Neurogenic Bladder After Spinal Cord Injury

GENERAL INFORMATION:

What is neurogenic bladder? Having a spinal cord injury (SCI) can interrupt the nerve pathways from your brain to your bladder (the organ where urine is stored). Neurogenic (ner-oh-JEN-ik) bladder is a condition that may happen after a spinal cord injury. With this condition, you may not be able to tell if your bladder is full. You also may not be able to stop your bladder from emptying.

How does the urinary system work? Kidneys clean wastes out of the blood and make urine. The urine then travels from the kidneys to the bladder through two thin tubes called ureters (u-REE-ters). Sphincter (SFINGK-ter) muscles act as a valve to keep urine in the bladder until it is time to urinate. Normally when it is time to urinate, the bladder contracts and the sphincter muscles relax and open. The urine can then leave your body through a tube called the urethra (u-REE-thrah).

What kind of bladder or sphincter problems may I have? The bladder or sphincter muscles may be affected after a SCI. Following are three conditions that you may have after a spinal cord injury:

• Dysnergia (dis-NER-gee-uh): Urine cannot leave the bladder and flow through the urethra if the sphincter muscles do not relax when the bladder contracts. Urine may back up through the ureters into the kidneys. This is called reflux. Reflux may cause a kidney infection. The bladder may not empty completely if the sphincter muscles cannot open fully. Caregivers may use medicine or surgery to open your sphincter.
  
  
• Flaccid bladder: This is also called non-reflex bladder because the bladder muscles are flaccid (weak or absent). You may not feel when the bladder is full. With time the bladder gets over full and stretches. You may also have reflux with this condition.
  
  
• Spastic bladder: This is also called reflex bladder. When your bladder fills with urine, a reflex causes it to automatically empty. With spastic bladder, you do not know when your bladder may empty.

Can anything be done about neurogenic bladder? You may lose some or all of your bladder control depending on what type of a spinal cord injury you have. Caregivers can teach you how to develop reflexive elimination. This practice teaches your body to urinate at specific times each day. Doing this prevents urine from building up and overflowing from your bladder. A bladder training program includes reflexive elimination and other methods to empty your bladder. Ask caregivers for more information about bladder management programs.

What types of bladder tests may I need? You may need one or more of the following tests. These tests help caregivers find out what is causing your problems, and help them plan your treatment.

• Urinalysis (u-ri-NAL-i-sis): This is a test that looks at your urine to find out how your kidneys are working. Caregivers look for white blood cells, protein, sugar, blood, and bacteria (bak-TEER-ee-uh) (germs) that are not normally in urine.
  
  
• Urine culture and sensitivity: A sterile (clean) sample of your urine is collected and sent to a lab for tests. Your caregiver may give you a special wipe and clean cup. Use the wipe to clean the skin around the opening where you pass urine. Urinate into the clean cup. Put the lid on the cup. Do not touch the inside of the cup or the lid. Give the urine sample to your caregiver. Caregivers look at the urine to find out how much and what type of bacteria are growing in it. Then caregivers can test the bacteria to see which antibiotic medicine can kill it.
  
  
• 24-hour urine test: All of the urine that you pass for one day is collected. Every time you urinate you put the urine into a jug. Caregivers measure and write down how much you urinate. The urine is put into a larger container that is kept cold. If you urinate during the night, save this urine also. At the end of 24 hours, the urine is sent to a lab to be tested. A sample of your blood also is taken at the end of the 24 hours. Caregivers compare the amount of creatinine in both samples to check how your kidneys are working.
  
  
• BUN and creatinine: Caregivers measure how much blood urea nitrogen (BUN) and creatinine are in your urine. The levels tell caregivers how well your kidneys are working.
  
  
• Cystogram (SIS-toe-gram): This is an x-ray test during which a catheter is put into your bladder. Dye is put through the catheter into your bladder while x-rays are taken. The size and shape of your bladder can be seen on the x-rays. The x-rays also show how much urine your bladder can hold. Caregivers also look to see if urinary reflux is happening. Urinary reflux is when urine backs up from the bladder into your ureters and kidneys. This can cause a kidney infection.
  
  
• Cystometrogram (sis-toe-MET-roh-gram): This test measures the way your bladder contracts when it fills and empties. Caregivers put fluid or a gas slowly through a catheter into your bladder. You will need to tell caregivers if you can feel your bladder getting fuller. If you can, you may be asked to empty your bladder. Then caregivers measure the amount you urinated compared to the amount they put in. This test tells caregivers how much your bladder can hold. The tests tell how well the sphincter closes to hold urine in and how well it relaxes to let the urine out.
  
  
• Cystoscopy: A cystoscopy allows caregivers to look for problems inside your bladder. A cystoscope is put into your bladder through your urethra. The urethra is the tube that urine flows through when you urinate. The cystoscope is a long tube with a lens and a light on the end. The scope may be hooked to a camera or monitor, and pictures may be taken. A tissue sample may also be taken during your cystoscopy. During this test, small tumors may be removed or bleeding may be stopped.
  
  
• IVP: This is also called an intravenous pyelogram. An IVP is an x-ray of the kidneys, bladder, and ureters (tubes that carry urine). Dye is put into your IV, which makes these organs show up better in x-ray pictures. You may need to have more than one x-ray over short periods of time during your IVP. People who are allergic to shellfish (lobster, crab, or shrimp) may be allergic to this dye. Tell your caregiver if you are allergic to shellfish, dyes, or other medicines.
  
  
• KUB x-ray: An x-ray machine takes pictures of your kidneys (K), ureters (U), and bladder (B). The ureters are tiny tubes that carry urine from your kidneys to your bladder. The bladder is where the urine is stored before leaving your body. Caregivers use these pictures to check for problems with your intestines , kidneys, or abdomen.
  
