Spinal Cord Injury Information

I sincerely hope the information presented will be useful and help you and yours cope with this devastating injury.

If you do not find a subject shown here, please let me know and I will certainly try to research the information and present it on this website in continuing updates.

SCI INFORMATION, Hygiene

This important section is devoted to hygiene, and includes information and tips on daily and SCI specific hygiene, our skin and how to care for it, how to protect our skin from injury, suggestions for the alleviation and treatment of pressure sores, bladder and bowel programs.

Bladder Program

  Before your spinal cord injury, you probably did not pay much attention to your urinary system because urinating occurred so automatically. During the first few months after injury, you and certain members of the spinal cord injury team will be spending what seems like a great deal of time establishing and managing your bladder program. Eventually, your bladder program will become quick and routine for you.

  The urinary system consists of the kidneys, the ureters, the bladder, and the urethra. (See figures)

Male Urinary System		Female Urinary System

  The primary difference between the male and female urinary systems are the length of the urethra and the absence of the external sphincter in the female. Otherwise, the systems are the same.

  The kidneys remove waste and excess water from your blood stream and process them into urine. The urine then flows down the ureters (which are small tubes) to your bladder. The bladder is a muscular sac that stretches to hold urine until you are ready to void (urinate). When voiding occurs, the bladder (also called the detrusor muscle) contracts and the sphincter (which is a circular muscle acting as a gate) opens. Urine then passes through the urethra and you urinate.

  Urination is due to a finely balanced coordination of bladder and sphincter muscles. This coordination involves both voluntary and involuntary (or automatic) control by the nervous system. When the bladder becomes full, messages are sent to the sacral level of the spinal cord. Messages are then sent to your brain to let you know that your bladder is full. At that time, you can decide to either urinate or hold the urine. This is the part under voluntary control. If you want to void, the brain will send messages (nerve impulses) back to the urinary system. The involuntary part involves the opening of the sphincter muscle, and bladder muscle contraction.

  Nerve impulses from the bladder can no longer get to and from the brain to let you sense that your bladder is full or to let you void. There are two general kinds of bladder dysfunction that can occur depending on your level of injury. Because there can be individual variations, you will probably have some tests to diagnose your particular bladder type. These are described in the next section.

  Upper Motor Neuron Bladder (Reflex or Spastic Bladder): In this condition, the bladder tends to hold smaller volumes of urine than before SCI. Just like your other muscles may have spasms and contract on their own, so can the bladder muscle. The result is that you may have frequent, small urinations. This bladder type is common in most spinal cord injuries above the sacral level.

  Lower motor neuron bladder (flaccid bladder): In this condition, the bladder muscle has lost its ability to contract and can be easily stretched. Therefore, large volumes of urine can be held by the bladder. Because the muscle cannot contract, urine leaves the bladder when it is over-distended (overfilled). The urine "spills over" like a glass that is too full of water. This bladder type is common when SCI affects the sacral level of the cord (cauda equina injuries).

  There are a number of tests that can evaluate the structure nd function of the urinary system. Because they are all commonly done, the tests are described here to prepare you in advance. You may have one or several of them.

  Intravenous Pyelo gram (IVP): An IVP is performed by injecting dye containing iodine into a vein, This is excreted by the kidneys and shows up on X-ray. This X-ray will show the size, shape, and working order of the kidney, ureters, and bladder.

  Important note — if you have ever had an allergic reaction to IVP dye, be sure to tell your physician.

  Your bowel needs to be empty for this test, so do a good bowel program the evening before or the morning of the test. You may also have to refrain from eating and drinking the night before the test. The nursing staff will let you know if other preparation is necessary.

  Renal Scan: The purpose of a renal scan is to assess the function and the blood supply of the kidneys. It is done by injecting a radioactive substance into a vein and then "reading" counts over the kidneys. The amount of radioactivity is extremely low.

  Ultrasound: This test is useful in identifying tumors. cysts, and stones in the urinary tract. It also is used to measure the prostate, testicles, and other organs in the abdomen.

