Managing the Effects of Spinal Cord Injury and Neurogenic Bladder
By Michael Ritmiller, MS, Pa-C
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March 12, 2012
Patients with spinal cord injuries can experience multiple systemic problems. In general, all normal functioning has changed. Let’s take a look at what exactly changes.
Prior to their injury, the patient’s bladder will typically fill via the ureters. As the bladder fills, there are receptors in the bladder that sense the stretching of the Detrusor muscle. Messages are then relayed up the spinal cord to the base of the brain. The message is then processed by the Pontine Micturition Center (Pons). From there, messages are sent to the frontal and temporal lobes of the brain. These messages are then relayed back to the Pontine Micturition Center. The messages are constantly sent back down the spinal cord to the bladder. Once the bladder receives the messages, multiple responses occur. When the bladder reaches its maximal capacity, the sphincter muscles underneath the bladder will relax and then the Detrusor muscle will contract. This will cause the natural voiding response and the bladder will empty.
Now imagine that you were in a multitrauma event. In this trauma you had an injury or a total transection of your spinal cord. The bladder will still fill with urine, but in many instances, the patient will experience spinal/bladder shock. During this time the bladder will just fill with urine and retention will occur. Depending on the severity of the injury, this may last from one week to three months.
After the initial spinal cord injury, the bladder will still fill with urine but the patient will not typically sense the filling of the bladder nor have the ability to void. The nerve messages will still get sent up the spinal cord, however those messages hit the area of injury and will stop at that point. In these cases the patient’s bladder will continue to fill and eventually the bladder will reach its maximal capacity. Urine will start to leak out or overflow incontinence will occur.
To assure that the bladder is managed properly, intermittent catheterization is recommended. Ideally the patient should be catheterized every four to six hours to assure that the patient’s bladder does not reach volumes great than 500 mL. As time passes following the initial injury, problems will start to occur.
The following section will describe problems that may occur due to injuries at certain levels on the spinal column.
Supra-Sacral Spinal Cord Injury
- From T6 and Above: The individual with this type of injury is the most susceptible to many problems. These individuals are commonly diagnosed as tetraplegics or maybe paraplegic and may experience multiple systemic problems. The problems that pertain to the bladder are as follows:
- Neurogenic bladder: Impaired bladder function due to neurological injury/disease or impairment.
- Urinary retention occurs when the bladder has the inability to perform Detrusor contractions.
- Overflow: Due to retention, the bladder has reached its maximal capacity and urine will start to leak out.
- Neurogenic Detrusor Overactivity: This is leakage of urine due to an uncontrolled Detrusor muscle spasm. These spasms usually occur when the bladder is “waking up” from the shock phase. However this is not considered voiding since the patient has no physiological or neurological control.
- Detrusor Sphincter Dyssynergia: This is a common problem for most tetraplegics. Basically the external sphincter and the detrusor are working against one another (as previously stated, when the bladder is full, nerve messages are sent to the sphincter to relax. Once relaxed, the detrusor will contract and empty urine). In this case the bladder will typically continually spasm. However the sphincter muscle is still contracted. Urine leakage does occur, but at elevated intravesicular pressures which may cause damage to the bladder muscle and eventually may cause vesicoureteral reflux.
- Vesicoureteral Reflux: Due to elevated vesicular pressures and detrusor muscle damage, urine may be forced back up into the ureters which may cause hydroureter, hydronephrosis, and pyelonephritis.
- Autonomic Dysreflexia: This is a serious problem that must be treated emergently when it occurs. Typically it is the body’s response (warning) to an unwanted stimulus. It can be caused by a distended bladder, fecal impaction, pressure ulcer or tight clothing. Typical signs are severe headache, profuse diaphoresis, feeling of pressure behind the eyes, flashing of light in front of the eyes, elevated blood pressure and uncontrolled glucose levels. If left untreated, this may eventually cause a stroke to occur.
- Lower Spinal Cord Injury From T10 Below: These patients also have neurogenic bladders and urinary retention. However they may experience incontinence of a different nature. Many of these patients will have problems of stress urinary incontinence due to impairment of the nerves that control the bladder neck and the external sphincter. These individuals will have incontinence on transfers or they may have continued incontinence throughout night and day. All patients that have spinal cord injuries are susceptible to renal and bladder calculus and multiple occurrences of urinary tract infections. One special note for urinary tract infections, many of these patients may be colonized with one or many bacteria. The recommended treatment is to hold antibiotic therapy until the patient is experiencing systemic signs or symptoms of infection.
Mr. Smith is a 51-year-old male who suffered a C6 level spinal cord injury and was diagnosed as an ASIA A complete tetraplegia. In acute rehabilitation, the patient was seen by urology. The foley catheter that was indwelling was removed and the patient was started on intermittent catheterizations every four hours.
His catheter volumes typically ranged from 300 to 400 mL. As his stay continued, the patient started to have incontinence where he was leaking urine between catheterizations and his catheter volumes were still 300 mLs. At this time, the patient was started on anticholinergic therapy (Ditropan XL 15 mg b.i.d.) to help stop the overactivity incontinence and increase the bladder’s capacity. The patient did well on this therapy while he was admitted. He was then discharged to a nursing home facility in which orders requested continued intermittent catheterizations and medications that were previously prescribed and he was to follow up in the urology clinic in one to two months.
Unfortunately the patient did not return to the urology clinic until six months later. When he did return, the patient was reported to have multiple urinary tract infections. He was not getting catheterized and had a condom catheter on to catch his “voided” urine. He was also experiencing signs of dysreflexia with elevated systolic pressures and profuse diaphoresis. At that point the patient had an indwelling catheter placed since he was not voiding, but was incontinent. He was also restarted on anticholinergic therapy. The patient was also seen one or two more times in which he was started on intermittent catheterizations and was recommended to have a video urodynamic study completed for assessment of the bladder’s function/dysfunction.
The patient was then lost to follow-up due to the formation of a large decubitus ulcer and a hospital readmission – after which he was transferred to a new nursing home facility. Sometime later the patient returned to the clinic – at his request. He was getting catheterized, but on an infrequent schedule and was taken off of his anticholinergics since he was unable to tolerate the side effects (dry mouth). The patient was then rescheduled for the video urodynamic study and a flexible cystoscopy.
When the procedure was done, the patient was found to have continued urinary retention with severe neurogenic detrusor overactivity. He was also found to have detrusor sphincter dyssynergia and a slightly opened bladder neck that was seen on video cystogram. Vesicoureteral reflux was seen on video cystogram. Of note, at the time of the procedure, the patient’s bladder was being managed with an indwelling Foley catheter due to the large decubitus ulcer and continued incontinence.
Recommendations at that time were to go ahead with a rigid cystoscopy and Botox injection to stop the overactivity and increase the bladder’s capacity. Another recommendation was for possible placement of a suprapubic tube for management of the bladder since the patient was not considered a good surgical candidate for bladder augmentation or a urinary diversion.
Michael Ritmiller, MS, Pa-C, is a urology physician assistant at Kernan Orthopaedic and Rehabilitation Hospital and is employed by Chesapeake Urology Associates. His special interests include voiding dysfunctions due to neurogenic and spinal cord injuries, sexual medicine and general urology. He earned his bachelor's degree in community health with cum laude honors and earned his masters degree in physician assistant science from Towson university/Essex PA program. He is certified by the National Commission on Certification of Physician Assistants.