The urinary system

The urinary system helps the body filter and remove waste products and excess fluids. It consists of the kidneys, ureters, bladder, urethra, and bladder and sphincter muscles.

The kidneys filter the blood to produce urine, which is passed through narrow tubes called ureters to the bladder. The bladder is a sac that collects urine. Urine passes out of the body from the bladder through a tube called the urethra.

Filling and emptying of the bladder are partly controlled by the bladder muscles:

• The bladder wall muscle (detrusor muscle) is smooth muscle that covers the outside of the bladder. When it contracts, it squeezes the bladder and pushes urine out through the urethra. When it is relaxed, the bladder is loose and can be filled with urine.
• The bladder sphincter muscles (urethral sphincter or valve muscles) are two muscles which surround the exit of the bladder like a ring. When they tighten, they close off the urethra and hold urine in the bladder. When they relax, they allow urine to drain. The internal sphincter muscle is controlled unconsciously and the external sphincter muscle is controlled consciously.

Bladder function

When the bladder is not full, the bladder wall muscle is relaxed and urine produced by the kidneys passes through the ureters to fill the bladder. The bladder sphincter muscles are tightened so urine does not leak out.

When there is enough urine to stretch the bladder walls, a nerve signal is sent up the spinal cord to tell the brain that the bladder is full. Because the brain controls the external sphincter muscle, urine can be held until an appropriate time to empty.

When the bladder is to be emptied, signals are sent from the brain down the spinal cord to cause the coordinated squeezing of the bladder wall muscle and relaxation of the bladder sphincter muscles to allow urine to pass through the urethra and out of the body. Control of urination involves both bladder reflexes (in which emptying is triggered when the bladder is full) and voluntary control (in which urine can be held until a socially appropriate time to empty).

Neurogenic Bladder

Neurogenic bladder is bladder dysfunction caused by damage to the nerves, brain or spinal cord. After a spinal cord injury, nerve signals that normally allow the brain and bladder to communicate with one another cannot get through. This can affect bladder sensation and control.

Loss of bladder control

Signals from the brain are needed for the bladder muscles to contract and relax properly. If these signals cannot get through, the bladder muscles may contract too much, too little, or at the wrong times, depending on whether the person has spastic or flaccid bladder.

Reduced bladder sensation

Normally, signals that are sent up the spinal cord to the brain when the bladder is full. When the signals are interrupted, the ability to feel fullness and other sensations from the bladder may be reduced.

Bladder changes after SCI are different for everyone. Some people experience only mild changes to how the bladder works (such as greater sense of urgency when the bladder is full); while others experience complete loss of bladder sensation and control.

The symptoms of neurogenic bladder depend on the characteristics of the SCI, such as the level and completeness of the injury. There are two main types of neurogenic bladder after SCI, spastic bladder and flaccid bladder (see below).

Spastic Bladder

Spastic bladder (also called “reflex bladder” or “overactive bladder”) happens when the spinal cord is injured above T12. Spastic bladder happens because the brain can no longer control reflexes in the bladder muscles. This leads to tension in the bladder wall muscle when it is supposed to be relaxed and spasms of the bladder muscles which cause emptying.

Usually, the bladder sphincter muscles are also overactive and cannot coordinate very well with the bladder wall muscle. This is called detrusor dyssynergia or detrusor sphincter dyssynergia (DSD). When this happens, the bladder sphincter muscle tightens while the bladder wall muscle contracts, like squeezing a balloon that is tied off. This can cause high pressures within the bladder that can damage the bladder and kidneys.

Symptoms of spastic bladder:

• Loss of control of bladder emptying (incontinence), leading to random emptying (accidents), inability to empty when you want to and leaking
• Reflex emptying in response to things like touching the thigh or abdomen
• People with some bladder sensation may experience sudden strong urges or a frequent need to urinate
• Incomplete emptying of the bladder caused by poor coordination of the bladder wall muscle and bladder sphincter muscles (detrusor dyssynergia)
• Reduced or complete loss of bladder sensation

Flaccid bladder

Flaccid bladder (also called “non-reflex bladder” or “underactive bladder”) happens when the spinal cord is injured below T12-L1 (i.e cauda equina injuries). Flaccid bladder happens because there is a loss of both input from the brain and reflexes from the spinal cord. This causes the bladder wall muscle to stay loose and floppy all the time. When this happens, the bladder wall muscle cannot squeeze the bladder to empty urine.

