Rural Spinal Cord Injury Project

A collabora t i ve pro j e ct betwe e n :

Prince Henry & Prince of Wales Hospital
R oyal North Shore Hospital
R oyal Rehabilitation Centre Sydney
A u s t ralian Quadriplegic A s s o c i a t i o n
JUNE 2002 Pa raplegic & Quadriplegic Association of NSW

Management of the
Neurogenic Bladder
for adults with spinal cord injuries

Ta rgeting Health Pro f e s s i o n a l s

© Author: Dr James Middleton, Medical Director,

Moorong Spinal Unit, Royal Rehabilitation Centre Sydney

Project funded by the Motor Accidents Authority of NSW

 Functional Anatomy of the
Lower Urinary Tract
The bladder acts as a reservoir normally storing up to 400-500mls of urine under low -
p re s s u re before voluntary voiding occurs at a socially convenient time. Under normal
c i rcumstances, the dynamic phases of bladder filling and emptying involve the bladder
(detrusor muscle) and it’s outlet (bladder neck, proximal ure t h ra and striated muscles of
pelvic floor) acting re c i p ro c a l l y. During storage of urine the bladder neck and prox i m a l
u re t h ra are closed to provide continence with the detrusor re l a xed to allow low pre s s u re
filling, whereas during voiding initial re l a xation of the pelvic floor with opening of the
bladder neck is followed by detrusor contra ction until the bladder is completely emptied.

C o o rdination of mic t u r i t i o n
involves control by two main
c e n t res in t he CNS:

(1) the Pontine Centre i n

the brainstem, which is
responsible for co-ord i n a t e d
a ctivity between the detrusor
and the bladder outlet, and

(2) the S ac ral Centre w h i c h

c o n t rols local re f l exes and
initiates detrusor contra ction.

Spinal cord injury (SCI)

disrupts descending motor
and ascending sensory
p a t h wa ys, pre v e n t i n g
normal control of m i cturition
( i l l u s t rated in Figure 1).

F i g u re 1 Loss of voluntary control of micturition, co-ordinated voiding and bladder

sensation due to the Sacral Reflex Centre being isolated from the higher centres (adapted
f rom DeLisa J.A. Ed., Rehabilitation Medicine: Principles and Pra ctice. J.B. Lippincott Co.,
Philadelphia, 19 8 8 ) .

1
Bladder Impairment following SCI
The different types of bladder impairment caused by damage to the spinal cord are
summarised in Table 1.It is important to remember that different underlying impairments
may lead to a similar outwa rd appearance of bladder dy s f u n ction. For instance, detrusor
h y p e r re f l exia (overa ctivity), poor bladder compliance (with increased resistance to filling)
or b l a d d er n e ck i n s u f f i c i e n cy a ll c a u se s t o rage f a i l u re. S i m i l a r l y, (ie. detrusor- ex t e r n a l
s p h i n cter co-contra ction or dys s y n e rgia {DESD}), a non-contra ctile bladder, myogenic
detrusor insufficiency from chronic overdistension or mechanical outlet obstruction fro m
benign prostatic hyper t rophy or ur e t h ral stric t u re may cause voiding failure
( Wein, 1981).

S u p ra s ac ral (Infrapontine) Bladder

An Upper Mo t o r N e u rone lesion (releasing automatic sacral re f l ex micturition centre
f rom descending inhibition) results in:
• detrusor hyperre f l exia (overa ctivity)
• d e t r u s o r- external sphincter dys s y n e rgia (DESD), referring to inappropriate
c o - c o n t ra ction of the external ure t h ral sphincter (EUS) with voiding detrusor contra ct i o n .

