Spinal cord injury (SCI) can occur secondary to spinal column fracture after road traffic accidents or trauma or as a consequence of vascular ischemia or infection. The most common urologic complications following SCI are urinary tract infection (UTI), upper and lower urinary tract deterioration, and bladder or renal stones. One of the most fundamental steps following the initial injury is bladder management. However, many factors are involved in bladder management, including sex, lifestyle issues, hand dexterity, and access to health care providers. When an efficient bladder management program is applied, the patient will experience less incontinence, with improved quality of life. More than 250,000 people are living with SCI in the USA. The National Spinal Cord Injury Statistical Center reports 40 new cases per million of the population per year. More than 80% of these individuals exhibit at least some degree of bladder dysfunction. There is no single management program that can work for every patient.
Does the level of injury on my spine affect what problems I experience?
- Yes, however everyone’s bladder and sphincter act a little differently because the amount of nerve injury is a little different for each
person even if you have the same level of injury as someone else. - Keeping that in mind, the major areas to consider are:
- At or below the sacral micturition center
- Above the sacral micturition center.
At or Below the Sacral Micturition Center:
• If the SCI damaged the spinal cord at or near the base of your spine, the sacral micturition
center might be damaged.
• When this center is damaged, signals can’t be sent to the bladder to tell the bladder to
squeeze (neurogenic underactive bladder).
• It the damage is below your sacral micturition center then even though signals are sent
towards the bladder, the nerves to the bladder are damaged so the signals do not reach the bladder
and your bladder will not squeeze.
• Your bladder will then become very full (over distended).
• If you have a weak urinary sphincter, urine will probably overflow from your bladder without
your control (urinary incontinence).
• If you have a strong urinary sphincter, urine may not be able to be released leading to a
possible increase in bladder pressure and possible back-up of urine in your kidneys.
Above the Sacral Micturition Center:
• The sacral micturition center sends signals to your bladder causing it to squeeze. Your spinal
cord injury also blocks signals coming down from the brain which are telling the bladder when and
when not to squeeze, causing you to have an overactive bladder. (See above section.)
• Signals also don’t usually get to your urinary sphincter to tell it to relax when your bladder
is squeezing (detrusor sphincter dyssynergia). (See above section.)
• If your injury is at T6 or above you may get autonomic dysreflexia from your overactive
bladder and detrusor sphincter dyssynergia.
What are some types of bladder management?
There are many types bladder management following SCI, each with various advantages and disadvantages. Several of the more
common types of bladder management are listed below. It is important to speak with your healthcare provider to determine which option
is best for you.
Intermittent Catheterization (pronounced kath-et-er-iz-AY-shun)
This option is used for draining your bladder without keeping a catheter in the bladder all
the time.
• You (or someone else) insert a catheter into your bladder to keep your bladder from getting
too full.
- To do this, pass the catheter up your urethra into the bladder. The urine drains out the
other end. - When done, remove the catheter and return to normal activities.
- Do this as often as needed (usually 4-6 times per day). The goal is to keep your
catheterization volumes less than 500 ml. (about 17 fl oz) so you may have to catheterize more or
less often depending on how much you drink. - You will often need medication or injections (such as Botox) to keep your bladder quiet in
order to prevent leaking and high pressures in your bladder.
Bladder Management Options Following SCI
• This option might NOT be for you if:
- You are unable to catheterize yourself (or don’t have someone to help you).
- Your bladder is very small (so you would have to catheterize your bladder very frequently).
- Your bladder is overactive (even with treatment; so you may have high bladder pressures or
incontinence). - Your sphincter is overactive (will not relax easily; so the catheter will not pass easily
into your bladder). - Your sphincter is underactive (will not tighten; so you will have frequent urinary
incontinence). - You have a false passage in your urethra (so the catheter may get caught in the false
passage). - You drink a lot of fluid (more than 2 -21/2 quarts or 2 liters) every day so you would need
to catheterize very frequently). - You have a lot of pain when inserting or removing the catheter.
• You can use different types of catheters. Your doctor can help you decide which type of
catheter is best for you. For example, the catheter might:
- Have a slight curve at the tip. This is known as a Coudé (pronounced ku-DAY) catheter.
- Have a bag attached at the end to catch the urine.
- Be covered with lubricant to help it slide through your urethra.
Advantages:
• Intermittent catheterization simulates normal bladder filling which helps to maintain your
normal bladder size
• You will not wear an internal or external catheter and leg bag all the time.
Disadvantages:
• You need to keep track of your fluid intake so that your bladder doesn’t fill up too soon and
get overstretched, especially while you are sleeping.
