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Bladder management


Spinal cord injury at any level almost always affects your control over your bladder and bowels. This is
because the nerves controlling these internal organs are attached to the very base of the spinal cord
(levels S2 - 4), and then pass down through the cauda equina, the ‘horse’s tail’ below the cord itself.
Although you will not have the same control that you were used to before your injury - a whole range of
techniques exist to help you to ‘manage’ your bladder and bowels.
These techniques include the use of movement, implanted electrodes and/or drugs to stimulate
muscles which no longer respond to your brain; diet and/or drugs to slow down or speed up the way the
body handles fluids and solids; the use of tubes and drainage bags; and re-routing of the body’s
drainage channels.
Each individual is different, but used singly or in combination, appropriate continence aids and
techniques should enable you to re-establish a degree of control over both your bladder and bowels.

How the bladder works
Urine consists of excess water and salts which are extracted from the bloodstream by the kidneys,
which continually control the level of these in the blood. From the kidneys the urine is pumped down
thin tubes called ureters, which normally allow the urine to flow only in one direction. The ureters are
connected to the bladder, a muscular bag in which urine is stored until it is convenient to empty it.
Expansion and contraction of the bladder is controlled by the detrusor muscle. When the bladder is full,
nerves send a message via the spinal cord to the brain. When you decide to urinate, the brain sends a
message down the spinal cord to release the inhibition on the spinal reflex arc. This will allow the
detrusor muscle to contract, and the sphincter muscle around the top of the urethra to relax and open.
Urine then passes down the urethra to exit via your penis or by your vulva.
Reflex activity of the nervous system (where messages are processed within the lower part of the spinal
cord, without having to travel all the way to and from the brain) also controls the bladder muscles - a
baby doesn’t wet itself continually, but only when its bladder is full enough to trigger the reflex to empty
it.

Acontractile & reflex bladders
After injury, the body’s normal system of bladder control no longer works, because messages can no
longer pass between the bladder muscles and the brain. If your injury is T12 or above, you usually have
what is called a reflex (or ‘automatic’ or ‘spastic’ bladder). With an injury below the T12 level you will
usually have an acontractile (or ‘flaccid’) bladder.

Reflex bladder:
reflex bladder allows automatic involuntary control of the bladder so that when the
bladder fills above a certain level it contracts and urine flows out automatically. The reflex can be
triggered by ‘tapping’ (see ‘tapping’). However, a rapid movement, laughter or spasm can trigger bladder
emptying when you don’t expect it
Acontractile bladder: with lower lesions, the reflex arc is also damaged, the bladder has no muscle
tone and doesn’t contract to empty automatically. Instead, it continues to fill and small amounts of urine
may eventually dribble out. The bladder can be emptied at regular intervals by intermittent self-
catheterisation (see below). The final outcome of how your bladder would behave is not solely related to
the level of injury. There may be other factors which will have influence.

After injury


Although there have been huge improvements (in 1917 almost half of all people with spinal cord injury
died of urinary sepsis within two months), urinary tract (and hence kidney) complications are still one of
the main causes of illness and death in spinal cord injured people. So correct bladder management is,
literally, vital.
In the first few weeks after injury, your bladder will commonly need to be emptied regularly through a
fine tube or catheter. This is either inserted every few hours by a nurse through your urethra (the tube
through which you void or ‘pee’) and up into the bladder, and then withdrawn when the bladder is
empty; or a small surgical incision is made just above your pubic area, and a ‘suprapubic’ catheter
inserted directly into your bladder and left in place.
After a few weeks you will be gradually trained to empty your own bladder. The method used depends
on the level of your lesion, your bladder behaviour and whether you are male or female.
Bladder training

Bladder training is a process to teach the individual to manage and to empty their bladder without the
need for an instrument. Bladder training depends on your bladder behaviour. Some bladders would
require training to become reflex bladders and others would need training as contractile bladders. All
methods of bladder management involve a degree of training and routine. In the past some people with
spinal cord injury were taught to regularly transfer onto a toilet and to express or ‘bear down’, to expel
urine, negating the need for catheters or drainage bags. This method of management is no longer
taught at spinal injuries centres as it may result in stress incontinence, and cannot be relied upon as a
sole method of bladder management to achieve continence. It is important that your bladder strength
and capacity is not reduced by allowing your bladder to remain empty (ie. by indwelling catheter on free
drainage). To maintain or increase bladder strength and capacity your bladder is trained to regularly
hold a volume of urine.