M i xed Neuropathic Bladder (Type A)

A lesion in the conus with damage to detrusor (para sy m p a t h e t i c ) nucleus causes:
• detrusor hypore f l exia (undera ctivity) with external sphincter hyperre f l ex i a
• c h a ra cteristically large volume with overf l ow incontinence

M i xed Neuropathic Bladder (Type B)

A lesion in conus involving pudendal (somatic) nucleus causes:
• detrusor hyperre f l exia with external sphincter hypotonia
• small volume, fre q u e n c y, incontinence

I n f ra s ac ral Bladder
A Lower Motor Neuro n e lesion from conus medullaris and/or cauda equina damage
results in:
• a re f l exia (not atonia) of detrusor (due to post-ganglionic fibres being in bladder wa l l )
and are f l exia with atonia of pelvic floor muscles
• may have isolated increase in bladder neck/internal sphincter resistance (intact T11- L 2
sympathetics)
• n o n - c o n t ra ctile bladder with leakage from overf l ow
(NB. May also be sequelae to re c u r rent bladder overd i s t e n s i o n s )

TABLE 1 - Types of Neuropathic Bladder Impairment

Bladder Management
During the first few weeks after injury, overdistension of the bladder should be avoided by
continuous drainage of the bladder with an indwelling ure t h ral catheter or perc u t a n e o u s
s u p rapubic drainage (eg. "Cystocath "), until after the post-injury diuresis (usually 7- 10
d a ys after injury) has occurred. After this period, intermittent clamping of the catheter or
regular intermittent catheterisation by an attendant may be commenced with appro p r i a t e
fluid re s t r i ction, helping to maintain bladder capacity and compliance.
2
 Assessment includes a baseline intravenous pyelogram and urine specimen for culture and
sensititivies. Urodynamic assessment (cystometry/anal sphincter EMG or x- ray video-
c ys t o g raphy) is performed several months after injury following passage of spinal shock
and return of spinal re f l exes to classify bladder type.2

Goals for bladder manag e m e n t i n c l u d e :

• p ro t e cting upper urinary tra cts from sustained high filling pre s s u res (ie. > 40cm wa t e r )
• minimising post-voiding residual volumes to less than 100mls (ideally < 5 0 m l s )
• p reventing urinary tra ct infect i o n s
• avoiding bladder overd i s t e n s i o n
• maintaining continence
• choosing a technique which is compatible with person’s lifestyle

Choice of d ef i n i t i ve bladder manag e m e n t will be determined by the follow i n g

f a ct o r s :
• type of bladder impairment (Table 1): level and extent of neurological lesion is
based on clinical examination (including perianal sensation, anal tone/re f l ex, bulbo-
cavernosus re f l ex) and urodynamic testing (Watanabe, Rivas, Chancellor, 1996).
(NB. It may be difficult to assess bladder and sphincter behaviour on the basis of
n e u rologic exam alone; in addition, urodynamic parameters are valuable for pre d i ct i n g
development of renal complications).
• f u n ctional ability : p a rticularly mobility, sitting balance and hand function.
• status of upper urinary tract s .
• p a t i e n t ’s cognitive ability, motivation and lifesty l e .

In both male and female patients with paraplegia or males with tetraplegia and sufficient
hand function, clean intermittent self-catheterisation (CISC) every 4-6 hours is the
p ref e r red method, with anti-cholinergic medication such as oxybutynin hydr o c h l o r i d e
(5mg tds) or propantheline bromide (15-30mg tds or qid) to relax the detrusor and pre v e n t
incontinence between catheters. Other factors important for self-catheterisation, apart fro m
we l l - c o n t rolled detrusor act i v i t y, include good bladder capacity, adequate bladder outlet
resistance, absence of ure t h ral sensitivity to pain with catheterisation and patient
motivation.

In males with tetraplegia and insufficient hand dexterity to perform CISC, drainage by
re f l ex voiding with suprapubic tapping, using an external urinary collection device such as
a uridome, or by indwelling ure t h ral or suprapubic catheter is possible. Other methods such
as Valsalva or Crede manoeuvre (pressing over the bladder) may exa c e r b a t e
haemorrhoids and vesico-ureteric reflux and are no longer re c o m m e n d e d .

Female patients with tetraplegia, due to greater difficulty with CISC and lack of a
s a t i s f a ctory external collecting device generally use either a suprapubic or an indwe l l i n g
u re t h ral catheter.

Methods of possible bladder management for individuals with different impairments are
summarised in Table 2.

