1. Your Name

2. Table of Contents
 How the urinary system works
 How we figure out what the bladder is doing
 Choosing the best method of bladder drainage
◦ No catheter in the bladder
◦ Bladder emptying for males: Open the sphincter
◦ Intermittent Catheterization (ICP)
◦ Indwelling Catheter
◦ What’s different about females?
◦ Considerations: What's the best method for you?
◦ Other surgical options
◦ Functional electrical stimulation (FES)
◦ Botulinum toxin injection to the bladder
◦ Table: Most common methods of urinary drainage
 Urinary complications
 Screening tests
 UTIs, antibiotics, cranberry and methenamine

4.  The upper urinary tract consists of the kidneys, which filter the
blood and produce urine, and the ureters, which connect the kidneys
to the bladder. The upper tract is not directly affected by spinal cord
injury.
 The lower urinary tract has muscles which are affected by the spinal
cord injury: the bladder muscle (detrusor) and the valve muscles
(sphincters). The urethra connects to the outside of the body where
the urine passes through.
 In normal urination, the bladder is either filling or emptying. The
bladder is relaxed as it fills with urine, and the sphincter stays
closed during this time so the urine doesn’t leak out. When it’s time
to empty, the bladder contracts and the sphincter relaxes so the
urine can flow out. Most of the time the bladder is relaxed and filling
as urine is made. The bladder and sphincter muscles are
automatically coordinated to contract and relax at the correct time.
These are reflex patterns wired into the brainstem and spinal cord.
 After spinal cord injury, several different kinds of urinary problems
can result, depending on the level of injury and which nerves and
reflexes have been disrupted. Bladder and sphincter muscles may be
weak, overactive or poorly coordinated.

5.  Essentially, two basic problems occur. Filling problems (incontinence or
leaking) occur when the bladder is overactive and contracts too much or at
the wrong time, or the sphincter doesn’t contract enough to keep the urine
from leaking out. Emptying problems (retention) occur when the bladder
doesn’t contract enough or the sphincter won’t relax. Treatment will depend
on what kind of problem you are having.
How we figure out what the bladder is doing
 We can get a lot of the information just starting with the history of when and
under what circumstances incontinence occurs.
 A neurological exam can tell us what is happening with the whole nervous
system in terms of strength, sensation and reflexes. This gives us a good
picture of what is likely to be happening with the nerves to the bladder and
sphincter, what is working and what's contracting and what's not.
 A postvoid residual test shows how much urine remains in the bladder after
voiding (emptying). This can be done using a catheter or by ultrasound.
 A group of tests called urodynamics tells us more precisely what the nerves
and bladder are doing during filling and emptying. These tests require the
bladder to be slowly filled with fluid through a small catheter, while the
activity of different muscles is measured. Urodynamics help answer these
types of questions:
◦ Is the bladder relaxing enough to allow it to fill up with urine?
◦ Is the sphincter opening at the right time?

6.  Choosing the best method of bladder drainage
 The goal in choosing a method of bladder drainage is to find the
simplest, most convenient and least expensive method that will keep you
dry, avoid serious complications and treatment side effects, and preserve
your kidneys for your entire life. There are several different
methods, depending on your injury and circumstances, and almost all of
them give good outcomes, with just a few exceptions.
 No catheter in the bladder
 Voluntary voiding (bladder emptying) under normal control, possible in
combination with medications to calm an overactive bladder muscle if
necessary.
 Involuntary voiding, where the bladder fills to a certain point, kicks off and
empties. Emptying might occur spontaneously or in response to pressure on
the bladder such as tapping the bladder (Crede) or bearing down
(Valsalva). These are NOT recommended for most
patients, however, because they can cause problems such as high pressure
that can damage the kidneys. For males, a condom catheter can be used to
collect the urine.
 Bladder emptying for males: Open the sphincter
 There are a few methods for keeping the sphincter open so urine can flow
freely from the bladder into a condom catheter.
 Sphincterotomy: Surgically cut and open the sphincter. Scarring can occur
over time, and the surgery may need to be repeated. It can also worsen
erectile dysfunction.
 Botox injected into the sphincter. This needs to be repeated every three to
nine months, and as it wears off there is an increased chance for urinary
retention.

7.  Urethral stent (small steel tube) placed in the sphincter. Disadvantage are
that the stent can move around or tissue may grow into it and block the flow
or urine, requiring corrective surgery.
 Methods that keep the sphincter open only work for people whose bladders
are able to contract, allowing urine to continuously drain into a collection
device like a condom catheter. If your bladder does not contract, the urine
won’t drain out, and you are at risk for infection.
 The downside of any sphincterotomy method is that the bladder may lose its
ability to contract and urinary retention may develop over time.
Also, condom catheters are not without problems. They can be hard to keep
in place, and some patients will need to have a penile prosthesis put in so
there is enough penis for the condom to attach to. And even though the
condom catheter does not involve a tube going into the bladder, it does not
seem to result in fewer UTIs than indwelling or Foley catheters.
Intermittent Catheterization (ICP)
 This method is also known as ICP (Intermittent Catheterization Program), CIC
(Clean Intermittent Catheterization) and I & O (In and Out) catheterization.
With this method, you insert a catheter into the bladder and empty it
completely every four to six hours. The goal is to cath frequently enough to
keep urine volumes in the bladder lower than 500 ml. This method requires
that you closely monitor your fluid intake, usually around 2 liters per
day, otherwise you might be cathing too frequently to make this practical.

