MEDICAL PROBLEMS IN TBI: URINARY TRACT PROBLEMS: URINATION AND THE URINARY TRACT IN TBI

     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 you.

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:

Indwelling (Foley) Catheter

     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.

Intermittent 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.

Catheter Free 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 frequently incontinent.

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.

Medications

     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 Bags or Irrigating the Catheter links.

Based on Brain Injury Patient Care and Education Manual, by Pinecrest Rehabilitation Hospital; Neuro section of the Trauma Manual, Jackson Memorial Hospital; and Recovering from Head Injury; a Guide for Patients, by Nova University Neuropsychology Service, and edited for PoinTIS by the Louis Calder Memorial Library of the University of Miami School of Medicine and the PoinTIS Advisory Committee, and on Rehabilitation of Persons with Traumatic Brain Injury, NIH Consensus Statement 1998 Oct. 26-28.