3
TABLE 2 - Bladder Management versus Neuro l o g i c a l Le v e l

Paraplegic (male/female) and Tetraplegic C6 level & below (male)

• Clean intermittent self-catheterisation
• Anti-cholinergic medication
• Fluid restriction (approx. 1.8-2 litres/day)
• Regular fluid intake/catheterisation schedule

Tetraplegic (female/male above C6 level)

• Permanent suprapubic catheter (indwelling urethral catheter discouraged)
• Anti-cholinergic medication
• Intermittent catheter clamping with Staubli/Flip-flow valve may be useful

Tetraplegic Male
• Voiding by reflex (and tapping) wearing uridome
± cholinergic medications (short-term only) and alpha blockers (long-term)
± sphincterotomy/urethral wall stent
NB. Check residuals (less than100 mls) and monitor upper tracts diligently

If employing bladder training to achieve balanced re f l ex voiding, use of short-t e r m

c h o l i n e rgic medication such as bethanecol (10-20mg tds) to enhance detrusor tone
with an alpha adre n e rgic blocker such as phenoxybenzamine (10- 20mg bd) to re d u c e
internal sphincter spasm and/or a muscle re l a xant such as Baclofen (10-25mg qid) or
Diazepam (2.5-5mg bd or tds) is frequently re q u i red. In addition, a sphinct e rotomy or
u re t h ral wall stent may also be re q u i red to help manage detrusor- external sphinct e r
d ys s y n e rgia (DESD). Common clinical presentations of DESD include high residuals and
re c u r rent urinary tra ct infections, greater amounts of percussion (suprapubic tapping)
re q u i red, autonomic dys re f l exia (with sweating on voiding), increased spasticity and
p o s t u re - related difficulty in voiding. Late complications include vesico-ureteric re f l u x ,
h y d ro n e p h rosis, pyelonephritis and deterioration of renal function. Often
h y d ro n e p h rosis is asymptomatic until well advanced in this patient gro u p .

A n t i s e p t i c medications, such as Hiprex (dissociating to hippuric acid and

methenamine) in combination with vitamin C for urinary acidification or Cranberry juice
tablets, which in addition appear to inhibit bacterial adhesion, are often pre s c r i b e d
p a rticularly in patients using re f l ex emptying or CISC. Anecdotally, altering urinary pH
regularly between acidification and alkalinisation may prove helpful when above
s t rategies have failed to prevent re c u r rent urinary tra ct infection. A low-dose antibiotic
medication may be prescribed when other measures have proven unsuccessful.
H owe v e r, prophylaxis with a low-dose antibiotic is only recommended in those patients
suffering fre q u e n t, disabling urinary tra ct infections due to an increased risk of
developing resistant bacteria. The most important advice for patients with permanent
catheters is to ensure a high fluid intake and urinary output is maintained. Whereas for
patients who void by re f l ex or ex p ression, the most critical factor in reducing infec t i o n
risk is to minimise the residual volume of urine left behind in the bladder after voiding
( Table 3).

4
 TABLE 3 - P rophylaxis for urinary tra ct infect i o n

• Unless CISC, maintain high fluid intake (approx. 3-3.5 litre s / d a y )

• E n s u re residual urine volumes less than 100mls (pre f e rably < 50mls)
• Urinary antiseptics (scientific evidence currently lacking)
H i p rex ± Vitamin C (max 2gm/day)
C ranberry Juice tablets (which may be combined with Hiprex )
H i p rex and/or Cranberry alternating with Ural fort n i g h t l y
• Low-dose antibiotic (eg. Trimethoprim, Ke f l ex or Macro d a n t i n )

Treatment of Bladder Dysfunction

Bladder dy s f u n ction can be classified into either a failure to store urine (incontinence) or
f a i l u re to effectively void and empty the bladder. As previously mentioned, differe n t
underlying causes may be responsible for the same manifest symptom/s of bladder
d ys f u n ction and re q u i re quite different pharmacological or surgical treatment (Table 4).

