Spinal cord injury at any level can affect bladder control and cause urinary problems. The nerves that control the bladder and urine output are located at the lowest levels of the spinal cord, S2-S4. Therefore, spinal cord paralysis at any level leads to the disconnection of these levels from the brain. Bladder problems and urinary problems due to nerve damage are called “ neurogenic bladder ”. Normal urinary retention and voiding functions may not be restored after spinal cord stroke, but several techniques are available to manage the process. With the right medical care and treatment, negativities related to urinary problems can be minimized.
How Does the Bladder Work?
The urine formed in the kidneys fills the bladder with tubes called ureters (one for each kidney, two in total). Urine flow in the ureters is normally unidirectional; from the kidneys to the bladder. The bladder collects urine. As the bladder fills up to a certain volume, it expands, so the pressure inside does not increase. When the bladder is full, the pressure and the tension in its wall increase, these feelings are transmitted to the brain via nerve fibers and spinal cord, and a feeling of compression occurs.
With the control of the brain, voiding can be delayed as much as the bladder capacity. When ready to urinate, signals from the brain are transmitted to the bladder via the spinal cord and nerve fibers. While the detrusor muscle, which forms the bladder wall, contracts, the sphincter muscle surrounding the bladder outlet urethra relaxes. Thus, urine exits the urethra and is excreted from the body. As can be seen, the storage and evacuation of urine occurs by coordinated contraction and relaxation of the muscles in the bladder body and urethra neck.
After a spinal cord injury, communication between the brain and the bladder is broken. Because the brain cannot control it, both the detrusor and sphincter muscles can become overactive. An overactive detrusor can contract against an overactive sphincter even though there is little urine in the bladder. In this case, problems such as high pressure in the bladder, urinary incontinence, incomplete emptying of the bladder, reflux (backflow of urine into the kidneys) occur. As a result, frequent urinary tract infections, bladder or kidney stones, enlargement of the kidney ducts (hydronephrosis), kidney infection (pyelonephritis), and even kidney failure may develop.
There are roughly two types of neurogenic bladder: spastic (reflex) bladder and flaccid (non-reflex) bladder.
When the bladder is filled with urine, its emptying is triggered by an unpredictable reflex. This is generally seen in injuries above T12 level. In spastic bladder, the person does not know when the bladder will empty.
In spastic bladder, doctors may recommend bladder relaxant anticholinergic drugs. These drugs can cause various side effects, especially dry mouth. Intra-bladder Botulinum toxin A injection can relax the detrusor muscle without causing side effects in the body.
Flask (non-reflex) Bladder
Since there is no bladder reflex, the bladder can accumulate excess urine and overstretch. Stretching can affect muscle tone in the bladder. In addition, urine may not be completely emptied.
In treatment, drugs that relax the bladder neck (alpha blockers) can be used. Injection of Botulinum toxin A into the external urethral sphincter may facilitate bladder emptying. The surgical method called sphincterotomy is another treatment option.
Dyssynergia is the inability of the sphincter muscles (outlet) to relax when the bladder body contracts. Since urine cannot exit the urethra, it can escape to the kidneys, causing serious problems.
Urinary Problems Treatment
Clean intermittent catheterization is the most common method for people with spinal cord paralysis to urinate . In this method, the bladder is emptied by following a certain program (every 4-6 hours) with disposable catheters and urinary problems are tried to be solved.
Another option is the continuous presence of the probe. Long-term use of the permanent (Foley) catheter is not preferred due to its negative effects such as susceptibility to infection and reduction in bladder volume.
It is called suprapubic catheterization when the urine output is carried out through an opening (stoma) in the bladder around the groin by bypassing the urethra.
Condom catheter or condom catheter is another type of permanent catheter that can be used in men.
Permanent probes make it necessary to carry a collector bag. There is also a greater risk of infection. However, it does not require fluid restriction.
Various surgical techniques can be recommended for bladder management of spinal cord paralyzed patients. Surgical enlargement of the bladder, creation of a new bladder outlet using an appendix (Mitrofanoff procedure) are some of them.
People who complain of urinary incontinence during coughing and sneezing can compensate this situation with appropriate clothes and pads. Kegel exercises can increase urinary control by strengthening the groin muscles.
Urinary Tract Infections
Until the 1950s, the most common cause of death for people with spinal cord paralysis was urinary tract infections. The use of a permanent catheter makes it easier for bacteria to reach the bladder. In addition, the incomplete emptying of the bladder provides an environment for the growth of bacteria.
Cloudy-looking, foul-smelling urine, fever, chills, nausea, headache, increased contractions and autonomic dysreflexia are the main signs and symptoms of urinary tract infection. Antibiotic treatment is given when there are complaints.
To prevent infections, it is necessary to pay attention to hygiene. Cranberry juice has been shown to make it harder for bacteria to grow in the bladder. Medical check-up should be done at least once a year. In the control, urinalysis, kidney scintigraphy or ultrasonography are performed to evaluate kidney functions. There is an increased risk of bladder cancer in people who use long-term catheters. Smoking is another important risk factor for bladder cancer.