Usually, the external sphincter muscle is also overly relaxed, causing leaking during activities like transfers and coughing. However, the internal sphincter muscle is often in spasm and does not relax enough to allow urine to pass out of the body easily.

Symptoms of flaccid bladder:

• Inability to empty the bladder, including loss of reflex emptying
• Incomplete bladder emptying, leading to some urine remaining in the bladder after emptying (urinary retention)
• Damage to the walls of the bladder when they are overstretched
• Backflow of urine back to the kidneys (reflux), which can damage the kidneys
• Reduced or complete loss of bladder sensation

Changes to bladder function after SCI can lead to greater risk of developing bladder complications.

Urinary tract infections

A common side effect of bladder problems and their treatments is infections of the bladder and kidneys. These are known as urinary tract infections or UTIs.

Urinary tract infections can be a very serious problem when severe, and if left untreated, they can lead to a life-threatening condition called sepsis. In the early days of SCI care, complications of urinary tract infections were the most common cause of death after SCI.

Today, treatment and prevention of urinary tract infections is much more effective and infections can be treated effectively in most cases. However, it is very important to take steps to prevent infections and to seek out treatment for new infections as soon as they are detected.

The symptoms of urinary tract infections are not always easy to recognize. They usually consist of both generalized symptoms of infection and symptoms related to urination, such as:

• Fever, chills, or tiredness
• Cloudy, red (from blood), or bad-smelling urine
• More frequent or severe muscle spasms
• Autonomic dysreflexia (in people with injuries above T6)
• An urge to urinate often (if sensation is present)
• Pain or burning feeling while urinating (if sensation is present)
• Pain in the abdomen or back (if sensation is present)

If you suspect you might have a urinary tract infection, contact a health provider as soon as possible. Urinary tract infections are usually treated with antibiotics. However, keep in mind that people who use indwelling catheters or intermittent catheterization will often have bacteria in their urine that does not cause symptoms. It is recommended that antibiotics are not taken to treat bacteria unless you also have symptoms.

Refer to our article on Urinary Tract Infections for more information!

Kidney and bladder stones

Kidney stones and bladder stones are solid pieces of material that form within the kidneys or bladder. They form because of high concentrations of minerals in the urine and other factors. If these stones become large, it can be difficult to pass them out of the body in the urine, leading to pain and other symptoms. Stones in the kidney can interfere with the filtering of blood and drainage of urine to the bladder. Stones in the bladder can block the flow of urine.

People with SCI are at risk of developing kidney or bladder stones because of changes to how the urinary system works. A number of different factors can contribute to kidney stones, such as improper use of catheters, urinary tract infections, not drinking enough water, backup of urine to the kidneys, and high levels of calcium in the body.

Kidney stones are solid mineral “stones” that form in the kidneys or bladder.²

The symptoms of kidney and bladder stones may include:

• Pain in lower back or abdomen (if sensation is present)
• Frequent urinary tract infections
• Increased sweating
• Blood in the urine
• Increased spasms
• Seeing stones in the urine
• Nausea and vomiting
• Burning or pain during urination (if sensation is present)

Kidney and bladder stones that do not cause symptoms are not treated, but are allowed to pass out of the body on their own. Kidney stones that do cause symptoms are treated with a number of different treatments including medications, extracorporeal shock wave lithotripsy (a form of treatment using ultrasound waves to break a stone into smaller pieces), ureteroscopy (using a thin scope that is inserted into the urethra to break up or dislodge a stone), and surgery. Many bladder stones can be removed at the time of cystoscopy.

Kidney damage and failure

Long-term bladder problems, especially when poorly managed, can damage the kidneys. When kidney damage has progressed to the point where the kidneys no longer function effectively, it is called kidney failure or renal failure.

