Bladder Managment for Adults with Spinal Cord Injury - 25

CLINICAL PRACTICE GUIDELINE

Personal care. The genital area is cleaned daily with mild soap and water. Care of equipment. If daytime and nighttime urinary collection devices are being reused, they should be cleaned daily. A 1:10 solution of bleach to water has been shown to afford effective cleansing (Dille and Kirchhoff, 1993). Fluid intake. Maintaining a high fluid intake (greater than 2000 ml) is encouraged to facilitate mechanical washout, decrease solute concentration, and lessen the likelihood of stone formation. Assistance required. Because either the individual or a caregiver can maintain the catheter, individuals with minimal function and limited assistance are suitable for this method of bladder management. Cosmesis. A leg bag is worn during the day and a nighttime collection device is used overnight. The leg bag can be concealed under clothing. Cloth bags can be made or purchased to conceal the large nighttime collection device. Interference with social/sexual function. Indwelling urethral catheters may need to be removed for intercourse. Some males disconnect the catheter, bend it back over the penis, and place a condom over the penis and catheter for intercourse. This method may cause urethral irritation and a subsequent UTI. Males who are concerned about fertility may find that removal of the catheter decreases colonization and increases fertility. Suprapubic catheters have advantages for both males and females. Both can have intercourse without having to be concerned about a catheter. Females who opt for suprapubic placement can avoid the enlargement of the urethra and subsequent urinary leakage common with urethral catheters. Medications. If the catheter tip and balloon irritate the trigone of the bladder, an anticholinergic medication may be prescribed to prevent involuntary detrusor contractions and urinary leakage. Reversibility. The catheter can be removed if an alternative type of treatment can be found that affords a low-pressure bladder and periodic bladder emptying.
Adapted from Joseph, A.C., A. Hixon, J. Giroux, D. Briggs, M. Gardenhire, D. Diaz, and J. Wells. Nursing clinical practice guideline: neurogenic bladder management. Spinal Cord Injury Nursing 15 (2) (1998): 21–56.

Reflex Voiding
Reflex voiding is a method that depends on an intact sacral micturition reflex. As bladder filling begins, sensory afferents begin to feed this information into the sacral cord. Continued bladder filling eventually triggers sacral efferents to cause an uninhibited (involuntary) bladder contraction. But because of the spinal cord injury, coordinated relaxation of the sphincter mechanism is absent; thus, detrusor sphincter dyssynergia is usually present. Despite dyssynergia between the bladder contractions and sphincter relaxation, voiding occurs because the sphincter relaxes intermittently during the bladder contractions. However, detrusor sphincter dyssynergia frequently results in elevated voiding pressures, which can then cause poor drainage and complications to the upper tract. Another problem that commonly occurs in those with detrusor sphincter dyssynergia is poor drainage of the bladder. In those with spinal injuries at T6 and above, autonomic dysreflexia can occur when the bladder contracts against a dyssynergic sphincter. Autonomic dysreflexia can also occur from bladder distention from incomplete bladder emptying. Because the bladder contractions are involuntary with little or no warning, individuals who reflex void require a collecting device. The presence of detrusor sphincter dyssynergia frequently necessitates other interventions (e.g., suprapubic bladder tapping, alpha-blockers, botulinum toxin injection, urethral stents, or sphincterotomy) to allow the bladder to empty effectively and prevent upper tract complications. 1. Consider using reflex voiding for males who demonstrate post-spinal shock with adequate bladder contractions and have: Sufficient hand skills to put on a condom catheter and empty the leg bag or have a willing caregiver. Poor compliance with fluid restriction. Small bladder capacity. Small post-void residual volumes. Ability to maintain a condom catheter in place.
(Scientific evidence–None; Grade of recommendation–None; Strength of panel opinion–Strong)

Rationale: A reflex (uninhibited) bladder contraction adequate for bladder emptying is needed for those who are considering reflex voiding as their method of bladder management. It should be

Bladder Managment for Adults with Spinal Cord Injury

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