Authors: SCIRE Community Team | Reviewed by: Bonnie Nybo, RN, NCA | Last updated: Jan 18, 2018
Bladder changes are common after spinal cord injury (SCI). This page provides an overview of the types of bladder changes that happen after SCI and the basics of bladder care.
- Most people with SCI experience some bladder changes after injury, but the type and symptoms depend on the characteristics of the injury.
- There are two main types of bladder problems after SCI:
- Spastic (reflex) bladder involves unpredictable emptying caused by overactive bladder muscles. It happens with injuries above T12.
- [glossary_exclude]Flaccid (non-reflex) bladder[/glossary_exclude] involves an inability to empty the bladder because of ‘floppy’ and underactive bladder muscles. It happens with injuries below T12.
- People with SCI are also at risk of complications like urinary tract infections, autonomic dysreflexia (if above T6), kidney and bladder stones, and kidney damage.
- Bladder care after SCI involves developing a regular bladder routine that meets your unique bladder needs. This may include a variety of treatments, such as catheters, medications and injections.
Neurogenic bladder is bladder dysfunction caused by damage to the nerves, brain or spinal cord. After a spinal cord injury, nerve signals that normally allow the brain and bladder to communicate with one another cannot get through. This can affect bladder sensation and control.
Bladder changes after SCI are different for everyone. Some people experience only mild changes to how the bladder works (such as greater sense of urgency when the bladder is full); while others experience total loss of bladder sensation and control.
The symptoms of [glossary_exclude]neurogenic bladder[/glossary_exclude] depend on the characteristics of the SCI, such as the level and completeness of the injury. There are two main types of [glossary_exclude]neurogenic bladder[/glossary_exclude] after SCI, spastic bladder and flaccid bladder (see below).
How does the bladder work when the spinal cord is intact?
When the bladder is not full, the [glossary_exclude]bladder wall muscle[/glossary_exclude] is relaxed and urine produced by the kidneys passes through the [glossary_exclude]ureters[/glossary_exclude] to fill the bladder. The [glossary_exclude]bladder sphincter muscles[/glossary_exclude] are tightened so urine does not leak out.
When there is enough urine to stretch the bladder walls, a nerve signal is sent up the spinal cord to tell the brain that the bladder is full. Because the brain controls the external sphincter muscle, urine can be held until an appropriate time to empty.
When the bladder is to be emptied, signals are sent from the brain down the spinal cord to cause the coordinated squeezing of the [glossary_exclude]bladder wall muscle[/glossary_exclude] and relaxation of the [glossary_exclude]bladder sphincter muscles[/glossary_exclude] to allow urine to pass through the [glossary_exclude]urethra[/glossary_exclude] and out of the body. Control of urination involves both bladder reflexes (in which emptying is triggered when the bladder is full) and voluntary control (in which urine can be held until a socially appropriate time to empty).
The bladder after SCI
When the spinal cord is injured, nerve signals that normally allow the brain and bladder to communicate with one another cannot get through. This can lead to changes to bladder control and sensation.
Signals from the brain are needed for the bladder muscles to contract and relax properly. If these signals cannot get through, the bladder muscles may contract too much, too little, or at the wrong times, depending on whether the person has spastic or flaccid bladder.
When the bladder is full, the nerve signals that would normally be sent up the spinal cord to the brain are interrupted. This can lead to reduced ability to feel sensations from the bladder, such as when it is full.
Spastic bladder (also called ‘reflex bladder’ or ‘overactive bladder’) is when the bladder wall muscle is overactive. [glossary_exclude]Spastic bladder[/glossary_exclude] happens because the brain can no longer control reflexes in the bladder muscles. This leads to tension in the [glossary_exclude]bladder wall muscle[/glossary_exclude] when it is supposed to be relaxed and spasms of the bladder muscles which cause emptying. [glossary_exclude]Spastic bladder[/glossary_exclude] happens when the spinal cord is injured above T12.
Usually, the bladder sphincter muscles are also overactive and cannot coordinate very well with the [glossary_exclude]bladder wall muscle[/glossary_exclude]. This is called detrusor dyssynergia or detrusor sphincter dyssynergia (DSD). When this happens, the [glossary_exclude]bladder sphincter muscle[/glossary_exclude] tightens while the [glossary_exclude]bladder wall muscle[/glossary_exclude] contracts, like squeezing a balloon that is tied off. This can cause high pressures within the bladder that can damage the bladder and kidneys.
