Goals of Bladder Programs

Posted by Nurse Linda in Life After Paralysis on February 03, 2021 # Health

Everyone has thought about the bladder program. Some people just do it and move on. Others have challenges with the routine. When you reduce the complexities, it becomes an easier, natural part of daily life.

Emptying the bladder is critical to maintaining health and living a long life. That sounds really serious and it is. However, you can make the process customary and routine. With repetition, everything becomes less stressful.

Goals of bladder programs include emptying urine from the bladder to avoid overfilling and incontinence, avoiding infection, and maintaining the kidneys.

Bladder Overfilling and Incontinence

The bladder is a urine collecting organ. The job of the bladder is simply to hold urine until the time is right to empty it. The bladder does not process urine; that is the job of the kidneys. Think of the bladder as a stretchy bag. Urine enters the bladder from each of two ureters, which are attached to each of the kidneys. The ureters should direct the urine one way, from the kidneys to the bladder. The kidneys are constantly working to filter waste from the body by processing blood. The kidney's never stop working, so urine is constantly being produced.

As your bladder fills, a message is sent to the brain through the autonomic nervous system the amount of urine that is collecting. At first, the message is just slight, but as more urine collects, the message becomes stronger, indicating a more and more urgent need to find a location (toilet) to empty your bladder. After spinal cord injury, you might not receive this message. Therefore, you must control the timing of emptying the bladder by use of a bladder program.

If urine is held in the bladder for too long, the stretchy bladder wall will over-expand. Like a balloon, this constant overstretching will make the bladder's muscle unable to retract to its original taut, muscular form. The result is a saggy bladder that can develop pockets and become more difficult to empty.

Most importantly, with an overfilled bladder, urine will be misdirected somewhere. This might be expulsion through the urethra resulting in urinary incontinence, risking not only embarrassment but also skin breakdown. Or even more dangerously, the urine might travel the other direction back up the ureters into the kidneys. There is no storage in the kidneys; they process only. If urine backs up into the kidneys or is unable to pass through the ureters, the result is damage to the kidneys, which can eventually lead to kidney failure.

Another cause of bladder overfilling occurs when the sphincters of the urethra (the bladder outlet of the body) close due to a timing error. When a person voluntarily empties their bladder, they usually do so by relaxing the bladder sphincters while at the toilet. There are two sphincters, one at the opening of the bladder and the second, a bit further down the urethra. Both must relax at the same time for urine to flow out of the bladder.

After spinal cord injury, the urinary sphincters can become reversed in their function due to a lack of correctly processing messages from the brain. Due to miscommunicated messages, the bladder may relax to expel urine, but the sphincters may tighten rather than open. Another cause for the uncoordinated function is spasticity or tone. In other words, the sphincters can close when they should open or open when they should be closed. The two sphincters can act independently of each other, one opening while one closes, or they can act in unison, both closing when they should open. When this occurs, a diagnosis of detrusor sphincter dyssynergia (DSD) is made. Detrusor is the medical term for the bladder, and sphincter are those muscles that open and close at the opening of the bladder and dyssynergia is incoordination. DSD is the medical diagnosis for bladder sphincter incoordination.

Bladder emptying is a complicated process that is managed by the autonomic nervous system as well as with voluntary sphincter control and abdominal muscle assistance. The bladder will fill with urine automatically, but when it is time to empty the bladder, we voluntarily open the external urinary sphincter to let urine flow out.

A routine bladder program of removing urine from the bladder reduces the risks of urinary incontinence with incomplete emptying or overfilling your bladder.catheter

Avoiding Infection

Regular emptying of the bladder keeps bacteria from growing in urine. Stagnant urine sitting in the bladder for long periods of time is a key feature to encourage the growth of bacteria. Too much time between catheterization allows urine to sit in the body. Too little time between catheterization, poor technique, or ineffective drainage equipment provides further opportunity for bacteria to enter the bladder.