Bladder problems after SCI can lead to kidney damage if the bladder frequently overfills and cannot empty. Bladder overfilling can result from poor bladder care (such as not emptying the bladder completely or regularly). This can lead to high pressures in the bladder that cause urine to back up to and damage the kidneys.

Kidney failure is permanent and is treated with dialysis or kidney transplants. Early consideration and careful bladder management throughout life is the most important part of preventing kidney damage long-term. This may include catheterizing regularly and on-time, emptying the bladder completely each time, and regularly checking in with your doctor about your bladder care.

Bladder cancer

There is an increased risk of bladder cancer among people who use indwelling catheters. However, screening recommendations are controversial since we do not yet know who needs to be screened, how often, and how soon after injury. Speak to your health provider for more information.

Other related problems

Bladder changes after SCI can also contribute to a number of other medical conditions, such as:

• Bladder complications can cause increased spasticity
• Bladder complications can trigger episodes of autonomic dysreflexia (with injuries above T6)
• Wetness from bladder complications can contribute to skin irritation and breakdown

To learn more about these topics, check out our articles on: Pressure Injuries, Spasticity, and Autonomic Dysreflexia

Bladder examination

Bladder changes are diagnosed primarily through a bladder examination. A bladder examination typically involves several components:

• Your health provider will ask you questions about your medical history, symptoms, bladder routine, and current treatments.
• You may be asked to complete a “urinary diary” and/or detailed questionnaires about your bladder care. This often involves recording how often you empty your bladder, how much urine is produced each time, and details about your fluid intake (what you drink, when and how much).
• A physical examination may involve an inspection of the abdominal, pelvic and genital areas, as well as neurological testing of your reflexes, muscle strength, and sensation.

Other testing

Other testing may also be done if your health providers need further information.

The dipstick or urine test strip is a basic diagnostic tool for identifying presence of substances or infection in urine.³

Urine culture

A urine culture and sensitivity test involves collecting urine in a sterile container to test for infection. Urine samples are usually collected mid-stream while emptying so the test is more accurate. If the sample is collected from an indwelling catheter, the catheter should be changed first. Samples are never taken from a urine drainage bag.

Blood tests

Blood tests may be done if there is concern about kidney function, kidney damage, or an infection. This usually involves testing for blood urea nitrogen (BUN) and creatinine.

Ultrasound

Ultrasound is an imaging technique that uses sound waves to visualize deep tissues. Ultrasound imaging may be done over the kidneys (known as renal ultrasound) to detect damage, kidney stones and infections.

Urodynamic testing

Urodynamic testing includes special tests that can be used to look at bladder pressures and urine flow. It can test how the bladder acts when it fills and empties, how well it coordinates, and the pressure within the bladder. This test may involve urinating into a special container that can measure the flow and volume of urine, insertion of a catheter to measure the leftover urine, and inserting water into the bladder to measure your ability to prevent emptying. It may also involve placing a small catheter into the rectum that measures the electrical activity of muscles.

Imaging

Other imaging, such as x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) are sometimes used for further investigation of bladder problems.

Cystoscopy

Cystoscopy (sometimes known as a “bladder scope”) is the use of a very small camera that can be inserted into the urethra to look at the urinary tract. Cystoscopy can be used to identify bladder stones, bladder health issues or damage including bladder cancer. It can also perform therapeutic procedures if needed such as removing tissue or stones.

Early bladder care

In the early hospital phase right after injury, the circulatory system is stabilizing, and the prevention of infections and other complications is the priority. During this phase, an indwelling catheter is placed in the bladder to constantly drain urine from the bladder. The catheter will be changed regularly and maintained in a sterile way by your nurse.

After the acute phase, bladder care will involve transitioning to more long-term bladder care techniques and developing a suitable bladder routine.

Bladder Routine

A bladder routine is a regular routine of bladder techniques and treatments that are done every day to maintain bladder function and health. This usually involves techniques to regularly empty the bladder, prevent leaks, and avoid serious complications long-term.

Every person’s routine is different and often involves trial and error to find the methods that best meet your unique symptoms, abilities, preferences, and lifestyle. There is a wide range of different techniques and treatments that may make up your routine, including catheters, medications, and methods of stimulation like electrical stimulation. Keep in mind that spastic bladder and flaccid bladder happen for different reasons and are managed differently.