  
• Renal ultrasound: This is a simple test using sound waves to look at your kidneys. Pictures of your kidneys show up on a TV-like screen. An ultrasound can show if you have a kidney stone, an abscess, or certain other problems.

Is it possible to have surgery to fix my urinary tract problems? Some surgeries are possible to help the bladder store more fluid or to fix problems with the urinary sphincter. Ask your caregiver if you want more information on any of these procedures.

• Balloon dilation: A balloon catheter is used to dilate (stretch) the urinary sphincter.
  
  
• Bladder augmentation (awg-men-TAY-shun): A piece of intestine is used to make the bladder larger so it can hold a larger amount of urine.
  
  
• Sphincterotomy (sfingk-ter-AW-tuh-mee) or transurethral (trans-ur-EE-thrull) resection: The sphincter or bladder neck is cut using a knife or a laser to make it looser. This surgery is used to treat dysnergia.
  
  
• Stent placement: Caregiver use a cystoscope to put a stent (a very small tube) through the sphincter to keep it open.
  
  
• Urinary diversions: Urinary diversions like ileal conduit are done to drain urine into a pouch made from a piece of intestine. After surgery, you will wear a bag to collect urine.

What other problems may happen after a spinal cord injury?

• Autonomic dysreflexia:
  
  
  • Autonomic (aw-toe-NOM-ik) dysreflexia (dis-ree-FLEK-see-ah) is a condition that happens when your body reacts to a problem. Common problems causing autonomic dysreflexia include having a full bladder, or being unable to have a bowel movement. It is also called "AD" or autonomic hyperreflexia (heye-per-ree-FLEK-see-ah). This very serious emergency can be life threatening. AD causes your blood pressure to go dangerously high. High blood pressure can cause a stroke, seizure, and even death. It is most common in people who have a SCI at or above the 6th thoracic (chest) level (T6).
    
    
  • Noxious (NAWK-shus) stimuli are things that the body considers bad or hurtful. AD is most often caused by noxious stimuli, such as bowel or bladder problems. An over-full bladder, being constipated, or having a bowel obstruction are the most common causes of AD. Other things also can cause AD, such as a bladder infection or blood clot in your leg or in your lungs. A pressure sore, a wrinkle in clothing, or an erection also can cause AD. Ask your caregiver for more information about autonomic dysreflexia.
  
  
• Urinary tract infection: This is also called a "UTI". It is normal for people with SCIs to have bacteria in their bladder often. Bacteria are germs that live on the skin and in the urethra, and can cause infection. The bacteria can be carried into the bladder during catheterization. It may grow there when urine is not emptied completely from the bladder. Call your caregiver if you have a high temperature or feel unwell. This may be a symptom of a UTI or some other illness.
  
  
  • Signs and symptoms of a UTI: Having a UTI makes you feel unwell. You may have a fever, chills, and feel sick to your stomach. You may feel burning when you urinate, or pain in your abdomen (belly) or low back. You may also have more bladder spasms than usual. It is very important to get treatment for a UTI because UTI's may lead to autonomic dysreflexia.
    
    
  • How do I prevent a UTI? It is easier to prevent a UTI than to treat one.
    
    
    • Drink plenty of fluids. Check with your caregiver to find out how much liquids you should drink. While you are learning the bladder management program caregivers may have you drink 2000 cc (about 68 ounces, or eight and one-half, eight-ounce cups) of liquids. You may be told to increase your liquids to about 3000 cc (about 101 ounces, or 13 eight-ounce cups) when you are managing your bladder program well.
      
      
    • Keep your skin clean. Bathing and cleaning your genital area frequently is very important to help decrease the risk of infection.
      
      
    • Empty your bladder at the same times each day.
      
      
    • Clean personal care supplies, and leg and bed urine bags. Ask caregivers for more information about urinary catheterization, and keeping your supplies as clean as possible.
      
      
    • See your caregiver regularly, and keep appointments for regular exams.
    
    
  • How do I treat a UTI? Antibiotics (an-ti-bi-AH-tiks) are a type of medicine used to treat UTIs. Always take your medicine as directed by caregivers. Call your caregiver if you think your medicines are not helping or if you feel you are having side effects. Do not quit taking your medicines until you discuss it with your caregiver. Take your antibiotics as ordered, until they are all gone, even if you feel better.

Where can I go for support?

• Having a spinal cord injury is life changing for you and your family. Accepting that you have a spinal cord injury is hard. You and those close to you may feel angry, sad, or frightened. These feelings are normal. Talk to your caregivers, family, or friends about your feelings. Let them help you. Encourage those close to you to talk to your caregiver about how things are at home. Your caregiver can help your family better understand how to support a person with a spinal cord injury.
  
  
• You may want to join a support group. This is a group of people who also have spinal cord injuries. Ask your caregiver for the names and numbers of support groups in your town. You can contact one of the following national organizations for more information:
  • Paralyzed Veterans of America
    801 Eighteenth Street NW
    Washington, DC, 20006
    Phone: 1-800-424-8200
    Web Address: www.pva.org
    
  • American Spinal Cord Association
    2020 Peachtree Road, NW
    Atlanta, Georgia, 30309-1402
    Phone: 1-404-355-9772
    Web Address: www.asia-spinalinjury.org
    
  • National Spinal Cord Injury Association
    6701 Democracy Blvd, Ste 300-9
    Bethesda, MD 20817
    Phone: 1-800-962-9629
    Web Address: www.spinalcord.org
    

CARE AGREEMENT:

You have the right to help plan your care. To help with this plan, you must learn about neurogenic bladder. You can then discuss choices with your caregivers. Work with them to decide what choices may be best for you. You always have the right to refuse and make your own decisions.

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