Bladder Course Script

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Section 1 – Knowing your (new) body

1.1 – Knowing Your (New) Body

Everyone needs to pay attention to their bodies and monitor their health.   After a change like a spinal cord injury, it becomes especially important to listen to what our bodies are telling us.

We need to pay special attention to certain body parts or systems, like the urinary system, in order to keep them running well.  Things that previously seemed simple, like going to the bathroom, can become more complicated.

In addition, with an SCI, our knowledge of what’s happening in our bodies, including our ability to feel certain sensations like pain, can become altered.

This course will help you get the information you need to understand your urinary system and keep it healthy.

1.2 – How the Urinary System Works           

The function of the kidneys is to filter the blood and remove excess water and waste materials, turning them into urine.  From the kidneys, the urine flows down small tubes called ureters into the bladder.

The bladder is a sac lined with muscle that stores urine until it can be expelled from the body.  At the exit from the bladder, a circular outlet muscle called the sphincter acts as a gate; when the muscle contracts, it tightens and prevents urine from flowing; when the sphincter relaxes, it allows urine to flow out through the urethra.

Normally, the process of urination requires coordination between different sets of nerves and muscles.  First, sensory messages tell your brain that your bladder is full.  Then, when you want to urinate, you can open the sphincter and allow the muscle lining the bladder wall to contract, squeezing the urine out of the bladder.  This muscle is called the detrusor.

1.3 – Neurogenic Bladder

A spinal cord injury can disrupt the coordination between brain and bladder that makes it possible to urinate.

The detrusor muscle that lines the bladder wall and the sphincter muscle that closes the exit from the bladder can both fail to operate normally. In addition, you may not sense when your bladder is full.

When the functioning of your urinary system is affected by spinal cord injury, this condition is called neurogenic bladder.

Everyone’s situation is different and requires individual evaluation and management, but there are two basic kinds of problems people tend to experience:

-a higher-level spinal cord injury may result in detrusor or sphincter muscles that are too tight and spastic; in this case, urine may be forced out of the bladder, causing an involuntary loss of urine, known as leaking or incontinence; the urine can also be forced back up the ureters to the kidneys, causing kidney damage.  This type of neurogenic bladder is called a reflex or spastic bladder.

-a lower-level injury may result in a  loose, floppy bladder; in this case, the detrusor may fail to contract and the bladder will become too full.  However, in this case the outlet sphincter may also fail to work, and urine can leak out for example when you strain to cough or sneeze.  This type of neurogenic bladder is called a flaccid bladder.

1.4 – Rehab and Adapting

After a spinal cord injury, it takes time to learn all about your new body and how to care for it.

During the time you spend in rehab, as well as once you’re back at home, you’ll have a chance to learn all the things you need to know.  Your rehab team will help you develop the best solutions for you.

The best bladder management method for you depends on a number of factors, including your injury level, the type of bladder you have, your personal situation, your lifestyle and your preferences, so make sure you tell your health care providers about your needs and views.

Although many things will seem very new and may be confusing at first, with time you’ll learn to master the different routines that are part of a healthy life.

With practice, adaptation and trial and error, you’ll learn how to make things faster and easier so that you can lead an independent life.

1.5 – Your Bladder Program

Depending on your level of injury, there will be different methods to empty their bladder and keep your urinary system healthy.  You’ll work with your health care team to develop, monitor and change your bladder program or bladder routine.

The foundation of any bladder program is proper hydration, which means drinking as much water as your body needs.  Without sufficient hydration, you’re much more likely to suffer complications and damage to your urinary system. The recommended amount of water to keep your body hydrated is about eight cups or two litres of water a day.  It’s important to keep a steady flow of fluid going through the urinary system, to flush out bacteria.

Some people use medications as part of their bladder program, often to relax the detrusor muscle and prevent it from having spasms that could squeeze urine out and cause incontinence.

Your bladder program may change over time, in response to changes in your body and your lifestyle.  It’s important to work closely with your health care team to monitor your urinary health with regular testing, so you can detect any problems or signs of damage and take action before it’s too late.

 

Section 2 – Healthy Habits

2.1 – Healthy habits

Healthy habits are the foundation of a healthy life.  Good patterns of sleep, nutrition, exercise and activity allow us to give our bodies the resources they need and help us avoid sickness.

After a spinal cord injury, you need to take special care to build good habits. You may learn new ways of emptying your bladder and it’s important to develop good habits of hygiene and proper technique.  Drinking enough water and getting enough sleep and regular exercise are other habits you may need to work on.

