The bladder forms part of the urinary system, it includes your kidneys, ureters and the urethra.

How does the bladder work?

The bladder is a muscular bag which stores urine until it is convenient to be emptied. When the bladder is full your nerves send a message via the spinal cord to the brain, and when you come to pass urine the brain sends messages down the spinal cord to the muscles of the bladder wall to contract, and to the ring-like muscle called the sphincter which then opens for the bladder to release the urine, which passes down the urethra via the penis (male) or the vulva (female).  

With spinal cord injury (SCI) these messages no longer pass between the bladder muscle and the brain, which results in leakage and/or urine retention.

The ageing bladder

The ageing bladder loses its muscle tone and the lining becomes thinner, and because the bladder may no longer empty completely there is an increased risk of developing urinary tract infections (UTI’s). The ability of the ageing bladder to store urine is reduced so you may have to adjust your routine to more frequent emptying, or change to a different bladder management system.

Bladder management

There is more than one way to manage your bladder and the method you choose is most likely to be influenced by your level of injury; keep in mind that over time the method that best suits you could change.

Correct bladder management is very important to your health and independence. If your method of bladder management is not working properly it can disrupt your working life, affect your social life and increase the risk of Autonomic Dysreflexia (AD).

Types of Bladder Management 

Indwelling urethral catheters

In this type of bladder management, a catheter is inserted through the urethra and kept permanently in place by a small balloon on the end inside the bladder.  Once the catheter has been inserted, the balloon is inflated with sterile water so that it expands to hold the catheter in place. This method is normally used for short periods of time.

Disadvantages include:

• sediment and small calcium granules can build up and cause blockages
• you may need to perform  regular bladder washouts
• catheters need to be changed every 4-6 weeks and this will require your carer or healthcare professional to perform this function
• you may have to increase your daily intake of fluid to help prevent infection and build-up of sediment
• there is a higher risk of infection
• a major risk is that the catheter may be pulled out accidentally, causing damage to the bladder neck and urethra. Taping the catheter to the leg should help to prevent this. 

It is best to avoid long term use of indwelling urethral catheters as it can increase the risk of urethral enlargement, chronic bladder infection and bladder stones; but if you have become frail and unable to cope with self-catheterisation, it may be the best method for you.

Intermittent Self Catheterisation

You can learn to self-catheterise if you have sufficient dexterity in your hands. If you have a flaccid bladder this method may be the best choice for you, but equally, if you have a reflex bladder that has good capacity to hold urine you can use this method successfully.  

The aim of intermittent self-catheterisation is to empty the bladder completely at regular intervals and to achieve continence without the need to wear an appliance.

Advantages:

• you can usually carry out intermittent self-catheterisation on the bed, on the toilet or in your wheelchair
• you are less likely to get an infection if you change your own catheter

Disadvantages:

• you need access to a toilet or a private space
• privacy may be a problem when travelling or being away from home

Suprapubic catheters

A suprapubic catheter is an indwelling catheter inserted into the bladder via a small surgical incision made just above the pubic area, therefore bypassing the urethra. The incision is not permanent and starts to close up within 24 hours if the catheter is permanently removed. The catheter used is similar to that used for indwelling use, and It should be changed every 4-6 weeks or at the advice of your healthcare professional.

If you have a flaccid bladder but no longer have the manual dexterity to carry out intermittent self-catheterisation, you may consider changing to this method.

This method of bladder management carries a similar risk of infection, blockage and stone formation as the indwelling urethral catheter. If the catheter becomes blocked, urine may drain via the urethra and you may not realise you are sitting in wet clothing.

Bladder washouts will help to remove a build-up of deposits that can ultimately form bladder stones. It is important to drink plenty of fluids to keep the urine as dilute as possible.

It is important to keep the area around the catheter clean and dry, as sometimes oozing occurs around the catheter site. A dry gauze dressing can be used but it will need changing daily.

You can change the catheter whilst sitting in your wheelchair or you may prefer a healthcare professional to carry out the procedure for you.

