Bladder management options in spinal cord injury

By Scihealthhub – September 10, 2024

Do you wish to learn more about the different bladder management methods for individuals with spinal cord injury? If yes, then you’re in the right place.

A good knowledge about changes in your body system occasioned by spinal cord injury and how to manage these changes is important to help you prevent some of the complications of spinal cord injury. 

People with spinal cord injury who are better informed are more likely to experience reduced complications related to spinal cord injury and improved quality of life. 

One research showed that less than 50% of people with spinal cord injury had good knowledge about bladder management and pressure ulcers after being discharged (1).

Understanding how your urinary system works 

First, you need to understand how the normal urinary system works. 

The 4 organs of the urinary system – kidneys, ureter, bladder and urethra – must work harmoniously for you to urinate normally. 

The process begins in the kidney, which contain millions of tiny filters through which it filters the blood and produces urine as a waste by-product. 

From the kidneys, the urine passes through the ureter into the bladder and the stores here for a while. When the urine exceeds the bladder storage capacity of 400 to 500cc, you’ll get a signal from your brain of being pressed. But you are still able to hold the urine and release it at your convenient time through the urethra. 

The effective transmission of electrical signals between the bladder and the spinal cord and brain is crucial for normal bladder function of urine storage and release of urine at an appropriate time. 

How spinal cord injury affects your bladder function 

Spinal cord injury can cause disruption in the flow of electrical signals between the bladder and the brain and spinal cord resulting in abnormal bladder function, a condition medical known as neurogenic bladder. 

Neurogenic bladder is very common in people with spinal cord injury. One study shows that 70 to 84% of people with spinal cord injuries have varying degrees of neurogenic bladder at some point in their life {2, 3).

Some of the symptoms or negative effects of neurogenic bladder include difficulty in passing urine, urinary incontinence (leaking urine), inability to empty the bladder fully, raised bladder pressure and vesico-ureteral reflux (abnormal flow of urine from the bladder back up towards the kidneys). 

If not well controlled, neurogenic bladder is potentially deadly because it may result in kidney damage and kidney failure. 

What is bladder management? 

Bladder management is a set of measures and treatments that facilitate voiding, improve bladder function, keep the kidneys healthy and prevent kidney damage in people with neurogenic bladder. 

An appropriate bladder management will reduce the risk of urinary tract infections, reduce bladder pressure, prevent kidney damage and improve quality of life. 

Conversely, inappropriate bladder management can result in serious complications, including repeated urinary tract infections and progressive kidney damage (4).

Your doctor will help you choose a bladder management method that suits your lifestyle and is appropriate for you. 

What are some bladder management options for people with spinal cord injury? 

There are different bladder management methods, each with its own peculiarities, advantages and disadvantages. 

Some of the common bladder management methods include:

• Clean intermittent catheterization
• External condom catheter
• Indwelling urethral catheter
• Indwelling supra-pubic catheter
• Incontinence pads
• Valsalva voiding, Credé Voiding and abdominal tapping

Clean intermittent catheterization

This method involves the insertion of a catheter through the urethra to the bladder to drain urine from the bladder. Once the urine is fully drained, you remove the catheter and return to normal activities. 

It is recommended that you perform clean intermittent catheterization every 4 to 6 hours (usually 4 to 6 times in a day), depending on the quantity of fluid you consume. 

Experts generally agree that clean intermittent catheterization is the safest and preferred method of emptying the bladder in people with spinal cord injury (3, 5).

Nonetheless, research demonstrates that only 30% of people living with spinal cord injury who start clean intermittent catheterization continue it over time and that most will change to indwelling catheters, which is the bladder management method with the highest complication rate (9).

Pros 

• It is as close as you can get to normal bladder storage and release of urine. 
• It allows you to regularly empty your bladder completely and this can have the following benefits:
• Reduces bladder pressure
• Reduces vesico-ureteral reflux
• Increases bladder resistance to bacteria infection, and 
• Preserves kidney health 

Other advantages include:

• It is not a barrier to sexual intimacy 
• It improves independence and self-care – your ability to take care of your self so you can be healthy and go about your normal activities (5, 6, 7, 8}.

Cons 

• You might find the whole process of insertion and removal of catheter every time you want to pee cumbersome and uncomfortable. 
• You may need to monitor your fluid consumption – too much fluid means your bladder will fill up quickly and too little fluid may raise your risk of having a urinary tract infection. 
• Women may have a challenge finding and passing a catheter into the urethra. 
• It has been reported that people who regularly perform clean intermittent catheterization may be at higher risk of having erection problems. 
• It has been associated with a higher risk of depression. 
• Some people may have to take medicines to suppress overtime bladder and reduce the risk of urine leakage. 

External condom catheter

This is an external urine collection device for men that is worn like condom on the penis and connects to a tube and a collection bag. 

Condom catheters are attached to the manhood using adhesives specifically made for this purpose. 

The risk of urine leakage can be minimised by using the correct-sized catheter, achieving reasonable seal with the adhesive, ensuring free flow of urine to the collection bag and frequent emptying of the collection bag. 

Experts say condom catheter is appropriate for men whose bladder can store and release urine on their own and who are unwilling or unable to perform clean intermittent catheterization. 

Pros 

• Generally more comfortable – many people find condom catheters are a lot more comfortable than indwelling catheters, as they are non-invasive. 
• Research shows that external condom catheter is associated with reduced risk of urinary tract infections compared to indwelling catheter (10).
• It is generally easier to apply and remove. 