Catheter valve

This is placed between the catheter tube and the urinary drainage bag. The valve has a tap which when
turned off stops urine from draining into the bag. Bladder strength and capacity may be improved by
gradually increasing the time that the catheter valve tap is turned off. Some spinal cord injured people
are able to use a catheter valve without a drainage bag, by opening the valve’s tap over a toilet or into a
urinal at regular intervals. Other people use a spigot to stop urinary drainage.
Bathing, swimming, wearing shorts or skirts is not a problem as a ‘spigot’ can be put on the end of the tube [of an indwelling catheter] instead of the leg bag. This effectively stops the bladder draining but it can be opened for drainage straight into a toilet. These spigots work excellently, enabling the tube to be just tucked away in a swimsuit or under clothing. I wished these had been made available to me at the same time I started using the suprapubic catheter, as I feel I would probably have used the leg bag less, and the spigots more. Jean Ginder, T10/11 complete Care should be taken when using a catheter valve or spigot if you easily develop autonomic dysreflexia.
Warning signs of a full bladder

Training also involves learning to recognise the signs that your bladder needs emptying. These will vary
depending on the level of your lesion, but may include backache, abdominal fullness and, in high lesion
paraplegics and tetraplegics, headache, sweating, flushing of the face, neck and shoulders and goose
pimples.

Autonomic dysreflexia


WARNING: In tetraplegics and paraplegics with lesions at T6 or above, an overfull bladder, or a bladder
that is generating high pressure during passing water, are the commonest causes of autonomic
dysreflexia, a sudden and potentially life-threatening surge in blood pressure. It is vital that you know
how to recognise the signs of this and take appropriate action.

Fluid intake
Given the difficulties with continence, it may be tempting to drink less fluid. This is a mistake, especially
if you use an indwelling catheter: you need a good fluid throughput to keep your kidneys clean and
bladder washed out and functioning properly. If you are prone to urinary tract infections, then increase
your fluid intake (preferably to at least 3 litres or 5 pints per 24 hours), make sure your urine is slightly
acid and if necessary take vitamin C (but not the effervescent type) or drink cranberry juice to increase
the acidity. Some people also take urinary antiseptics in conjunction with Vitamin C to maximise its
effects.

Regular emptying

It is essential that your bladder is emptied regularly (preferably every 3–4 hours during waking hours)
and as completely as possible. An overfull bladder may cause urine to reflux or ‘back up’ into your
kidneys and can cause infection and damage. In tetraplegics it can cause autonomic dysreflexia).
Inadequate emptying of the bladder causes sediment and deposits to build up, increasing the likelihood
of infection and bladder stones.
Toilets

Make sure that your toilet at home is well adapted for you: easy to get in and out of, with hand rails in
the right place, a handbasin at a suitable height, a padded toilet seat (important to avoid pressure
sores), a low shelf or work surface and the supplies you require within easy reach. If you are able to use
one, a bidet can be a godsend. Alternatively, there are special combined toilet/bidets. Take care that
the water is not too hot.
Catheters

