Back to Basics: Urinary Catheterization Part II
Maintaining urinary health is essential for individuals with spinal cord injury. Last week, your own catheterization processes and techniques was reviewed. However, you can also enlist the help of healthcare providers to ensure you are doing all you can to protect your urinary health especially when something does not seem right or for what you might not see.
The main complication of the urinary tract for individuals with spinal cord injury is a bladder infection. The concern of difficulty and cost of going to a professional’s office is great for some especially when visits are frequent. Urinary tract infection (UTI) like most health issues, is best treated when caught early. It is much easier to treat an early infection than one that has a good hold on the bladder. In addition, bladder infections can easily migrate to the kidneys which can be more dangerous. Through the kidneys, the infection can spread to other parts of the body, even turning to sepsis, which is a potentially fatal infection affecting all internal organs.
Infections are treated with antibiotics. Different bacteria types are susceptible to different antibiotics. A urinalysis test will indicate if an infection is present. Culture and sensitivity tests are performed on the same urine sample if an infection is present. The culture will indicate the type of bacteria present. Sensitivity will indicate the antibiotic specifically needed to eliminate it.
When an antibiotic is prescribed, it must be taken for the full prescription. Once you start an antibiotic, the bacteria will try to change itself making the antibiotic ineffective. This is how the bacteria survive. If the entire prescription is taken, you will be sure the bacteria are completely eliminated. You do not want a bacteria cell or two to survive and to go through the process again.
Antibiotics come in ‘generations’. This is as they are discovered or developed, first generation, second generation, third generation and fourth generation. Beginning with the lowest generation (first) of antibiotic when you have an infection is helpful to your health as each time you take an antibiotic, the bacteria will become just a bit resistant to it. As you take higher level ‘generations’ of antibiotics, your options for treatment become less to eliminate the bacteria. Some people take so many high level ‘generations’ of antibiotics that they develop allergies or resistance to the prescribed antibiotic. With antibiotic resistance, there are less options. Super infections can evolve for which there is no antibiotic treatment. For these reasons, it is best to treat infections early and with the lowest ‘generation’ of antibiotic.
Symptoms of urinary tract infections (UTI) include: urgency to empty the bladder or burning when toileting. Neither of these most common symptoms are felt by individuals with complete spinal cord injury. You will rely on later symptoms such as cloudiness in the urine, not to be confused with sediment. Over time, you will learn to tell the difference. Blood might be present with a urinary tract infection. You may have a fever. Pain is a general symptom of a UTI. With SCI, you might not feel pain in the bladder, but it could be referred to your left shoulder or left jaw (much like the symptoms of a heart attack are referred to the shoulder or jaw) or to another part of your body where you have sensation.
A UTI can also lead to autonomic dysreflexia (AD). This is an issue for individuals with spinal cord injury above T6 but some have AD in lower thoracic injuries as well. Most know the symptoms of AD, especially the primary symptom of a pounding headache. There are other symptoms that may appear with the headache and sometimes without the headache. These include:
- ABOVE LEVEL OF INJURY
- Hypertension (a fast increase in blood pressure, 20-40 mm Hg systolic higher than usual)
- Bradycardia (slow heart rate) or Tachycardia (fast heart rate)
- Pounding headache
- Apprehension/anxiety/ uneasy feeling
- Changes in vision
- Nasal congestion
- Sweating, flushed skin, goosebumps, tingling sensation
- BELOW LEVEL OF INJURY
- Nausea, chills without fever, clammy, coolness, paleness
Recently, there has been a lot of research in the understanding of AD. It is important to note that often individuals have AD without the pounding headache. Being aware of the other symptoms is important. If you suspect AD, check your blood pressure. If it is higher than your average with any one or a combination of symptoms, you probably are having AD. Medical treatment is available for AD. The first effort is to remove the noxious stimulus causing the AD. A bladder infection takes some time to treat, so you might need some medical intervention to treat the AD episode until the antibiotics are able to work.
A great prevention for urinary tract issues is a urodynamic study. Even if you do not feel that you have any urinary issues, a urodynamic study is critical to understand your baseline. We all age. As our bodies age, so do our bladders. If you know your baseline, you will be able to catch issues before they become problems.
In the urodynamic study, a small catheter with pressure sensors is inserted into the bladder. These sensors measure pressure in your bladder and urinary sphincters. A sensor might also be placed in the rectum to measure abdominal pressure. A sterile fluid is then dripped into your bladder. Measurements are assessed to ensure all parts of the urinary system are working in unison.
One issue that could be found in the urodynamic study is a small capacity bladder. This is often connected with individuals who use indwelling catheters or suprapubic catheters because urine is continuously drained which does not allow the bladder muscle to expand and contract. The lack of contraction may cause an issue if you want to convert to an intermittent program or other interventions may need to occur to enlarge your bladder.
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Another important diagnosis found through urodynamic testing could be detrusor sphincter dyssynergia (DSD). DSD means the bladder and urinary sphincter are not acting in unison. The bladder should contract while the urinary sphincters open. This allows urine to flow out. When the urine has emptied from the bladder, the bladder muscle should relax, and the sphincters should close. In DSD, the bladder may be contracting while the sphincter is also contracting. The result is increased pressure in the bladder which pushes urine back up into the kidneys. Medication is available to align the contraction of the bladder with relaxation of the sphincter.
Sometimes just the bladder or just the sphincter is over or under contracting. These conditions can also be corrected with medication. Some procedures can help correct these issues. A sphincterotomy is a small slit in the sphincter which limits the ability for it to contract. The result is a continuous outflow of urine but pressures in the bladder are avoided. Another option is the insertion of a stent to hold the sphincter open. Botox injections into the bladder or sphincter can aid in over contractions. One of these procedures might be performed if a person has an upper motor neuron bladder (UMN) or a bladder that is spastic.
For those without tone in their bladder or sphincter, trans obturator tape insertion, sling surgery, or artificial sphincter implantation is available. These procedures will tighten the sphincter or support the bladder but require intermittent catheterization for bladder emptying.
Other procedures include bladder augmentation where a small piece of bowel enlarges the bladder thereby increasing capacity. Urinary diversion is a stoma that is surgically created in the abdomen with a bag for collection of urine attached to the skin (much like a colostomy but for the urinary system). These procedures are generally not performed until less invasive interventions have failed.
Neuromodulation of the coordination of bladder and sphincter helps some individuals. External and internally placed functional electrical stimulation devices are used to supply messages to the bladder and sphincter to work on the individual’s demand. Some models are available, much more research is being conducted to further develop these treatments. Other research includes transferring nerves in the cauda equina (end of the spinal cord) to improve bowel and bladder function. Nerves in the cauda equina are peripheral nerves, not central nerves. Peripheral nerves can be transferred, central nerves currently cannot.
The important message from this blog are to have urinary tract infections treated early and to have urodynamic studies completed. Both procedures will ensure a healthy urinary tract for years to come.
Pediatric Consideration: Pediatric physiology including the urinary system is different from adults. The bladder is smaller making storage volumes less. Frequency of catheterization and intake will be different than from adults depending on the size of the child. Volumes for the pediatric populations are much smaller than for adults. It is critical for the parents and caretakers of children understand bladder care for the individual needs of the child. Watch for changes in babies or small children’s behavior, mental status and fever as the child might not be able to tell you something is wrong with their urinary system.