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SPINAL CORD MEDICINE EDUCATIONAL MATERIALS FOR PATIENT AND FAMILY BLADDER MANAGEMENT FOLLOWING SPINAL CORD INJURY/IMPAIRMENT Frazier Rehab Institute Copyright, 2009 DISCLAIMER The information contained herein is intended to be used in accordance with the treatment plan prescribed by your physician and with the prior approval of your physician. You should not begin using any of the information and/or methods described in these publications until you have consulted your physician. Jewish Hospital & St. Mary’s HealthCare, Inc. D.B.A. Frazier Rehab Institute, its affiliates, associates, successors and assigns, as well as its trustees, officers, directors, agents and employees are not liable for any damages resulting from the use of this publication. COPYRIGHTED MATERIALS The Spinal Cord Medicine Handbook for Patient and Family and related Educational Materials are copyrighted. You may make single copies of these materials for individual use only. Any alteration of the original copyrighted materials if prohibited. Direct all inquiries to the Spinal Cord Medicine Program at Frazier, 1-866-540-7719 or 502-582-7495. Frazier Rehab and Neuroscience Center, 220 Abraham Flexner Way, Louisville, Kentucky. See website: www.spinalcordmedicine.com Frazier Rehab Institute Copyright, 2009 Bladder Management After Spinal Cord Injury Belinda N. Coyle, RN, BSN, CRRN Spinal Cord Medicine Program Frazier Rehab & Neuroscience Center The Urinary System Consists of the kidneys, ureters, bladder, sphincters, & urethra Major functions: 1. Regulates electrolytes to keep balance of chemicals needed for body function 2. Removes waste products and excess H2O (urine) from the blood via the kidneys Frazier Rehab Institute Copyright, 2009 Process of Urination Kidneys filter blood to remove waste products & create urine Urine travels thru the ureters to the bladder Sensory nerves send messages up the spinal cord to the brain when bladder is full Frazier Rehab Institute Copyright, 2009 Process of Urination cont… The brain then sends message down the spinal cord to the bladder telling it to empty The sphincter muscles relax, the bladder muscles tighten to push urine from the bladder, & the urine leaves the body thru the urethra Frazier Rehab Institute Copyright, 2009 The Urinary System Right Kidney Left Kidney Left Ureter Right Ureter Sphincter Urethra Abdominal Aorta Urinary Bladder & Detrusor Muscles Frazier Rehab Institute Copyright, 2009 Urination After SCI Messages/signals from the bladder to the brain and vice versa become disrupted or lost completely due to the SCI Neurogenic Bladder The level of injury of the spinal cord will determine how urination will occur Frazier Rehab Institute Copyright, 2009 Spastic Bladder (above T12- L1) Also called reflex or Reflexes are triggered to let urine hyperactive bladder flow but it may occur Occurs with upper when you are motor neuron injuries unaware (above T12- L1) (incontinence) The bladder fills, The brain does not stretches, pushes out get the messages to on nearby nerves that tell you the “right” time to urinate send signals to the spinal cord Frazier Rehab Institute Copyright, 2009 Flaccid Bladder (below L1-L2) Also called areflexic Signals are not able or “floppy” bladder to reach the spinal Occurs with lower cord; bladder does motor neuron injuries not get the message (below L1-L2) to empty The bladder fills, Bladder will become stretches, & pushes too full & urine will out on nearby nerves leak out (may back that send signals to up into kidneys and the spinal cord can cause problems) Frazier Rehab Institute Copyright, 2009 A Bladder Management Programs May Include: Indwelling catheter Suprapubic catheter Intermittent catheterizations External catheter Incontinence devices Manual techniques to trigger voiding (Crede' maneuver, Valsalva, suprapubic triggering) Medications/Surgery Behavioral strategies Frazier Rehab Institute Copyright, 2009 Indwelling Catheter Foley—catheter that remains in the bladder & continuously empties urine into a drainage bag/device. Small balloon at the end of the catheter is filled with normal saline to keep it in the bladder. Area around catheter should be cleaned at least 1-2 times daily & catheter changed at least once per month Increases risk of infection Frazier Rehab Institute Copyright, 2009 Suprapubic Catheter Catheter surgically inserted into bladder through the abdomen (stomach) that continuously empties urine into drainage bag/device. Can be sutured (stitched) to skin &/or balloon filled with normal saline used to hold in place in the bladder Insertion site should be cleaned a couple times daily & catheter changed every 1-2 months. Increases risk of infection Frazier Rehab Institute Copyright, 2009 Intermittent Catheterization (IC) Also known as “in & out” catheterization Catheter inserted into bladder which drains urine into collection device and then the catheter is removed Typically performed about every 4-6 hours around the clock (varies person to person) Preferred over Foley because there is less risk of infection Frazier Rehab Institute Copyright, 2009 External Catheter--MALES Also known as Texas or condom catheters Beneficial for males who experience spontaneous voiding Fits over penis (much like a condom) & hooks to drainage bag to keep you dry Adhesive on the condom catheters holds the catheters in place Frazier Rehab Institute Copyright, 2009 External Protection-FEMALES Because of their anatomy, the only available external option for a female would be in the form of an incontinence pad or brief. Frazier Rehab Institute Copyright, 2009 Choosing Incontinence Devices Many different kinds of catheters available Insurance benefits vary person to person Can be purchased off Internet or at a local drug store/pharmacy Your rehab team can help you choose which