Intermittent self-catheterisation
This is often the method of choice for people with acontractile bladders, and is commonly used by men
and women with paraplegia. Patients with reflex bladders that have good capacity can also use this
method. Anyone with sufficient hand control can learn to self-catheterise, though dexterity is required to
insert the catheter without damaging the urethra. You are less likely to get an infection if you change
your own catheter than if someone else does it for you.
Both men and women can usually catheterise while in bed, in the wheelchair or on the toilet. The aims
of intermittent self-catheterisation are to empty your bladder completely at regular intervals, and to
achieve continence without the need to wear an appliance. It is important with all catheters not to use
too large a size which can damage your urethra. The main disadvantage is that you need some privacy
or access to a toilet or bathroom, and you may not be able to rely on this when travelling or away from
home.
Care with hygiene is required to avoid bladder infections, but the risk is less than with an indwelling
catheter. It is important to thoroughly cleanse your hands and genital area before passing the catheter.
To insert a catheter, wash your hands and your penis or labia thoroughly with soap and water (if you
have no access to these, baby wipes will do, but should not be used too often as they may cause
soreness). Men insert gel into the urethra, women dip the tip of the catheter into a blob of gel placed on
a clean surface (e.g. a paper towel). Men need to hold the penis up to straighten the urethra. Pass the
catheter gently up into the bladder, pausing if resistance is felt. Once urine begins to flow apply gentle
pressure to the lower abdomen with the flat or heel of your hand and continue until the urine flow stops.
Gradually withdraw the catheter (1-2cm at a time), stop each time urine begins to flow out and wait until
the flow stops before continuing to withdraw the catheter out. Unless you are in the toilet, a plastic bag
or small container is needed to collect the urine.
There are two types of catheters – plain and lubricated. With plain catheters a separate lubricant is
required. A catheter can be reused for up to one week - it should be washed in soap and water, then
rinsed and flicked dry. It should be stored in a container of Milton, and the solution changed daily. While
you are away from home the catheter can be dried and stored in a clean plastic bag.
Lubricated catheters either come packaged in their own solution and are ready for use, or need water
(tap water is fine in the UK) added to the packaging to activate the lubricant (this takes 30 seconds).
After use the catheter is then disposed of, i.e. single use only. Also available are complete sets of
intermittent catheterisation equipment which contain the catheter, lubricant and a collecting bag. These
are particularly useful where toilets are not available or suitable, at work, when abroad or during the
night.
Indwelling urethral catheters
Using an indwelling urethral catheter for long term bladder management is best avoided. Long term use
can cause urethral dilatation, chronic bladder infection, penis splitting and bladder stones. Sediment
and small calcium granules (which grow to form stones) gather around the balloon and can easily block
the catheter. Regular bladder instillations may be recommended, with caution, and you should increase
your daily intake of fluid to 3.5 litres (6 pints).
Many women use one occasionally when travel away from home means that they cannot rely on access
to toilets to self-catheterise. The catheter is inserted through the urethra in the usual way, but kept
permanently in place by a small balloon on the end inside the bladder. Once the catheter has been
inserted, the balloon is inflated with sterile water, and expands to hold the catheter in place.
Indwelling urethral catheters need to be changed regularly, every 4-6 weeks. If you have sufficient hand
control (and not too much spasm) you should be able to change your own. Otherwise your personal
assistant or district nurse will need to do it. Great care needs to be taken to ensure that the catheter
itself and everything used in the changing process are sterile. There is a high risk of infection as an
indwelling catheter leaves the urinary tract permanently ‘open’ for bacteria to enter.
You may be advised to use a catheter valve and to close this for 3–4 hours at a time to ensure that your
bladder fills regularly and doesn’t get ‘lazy’.
To remove: a syringe is inserted into the side entrance of the catheter and the balloon is deflated by
allowing the sterile water to drain into the syringe. This should happen without the need to ‘pull back’ on
the syringe. However, if you have difficulty deflating the balloon, leave the syringe in place for al minute
before applying gentle suction. If this fails, seek help from a doctor or hospital. Never apply force or cut
any part of the catheter.
Indwelling catheter
Male Female

To insert:
1.
place a sterile paper sheet over the abdomen with a hole cut out in the appropriate place.
2. place a sterile swab around the penis or between the labia.
3. thoroughly swab the glands of the penis, or the labia with an antiseptic wash.
4. men insert lubricant gel into the urethra or onto the catheter, and hold the penis up to straighten the

5. women put a blob of lubricant gel on a paper towel and dip in the tip of the catheter just before

6. with a pair of sterile gloves or forceps thread the catheter from its packet into the urethra. Ensure that
it is well into the bladder and the urine flowing.
7. inflate the retaining balloon according to manufacturer’s advice.
8. gently withdraw the catheter until resistance is felt.
9. connect to drainage bag.
Sometimes an indwelling catheter is expelled by spasm, or because of a blockage or stone. Although a
catheter with a larger size bulb is less likely to be expelled, the urethra can be damaged and
permanently enlarged if the larger one is in turn expelled. If you have problems with an indwelling
catheter, you should get advice from your spinal injuries centre. During periods, women may find that at
the time of their menstrual period they tend to ‘leak’ around the catheter
I have experienced difficulties achieving the best position on my leg to enable maximum drainage. A woman’s catheter is no use to me so I use a male catheter because of the longer length. Through my own research following advice from a community nurse experienced in catheter care, I have now managed to obtain the Simpla System, whereas before I was using mixed catheters and different makes of drainage bags. I think it important to mention that tetraplegics, because of low blood pressure, do not drain when in a sitting up position, but when in a recumbent position the urine drains freely, which is normally throughout the night. Suprapubic catheters

