9

Urinary Tract and Bladder Health

IF You Had Asked me, before I was living with my disability, which organ would give me the greatest difficulty, I would have said my brain (because the medications make people sleepy and forgetful) or my arms and legs (because they were paralyzed). I was surprised to find that my bladder has actually given me the most problems, including but not limited to urinary tract infections (UTIs). In fact, this is true for almost everyone with an SCI and for many people after stroke.

The urogenital tract (Figure 16) starts at the kidneys, which filter the blood and create urine. Urine flows to the bladder via tubes called the ureters and into the bladder. As the bladder fills up and descends, it sends a signal to the brain that it is time to empty. When you are ready to go to the bathroom, the external sphincter of the urethra opens, allowing urine to pass. In people with penises, the urethra passes through the prostate, which frequently enlarges and squeezes the urethra, causing difficulty in passing urine. The urethra then goes through the penis. In people with vaginas, there is no prostate and a much shorter urethra, with an opening in the vulva.

Figure 16. Male urinary tract anatomy

A Disaster Waiting to Happen

It turns out that when you no longer have control of your bladder, urine either doesn’t come out when you want it to (neurogenic bladder) or comes out when you don’t expect it (incontinent bladder). In both situations, urine is likely to come in contact with bacteria in your groin, which can swim up into your bladder. Here, bacteria find a warm, nutrient-rich environment, so they grow quickly—the perfect scenario for infection.

In my case, this lack of control can mean not only UTIs but also embarrassing leaks around the tube site (I’ve found all kinds of tactics to avoid that, but urine can leak down my groin, wetting my underwear, shirt, pants, and finally, my wheelchair cushion). If you’re particularly unfortunate, the urine will drip onto your wheelchair or, even worse, onto the floor (usually carpeted!).

Neurogenic Bladder

Neurogenic bladder describes a number of urinary conditions in people who lack bladder control due to a brain, spinal cord, or peripheral nerve problem. Even if you suffered from neurogenic bladder at the time of your hospitalization, you’ll likely recover if your injury was a stroke or TBI. SCI survivors are the most likely to experience chronic neurogenic bladder, although some stroke patients will as well. People with chronic neurogenic bladder frequently have some of these symptoms: problems starting to urinate or emptying their bladder, frequent urination in small amounts, incontinence due to both sudden spasms and a constant leak, and inability to sense how full their bladder is.

SCI-Specific Urinary Problems

After SCI, you may experience “spastic bladder” or “flaccid bladder.” A spastic bladder fills with urine, and a reflex automatically triggers it to empty. Since you don’t know when the bladder will empty, sudden leakage can occur. With a flaccid bladder, the reflexes of the bladder muscles are absent. You can’t feel when the bladder is full, so it can become stretched (or overdistended) beyond its normal capacity, causing urine to back up through the ureters into the kidneys. This chronic reflux is damaging to the kidneys and, over time, can cause kidney failure. Both spastic and flaccid bladders can be treated with continuous bladder drainage. This can be accomplished using Foley catheters (see page 133) for short periods of time or suprapubic tubes (see page 136) for long-term treatment.

Urinary Tract Problems and Treatments

Keep in mind that as we get older, problems that impair bladder function increase in everyone, disabled or not. In people with penises, the most common problem is enlargement of the prostate (benign prostatic hypertrophy, or BPH), which then squeezes the urethra (Figure 16), making it difficult to urinate and necessitating frequent trips to the bathroom. In people with vaginas, the pelvic floor that keeps the bladder and its opening (sphincter) tight can become weak, making incontinence common. Because these changes are frequently part of the aging process, bladder management can be even more difficult as you get older. But there are a variety of treatments to combat these issues.

Bladder Management

There are several short- and long-term solutions for treating bladder dysfunction. After my accident, when I was in the intensive care unit, my bladder was drained continuously using a Foley catheter, a sterile tube inserted into the urethra (Figure 17). The Foley catheter is a temporary, short-term solution due to its size and the fact that it can introduce harmful bacteria into the urethra. It can also irritate and even damage the urinary tract, especially in people with penises.

