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Spinal Cord Injury Paralysis Resource Center

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Bladder Management

Bladder Health

- Download a FREE PDF fact sheet about Bladder Management
- Catheters: Sterile vs. Clean
- Cranberries and bladder health

Paralysis at any level usually affects bladder control. The nerves controlling these organs attach to the very base of the spinal cord (levels S2–S4) and are therefore cut off from brain input. Although it may not be possible to regain the control one had before paralysis, a wide range of techniques and tools are available to manage what is termed a  neurogenic bladder.

Here's how an unaffected bladder works: Urine, the excess water and salts that are extracted from the bloodstream by the kidneys, is piped down thin tubes called ureters, which normally allow urine to flow only in one direction. The ureters connect to the bladder, which is basically a storage bag that does not like pressure. When the bag is full, pressure rises and nerves send a message via the spinal cord to the brain. When one is ready to empty the bladder, the brain sends a message back down the spinal cord to the bladder, telling the detrusor muscle (the bladder wall) to squeeze and the sphincter muscle (a valve around the top of the urethra) to relax and open. Urine then passes down the urethra to exit the body.
It is a rather elegant process of muscle coordination just to go pee.

After paralysis, however, the body's normal system of control goes haywire; messages can no longer pass between the bladder muscles and the brain. Both the detrusor and the sphincter may be overactive due to lack of brain control. An overactive detrusor can contract at small volumes against an overactive sphincter; this leads to high bladder pressures, incontinence, incomplete emptying, and reflux -- along with recurrent bladder infections, stones, hydronephrosis (kidney distention), pyelonephritis (kidney inflammation), and renal failure.

The neurogenic bladder is usually affected in one of two ways:

1. Spastic (reflex) bladder: when the bladder fills with urine, an unpredictable reflex automatically triggers it to empty; this usually occurs when the injury is above the T12 level. With a spastic bladder you do not know when, or if, the bladder will empty. Physicians familiar with spinal cord injury often recommend a bladder relaxing medication (anticholinergic) for reflexive bladder; oxybutynin (Ditropan) is common, with a primary side effect of dry mouth. Tolterodine, propiverine, or transdermal oxybutinin may result in less dry mouth. Botulinum toxin A (Botox) may be an alternative to anticholinergics. It has been FDA approved for detrusor overactivity treatment in individuals with SCI and multiple sclerosis. The advantage: Botox is used focally in the bladder, thus avoiding systemic side effects, including dry mouth.

2. Flaccid (non-reflex) bladder: the reflexes of the bladder muscles are sluggish or absent; it can become over-distended, or stretched. Stretching affects the muscle tone of the bladder. A flaccid bladder may not empty completely. Treatments may include sphincter relaxing medications (alpha-adrenergic blockers) such as terazosin (Hytrin) or tamsulosin (Flomax). Botox injected into the external urinary sphincter may improve bladder emptying. Also, surgery is an option to open the sphincter. Bladder outlet surgery, or sphincterotomy, reduces pressure on the sphincter and thus allows urine to flow out of the bladder easier. An alternative to sphincterotomy is placement of a metal device called a stent through the external sphincter, thus ensuring an open passage. One drawback to both sphincterotomy and stenting is that sperm from an ejaculation ends up in the bladder (retrograde), rather than coming out the penis. This doesn't rule out having a child but complicates it; sperm can be collected from the bladder but can be damaged by urine.

Dyssynergia occurs when the sphincter muscles do not relax when the bladder contracts. The urine cannot flow through the urethra, which can result in the urine backing up into the kidneys (called reflux), which can lead to serious complications.

The most common method of bladder emptying is an intermittent catheterization program (ICP), which drains the bladder on a set schedule (every four to six hours is common). A catheter is inserted in the urethra to drain the bladder, then removed. An indwelling catheter (Foley) drains the bladder continuously. If drainage originates from a stoma (a surgically created opening) at the pubic bone area, bypassing the urethra, it's called a suprapubic catheter. Advantage: unrestricted liquid intake. Disadvantage: besides the need for a collection device, indwelling catheters are more prone to urinary tract infection. An external condom catheter, which also drains continuously, is an option for men. Condom catheters also require a collection device, e.g. legbag.

There are several surgical alternatives for bladder dysfunction. A Mitrofanoff procedure constructs a new passageway for urine using the appendix; this allows catheterization to be done through a stoma in the abdomen directly to the bladder, a great advantage for women and for people with limited hand function. Bladder augmentation is a procedure that surgically enlarges the bladder, using tissue from the intestines, to expand bladder capacity and thus reduce leaking and the need for frequent catheterization.

It is common for people with multiple sclerosis and other spinal cord diseases to have problems with bladder control. This can involve a little leaking after a sneeze or laugh, or loss of all control. For many people, appropriate clothing and padding can compensate for lack of control. Some women benefit from strengthening the pelvic diaphragm (Kegel exercises) to improve retention of urine.