device(s) would work best for you Frazier Rehab Institute Copyright, 2009 Behavioral Strategies Timed toileting/voids Pelvic muscle exercises (Kegel) Electrical stimulation (stress or urge incontinence problems only) Frazier Rehab Institute Copyright, 2009 Medications for Bladder Management Anticholinergics—help prevent bladder spasms; promote storage (examples Ditropan, Oxytrol, Detrol, Bentyl) Alpha adrenergics— increase pressure on bladder neck; promote storage (ex. Pseudoephedrine) Cholenergics—help bladder contract; promotes emptying (ex. Bethanechol) Alpha blockers—relax muscles at base of bladder; promotes emptying (ex. Flomax, Uroxatral, Minipress, Hytrin, Cardura) Frazier Rehab Institute Copyright, 2009 Surgical Procedures Mitrofanoff procedure: requires surgery to construct a new passageway for urine using the appendix tissue; passageway allows catheter to pass through the abdomen and directly into bladder. It is good for women & those w/decreased hand function. Bladder augmentation: surgical enlargement of bladder; reduces need for frequent caths Frazier Rehab Institute Copyright, 2009 Surgical Procedures cont… Sphincerotomy: allows easier urine flow by reducing pressure on sphincter; may affect ability to have reflex erection; usually not done on women. Frazier Rehab Institute Copyright, 2009 Clean Intermittent Catheterization Technique used in home setting; a sterile technique is used in the healthcare setting Equipment needed: clean catheter, waterbased lubricant, washcloths or baby wipes, clean tray, and antiseptic soap Can be performed lying down (in bed) or in a seated position (on toilet/BSC or in wheelchair) Frazier Rehab Institute Copyright, 2009 Clean IC cont… Wash hands with soap & water Clean genital area with baby wipe or damp washcloth and soap *Males clean from tip to base of penis *Females clean front to back Lubricate catheter & position tray between legs (point end of catheter toward toilet/BSC if seated) Frazier Rehab Institute Copyright, 2009 Clean IC cont… Insert catheter into meatus until urine flows & allow urine to drain When urine stream starts to trickle, massage abdomen (Crede’ maneuver) Slowly remove catheter when urine is no longer flowing out Place used catheter in a storage container to be cleaned later or discard if one-time use Inspect urine for color, amount, odor, or sediment (should generally be clear to light yellow) Frazier Rehab Institute Copyright, 2009 Clean IC cont… Rinse genital area with baby wipe or damp washcloth & soap Always wash your hands when finished! Frazier Rehab Institute Copyright, 2009 Cleaning Catheters at Home After using the catheter, wash & rinse inside and out with soap and water Dry on clean towel, making sure to drain inside of catheter Inspect catheters after each use and after cleaning Discard those that are damaged & store the rest for reuse Frazier Rehab Institute Copyright, 2009 Cleaning Catheters at Home cont… Those with frequent Urinary Tract Infections (UTIs) or if you have a current UTI, you may want to alter the cleaning technique a little After cleaning and rinsing with soap & water, you will boil the catheters on the stovetop for 15-20 minutes Drain, dry, and store as described before Frazier Rehab Institute Copyright, 2009 Urinary Tract Infection (UTI) Bacteria that multiply in the urinary tract can cause an infection Possible signs & symptoms include: cloudy &/or foul smelling urine, increase in mucous or sediment, blood in urine, pain or burning with urination, increase in bladder spasms, increase in frequency of urination or incontinence, low back or flank pain, elevated temp/fever, chills, nausea/vomiting Frazier Rehab Institute Copyright, 2009 Prevention of UTI: Things to Do Proper fluid intake (8-10 glasses of liquid per day, preferably water) Routine bladder emptying (keep on bladder management schedule; volumes should not to exceed 400-500ml at once) Good hygiene (wash hands & keep skin around genitals clean) Frazier Rehab Institute Copyright, 2009 Prevention of UTI: Things to Do Proper positioning & draining of collection device (leg bag/bedside drainage bag) Daily cleaning of drainage devices & proper cleaning of catheters (after each use) Regular check-ups with your healthcare provider (at least yearly) Frazier Rehab Institute Copyright, 2009 Detection & Treatment of UTI Call MD if you suspect UTI May need urine specimen (UA C&S) to determine if true infection Treatment may include use of antibiotics Continue to always use preventative measures! Frazier Rehab Institute Copyright, 2009 Conclusion It may take time & effort, but proper bladder management can be achieved in those with spinal cord injuries. Try to keep a healthy urinary system by staying educated, sticking to a regimen, and using preventative measures. Follow the recommendations of your healthcare providers! Frazier Rehab Institute Copyright, 2009 Questions or Concerns? Please Contact: Frazier Rehab Institute Spinal Cord Medicine Clinic Belinda Coyle, SCMP Nurse Coordinator (502) 582-7495 (866) 540-7719 www.spinalcordmedicine.com References Bladder care. (n.d.). Retrieved July 25, 2006, from http://www.spinalcordcenter.org/manual/index.html. Bladder care. (n.d.). Retrieved July 25, 2006, from http://www.spinalcord.uab.edu/show.asp?durki=21484. Bladder care. Chapter in Patient and Family Handbook for Spinal Cord Injury. Frazier Rehab Institute, 2009. Available under Education section at www.spinalcordmedicine.com Fine, C.K., & Nelson, A. (Eds.). (2001). Nursing practice related to spinal cord injury and disorders: A core curriculum. New York: Eastern Paralyzed Veterans Association. Haeman, S.P. (2002). Rehabilitation nursing: Process application and outcomes, 3rd edition. Mosby. Maddox, Sam. (2003). Paralysis Resource Guide. New Jersey: Christopher Reeve Paralysis Foundation. Frazier Rehab Institute Copyright, 2009