Figure 17. Foley catheter

The long-term solutions to bladder management share three goals: 1) to make you as independent as possible, 2) to control when you urinate, and 3) to prevent urinary tract infections (UTIs) and kidney damage. The most common long-term solutions are Credé and Valsalva, self-catheterization, suprapubic tube, indwelling Foley catheter, and condom catheter.

Credé and Valsalva: In people with near-normal bladder function, it can be difficult to initiate urination because the external urethral sphincter won’t open. A simple solution is to increase the pressure in the bladder that forces the sphincter to open. The most common technique is called Credé’s maneuver, in which pressure is put on the abdomen below the navel to push on the bladder. The pressure can be further increased by performing a Valsalva maneuver, in which you inhale a large breath and then bear down as if having a bowel movement. The increased downward pressure forces the sphincter to open, but be careful: Too much pressure can cause sphincter damage and incontinence.

Self-catheterization: Self-catheterization involves manually inserting a sterile tube through the urethra and into the bladder (Figure 18A & B). Depending on your fluid intake, you’ll have to do this four to six times daily. You need to be able to sense bladder fullness, and/or regulate fluid intake so that the bladder does not overdistend. If there’s too much urine in the bladder, pressure can be transmitted up through the ureters to the kidneys, eventually resulting in kidney damage. Self-catheterization requires good manual dexterity to ensure that the catheter enters the urethra properly and to maintain tube sterility during the process so as not to introduce bacteria into the bladder. Recent advances in catheter design have resulted in self-lubricating catheters that contain their own drainage bag and can be used with only one hand. Of course, they cost quite a bit more than the basic catheters. The major advantages of self-catheterization are independence, cosmetic appearance, and no permanent object (catheter) in the bladder. A permanent catheter, like the Foley or suprapubic tube, will become colonized with bacteria over time, which may cause UTIs.

Figure 18. Self catheterization

Reflex voiding—condom catheter: Reflex voiding occurs when the bladder contracts involuntarily, even when it’s not full. To manage this, condom catheters, or external catheters, can be worn on the penis like a condom (Figure 19A & B). These are much less invasive than internal catheters, like Foley catheters, which must be inserted into the bladder. The major advantage of condom catheters is convenience, since a leg bag can be used to collect urine continuously (Figure 19B). The biggest advantage of a condom catheter is that incontinence won’t interfere with sleep; the major disadvantage is irritation of the penis, which can be minimized by appropriate sizing of the condom catheter, maintaining excellent hygiene, and moisturizing the skin. However, sometimes the skin on the penis becomes so damaged that it cannot tolerate the condom catheter. If a condom catheter cannot be used due to breakdown of penis skin, absorbent underwear must be worn until the skin recovers. This is unpleasant in terms of comfort and smell.

Figure 19. Condom catheter

Suprapubic tube (SPT): Insertion of an SPT requires a small surgery in which a tunnel is made from just below the navel to the bladder, and a catheter is passed into the bladder (Figure 20). Similar to a Foley catheter, it continuously drains the bladder. It’s connected to a leg bag that can hold 1 to 2 liters (about 1 to 2 quarts) of urine, depending on the size you need. SPT has several advantages over both an indwelling urethral catheter and self-catheterization. Since it doesn’t require sterile technique, it can be used by people with poor dexterity; you either unscrew a tip or flip a clamp to let the urine drain out. Compared to the Foley catheter, the SPT cannot damage the urethra; it’s less likely to get kinked or blocked, since the catheter is wider; everyone can use it; and it doesn’t interfere with sex. The SPT can be easily removed if bladder function improves; once the catheter is removed, the tunnel closes in a few days. There’s no restriction on fluid intake, and if your urine output varies significantly over the course of the day, there’s no risk of bladder distension and subsequent kidney damage. The cost of SPT is comparable to self-catheterization as long as the collection bags are changed every seven to fourteen days and sterilized daily with bleach.

Figure 20. Suprapubic tube

There are, however, more complications with SPT than with self-catheterization. The two major problems are bladder or kidney stones, and an increased risk for bladder cancer (especially if using the SPT for more than ten years). Bladder stones occur in at least 10 percent of people with SPTs.¹ They are problematic because they can plug the catheter, shorten the duration of its use, cause more bladder spasticity and leaks, and serve as additional objects for bacteria to colonize.

