Non-Surgical Methods Used to Safely Empty the Bladder-Part 1

Posted by Nurse Linda in Life After Paralysis on February 10, 2021 # Health

This is a start to bladder management programs. Be sure to check out part 2 next week for the continuation.

The type of bladder program that is designed for you is unique to your individual needs. The method is selected based on the type of bladder issues you have. The selection is not a choice but one that will help keep your bladder, kidneys and body working effectively and efficiently. It is important to follow your bladder program carefully.

The bladder program is selected for you based on your injury and resulting bladder function. It is not a personal choice of bladder emptying techniques. These are the bladder removal and containment programs with the reasons why the specific program would be appropriate for your level of injury.image of someone's left side of their body sitting in a wheelchair

Suprapubic Catheter is used for individuals who have high-pressure bladders or are at extreme risk for high pressure in the bladder. It is usually done early after the trauma but can be recommended anytime in disease processes or with the development of uncontrolled or increased pressures in the bladder.

Suprapubic catheters are placed through a surgical opening in the skin above the pubic bone over the bladder. Therefore, they are called supra meaning above the pubic bone. A catheter is then placed through this opening for continuous drainage of urine. Eventually, the skin will heal around the edges of the opening but will remain open around the catheter.

The catheter is changed using a sterile technique. Changing the catheter is dependent on your needs, typically every month to ten weeks but sometimes as often as every other week or more frequently. A sterile dressing is placed around the catheter at the opening in the skin to protect the wound. The wound area needs cleaning, and the dressing should be changed one to two times per day. The catheter drains into a drainage bag or leg bag. The tubing from the catheter to the drainage collection system should be secured to the abdomen or upper thigh to keep from pulling the catheter or from dislodging it during dressing, transfers, or activity.

Drinking fluids is unlimited unless restrictions are indicated due to other healthcare issues. Fluids are encouraged as the catheter is constantly draining and fluids help flush the urinary system of toxins and bacteria.

Risks: Sometimes, the opening can enlarge, which requires the use of a larger diameter catheter or there is leakage around the opening in the skin, which requires a larger balloon. The bladder tends to remain small as urine is constantly removed, which does not allow the bladder to expand or contract with urine filling and emptying. Because there is an open area in the skin with a catheter continuously placed in the bladder, the normal protection of the internal body is at risk.

Benefits: Most importantly, your kidneys are well protected from urine backing up into them as long as the drainage bags do not overfill. With proper care, infection rates are about the same as intermittent catheterization. Some individuals enjoy not having to catheterize or monitoring fluids. This procedure is also helpful if you have issues with hand function.

Sphincterotomy is a small incision most often in the urinary sphincter to allow for the free release of urine. Both the internal and external urinary sphincters typically will open with bladder contractions. If there is an issue in the process, one or both sphincters will be surgically opened by a small slit. The procedure is typically performed under anesthesia or sedation by inserting a tube through the urethra or bladder opening. The incision(s) are then made through the access of this tube. It is typically done early after a traumatic spinal cord injury but can be done at any time when needed if the disease progresses, affecting bladder function.

This procedure is performed in men who have high pressure or the risk of developing high-pressure bladders from overactive bladders or detrusor-sphincter dyssynergia DSD where the sphincters do not work in conjunction with bladder contractions. With spinal cord injury, this procedure is more often done in men because an external catheter can be used to collect and contain the urine flow.

Although most will not need a repeat procedure, occasionally, the sphincterotomy needs to be repeated due to scaring from the original procedure. A containment device such as the external catheter must be used to avoid incontinence, which leads to skin breakdown.

There are typically no restrictions on fluid after this procedure. The fluid is encouraged unless restricted by other healthcare issues. Intake of fluid helps flush the urinary system of toxins and bacteria as well as maintaining general health.

External Catheters for Men are used for men who have spontaneous elimination of urine from contraction or overflow of the bladder or incompetent sphincters. External catheters are sometimes called condom catheters because of their resemblance to condoms. They consist of a sheath secured around the outside of the penis that has an opening at the end to collect urine as it is spontaneously released from the bladder. The open end is connected to a leg bag or night drainage bag either with a tubing extension or directly.

External catheters are used as the bladder management system for men whose bladders spontaneously release all the urine or more likely, in conjunction with a sphincterotomy or even as a collector for breakthrough urination with intermittent bladder catheterization. If all urine is not spontaneously emptied from the bladder, a combination of the external catheter and intermittent catheterization is used.

External catheters are secured by spirally wrapped tape around the penis with the external catheter placed over it or spirally wrapped tape on the outside of the catheter. It is critical that the tape is placed in a spiral due to a spontaneous erection. Men with SCI or high-pressure bladders have spontaneous erections. A tape or strap that encircles the penis will restrict blood flow, causing injury or even loss of the penis. External catheters come in a variety of sizes to match your body.

Penial skin needs protection from urine, which is caustic. As urine is released, it is briefly caught in the external catheter before it drains out. The external catheter is waterproof, so a residual of urine will remain against the skin of the penis once urine is in the device. A product called skin prep comes with an external catheter device. Skin prep is wiped on the penis where the external catheter will be placed. It is clear and dries a bit tacky. The skin prep provides an amazing amount of skin protection from the urine. Twice a day, the external catheter needs to be removed, the penis washed to remove residual urine and aired. The external catheter is waterproof, which also does not let air into the area.

At the top of the external catheter is a ring ridge. This should be placed just below the penile/scrotal junction below the penis. The external catheter can rub this delicate skin leading to a pressure injury that is difficult to heal.

Sometimes, the pressure of urine output is greater than the drainage hole of the external catheter. This can cause the external catheter to blow up like a balloon until the urine drains. You will need to keep the external catheter clear from constrictions like between the legs to allow this to happen. Sometimes, the catheter will explode due to the force of urine output. Avoid using excessive tape to secure the catheter, as this can lead to damage to the penis. If this happens regularly, try a different brand or size of the external catheter.

External Catheters for Women As the female anatomy is internal. It has been difficult to develop a device for external catheter placement. There have been many attempts through the years, from unsuccessful apparatuses to even surgical rearrangement of the anatomy to meet women’s needs with urinary incontinence from any cause, including high-pressure bladders.

New devices are on the market. There is a need to control female urinary incontinence from non-nerve issue. There are a few new options that are now available. As these devices are new, the idea of use along with a sphincterotomy for women may be a way for the future. The new devices are unproven in the neurogenic bladder (bladder issues from nerve disfunction as in spinal cord injury). These devices fit within or surrounding the labia. They pull expelled urine away from the body. Some have a flange that fits in the labia around the urethral opening. This helps overflow or leakage but will not empty a neurogenic bladder. Intermittent catheterization still needs to occur.

How these devices work for individuals with spinal cord injury is being studied. The concerns are about skin breakdown from pressure in the labia, especially when sitting and how well they will stay in place for active women. Since these products are new, many are quite expensive.

The important point is that incontinence in women with spinal cord injury is being addressed. This will reduce the dependence on adult incontinence pads that have skin breakdown issues and indwelling catheters that can lead to infection.

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. Next week, this column will continue with Part 2 of bladder management techniques. Nurse Linda

Pediatric Consideration: Bladder emptying programs are the same for children, but timing and amounts will be different due to bladder size. Children with spinal cord injury or neurogenic bladder require a bladder program from the moment of injury or disease that affects the bladder. Diapering the small child with a neurogenic bladder does not remove urine. Keep your child safe for a lifetime with a bladder program. 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.