A suprapubic catheter is an indwelling catheter inserted into the bladder, bypassing the urethra, via a
small surgical incision made just above the pubic area (see diagram on next page). It is sometimes used
for newly injured people, and it is often used by women with reflex bladders, and people with
acontractile bladders who do not have the manual dexterity to carry out intermittent self catheterisation.
The catheter used is similar to that used for urethral use. It is changed in the same way as an indwelling
urethral catheter. Hydrogel catheters are recommended for suprapubic use. 100% silicone catheters
may be used with caution due to the occasional difficulty that is sometimes experienced on removal.
The catheter should be changed every 4-6 weeks. The catheter should be taped to the lower abdomen
and connected to a leg bag. A suprapubic catheter carries a similar risk of infection, blockage and stone
formation as an indwelling urethral catheter, but protects and frees the private parts for sexual function.
Because of the position of the opening, changing is easier than with a catheter passed through the
urethra, especially for tetraplegics. Another advantage is there is less chance of the catheter tubing
being sat on or kinked, and catheter changes can be carried out whilst sitting in a wheelchair. If the
catheter becomes blocked urine may drain via the urethra, therefore reducing the risk of autonomic
dysreflexia, but makes the patient wet. The incision is not permanent and closes on its own if it is later
decided to manage the bladder by another method.
I changed to the suprapubic catheter at the suggestion of the spinal unit and it is wonderful. I have the
extra degree of independence of being able to change it when I want to and am not at the mercy of
district nurses and continence advisers who are often at odds with the policies taught to you by the
Spinal Unit. I welcomed the change as I had been experiencing problems with the urethral catheter for
some years - I frequently rejected them (balloon still inflated) either due to spasms which had increased
in intensity over the years or because I was passing a bladder stone - a condition I unfortunately
developed during the last 7 years.
Maybe I’ll pass enough to make a necklace! There are still stones with the new-style catheter, but they pass down the urethra without interfering with the catheter, and although I may get a little wet, I am not sitting in great puddles of urine as before. Mrs D., Essex, C8/T1 complete
The insertion of a suprapubic catheter may initially cause an increase in spasm. People with suprapubic
catheters may experience oozing around the catheter site and this should be cleaned each day as part
of your normal bathing routine. A dry gauze dressing may be applied each day.


Suprapubic catheter
Male Female
Bladder installation

Bladder installation should only be used if necessary. If your catheter consistently blocks with
encrustations and requires frequent changing you may benefit from increasing your fluid intake and
washing out your catheter with a solution. Prepacked sterile solutions can be prescribed by your GP.
These vary from Saline solutions to acidic solutions. The frequency of use depends on how often
catheters become blocked. It is advisable not to use acidic solutions more than once a week as they
can irritate the bladder lining. It is best to warm the solution to reduce discomfort and spasm.
Disconnect the catheter from the drainage bag, discard the bag and connect the sterile solution pack to
the catheter. Gently squeeze the bag to push the fluid up into your bladder. Clamp the tube for the
prescribed time (usually 20 minutes or so) and then release it, allowing the fluid to drain out.
Bladder washout

Bladder washout should only be used if necessary. This is similar to a bladder instillation. However
instead of a pre-packed sterile solution, a bladder syringe is used to inject fluid into your bladder. It is
not common practice and advice should be sought from your spinal unit before attempting to carry out a
bladder washout. If you have a urinary infection, care must be taken not to inject too much solution or
too quickly, as this can carry the infection up to the kidneys. If anyone other than yourself performs the
washout for you, they must wear sterile gloves. Use Milton or a similar solution to sterilise equipment. If
you have an active bladder infection, take care not to inject too much solution or too rapidly, as fluid
could carry the infection back up the ureters to the kidneys.
1. pour 300mls of sterile saline into a sterile jug; make sure it is not too hot or too cold.
2. disconnect the catheter from the drainage bag, discard the bag, and put the end of the catheter into

3. wash your hands or put on sterile gloves.
4. draw up 60mls of solution into a syringe. Inject into the bladder via the catheter with gentle but firm
pressure; wait 5 seconds, then withdraw the fluid slowly into the syringe.
5. disconnect the syringe from the catheter; don’t allow the end of the catheter to touch anything.
6. discard the used solution.
7. repeat (see instructions 4 - 6 above) until all the solution is used up.
8. reconnect the catheter to a new sterile drainage bag.
9. check to make sure that the urine begins to flow and no blood is present.
Sheaths and condoms

This form of bladder management may be used by men with reflex bladders. A urinary sheath or
condom is applied to the penis, attached by a plastic tube to a collecting bag which is strapped either to
your leg or belly, or can be hung beside your bed or wheelchair.
There are two main types. Each type is available in different sizes in width and in length to ensure the
best fit. Also available are latex and non-latex hypoallergenic sheaths to reduce skin problems.