Surgical procedures: There are several surgical procedures that can be considered as alternatives to SPT. Among these, the Mitrofanoff procedure (Mitrofanoff appendicovesicostomy) involves connecting the navel to the bladder using the appendix as a conduit. It’s most commonly performed as an elective procedure for people with vaginas, because it avoids contamination from bacteria in the vagina, is easier than self-catheterization, is cosmetically appealing, and doesn’t interfere with sex. The major disadvantage is that it requires surgery, which has a higher risk of complications than SPT surgery.

Drug treatments: There are a number of drugs that can improve bladder function, but many of them have undesirable side effects: constipation, dry mouth, and blood pressure increases or decreases. Drugs that inhibit bladder spasticity include anticholinergic drugs (e.g., oxybutynin, solifenacin, tolterodine, and fesoterodine), and mirabegron, a beta 3-adrenoceptor agonist with fewer side effects than anticholinergics—notably, less dry mouth and constipation. These medications decrease bladder tone and suppress bladder spasms, thereby reducing urinary frequency and incontinence.

More invasive and expensive therapies are usually reserved for people who are intolerant to drug therapy. Botulinum toxin (Botox) can be injected into the bladder to relax the muscle and lessen spasticity by inhibiting the nerve transmitter acetylcholine. A comprehensive analysis of nineteen trials showed significant decreases in urgency, bladder spasms, and leakage that were better than medications.² The toxin lasts for six to twelve months and has no systemic side effects, making it particularly safe and effective, though it increases the risk for UTIs and urinary retention.

My History of UTIs

I used a Foley catheter for the first six weeks after my injury, but I developed a UTI and had blood in my urine. Because my injury was high in the cervical spine, the strength and dexterity of my hands and arms were limited. I couldn’t self-catheterize, so I chose a suprapubic tube (SPT), which worked quite well, at first. I had only one UTI, which was readily treated with antibiotics. Then, after two years of use, I began to develop leaks around the SPT that occurred at the most inopportune times. In the middle of an important meeting, I would look down and see an expanding area of my pants becoming darker. I would smell an odor that resembled apple cider, which indicated that urine was flowing around the SPT and into my pants. Sometimes, it was wicked up by my undershirt and dress shirt, leaving a visible yellowish-brown stain. With the help of my urologist, we battled the problem on two fronts: prevention and defense.

Devices: Electrical stimulation of nerves that supply the bladder to control bladder spasticity is a rapidly evolving technology. The most common approach is sacral neuromodulation, in which an electrode is placed into the lower spine and connected to an electrical stimulation device. The current approved FDA devices are the Axonics and InterStim. But these devices have not been extensively used in people with ANI, so I wouldn’t recommend them at this time. I believe that in the future, there will be significantly better devices to restore bladder function.

UTI and Bladder Spasm Prevention and Defense

The major goals of prevention are to limit bladder spasms and UTIs. A common cause of leaks for those using SPT is bladder spasms. These occur more commonly in people with indwelling catheters, because the bladder shrinks and the muscle becomes irritable. This is worsened by UTIs, which make the bladder even more spastic. The medical solution is drugs (such as oxybutynin) that inhibit spasticity. These drugs have numerous side effects; the most notable of which are dry mouth, constipation, and drowsiness.

The first line of defense is absorbent padding, such as disposable absorbent briefs (such as Depend), which are commonly used for people with vaginas. But briefs can be bulky in those with penises, making your pants fit poorly. They can also make you hot, sweaty, and uncomfortable. Instead, people with penises may choose to use an abdominal barrier pad, which is absorbent on one side and water-resistant on the other, taped into their underwear. The problem with this solution is that the pad can absorb only a small amount of urine before the urine finds a way to flow down below the pad and onto your clothes.

If you’re experiencing frequent leaks and/or UTIs, use this chapter to help you identify the problems that give rise to them, and develop solutions. Each person is unique, so whatever system works best for you is what matters.

Urinary Tract Infections (UTIs)

Diagnosis: You may be surprised to read that UTI diagnosis can be difficult—even more so if you have an indwelling catheter. The catheter constantly irritates the bladder, causing white blood cells to accumulate, and over time, the bladder becomes colonized with bacteria. In people with normal bladder function, the presence of white blood cells and bacteria, accompanied by frequent urination (with urgency) is typical of a UTI. In people with ANI, however, these things are present when there is no UTI. The question, then, is what are symptoms of a UTI that requires treatment in people with ANI?