• You need to partially undress each time you use a catheter.
• You might find removing and inserting a catheter uncomfortable.
• If you are a woman, you might have trouble finding and passing your catheter into your
urethra. You might cause some irritation or bleeding when passing a catheter into your bladder,
especially if you are a man and have a very spastic urinary sphincter that tightens when you try to
remove the catheter.
• You may need to take medication to keep your bladder from being overactive and causing urinary
leakage.
Indwelling Catheterization
This option is used for ongoing protection from urinary retention or urinary incontinence.
Indwelling catheterization uses a catheter and a urine collection bag that stays in place all the
time. The catheter has a balloon at the tip of the catheter which sits in your bladder. Once the
catheter is in your bladder, the balloon can be inflated to keep the catheter from falling out or
deflating when it’s time to change the catheter.
There are two types of indwelling catheters: urethral catheters and suprapubic (pronounced
soo-prah-PEW Bik) catheters. Most urethral catheters that are kept in place by filling up a
balloon. People might call your indwelling catheter a Foley catheter.
Type 1: Urethral Catheters
A urethral catheter is inserted through your urethra, by yourself, by a physician, nurse or a
trained family member using a similar technique as intermittent catheterization. However, instead
of removing the catheter when your bladder is empty, the indwelling catheter stays in your bladder
and is held in place in your bladder by a small balloon at the end. A small tube connects the other
end of the catheter into a collection bag. It is not a good idea to plug your catheter, especially
if you do not have good sensation in your bladder. If your bladder fills up and gets over
distended, it can cause serious problems such as a bladder or kidney infections or autonomic
dysreflexia (if your injury is at T6 and above).
There are several types of collection bags:
• Smaller bags can be strapped to your leg so that you can move freely.
• Some larger bags don’t have to be drained as often and are used when you are sleeping (called
night bags).
Bladder Management Options Following SCI
• A modified bag can be strapped around your waist (called a belly bag) instead of your leg.
A collection bag must be emptied frequently:
• A collection bag must be emptied several times a day to keep it from getting too full. It is
best to try to empty the bag when it gets about one half full.
• If the bag gets too full, pressure may build up in the bag and keep the urine from flowing
down the tube. Instead, the urine will back up. This could cause your bladder to become over
stretched and cause problems such as bleeding, bladder infection, or autonomic dysreflexia.
A urethral catheter stays in place all the time. About once a month, the catheter is removed and a
new one is put in place. This may be done sooner if the catheter gets blocked from bladder stones
or if there are other problems with the catheter’s drainage.
Advantages
• You do not need to worry about inserting and removing the catheter into your bladder several
times a day.
• You do not need to limit the amount of liquid you drink.
• You do not need to undress to use the catheter.
Disadvantages
• About 3 out of 10 people who use a urethral catheter get bladder stones, which are small
hardened pieces that collect and can block your catheter and cause your bladder to get
overstretched. This can cause leaking around the catheter, pain, a urinary tract infection,
hematuria (blood in the urine), or autonomic dysreflexia.
• You might have discomfort or pain from the catheter, especially when inserting or replacing
it.
• You might be uncomfortable wearing a urine collection bag and worry about it leaking.
• It can be difficult to keep the area around the catheter clean, especially for women.
• A constantly empty bladder can reduce the size of your bladder, making it less able to hold
more urine.
• You may need to take medication to keep your bladder from being overactive and causing urinary
leakage.
• There can be sexuality issues due to having a catheter in the urethra.
• There may be a slight increase in bladder infections with urethral catheters but not
suprapubic catheters compared to other types of management.
Type 2: Indwelling Suprapubic Catheter
In order to insert an indwelling suprapubic catheter, a doctor first needs to make a small incision
below the beltline This is done under an anesthetic. He or she then inserts the catheter through
the incision into the bladder. Urine drains out from the catheter and is then stored in a
collection bag on the outside of your body. The collection bag is drained as needed, to keep the
bag from getting overfilled. The catheter is changed on a monthly basis just like a urethral
catheter.
After the catheter has been put in by a doctor, the incision heals and there is a small hole so
that the old catheter can be removed and a new catheter can be inserted. It is important to measure
the distance that the catheter is in your bladder by marking the catheter at the skin level before
removing it and then putting the new catheter in the same distance in. As long as a catheter is in
the hole, it stays open. Once the catheter is removed the hole will close in 1-3 days. There are no
restrictions with bathing or showering with a suprapubic tube.