Symptoms of spastic bladder:
- Loss of control of bladder emptying (incontinence), leading to random emptying (accidents), inability to empty when you want to and leaking
- Reflex emptying in response to things like touching the thigh or abdomen
- People who have some bladder sensation may experience sudden strong urges or a frequent need to urinate
- [glossary_exclude]Incomplete[/glossary_exclude] emptying of the bladder caused by poor coordination of the [glossary_exclude]bladder wall muscle[/glossary_exclude] and [glossary_exclude]bladder sphincter muscles[/glossary_exclude] (detrusor dyssynergia)
- Reduced or complete loss of bladder sensation
Flaccid bladder (also called ‘non-reflex bladder’ or ‘underactive bladder’) occurs with injuries below T12-L1 (i.e., cauda equina injuries). In this situation, the bladder wall muscle is ‘floppy’ and cannot squeeze to empty the bladder.
[glossary_exclude]Flaccid bladder[/glossary_exclude] happens because there is a loss of both input from the brain and reflexes from the spinal cord. This causes the [glossary_exclude]bladder wall muscle[/glossary_exclude] to stay loose and ‘floppy’ all the time. When this happens, the [glossary_exclude]bladder wall muscle[/glossary_exclude] cannot squeeze the bladder to empty urine.
Usually, the external sphincter muscle is also overly relaxed, causing leaking during activities like transfers and coughing. However, the internal sphincter muscle is often in spasm and does not relax enough to allow urine to pass out of the body easily.
Symptoms of flaccid bladder:
- Inability to empty the bladder, including loss of reflex emptying
- [glossary_exclude]Incomplete[/glossary_exclude] bladder emptying, leading to some urine remaining in the bladder after emptying (urinary retention)
- Damage to the walls of the bladder when they are overstretched
- Backflow of urine back to the kidneys (reflux), which can damage the kidneys
- Reduced or complete loss of bladder sensation
Bladder changes are diagnosed primarily through a bladder examination. A bladder examination typically involves several components:
- Your health provider will ask you questions about your medical history, symptoms, bladder routine, and current treatments.
- You may be asked to complete a ‘urinary diary’ and/or detailed questionnaires about your bladder care. This often involves recording how often you empty your bladder, how much urine is produced each time, and details about your fluid intake (what you drink, when and how much).
- A physical examination may involve an inspection of the abdominal, pelvic and genital areas, as well as neurological testing of your reflexes, muscle strength, and sensation.
Other testing may also be done if your health providers need further information.
A urine culture and sensitivity test involves collecting urine in a sterile container to test for infection. Urine samples are usually collected mid-stream while emptying so the test is more accurate. If the sample is collected from an indwelling catheter, the catheter should be changed first. Samples are never taken from a urine drainage bag.
Blood tests may be used to identify if there is an infection or to test kidney function. This usually involves testing for blood urea nitrogen (BUN) and creatinine. This test may be done if there is concern about kidney function and possible kidney damage.
Ultrasound is an imaging technique that uses sound waves to visualize deep tissues. Ultrasound imaging may be done over the kidneys (called renal ultrasound) to detect possible damage, kidney stones and infections.
Urodynamic testing includes special tests that can be used to look at bladder pressures and urine flow. It can test how the bladder acts when it fills and empties, how well it coordinates, and the pressure within the bladder. This test may involve urinating into a special container that can measure the flow and volume of urine, insertion of a catheter to measure the leftover urine, and inserting water into the bladder to measure your ability to prevent emptying. It may also involve the use of electrical measurement of muscle activity by placing a small catheter into the rectum.
Other imaging, such as x-ray, computed tomography[glossary_exclude] (CT)[/glossary_exclude], and magnetic resonance imaging [glossary_exclude](MRI)[/glossary_exclude] are sometimes used for further investigation of bladder problems.
Cystoscopy (sometimes called a ‘bladder scope’) is the use of a very small camera that can be inserted into the urethra to look at the urinary tract. [glossary_exclude]Cystoscopy[/glossary_exclude] can be used to identify bladder stones, bladder health issues or damage including bladder cancer. It can also perform therapeutic procedures if needed such as removing tissue or stones.
