Methods to Safely Empty the Bladder- Part 2

Posted by Nurse Linda in Life After Paralysis on February 17, 2021 # Health

Last week, I started a list of ways to empty the neurogenic bladder. This week is a continuation of the processes. How your bladder is managed is based on your unique situation. Discuss options for you as an individual with your healthcare provider to be sure you are safely maintaining your urinary system.

Indwelling catheters are mostly used long-term by women purely due to lack of options, but men sometimes use them as well. Indwelling catheters are avoided for long-term control methods of bladder emptying and urinary containment due to infection risk. A catheter is an open conduit for bacteria to enter the bladder. Research indicates that within five days of indwelling catheter use, a urinary tract infection could be present.

CatheterThat being said, some men but many women use indwelling catheters as management for neurogenic bladder. Due to anatomical issues, intermittent catheterization can be challenging. The indwelling catheter allows an outflow of urine while keeping the urine contained and skin dry, which avoids pressure injury. The indwelling catheter is connected to a leg bag or night collection bag. Connecting tubing may or may not be used.

The indwelling catheter should be secured using paper tape or a catheter thigh strap to the thigh of a woman to keep it from pulling with movement. For men, the catheter should be paper taped to the abdomen to keep it from pulling with movement but also to avoid a kink at the penile/scrotal junction internally. The urethra in men does a U-turn at that area internally in male anatomy. Taping the indwelling catheter up on the abdomen allows a more direct flow of urine out of the bladder.

Indwelling catheters should be changed using a sterile technique on a schedule indicated by your healthcare professional. The area at the urethra should be cleaned as per instructions of the healthcare professional. Some will want frequent cleaning, while others believe frequent cleaning introduces more bacteria. An individual with an indwelling catheter can usually shower as the water flows off the body but should not sit in a bath since the water will linger or can seep in at the catheter entrance site.

Over time, an indwelling catheter will dilate the urethra. If urine leaks around the indwelling catheter, a larger size or larger balloon is needed. An indwelling catheter keeps the bladder continuously empty of urine. This does not allow for the natural stretching and contracting of the bladder muscle. Over time, the bladder will become small and less elastic.

Individuals with indwelling catheters can drink fluids freely unless restricted by other medical conditions. Keeping urine flowing out of the body is one of the best ways to avoid urinary tract infections.

Cleaning your drainage bags, tubing and connectors at each change from night bag to leg bag. Cleaning the connections with an alcohol pad each time the system is opened and keeping the drainage bag lower than the level of the bladder are other ways to avoid bacteria from entering the bladder. When in bed or seated, be sure the drainage bag is hooked onto the side of the bed, chair or your leg, lower than the bladder. The drainage tube should be coiled on the bed next to you. Dependent drainage tubes do not let urine flow freely out of the bladder. The drainage bag should never be placed on the floor.

Intermittent Catheterization (IMC) is the most preferred method of bladder management because it mimics the natural stretching and contracting of the bladder muscle and has less risk of infection. This system can be used by individuals with high or low pressure bladders and flaccid bladders. This is the basic IMC process:





Collect your equipment, catheter, lubricant, urethral cleaning supply

-Once you begin, you do not want to interrupt your procedure. If you do, you will need to wash your hands again and could contaminate your supplies.

-Keep supplies together and handy.


Get into position for catheterizing. This can be on the toilet, next to the toilet, in your chair, in bed

-Sitting takes advantage of gravity to empty the bladder.

-Being on the toilet makes an easy clean up as you can simply flush the urine away.

-If you must catheterize in bed, be sure to sit up, if possible.


Wash your hands

-Dry with a clean towel Use warm, flowing water and soap, rubbing vigorously for 20 seconds or two rounds of happy birthday.

-Used towels collect bacteria, so use a clean one when possible.

-Once your hands are clean, you do not want to dirty them by moving around to your cathing location.


Open supplies

-At home, supplies are not in neat little kits like at the rehabilitation center.

-Supplies are purchased in bulk, so you will have several different items to open.

-Once open, keep supplies on the inside of the packaging to maintain cleanliness.