Over time, you’ll find that you can develop your skills and use information to build these healthy habits. As you encounter problems or obstacles, you’ll need to seek out more information and you may need to get help.  Working with others, including health care professionals, is another important habits.  As you work on your habits, be patient, and remember, the little things you do every day can add up to a big difference over time.  Paying attention to the details of your daily habits can have a big pay-off.

2.2 – Emptying your bladder

There are different methods of emptying your bladder to keep your urinary system healthy following a spinal cord injury.  The method you use depends on the needs of your urinary system and other circumstances like your ability to perform your own self-care or to get assistance.

One option is intermittent catheterization, often called simply IC.  This involves inserting a catheter into the bladder on a regular schedule to empty the urine.  It is important to use good technique and proper cleanliness when you IC, in order to reduce the risk of infections.

Another option for men is to use an external urinary collection system.  This is a condom connected with a tube to a leg bag, called a condom catheter.  You will need to use the correct size condom catheter, use good technique and proper cleanliness when using your condom catheter in order to reduce the risk of skin breakdown, infections and other complications.

Finally, both men and women can use an indwelling catheter, sometimes called a Foley catheter.  In this case, the catheter stays in the bladder and continually drains into a collection bag. Since this method has the most long-term complications, your health care team will only use this as a last resort when other methods have failed.

Your health care team will explain how often your catheter needs to be changed, how to clean your catheter, tubing and drainage bag, as well as how to inspect it and make sure it is not damaged.

2.2a – Step-by-step: Intermittent Catheterization (Female)

Step 1: Prepare supplies & position yourself. Begin by preparing the materials you will need, like the catheter, lubricant, and a container to catch the urine.  Assemble the supplies so you can reach them easily. Get into the position that is best for you; either sitting in a wheelchair or a toilet, or sitting up in bed with your legs spread.  You may want to use a mirror to help you see your genital area better.

Step 2: Wash hands & clean vulva. Wash your hands thoroughly with soap and water. Clean the vulva and the urinary opening with soap and water.  Make sure you separate the labia and wipe from front to back.

Step 3: Open catheter & apply lubricant. Open the catheter package and expose one end of the catheter.  Be careful not to let it touch any surrounding items or surfaces.  Apply lubricant to the first 5 centimeters of the catheter.

Step 4: Insert catheter. Locate the urinary opening, below the clitoris and above the vagina.  You may find it helpful to spread the labia with your second and fourth fingers, while using your middle finger to feel for the opening.  Gently insert the lubricated tip of the catheter into the urinary opening. Push the catheter in slowly, without forcing, and guiding it upward, toward the belly button.  You should reach the bladder once you’ve inserted about 10 cm.

Step 5: Drain urine. When urine begins to flow through the catheter, continue inserting it for another 2 cm.  Hold it in place until the flow stops and the bladder is empty.  As you remove the catheter, stop every centimetre or so at first, so you can make sure your bladder is totally empty.

Step 6: Clean up. Clean your genital area, making sure to wipe from front to back.  If you reuse your catheter, wash it with warm soapy water, dry it and store it.  Otherwise, dispose of the catheter, packaging and any other garbage.

2.2b – Step-by-step: Intermittent Catheterization (Male)

Step 1: Prepare supplies & position yourself. Begin by preparing the materials you will need, like the catheter, lubricant, and a container to catch the urine.  Assemble the supplies so you can reach them easily. Get into the position that is best for you; either sitting in a wheelchair or on a toilet, or sitting up in bed with your legs spread.

Step 2: Wash hands & clean penis. Wash your hands thoroughly with soap and water. Clean the tip of the penis with soap and water.  Begin at the tip and wipe toward the base.

Step 3: Open catheter & apply lubricant. Open the catheter package and expose one end of the catheter.  Be careful not to let it touch any surrounding items or surfaces.  Apply lubricant to the first 10 to 15 centimeters of the catheter.

Step 4: Insert catheter. Gently insert the lubricated tip of the catheter into the urethra, the opening at the end of the penis.  Push the catheter in slowly, without forcing.  The catheter may become hard to push just before it enters the bladder. If this happens, try relaxing, deep breathing or coughing, and continue inserting the catheter once the resistance goes away.  You should reach the bladder once you’ve inserted about 20 to 25 cm.

Step 5: Drain urine. When urine begins to flow through the catheter, continue inserting it for another 2 cm.  Hold it in place until the flow stops and the bladder is empty.  As you remove the catheter, stop every centimetre or so at first, so you can make sure your bladder is totally empty.