Early bladder care
In the early hospital phase right after injury, the circulatory system is stabilizing and the prevention of infections and other complications is the priority. During this phase, an indwelling catheter is placed in the bladder to constantly drain urine from the bladder. The catheter will be changed regularly and maintained in a sterile way by your nurse.
Bladder care in rehab and after
After the acute phase, bladder care will involve transitioning to more long-term bladder care techniques and developing a suitable bladder routine. Keep in mind that spastic bladder and flaccid bladder happen for different reasons and are managed differently.
Spastic bladder management
The goals of [glossary_exclude]spastic bladder[/glossary_exclude] management are to reduce overactivity in the bladder wall muscle which causes accidents, leaking, and wetness; as well as preventing high pressures within the bladder. This may include treatments such as:
- Indwelling catheters, condom catheters, and/or intermittent catheterization to drain the bladder
- Reflex voiding may help to empty the bladder for some people
- Anticholinergic medications may help to relax the bladder muscles
- Botulinum toxin (Botox) injections to help relax the bladder muscles
- Bladder augmentation surgery to increase the capacity of the bladder to hold urine
Flaccid bladder management
The goals of [glossary_exclude]flaccid bladder [/glossary_exclude]management are to regularly empty the bladder to prevent overfilling and increased pressure in the bladder; and to prevent leaking and wetness. This may include treatments such as:
- [glossary_exclude]Intermittent catheterization[/glossary_exclude] or [glossary_exclude]indwelling catheters[/glossary_exclude]
- [glossary_exclude]Condom catheters[/glossary_exclude] or pouches may be used to catch leaks but not for emptying
- Alpha-adrenergic blockers may help to relax the [glossary_exclude]bladder sphincter muscles[/glossary_exclude]
- Botulinum toxin (Botox) injections
- Surgical techniques such as sphincterotomy or stents
Urinary catheters are pieces of equipment that are used to drain urine from the bladder. There are many different ways that catheters are used.
Intermittent catheterization is when a catheter is inserted and removed through the urethra to drain the bladder at regular intervals throughout the day. Bladder emptying with [glossary_exclude]intermittent catheterization[/glossary_exclude] must be done hygienically and on a regular schedule.
[glossary_exclude]Intermittent catheterization[/glossary_exclude] is usually used by people who have enough hand function to perform the procedure independently. It is the closest method to normal bladder function, where the bladder fills continuously for a period of time and then empties all at once.
Indwelling catheters (such as Foley catheters) are catheters that are inserted directly into the bladder and remain in place to continually drain the bladder. [glossary_exclude]Indwelling catheters[/glossary_exclude] may be inserted through the [glossary_exclude]urethra[/glossary_exclude] (called urethral catheters) or through a surgically created hole through the abdomen (called suprapubic catheters).
[glossary_exclude]Indwelling catheters[/glossary_exclude] are usually used if inserting your own catheter independently is difficult or there are concerns about leaking between sessions of emptying.
Condom catheters (only for males)
Condom catheters are catheters that resemble a condom and are placed over the penis and connected through tubes to a collection device. [glossary_exclude]Condom catheters[/glossary_exclude] are usually used by people that leak in between emptying or for individuals who have the ability to trigger emptying by causing a spasm of their bladder (called reflex voiding).
[glossary_exclude]One of the main concerns of condom catheters is incomplete bladder drainage, which can cause kidney damage. A careful medical examination is needed to ensure that condom catheters are a safe option for use.[/glossary_exclude]
For more detailed information about catheters, see Urinary Catheters.
Reflex voiding is a technique that can be used by some people with spastic bladder to stimulate urination. Reflex voiding is usually done by tapping over the bladder lightly and repeatedly with the fingertips or the side of the hand to stimulate reflexes in the bladder muscles. This technique can be used to help improve bladder emptying during intermittent catheterization and when using condom catheters. However, only a small number of people can use this technique safely without increasing the pressure too high in the bladder. Speak to your health team for more information about this technique.
Several medications may be used to help manage bladder problems after SCI. These may help to relax overactive muscles or cause the bladder muscles to contract, depending on the type of bladder change experienced. A number of other medications may also be used for different aspects of bladder treatment after SCI.
Anticholinergic medications (sometimes called antimuscarinic medications) are used to relax muscle spasms in the bladder wall muscle. This can help to reduce pressure within the bladder, increase the ability of the bladder to hold urine, and help reduce incontinence.