8.  ICP is a preferred method for patients who have enough hand function
(usually C7 and below, or C6 for motor incomplete injuries) to perform it
independently and who can remember to cath on schedule. It is the closest
thing to the normal bladder function, where the bladder fills continuously for
a period of time and then empties all at once. This method reduces the risk
for infections because there isn’t enough time for any bacteria left in the
bladder to reproduce enough to cause symptoms.
 Complications of ICP include narrowing of the urethra from passing the
catheter through frequently. More rarely, inflammation of the epididymis (a
duct that stores sperm) , hydronephrosis (enlargement of the urine collection
section of the kidney) and reflux (backup of urine into kidney) may occur.
 ICP is not usually a good method for someone who is unable to perform it
independently. Having someone else cath you increases your risk for
infections and also reduces your independence, since you need someone
with you to perform the ICP.
 Anticholinergic medications, such as oxybutynin (Ditropan) or tolterodine
(Detrol), may be necessary to inhibit bladder contraction. Botox injection to
the bladder muscle can also be used for this purpose.
Indwelling Catheter
 An indwelling catheter is a common bladder-emptying method for those who
cannot perform ICP. A tube is inserted into the bladder, where a balloon on
the end holds it in place. It remains in the bladder and drains constantly into
a container, such as a leg bag. There are two types of indwelling catheter:
 Foley catheter: the tube is inserted through the urethra.
 Suprapubic (SP): the tube goes through a hole in your abdomen.

9. Advantages:
 It will usually empty the bladder and keep you dry regardless of what kind of
bladder or sphincter problems you have.
 Even those with higher level injuries can be completely independent—once
you're set up, even if you have a high level injury, you can use an electric leg
bag opener to empty out urine and not need assistance from anybody all day
long.
Disadvantages:
 Having a catheter sitting in the urethra all the time can cause urethral
erosions, which is often a reason for switching to a suprapubic tube.
 The suprapubic tube requires surgery, and sometimes the bladder neck
needs to be closed to prevent leaking.
 There is a catheter coming out of your body and a bag of urine with you all
the time. Some people just don’t want that.
 Increased risk of bladder cancer and bladder stones.
 More infections than with ICP.

10. What’s different about females?
 Because women have no penis, collecting urine is more difficult. There is no
good external collection device, like a condom catheter, for women. Women
doing ICP have more problems with incontinence than men because the
female urethra is short and more likely to leak urine.
 Women get different complications from having an indwelling Foley catheter
for a long time. The urethra can become dilated (larger), which results in
more leakage. Switching to a larger catheter just dilates the urethra
more, causing more incontinence. For this reason, a suprapubic (SP) tube is a
good option for a woman who otherwise would be using a Foley catheter.
What is the best method for you?
 Considerations:
 Do you have the hand function to do ICP independently?
 How much mobility is required? For example, does the method require
transferring to a toilet?
 How much of the day is going to be devoted to bladder management?
 What are the risks if you don’t follow the program? Are you likely to comply?
 Do you live in a remote location with no follow-up around, or are you close
to specialized medical care?
 What's the likelihood that you would benefit from one of the more
complicated, more time-intensive techniques?

11.  Other surgical options
 An artificial urinary sphincter can be placed if there is incontinence
due to the sphincter being open. This is a device that is surgically
implanted in the body to substitute for the sphincter muscles. They
have not been used commonly in people with SCI, since implanted
devices are prone to infection, but some urologists do recommend
them for certain individuals with SCI.
 Bladder augmentation, which uses a piece of the bowel to enlarge
the bladder, may be a good option for someone doing ICP whose
bladder doesn’t hold enough urine in spite of medications.
 Urinary diversion (diverting the urine away from the urethra)
◦ Urostomy, which uses a piece of bowel to create a connecting
tube from the bladder to the outside of the body (like a colostomy
does for stool). Urine drains out and collects into a bag fastened
to the opening (called a stoma). This is usually a fall-back method
in cases where there have been major complications that cannot
be treated with other methods.
◦ Catheterizable stoma (Mitrofanoff) creates a thin tube from a
piece of bowel that connects the bladder to the abdomen where a
person can insert the catheter to drain the bladder (rather than
inserting the catheter through the urethra).

