Different Types of Bladder Management and Care
- Function of the Urinary System
- Function of the Urinary System After a Spinal Cord Injury
- The Spastic (Reflex) and Flaccid Bladder
- Reasons for Requiring a Bladder Management Program
- Methods of Bladder Management and Care
- Possible Urinary System Complications Following a Spinal Cord Injury
Methods of Bladder Management and Care
There are many ways of managing a bladder following a spinal cord injury. The way in which the bladder will be managed will depend on many factors, but the type of post spinal cord injury will have the main impact on the method of management chosen.
Typically, bladders are one of either two types, spastic (reflex) or flaccid bladders.
Bladder Management for Spastic (Reflex) Bladders
There are several options for managing a spastic bladder to ensure correct emptying (voiding).:
- Reflex contractions can be utilised to empty the bladder.
- Reflex contractions can be suppressed to produce a bladder that will need emptying by catheter.
When the reflex method is used in a male with a spinal cord injury, a sheath drainage system may be used. The sheath is attached to the penis with a special adhesive, and the end of the sheath has a hole in it, which can then be connected to a drainage bag.
Sheath drainage is very good, as long as bladder pressures remain at a safe level, and the bladder completely empties. In some cases, a surgical procedure may be required to ensure the sphincter allows the bladder to fully empty during reflex voiding.
Sometimes a full reflex bladder can be tricked into emptying by using different techniques:
- Crede Method - This is done by gently pressing down on the bladder.
- Tapping - This is done by tapping over the bladder with the finger tips. This stimulates the detrusor muscles.
- Valsalva - Involves leaning forwards to increase pressure in the abdomen, thus triggering the detrusor muscles.
Where the bladder reflex has been suppressed by medication, catheterisation will be required to empty the bladder.
A bladder catheter is a flexible plastic tube inserted into the bladder to enable urinary drainage. There are two types of catheter, an indwelling catheter, and an intermittent catheter (used for intermittent self catheterisation).
The main type of indwelling bladder catheter is the "Foley" catheter. This catheter has a balloon on the bladder end. After the Foley catheter is inserted in the bladder, the balloon is inflated with saline so that the catheter cannot pull out but is retained in the bladder as an indwelling catheter. Removal is accomplished simply by deflating the balloon and slipping the catheter out.
Intermittent self catheterisation is a process where by a person inserts a temporary catheter into the bladder via the urethra to enable it to drain.
Intermittent catheters are used once to empty the bladder, and then disposed of. This type of catheter is only used once, and is not designed to be left in the bladder for continuous urinary drainage. Intermittent catheters do not have the balloon or the side port, found at the end of the Foley catheter for balloon inflation.
Bladder Management for Flaccid Bladders
Management of flaccid bladders requires the need to empty the bladder before overflow leakage or stretching of the bladder occurs. Catheterisation on a regular basis is also often required. Patients learn to self-catheterise, and will usually have to wake up at night to use the catheter.
For some patients who have difficulty trying to self-catheterise, other options may be available to empty the bladder. Credé is a bladder voiding technique in which the patient manually presses down on the bladder. In effect, this squeezes the urine out of the bladder. Valsalva, another technique, works by using the abdominal muscles as if having a bowel movement. This puts pressure on the bladder, and forces urine out.
Surgical interventions are available such as bladder augmentation (see below).
Mitrofanoff procedure (Mitrofanoff appendicovesicostomy) is a technique which creates a passage using a removed section of the appendix so that catheterisation may be performed through the abdomen rather than the urethra. One end of the appendix is connected by sutures to the bladder and the other is connected to the skin. Generally an incision is made into the umbilicus (belly button) so that it may serve as the canal for the catheter. Urine is typically drained several times a day by use of a catheter inserted into the Mitrofanoff canal.
The Mitrofanoff procedure allows the individual to self-catheterise so that he or she is not dependent on a family member or a medical professional to catheterise him or her.
Supra-pubic Catheterisation (Cystostomy)
The technique of supra-pubic catheterisation involves the insertion of a catheter into the bladder via the abdominal wall. This is performed either under local or general anaesthetic.
Advantages of Supra-pubic Catheters
- Prevents damage to urethral/sphincter tissue, during urethral catheter insertion and long term use.
- Helps prevent ‘kinking’ of the catheter (Catheter not so likely to be sat on, or trapped in the groin).
- Usually easier to maintain hygiene and carry out routine changes.
- Unlike a urethral catheter, a supra-pubic catheter frees your private parts for sexual activity.
- Convenient; no need to visit the toilet to pass urine.
- Easily reversible; the exit site will start to heal within minutes of removal of the catheter.
- The urine can drain via the urethra if the catheter is blocked.
Disadvantages of Supra-pubic Catheters
- Exit site discharge may take several weeks or more to disappear.
- In obese patients sitting the catheter may pose a problem.
- Hypersensitivity around the exit site area may be a problem.
- Requires to be changed every 4 - 6 weeks.
- Some patients develop bladder stones in the presence of the catheter.
Bladder augmentation, also known as augmentation cystoplasty, is a technique which increases the bladder's storage capacity, lengthening the time periods between catheter use. The procedure involves tissue grafts (anastomosis) from a section of the small intestine (ileum), stomach, or bowel, and the grafts are attached to the urinary bladder by sewing or stapling to create a pouch or wider wall for the bladder in order to enhance its reservoir capacity.