Most infections increase body temperature, but UTIs frequently don’t, especially in older people. Symptoms may include pain in the lower abdomen, increased spasticity, feeling sick, fatigue, headache, incontinence, and urgency. The first time I had a UTI after my injury, I knew something was wrong—I was incredibly cold, my muscles hurt, and my arms and hands were flexed inward (assuming an almost fetal position). When I have a UTI, I can tell from three changes in my urine, which are common in most people with UTIs. First, my urine becomes cloudy; when I hold a piece of printed paper behind the urine container (I use a clear container), I can’t read the words. Second, it begins to smell bad, like rotten meat. Third, I experience bladder spasms that result in urine leaking around my SPT site. After two or three UTIs, you’ll learn to recognize your symptoms, too. If these symptoms don’t resolve within twenty-four hours, ask your doctor to order a urinalysis and a urine culture to determine which bacteria are present and what antibiotics you’ll need.

Treatment: Once a UTI has been diagnosed, there are two highly effective treatments: antibiotics and forcing fluids. If you don’t have a catheter, your doctor may prescribe antibiotics if you show systemic signs of UTI (fever, spasticity, pain, and fatigue). The antibiotics must be proven by laboratory testing to kill the bacteria, and you’ll need to drink at least two quarts of water and other fluids every day to help “wash out” the bacteria.

If you have a catheter (Foley or SPT), it’s best to avoid antibiotics unless you have significant systemic signs. The catheter will almost always contain bacteria that can’t be killed, so using antibiotics will ultimately lead to dangerous drug-resistant bacteria in your catheter.

So what can you do? There are no good clinical studies to guide us, but there are several treatments I and many others have found effective. The safest is to increase fluid intake so that the volume of urine increases. My mantra for this treatment is the more the flow, the less they grow. When you have an infection, the bacteria attach themselves to your bladder wall and build a covering called a biofilm, which protects them from patrolling white blood cells. But when there’s a large volume of urine flow, the bacteria can’t build their biofilm, and they are flushed out of the bladder. Another approach is to lower the pH of your urine (acidification), which makes it difficult for the bacteria to live and grow. There are many suggested remedies, but I have found that using a dilute form of bleach, clorpactin, is very effective when I have a UTI. It is infused into my bladder through the SPT and stays there for two treatments of two minutes. Also, lowering your pH with vitamin C and methenamine hippurate or methenamine mandelate (my preference), can be effective as prevention in the long term. Some people use a powerful antibiotic (like gentamicin) in saline solution to wash their bladder. (This treatment was never effective for me.)

If you have bladder stones, the best treatment is to dissolve the stones. Renacidin—a combination of citric acid, glucono-delta-lactone, and magnesium carbonate—is often prescribed as a solution of 50 ml, which is infused through the tube and drained after forty-five minutes. It must be used three to four times daily for several days to dissolve the stones. If the stones are too large, it won’t work, and your urologist will have to physically remove the stones using a special endoscope.

Prevention of UTIs

Frequent UTIs can be extremely frustrating. If left untreated, they can spread to the kidneys and even to the bloodstream, causing an infection called sepsis; it’s serious, and it requires hospitalization and intravenous antibiotics. For all these reasons, prevention should be a major focus of your everyday life.

Treat Fatigue and Stress: Unfortunately, fatigue and stress are prevalent in many of us, and they make you more susceptible to UTIs. Fatigue is slightly easier to address. You’ll need to get enough sleep for your body to heal (at least seven hours and preferably eight each night). And don’t overdo it when working or playing. When you begin to feel tired, it’s time to stop and rest. Stress is much more difficult to treat because we don’t always recognize when we’re experiencing it. The good news is that the same methods that increase your awareness of stress also help you reduce stress: self-awareness, mindfulness, and meditation (see chapter 8).

Take D-mannose: One of the most common bacteria that cause UTIs is Escherichia coli (E. coli), which is found in stool. E. coli infects the bladder by binding to the epithelial cells that line the bladder. Because the binding site looks like D-mannose (a sugar, like glucose), the idea is to trick the E. coli to bind to the D-mannose and then be flushed out with the urine. Because D-mannose is specific for bacteria and is 100 percent excreted in the urine, it has almost no side effects. D-mannose is taken as 1 g twice daily, either dissolved in a powder or as a pill by mouth.