TABLE 4 - Causes of Bladder Dys f u n ction and Possible Treatment Options

Ma n agement of Storage Fa i l u re
Detrusor Hyperre f l ex i a
• o ral anticholinergic medications (oxybutynin, pro p a n t h e l i n e )
• i n t ravesical anticholinergics (oxybutynin, atro p i n e )
• i n t ravesical desensitisation (capsaicin)
• denervation (nerve blocks using tra n svesical phenol, botulinum tox i n )
• s a c ral deafferentation (surgical division of sacral posterior ro o t s )

Low compliance/capacity
• a n t i c h o l i n e rgic medications
• bladder augmentation surgery (clam ileocys t o p l a s t y, myomect o m y )

Bladder neck/sphincter insufficiency

• alpha agonist (ephedrine, imipra m i n e )
• p e r i u re t h ral injection of macroplastique
• a rtificial sphincter (inflatable cuff) device

Ma n agement of Voiding Fa i l u re
Detrusor insufficiency
• c h o l i n e rgic medications (bethanecol, distigmine bro m i d e )

Ac o n t ra ctile bladder
• CISC, IDC or SPC
NB. Straining should be discouraged due to complications such as stre s s
incontinence, haemorrhoids and re ctal pro l a p s e

Outlet obstruct i o n
• alpha adre n e rgic antagonist (phenoxybenzamine, prazosin)
• spasmolytic agents (baclofen, diazepam; botulinum toxin inject i o n )
• local anaesthetic (xylocaine gel per ure t h ra)
• s p h i n ct e ro t o m y / u re t h ral wall stent
• p ro s t a t e ct o m y / u re t h rotomy (for mechanical causes such as benign pro s t a t i c
h y p e rt rophy or ure t h ral strict u re )
5
 Urinary tra ct infection should alwa ys be excluded whenever new bladder symptoms arise,
p a rticularly incontinence in a re f l ex bladder, although an infection may also cause failure
to void due to DSD. Drinking and voiding schedules should be re v i ewed along with post-
voiding residual urine volumes. Cessation of fluid intake after 6pm may help to pre v e n t
urinary incontinence overnight in those performing CISC.

R e v i ew of medications is recommended. It is not uncommon for patients to reduce or even

cease prescribed anti-cholinergic medication after discharge when experiencing side
e f f e cts, such as a dry mouth or constipation. As a consequence, bladder compliance and
capacity may decrease overtime. Unwanted side effects from other commonly pre s c r i b e d
medications may occur; for instance, urinary retention and autonomic dys re f l exia in a
male voiding by re f l ex can be precipitated by Amitriptyline, prescribed for pain
management. Depending on the desired effect, alpha adre n e rgic agonist or antagonist
medications may be prescribed to increase or decrease bladder neck tone (Table 5).

TABLE 5 – Commonly prescribed medications for urinary dys f u n ct i o n

Ac t i on ( I n d i c a t i o n ) Drug Name Usual Dosag e Side Eff e cts & Pre c a u t i o n s

D e c re a se detrusor O xy b u t y n in H C l 5 mg t . d . s. a . c . D ry m o u t h, b l u r red vision,

a ct i v i ty ( a n t i c h o l i n e rg i c
medication used t o
s u p p re ss bladder
o v e ra ct i v i ty and
prevent incontinen c e )
( D i t ropan)
P ro p a n t h e l i ne B r
( P ro b a n t h i n e )
To l t e ro d i n e
( R e s t r i cted access)
d row s i n e s s, c o n f u sion,
nausea, vomiting,
15 - 3 0 mg q . i . d . constipation, re s t l essness,
u r i n a ry re t e n t i on and
d e c re a s ed swe a t i ng (causing
1- 2 mg b . d . body tempera t u re to rise).
. C a re must be t a ken to
a v o id overheating during
exe rcise or hot weather.
Caution with operating
m a c h i n e ry or driving.

I n c re a se detrusor act i v i ty
(cholinergic medication
used for 6-8 wee ks o n ly t o
increase smooth muscle
tone and s t re n g t h en
bladder c o n t ra ct i o n s )
B e t h a n e c h ol C l
( U re c h o l i n e, U ro c a r b )
10 - 2 0 mg t . d . s A b d o m i n al c ra m p s,
d i a r r h o e a, n a u s ea and
belching, flushing, sweating.
Not to be used in asthmatics
or p e r s on w i th I H D.

D e c re a se bladder outflow P h e n oxy b e n z a m i n e 10-20mg b.d. Po s t u ral hypotension and

resistance (alpha-adre n e rg i c H Cl ( D i b e n y l i n e ) d i z z i n e s s, d row s i ness,
antagonist to rela x fatigue, nasal congestion,
bladder neck) P ra z o s in H C l 0.5-2mg b.d. b l u r red vision, inhibition of
( M i n i p re s s ) (or re t ro g rade) ejaculation.

