Bladder Management for People with SCI

Neurogenic Bladder Management Following a Spinal Cord Injury

Before a spinal cord injury, when the bladder becomes filled with urine, messages pass through the spinal cord from the bladder up to the brain.

This causes the urge to urinate. Until you have reached a toilet, your brain will send signals to your bladder’s sphincter muscles to remain tight so as not to allow urine to exit the body.

Once in the toilet, your brain sends a new set of signals to the bladder that encourages those sphincter muscles to relax and simultaneously tells the bladder’s detrusor muscles to contract and force urine out of the body.

After Spinal Cord Injury

After a spinal cord injury, the flow of messages between the brain and spinal cord is blocked. The injured party will not feel the urge to urinate when the bladder is full and will not be able to purposefully contract the bladder.

Types of Neurogenic Bladder After Spinal Cord Injury

A bladder after a spinal cord injury is known as a neurogenic bladder. The injured party can neither feel the urge to urinate nor can they contract it to pass urine out of the body. Neurogenic bladder is of two types:

1. Spastic or Reflex Neurogenic Bladder. This type of neurogenic bladder is often seen in people with a spinal cord injury above the T12 level. Once full, the bladder will attempt to contract and subsequently push the urine out.

2. Flaccid or Non-reflex Neurogenic Bladder. This type of neurogenic bladder is often present in people with a spinal cord injury below the T12 level. In this type of bladder, there is no reflex and no contraction. The bladder can overfill and get stretched out and often will not fully empty. A doctor may prescribe a sphincter relaxant in these cases.

Bladder Management Techniques

After a spinal cord injury, different techniques may be used to assist in emptying the bladder. Here are some common techniques:

Clean Intermittent Catheterisation (CIC)

Catheterization is the insertion of a hollow flexible tube, called a catheter, to drain the urine from the bladder. Clean Intermittent Catheterization (CIC) is usually performed at regular intervals throughout the day.

The injured party’s ability to perform the catheterization and to stick to a strict schedule is essential to the success of any CIC program. Most people will require catheterization every four to six hours. (Clar, 2006)

Recent studies have shown that clean intermittent catheterization of the bladder does not increase the risk of urinary tract infections.

Possible downsides to consider: the intake of all liquid must be closely monitored and controlled. Individuals with quadriplegia have limited hand function and will find it difficult to insert a catheter alone.

Condom Catheter

A condom catheter is a rubber sheath that is put over the penis. The condom is attached to a tube that feeds urine into a drainage bag.

Possible downsides to consider: If the bladder is not completely emptied, the chance of a bladder stone forming may increase. Additionally, bladder sphincter dyssynergia — also known as detrusor sphincter dyssynergia (DSD) and neurogenic detrusor overactivity (NDO) — may occur in a reflex bladder when the sphincter muscle fails to open and release urine, causing the urine to flow back to the kidneys and potentially cause them harm. (Corcos, 2004)

Indwelling Catheter

A catheter is inserted into the bladder with a urine bag already attached. The catheter stays inside the bladder for a couple of days before being changed. These catheters are made of silicone or rubber. If made of silicone, the catheter will need to be changed once per month. If made of rubber, it will need to be changed every two weeks.

Urethral Catheter

One type of indwelling catheter, a urethral catheter passes through the urethra and into the bladder.

Suprapubic Catheter

Another type of indwelling catheter, a suprapubic catheter is inserted into the bladder during a small operation. It is relatively simple to change and to clean, and there is less chance of infection since a portion of the catheter is inside the body.

Urinary Tract Infections and How to Stop a Bladder Infection

After a spinal cord injury, the injured party will often suffer from urinary tract infections (UTI).

Initial warning signs of a UTI are often cloudy and foul-smelling urine. If the UTI is not treated early, bad bacteria from the bladder can travel to the kidneys and infect them. This can cause a serious condition called pyelonephritis, which can be fatal to individuals with a spinal cord injury. (Lippincott, 2012)

Contact a doctor as soon as possible if you spot any UTI symptoms.

