Bladder Management after spinal cord injury, Neurogenic bladder

Bladder Management after spinal cord injury, Neurogenic bladder

Bladder management programs are developed for the urinary health of individuals with nerve damage. Neurogenic bladder is nerve miscommunication binding the appropriate control of your bladder.

Bladder issues are of two types:-

Incontinence

Urinary incontinence is an inability to control urine output until a socially acceptable moment. Bladder contractions overpower the strength of the sphincters or weak sphincters leading to urinary incontinence.

Retention

Urinary retention is an inability to empty the bladder either partially or fully.

Bladder dysfunction can be termed as mismanagement by the body to regulate bladder contractions with sphincter function. Bladder dysfunction can be a result of many factors like illness or Spinal Cord Injury. Bladder contractions that overpower the strength of the sphincters or weak sphincters can lead to urinary incontinence. Obstruction can lead to urinary retention. Any illness or Spinal Cord Injury causes the central nervous system miscommunication between the bladder and sphincters which results in retention or neurogenic bladder.

Neurogenic Bladder Types and Treatments 

The parts of the urinary system need to work in coordination for effective urine elimination. Neurogenic means there is a difficulty with nerve transmission. When messages are impaired from being sent to and from the brain, a neurogenic bladder is diagnosed. This can be caused by disease or injury to the central nervous system (brain and spinal cord) or peripheral nervous system (nerves in the body).

Examples of causes of neurogenic bladder include these and others:

·         Infection in the urinary system or body

          ·         Multiple Sclerosis

            ·         Cerebral Vascular Accident.

            ·         Stroke in the brain or spinal cord

            ·         Cerebral Palsy

            ·         Brain or spinal cord tumors

            ·         Birth defects that effecting the spinal cord  

            ·         Diabetes

            ·         Accidents to the brain or spinal cord injury

         ·         Peripheral nerve damage

            ·         Parkinson’s Disease

            ·         Genetic nerve problems

            ·         Heavy metal poisoning

            ·         Spina Bifida 

 

Neurogenic bladder are divided into 4 types: -

         Neurogenic Uninhibited bladder

Uninhibited bladder is a condition where there is a less sensation or recognition that the bladder is full. Urinary incontinence (involuntary leakage of urine) occurs because the individual does not recognize the urge to pee. It can be associated with brain injuries, stroke, dementia, and multiple sclerosis.

Uninhibited bladder may be treated by scheduling bladder management times with slowly increasing the time between peeing. Monitoring fluid intake, Medications to tighten the sphincter muscles or relax bladder contractions should be taken in consideration. Intermittent catheterization program (IMC) should be followed at fixed intervals to drain urine from the bladder.

          Hyper-Reflexive (Spastic) bladder 

Hyper-Reflexive (Spastic) bladder in case of injury to the upper motor neurons (UMNs) of the nervous system. Upper motor neurons are the primary source of movement in humans. UMN injuries are seen in individuals with cervical and thoracic disease or road injury. The reflexive neurogenic bladder occurs in individuals with spinal cord injury above T10.

 

In this condition urine is retained in the bladder creating high pressures which causes urine to backflow up the ureters into the kidneys. As the kidneys does not store urine, damage is seen.

Treatment for reflexive neurogenic bladder depends on the individual’s needs. People with higher level injuries where hand function is limited and have high pressure in the bladder may have a sphincterotomy performed. This is a surgical procedure where a small cut is made in the external sphincter muscle resulting in a free flow of urine out of the bladder. An external catheter is then used to collect and contain urine. This reduces the risk of urine flow back into the kidneys.

If hand function is sufficient, self-intermittent catheterization is initiated. This is a process where urine is drained from the bladder through a temporary catheter placement. Once the urine is drained, the catheter is removed.

          Neurogenic Flaccid Bladder 

When the lower motor neurons (LMNs) are damaged, messages from the brain are misinterpreted or not transmitted to the body. As LMNs are located in the lower central nervous system in the spinal cord, nerve roots, cranial nerve of the brainstem and cranial nerves with motor function. The result is flaccidity. LMN injury is most often seen in individuals with lumbar and sacral disease or Spinal injury.