Other things to consider when developing a bladder routine:

• Timing and amount of fluids
• Caffeine and alcohol consumption
• Scheduling of bladder emptying (such as how long between catheterizations, before going to bed or certain activities, after drinking fluids)
• What type of equipment to use, such as type of catheter and collection bag for different situations
• What to do if you have a bladder infection or other new health problem
• Regular assessment of bladder care with your health team

Spastic bladder management

The goals of spastic bladder management are to reduce overactivity in the bladder wall muscle which causes accidents, leaking, and wetness; as well as preventing high pressures within the bladder. This may include treatments such as:

• Indwelling catheters, condom catheters, and/or intermittent catheterization to drain the bladder
• Reflex voiding may help to empty the bladder for some people
• Anticholinergic medications may help to relax the bladder muscles
• Botulinum toxin (Botox) injections to help relax the bladder muscles
• Bladder augmentation surgery to increase the capacity of the bladder to hold urine

Flaccid bladder management

The goals of flaccid bladder management are to regularly empty the bladder to prevent overfilling and increased pressure in the bladder; and to prevent leaking and wetness. This may include treatments such as:

• Intermittent catheterization or indwelling catheters
• Condom catheters or pouches may be used to catch leaks but not for emptying
• Alpha-adrenergic blockers may help to relax the bladder sphincter muscles
• Botulinum toxin (Botox) injections
• Surgical techniques such as sphincterotomy or stents

Urinary catheters are pieces of equipment that are used to drain urine from the bladder. There are many different ways that catheters are used.

Intermittent catheterization

Intermittent catheterization is when a catheter is inserted and removed through the urethra to drain the bladder at regular intervals throughout the day. Bladder emptying with intermittent catheterization must be done hygienically and on a regular schedule.

Intermittent catheterization is usually used by people who have enough hand function to perform the procedure independently. It is the closest method to normal bladder function, where the bladder fills continuously for a period of time and then empties all at once.

A diagram of an indwelling (Foley) catheter.⁴

Indwelling catheters

Indwelling catheters (such as Foley catheters) are catheters that are inserted directly into the bladder and remain in place to continually drain the bladder. Indwelling catheters may be inserted through the urethra (urethral catheters) or through a surgically created hole through the abdomen (suprapubic catheters).

An example of a condom catheter, for male use.⁵

Indwelling catheters are usually used if inserting your own catheter independently is difficult or there are concerns about leaking between sessions of emptying.

Condom catheters (only for males)

Condom catheters are catheters that resemble a condom and are placed over the penis and connected through tubes to a collection device. Condom catheters are usually used by people that leak in between emptying or for individuals who have the ability to trigger emptying by causing a spasm of their bladder (reflex voiding).

One of the main concerns of condom catheters is incomplete bladder drainage, which can cause kidney damage. A careful medical examination is needed to ensure that condom catheters are a safe option for use.

Refer to our article on Urinary Catheters for more information!

Reflex voiding is a technique that can be used by some people with spastic bladder to stimulate urination. Reflex voiding is usually done by tapping over the bladder lightly and repeatedly with the fingertips or the side of the hand to stimulate reflexes in the bladder muscles. This technique can be used to help improve bladder emptying during intermittent catheterization and when using condom catheters. However, only a small number of people can use this technique safely without increasing the pressure too high in the bladder. Speak to your health team for more information about this technique.

Several medications may be used to help manage bladder problems after SCI. These may help to relax overactive muscles or cause the bladder muscles to contract, depending on the type of bladder change experienced. A number of other medications may also be used for different aspects of bladder treatment after SCI.

Anticholinergic medications

Anticholinergic medications (sometimes called antimuscarinic medications) are used to relax muscle spasms in the bladder wall muscle. This can help to reduce pressure within the bladder, increase the ability of the bladder to hold urine, and help reduce incontinence.

