Bladder Management in Spinal Cord Injury

Original Editor - Eugenie Lamprecht Top Contributors - Eugenie Lamprecht, Kim Jackson and Naomi O'Reilly

Introduction

Neurogenic urinary tract dysfunction is common among individuals with spinal cord injuries (SCIs) and may lead to common complications such as; renal insufficiency, incontinence, and urinary tract infections[1]. Research indicates that urinary tract infections (UTI's) are the most common secondary complication (62%) reported among individuals with SCIs in the first year following discharge from in-hospital treatment. It was also found that UTI's were more prevalent among individuals with higher SCI-levels and complete SCIs[2].

Bladder dysfunction also decreases psychological and social well-being in individuals with SCIs[3].

Pathophysiology

SCI often affects the urinary system and leads to bladder dysfunction or neurogenic bladder. Neurogenic bladder is when bladder control is affected due to the brain-, spinal cord- or nerve complications[4].

The 3 areas of the CNS that control bladder function is;

  1. The cerebral cortex,
  2. The pontine micturition centre, and
  3. The sacral micturition centre.[3]

In SCIs, lesions can interrupt 3 pathways that will lead to bladder dysfunction;

  1. Interruption of the pontine and sacral micturition centres (central lesions) or
  2. The detrusor muscle innervation ( sacral cord lesions) or
  3. The bladder neck innervation (sympathetic) and the external urethral sphincter's innervation[3]

Neurogenic bladder can be classified according to different types of conditions involving the detrusor and sphincter activity.

  1. Hypereflexia with an involuntary contraction: This leads to sphincter dyssynergia, reflex incontinence and residual urine.
  2. Arefelxia of both the detrusor - and sphincter muscles: This is due to sacral injury and leads to stress incontinence and residual urine.
  3. Areflexia of the detrusor muscle and hyperreflexia of the sphincter: This leads to urinary retention and overflow incontinence.
  4. Areflexia of the sphincter and hyperreflexia of the detrusor muscle: This leads to reflex incontinence.[3]

Other classifications include injury to levels in the suprasacral, sacral, or infrasacral segments.

Suprasacral neurogenic bladder occurs due to SCI between the brainstem and sacral centre. This leads to disinhibited sacral reflexes, overactivity of the detrusor, overactivity of the external and/or internal sphincters, and impaired coordination between these two muscles. Possible complications are voiding, urgency, frequency, incontinence, and high pressures in the bladder, leading to reflux, hydronephrosis, and kidney failure.

Sacral neurogenic bladder occurs due to injury to the sacral spinal cord.

While Infrasacral neurogenic bladder occurs due to SCI to the cauda equina.

Both these (sacral and infrasacral) are classified as lower motion neuron lesions (LMNL) and often result in difficulty bladder emptying and lack of sensation, which leads to overflow and stress incontinence, urinary tract infection, bladder distension, and possible renal failure[5].

It is important to remember that spinal shock can last up to 3 months following the SCI and will influence the bladder function, therefore, bladder assessment should be conduction after the spinal shock stage. If involuntary and uncoordinated bladder contraction occurs following the spinal shock stage, it may present neurogenic bladder dysfunction[6].

Common Urinary Complications Following SCI

  1. Urinary tract infection (UTI): Symptoms include; fever, foul-smelling urine, and/or hematuria. UTI's are more common when catheterized by someone else instead of self-catheterization.
  2. Urethritis and prostatitis: Inflammation of urethra and prostate gland.
  3. Epididymitis and epididymoorchitis: Inflammation of the epididymis and/or testis.
  4. Bladder and renal stones.
  5. Renal impairment.
  6. Bladder cancer: Individuals with SCI are 20 times more likely to develop bladder cancer. Risk factors include; UTI, bladder stones, and indwelling catheters.
  7. Autonomic dysreflexia (AD): Distention of the bladder can cause AD.[6]

Management

The main aim of bladder management in individuals with SCIs is to preserve upper tract function with low intravesical pressure through adequate bladder drainage and to maintain urinary continence[3].

Evaluation

  • A voiding-diary and history should be taken in the first assessment, as well as assessing the pelvic anatomy.
  • Determine the motor level of SCI. (level, complete vs. incomplete, extremities tone, rectal tone and bulbocavernosus reflex.
  • Symptom score (questionnaire or outcome measure).
  • Urinalysis, urine culture and sensitivity.
  • Serum blood urea nitrogen/creatinine.
  • Creatinine clearance.
  • Urodynamics.
  • Urinary tract imaging.[6]

Treatment

Treatment should be specific and individualized according to the type of voiding dysfunction, level of injury, the extent of disability and care available to the patient[3].

