Triggering-Type or Expression Voiding Methods of Bladder Management

Individuals with SCI undergoing inpatient rehabilitation are sometimes taught various maneuvers in order to initiate or attempt spontaneous voiding, termed “expression voiding” as well as to provide a “trigger” to initiate voiding (Wyndaele et al. 2001). Only one study examining these methods met the criteria for inclusion in the present review.

Table: Triggering-Type or Expression Voiding Methods


Greenstein et al. (1992) documented the use of Valsalva (n=4) and Crede (n=1) maneuvers to initiate spontaneous voiding in a small case series of five males with paraplegia (upper motor neuron bladder=3, lower motor neuron bladder=2). Greenstein et al. (1992) note that “Valsalva is defined as increased abdominal pressure using the diaphragm and/or abdominal musculature. The Crede maneuver is suprapubic manual pressure applied over the bladder” (p. 254). Greenstein et al. (1992) intended to examine the potential for long-term complications in those who employed these techniques over an extended period of time. High intravesical pressure was documented during voiding. The authors suggested that long-term monitoring for these individuals is advisable and intermittent catheterization should replace these methods in the event of urological complications. Triggered voiding and use of the Crede maneuver to initiate “voiding” should only be considered in patients with normal upper tracts, provided that urodynamic studies demonstrate low pressure storage and “voiding”, and that there is a low incidence of UTI.


There is level 4 evidence (from one case series study; Greenstein et al. 1992) that triggering mechanisms such as the Valsalva or Crede maneuvers may assist some individuals with neurogenic bladder in emptying their bladders without catheterization; however, high intra-vesical voiding pressures can occur which can lead to renal complications.

  • Valsalva or Crede maneuver may assist some individuals to void spontaneously but produce high intra-vesical pressure, increasing the risk for long-term complications.