There are many different types of anticholinergic medications, with the most common being:

• oxybutynin (Ditropan, Ditropal XL, Oxytrol, Uromax)
• tolterodine (Detrol)
• fesoterodine (Toviaz)
• trospium chloride (TCL, Trosec)
• propiverine hydrochloride (Mictonorm)
• darifenacin (Enablex)
• solifenacin (Vesicare)

These can be taken by mouth or administered directly into the bladder in a liquid form.

Alpha-adrenergic blockers

Alpha-adrenergic blockers are medications that are used to encourage the bladder sphincter muscles to relax to allow urine to flow out of the body. This can help with bladder emptying and help prevent urinary retention. Common alpha-adrenergic blockers that may be used include tamulosin, mosixylyte, terazosin, and phenoxybenzamine.

Botulinum toxin injections

Injecting small doses of some strains of botulinum toxin (Botox) into muscles can help to reduce muscle spasms. Injections into the bladder wall muscle or the external sphincter muscle can help to relax these muscles to help prevent leaking and incontinence or to improve bladder emptying. The effects of these injections can last for 6 to 12 months.

Read our article on Botulinum Toxin for more information!

Other medications

• 

  Capsaicin is commonly found in hot peppers.⁷

  Capsaicin, a chemical commonly found in hot peppers, and its derivative resiniferatoxin, may be administered as a liquid into the bladder to help reduce urinary frequency, leaking, and bladder pressures related to bladder wall muscle overactivity, and increase bladder capacity.

• Nociceptin/orphanin phenylalanine glutamine is another medication with effects similar to capsaicin and resiniferatoxin. It may also be given into the bladder to reduce overactivity in the bladder wall muscle.
• Medications that are normally used to treat spasticity may also help with bladder problems related to spastic bladder. For example, baclofen and clonidine may help with bladder function after SCI.
• Phosphodiesterase-5 (PDE5) inhibitors such as tadalafil and vardenafil may help to reduce overactivity in the bladder wall muscle and increase bladder capacity.
• 4-Aminopyridine (fampridine) improves the transfer of nerve signals, which may help individuals regain sensation and control of the bladder sphincter muscles to improve emptying.

Bladder surgery is usually only considered if other less-invasive treatments are not effective. Surgical procedures that may be used include the Mitrofanoff procedure, bladder augmentation, sphincterotomy (for males), and urethral stents.

Mitrofanoff procedure

The Mitrofanoff procedure involves the use of the appendix or part of the intestine to create a channel between the abdomen and bladder. The channel self-seals shut when the catheter is removed. This channel can be used for insertion of a catheter for intermittent catheterization. The urine can then be drained into a cup or toilet. This may be useful for people who have difficulty self-catheterizing directly into the urethra and is often used for women (who have greater difficulty inserting catheters).

The Mitrofanoff procedure involves connecting parts of the intestine to the bladder.⁹

Bladder augmentation

Bladder augmentation (also called augmentation cystoplasty) is a procedure in which the bladder is made bigger to create more room to hold urine. This is done by removing a segment of the intestine and stitching this tissue to an incision into the bladder to make the bladder bigger. Bladder augmentation may help to reduce pressure in the bladder and help to prevent incontinence related to spastic bladder.

Bladder augmentation is a surgical procedure done to enlarge the bladder by using parts of the intestine.¹⁰

Sphincterotomy (for males)

Sphincterotomy is a surgical procedure where the internal sphincter muscle (the circular muscle that surrounds the outlet of the bladder) is cut to weaken the muscle. This is done to improve bladder emptying if this muscle is causing difficulties emptying. After a sphincterotomy, bladder emptying will happen; therefore, you must wear a collection device.

Urethral stents

Urethral stents are prosthetic tubes (usually coils of metal) with openings on both sides that are be inserted into the opening of the bladder to hold it open. This is done to allow for improved bladder emptying for people with difficulty emptying due to overactivity in the bladder sphincter muscles.

Electrical stimulation

Electrical stimulation can be used to help normalize the activity of the bladder muscles and control of bladder emptying. This may involve the implantation of a stimulator and electrodes that stimulate the sacral nerves that send brain signals to the bladder. This is sometimes referred to as neuromodulation.

