Introduction:

Urinary tract refers to the system that is concerned with formation storage and excretion of urine. It consists of two kidneys that lie at the back of upper part of abdomen, one on each side. Urine formed in the kidneys is drained by two hollow tubular structures, called the ureters into the bladder.

Bladder is a hollow muscular bag that lies in the lower part of abdomen. Bladder serves to hold urine till it is full and then contracts to empty itself through another hollow tube called urethra, to the outside. A muscular valve, called the sphincter, located in the urethra, keeps the urethra closed & opens when a person wishes to pass urine.

How does the bladder function?

Urine is stored in the bladder. As the bladder becomes full this information is passed via your spinal cord centers to your brain. If you wish to empty your bladder, then the bladder muscle contracts to empty the bladder.

Normally the desire can be modified. One can suppress the desire to pass urine until an appropriate time or place is available. Usually, the bladder empties completely leaving behind insignificant residue. Presence of large volume of urine at the end of voiding happens either because of weak muscles or some obstruction along the outlet.

After a spinal cord injury the nerves are no longer in communication with the brain. The bladder continues to fill, but the spinal injured person no longer is aware of the sensation of a full bladder. He/she no longer has the ability to control the bladder. In the first few weeks after injury, bladder will normally be emptied every few hours through a fine tube or catheter.

How does urinary system be affected by the SCI?

Depending upon the type and level of your injury, some functions of the bladder will be affected either temporarily or permanently. Some of the common changes that you may observe are:

• Lack of sensation of

• bladder fullness and/or
• bladder fullness recognized by excessive sweating, flushing, tremors, headache.

• Inability to judge urine leakage that occurs without one’s knowledge
• Inability to control passage of urine
• Inability to pass urine at all or fully.

Depending upon neurological status, each person will observe either one or various combinations of above mentioned symptoms. Neurological recovery takes a long time and this period may vary from few weeks to months to years. Therefore, the final behavior pattern of bladder function will also take time to emerge.

Immediately after SCI, the spinal is in a shock phase. During this phase, there is complete inactivity of the bladder and its muscles are not capable of contraction. Therefore, the bladder will continue to store large volumes of urine, becoming over distended. This state of over distention is detrimental for eventual bladder muscle recovery and imparts over stretching and thinning of its muscle. Over distension is prevented by an indwelling catheter placed in the bladder to keep it empty. This catheter is passed via the urethra and connected to a collection bag. Between 2-4 weeks when the spinal shock begins to wear, the indwelling catheter is removed and you will start doing intermittent catheterization scheduled every 4-6 hours

How level of injury affect your Bladder Management Programme?

Generally there are two ways the bladder works after a spinal cord injury.

• Spastic or Reflex Bladder means that when your bladder fills with urine, a reflex automatically triggers the bladder to empty. The problem in a reflex bladder is you do not know when the bladder will empty. Reflex or spastic bladder usually occurs when the injury is above the T12 level. The choice of bladder management methods for an individual with a spastic/reflex bladder include intermittent catheterisation, indwelling catheter and condom drainage.
• Flaccid or non-reflex bladder means ones reflexes may be sluggish or absent. You may not feel when the bladder is full. It then becomes over distended and stretched. This can cause the urine to back-up through the ureters to the kidneys. Individuals with injuries below T12/L1 usually have a flaccid bladder. The bladder management system most commonly used is intermittent catheterisation. To avoid problem do not allow more than 400 cc of urine to fill in your bladder.

What is a Bladder Management Programme?

A bladder management programme allows you to plan for bladder emptying in an acceptable manner when it is convenient for you. This helps you to avoid accidents and prevent infections. Your level and type of injury will affect the choice you and your doctor make for your bladder programme. Because each person’s injury is different, your doctor will probably conduct some tests to see how your bladder functions. You also need to consider your hand function. How easy is it for you to do your own bladder programme? Can you manage alone or will you need help? During your rehabilitation you learn different ways to empty your bladder. The methods most frequently used are intermittent catheterisation; indwelling catheter; and the Condom external catheter for male. You may use just one programme or a combination of methods. You will decide the method that works best for you.

How can I prevent leaking when I have to go out for more than 6 hours?

You can prevent leaking and have a pleasant outing by regulating your water intake. Maintaining a voiding diary may help you plan. A voiding diary is a statement of water intake Vs urine output in relation to time. By analyzing the diary, one can find out that by regulating the water intake at these times, one can reduce my urine output at specified times to be comfortable.

Indication of Bladder Fullness

• Restlessness
• Perspiration
• Chills Headache
• Flushing or paling
• heavy feeling in the lower abdomen.