Urinary sheaths
are purpose made. They have a tube outlet at the end, are designed to resist twisting
and tearing, and usually come with their own adhesive strip, or an adhesive coating on the inside of the
sheath itself.

Contraceptive - type condoms
(unlubricated), used together with an adapter or ‘stud’ which is placed
inside the rolled-up condom. Scissors are used to make a hole through the condom where the stud
projects, and it is connected to a drainage tube. Special adhesive is brushed or sprayed onto the penis
and the condom rolled down and pressed into place. The tubing is then connected to a collecting bag. A
handy tip to avoid getting adhesive on your pubic hair and scrotum is to fold a tissue in four, cut the
corner and fit it over the penis to make an ‘apron’.
Fit a new sheath or condom daily, and try to give your penis a rest for 2 hours in every 24. During this
time thoroughly wash with soap and water, especially under the foreskin. Your skin may be allergic to
some condom adhesives and you will need to experiment to find one that suits you. Inspect your penis
carefully, and stop using a sheath/condom immediately if there are any signs of a rash, pressure or
broken skin. If skin is particularly sore it may be necessary to have an indwelling urethral catheter for a
short period to allow the skin to heal.
If you are heavy and have a large abdomen which ‘overhangs’ your penis, you may find it difficult or
impossible to fit a sheath/condom and keep it in place. There is no real remedy other than to lose some
weight. Some men might be suitable for the insertion of penile implants to allow a condom sheath to fit
appropriately. A tip: some men use a strategically placed shaving mirror to help them apply the sheath.
Tapping
The reflex to empty the bladder can be triggered by tapping with the side of the hand at the base of the
stomach, just above the pubic area; some people find it helpful to stroke the inside of the thighs or
perineum (the area just in front of your anus), pull on their pubic hairs, or gently stretch the rectum with
a finger. Nowadays it is not routinely recommended that you express the bladder by applying pressure
over the lower abdomen, as it is felt to contribute to stress incontinence and reflux of urine to the
kidneys.
Because of the convenience and reliability of sheath/condom drainage systems, it is easy to forget your
bladder training. Unless you ‘tap’ at regular intervals (every 3-4 hours) to ensure that the bladder is
properly emptied, you will be prone to infections. Also, your bladder muscles will become ‘lazy’ and your
bladder will gradually tend to retain increasing amounts of urine.

Urinals

There are numerous different models, some in plastic, some in stainless steel. Some merely have a
snap-on lid, but others have a no-spill adapter with a rubber sleeve which fits around the penis, and a
non-return valve. Some are disposable. Contact your local Continence Advisor or Spinal Injury Centre
for advice about the best one for you.
Specifics for women

You may find that your bladder becomes much harder to control just before and during your period, and
possibly also around the time of ovulation. Your difficulties may also increase during pregnancy,
especially the later phases.

Drainage bags

Urine drainage bags are connected to a condom or catheter by plastic tubing. Different bags can be
worn on the upper or lower leg, across the stomach, or hung beside a bed or wheelchair. They can be
disposable or reusable. Leg bags, with capacities from 350 to 1,300ml can be attached by straps or by
a stocking-type sleeve. Overnight bags have larger capacities, up to two litres.
Never lift a drainage bag above the level of the bladder, unless you are sure that your system has a
well-functioning non-return valve!
Continence supplies

To help you find out what’s available, we’ve included a list of companies that are frequently used by SIA
members for catheters and continence products.
Astra Tech Ltd, Stroud Water Business Park, Brunel Way, Stonehouse, Gloucester GL10 35W Tel:
01453 791763 Website: www.astratechuk.com