Catheterization Alternatives

External collection devices (ECD) all adhere in some way to the pubic area to collect urine. They are not inserted into the bladder in any way and can be divided into several device categories: condom catheters, reusable body-worn urinals, and a nonsheath, glans-adherent ECD. (Gray, 2016)

Link to image of external collection devices

External Catheter for Men

External catheters are also known as “condom catheters.” A urine containment device is fitted over the genitals and attached to a urinary drainage bag. (Gray, 2016)

Single-use Condom Catheters

Often referred to as “Texas catheters,” single-use condom catheters adhere to the penile shaft with an adhesive or strap. Condom catheter straps are made out of foam or other elastic materials to accommodate changes in penile shaft size with erectile activity. Urinary drainage is accomplished by attaching the distal end  — also called a catheter tip — of the device to a urinary drainage bag (either a leg bag or overnight bag). (Gray, 2016)

A single-use condom catheter is available that adheres to the penile shaft via an internal ring that is inflated with air and enables urinary containment. Most of these condom catheters come in a range of sizes. (Gray, 2016)

Be sure to choose a device that has a nonkinking junction between the catheter tip and drainage bag.

Correct Application

The correct application requires measuring the penile diameter at the base of the penile shaft, gently cleansing and drying the penile skin, and clipping any hair growing on the shaft to enhance adherence between the condom catheter or adhesive strap and skin. Anticipated wear times for condom catheters are 24 to 72 hours. (Gray, 2016)

Nonsheath Glans-adherent ECD

The Nonsheath glans-adherent ECD is an external device that can be applied to males who are circumcised and uncircumcised, as well as those who have smaller penile circumferences or leaks and obese men with retracted penile shafts. One size fits all. This device differs from traditional condom catheters because of the convenient design, technology that bypasses the need to cover the penile shaft, and the associated risk of skin damage. (Gray, 2016)

Intermittent Catheterization

Intermittent catheterization is the insertion and removal of a catheter several times per day to empty the bladder. This is also called “straight” catheterization or “in-and-out” catheterization. This type of catheterization is used to drain urine from a bladder that is not emptying properly or from a surgically created channel connecting the bladder with the abdominal surface. Intermittent catheterization is widely advocated as an effective bladder management strategy for patients with incomplete bladder emptying due to neurogenic bladder dysfunction. (UroToday, 2018)

Further, intermittent self-catheterization (IC) is a safe procedure that can help bring urinary complications under control. Many people self-catheterize and report that it has improved their quality of life. It allows individuals to completely empty their bladder at regular intervals, to protect their kidneys from infection and damage, to lower the risk of stretching the bladder, and to eliminate the need for wearing a continuously draining catheter. (UroToday, 2018)

Programmed Toileting (Behavioral Therapy)

Toileting programs typically consist of an individual assessment of incontinence and subsequent program of prompted voiding, timed voiding, and habit retraining.  (Fink, 2008)

Suprapubic Catheter

Suprapublic catheters are surgically inserted into the bladder through an incision made just above the pubis and can be used for both short and long-term catheterization. A doctor will need to complete the incision and insertion. In general, intermittent urethral catheterization is preferable to suprapubic catheterization. 

Compression Pouches

Compression pouches are disposable pouches that cover a part of the penis and gently compress the urethra to control the flow of urine. They are discreet and also effective at protecting clothes from stray urine. 

Penile Clamps

Penile clamps (a.k.a. incontinence clamps) are anatomically designed for comfort and maximum control. These washable clamps come in a range of different sizes, can be worn during regular daily activities, and can easily fit through trouser zippers.

Some of these clamps wrap around the shaft of the penis and with some, the penis is inserted into the clamp. The penile clamp maintains blood flow throughout the penis while gently maintaining pressure on the urethra to prevent leakage. (Garcia, 2015)

Tip: Travelers, don’t fret! Most incontinence clamps dare metal-free and will slip through metal detectors discreetly.

