This document discusses the early management of bladder dysfunction following spinal cord injury (SCI), highlighting the significant urinary complications associated with both traumatic and non-traumatic SCI. It details the phases of bladder response post-injury, the risks of autonomic dysreflexia, and various bladder management strategies such as intermittent catheterization and suprapubic catheterization. Additionally, it emphasizes the importance of early intervention through urodynamics to predict complications and optimize treatment outcomes.

1. Early management of bladder after
spinal cord injury
Dhaval Shukla,
Addl. Professor of Neurosurgery,
NIMHANS, Bangalore

2. Common Spinal Disorders N=373
Tuberculosis Spine
Tuberculosis
Arachnoiditis
Tumors
Transverse Myelitis
Degenerative Spine
Nair KPS , et al: Spinal Cord 2005.
Gupta A, et al: Spinal Cord 2008.

3. SCI Epidemiology
• Incidence:
– Traumatic: 13 to 53 / million
– Non Traumatic: 11 to 68 / million
• Prevalence:
– Traumatic:280 to 1298 / million
– Non Traumatic: 367 to 1227 / million
•
Bickenbach J , et al: WHO - International Perspectives on Spinal Cord Injury 2013.
Chhabra HS, et al. Spinal Cord 2012.
Mukherjee AK , et al: Rehab Council of India.

4. Urinary Complications in SCI
• Traumatic: 81%
• Non Traumatic : 75.4%
• Pre 1940:
– Death in first few months was due to urinary problems (UTIs)
• Post antibiotic era
– Kidney failure was leading cause of death
• With current urological management
– Less than 3% death due to kidney failure
Major reason for re-hospitalization in high-income countries and
premature mortality in developing countries
Bickenbach J , et al: WHO - International Perspectives on Spinal Cord Injury 2013.
Ku JH, et al. BJU 2006.

5. Pathophysiology of Neurogenic
Bladder in SCI

6. Events After SCI Involving Bladder
• Spinal Shock
– Distended flaccid bladder to hyperactive bladder
• Autonomic Dysreflexia
– Bladder Distension is a major precipitant

7. Spinal Shock
• Phase 1, (0–1 day)
– Areflexia/Hyporeflexia
• Phase 2, (1–3 days)
– Initial Reflex Return
• Phase 3, (1–4 weeks)
Early Hyperreflexia
• Phase 4, (1–12months)
Spasticity/ Final Hyperreflexia
Ditunno JP , et al: Spinal Cord 2004.

8. Phase 1, (0–1 day)
Areflexia/Hyporeflexia
• Areflexia/Hyporeflexia
• Caudal to complete SCI, DTRs absent
• Muscles are flaccid and paralyzed
• Bradyarrhythmias, atrioventricular conduction
block, and hypotension
• Bladder areflexic

9. Phase 2, (1–3 days)
Initial Reflex Return
• Cutaneous reflexes become stronger
– Bulbocavernous
– Anal
– Cremesteric
• DTRs are still absent
• Bladder areflexic

10. Phase 3, (1–4 weeks)
Early Hyperreflexia
• DTRs reappear
• Babinski sign
• Autonomic function evolve
• Bladder areflexic

11. Phase 4, (1–12months)
Spasticity/ Final Hyperreflexia
• Cutaneous reflexes, DTRs, and Babinski’s sign
become hyperactive
• Autonomic dysreflexia develops
• Bladder recovery

12. Autonomic Dysreflexia (AD)
• AD is a potentially life threatening condition
characterized by a sudden uncontrolled
sympathetic response secondary to noxious
stimuli resulting in a sudden rise in blood
pressure with dangerous consequences
• Higher the level of SCI, more severe bouts of AD
– 98% and 48% in patients with quadriplegia and high
paraplegia (above T6)
– Only 27% of patients with incomplete injury
Gunduz H , et al: Cardiol J 2012.