The supra pubic catheter should be taped to the lower abdomen and connected to a leg bag, by doing this there is less risk of the tube becoming kinked or being sat on.

This method can improve the quality of life for those ageing with a SCI.

Eating and drinking for a healthy bladder

Everyday food and drink can affect the pH balance of your urine (acidic versus alkaline balance). Ideally, urine should be slightly acidic to help prevent infections and the formation of stones, both in the kidneys and in the bladder. 

Eating citrus fruit and drinking juices such as cranberry can help to keep urine acid, but commercial juices often contain large amounts of sugar so you need to restrict the quantity you consume.

Some research demonstrates that chemicals found in cranberry juice alters the activity of certain bacteria by preventing them sticking to the lining of the bladder, but there is much doubt as to the overall effectiveness of this as a treatment for UTI and the jury is still out. 

Urine

Urine is normally straw coloured, if there is any change in its colour or if there is an unpleasant odour or the presence of blood you should seek advice immediately. Additionally, if you have sensation and experience unusual pain, you need to report all these things to your doctor.

Complications in the ageing bladder

Urinary Tract Infections

Urinary tract infections are a major cause of illness in SCI and urinary tract complications remain a substantial cause of re-admission to hospital. They not only cause unpleasant symptoms, which often require treatment with antibiotics, but increase the risk of complications if not treated promptly and correctly. Time spent recovering from a UTI can greatly interfere with your daily routines.

Leakage

Leakage can be caused by many things including:

• the ageing bladder
• a urinary tract infection
• bladder spasms

Untreated leakage can eventually result in skin damage, making you susceptible to a pressure ulcer and infection.

Reflux of urine

Reflux is when urine flows back up to the kidneys, which can cause infection to spread and result in permanent damage to them.

Reflux of urine is one of the main reasons to change your bladder management routine.

If you suffer from reflux of urine you may experience a swollen abdomen, feelings of nausea and raised blood pressure. UTI’s can also increase the risk of reflux.

Having a regular urological check-up will reveal conditions such as reflux of urine.

If you are diagnosed with reflux of urine it is important not to overfill/overstretch the bladder, and ensure that the bladder is emptied properly.

Bladder stones:

Stones or calculi can develop in both the bladder and kidneys. To help prevent stone formation: 

• drink sufficient fluids 
• keep your urine slightly acidic 
• exercise and/or stand regularly

Having a regular check-up of your bladder and kidneys should give an early indication of stone formation.

Bladder cancer

You should report any unusual signs or symptoms such as passing blood in the urine or pain as soon as possible. 

Other complications to be aware of:

Prostate enlargement:

If the prostate gland becomes enlarged it can result in the restricted flow of urine, which will increase the risk of a UTI and cause difficulty with catheterisation.

You may need to think about changing your bladder routine

What worked well for you 10 years ago may not work so well now and any change in lifestyle might require a change in your bladder regime. 

Considerations you may need to think about when changing your bladder management: 

• what type of regime is acceptable to both you and your carer(s)
• is your bladder type reflex or flaccid? – this will influence your options
• have you developed any complications or conditions recently which are likely to aggravate existing problems, such as bladder stones or Autonomic Dysreflexia?
• availability of products
• what professional support is available?

Top tips

• keeping a daily bladder diary if problems occur will help you and your doctor to understand what is happening, and to decide which course of action to take.
• cleanliness is crucial, handwashing (you / your carer) is essential to help avoid infections.
• keep all equipment to be used for bladder management clean and away from dirty areas: the area around a supra-pubic catheter should be kept clean and dry. 
• emptying the bladder properly is important – residual urine can become infected. 
• if you use an indwelling catheter, make sure the balloon is not so big that it prevents the bladder from emptying properly. 
• certain drugs and food can affect the colour and smell of urine.

Altering your bladder regime, like altering your bowel regime, will require the exercise of patience and perseverance; it will take time and you may not get it right first go. Try to change just one thing at a time, this will allow you to observe more easily where any problems arise.