12.  Functional electrical stimulation (FES)
This system allows emptying without using a catheter. A
surgically implanted stimulator and electrode trigger the bladder
to squeeze when you flip a switch on an external stimulator. It
requires cutting the sacral nerve roots, and you need to either
use a condom catheter, a hand urinal, or transfer onto a toilet
when the system is turned on. It can also be used to stimulate a
bowel movement. It was on the market in the US (called the
Vocare System) for a short time and continues to be available in
Europe.
A new FES system currently under development at Case Western
in Cleveland uses an electrode to block the sacral sensory roots
so that you wouldn't need to cut the nerve roots. Somebody with
an incomplete spinal cord injury could potentially use this
method.

13.  Botulinum toxin injection to the bladder
 If oral medicines (anticholinergics) are unable to relax the bladder muscle
enough for a person to do ICP, Botox injections to the bladder muscle can
accomplish this. Botox is effective for about six to nine months. When it
begins wearing off, you start having incontinence and need it done again.
 Urinary complications
Kidney and bladder stones
 Stones are common in people with SCI. They can develop early on because
large quantities of calcium leave the bones in the first few months after
injury. It is more common to get stones later, and this is due to infections
over the long term. Bacteria break down urea into chemicals that form
stones, which can cause blockages, kidney damage and serious infections.
 Hydronephrosis and reflux
 These are similar conditions involving either a blockage of urine or a
backwards flow of the urine up toward the kidney. It can have multiple
causes, and the treatment is to remove whatever is blocking the system and
to reduce the bladder pressure.
 Bladder cancer
 There is a small risk of bladder cancer for individuals using indwelling
catheters. Screening recommendations are controversial since we don’t know
who needs to be screened, how often, and how soon after injury.
Unfortunately, these tend to be such aggressive cancers that even yearly
screening won’t catch all of them because they grow so fast.
Fortunately, bladder cancer is not very common.

14. Screening tests
We use a variety of tests to detect problems in the urinary
system.
Lab tests
Serum creatinine (blood test): Creatinine is filtered out by the
kidneys. A high level in the blood means the kidneys are not
filtering enough. To be useful, results must be monitored over
time to see if there are changes. If it starts rising, it’s a sign
something is wrong with the kidneys.
Creatinine clearance: 24-hour urine collection to see how much
filtering the kidneys are doing over time. This test may not give
reliable results. Other lab tests are being studied as well to see
what is best for screening.
Imaging tests
Ultrasound is a radiation-free, risk-free way to pick up on stones
or blockages.
CT scan of the kidneys, ureters and bladder (CT-KUB): uses lots
of radiation and may carry a one in 3000 chance of producing a
fatal cancer. While not recommended as a routine test, it is
useful in specific situations.
Renal scan: used to show kidney function, but image is fuzzy.

15.  How often should the test be done?
Research has not established what testing should be done for
everyone and how often. To some extent it should depend on the
patient and what kinds of problems he or she is having. While
early screening is not necessary for those who have fairly normal
control of bladder, good sensation and not having
symptoms, most people with spinal cord injury should have
some sort of periodic testing of their urinary tract to detect
problems before they become big problems.
The Consortium for Spinal Cord Medicine publishes a guideline
for physicians stating that screening is usually done annually.
However, since research has not established the necessary
frequency for the screening tests, the guideline does not make a
strong recommendation about how often the tests must be
done. (Bladder Management for Adults with Spinal Cord Injury: A
Clinical Practice Guideline for Health-Care
Professionals, www.pva.org).

16.  UTIs and antibiotics
When considering the use of antibiotics for UTIs, it is important to
distinguish between actual infections and colonization.
If you have bacteria in the urine (found through a lab test) AND have
symptoms (fever, pain, spasticity), then you have an infection that
needs to be treated with antibiotics.
If you have bacteria in the urine but have NO symptoms, then you have
what is called “colonization” and you should not be treated with
antibiotics.
In general, treatment should be based on symptoms, rather than on
bacterial count alone. Some bacteria don’t cause any symptoms, and
their presence in the urine might even be keeping out other bacteria
that could cause problems. In fact, there is currently some
promising research into this idea of “bacterial interference” to
determine whether inoculating people with a specific, relatively
harmless bacteria will keep harmful bacteria away.
Prophylactic antibiotics, or taking antibiotics all the time to prevent
UTIs, have not proven to be beneficial in research studies and can
result in the proliferation of resistant bacteria that are hard to treat.
A substance called methenamine, which turns into formaldehyde in
the bladder, is used by some patients to try and reduce infections.

17. Cranberry (juice or tablets) has also been studied as a way of preventing
UTIs. Usually the tablet form is used since drinking cranberry cocktail is so
full of sugar and calories. Although cranberry has not proven effective in
clinical trials with people who have SCI, it does seem to help some
individuals. As with many aspects of bladder management after SCI, finding
what works is often a matter of trial and error.
POSTED BY ATTORNEY RENE G. GARCIA:
For more information:- Some of our clients have suffered this kind of injuries due to a
serious accident. The Garcia Law Firm, P.C. was able to successfully handle these types
of cases. For a free consultation please call us at 1-866- SCAFFOLD or 212-725-1313.
http://sci.washington.edu/info/forums/reports/urinary_problems.asp