13. AD - Clinical Features
• From asymptomatic, to mild discomfort, to a life-
threatening emergency
• A sudden 20 to 40 mm Hg increase of BP over baseline
with bradycardia
• Accompanied by at least one of the following signs
(sweating, piloerection, facial flushing, cold peripheries),
or symptoms (headache, blurred vision, stuffy nose,
chest tightness)
• Seizures, intracranial and retinal hemorrhages,
myocardial irregularities, coma, and even death

14. AD - Precipitants
• Commonest triggering factor is bladder (85%)
– Distension
– Urinary retention
– Catheter blockage
– Cystoscopy
– Urodynamics
– Urinary infections
– Bladder calculi
• Pain or irritation (13% to 19%)
• Constipation, hemorrhoids, and anal fissures
• Cutaneous triggers: pressure sores and ingrown toenails

15. AD- Treatment
• Identifying and removing trigger for AD
• Placing the patient in an upright position to take advantage of
orthostatic reduction in BP
• Loosen any tight clothing/ constrictive devices
• Frequent monitoring of BP
• Captopril (25 mg sublingually) is a primary medication in the
management of AD
• Nitrates
– Caution with sildenafil
• Alpha-1 adrenoceptor selective blocking agents prazosin
– Added effect includes inhibition of urinary sphincter
Gunduz H , et al: Cardiol J 2012.

16. Evaluation of Bladder Involvement in
SCI
• History
– Time since injury
– Time since last passed urine
– Difficulty, and adequacy of urination
• General examination
– Trauma survey
– BP
• Neurological examination
– Motor power
– Sensation
– Reflexes
• Post-void residual volume

17. Urodynamics in SCI
• To predict which patient will develop
complications and need early intervention
• High bladder pressure (>40 to 60 cm H2O)
during filling and voiding are associated with
upper tract complications and UTI
• Sensitivity and specificity of urodynamic
predictors is not known
• Initial urodynamics should be deferred until
after the spinal shock phase 3 (2 to 6 weeks)

18. Urodynamics in SCI
0
10
20
30
40
50
60
70
80
90
100
Detrusor
Areflexia
Detrusor
Hyperreflexia
DH with
Sphincter
Dyssynergia
Normal
Cervical
Thoracic
Lumbar
Sacral
Chancellor MB, et al: Pract Neurolurol. 1995

19. Spastic (automatic) Flaccid
Vertebral level Lesion above L1 Lesion at/below L1
Symptoms Urgency, frequency,
urgency incontinence,
hesitancy,
retention
Hesitancy, retention
Bladder scan ±Raised postvoid residual
urine
Postvoid residual urine
>100 ml
Uroflowmetry Interrupted flow Poor/absent flow
Bladder pressure High Low
Detrusor Overactivity, detrusor–
sphincter dyssynergia
Underactivity,
sphincter insufficiency
Bladder capacity Low High
Risks Back pressure changes Stasis
Panicker JN, et al: Pract Neurol. 2010

20. Bladder Involvement in
Multiple Sclerosis (MS)
• Only 6% present with urologic symptoms
• 50% have asymptomatic urodynamics findings
– Half of them require treatment
• Eventually 50% men, and 80% women have
urologic symptoms
• Voiding dysfunction difficult to predict because of
diffuse involvement and changing course of
disease
• No correlation between neurological and urinary
symptoms
Delisa , et al: PMR Textbook 2008.

21. Bladder Involvement in MS
Development of
Sphincter Dyssynergia
is indicator of
poor prognosis in MS

22. Bladder involvement in
Vertebral Metastasis
• Badly collected and poorly reported
• Bladder dysfunction tends to occur late
• Median survival from 2.4 to 30 months
• 2/3 have bladder involvement before
treatment
• 14% – 67% improve after treatment
• Most patients switch from indwelling
catheters to intermittent catheterization
Fattale , et al: APMR 2011.

23. Bladder Management in SCI
Neurogenic bladder dysfunction in
spinal cord injury is the prototype
neurourology dysfunction

24. Goals of Best Method of Urinary
Drainage
• Continence/ Collection of Urine
– Keep skin dry
– Hygiene
– Convenience
– Avoid indwelling catheters
– Social and vocational acceptability and adaptability
• Minimize Complications
– UTIs
– Urethral
– Upper urinary tract

25. Bladder Emptying Options
• No Catheter
• Urethral Indwelling Catheters (ID)
• Intermittent Catheterization (IC)
• Suprapubic Catheter (SC)