Anticholinergic Therapy

Anticholinergic drugs inhibit the transmission of certain nerve impulses and thus reduce muscle spasms in the bladder. These medications are used as the primary treatment for urinary incontinence. 

Reflex Voiding

Reflex voiding is a technique that works best for males but can also be used for females. For males, reflex voiding means training the bladder to urinate solely by reflex so that when the bladder is full to a certain point, the bladder muscles are forced to contract and thus squeeze the urine out. (CSET, 2018)

For male patients, this urine can be captured by applying a condom to the penis which is then collected to a drainage bag. (CSET, 2018)

This method has a low infection rate and is easy for caregivers, who will only need to change the condom once daily. (CSET, 2018)

Micturition Reflex – Neural Control of Urination

Micturition or urination is the process of emptying urine from the storage organ, namely, the urinary bladder. The detrusor muscle is the involuntary muscle of the bladder wall. The urethral muscles consist of both an external and internal sphincter. The internal sphincter and detrusor muscle are both under autonomic control. The external sphincter, however, is a voluntary muscle under the control of voluntary nerves. (Thomas, 2018)

The bladder normally accommodates up to 300-400 ml in adults. When the bladder is distended it sends signals to the brain, which is perceived as the ‘full bladder’ sensation. The process of emptying the urine into the urethra is regulated by nervous signals, from the somatic and the autonomic nervous systems. (Thomas, 2018)

Stimulated Voiding

Voiding is encouraged in one of several ways: 

Anal or Rectal Stretch: This method of relaxing the urinary sphincter is usually used in combination with an abdominal corset and valsalva (see below).

Credé: This method involves manually pressing down on the bladder.

Tapping: The area over the bladder is tapped with the fingertips lightly and repeatedly to stimulate detrusor muscle contractions and subsequent voiding.

Valsalva: This method involves increasing pressure inside the abdomen by bearing down like you are trying to initiate a bowel movement. (University of Washington, 2018)

Sacral Deafferentation

Spinal cord injuries that occur above the sacrum are referred to as suprasacral lesions. Individuals with a spinal cord injury who suffer from a suprasacral lesion will, more often than not, develop a spastic bladder. The overactive external sphincter causes incontinence, UTIs, renal failure and autonomic dysreflexia. All of these complications can be well managed by sacral deafferentation (SDAF) and implantation of a sacral anterior root stimulator (SARS). (Kutzenberger, 2007)

Advantages and Disadvantages

Catheter insertion can be quite painful, and catheters require special care to prevent UTIs. Catheters can also impair the ability to fully engage in daily activates because they can limit mobility. 80 percent of UTIs are attributable to an indwelling urethral catheter. In general, alternative devices and procedures provide a much lower risk of infectious complications. Additionally, these alternative methods can reduce or eliminate the non-infectious complications like discomfort and immobility that are associated with indwelling urethral (also called “Foley”) catheters. (Saint, 2008)

Relevant Studies

Study: Sacral deafferentation and neurostimulation of anterior spinal roots in the treatment of neurogenic bladder in patients with complete transverse spinal lesions.

Study: Investigating the occurrence of Charcot spinal arthropathy (CSA) after sacral deafferentation (SDAF) and sacral anterior root stimulation (SARS) of the bladder in patients suffering from neurogenic lower urinary tract dysfunction (NLUTD) as a result of spinal cord injury (SCI).

Results: Charcot spinal arthropathy should be considered a potential long‐term complication of SDAF/SARS, and spinal instability is a possible reason for SARS dysfunction.

Study: Deafferentation of the Urinary Bladder and Implantation of a Sacral Anterior Root Stimulator (SARS) for Treatment of the Neurogenic Bladder in Paraplegic Patients.

Study: Electrical Stimulated Micturition: Sacral Anterior Root Stimulator + Sacral Deafferentation.