There are many different types of anticholinergic medications, with the most common being oxybutynin (Ditropan, Ditropal XL, Oxytrol, Uromax), tolterodine (Detrol), fesoterodine (Toviaz), trospium chloride (TCL, Trosec), propiverine hydrochloride (Mictonorm), darifenacin (Enablex), and solifenacin (Vesicare). These can be taken by mouth or administered directly into the bladder in a liquid form.
Alpha-adrenergic blockers are medications that are used to encourage the bladder sphincter muscles to relax to allow urine to flow out of the body. This can help with bladder emptying and help prevent urinary retention. Common alpha-adrenergic blockers that may be used include tamulosin, mosixylyte, terazosin, and phenoxybenzamine.
Botulinum toxin injections
Injecting small doses of some strains of botulinum toxin (Botox) into muscles can help to reduce muscle spasms. Injections into the [glossary_exclude]bladder wall muscle[/glossary_exclude] or the external sphincter muscle can help to relax these muscles to help prevent leaking and [glossary_exclude]incontinence[/glossary_exclude] or to improve bladder emptying. The effects of these injections can last for 6 to 12 months.Other medications
Capsaicin, a chemical commonly found in hot peppers, and its derivative resiniferatoxin, may be administered as a liquid into the bladder to help increase bladder capacity and reduce urinary frequency, leaking, and bladder pressures related to [glossary_exclude]bladder wall muscle[/glossary_exclude]
- Nociceptin/orphanin phenylalanine glutamine is another medication with effects similar to capsaicin and resiniferatoxin. It may also be given into the bladder to reduce overactivity in the [glossary_exclude]bladder wall muscle[/glossary_exclude].
- Medications that are normally used to treat spasticity may also help with bladder problems related to spastic bladder. For example, baclofen and clonidine may help with bladder function after SCI.
- Phosphodiesterase-5 (PDE5) inhibitors such as tadalafil and vardenafil may help to reduce overactivity in the [glossary_exclude]bladder wall muscle[/glossary_exclude] and increase bladder capacity.
- 4-Aminopyridine (fampridine) improves the transfer of nerve signals, which may help individuals regain sensation and control of the [glossary_exclude]bladder sphincter muscles[/glossary_exclude] to improve emptying.
Bladder surgery is usually only considered if other less-invasive treatments are not effective. Surgical procedures that may be used include:
The Mitrofanoff procedure involves the use of the appendix or part of the intestine to create a channel between the abdomen and bladder. The channel self-seals shut when the catheter is removed. This channel can be used for insertion of a catheter for intermittent catheterization. The urine can then be drained into a cup or toilet. This may be useful for people who have difficulty self-catheterizing directly into the urethra, and is often used for women (who have greater difficulty inserting catheters).
Bladder augmentation (also called augmentation cystoplasty) is a procedure in which the bladder is made bigger to create more room to hold urine. This is done by removing a segment of the intestine and stitching this tissue to an incision into the bladder to make the bladder bigger. Bladder augmentation may help to reduce pressure in the bladder and help to prevent incontinence related to spastic bladder.
Sphincterotomy (for males)
Spincterotomy is a surgical procedure where the internal sphincter muscle (the circular muscle that surrounds the outlet of the bladder) is cut to weaken the muscle. This is done to improve bladder emptying if this muscle is causing difficulties emptying. After a spincterotomy, bladder emptying will happen; therefore, you must wear a collection device.
Urethral stents are prosthetic tubes (usually coils of metal) with openings on both sides that are be inserted into the opening of the bladder to hold it open. This is done to allow for improved bladder emptying for people with difficulty emptying due to overactivity in the bladder sphincter muscles.
Electrical stimulation can be used to activate muscles. Electrical stimulation may be used to assist with bladder problems after SCI by stimulating activity in the bladder muscles to help control muscle function.
Electrical stimulation can be used to stimulate the nerves to help normalize the activity of the bladder muscles. Stimulation of the sacral nerves through the implantation of a stimulator and electrodes may help to improve control of bladder emptying. This is sometimes referred to as neuromodulation.
Commercially available electrical bladder stimulation systems such as the Vocare system may be used for this purpose. However, these systems may not be available in all locations or for all individuals because of their cost.
Acupuncture and electroacupuncture have also been suggested as treatment options to help with bladder function by influencing nerve signals related to bladder function.
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