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 is a link to some common techniques.

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.

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].