Movement of the body will help shake the bladder, thereby shaking the urine within it. This will not completely eliminate the risk of bladder infection, but it does help reduce the risk of bacteria clumping together or adhering to the side of the bladder wall.

Food and fluids can change the slight natural acidity of urine. When this change occurs, the urine becomes more alkaline or a base solution. A slightly acid pH in the urine helps to keep bacteria from forming.

The technique used in the bladder program keeps bacteria from entering the bladder from the outside world. Careful attention to hygiene by washing your hands for 20 seconds or two rounds of singing happy birthday should be done prior to handling the catheter for insertion. As we have learned during this time of COVID-19, hand washing is an effective method of cleanliness. Rubbing the hands together with warm, soapy water and rinsing removes bacteria from our hands.

Cleaning the urethra needs to happen prior to inserting the catheter. The urethra is more tender than the skin of our hands, so a gentler cleaning approach needs to occur. Clean in just one direction, front to back, not back and forth. Remove soap or cleaner from your urethra with a wet cloth prior to insertion of the catheter to keep from irritating the internal urethra tissue. Soap and cleaners can be drying to the urethra, which can cause small cracks in the urethral lining, allowing bacteria to enter or general irritation to this tender tissue.

Maintaining the Kidneys

After SCI, individuals with upper motor neuron injury (typically in the cervical and thoracic areas) result in an upper motor neuron (UMN) bladder. This type of bladder will fill but will trigger automatic emptying, often by spasticity when a small amount of urine collects in the bladder. All the urine may be expelled, or only a small amount of urine will be expelled with a larger amount still stored in the bladder. Incomplete emptying is the result. Another risk with a UMN bladder is that the sphincters remain closed, which prohibits any urine from passing out of the body. Not being able to empty the bladder will lead to urine backing up into the kidneys, causing damage.

Individuals with injury to the lower motor neurons (LMN) in the spinal cord (typically in the lumbar and sacral levels) will have a lower motor neuron (LMN) bladder diagnosis. This bladder fills past capacity. Urine will continue to collect in the bladder as the bladder's muscular wall overstretches. Sometimes, a smaller amount of urine will leak out as overflow incontinence, but the bladder never empties. Or the bladder can be so full that the kidneys cannot drain, making them retainers of urine for which they have no storage capacity. This can lead to damage of the kidneys with eventual kidney failure. An LMN bladder can actually overfill until it ruptures.

Keeping the bladder routinely emptied prevents urine from backing up into the kidneys with either an upper motor neuron or lower motor neuron bladder. Too much urine in the bladder leads to either the urine coming out of the sphincter as incontinence or, more importantly, backing up into the kidneys.

Protection of the kidneys is extremely important. Once the damage has occurred, it cannot be returned. Maintaining an emptying process will prevent too much urine from backflow to the kidneys. This is critical at any time, but especially if DSD is present. The incoordination of bladder contractions and appropriate sphincter opening is a recipe for damage.

Maintenance of the bladder program cannot be taken too lightly. Incontinence leads to pressure injury. Catheterizing too soon can introduce infection. Catheterizing too late can lead to kidney damage.

Next week, we will examine the methods of effective bladder emptying. Nurse Linda

Pediatric Consideration: Bladder programs are as important for children as for adults. Maintaining and protecting from overfilling and incontinence, avoiding infection, and maintaining the kidneys need to be accomplished.

Babies wearing diapers is a socially accepted method of urine containment. Because of accepted diaper use, sometimes older children continue to use diapers when a bladder program should be in place. Infants and children with spinal cord injury need bladder programs. Diapers do not provide the care needed for a neurogenic bladder after spinal cord injury. A bladder program of emptying in a timely manner still needs to be performed for babies and children to keep them healthy for a lifetime.

Since the bladder program is how the child manages their bladder needs, it is natural to them. They will often find, especially as they enter school, that other children do not follow the same process. This can be a shock to the child because bladder programs are so natural to them. Understanding and helping children know that everyone is uniquely special can help them realize this is normal as their own unique personality. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.

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.