          Below the level of injury, your body is also flaccid, including the bladder, which                         will fill with urine but not expel it. The bladder does not contract in the usual manner.                 Urine just continues to fill the bladder to overcapacity or the full amount of urine in the               bladder is not eliminated. Residual urine remains in the bladder.

If the reflex arcs are preserved, stretching the rectal opening may result in expulsion of urine. Treatment of flaccid neurogenic bladder can also be managed with intermittent catheterization.

         Neurogenic Mixed Bladder 

There are cases where individuals have elements of both the UMN and LMN injury. For example, the bladder can be reflexive, but the external sphincter is flaccid which leads to urinary incontinence. Or the bladder can be flaccid with a reflexive external sphincter. This creates a large, high pressure bladder with an inability to urinate.

 

How to Gain control on Bladder Functions.

Bladder Augmentation 

In Bladder Augmentation bladder is enlarged surgically so that it can hold a greater capacity of urine. This it allows larger capacities of urine to be held within the bladder.

 

Electrical Stimulation Implant with Posterior Sacral Rhizotomy 

The nerves that control urination are from S2-S4. Implantation of an electrical stimulation device on the nerve roots can assist with sphincter and bladder contraction and relaxation. The electrodes are surgically attached to the nerve roots.

 

External Catheters for Men 

External catheters also often called Condom Catheters as they look alike condoms. They consist of a sheath secured around the outside of the penis that has an opening at the end to collect urine connected to a urine collection bag.

 

External catheters are used as the bladder management system for men whose bladders spontaneously release the entire contents of urine collected in the bladder. 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 external catheter.

Indwelling urethral catheters 

The indwelling catheter allows a continuous flow of urine while keeping the urine contained and skin dry which avoids pressure injury. The indwelling catheter is connected to a collection bag.

An indwelling urinary catheter is held in the bladder by a water-filled balloon, which prevents it falling out. These types of catheters are also known as Foley catheters. A Sterile technique should be used to change these catheters. If urine leaks around the indwelling catheter, a larger size or larger balloon is needed.

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.

Keeping the drainage bag lower than the level of the bladder are other way 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 and that the drainage tube is coiled on the bed next to you.

Clean Intermittent Catheterization 

Clean Intermittent Catheterization 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. The system can be used by individuals with high or low pressure bladders, reflexive or flaccid bladders.

 

 

How to do Clean Intermittent Catheterization 

• Keep your equipment’s handy i.e. catheter, lubricant, urethral cleaning supply. 

• Get into position for catheterizing i.e. on the toilet, in your chair, in bed. Prefer to be in Sitting position as it will give 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 catheterize in bed, be sure to sit up, if possible.

• Wash your hands, thoroughly using soap and running water or warm water if possible. Dry with a clean towel. Used towels collect bacteria so use a clean one. 

• Drop 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.  

• Insert lubricated catheter until urine starts flowing out. Drain urine until it stops flowing. Once urine stops flowing, the level of the urine is below the catheter. That does not mean your bladder is empty.

• Slowly remove catheter. Slow removal will drain that last bit of urine left in the lowest part of your bladder. 

• Wash your hands. Always thoroughly wash your hands after Intermittent catheterization.  

 

Intermittent catheterization is done every four to six hours. Your timing schedule is based on your needs. It is important to maintain your schedule to avoid overfilling your bladder resulting in possible incontinence or backflow into the kidneys. 

          Fluids need to be monitored with CIC

Men should have about 350ccs, women about 300ccs of urine in their bladder at catheterization time to avoid overstretching and back flow. Some fluids such as sugary drinks, caffeine, or alcohol pass through the body quicker than water so you can easily overfill your bladder with these drinks. You can still enjoy them, just maintain limitations. However, plain water is best.There are less urinary tract infections with this procedure as the catheter is not left in the bladder.