Candidates criteria for patient selection including the following:

  • Skeletally mature.
  • Intact reflex bladder contractions, i.e. sufficient efferent nerve pathways to the bladder and the bladder is able to contract. Contractions of at least 50 cm H2O in males or 30 cm H2O in females need to be present during filling cystometry.
  • At least 12 months post-injury to ensure stable lesion.
  • A clinically complete spinal cord lesion.
  • Preoperative MRI excluding arachnoiditis at the level of the conus and cauda equine.
  • Good support network.

The contraindications: including (1) Poor or inadequate bladder reflexes, (2) Active or recurrent pressure ulcers, (3) Active sepsis (blood poisoning), (4) having an implanted cardiac pacemaker. 

Study: Deafferentation of the urinary bladder and implantation of a sacral anterior root stimulator (SARS) for treatment of the neurogenic bladder in paraplegic patients. In the years 1978/79 Brindley implanted five paraplegic patients with so-called sacral anterior root stimulators; all of them were able to void under stimulation. This method of sacral anterior root stimulation (SARS) proved an alternative to frequent one-way catheterisation for patients with severe voiding dysfunctions, without achieving complete continence.

Study: Sacral anterior root stimulation improves bowel function in subjects with spinal cord injury.

Study: A 7-year follow-up of sacral anterior root stimulation for bladder control in patients with a spinal cord injury: quality of life and users’ experiences.

Results: From users’ experiences, the most important advantages reported were a decreased infection rate (68%), improved social life (54%) and continence (54%).

Article: Effect of spinal anterior root stimulation and sacral deafferentation on the bladder and sexual dysfunction in spinal cord injury.

Study: Sacral anterior root stimulation for bladder control.

Results: All patients have increased bladder capacity. Thirty-one patients are continent. Out of 33 males, 29 can achieve a sustained full erection using the stimulator. Twenty-seven patients use the implant for bowel function. It is concluded that the use of a bladder stimulator in selected patients gives long-term favourable results.

Study: Spinal Nerve Root Stimulation 2004.

Study: Sacral anterior root stimulation prerequisites and indications.

Results:  In all 30 patients, the operation has improved considerably the quality of life and no patient so far has regretted the operation.

Study: External Collection Devices as an Alternative to the Indwelling Urinary Catheter Evidence-Based Review and Expert Clinical Panel Deliberations Reducing Unnecessary Catheter Use: Alternatives to the Urinary Catheter.

Study: Anticholinergic therapy for lower urinary tract symptoms associated with benign prostatic hyperplasia.

Results: Several trials demonstrated an increase in postvoid residual with anticholinergic therapy, which was statistically significant in two trials. Despite the increase in postvoid residual, rates of acute urinary retention were low and the drugs were well tolerated. Of the five trials that used a validated symptom scoring scale, two demonstrated subjective improvement in urinary function. 

Study: Comparative Effectiveness of Anticholinergic Therapy for Overactive Bladder in Women.

Results: Evidence from more than 27,000 women participating in randomized controlled trials suggests that improvement in symptoms with anticholinergic management of overactive bladder is modest and rarely fully resolves symptoms.

Study: Anticholinergic Therapy vs. OnabotulinumtoxinA for Urgency Urinary Incontinence.

Results: Oral anticholinergic therapy and onabotulinumtoxinA by injection were associated with similar reductions in the frequency of daily episodes of urgency urinary incontinence. The group receiving onabotulinumtoxinA was less likely to have dry mouth and more likely to have complete resolution of urgency urinary incontinence but had higher rates of transient urinary retention and urinary tract infections.

Study: Manual stimulation of reflex voiding after spinal cord injury.

