Bladder Training and Catheters

This text is taken from the Body Care chapter in SIA’s publication
‘Moving Forward 3’ updated by Wendy Pickard. Coloplast have
sponsored the placing of this page in the Factsheets area

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the bladder, and then withdrawn when the bladder is empty; or a small surgical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, 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 (see 8.c).

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 (see 8.c). 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 (see 20.i). Take care
that the water is not too hot.
Catheters
(Astra Tech have sponsored the placing of this page of text from
‘Moving Forward 3’ into the Factsheets area)
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. While you are away from home the catheter can be
dried and stored in a clean plastic bag – and reused for a week.
Self-lubricating catheters usually require 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.