26. No Catheter
• Incomplete SCI
• Requires intact sacral micturition reflex
• Voluntary voiding
– Credé and Valsalva
• Involuntary voiding
• Reflex Voiding
Conduct a thorough urodynamic
evaluation to determine whether reflex
voiding is a suitable method for a
particular individual
Small post-void residual volume is must

27. No Catheter - Credé and Valsalva
Consider
• For individuals who have lower motor neuron
injuries with low outlet resistance or who have had a
sphincterotomy
– Bladder is flaccid and there is low outlet resistance
– Silent complications of the upper tract are not uncommon
with this technique and should be routinely monitored
Avoid
• Detrusor sphincter dyssynergia.
• Bladder outlet obstruction.
Consortium for Spinal Cord Medicine: J Spinal Cord Med 2006.

28. Credé and Valsalva
Complications
• Incomplete bladder emptying.
• High intravesical pressure.
• Developing and/or worsening vesicoureteral reflux.
• Developing and/or worsening hydronephrosis.
• Abdominal bruising.
• Hernia, pelvic organ prolapse, or hemorrhoids.
Credé and Valsalva increase bladder pressure but do not
empty the bladder effectively and can lead to complications.
Complications are frequent

29. No Catheter - Reflex Voiding
Consider
• For males who demonstrate post-spinal shock
adequate bladder contractions
• Sufficient hand skills to put on a condom catheter
and empty the bag or have a willing caregiver.
• Poor compliance with fluid restriction.
• Small bladder capacity.
• Ability to maintain a condom catheter in place.

30. Reflex Voiding
Avoid
• Detrusor sphincter dyssynergia
– High voiding pressures (which can cause upper tract
damage)
– Autonomic dysreflexia
• High post-void residuals
• Have incomplete bladder emptying despite
treatment to facilitate voiding
• Develop autonomic dysreflexia despite treatment
to facilitate voiding

31. Reflex Voiding - Complications
• Condom catheter leakage and/or failure.
• Penile skin breakdown from external condom
catheter.
• Urethral fistula.
• Symptomatic UTI.
• Poor bladder emptying.
• High intravesical voiding pressures.
• Autonomic dysreflexia.

32. Condom Catheter – Care and Concerns
• Should be applied securely to avoid leakage and
constriction for 24 hours.
• To avoid skin maceration and breakdown, the glans is
washed daily when the condom is changed, the skin is
aired for 20–30 minutes, and the condom is reapplied.
• Urinary collection bags are cleaned daily with 1:10
solution of bleach to water
• Interference with social/sexual function.
– Urine leakage may occur during sexual activity.
– Use of a regular condom may be an option for
management.

33. Urethral Indwelling Catheters (ID)
• ID is the first choice in acute stage of SCI
• Strict aseptic precautions
– Urinary infection rate 5% to 7% / day
• Continued
– Till hemodynamically stable
– During perioperative period
• Should be removed as early as possible
– Till fit for IC
Continuing ID beyond 2 weeks
requires justification

34. Continuing ID
• Poor hand skills (cervical SCI)
• High fluid intake
• Cognitive impairment or active substance abuse.
• Elevated detrusor pressures managed with anticholinergic
medications or other means
• Lack of success with other methods
• Need for temporary management of vesicoureteral reflux
• Limited assistance from a caregiver
• Women with technical difficulty
• IC not feasible because of urethral abnormality
Consortium for Spinal Cord Medicine: J Spinal Cord Med 2006.

35. Care of ID
• Large size and small balloon volume
• Replace every 2 to 4 weeks
– More frequent if catheter encrustation or bladder stones
• Anchoring the catheter
– Secure the catheter to the abdomen or thigh
– Alternating sides to which the catheter is attached
• Clogged catheters
– Silicone catheter preferred
– 30 mls of Renacidin can be instilled daily for 20–30 minutes
• Irrigation
– Not recommended because irrigation denudes the uroepithelium

36. Care of ID
• Intolerance to inflated catheter balloon
– Anticholinergic medication to reduce autonomic dysreflexia
• Personal care
– Genital area is cleaned daily with mild soap and water
• High fluid intake (> 2000 ml)
– To facilitate mechanical washout
– Decrease solute concentration
– Lessen the likelihood of stone formation
• Cosmesis
– Leg bag is worn during the day and a nighttime collection device is used
overnight
• Interference with social/sexual function
– Need to be removed for intercourse