Cons 

• The bladder does not empty completely resulting in residual urine, high bladder pressure and increases the risk of vesico-ureteral reflux. These factors may damage the kidneys if not controlled. However, you can increase bladder emptying by applying gentle pressure or tapping on the bladder (just above the pubic bone) with your hand. 
• Currently, there is no satisfactory external catheter suitable for use by women. 
• Men with small manhood or sore on the manhood may not be able to wear a condom catheter because of difficulty in attaching them. 
• There can be displacement of the catheter and urine leakage, especially if you do not consider the preventive measures highlighted earlier. 
• Sores may develop on the manhood if you apply too much pressure while attaching the catheter on the manhood. 
• Some men may experience allergic reactions from the latex or adhesives. 

Indwelling urethral catheter

This method involves the insertion of a catheter through the urethra into the bladder by the individual, a doctor, nurse or trained family member. However, unlike in clean intermittent catheterization, the catheter is stays in place in the bladder. 

The catheter is connected to a collection bag where urine is stored. It is important to empty the collection bag frequently to avoid a situation where it can get too full leading to backflow of urine, bladder over-distension and bladder damage. 

Once in 2 weeks, the catheter is removed and a new one put in place to reduce the risk of bladder infections. Also, if the catheter gets blocked, it must be removed and a new one replaced. 

Pros 

• It is less cumbersome because, unlike clean intermittent catheterization, you do not need to insert and remove catheters several times a day. 

Cons 

• Because the catheter stays in place in the bladder, it is associated with higher risk of urinary tract infections compared to external  condom catheter and clean intermittent catheterization. 
• High risk of bladder stones or sediments formation. 
• High fluid consumption (more than 3 litres per day) to flush the bladder and catheter of bacteria and sediments. 
• Because the catheter is in the urethra, you may have trouble with sexual function. 
• The size of the bladder may become smaller over time because of the constantly empty bladder and this may in turn reduce the ability of the bladder to store urine. 
• If the catheter becomes blocked, there may be bladder over-distension and urine leakage around the catheter. 
• There is risk of urethral damage. Strapping or tapping the catheter to the upper thigh may lower the chance of injury if the catheter is tugged accidentally. 

Indwelling supra-pubic catheter 

method is similar to the indwelling urethral catheter method, except that in this case your doctor makes an incision below the belt-line into the bladder and inserts the catheter through the incision into the bladder. 

The catheter is connected to a collection bag outside of the body for urine storage.

When this incision heals, it leaves a hole through which the old catheter can be removed and a new catheter inserted once in 2 weeks. 

It is recommended that you strap or tape the catheter to the upper thigh or lower belly to reduce chance of injury if the catheter is tugged accidentally. 

Pros 

• More people find it comfortable and satisfying compared to indwelling urethral catheter. 
• It is easier to change compared to the indwelling urethral catheter. 
• Since the catheter is not in the urethra, it does not interfere with sexual activities. 
• Hygiene issues such as cleaning the area around the catheter is easier to manage. 
• If the suprapubic catheter gets blocked or gets stuck, urine can be released through the urethra directly or by passing a catheter through the urethra.
• Does not pass through the urethra so there is no risk of damaging the urethra.

Cons 

• A relatively simple and safe surgery is required to create the incision. However, potential complications such as bowel injury, infection or even death may occur (11).
•  Like indwelling urethral catheter, there is an increased risk for developing urinary tract infections, bladder stones and a smaller bladder.

Incontinence pads

They are absorbent pads that are worn inside underwear to soak up urine. 

They may come in different forms such as pads or panty liners with adhesive strips for attachment to underwear. Undergarments, adult briefs and protective underwear are other examples. Some are reusable while others are single use. 

Incontinence pads are designed to absorb and hold urine, help protect the skin from direct contact with urine and keep urine from wetting clothing. 

Pros 

• It is easy to apply and remove. 

Con 

• It can be expensive. 
• Urine leakage overtime can irritate the skin resulting in rashes, skin redness or skin breakdown. The use of skin care products such as moisturising creams, lotions or pastes can help minimise this risk. 
• It is associated with a high risk of urinary tract infections. One study showed it raises the risk of urinary tract infections by as much as 4 fold (12). However, frequent change of incontinence pads can help reduce this risk. 
• Incomplete emptying of the bladder may cause residual urine which may put you at risk of high bladder pressure and vesico-ureteral reflux, both of which can result in kidney damage. 

Valsalva voiding, Credé Voiding and abdominal tapping 

These are common techniques used to enhance bladder emptying. 

Valsalva is method in which you try to breathe out forcefully against a closed airway. This is usually usually done by trying to breathe out while closing one’s mouth and pinching one’s nose. This will increase abdominal pressure and cause a stronger bladder squeeze and force more urine from the bladder. 

Credé is a method is performed by applying manual pressure with a closed fist on the lower abdomen between the belly button and public bone. Like the Valsalva method, this can also increase abdominal pressure and facilitate bladder emptying. 

Abdominal tapping involves tapping rhythmically on the lower abdomen (between the belly button and the pubis) in an attempt to stimulate the bladder to squeeze and trigger urination.

All 3 methods are usually combined with another method of bladder management, which could be either external condom catheters or incontinence pads. 

The long term use of these methods as the only method of bladder emptying is not recommended. 

Cons

• Using techniques that increase abdominal pressure can overtime can cause problems such as hemorrhoids, hernias, and other medical problems. 
• These bladder management methods are usually used in addition to other types of bladder management, namely external condom catheter or incontinence pads. 
• Incomplete bladder emptying is common and this can increase the risk of complications such as urinary tract infections, high bladder pressure and vesico-ureteral reflux and kidney damage. 

In conclusion, there are many bladder management methods that can help people with spinal cord injury improve bladder function and preserve kidney health. Your doctor can help you choose a bladder management method that best suits your lifestyle, improves your quality of life and helps you keep your bladder and kidneys healthy. 

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