Bard Ltd,
Forest House, Brighton Road, Crawley, West Sussex RH11 9BP
Tel: 01293 527888 Website: www.crbard.com
C.S.Bullen Ltd, 3-7 Moss Street, Liverpool L6 1EY Tel: 0151 207 6995
Coloplast Ltd, Peterborough Business Park, Peterborough PE2 6FX
Tel: 01733 392000 Website: www.coloplast.co.uk
Jade-Euro-Med Ltd, Unit 14, East Hanningfield Industrial Estate, Old Church Road, East Henningfield,
Chelmsford, Essex CM3 8BG Tel: 01245 400413
Manfred Sauer UK, Unit 3 IO Centre, Lodgefarm Industrial Estate, Northamption, NN5 7UW,
Tel: 01604 588090 Website: www.legbags.com
Simple Continence Care: A division of SSL International plc, Toft Hall, Knutsford, Cheshire WA16 9PD
Tel: 0161 654 3000
SIMS Portex Ltd,Colonial Way, Watford, Herts, WD24 4LG. Tel: 01923 246 434
Website: www.smiths-medical.com


Who can help?

● Your spinal injuries unit is your first source of help and advice as they have a vast amount of
experience specifically accumulated with spinal cord injured people • Your GP ● A Continence Advisor or nurse, employed by the local Trust may see you at a clinic or visit you at home, and can usually tell you what equipment and supplies are available and where to get them ● The district (or community) nurse may help you with bladder and bowel care, and arrange supplies for ● Social Services or the Local Authority in some areas run a laundry service for soiled linen and/or disposal service for soiled pads and bed pans. I strongly advocate that the best people to deal with any problems are those linked to the spinal injury centre. Do not be dictated to by district nurses or incontinence advisers who are usually governed by the local health authority rules and not by what suits you as an individual. It’s your body, let it be known how you want things done. • Mrs D., Essex, C8/T1 complete Drugs for bladder management
Various drugs are commonly prescribed to assist bladder management. Some of these are: MEDICATIONS FOR BLADDER MANAGEMENT
Function
How they work
relax sphincter muscles and Prazosin (Hypovase) neck of bladder * the ‘generic’ name is given first. Possible brand-name versions are given in brackets, but
there may be different names from other suppliers, as well as combination drugs

Urinary tract infections

Fortunately, the signs of infection are usually clear: cloudy urine, often dark coloured and strong
smelling, pink urine (however eating beetroot can also produce beautiful pink urine, and eating
asparagus can make the urine smelly!), a decrease in the amount of urine passed, and an increase in
mucus. Accompanying symptoms are an increase in spasm, high temperature, shivering and sweating.
Infection in the bladder can pass up to the kidneys and damage them. Frequent infections can cause
scarring of your bladder which may affect its ability to contract properly.
At the first sign of a urinary tract infection, increase fluid intake and ensure your bladder is emptied
frequently and completely. If you are ill or signs of infection persist contact your GP. Urinary tract
infection is defined as a positive urine culture indicating the growth of bugs in the urine. There will also
be flu-like symptoms including feeling unwell and running a temperature etc. NB; A positive culture on
its own, especially in the presence of a catheter is meaningless. There should always be symptoms
of infection in order to justify the taking of antibiotics.

Stones

Stones or calculi can develop in your kidneys and/or bladder. You are more prone to this after your
injury because of your lower mobility, the loss of some calcium from the bones of your paralysed limbs
(although this is usually limited to the months immediately after injury), and your less efficient bladder
function. Smaller stones can be passed out through the bladder and urethra without your noticing.
Larger ones can create obstruction in the kidney, or obstruct an indwelling catheter, and make you
more susceptible to urinary tract infections.
The symptoms are similar to those of a urinary tract infection, with greater difficulty in passing urine and
more likelihood of pink-tinged urine (with blood in it). You will need treatment in hospital. Nowadays
stones can often be broken up by ultrasound (lithotripsy) without the need for an operation or removed
through an endoscope. Stone formation is best prevented by increasing your fluid intake (see above),
cutting down on foods (especially milk and cheese) which are high in calcium, and trying to keep your
urine acid).
Bladder operations