  In an ultrasound, sound waves (like sonar) are bounced off tissue surfaces, and an electronic picture is produced on a screen. Variations in the color of the image can detail the structures or anatomy and thus define problems.

  Cystourethrogram: This is also called a cystogram and is another X-ray study that shows the size and shape of the bladder. Dye is inserted through a catheter into the bladder, and this shows up on X-ray. Among other things, this test shows if unne moves backward through the system from the bladder up to the kidneys. This condition is called reflux. Reflux is due to excess pressure in the bladder. This is one cause of kidney damage and needs to be detected early.

  Cystometrogram: A cystometrogram (CMG) shows how your bladder reacts when it is filled with either carbon dioxide (C0₂) or water. This mimics the way it would usually react when filled with urine. A catheter is inserted for this test. A CMG helps determine if you have a UMN or LMN bladder type. The amount of pressure that builds in your bladder will also be measured by this test.

  Urodynamics: A urodynamics evaluation consists of a series of studies that provide information about the mechanics of voiding.

  Tests that may be part of this urodynamics evaluation include a cystometrogram, a study of urine flow, a study of urethral pressures, and your response to medication that can affect voiding.

  These tests also give information on sphincter activity and urethral pressures, during bladder filling and emptying. This aids in planning the best bladder management program for you.

  Cystoscopy: Cystoscopy involves the urologist looking at the inside of your urethra and bladder through a lighted, hollow, specialized catheter inserted through the urethra. This is used in diagnosing problems occurring inside the bladder.

  There are a number of tests evaluating the blood and urine that show how your urinary system is functioning:

• Creatinine  clearance: This test involves collecting all of your urine for a 24-hour period. It is an important indicator of kidney function.

• Urine cultures: In this test, a sterile urine specimen is sent to the laboratory to look for bacteria. When a sensitivity is also ordered, specific antibiotics that kill these bacteria can be determined.

• Urinalysis: Urine is analyzed for a number of different chemical and cellular products.

  If you have an incomplete injury, you may in the long run regain all or some voluntary control of your bladder.

  If you have a complete injury, one or a combination of the following bladder emptying techniques will become part of your bladder management program.

  Catheterization: A catheter is a small rubber or plastic tube inserted into the bladder to drain urine, If this is done several times a day, the process is an intermittent catheterization program, or ICP. ICP is generally done by the nursing staff on all people with SCI in the first stages after injury. It may also be continued at home.

  A catheter that is left in the bladder is a Foley catheter, It is often referred to simply as a "foley."

  Another, less common, type of catheter is the suprapubic catheter. This type is placed through the abdomen into the bladder. What type of catheter you use depends on many factors and will be discussed with you by your doctor or nurse.

  Stimulated Voiding: Some bladders can be mechanically stimulated to empty. Just as a spastic muscle may move when tapped or brushed, so may a UMN bladder. This is called "tapping." The tapping is done on your abdomen over your bladder. An LMN bladder may empty with firm pressure over the bladder called crede or during straining or bending forward. 

  Spontaneous Voiding: Some UMN bladder muscles spontaneously contract. For those who have bladders that trigger on their own or who have had a sphincterotomy (surgery to open the bladder "gate"), wearing an external collecting device or condom catheter will keep you dry. There are many different types of catheters, and your SIC team will work with you to find the best method.

  There are a number of basic goals in a bladder program. They are:

• To have low bladder volumes,

• To have low bladder pressures,

• To avoid infections, and

• To keep your skin dry.

  Bladder volumes are kept low by:

• Watching your fluid intake, and

• Routinely emptying your bladder.

  If you are on an intermittant catheterization program (ICP), the amount of urine that collects in your bladder between catheterizations needs to be 500 cc or less. You will be asked to limit your fluid intake to 125 cc (about 4 oz.) per hour while awake. With four to six carefully timed catheterizations throughout the day, your bladder will not get too full. When you drink more than 125 cc per hour or if you do not catheterize yourself on time, you run the risk of exceeding the 500 cc bladder limit.

  Important note — more than 500 cc in your bladder will overstretch (overdistend) your bladder muscle and make you prone to infection or reflux.

