal cord.

When you decide to urinate, the brain sends messages through the spinal cord to the bladder wall muscles, telling them to contract. The sphincter opens, and the bladder releases urine, which passes through the penis or genitals into the urethra.

Urine is usually straw coloured but seek medical advice if there is an unusual smell, colour or change in blood. Certain foods and medications can affect the colour and smell of urine.

How does the bladder work after an injury?

Damage to the spinal cord also damages your body's bladder control system. Nerves no longer communicate with the brain and therefore cannot transmit messages. The bladder fills as before, but the awareness of fullness and the ability to control the flow of urine are altered.

A lesion at the T12 level or above is called a reflex bladder, also known as an automatic or spastic bladder. Injuries below T12 can cause a flaccid, or flaccid, bladder. It is possible to have elements of both.

What is reflex bladder?

A reflex bladder is where the neural pathway and nerve impulses between the bladder and spinal cord – known as the reflex arc – remain intact but messages no longer reach the brain. A reflex bladder allows automatic, involuntary control of the bladder, meaning that when the bladder fills above a certain level, it contracts, and urine flows out automatically.

However, a reflex bladder may not empty completely due to the sphincter not relaxing fully. This can leave a pool of urine in the bladder, known as residual urine, which increases the risk of infection. The pressure from bladder contractions can cause back pressure on the kidneys.

What is an areflexic bladder?

An areflexic bladder is where the reflex arc between the bladder and spinal cord is damaged. The impulses to the spinal cord are interrupted, so the bladder does not receive the message that it needs to empty.

An areflexic bladder has no muscle tone and, therefore, does not contract automatically to allow it to empty. It continues to fill, and small amounts of urine may leak out. The areflexic bladder needs emptying at regular intervals, and this can be achieved by intermittent self-catheterisation.

What is an areflexic bladder?

An areflexic bladder is where the reflex arc between the bladder and spinal cord is damaged. The impulses to the spinal cord are interrupted, so the bladder does not receive the message that it needs to empty.

An areflexic bladder has no muscle tone and, therefore, does not contract automatically to allow it to empty. It continues to fill, and small amounts of urine may leak out. The areflexic bladder needs emptying at regular intervals, and this can be achieved by intermittent self-catheterisation.

 

What is bladder management?

Bladder management is a personal programme developed during rehabilitation that allows you to gain as much control over your bladder as possible.

The main aims of bladder management are to:

• Establish a safe method for emptying your bladder at intervals throughout the day to protect your kidneys and help you stay dry

• Establish a long-term routine to help you achieve independence, improve your quality of life, allow you to carry out daily activities and enjoy a social life

• Maintain a good body image

• Reduce the risk of complications, such as bladder and kidney infections and the formation of bladder stones

• Correct bladder management is vital to your health and wellbeing. Urinary tract complications are still among the leading causes of illness, readmission to hospital and death in SCI people

What are my bladder management options?

In the first few weeks after SCI, the bladder will need to be emptied regularly through a catheter, a fine, flexible tube that carries urine out of your bladder.

During rehabilitation, you will be educated on the best method for emptying your bladder. This will depend on:

•  The level of injury
•  Whether your bladder is reflex or areflexic
•  Whether you are male or female
•  What is acceptable to you
•  Results of urological investigations
•  What is least likely to cause major complications, such as bladder stone formation, infection and autonomic dysreflexia (AD)

Catheters

There are three main types of catheters:

1. Indwelling urethral catheters

These are inserted through the urethra and held in place by a small water-filled balloon. This is typically a short-term solution for emptying the bladder, for example, before and after surgery or when you are away from home if you cannot rely on access to toilets to self-catheterise.

Things to be aware of with indwelling urethral catheters

• They can be convenient, but long-term use is best avoided as it can cause urethral dilation, chronic bladder infection, penis  splitting      and bladder stones.

• They can be easily blocked by sediment and small calcium granules that gather around the balloon and grow to form stones

• May require regular bladder washouts (care must be taken during this procedure)

• Need to be changed regularly, every four to six weeks

• Often need to be inserted by a PA or district nurse

• Require extra care to ensure good sterile technique

• Require you to increase your daily intake of fluid to 3.5 litres (6 pints)

• Can increase the risk of infection as bacteria can enter through the catheter’s permanent opening

• Can sometimes be expelled by spasms or because of a blockage or stone

• Require securing to the thigh to prevent urethral trauma

• Can cause leakage around the catheter during menstruation

2. Intermittent catheters (self-catheterisation)

This method is used for draining the bladder without a permanently fitted catheter. The catheter is inserted into the bladder every few hours to drain it.

Intermittent catheters are often the method of choice for people with an areflexic bladder, and they are commonly used by those with paraplegia. If you have a reflex bladder with good capacity, you can also use this method. Medications might be needed to increase bladder capacity.

People with some hand control can learn to self- catheterise, but you need to be sufficiently dexterous to avoid the risk of damaging the urethra. Your chance of infection is significantly reduced if you change your own catheter than if someone else changes it for you.

Both men and women can usually self-catheterise while in bed, in a wheelchair or on the toilet.

Remember that you will need privacy and access to a toilet, which can sometimes be difficult if you are away from home.

It’s essential to use good technique and hygiene practices when self-catheterising. Avoid bladder infections wherever possible, and ensure you wash your hands and genital area thoroughly before passing the catheter.

Benefits of intermittent self-catheterisation include:

• The ability to empty your bladder completely at regular intervals

• Achieving continence without the need to wear an appliance

3. Suprapubic catheters

A suprapubic catheter is an indwelling catheter inserted into the bladder via a small surgical incision made in the abdomen below the belly button.

Would a suprapubic catheter be suitable for me? These are typically used by:

• Newly injured people
• Tetraplegic women
• People who do not have the manual dexterity to carry out intermittent self-catheterisation
  
  

A suprapubic catheter is inserted through a hole in your abdomen into your bladder. The incision is not permanent and starts to close within 24 hours if the catheter is permanently removed.

The catheter used is similar to that used for urethral use. The insertion of it may initially cause an increase in spasms. People with suprapubic catheters may experience oozing around the catheter site, and this should be cleaned each day as part of a regular bathing routine. A dry gauze dressing may be applied each day.

 Suprapubic catheters:

• Should be changed every four to six weeks to prevent blockages
• Should be taped to the lower abdomen and connected to a leg bag
• Protect and free the genital area for sexual function
• Carry less risk of tubing being sat on or kinked
• Carry a similar risk of infection, blockage and stone formation as an indwelling urethral catheter
  
  

If the catheter becomes blocked, urine may drain via the urethra, and you may not realise you are sitting in wet clothing. Bladder washouts will help remove any build-up of deposits that may form bladder stones. It is essential to drink plenty to keep the urine as diluted as possible.