Bladder Considerations with Spinal Cord Injury

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Introduction

The bladder becomes neurogenic or neuropathic when it no longer receives an input from the brain to empty or store the urine. This interruption in communication occurs after a spinal cord injury (SCI) as the brain is not able to sent or receive signals to and from the organs below the level of injury. Urologic complications can be severe and life threatening. The pattern of bowel dysfunction varies depending on the level of injury. The complications of neurogenic bowel dysfunction include constipation, obstructive defecation, and fecal incontinence. Bowel and bladder dysfunction can cause major restrictions in person's social activities and quality of life. There is no single program that can work for every patient, but bladder and bowel dysfunction management program is a fundamental step following the initial spinal cord injury.

This article supplies additional information for the Bladder and Bowel Consideration with Spinal Cord Injury course

Bladder Management

The location of the spinal cord lesion defines bladder dysfunction.

Spastic Bladder

• Observed in people with a SCI above T12 (Upper motor neuron SCI)
• Limited/no ability to feel bladder fullness
• Limited/no control of the sphincter mm to hold urine.
• Spastic/overactive bladder causing involuntary reflex voiding and incontinence – The voiding reflex is intact between the spinal cord and bladder.
• Detrusor sphincter dyssenergia (DSD) may also be present – this is when the bladder contracts to void but the sphincter remains tight – this causes increased pressure in the bladder which can result in urine being forced back up the ureters to the kidney, which can result in kidney damage.
• May experience incomplete bladder emptying.

Flaccid Bladder

• Observed in people with a SCI below T12 (Lower motor neuron SCI)
• Limited/no ability to feel bladder fullness
• The bladder muscle cannot contract to empty the bladder resulting in the bladder overfilling( urinary retention)
• Voiding reflex is not intact between the bladder and spinal cord
• The sphincter muscle can also be relaxed causing urine to leak out of the bladder when it overfills or during some activities such as transfers, sneezing coughing etc.
• Unable to empty bladder voluntarily

Table 1 summarises storage and voiding dysfunction in relation to the level of the spinal cord lesion.

Table 1 Spinal cord level of injury and storage and voiding dysfunction

Spinal Cord Lesion	Bladder dysfunction
Suprasacral (Upper Motor Neuron Injury)	Overactive Detrusor Hyperreflexic External Urethral Sphincter High Detrusor Pressure (>40 cm H2O) Detrusor Sphincter Dyssynergia (DSD) Urinary incontinence
Mix (Upper and Lower Motor Neuron Injury)	Overactive Detrusor Hyperreflexic or Flaccid External Urethral Sphincter High Detrusor Pressure (>40 cm H2O) Detrusor Sphincter Dyssynergia (DSD) or Detrusor Sphincter Areflexia Urinary incontinence
Sacral (Lower Motor Neurone Injury)	Areflexic or Flaccid Detrusor External Urethral Sphincter Areflexia/Flaccidity Overflow Urinary Incontinence

Management of Bladder Dysfunction

Spastic Bladder Management

Goals:

1. To reduce overactivity in the bladder wall muscle to decrease or eliminate accidents, leaking, and wetness.
2. To prevent high detrusor pressure and damage to the upper urinary tract.

Draining the Bladder

The following methods can be used to drain the bladder:

• Indwelling catheters
• Condom catheters
• Intermittent catheterisation

Intermittent catheterisation (IC)

Women: Finding the right hole (meatus) can be difficult when first doing an IC. The meatus is located just below your clitoris and above the vagina. A magnified mirror may help to see the area. If mistakenly the catheter was inserted into the vagina, it should be left there as a landmark when new catheter is being inserted. A clean catheter should be inserted ABOVE the vagina into the meatus.

Men: Inserting the catheter can be done in different positions: sitting in bed, sidling, sting in the wheelchair or on the toilet.

Watch the video to learn about tools and technique for intermittent catheterisation

Medications

• Anticholinergic medications (sometimes called antimuscarinic medications) may help to relax the bladder muscles.
• This can help to reduce pressure within the bladder, increase the ability of the bladder to hold urine, and help reduce incontinence.

Botulin Injections

• Injecting small doses of some strains of botulinum toxin (Botox) into muscles can help to reduce muscle spasms.
• Injections into the bladder wall muscle or the external sphincter muscle can help to relax these muscles to help prevent leaking and incontinence or to improve bladder emptying.
• The effects of these injections can last for 6 to 12 months.

Bladder Augmentation Surgery

• Bladder augmentation surgery can increase the capacity of the bladder to hold urine

Resources

• Perez NE, Godbole NP, Amin K, Syan R, Gater DR Jr. Neurogenic Bladder Physiology, Pathogenesis, and Management after Spinal Cord Injury. J Pers Med. 2022 Jun 14;12(6):968.
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