initial recovery from SCI, there are many potential bladder management and training
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.
a patient has frequent UTIs using "clean" intermittent catheterization
procedures, it may be necessary to switch to only using sterile equipment and
- 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.
can be used to suppress bladder contractions between ICs, therefore
- ditropan also has
a local anesthetic effect on the bladder, which some patients may find
- 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
- 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"
- 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
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).
is a cholinergic drug that increases bladder muscle tone.