After initial recovery from SCI, there are many potential bladder management and training issues.

The following are some practical matters, collected from experts in the field.

• Intermittent catheterization training for the patient and their significant other/caregiver.
  • At this point of recovery, intermittent catheterization is learned as a self-care procedure. The patient's exposure to bacteria is much less at home, than in the hospital. Therefore, self-catheterization is often carried out as a "clean", rather than an aseptic or sterile procedure.
  • This means that catheters and bags are cleaned with soap and water and reused. The protocol may involve washing the catheters with antimicrobial soap and using bleach solution to cleanse the collection bag.
  • ICs are performed at 3 to 4 hour intervals to prevent overdistention of the bladder. The best results are obtained if only 300 to 400 ml are allowed to collect in the bladder between catheterizations.
  • If the patient subsequently presents with recurrent UTIs, or has an inpatient hospital stay for some reason, sterile, closed intermittent catheter systems are then considered and ordered if appropriate. There are also external catheter systems that may be an option for male patients.
  • Many insurance companies won't pay for sterile equipment unless medical necessity is documented. If a patient experiences 2 or more UTIs in a 12 month period, the physician may need to write a Letter of Medical Necessity. This wil help the patient qualify for a closed, sterile system through their insurance company. Medicare, Medicaid, HMOs and PPOs, as well as private insurance will usually approve the closed system with proper documentation. Sterile technique is then recommended to be used with the closed system.

• Medications can be employed to facilitate bladder management. They can change the contractility of the bladder muscle, decrease outflow resistance of the internal sphincter, or relax the external sphincter.

• Anticholinergic drugs, such as Pro-Banthine (propantheline), and Ditropan (oxybutynin chloride) decrease detrusor muscle tone and increase bladder capacity.
  • anticholinergics can be used to suppress bladder contractions between ICs, therefore prevent incontinence.
  • ditropan also has a local anesthetic effect on the bladder, which some patients may find helpful.
• Cholinergic drugs, such as Urecholine (bethanecol chloride), can increase bladder tone.
• Muscle relaxants, such as Valium (diazepam) and Lioresal (baclofen) may decrease the tone of the external sphincter.

• Fluid intake influences a number of important issues:
  • Very concentrated urine can stimulate afferent neurons. This can result in increased intravesicular pressures, vesicoureteral reflux and overflow incontinence.
  • It is also important it avoid over-hydration at night, as it may lead to bladder overdistention.

• In some very ill and debilitated patients, an indwelling catheter may be necessary on a permanent basis. However, an indwelling catheter increases the chances of urinary tract infections, bladder stones and bladder cancer.
  • Other reasons for an indwelling catheter are poor hand function, or cervical injuries. A suprapubic catheter may also be an appropriate option. Men can also use external collecting systems (a "condom" catheter).
  • With long-term indwelling catheters, it's important to stress issues such as oral fluids at least 2 liters/day, keeping the catheter secured (e.g. taped to the abdomen to prevent mechanical stress), cleansing the urethral meatus twice a day, preventing reflux of urine back into the bladder by never raising the collecting bag above the level of the bladder, and changing the catheter itself every 2 to 4 weeks. Also, before removing an indwelling catheter, it's important to obtain a urine culture and sensitivity and treat as needed.

Other management programs to consider, especially with sacral injuries, are:

• Timed voiding, which can lessen the incidence of incontinence.
• Urinary retention can be relieved by expressing urine with crede maneuvers (pushing down on lower abdomen) and/or valsalva maneuvers (using intrabdominal pressure).

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