Commercially available electrical bladder stimulation systems may be used for this purpose. However, these systems may be expensive and is not available in all locations.

Refer to our articles on Neuromodulation for more information!

Acupuncture

Acupuncture and electroacupuncture have also been suggested as treatment options to help with bladder function by influencing nerve signals related to bladder function.

Refer to our article on Acupuncture for more information!

Watch SCIRE’s video on bladder care to understand more about managing your bladder as you age.¹¹

Typically, people will experience changes in urination as they age. Some may need to go to the bathroom more often because the bladder can’t store as much urine, or find that the flow of urine is weaker. Others may experience more urine leaking because the muscles that keep the bladder closed are weaker or the bladder contracts when it is not supposed to. The kidneys that filter your blood and produce urine may not function as well, and the risk of developing kidney stones increases.

Women, both during and post-menopause may experience an increase in the frequency of UTIs.

The aging bladder in SCI

For people aging with SCI, the long-term use of indwelling catheters to manage the bladder increases risk for bladder stones, bladder cancer, UTIs, and urinary tract deterioration. Long-term use of intermittent catheterization can increase risk for urethral strictures. People with neurogenic bladder can experience high pressures in the urinary tract and urine back up to the kidneys. Over time, this damages the structures of the urinary system and increases the risk for stones.

Bladder changes that people aging with SCI may experience:

• Increased UTIs
• Increased urine leaking (incontinence)
• Urethral strictures
• Bladder/kidney stones
• Increased risk of bladder cancer
• Damage to urinary tracts and kidneys
• Reduced kidney function

Bladder changes may also trigger spasticity and autonomic dysreflexia. Other aspects of aging like pain, osteoarthritis, decreased strength and mobility, and thinning of the skin, may also affect the ability to carry out bladder routines.

All of the changes from aging listed above could lead to a need to reassess bladder management strategies.

Refer to the “What other complications are related to bladder changes?” section for more information on specific bladder problems.

Managing bladder changes with age

If you experience changes to your bladder function as you age with SCI, consult regularly with a health care provider about your bladder management. Your family doctor, physiatrist, or urologist may be familiar with the check-ins necessary for bladder care as you age with a SCI.

Strategies to consider for the management of bladder changes may include:

• Changing the catheterization method to reduce UTIs, avoid urinary tract damage, or accommodate reduced hand and wrist function
• Screenings for bladder/kidney stones and urinary tract/kidney damage
• Regular screening for bladder cancer if indwelling catheter has been used for 5-10 years
• Consulting with professionals to determine the root cause of recurrent UTIs
• Antibiotic medication to treat UTIs (only use if experiencing symptoms to avoid developing antibiotic resistance)
• Supplements to prevent UTIs (i.e. D-mannose)
• Botulinum toxin (Botox) injections to relax bladder muscles
• Surgical procedures to make the bladder bigger, improve emptying, or make catheterization easier
• Additional caregiver help
• Quit or avoid smoking (smoking can up to quadruple risk for bladder cancer)

Many people with SCI change their bladder management as they age. In one study, half of participants changed their bladder management methods over 20 years. Over time, men who used condom drainage and women who used straining to manage their bladder were most likely to change their management methods. The use of indwelling catheters increased for men. A change to intermittent catheters or suprapubic indwelling catheters for bladder management increased for both men and women.

There is research looking at the potential for epidural and transcutaneous nerve stimulation to improve bladder function and management. This may be available depending on your location.

Refer to the “Medications and injections”, “Bladder surgery and stents”, and “What other complications are related to bladder changes?” sections above for more information.) 

Bladder changes are common after SCI. Bladder care is an important part of self-management after SCI to prevent complications and maintain good health and quality of life.

Bladder care after SCI involves developing a regular bladder routine that meets your unique bladder needs. This may include a variety of techniques and treatments, such as catheters, medications, injections and other treatments. Speak to your health team about which bladder management options are best for you. Regular follow up with your doctor is recommended yearly.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

SCIRE Community. “Bowel Changes After Spinal Cord Injury”

SCIRE Community. “Urinary Catheters”

SCIRE Community. “Urinary Tract Infections”

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