Urinary tract infection: People who are paralyzed are at a high risk for urinary tract infection (UTI), which until the 1950s was the leading cause of death after paralysis. The source of infection is bacteria, a group or colony of tiny, microscopic, single-celled life forms that live in the body and are capable of causing disease. Bacteria from the skin and urethra are easily brought into the bladder with ICP, Foley and suprapubic methods of bladder management. Also, many people are not able to completely empty their bladder; bacteria are more likely to grow in urine that stays in the bladder. 
Some of the symptoms of UTI are cloudy, smelly urine, fever, chills, nausea, headache, increased spasms and autonomic dysreflexia (AD). One may also feel burning while urinating, and/or discomfort in the lower pelvic area, abdomen or lower back.

Once symptomatic, the first line of treatment is antibiotics, including the fluorquinolones (e.g. ciprofloxacin), trimethorprin, sulfamethoxazole, amoxicillin, nitrofurantoin and ampicillin. The key to preventing UTI is to halt the spread of bacteria into the bladder. Meticulous hygiene and proper handling of urinary care supplies can help prevent infection. Sediment in the urine can collect in tubing and connectors. This can make it harder for your urine to drain and can make it easier for bacteria to spread. Clean skin is also an important step in preventing infection.

Drinking the proper amount of fluids can help with bladder health, by washing bacteria and other waste materials from the bladder. Cranberry juice, or cranberry extract in pill form, can be an effective preventative for bladder infections. It works by making it hard for bacteria to stick to the wall of the bladder and colonize. Another way to keep the bacteria from colonizing on the bladder wall is the use of D-mannose, a type of sugar available at health food stores. It appears to stick to the bacteria so the bacteria can't stick to anything else.

A complete medical check-up is recommended at least once a year. This should include a urologic exam, including a renal scan or ultrasound to know that the kidneys are working properly. The exam may also include a KUB (kidneys, ureters, bladder), an X-ray of the abdomen that can detect kidney or bladder stones.

Bladder cancer is another concern. Research shows a moderate increase in the risk of bladder cancer among those who have been using indwelling catheters for a long period of time. Smoking also increases the risk for developing bladder cancer.

Sources:
National Multiple Sclerosis Society, Spinal Cord Injury Information Network, University of Washington School of Medicine

Resources:
Paralyzed Veterans of America, in support of The Consortium for Spinal Cord Medicine, offers authoritative clinical practice guidelines for bladder management. Consumer guides are available to download.

Urine Control program features details on bladder issues. Developed at Case Western Reserve Medical School, Center for Health Care Research and Policy and MetroHealth Medical Center.

The Spinal Cord Injury Rehabilitation Evidence (SCIRE) project is a Canadian research collaboration of scientists, clinicians and consumers that reviews, evaluates, and translates research knowledge to establish best practices following SCI.

A Reeve Foundation Fact Sheet on Bladder Management (PDF)

CareCure CommunityCareCure Community features a SpinalNurse bulletin board with informed comments on matters of the bowel, and all issues of paralysis.

CareCure's Capsaicin and Resiniferatoxin Therapy of Bladder SpasticityRecent clinical trials indicate that instillation of capsaicin (the essence of pepper) or resiniferatoxin (RTX, from a cactus like plant) into the bladder can reduce bladder spasticity for weeks.

CareCure’s Suprapubic Cystostomy vs. Urethral CatheterizationWise Young, Ph.D., M.D.; W. M. Keck Center for Collaborative Neuroscience;Rutgers University, Piscataway, New Jersey reviews several studies comparing urethral and suprapubic catheterization in people with spinal cord injury. These studies indicate that suprapubic catheterization is superior to both chronic indwelling and intermittent urethral catheterization for reducing bladder infections and kidney damage.

CareCure’s Cranberry Therapy of Urinary Tract InfectionsDo cranberry juice or concentrates prevent urinary tract infections? This article reviews clinical trials and mechanisms of cranberry effects on bladder infections.

Shepherd Center Learning ConnectionsBladder Care: An online course for patients and their families.

University of Alabama at BirminghamOffers an information sheet (Info Sheet #11) on bladder care and management.

University of Washington School of Medicine: Bladder Management
The University of Washington School of Medicine/Department of Rehabilitation Medicine.

Paralysis Resource Center The Reeve Foundation Paralysis Resource Center Information Specialists are reachable business weekdays, Monday through Friday, toll-free at 800-539-7309 from 9:00 am to 5:00 pm ET. You may also schedule a call or send a message online.

Reeve Foundation Online Paralysis Community Connecting people living with paralysis, families, friends and caregivers so we can share support, experience, knowledge, and hope.

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The Reeve Foundation Paralysis Resource Center Information Specialists are reachable business weekdays, Monday through Friday, toll-free at 800-539-7309 from 9:00 am to 5:00 pm Eastern U.S. Time. International callers use 973-467-8270. You may also schedule a call or send a message online.

This project was supported, in part by grant number 90PR3001, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.