Results: Thirty-four urodynamic studies were performed in 20 patients with spinal cord injury (SCI) to determine the most effective triggering mechanism for reflex voiding. The studies were performed at a time when the patient was normally scheduled for catheterization, which avoided stimulation of the detrusor and sphincter by bladder filling via a catheter. Suprapubic tapping and jabbing were equally effective in producing a rise in detrusor pressure, and the sphincter responses were almost identical. Cutaneous stimulation of the thigh rarely produced any change in detrusor and sphincter activity. When detrusor contractions were produced, a dyssynergic sphincter response prevented voiding in 46% of the studies; however, voiding always occurred when the sphincters were either coordinated or showed no change. Both tapping and jabbing were more effective as the time from injury increased, which reflects the natural recovery from spinal shock.

Study: Two Devices for Reflex Voiding Following Spinal Cord Injury. The purpose of this investigation is to evaluate methods in spinal cord injured individuals to improve reflex urination. Anal dilation is investigated to reduce high urethral resistance and a vibrator on the patient’s bottom is tested to induce more sustained bladder contractions for better bladder emptying.

References

Clar, D et al., 2006. Clinical Practice Guidelines – Adult Clean Intermittent Catheterization. Society of Urologic Nurses and Associates. Available at: https://www.suna.org/resources/adultCICGuide.pdf  [Accessed September 10, 2018]

Corcos, J. & Schick, E., 2004. Textbook of the neurogenic bladder: adults and children, London: Martin Dunitz, Taylor & Francis Group.

Lippincott’s Guide to Infectious Diseases Lippincott, 2012. Lippincotts guide to infectious diseases, Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins Health.

Gray, M. et al., 2016. External Collection Devices as an Alternative to the Indwelling Urinary Catheter. U.S. National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4870965/ [Accessed September 3, 2018].

Definition – Intermittent Catheters. UroToday. Available at:  https://www.urotoday.com/urinary-catheters-home/intermittent-catheters/description/definition-intermittent-catheters.html [Accessed September 3, 2018]

Fink, H.A. et al., 2008. Treatment interventions in nursing home residents with urinary incontinence: a systematic review of randomized trials. Advances in pediatrics. Available at: https://www.ncbi.nlm.nih.gov/pubmed/19046552 [Accessed September 3, 2018].

Garcia, P., 2015. Picking the Perfect Catheter Alternative. Vitality Medical Supplies. Available at: https://www.vitalitymedical.com/blog/picking-the-perfect-catheter-alternative.html [Accessed September 3, 2018].

MedicineNet, 2016. Definition of Anticholinergic. MedicineNet. Available at: https://www.medicinenet.com/script/main/art.asp?articlekey=2281 [Accessed September 3, 2018].

CSET, 2018. Reflex Voiding – VA Caregiver. CSET – VA Caregiver. Available at: https://sites.google.com/site/vacaregiver/bladder-care/skills/3-disreflexia [Accessed September 3, 2018].
Thomas, L., 2018. Micturition Reflex – Neural Control of Urination. News-Medical.net. Available at: https://www.news-medical.net/health/Micturition-Reflex-Neural-Control-of-Urination.aspx [Accessed September 3, 2018].
University of Washington, 2018. Featured Patient Care Article. Patient Care – Education – SCI bowels. Available at: http://rehab.washington.edu/patientcare/patientinfo/articles/sci_bladder.asp [Accessed September 3, 2018].
Musculoskeletal Key, 2017. Electrical Stimulated Micturition: Sacral Anterior Root Stimulator Sacral Deafferentation. Musculoskeletal Key. Available at: https://musculoskeletalkey.com/electrical-stimulated-micturition-sacral-anterior-root-stimulator-sacral-deafferentation/ [Accessed September 3, 2018].
Kutzenberger, J., 2007, Surgical therapy of neurogenic detrusor overactivity (hyperreflexia) in paraplegic patients by sacral deafferentation and implant driven micturition by sacral anterior root stimulation: methods, indications, results, complications, and future prospects. Advances in pediatrics.Available at: https://www.ncbi.nlm.nih.gov/pubmed/17691394 [Accessed September 10, 2018].
Saint, S. et al., 2008. Preventing hospital-acquired urinary tract infection in the United States: a national study. Advances in pediatrics. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18171256 [Accessed September 3, 2018].