Following spinal cord injury, instituting an effective bladder management program is key to ensuring optimal patient health. The overall goal is to develop a bladder management program that will allow the patient to reintegrate most easily back into the community. Specific goals include the prevention of bladder overdistention, urinary tract infections, and kidney damage. A practical bladder management program, in both the hospital and outpatient settings, is a critical component of an overall SCI management program.

The type of management program will depend on many factors. Some of them include:

• Level of injury and extent of loss of normal urinary system function
• Susceptibility to infection, including overall medical and surgical history
• Can/will the client adhere to the program?
  • Hand function should be assessed to determine ability to perform self-catheterization, as well as sitting, standing and ambulating.
  • Lifestyle (is the client active, working, etc.?)
• Availability of clinically effective products/systems.

The object of bladder training after SCI is to maintain the patient's bladder at the appropriate volumes for optimum overall health. Methods of bladder retraining are supplemented by monitoring fluid intake to prevent UTIs and control urine volume and concentration, developing scheduled times for urination, and using body positions to facilitate voiding.

• Urodynamic assessment is the only way to properly diagnose and treat the neurogenic bladder. After spinal cord injury, urodynamics will help determine which patients will develop complications, therefore permitting early treatment and intervention. The role of urodynamics in neurogenic voiding dysfunction include:

  • characterization of the detrusor function during bladder filling,
  • the evaluation of the bladder outlet including the urethral sphincter, and
  • the diagnosis of neuropathy.
  The timing of urodynamics after SCI is important. While a patient is still in spinal shock, the bladder doesn't contract, so testing detrusor function, etc. won't be fruitful. The tests would be most accurate if performed at 3 - 4 months after SCI.

For ideal bladder training, the 3 disciplines of nursing, physical therapy (PT) and occupational therapy (OT) work hand-in-hand.

• Bladder training often begins when OT and Nursing agree that the patient is physically and functionally able to begin.
• In general, PT assesses the ability of the patient to "transfer" him/herself. They also assess if a wheelchair is needed, and if so, what type.
• OT assesses if other equipment is needed and the patient's actual abilities and disabilities.
• Finally, nursing provides the follow-through and reinforcement on a daily basis. As always, nursing is also responsible for overall physical assessment, and is often the coordinator or "case manager" of the efforts of other disciplines.
• All disciplines are expected to document the effectiveness (or lack of) of their efforts.
• Ideally, the plan is to train the patient as well as a significant other and/or caregiver. Training also includes education about medications and their side effects, recognizing symptoms of a UTI and urine volume issues.

The next page will offer some practical matters related to bladder management and training after SCI

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