Spinal Cord Injuries
How does spinal cord injury effect the bladder?
Spinal cord injury has a profound effect upon bladder as well as bowel function. There are several patterns of bladder dysfunction that develop. The problems that occur are very dependant upon how the bladder and the urinary sphincter respond to spinal cord injury. The bladder can generally be either severely contracted and spastic or dilated without any contractile function. These type of bladder problems are treated very differently. The first can lead to kidney failure through very high pressures that are generated within the bladder. These patients need close monitoring to make sure that pressures are not high and may need treatments to decrease the pressure and resultant leakage, which often occurs. In the second type of bladder dysfunction, the main problem is with adequate emptying of the bladder. Usually these patients need to perform intermittent catheterization in order to empty their atonic bladder.
What are the goals of management in patients with spinal cord injury?
The goals are establishing a method of reliably emptying the bladder, and to make sure the bladder has adequate volume and does not develop high pressures that can damage the kidneys. It is also very important to control urinary leakage so chronic pressure sores do not develop.
Suprapubic and chronic Foley catheters
One issue that is a common problem is the use of chronic catheters in patients that have had a spinal cord injury. Most patients that have a spinal cord injury do not empty their bladder reliably and for this reason it is common to see patients that are reliant on a chronic indwelling catheter. This catheter is either placed in the urethra or through a puncture in the abdomen above the pubic bone. A catheter placed in the urethra is known as a Foley catheter and one placed through the abdomen is known as a suprapubic catheter. These catheters are very different from catheter that patients use to intermittently catheterize a few times a day to drain the bladder. Most patients eventually develop problems with chronic catheters. These problems mostly involve infections, chronic sores in the buttocks (sacral decubiti) and renal failure. It is very common to see patients that have had a chronic catheter for many years that begin to develop very severe urinary tract infections. These infections can require intravenous antibiotics or admission to the hospital and eventually become constant. These are the result of the body’s natural reaction to chronic foreign material in the urinary system. Intuitively patients and doctors think that a catheter will drain the bladder and prevent high pressures and urinary leakage. Unfortunately these catheters do not do well at either task. Bladders are often somewhat distended with a catheter in place and the catheters do not protect the kidneys well from damage and the development of kidney failure. Also, patients often leak around the catheter when the bladder spasms. This urinary leakage can dramatically worsen pressure sores called decubiti. If these sores progress they can cause terrible damage. Often in an attempt to control urinary leakage catheters are upsized to very large bore catheters. These measures usually do not improve things. Other common strategies to control infection are the use of suppressive antibiotics and frequent catheter changes. These measures may improve infection for a time, but usually once these kinds of problems manifest themselves when a patient has a chronic catheter it is time to consider other options.
A suprapubic tube is placed through a small incision over the bladder. Suprapubic tube can help with problems with the urethra or penis, but patients are still very prone to infections and bladder spasms
The other options include reconstructive surgery, which will increase the capacity of the bladder and eliminate high pressures in the bladder or to establish a catheterizable channel that can be intermittently catheterized to drain out the bladder. Every case is unique, but there is not much doubt that if a strategy can be found, which avoids chronic catheterization the patient’s long-term kidney function and overall health will be much better preserved.