| Bladder Management | | | | After injury | | | Due to the location of the nerve system controlling bladder functions, a spinal cord injury at whatever level will always cause a change in bladder function – this differs according to the level of injury and the individual. Bladder function immediately following a spinal cord injury
Although there have been huge improvements (in 1917 almost half of all people with spinal cord injury died of urinary sepsis within two months), urinary tract (and hence kidney) complications are still one of the main causes of illness and death in spinal cord injured people. So correct bladder management is, literally, vital.
In the first few weeks after injury, your bladder will commonly need to be emptied regularly through a fine tube or catheter. This is either inserted every few hours by a nurse through your urethra (the tube through which you void or ‘pee’) and up into the bladder, and then withdrawn when the bladder is empty; or a small surgical incision is made just above your pubic area, and a ‘suprapubic’ catheter inserted directly into your bladder and left in place.
After a few weeks you will be gradually trained to empty your own bladder.
The method used depends on the level of your lesion, your bladder behaviour and whether you are male or female.
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Bladder training
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Bladder training is a process to teach the individual to manage and to empty their bladder without the need for an instrument. Bladder training depends on your bladder behaviour. Some bladders would require training to become reflex bladders and others would need training as contractile bladders.
All methods of bladder management involve a degree of training and routine. In the past some people with spinal cord injury were taught to regularly transfer onto a toilet and to express or ‘bear down’, to expel urine, negating the need for catheters or drainage bags.
This method of management is no longer taught at spinal injuries centres as it may result in stress incontinence, and cannot be relied upon as a sole method of bladder management to achieve continence.
It is important that your bladder strength and capacity is not reduced by allowing your bladder to remain empty (ie. by indwelling catheter on free drainage). To maintain or increase bladder strength and capacity your bladder is trained to regularly hold a volume of urine.
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Warning signs of a full bladder |
Training also involves learning to recognise the signs that your bladder needs
emptying. These will vary depending on the level of your lesion, but may include backache, abdominal fullness and, in high lesion paraplegics and tetraplegics, headache, sweating, flushing of the face, neck and shoulders and goose pimples.
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Fluid intake |
Given the difficulties with continence, it may be tempting to drink less fluid. This is a mistake, especially if you use an indwelling catheter: you need a good fluid throughput to keep your kidneys clean and bladder washed out and functioning properly. If you are prone to urinary tract infections, then increase your fluid intake (preferably to at least 3 litres or 5 pints per 24 hours), make sure your urine is slightly acid and if necessary take vitamin C (but not the effervescent type) or drink cranberry juice to increase the acidity. Some people also take urinary antiseptics in conjunction with Vitamin C to maximise its effects.
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Regular emptying |
It is essential that your bladder is emptied regularly (preferably every 3–4 hours during waking hours) and as completely as possible. An overfull bladder may cause urine to reflux or ‘back up’ into your kidneys and can cause infection and damage. In tetraplegics it can cause autonomic dysreflexia. Inadequate emptying of the bladder causes sediment and deposits to build up, increasing the likelihood of infection and bladder stones. |
Catheters |
Intermittent self-catheterisation
This is often the method of choice for people with acontractile bladders, and is
commonly used by men and women with paraplegia. Patients with reflex bladders that have good capacity can also use this method. Anyone with sufficient hand control can learn to self -catheterise, though dexterity is required to insert the catheter without damaging the urethra. You are less likely to get an infection if you change your own catheter than if someone else does it for you.
Both men and women can usually catheterise while in bed, in the wheelchair or on the toilet. The aims of intermittent self -catheterisation are to empty your bladder completely at regular intervals, and to achieve continence without the need to wear an appliance. It is important with all catheters not to use too large a size which can damage your urethra. The main disadvantage is that you need some privacy or access to a toilet or bathroom, and you may not be able to rely on this when travelling or away from home.
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Urinary Tract Infection (UTI) |
Normally the urine is sterile - that is, it contains no bacteria. The body has many defence mechanisms against urinary infection but the most important is that the bladder is regularly and completely emptied and any bacteria present are therefore flushed out. If this does not occur there will always be stagnant urine in the bladder and bacteria present will be able to multiply and cause an infection.
A urinary tract infection (UTI) will normally produce cystitis (inflammation of the bladder) and may ascend up the ureter to cause a kidney infection as well.
Normally, cystitis causes painful and frequent passage of discoloured, bloody or smelly urine. There may or may not be a temperature and a general flu-like illness. There will be a high temperature, shivers and shakes and pain in the affected kidney – though with some people this pain may not be felt.
In patients with SCI the signs and symptoms of UTI may differ. Some will get all of the above whilst others will get none. Some will just feel unwell, sweaty and headachy but not notice any change in the water. Others will notice difficulty in passing water or passing catheters. Most people will learn from experience what symptoms or signs they personally get with a
UTI. UTI is more common in people with SCI because of incomplete bladder emptying and the use of catheters, which can introduce bacteria into the bladder. Constipation may also contribute and other factors such as urinary stones or kidney scarring. Apart from making people feel ill, UTI may contribute to kidney damage.
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