I n c re a se bladder outflow I m i p ra m i ne H C l 10-25mg t.d.s Dry mouth, blurred vision,

resistance (alpha-adre n e rg i c (Tofranil) confusion, nausea, vomiting,
and mild anti-cho l i n e rg i c abdominal cra m ps.
a ct i o n )

Urinary antiseptic ( t o H i p rex ( H exa m i n e 1g b.d. Nausea, stomach upset, rash,

p re v e nt urinary t ra ct infect i o n ) h i p p u ra t e ) stomatitis.

C ranberry 1 t a b l et b . d . No significant known side

e f f e ct s .
6
 Symptomatic Urinary Tract Infection
Urinary tra ct infection (UTI) is the most common complication suffered by the majority of
individuals with spinal cord injury. Symptoms of UTI in the general population include:
f e v e r, dysuria, fre q u e n c y, urg e n c y, voiding of small volumes, abrupt onset, supr a - p u b i c
pain, and loin pain (Stamm, 19 91). In spinal injured patients, unless the lesion is very
incomplete, symptoms may be altered or absent. Relevant symptoms should be
u n explained by other inter- c u r rent pathology and include: fever, autonomic dy s re f l ex i a ,
i n c reased frequency of muscle spasms or spasticity, failure of usual control of urinary
incontinence and new abdominal discomfort (NIDRRS 19 9 2 ) .

Treatment should be based on a urine specimen, culture and sensitivity. Colonisation and
asymptomatic bacteriuria is common in populations with permanent catheters in situ,
p a rticularly with low-pathogenic organisms like Pseudomonas aeruginosa or mixe d
g rowth. Unnecessary or over-t reatment using single antibiotics should be avoided as this
may result in development of antibiotic resistant strains over time. Criteria to help guide
clinical decision making appear in Table 6. Note: to avoid contamination, urine specimen
should be taken at a fresh catheter change.

TABLE 6 - Criteria for diagnosing symptomatic urinary tra ct infect i o n

Suggested by findings on microscopy WCC > 100 OR Leukocyte esterase of +++ to ++++
on urology dipstick (with culture confirming pure growth of organism)
AND
One “Category 1” Symptom OR Two “Category 2” Symptoms:

"Category 1" Symptoms:

• Temperature:
Greater than 38°C core
(37.5°C per axilla)
• New or increasing symptoms of Autonomic Dysreflexia, as detected by any of the
following signs:
Pulse < 50 or increased flushing or sweating or headache AND
increased Systolic or Diastolic Blood Pressure > 25% above baseline.

OR
“Category 2” Symptoms:
• Increased frequency of muscle spasms or spasticity
• Failure of usual control of urinary incontinence (including increased bladder spasm,
leaking around catheter sites)
• New abdominal discomfort unexplained by other pathology

* Modified by Dr B Lee (RNSH Spinal Unit) and Dr G Kotsiou (RNSH Microbiology Department) from the 1992 National
Institute on Disability and Rehabilitation Research Statement on symptomatic urinary tra ct infections in the spinal cord
i n j u red.

If symptomatic UTIs become re c u r rent despite adequate tre a t m e n t, patient hygiene and
catheterisation techniques should be re v i ewed. Other investigations such as a
b l a d d e r / renal ultrasound or cystoscopy may be re q u i red to exclude other sources of
re c u r rent infection, such as calculi, bladder diverticulum or catheter cystitis (if permanent
7 catheter in situ).
Urinary tra ct calculi are a common complication that should be suspected when difficulty
clearing or re c u r rent urinary tra ct infections with the same or different org a n i s m s ,
p a rticularly urea-splitting Proteus. These will re q u i re removal by lithopaxy, lithotripsy or
ra rely open methods.

Long Term Management

Regular monitoring of upper renal tra cts by ultrasound or intravenous pyelogram is
recommended, particularly in individuals using re f l ex voiding/ex p ression techniques to
monitor for early signs of hydro u re t e r / h y d ro n e p h rosis. Imaging should be performed on
a yearly basis in persons voiding by re f l ex, but may only be re q u i red every 2-3 years in
those using CISC or a permanent catheter, unless indicated more frequently because of a
p revious abnormal study.