37. Complications of ID
• Urethral
– Diverticula
– Periurethritis
– Fistula
– Erosion
– Strictures
• Bladder
– UTI and Calculi
• Bed rest
demineralization
• Infection
• Stasis due to catheter
block
• Diverticuli

38. Suprapubic Catheterization (SC)
Consider :
• Immediately following acute SCI if urethral injury is
suspected, especially after pelvic trauma
• Urethral abnormalities
– Stricture
– False passages
– Bladder neck obstruction
– Urethral fistula.
• Urethral discomfort.
• Recurrent urethral catheter obstruction.
Consortium for Spinal Cord Medicine: J Spinal Cord Med 2006.

39. Suprapubic Catheterization (SC)
Consider
• Difficulty with urethral catheter insertion.
• Perineal skin breakdown due to urine leakage
secondary to urethral incompetence.
• Psychological considerations
– Body image or personal preference.
• A desire to improve sexual genital function.
• Prostatitis, urethritis, or epididymoorchitis.
• If bladder capacity is small, with forceful uninhibited
contractions despite treatment.
Consortium for Spinal Cord Medicine: J Spinal Cord Med 2006.

40. Intermittent Catheterization (IC)
• Effective alternative during spinal shock when the
bladder is not contracting
• IC provides complete bladder emptying and offers a
practical means of obtaining a catheter-free state
• Advantages:
– No changes in cosmesis
– No Interference with social/sexual functioning
– Reversibility
• Should be considered for patients with sufficient hand
skills or a willing caregiver to perform IC
• Institute clean IC training prior to discharge
Consortium for Spinal Cord Medicine: J Spinal Cord Med 2006.

41. IC Care
• Hand washing
• Correct technique
• Catheter care
– Cleaned with mild soap and water, air-dried, and
placed in a paper bag
• Fluids restriction to 2 L/ day
• Timing
– Every 4–6 hours so that the amount of urine
obtained with each collection is less than 500 ml

42. Avoid IC
• Inability to catheterize themselves.
– A caregiver who is unwilling to perform catheterization.
• Abnormal urethral anatomy, such as stricture, false passages,
and bladder neck obstruction.
• Bladder capacity less than 200 ml.
• Poor cognition, little motivation, or inability or unwillingness
to adhere to the catheterization time schedule.
• High fluid intake regimen.
• Adverse reaction to passing a catheter into the genital area
multiple times a day.
• Tendency to develop autonomic dysreflexia with bladder
filling despite treatment.

43. Complications of IC
• Urinary tract infections.
• Bladder over-distention.
• Urinary incontinence.
• Urethral trauma with hematuria.
• Urethral false passages.
• Urethral stricture.
• Autonomic dysreflexia.
• Bladder stones.

44. Other Considerations with IC
• Consider anticholinergics if reflux is present
• Investigate and provide treatment for individuals on
IC who leak urine between catheterizations
• Monitor individuals using this method of bladder
management
• If bladder volumes consistently exceed 500 ml
– Adjust fluid intake
– Increase frequency of IC
– Consider alternative bladder management method

45. Recurrent UTI with IC
• Technique and bladder check
• Single-use catheter
• Single-use hydrophilic catheter
– Reduces urethral irritation
– Requires sterile water for injection
• Antibacterial catheter
• Touchless catheter
• Fluids intake
• Timing change
Joseph, AC, et al: Spinal Cord Injury Nursing 1998.

46. Catheterization Techniques –
Current Evidence
No evidence that any of the following strategy is
better than any other for all clinical settings:
• Specific technique (aseptic or clean)
• Catheter type (coated or uncoated)
• Method (single-use or multiple-use)
• Person (self or other)
Moore, et al: Cochrane Database Syst Rev 2007.

47. Red Flags for Referral to Urologist
▶ Haematuria
▶ Renal impairment
▶ Recurrent urinary tract infections
▶ Bladder stones
▶ Pain thought to be arising from the urinary tract
▶ Suspicion of concomitant local pathologies such
as bladder outlet obstruction due to prostate
enlargement in men, stress incontinence in
women
▶ Symptoms refractory to treatment

48. Algorithm for Bladder Management in SCI