Conservative Management

Timed voiding

Timed-voiding is behavioural exercise to practise bladder control as generally done in combination with fluid-intake diaries. The recommended daily fluid-intake is 6 to 8 glasses of water per day. Acidic and caffeinated beverages should be avoided if possible. General bladder retraining should include;

  • Limit fluid-intake after 6 pm.
  • Routine bladder emptying, between every 4 to 6 hours.
  • Limit caffeinated and carbonated beverage usage.
  • Attempt to not rush to the bathroom.[7]
Education

Education including treatment possibilities, possible risks and complications, as well as precautions and techniques such as self-catheterization and bladder retraining if applicable, etc.

Valsalva - and Crede Manoeuvers

Long-term use is not recommended because it raises intravesical pressures, and increases the risk of vesicoureteral reflux, hernia, rectogenital prolapse and haemorrhoids [6][3].

Intermittent catheterization

This method can be used by individuals with good hand function and is proven to be the safest emptying method[3].

Depending on fluid intake and frequency of incontinence, it is recommended that individuals perform intermittent catheterization every 4 to 6 hours[6].

Common complications include; erectile dysfunction, poor sexual activity and increased incidents of depression [6].

This method is also commonly used by individuals with paraplegia, while suprapubic catheters are commonly used by individuals with tetraplegia [2]. Suprapubic catheters are generally easier to manage in terms of hygiene and catheter changes[6].

Indwelling Urinary Catheters

This method is often used in the acute phase and not recommended for long-term use due to the higher risk of complications [3].

Long term use is only recommended if individuals have difficulty self-catheterizing[6], as well as in incidents to prevent contamination during wound healing and stage 3 or 4 perineal pressure ulcers[3].

Pharmacological Intervention
  • Anticholinergic medications (works by blocking cholinergic transmission at muscarinic receptors),
  • α-blockers and,
  • Botulinum toxin[3].

Surgical management[6]

  • Botulinum toxin injection in the detrusor and augmentation cystoplasty (decreasing bladder tone & increase the capacity).
  • Artificial urinary sphincter (AUS), abdominal slings, or a transobturator tape procedure (treating incompetent sphincters).
  • Neuromodulation and nerve grafting (improve bladder emptying coordination).
  • Muscle grafting (treating acontractile bladder. acontractile bladder is when the bladder is unable to demonstrate any contraction during a pressure-flow study).

Relevance to Physiotherapy[8]

SCI influences the functioning of many systems including; respiratory-, cardiovascular -, sexual - and bladder and bowel functioning. Ongoing intervention and management are required in individuals with SCI.

Individuals with SCI are often seen by Physiotherapists more regularly that physicians or other healthcare professionals and therefore it is essential that physiotherapists continue monitoring, assessing and addressing possible complications such as pressure ulcers, bladder problems, contractures, etc. when it arise.

Bladder retraining forms part of a multi-disciplinary approach and Physiotherapists also form a vital part of the individual's education and technique training of catheterization (in certain settings).

Conclusion

Research indicates that depression and quality of life following SCI is directly related to bladder dysfunction. It also has a significant impact on the social and financial factors in individuals with SCI as well as their families and communities. Because bladder dysfunction is such a common secondary complication among individuals with SCIs, it is essential that physiotherapists are well educated about the signs and symptoms as well as the general management thereof.

References

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  1. Edokpolo L, Stavris K, Foster, Jr H. Intermittent catheterization and recurrent urinary tract infection in spinal cord injury. Topics in spinal cord injury rehabilitation. 2012 Apr 1;18(2):187-92.
  2. 2.0 2.1 Hagen EM, Rekand T. Management of bladder dysfunction and satisfaction of life after spinal cord injury in Norway. The journal of spinal cord medicine. 2014 May 1;37(3):310-6.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 Sezer N, Akkuş S, Uğurlu FG. Chronic complications of spinal cord injury. World journal of orthopedics. 2015 Jan 18;6(1):24.
  4. https://www.urologyhealth.org/urologic-conditions/neurogenic-bladder
  5. Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, Wolfe D, Teasell R. Bladder management following spinal cord injury. Spinal Cord Injury Rehabilitation Evidence. Version. 2014;5:1-96.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Al Taweel W, Seyam R. Neurogenic bladder in spinal cord injury patients. Research and reports in urology. 2015;7:85.
  7. Paraiso MF, Abate G. Timed voiding and fluid management. InPelvic Floor Dysfunction 2008 (pp. 311-314). Springer, London.
  8. Harvey LA. Physiotherapy rehabilitation for people with spinal cord injuries. Journal of physiotherapy. 2016 Jan 1;62(1):4-11