Early signs suggestive of possible hydro n e p h rosis should be followed up early (Staskin,
19 91). It must be re m e m b e red that the classical symptom of flank pain will be absent with
a lesion above about the T6 level. This may result in a delayed and non-specific
p resentation, including feeling unwell, abdominal discomfort, increased spasms, swe a t i n g
and autonomic dys re f l exia. Other possible complications which may occur include re n a l
and/or bladder calculi, epididymo-orchitis, ure t h ral fistulae, false passages and strict u re s .
Patients managed long-term by permanent indwelling or suprapubic catheterisation to
d rain the bladder are exposed to 5-fold greater risk of developing bladder cancer than
those managed by intermittent catheterisation or condom drainage, with onset re p o rt e d
on average 20 years, but as early as 12 years, post injury (Groah, We i t z e n ka m p ,
La m m e rtse, Whiteneck, Lezotte, Hamman, 2002). The increased incidence of bladder
cancer in this group wa r rants regular screening by cys t o s c o p y, particularly 20 years or
m o re after injury. Tests and investigations that may prove helpful for the diagnosis and
management of various complications are listed in Table 7.

TABLE 7 - Useful urinary tests and investigations

Specialised investigations include cystometry to

• Serum creatinine
• Urine culture/sensitivities
• Residual urine volumes
• Plain abdominal (KUB) x-ray
• Renal/bladder ultrasound scan
• Intravenous pyelogram
• Isotope renogram
• Cystometrogram
• Cystourethogram
• Video-urodynamics
p resence of vesico-ureteric reflux, bladder neck opening, DESD, and ure t h ral strict u re .
assess sensation of fullness, bladder
compliance, capacity and detrusor pre s s u re s
(NB. low compliance is a significant risk fac t o r
for development of upper tra ct complications)
and video-urodynamics to identify pro b l e m s
such as DESD or reflux by fluoroscopy during
voiding. A filling and voiding cys t o u re t h ro g ra m
(with or without tapping) can provide useful
information when video-urodynamics is not
readily available to assess bladder
c o n f i g u ration, trabeculation and divert i c u l u m ,

8
 Notes:

9
Notes:

10
Reading
G roah SL, We i t z e n kamp DA, La m m e rtse DP, Whiteneck GG, Lezotte DC, Hamman RF. Excess risk of bladder cancer in
spinal cord injury: Evidence for an association between indwelling catheter use and bladder cancer. Arch Phys Med
Rehabil 2002; 83: 346-351

National Institute on Disability and Rehabilitation Research Statement. The prevention and management of urinary tra ct
i n f e ctions amongst people with spinal cord injuries. Journal of American Pa raplegia Society 1992; 15(3):194-204.

Stamm WE. Catheter-associated urinary tra ct infections: epidemiology, pathogenesis, and prevention. American Journal
of Medicine 19 91; 91((3 B)):(Pp 65S-71 S ) .

Staskin DR. Hydro u re t e ro n e p h rosis after spinal cord injury: Effects of lower urinary tra ct dys f u n ction on upper tra ct
a n a t o m y. Urol Clin North Am 19 91; 18(2), 309-316 .

Watanabe T, Rivas DA, Chancellor MB. Urodynamics of spinal cord injury. Urol Clin North Am 1996; 23(3), 459-473 .

Wein AJ. Classification of neurogenic bladder dys f u n ction. J Urol 19 81; 125, 605-609.

contributors
Dr Stella Engel
(Clinical Pro g ram Dire ct o r, Rehabilitation & Spinal Medicine,
The Prince Henry & Prince of Wales Hospitals)

Dr Sue Rutkowski
( D i re ct o r, Spinal Cord Injuries Unit, Royal North Shore Hospital)

acknowledgements
Dr Jane Watt (LMO, Armidale)
Vivienne Van Dissel (CNC, Southern Area Health Services)

rural spinal cord injury project

P ro j e ct Officer:
Nickie Flamboura s
PO Box 63 Auburn 2144 Tel: (02) 9637 9069

Designed by Guy Domenici Mobile: 0415 380 210