  Foley / Suprapubic Catheter: These catheters are always draining urine, so your bladder does not fill at all. In this case, you need to drink as much fluid as you can to flush the normal mineral deposits out of your urinary system.

  Spontaneous/Stimulated Voiding: If you are using these methods of voiding, you will need to carefully balance your fluid intake if you do not wear a condom catheter or if you are a woman. Since a certain volume of urine will trigger a UMN bladder to empty, you may want to know what this volume is so that you can time yourself to get to an accessible bathroom to empty your bladder. By knowing at what volume your bladder will trigger and by watching your fluid intake (usually 125 cc per hour), you may be able to establish a routine time for bladder emptying.

  In some bladders, there is a buildup of very high pressures before the bladder empties. These high pressures can cause urine to "back up" or reflux into the kidneys, causing damage. High pressures can be caused by:

  1. Irritable bladder — (anywhere from 150 cc to 500 cc). Your CMG or urodynamics study will measure and record the pressure and volume of your bladder.

  2. Dyssynergia — This happens when the bladder contracts and the sphincter will not open. It is like trying to press the air out of a mattress with the plug closed. Autonomic dysreflexia can also occur with dyssynergia.

  To keep pressures low, keep your volumes low and treat the dyssynergia. Dyssynergia can be treated by either the use of medication to relax the sphincter or by surgery to open it up.

  Reflux can damage your kidneys without you knowing it. This is a silent problem. Therefore, regular examinations will detect the problem early. If this problem develops, your doctor will recommend a change in bladder management.

  To avoid the possibility of infections you can:

  1. Maintain your consistent fluid intake to "wash out" bacteria and to limit stone formation.

  2. Empty your bladder routinely and prevent overdistension. More than 500cc can weaken your bladder muscle in two ways. First, the muscle cells cannot fight off infection as well. Second, the muscle cannot contrract as tightly and leaves behind a pool of urine in which bacteria can grow.

  3. While in the hospital, make sure you or your nurse uses a sterile technique for your catheterizations. A "clean" technique is O.K. for home but not in the hospital.

  4. Take your bladder medications at the times they are prescribed. These may be recommended to decrease the chance of infections. Some of these antibiotics and some make the urine more acidic. Bacteria are less likely to grow in an acid urine.

  The best way to keep your skin dry is to carefully follow your bladder management program.

• Routinely empty your bladder by the method that works best for you.

• Watch your fluid intake.

• Wear a condom catheter or diaper up.

• Avoid infections. Infections may make your bladder irritable, which can cause frequent incontinence or leakage around foley or suprapubic catheters.

• Change your clothes as soon as they are wet.

  Sometimes, infections cannot be completely avoided even with your best management. People with SCI are at risk for infection because mechanical methods are needed to empty the bladder. Infections are caused by bacterial growth. Three sites of infection common to SCI are the kidney, bladder, and testicles.

  A kidney infection is called pyelonephritis; a bladder infection is called cystitis; and an infection involving your testicles is called epididymitis.

  The following table will help you understand these infections and the diagnostic tests and treatments that may be required.

 Kidney damage and failure is a complex combination of conditions. Basically, it means that your kidneys do not function properly. Infections, stones, or reflux can damage your kidneys. The SCI staff will check your kidney function by blood and urine tests and let you know the results.

  If your SCI is at the sixth thoracic level (T6) or above, you may develop autonomic dysreflexia. It is important that you read the medical section on autonomic dysreflexia. You will need to know the symptoms and how to take care of this condition immediately. This can be a serious problem!

  Urinary stones can develop in the kidney, ureter, or bladder, They are collections of mineral deposits and can develop because of infection, high-calcium levels, or an increase of other chemicals. They usually are small enough to pass through the urinary system and appear in the urine as sediment that looks like sand. If they are large, they may block the urinary system and could damage your kidneys.

  The table below will help you understand urinary stones. Stones may develop without your realizing it, so the SCI staff will probably evaluate your urinary system yearly. Sometimes you may have the following symptoms.