Step 6: Clean up. Wipe any excess lubricant off your penis.  If you reuse your catheter, wash it with warm soapy water, dry it and store it.  Otherwise, dispose the catheter, packaging and any other garbage.

2.3 – Medications           

Medications are an important part of staying healthy for many people.  Medications can relieve symptoms, prevent further problems and replace substances the body naturally produces.  Some people use medications as part of their bladder program, often to relax the bladder’s detrusor muscle and prevent it from having spasms that could squeeze the urine out, causing incontinence.

In addition to the desired effect, medications can also have side effects, which need to be considered and managed.  Some bladder medications may cause dryness of the mouth.  You’ll find it helps if you drink lots of fluids. Water is the best choice since there may be a lot of sugar, salt, or caffeine in other drinks.

A different medication may cause less dryness in the mouth, so talk to your health care provider if you’re having problems with dryness, and you may be able to try a different medication.

Medications can interact either with each other or with things you eat and drink. Some can cause allergic reactions in some people.  Be sure to tell your health care team if you have an allergy to any medication.

For all these reasons, it’s very important to work with your health care team to manage your medications.  Let them know about all your medications and dosages including any herbal preparations, vitamins or over the counter medications.  And make sure that you know about all your medications including the dose you are on as well as the times you take them. Use your medications as prescribed and make sure you report any problems.

Over time, you will adapt your bladder program to changes in your body and your lifestyle, and as you learn more, you will become more skilled in your self-care. From time to time you may encounter problems with your bladder program. Leaks and incontinence, UTIs and other problems could have a major impact on your daily life.  When you’re having a problem, and you’re not sure what to do, the best option is to use this problem-solving approach to tackle it.

2.4 – Directing Your Care

Many people with a spinal cord injury use the assistance of attendants or others to help them with their self-care. If you use assistance with your self-care activities, you need to develop your ability to direct your own care.

Make sure you can explain to somebody the basics about your injury and how your body works. Be clear and detailed when you give instructions, and be patient if there are any misunderstandings. But, don’t be shy and don’t neglect your own needs. It can be tricky to use help with very personal and private self-care activities, especially at first. But with practice and attentiveness, you should be able to develop the right balance of assertiveness and respect.

2.5 – Problem solving

Over time, you will adapt your bowel program to changes in your body and your lifestyle, and as you learn more, you will become more skilled in your self-care.

From time to time, you may encounter problems with your bladder program.  Leaks and incontinence, UTIs and other problems can have a major impact on your daily life.

When you’re having a problem and you’re not sure what to do, the best option is to use this problem-solving approach to tackle it:

Step 1: Identify the problem.  Start by getting a clear picture of what’s wrong.  If you’re having problems with urinary tract infections, pay attention to when they happen and what seems to cause them.

Step 2: Gather information.  Try to get a better understanding of what may be causing your problem, and some different ways you might try to solve it.  This may involve doing research or consulting health care providers.  You may also find it helpful to speak with peers, people who have had similar experiences.  Make sure you evaluate the reliability of the information you find, and try not to rely on information from only one source.

Step 3: List possible solutions. Based on the information you find, list some things you might try. To deal with recurring UTIs, you might want to drink more water, take cranberry supplements, and pay special attention to hygiene.

Step 4: Try one & evaluate the results.  Using your list of solutions, choose the one that seems best and give it a try.  It’s important to make only one change at a time so you can tell whether it works or not.  Make sure you keep track of what you do and what the results are.   If you solve the problem, that’s great!  If not, you may want to go back to step 3 and choose another option.  Problem-solving can involve lots of trial and error.

Step 5: Know when to ask for help. Don’t try to take everything on by yourself.   You can ask your health care team for information and help with your problem-solving, as your needs change over time.

 

Section 3 – Prevention

3.1 – Prevention

A daily routine built on healthy habits is the key.

To keep your urinary system healthy over time, build your daily routine built on healthy habits.

Start with the basics:

1. Drink enough liquid throughout the day—remember, you need about 2 litres of water;

2. Eat a healthy diet— with lots of fresh fruits and vegetables;

3. Keep an active lifestyle—every body system, including the urinary system, works better when you get regular exercise and activity.

Hygiene is another important part of preventing urinary tract infections and other complications.  Make sure to use proper technique when draining your bladder, and keep your equipment and supplies clean.

If you want to prevent urinary tract infections, you may also find it helpful to take cranberry supplements or drink unsweetened cranberry juice, NOT cranberry cocktail, which has a lot of added sugar.

The final key to prevention is knowledge.  By knowing what to look for, you can catch warning signs early on and treat potential problems before they get serious.