Drop lubricant onto the catheter

-If the lubricant tube opening touches anything, including your catheter, it is no longer clean. Drop the lubricant from the tube to the catheter without touching the opening of the tube.

-Lubricate the catheter for the length of insertion. Men 6-8 inches, women 2 inches.

-A well-lubricated catheter lessens damage to the urethra and passes much more smoothly.


Clean the opening to the bladder

-Most people will use soap and water.

-Use a gentle soap to avoid irritation of the urethra.

-Wash from front to back of the urethra in one swipe. Then pick up the washcloth from your skin and wash front to back again. Repeat this process. This avoids recontamination of the urethra with each pass of the washcloth.

-Scrubbing back and forth can irritate the urethra and leads to recontamination.


Insert well-lubricated catheter until urine starts flowing out

-The catheter is in far enough when urine starts to flow out.


Drain urine until it stops flowing

- Once urine stops flowing, the level of the urine is below the eye of the catheter. That does not mean your bladder is empty.


Slowly, remove the catheter

- Slow removal will drain that last bit of urine left in the lowest part of your bladder.


Clean residue from bladder opening

-Soap or urethra cleaning solutions can dry and crack skin, providing the opportunity for bacteria to enter.


Clean up and discard supplies

- Clean the area where you catheterized by picking up your equipment and disposing of it properly.


Wash your hands

-Always thoroughly wash your hands after toileting.

Intermittent catheterization is done every four to six hours. Your healthcare provider will establish your timing schedule based on your needs. It is critical that you maintain your schedule to avoid overfilling your bladder resulting in possible incontinence or backflow into the kidneys.

Fluids need to be monitored with IMC. Men should have about 350ccs of urine in their bladder at catheterization time to avoid overstretching and backflow. Women's typical catheterization amount is 300ccs. Some fluids such as sugary drinks, caffeine or alcohol pass through the body quicker than water. You can easily overfill your bladder with these drinks. You can still enjoy them, just use moderation. However, plain water is best.

Advantages to IMC include keeping the bladder exercised as the bladder wall's natural stretching and contracting is maintained. There are fewer urinary tract infections with this procedure as the catheter is not left in the bladder but removed.

Reflex Bladder Emptying: Individuals with lower level spinal cord injury in the lumbar or sacral levels of the spine will find that they may expel some urine when performing their bowel program. This can be harnessed to empty the bladder. The use of tapping over the bladder can stimulate a spontaneous expulsion of urine. Credé is an older technique where one rolls their fingers over the bladder on the abdomen's skin from top to bottom. Valsalva or bearing down using the functional muscles of your abdomen can also evacuate the bladder. Some will find their bladder empties by stretching the rectum. Reflex techniques need to be approved by your healthcare professional or urologist as the added pressure can cause reflux of urine into the kidneys.

Mitrofanoff Procedure: A surgical procedure where an opening is created in the bladder by use of repurposing the appendix or part of the bowel is done to create a new pathway to the bladder. A straight catheter is used to remove urine. Then the catheter is removed. This procedure was developed for children, but adults with SCI find it helpful, especially for women, as access is practical. Some men opt for this in unique situations such as the retracted penis. The timing and fluids process is much like intermittent catheterization.

Ostomy: Another surgical procedure is an opening in the abdomen, which allows urine output to flow into a collection bag worn on the abdomen. The ostomy area must be cleaned carefully as the opening is directly into the urinary system. Fluids may be freely consumed as the urine is constantly flowing out of the body.

Bladder Augmentation is a process in which the bladder is enlarged so it can contain a greater capacity of urine. This is not a urine removal process, but it allows larger capacities to be held within the bladder.

A diagnosis of the type of bladder function you have needs to be done to establish the bladder program that is right and safe for you. Learning proper technique will help you avoid infection and keep your urinary system working well for a lifetime. Nurse Linda

Pediatric Consideration: Selection of a urine removal process is based on the needs of your child. Even infants and small children with spinal cord injury or other diseases leading to neurogenic bladder require a bladder program. Not providing a bladder program for a child with a neurogenic bladder can lead to detrimental, long-term consequences. 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.