Life after spinal cord injury can be challenging in many ways.  Dealing with bladder management issues can be frustrating and cumbersome, but obtaining a better understanding of the physiology of the bladder and effective strategies to minimize risk of bladder complications can provide you with the tools necessary to make your bladder work for you, rather than against you. 

This article is intended to provide you with a basic understanding of how the bladder is designed to function and the types of changes that can be expected to follow spinal cord injury.  Furthermore, it will provide you with tips to minimize bladder complications and provide information to help you maintain a healthy bladder going forward.

Why doesn’t my bladder work normally after spinal cord injury?
The bladder has two essential functions: storing and emptying.  All bladder problems can usually be classified as a malfunction of one of these two phases.  When the bladder is in the storage phase, it should allow for low pressure filling until capacity is reached, at which point it signals the brain that it is time to empty.  The key to an effective storage phase is ‘low pressure.’  The brain is the main facilitator of the storage phase.   It is constantly sending signals via the spinal cord to the bladder to inhibit contraction, which is the beginning of the emptying phase.  One of the primary issues that arises after spinal cord injury is the interruption of this inhibitory pathway, allowing the bladder to enter a reflex mode.  Unfortunately, the evolutionary ‘reflex’ of the bladder is to maintain a state of emptiness, which results in unpredictable bladder contractions and episodes of urinary incontinence.  

At this point, you may be wondering, “Why do I have to catheterize myself if the reflex of the bladder is to empty?”  Well, it is not quite as simple as I have described.  Sometimes the bladder gets its signals crossed, and the opening of the bladder remains closed despite a bladder contraction, which is known as ‘bladder-sphincter dyssnergia.’   This dyssnergia may result in urinary retention and also may eventually lead to the bladder storing urine at higher pressures, putting the kidneys at risk of progressive damage.  Dyssenergia can be viewed as a problem that links both the storage phase and the emptying phase.  Finally, in contrast to the reflexic ‘hypercontractile bladder,’ some spinal cord injuries result in the opposite scenario which is termed an ‘areflexic bladder.’  This result usually occurs with lower levels of injury and usually is characterized by complete retention of urine without major issues with incontinence.  An ‘areflexic bladder’ is generally at much lower risk of higher storage pressures and eventual risk of kidney damage.  A basic understanding of your level of injury and the effects it has on your bladder are important in determining your best bladder management strategy.

What can I do to make my bladder work for me?
After gaining an understanding of why your bladder is functioning differently, the next important question to address is, “What can I do to optimize my bladder function?”  Regular follow-up with a Urologist with experience managing spinal cord injury patients is paramount.  It is generally accepted that a urodynamics test should be performed initially at approximately six months post-injury to best characterize your bladder function.  It may be necessary for you to catheterize your bladder, or depending on the level of your injury, it may be recommended that you are managed with an indwelling catheter (foley or suprapubic).  If any form of catheterization is necessary, you will be at increased risk for bacterial colonization of the bladder and possibly urinary tract infection.  In the grand scheme of things, it is very important to differentiate between the bladder colonization and UTI. 

Nearly 100% of patients that catheterize in some form will have bacteria introduced into their bladder;  however, most of the time this does not result in a symptomatic UTI.  A UTI results from a loss of balance between the colonizing bacteria within the bladder and the bladder’s natural defenses leading to an inflammatory response within the urinary tract.  The inflammatory response is what produces the typical symptoms of UTI, which include worsening urinary incontinence, cloudy urine, pain or burning within the bladder or urethra, blood in the urine and sometimes systemic infection signaled by fever, chills, etc.  Maintenance of the balance can prevent symptomatic UTI and allow for a ‘peaceful coexistence’ between the colonizing bacteria and the bladder.

There are many strategies for maintaining this balance, but one of the most important includes minimizing exposure to multiple antibiotic courses. Antibiotics will effectively eliminate bacteria in the urinary tract, but this often leads to the presence of more resistant bacteria within the bladder that may be more prone to initiate an inflammatory response and develop a symptomatic infection inside the urinary tract.  In order to minimize selection for these more pathologic bacteria, I try to avoid daily prophylactic antibiotics as well.  Rather than use antibiotic prophylaxis, one strategy that we utilize at the Shepherd Center in Atlanta, GA is the use of a daily cranberry extract supplement called ellura.  This supplement has demonstrated efficacy in reducing bladder colonization as well as symptomatic UTIs in spinal cord injury patients in well-conducted randomized, controlled trials.  Essentially, it augments the bladder’s natural defense by blocking the binding of bacteria to the cells that line the bladder.  Additionally, it does not lead to the development of progressively more resistant bacteria within the bladder which minimizes the risk of developing more serious urinary tract infections.

What can I do to keep my bladder healthy in the long run?
Once you and your Urologist have determined the best bladder management strategy for your situation, you should continue to maintain close follow-up as things can change. 

Initially, urodynamics may be recommended to be repeated every one to two years to ensure that your bladder maintains safe storage pressures.  Once you are on a stable regimen, it may be safe to perform urodynamics less frequently.  In this case, ultrasounds of the kidneys and blood tests of your kidney function may be sufficient.  Finally, bladder surveillance with cystoscopy may be recommended every one to two years, especially if you have an indwelling catheter.  Bladder management can be difficult at times, but developing an understanding of the issues at hand and strategies to address them is very attainable by educating yourself and seeking the help of an experienced Urologist. 

Dr. Matthew Sand (M.D.)

Urologist, Shepherd Center

Piedmont Hospital, Atlanta GA