Urine Drainage Collection

• Lag Bags
• Bed Bags
• Urinals

METHODS OF VOIDING THE BLADDER

1. Bladder training

This training is possible for many spinal cord injured persons. Methods used for bladder stimulation:

• Tapping the suprapubic area of the bladder
• Stroking the inside of the thighs or perineum
• Stretching rectum with a finger
• Pulling on pubic hairs
• Tapping and pushing into the outer bladder wall (flaccid bladder)

2. Condom drainage system
There are many different types of male urinary sheaths available. They provide a convenient unrestricted drainage once connected to leg bag or bed bag. This sheath or external catheter mainly falls in two categories

• A condom identical to the contraceptive variety can be used together with a length of tubing and an adapter or "stud'. The condom is secured at the stud with the help of sticking plaster or any other method. Glue is either sprayed or brushed on the shaft of the penis and the condom is then rolled down and trimly pressed in place. It can also be secured there by putting a Velcro band or a piece of bandage and sticking plaster. The other end of the tube is then connected to a suitable urine collecting bag.
• External catheters or sheath especially made for this purpose are getting popular though they cost little extra. May be out of question for lower middle class and those spinal injured persons living in remote rural areas. These purpose made sheaths have an integral outlet tube and are designed to resist twisting, and generally come with their own fixative as a double sided adhesive strip. Some are also deigned with an adhesive coating on the condom itself

3.Indwelling Catheter - An indwelling catheter is used sometimes by those men who cannot manage with a condom because of limited hand movements. It is mostly used by those who cannot empty their bladder for medical reasons and thus can avoid kidney damage and other bladder complications. Foley type catheter is normally used
4.Intermittent SeIf-Catheterisation - This technique successfully prevents the bladder becoming abnormally distended and also avoids the problem of high residual urine and it's inherent dangers. It is sufficient to follow a clean procedure then sterile one. This is because any bug that is introduced should not be able to get a hold as the bladder is being efficiently emptied at regular intervals and unlike an indwelling catheter, there is no permanent channel open for infection to occur.
5.Surgical Intervention
The main surgical options available are

• Supra- pubic catheter - It is an indwelling catheter inserted into the bladder bypassing the urethra, through a small surgical incision made just above the pubic area. It is sometimes used for newly injured but mostly by people especially women for whom other methods have failed.
• illeal conduit - the procedure involves diverting the flow of urine from the kidneys through the abdominal wall via the ileum (small intestine) in the supra-pubic area.
• Sacral Anterior Root Stimulator (Bladder Implant) - The Platinum electrodes of the device are implanted through an operation on the spinal nerves in the sacrum which control bladder function. These electrodes are connected by cables to a silicone rubber covered passive radio receiver implanted beneath the skin of the lower chest wall. To empty the bladder- a radio transmitter is held over the receiver and switched on. Within a few second's urine flow commence and the procedure is repeated until the bladder is empty. The bladder should be emptied every four to five hours.

Some disadvantages of this method are

• Some people find that the implant has increased their spasm
• The need to carry a radio transmitter when traveling
• checking whether the transmitter is always charged.
• Loss of reflex bowel evacuation with suppositories may occur
• Major lengthy operation

COMPLICATION OF BLADDER MANAGEMENT
1.Urinary Infection
symptoms indicating urinary infection

• General feeling of being unwell, exertion, nausea etc.
• Cloudy urine with strong odor.
• Blood in the urine, giving pink or dark red colour
• Only being able to pass small amount of urine thus increase in residual urine
• Increase in spasticity in the legs
• Difficulty in passing urine
• High temperature
• Throbbing headache at the time of passing urine
• |Shivering and sweating
• Urine leakage between routine bladder emptying times
• May have pain in the lower abdomen.

Steps to Prevent Urinary Infection

• Drink adequate fluids - 2-3 liter per day.
• Empty bladder regularly after every 3-4 hours.
• Ensure high standards of Cleanliness of all urinal equipment

Treatment for Infection

• Maintain good fluid intake
• Empty bladder more frequently
• If one has high temperature or feel nauseated, stay in bed and contact doctor
• Obtain a clean urine specimen and get the routine examination and also culture if required.
• Antibiotics may have to be used but as per the doctors advice on prescription

Autonomic Dysreflexia
People with Spinal cord injury above the T6 level can suffer from a sudden upsurge in blood pressure and it could be life threatening. It is a medical emergency as it could lead to fits, a cerebral hemorrhage (stroke) and death. It is caused by pain, irritation or over stimulation in a paralyzed part of the body. The body's normal reflex is to constrict blood vessels and speed up the heart beat, but because of the spinal cord injury control mechanism do not operate and blood pressure rises. It is important that you empty your bladder immediately.
Symptoms

• Reduced urine output
• Pounding headache
• Goose pimples
• Profuse sweating
• Flushed and blotchy skin on the face and upper trunk
• High blood pressure
• Lower abdomen becomes distended
• Spasm become more severe

Causes

• Over fall bladder
• Urinary tract infection
• Bladder stones
• Constipation, wind, an anal fissure
• Ingrown toenails
• Burns or Scalds
• A pressure sore
• Ejaculation during sexual intercourse
• Menstrual cramps
• Labor pain

Treatment

• Make the effected person sit up
• If symptoms persist, give drug to lower the blood pressure.

Removing the cause - Bladder

• Tap the bladder very gently to allow urine to pass
• Check indwelling catheter check for blockage or kinked tubing
• If there is no catheter, catheterise immediately

Removing the cause - Bowel

• Check for distended swollen bowel
• Put some Lignocaine gel into the rectum and remove stool gently after 15 minutes

2.Stone (Calculi) Formation
Obstruction of urine flow^ and infection . Most of the signs and symptoms of calculus formation are similar to urinary infection. Difficulty in passing urine, bloods in the urine and recurring bladder infections is symptomatic enough to consult a doctor as surgery is necessary to remove stones. Can also be removed by SWL.
Prevention

• Drink adequate fluid, 2-3 litres per day
• Restrict intake of foods containing Calcium such as milk and cheese
• Limit the use of indwelling catheter
• Stand daily if possible for allowing adequate urine drainage