Bladder Management in Spinal Cord Injury

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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. Research indicates that urinary tract infections(UTIs) are the most common secondary complication (62%) reported among individuals with SCIs in the first year after discharge from in-hospital treatment. It was also found that UTI's were more prevalent among individuals with higher SCI-levels and complete SCI.

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

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 brain-, spinal cord- or nerve complications.

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.

In SCI, 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

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 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.

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 SCI to the sacral spinal cord, while infrasacral neurogenic bladder occurs due to SCI to the cauda equina. Both these 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.

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 occur following the spinal shock stage, it may present neurogenic bladder dysfunction.

Common complications

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.

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.

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, and
• Urinary tract imaging.

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.

.References

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