After brain injury, the bladder is referred to as a
neurogenic bladder. This means nervous system control of the bladder has
been lost as a result of the injury. This loss of nervous system control,
in turn, means that, while the bladder fills with urine, the message that
the bladder is full cannot reach the brain. As a result, you are no longer
able to feel the urge to urinate.
The muscle activities of the bladder and external sphincter
muscle are also affected by the injury. The bladder may be hypertonic, or
spastic. The bladder will tighten and spasm as it fills and if the sphincter
muscle will relax, these spasms (or contractions) may expel urine. If the
sphincter muscle will not relax, voiding may not occur.
Whatever the altered function of the neurogenic bladder,
the most important issue is one of control. The bladder has a disability
and can no longer control the amount of urine it stores and/or the voiding
process itself may be interrupted. Because of this disability, urinary tract
complications can occur if the bladder is not managed properly.
Urinary Tract Complications
To prevent possible problems, you must be aware of the
urinary tract complications that can occur. These complications, which can
cause kidney damage or kidney failure, include:
Infection, such as bladder infection, kidney infection, or blood
poisoning. Serious infections can be avoided by scrupulous urinary care and
knowing the early signs of infection. Sometimes your doctor will prescribe
medication to prevent symptoms from occurring. You need to observe your
urine and know the symptoms of urinary tract infection, which include:
Urine that is cloudy or has a foul odor
Sediment in the urine
Chills and fever, and/or a lack of appetite or energy
Calculi, or stones, may occur in the bladder or in the kidney. Bladder
stones are easily removed. Kidney stones may require major surgery to remove.
Reflux is the backward flow of urine from the bladder to the kidneys.
It can be caused by high pressure in the bladder from the bladder being too
full, or, from the bladder contracting against a sphincter muscle which will
not relax. Reflux can also be caused by an infection that damages the valve
between the bladder and the ureter.
Hydronephrosis is a distension of the collecting system in the kidneys.
It may be caused by reflux or from high pressure in the bladder from spasms.
Urinary Tract Tests and Evaluation
The following tests evaluate your urinary system and diagnose complications.
Your physiatrist, or the urologist assigned to you, will determine whether
any of these tests are appropriate for you.
History/Physical exam will be done by your physician.
Urine Culture and Sensitivity Test/Urine Analysis may be done to check
for infection of the bladder. In this test, a urine sample is checked for
the amount of bacteria, type of bacteria, and the antibiotics which will
be most effective in killing the bacteria.
Blood Tests help determine the level of kidney function.
Intravenous Pyelogram (IVP) is an X-ray of the kidney to determine
its structure and function.
Cystogram (CG) is an X-ray that shows the contours of the bladder
and detects reflux, if present.
Urodynamic Studies are special tests for bladder function which help
your urologist determine the best program of urinary tract management for
Goals and Methods of Urinary Tract Management
The goals of a program of urinary tract management are:
Preservation of kidney function and health
Adequate emptying of the bladder
Prevention of complications listed above
Staying dry, also called "continence"
Managing the bladder in the simplest, safest possible way
There are several methods of urinary tract management
that address the loss of bladder control that may occur with brain injury.
An individual program will be worked out for you by your doctor and nurse
which will tell you what liquids and how much to drink, how often to catheterize,
check the pH of your urine, have check-ups, etc.
The most common types of bladder management are:
Many patients have this form of internal catheter when
they are admitted to a rehabilitation facility from an acute care hospital.
Urine drains from the bladder through a tube into an external collection
bag. This form of bladder management is typically used with patients in coma
and patients who have significant movement limitations.
Catheterization Program (ICP)
An ICP program is typically used with patients who have
difficulty passing urine and/or who have difficulty emptying the bladder
fully. Typically, a catheter is inserted in the bladder every 6 to 8 hours
to remove and measure any residual urine. The catheter is then removed. Residual
urine is measured routinely until the amount is as low as possible. As the
amount of residual urine decreases, catheterizations become less frequent
and may eventually be discontinued. Restrictions on fluid intake will also
be ordered when an ICP program is in effect to help control fluid volume
in the bladder.
Voiding Program (With External Collector)
Male patients who have difficulty controlling urination
may wear an external catheter (sometimes called a condom or Texas catheter)
during the day and/or evening to assist in bladder management. When an external
catheter cannot be used, diapers are sometimes used with patients who are
Bladder Retraining Program
A scheduled toileting program to reestablish bladder
control may be initiated as physical and thinking skills improve following
a brain injury. The patient is placed on a frequent toileting schedule, such
as every 2 to 3 hours, to help retrain the bladder and increase awareness
of the "signals" that indicate the need to urinate.
In some cases, mediation may be helpful in decreasing
spasticity or increasing bladder muscle tone.
Detailed information on each of the above methods is
available by clicking on the above link for each method. Additional information
is also available by clicking the
Caring for Drainage
the Catheter links.