Sphincterotomy - some men with ‘reflex’ bladders (most lesions T12 and above) may need a minor
operation to cut the sphincter at the outlet of their bladder, as although their bladder reflexes work, they
are not synchronised properly so that when their detrusor muscle (in the wall of the bladder) contracts
to squeeze out the urine, the sphincter at the outlet of the bladder does not relax to allow bladder
emptying. If left untreated, this condition leads to over-filling of the bladder and the risk of urine backing
up to and infecting the kidneys. There is a small chance that the operation will affect the ability to obtain
a reflex erection. It also might lead to disruption of ejaculation. This operation is not normally carried out
on women.
Bladder neck incision -
in some men there is an obstruction at the neck of the bladder which needs a
small incision to correct. This operation commonly leads to disruption of normal ejaculation if this
existed before.
Cystoplasty - this is an operation to enlarge the bladder and to reduce bladder activity by positioning a
section of the bowel into it, or using the bladder wall itself to enlarge the bladder.
Cystoscopy - this is a visual examination of the bladder by means of a tiny instrument inserted through
the urethra.
Feneley procedure - this is an uncommon operation performed on women to close the urethra and
bladder neck and insert a suprapubic catheter. It is used when other methods of bladder management
have failed and there is frequent leakage around an indwelling urethral catheter.

Ileal conduit -
now seldom used for spinal cord injured people, this is an operation to bypass the
bladder completely. The ureters, which bring urine from the kidneys are diverted into a small pouch
made from a section of the small intestine and thence by an opening in the abdomen to a removable
external drainage bag.
I had an ileal conduit done in September 1991. It was a last resort for me. I didn’t go through a spinal unit when I was injured, but spent the first year in a neurology ward. When I went home I had an indwelling catheter and I was never told there was any other option. I was sent to the spinal unit about five years after my injury as by this time I was having a lot of problems with my bladder. I was told it had shrivelled up and this was why it was going into spasm continuously and pushing out my catheter size 16 with 30mls of water [in the balloon]. I really wanted to do intermittent catheterisation, but when I tried it didn’t work for me as my bladder was damaged beyond repair. I was angry that the staff in the neurology ward didn’t send me to the spinal unit when I was well enough after my accident. I am sure if they had I wouldn’t have half the problems I do now. Since I had my ileal conduit, life has improved as I don’t have the worry I had before of my catheter bypassing and also of my bladder going into spasm regularly. Margaret McEleny, T4 complete Mitrofanoff procedure - the appendix or a piece of bowel is fashioned to form a ‘channel’ between the
bladder and the abdominal wall. The ‘channel’ contains a non-return valve to prevent urinary leakage.
As the bladder fills pressure is applied to the channel so that leakage doesn’t occur and the person can
catheterise as appropriate, through the abdominal wall. This procedure is commonly carried out with
cystoplasty.
Stamey colposuspension - this is almost the opposite of a sphincterotomy. It is an operation,
performed on women, to tighten the bladder neck to make it more ‘water-tight’.
Stents - a small metal mesh implant is inserted at the external sphincter. The sphincter remains slightly
open and aids urinary drainage.
Stress leakage surgery - e.g. macroplastique and collagen implants are injected around the bladder
neck to make the bladder more ‘water tight’. Colposuspension surgery involves ‘hitching’ the bladder
neck up to prevent urinary leakage.
Implants

