AA

Bladder Management

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Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, Wolfe D, Teasell R. (2014). Bladder Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-196.


Introduction

Bladder dysfunction in persons with spinal cord injury (SCI) can be disabling medically, physically, and socially. Most people with SCI have some degree of bladder dysfunction. Normally, the bladder is able to store urine with detrusor (bladder wall smooth muscle) relaxation, at low pressures, until it is socially appropriate to void. In the uninjured state, as the relaxed bladder fills to approximately 250 mL to 300 mL, its stretching will signal the brain to coordinate volitional sphincter relaxation and detrusor contraction to empty the bladder in a low pressure, environment. This coordinated function is achieved by the pons micturition centre and timing is controlled by the frontal cortex. The ability to fill and empty the bladder under low pressure is of utmost importance in maintaining health of the kidneys, maintaining continence and preventing urinary tract infections (UTI).

After SCI, neural connectivity from the sacral region of the spinal cord to the pons and cortex are disrupted, hence the loss of coordinated bladder filling and emptying. Involuntary functions of the kidney filtering urine from the blood and of the ureters pushing urine into the bladder for storage will continue despite the SCI. However, various types of SCI can affect bladder function in different ways such as: sensing a full bladder, overactivity or underactivity of the detrusor muscle and/or external sphincter, and dys-coordination between the two structures in the process of urination, The spastic (reflex) bladder usually occurs with injuries of T12 and above while the areflexic (flaccid) bladder usually occurs in injuries below T12-L1 in the region of the spinal cord known as the cauda equina. The functional goal of bladder dysfunction management following SCI is to find a bladder emptying program that is specific to the individual and his/her activities of daily living. This is an important overall goal since no two injuries are equivocal and therefore management strategies will differ accordingly and over time. Clinically, bladder management goals include achieving regular bladder emptying and avoiding stasis; avoiding high filling and voiding pressures; maintaining continence and avoiding abnormal frequency and urgency; and preventing and treating complications such as UTI, autonomic dysreflexia (usually only in those with injuries at or above T6), reflux, stones, and strictures.

In the present chapter, the literature has been classified into sections pertaining to type of bladder dysfunction, that is, neurogenic overactivity (hypperreflexia) or areflexia, assessment, and then methods of pharmacological or non-pharmacological treatments and methods of management. Prevention of complications is discussed according to the type of bladder dysfunction and relevant management methods. The last section focuses on UTI prevention and treatment.