Bladder Issues

Posted by Nurse Linda in Life After Paralysis on December 20, 2022 # Health

catheterMany individuals who have neurological issues have a diagnosis of neurogenic bladder. Neurogenic bladder is a concern when messages do not connect between the brain and the bladder. Although this occurs with spinal cord injury, it also can occur in more than half of the individuals with brain injury or other neurological diseases such as multiple sclerosis or even in health issues such as diabetes. If you have a diagnosis of neurogenic bladder, you need to treat that issue specifically. Not doing so will create significant health issues.

However, there are individuals with healthcare issues that do not have a neurogenic bladder but do have other types of bladder concerns. These generally lead to bladder incontinence and/or retention of urine. The source of these bladder issues occurs particularly with how the bladder functions. A neurological issue may or may not be present.

Stress Incontinence occurs when there is pressure on the bladder. It usually begins with just a small amount of urine leaking out of the urethra, but the incontinence usually increases over time. This is not a continual leak of urine but occurs with some form of stress being placed on the bladder, such as when coughing, sneezing, bending over, lifting something heavy, jumping, or exercising. Mobility issues can lead to stress incontinence if extra pressure occurs in the abdomen when transferring, standing, or walking. Sometimes a good laugh will put pressure on the abdomen leading to some leakage. The trigger for stress incontinence may begin with just one source of abdominal pressure challenge, but without intervention, any abdominal pressure change will cause leakage. Stress incontinence begins with a slight dampness on your underwear but eventually leads to the need for pads (in both women and men).

Stress incontinence occurs because the urethral sphincter and surrounding pelvis musculature are not strong enough to keep the urethra closed during this time of added stress or pressure in the abdomen.

Women are more predisposed to stress incontinence, especially due to challenges of the pelvic floor musculature from pregnancy, childbirth, uterine prolapse, or hormonal changes from perimenopause and menopause or surgical interventions such as hysterectomy. Men may have stress incontinence due to an enlarged prostate or prostate cancer. Chronic health conditions may lead to stress incontinence such as obesity or coughing. Nerve damage from a fall, neurological diagnosis, or diabetes is also a source.

Treatments for stress incontinence include Kegel exercises. This is a process of tightening your pelvic floor muscles for 3 to 5 seconds, then relaxing for 3 to 5 seconds. These should be done in rounds of ten, three times a day. You can do them anytime, as no one can tell when you are doing them. They work for both women and men. Your physician, urologist, or gynecologist will provide specific directions for you. There are many devices and products available for Kegel exercises, but most individuals can be successful without extra purchases.

Medical treatments may be required which include medications such as anticholinergics, estrogen creams, vaginal pessary devices to help close the urethra, or surgery to support the urethra in women. Men may have urethral sling surgery or implantation of an artificial sphincter.

Urge Incontinence is often confused with stress incontinence, but the mechanics are different. In urge incontinence, you have a message from the bladder to the brain that says you need to empty your bladder right now! The bladder then empties. This is not a small leak, but an actual emptying of all or some of the urine in your bladder that you cannot control.

Urge incontinence occurs when the bladder is squeezing involuntarily or due to increased tone (spasm), which overpowers the urethral sphincter. The hallmark of urge incontinence is the short notification between noticing the need to toilet and the quick resulting urinary incontinence that cannot be stopped.

Most often, urge incontinence is a temporary issue due to a bladder infection. Once the bladder infection is treated, urge incontinence resolves. There are other causes of urge incontinence which include a blockage such as a stone, prostate enlargement, bladder inflammation, or cancer. Individuals with brain injury, stroke, or multiple sclerosis, among others without neurogenic bladder diagnosis, may have urge incontinence. Individuals with neurogenic bladder may also have urge incontinence but do not feel the ‘urge’ but have urinary incontinence, especially with a bladder infection. For these individuals, sudden leaking may be a sign of the presence of a bladder infection.

Treatment for urge incontinence includes scheduling times for urination so the bladder does not become too full, leading to a contraction to empty. Pelvic muscles can be strengthened by Kegel exercises, the use of a vaginal weight, or electrical stimulation therapy.

Medications for urge incontinence include anticholinergics, beta-agonists, tricyclic antidepressants, and Botox injections. These medications relax the bladder muscle. Flavoxate is sometimes effective for muscle spasms. In severe cases, surgery, including sacral nerve stimulation or bladder augmentation (enlargement) can be done.

Overflow Incontinence occurs when your bladder empties but not completely. You will receive a message from your brain to toilet, but you cannot completely empty your bladder when you do. You may leak a little or a lot of urine later. Overflow incontinence is often found in men with enlarged prostrates, however, blockages in the passage of urine can also occur in women. You may feel that you have not completely emptied your bladder or may try unsuccessfully to urinate even though you have the message to do so. Something is blocking the passage of urine.

Causes of overflow incontinence besides enlarged prostate include tumors, stones, scar tissue, and pelvic floor muscle dysfunction. Individuals, including those with neurological issues, can have overflow incontinence from lax pelvic floor muscles, less ability to contract the bladder muscle, Parkinson’s disease, multiple sclerosis, or spina bifida. Nerve damage can also be a source occurring from diabetes and alcoholism. The use of medically prescribed anticonvulsants and antidepressants can have the side effect of overflow incontinence and incomplete emptying.

Timed toileting will help keep your bladder empty. After emptying your bladder, wait a minute and try to void a second time for more complete emptying.

Medical treatment includes alpha-adrenergic blockers. Intermittent catheterization may be needed to ensure the bladder is emptied. Surgery to correct enlarged prostate or other blockages may be needed.

Functional Incontinence is the inability to get to the toilet in time because of an impediment in your environment. You might not be able to maneuver your wheelchair into your bathroom, lower your clothing, undo fasteners or zippers, or transfer quickly enough. There are many reasons why people cannot reach their toilet in time. One example is the ‘key in the door’ syndrome where you arrive home and have to toilet but cannot get into your house fast enough.

Individuals with any type of mobility issue may have functional incontinence. Providing adaptive equipment, clothing, or other ease of movement will assist with the ability to toilet. Using a toileting schedule to empty the bladder before immediately needing to the toilet will decrease the urgency factor to allow successful toileting.

Mixed incontinence is any combination of the situations listed above. Most often, it is a combination of stress and urges of incontinence. Treatment for mixed incontinence is usually a combination of treatments or the use of one treatment that covers both situations.

You can help yourself to improve bladder function by monitoring the amount and type of fluids that you drink, performing Kegel exercises, avoiding constipation which puts pressure on the urethra and bladder, maintaining a healthy weight, managing health conditions that affect bladder function, stopping smoking as nicotine is excreted through the bladder affecting toileting and control, and set established times to empty your bladder, so it does not overfill.

Your healthcare provider will need to perform a physical examination as well as perhaps a neurological examination to determine the status of your urinary system. The treatments for stress, urge, overflow, and functional incontinence do not treat neurogenic bladder. However, you can have a neurogenic bladder and still have some of the symptoms of these bladder issues. For those with neurological issues from disease, these concerns will be more imperative to be treated to maintain a healthy urinary system.

Pediatric Consideration

It is important to keep your child’s toileting concerns in the conversation with their healthcare provider. This will help the provider to be able to note changes or new issues as your child develops. Especially, in the younger years, when a child is transitioning to toileting, you will want to be sure they are not developing any of the types of urinary incontinence noted above. In the older child, the development of these issues is as with adults.

As in adults, treatment for neurogenic bladder is different because neurogenic bladder is a brain-body transmission issue and requires specific treatment for that issue.

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.