Artificial Urinary Sphincter (AUS) -
this is an inflatable cuff implanted around the neck of the bladder,
with a control pump located in the scrotum or labia, and a balloon is placed in the abdomen. The cuff,
which is filled with fluid, gently squeezes the bladder neck and urethra closed to keep urine in the
bladder. When the pump is squeezed the fluid in the cuff flows into the balloon, allowing access to the
bladder and drainage of urine. Within several minutes, fluid in the balloon automatically returns to the
cuff, and the cuff again closes around the urethra. Carries some risk of infection. The average life span
of an implanted artificial urinary sphincter is 10-12 years. This is because of the risk of infection and
mechanical failures.
Sacral Anterior Root Stimulator (SARS) - requires a major operation to install electrodes to stimulate
the S2 to S4 anterior (front) nerve roots which control bladder function. These are connected to a tiny
receiver block, installed beneath the skin below the rib cage. When you want to empty your bladder,
you hold a small ‘transmitter’ control box up against your body.
During the operation to implant the electrodes, the posterior (rear) nerve roots at the same level are
usually severed permanently (‘posterior rhizotomy’), which is necessary to suppress reflex activity of the
bladder (the main cause of incontinence in people with lesions T12 and above). The idea to sever some
nerves might be disliked by some people. A SARS implant can achieve dramatic improvement in
bladder continence and may also help bowel management. SARS operations have been performed
worldwide, the majority on women, who have more to gain (because of their greater continence
problems) and less to lose (some men may lose the ability to get a reflex erection as a result of the
operation, though some do get good erections).
Medical opinions about the costs and benefits of SARS differ. The operation is unsuitable for people
with very low lesions (where the sacral segments of the spinal cord are damaged), those whose
bladders have already been badly damaged, and those with incomplete lesions who retain pain
sensitivity or good sensation in the genital area (which they are unlikely to want to forego). Tetraplegic
women who cannot transfer to the toilet without assistance are unlikely to derive much benefit from the
operation.
To my great satisfaction and disbelief, I have not been wet since the day I had the operation. Neither have I had any complications as a result of having the implant. My bladder function continues to improve and I can sleep comfortably through the night without having to get up to use the loo at all. my bowel function is much more regular now and I have to take less laxatives than I used to. this operation has changed the quality of my life. Susan Abbott, T10 The one disadvantage of increased spasm in my legs is one I am prepared to put up with, as the advantages far outweigh the disadvantages Margaret Maugham, T11
Both the above SIA members had their SARS operations more than 10 years ago, and confirm that the
benefits have continued, and that they have no regrets. Margaret Maughan recently had a minor
operation to replace the receiver unit, but has had no further problems. For more bladder information
go to www.spinal.co.uk and download the Bladder Factsheet in the Help & Advice zone.
‘Choosing Products for Bladder & Bowel Control’ is a guide to the most suitable products for adults
with tips on choosing and using, complete with addresses. To order phone Ricability on 020 7427
2460. Also available on-line at www.ricability.org.uk
The Continence Foundation have a mass of leaflets and books covering most aspects of bladder
management for very reasonable prices (50p a leaflet). For a full list of these phone the Foundation on
020 7404 6875. Or go to their comprehensive web site at www.continence-foundation.org.uk
We are grateful to Wendy Pickard, Senior Clinical Nurse at the Outpatient Services at the Duke of
Cornwall Spinal Treatment Centre for helping SIA with this text.
SIA have checked with sources believed to be reliable in their efforts to provide information that is
accurate, comprehensive, and timely at the date of publication. However, human error and changes can
and will occur. The Spinal Injuries Association expressly disclaim any representation or warranty,
expressed or implied, concerning the accuracy, comprehensiveness, or suitability of the information for
a particular purpose. SIA have produced this document in good faith and are not responsible for any
errors, omissions, or results obtained from the use of the information herein.

Bladder and Bowel Management for people with spinal cord injuries (2004 booklet) is
available from SIA Price £5.00
The essentials of understanding the functioning of, and looking after one’s bladder and bowel after
becoming spinal cord injured. This booklet is for the spinal cord injured person and anyone else
who is involved in helping with this part of an SCI’s bodycare. It deals with the subject in a
straightforward manner and looks at current practice both in hospital and at home.
SIA has checked with sources believed to be reliable in their efforts to provide information that is accurate, comprehensive, and timely at the date of publication. However, human error and changes can and will occur. The Spinal Injuries Association expressly disclaims any representation or warranty, expressed or implied, concerning the accuracy, comprehensiveness, or suitability of the information for a particular purpose. SIA has produced this document in good faith and is not responsible for any errors, omissions, or results obtained from the use of the information herein. Last Updated March 2006.

Source: ftp://84-45-175-163.static.enta.net/Live_Archive/pdf/factsheet_bladdermanagement.pdf

Medikamenten-merkblatt

Stadtspital Triemli Zürich Prof. Dr. Elisabeth Minder Birmensdorferstr. 497 Zentrallabor Stadtspital Triemli Zürich Merkblatt Arzneimittel bei akuten Porphyrien (Akut-intermittierende Porphyrie, Porphyria variegata, Hereditäre Koproporphyrie) Wichtigste Auslöser von Symptomen: 3. Verminderung der Kalorienzufuhr (Fasten, strenge Diät) Generel e Richtlinien Patienten mit

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See also Chapter 7, LIA technique for TKA • Bupivacaine 0.25% or ropivacaine 0.25% delivered Review of evidence intra-articularly as wel as subcutaneously at the• Four clinical trials have shown a beneficial effect ofdonor site, via indwel ing catheter, at at least 4 mL/hcontinuous delivery of ropivacaine (Andersen KV et al. for 48 h, improves pain relief and reduces opioid2010; Bia

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