One study showed that in women, there were fewer bladder infections with a suprapubic tube than any
other type of bladder management.
Advantages:
• Has all the advantages of a urethral catheter, and a suprapubic catheter also keeps you from
feeling pain or discomfort from inserting and removing the catheter from your urethra.
• This catheter is easier to change than a urethral catheter. You do not need to lie down or
undress to change the catheter.
• It is easy to keep the area around the catheter clean, and you are less likely to get an
infection than with a urethral Foley catheter.
• It is preferable to a urethral catheter for sexuality reasons because the catheter is not in the
urethra. If the suprapubic catheter becomes blocked or can’t be removed, the urethra can sometimes
act as a “pop off valve” releasing some of the urine, or the urethra
can be used to pass a temporary urethral catheter.
Bladder Management Options Following SCI
Disadvantages:
• Like urethral catheters, there is an increased risk for developing bladder stones and a
smaller bladder.
• You may need to take medication to keep your bladder from being overactive and causing urinary
leakage.
• Same day surgery is needed to create the opening for the catheter.
Reflex Voiding
This option primarily is used by men with bladders that fill and squeeze on their own because a
convenient way to capture urine is needed.
• This method usually uses an external condom catheter. These catheters fit like a condom around
the penis and connect to a tube and collection bag. (There is no effective external collecting
device for women.)
• This method requires a relaxed sphincter, and you might need help relaxing it. Methods of
relaxing your sphincter include suprapubic bladder tapping (where you lightly tap the area over
your bladder), medication, injections, and surgery.
• A man or a woman who uses a reflex voiding option might decide to have their bladder drain
directly into a protective undergarment. Undergarments must be changed frequently to avoid the
urine causing a skin rash.
Advantages:
• You do not need to limit your liquids.
• You do not need to undress to empty your bladder.
Disadvantages:
• Men need to wear an external condom catheter, and a leg bag or a protective undergarment to
collect urine.
• Women must use a protective undergarment.
• Protective undergarments must be changed frequently.
• The skin around the penis might get irritated from the condom catheter being too tight.
• The external condom might twist or kink and fall off during voiding.
• If you have a “retractile” penis that pulls back into the abdomen, especially when you sit up,
the condom catheter might not stay on.
• Additional treatment or medication might be needed to relax your sphincter, and these
treatments could cause side effects.
Valsalva and Credé Voiding
This option is for people who have difficulty getting their bladder to squeeze. Credé (pronounced
kre-DAY) is a method where you push inwards with a closed fist over your bladder to empty it.
Valsalva (pronounced vahl-SAL-vah) is a method where you tighten your abdominal muscles and bear
down to force urine from your bladder.
• The amount of bladder emptying depends on how much force you use to push urine from the
bladder and how much your sphincter relaxes.
• While not recommended, people sometimes use crede or valsalva voiding in addition to their
other type of bladder management. For example bearing down when they catheterize themselves to try
to make their bladder empty a little quicker by forcing the urine flow through the catheter quicker
or bearing down and forcing a little urine out of their bladder so they do not catheterize
themselves as often.
Advantages:
• You do not need to use a catheter of any kind.
Disadvantages:
• The pushing or straining to empty your bladder can cause problems over time (such as
hemorrhoids, hernias, and other medical problems).
• To catch the urine, you will need to undress and transfer onto a toilet, use a bed pan, or
wear protective undergarments.
• It often takes a lot of effort and time to bear down in an attempt to empty your bladder.
• You may not be able to empty your bladder completely leading to complications such as UTI’s and
bladder stones.
Reference
Consortium for Spinal Cord Medicine (2002). Acute management of autonomic dysreflexia: individuals
with spinal cord injury presenting to health-care facilities. J Spinal Cord Med. 25, Suppl
1:S67-88.
Authorship
Bladder Management Options Following Spinal Cord Injury was developed by Todd A. Linsenmeyer, M.D.,
and Steven Kirshblum, M.D., in collaboration with the Model Systems Knowledge Translation Center.
Source: Our health information content is based on research evidence and/or professional consensus
and has been reviewed and approved by an editorial team of experts from the Spinal Cord Injury
Model Systems.
Disclaimer: This information is not meant to replace the advice of a medical professional. You
should consult your health care provider regarding specific medical concerns or treatment. The
contents of this fact sheet were developed under a grant from the National Institute on Disability,
Independent Living, and Rehabilitation Research (NIDILRR grant number 90DP0012). The contents of
this fact sheet do not necessarily represent the policy of Department of Health and Human Services,
and you should not assume endorsement by the Federal Government.