3.2 – Autonomic Dysreflexia (AD)

Autonomic Dysreflexia is a serious medical condition that can affect people with spinal cord injury, particularly above the T6 level.   You should be aware of the symptoms of autonomic dysreflexia and know what to do about it, especially if you have an injury above T6.

Autonomic Dysreflexia is caused by a harmful or unpleasant stimulus, such as a bladder or bowel that needs to be emptied, or a pressure sore.  Different people experience different symptoms, and you may notice a variety of signs including goose bumps, flushing, unusual sweating and a sudden, painful headache.

In every case, though, Autonomic Dysreflexia is accompanied by a sudden spike in blood pressure.

It’s very important to find out what stimulus is causing the dysreflexia and relieve it.  If you find yourself experiencing these symptoms, you should begin by checking whether you need to drain your bladder or empty your bowel, and inspecting your skin for signs of pressure sores.

If you’re not able to resolve the issue and end the episode of autonomic dysreflexia, you should seek medical help immediately.

3.3 – Complications

People with spinal cord injury need to be aware of possible secondary complications so they can take steps to prevent them.  There are two common problems that affect the urinary system of a person with spinal cord injury: urinary tract infections, and urinary stones.

Urinary tract infections, known as UTIs, are bacterial infections of the bladder, and in some more serious cases, the kidneys. Signs that you may have a UTI can vary; typically they include things like:

-urine that is foul-smelling, cloudy with sediment, or dark with blood;

-pain, discomfort or autonomic dysreflexia;

-fever, chills or fatigue; and

-increased spasms.

Over time you may come to recognize patterns of symptoms that are typical for you. When you know the signs of a urinary tract infection, you should contact your healthcare team. They will help you with advice and treatment – often involving an antibiotic.  Make sure you follow their advice carefully, and take all your medication.  If you have problems with repeated UTIs over time, this may indicate a problem with your bladder program.

Urinary stones are another potential secondary complication.  Signs of urinary stones include pain in the abdomen or lower back, nausea, recurring UTIs, fever and chills, and blood in the urine.  Your health care provider can help determine whether you have urinary stones and how to treat them.

3.4-Follow-up and Testing

Taking care of your urinary health is a life-long priority for people with a spinal cord injury.  Make sure you have regular follow-up appointments with a urologist to evaluate your health and monitor your bladder program.

Your health care team will schedule routine tests to check your kidneys and bladder every year or two.  Usually, these tests will include urodynamics, a procedure that shows how your urinary system works as your bladder fills up.  Your healthcare team may also want to see pictures of your urinary system: they can look at the kidneys using ultrasound, and examine the bladder by inserting a small probe with a camera.

These procedures are an important way to prevent health problems, so make sure you keep these appointments. Even if you feel well, signs of damage to the kidneys are minimal, and the damage can only be found with regular testing.

3.5 – PARTnerships

Your health care team is your partner in living a healthy life.

Your relationships with your rehab team, family health team, urologist, and other health care professionals can support you with the advice and information you need.

If you want to get the most out of your appointments with your health care professionals, here are a few tips that you can use to take part in your health care.  PART stands for prepare, ask, repeat, and take action.

First, prepare for appointments by keeping track of problems and issues you want to discuss.  You may want to make a list and give the list to your health care provider at the beginning of the appointment.  For instance, if you are noticing symptoms of urinary tract infections or problems with your bladder routine, write down what is going on and make a list of problems, symptoms, or questions.

Make a note of what is happening: when, for how long, and what makes it better or worse.  You should also make sure your health care has a full and up-to-date list of all the medications you take.

Next, during your appointment make sure you ask any questions you have about what your health care provider is telling you.  If what they are saying is not clear, let them know.

You will also find it helpful to repeat back the information you receive, to make sure there are no misunderstandings.   This is especially important with information you need to act on.

Finally, take action.  Follow the guidance you receive, and take note of any problems so you can tell your health care provider about them.

 Back to course page

Course contents
Section 1 – Knowing your (new) body
1.1-Knowing your (new) body
1.2-How the urinary system works
1.3-Neurogenic bladder
1.4-Rehab and adapting
1.5-Your bladder program

Section 2 – Healthy Habits
2.1-Healthy habits
2.2-Emptying your bladder
2.3-Medications
2.4-Directing your care
2.6-Problem-solving

Section 3 – Prevention
3.1-Prevention
3.2-Autonomic dysreflexia (AD)
3.3-Complications
3.4-Urinary stones
3.5-Follow-up and testing
3.6-PARTnerships