Practice good dental hygiene: If you have periodontitis (infection of the gums), your gums shed bacteria that enter the bloodstream. During routine flossing and hygiene, this bacteria shedding can increase significantly. The bacteria travel through the bloodstream to the kidneys and then are excreted in the urine. Meticulous attention to dental hygiene to prevent and cure periodontitis is very important to decrease bacteria in the bladder.

Increase fluid intake: A very simple approach to preventing UTIs is to increase flow through the bladder. Try to drink eight 8-ounce glasses of liquid every day. This regimen is simple to remember and easy if you have continuous drainage of your bladder by Foley, SPT, or condom catheter. If you use self-catheterization, it’s inconvenient to catheterize more than three or four times per day, so most people will limit fluid intake, especially after dinner. Because you have no permanent catheter for bacteria to attach to and grow, it’s less important for you to increase urine flow.

Take methenamine hippurate or methenamine mandelate and vitamin C: Acidic urine (low pH) prevents bacterial growth. Methenamine, when taken with vitamin C, lowers urine pH. It is generally well tolerated, except for mild abdominal cramps; many people (myself included) have found it to be beneficial. You can do an empirical trial yourself: Count the number of UTIs you have over six months while taking 500 mg methenamine plus 1,000 mg vitamin C, three times daily. Then count the number of UTIs over six months without treatment. If you have fewer infections and no side effects, you may decide to continue use. I would start with mandelate and, if not effective, then try hippurate.

Take vitamin C alone: Vitamin C alone (500 to 1,000 mg twice a day) has been proposed to prevent UTIs by two mechanisms. First, it can be converted into ascorbic acid in the bladder, and if sufficient acidification occurs, it may prevent bacterial growth. Second, it’s an antioxidant, which may restore the health of bladder tissue. There are, however, no strong studies showing a benefit of vitamin C alone; it is more effective when used with methenamine, as discussed above.

Take probiotics: Probiotics are cultures of bacteria thought to be beneficial by inhibiting bacteria that cause disease. In particular, certain strains of bacteria, such as lactobacillus (which is present in almost all yogurt), interfere with the colonization of the bladder by harmful bacteria such as E. coli. Studies using probiotics have yielded conflicting results, probably because the composition of probiotics is highly variable. The use of probiotics by mouth has shown no benefit. The best positive studies for probiotics have been in people who use vaginal suppositories containing live cultures at least twice weekly. You may consider performing your own test over six months to determine whether suppositories work for you.

Treatments That Are Not Recommended

Even with the best of intentions, many people will still have at least one UTI a year. Consequently, there are some preventive practices, many of which I do not recommend, that have become popular with both disabled and nondisabled people.

Antibiotics: Antibiotics should not be used as prevention but instead limited to situations in which a UTI is clearly present; there are simply too many harmful consequences of using antibiotics daily: 1) If you use the same antibiotic daily, it’s likely that the bacteria will eventually become resistant to it; 2) Antibiotics modify the types of good bacteria present in your intestines (your gut microbiome), and changes in the gut microbiome can produce molecules that are harmful to other organs, such as the brain, heart, and liver. Antibiotics can also allow overgrowth of harmful bacteria such as Clostridium difficile (C. diff), which secretes a toxin that causes severe diarrhea and can lead to death; 3) Many antibiotics interfere with the metabolism of other drugs, which can cause toxic side effects. For example, the antibiotic ciprofloxacin (brand name Cipro) interacts with 129 different medications; and 4) Antibiotics can be expensive.

Cranberry: There are many studies of cranberry juice or concentrate, cranberry tablets, and cranberry capsules to prevent UTI. The studies included people with neurogenic bladder, women with recurrent UTIs, pregnant women, and cancer patients. In all groups, there was no benefit of taking cranberry for UTI prevention.

New Approaches on the Horizon

Three areas hold great promise for bladder health:

1. Probiotics: In addition to the bacteria present in the bladder, there are also bacteria present in your intestines, which are called the gut microbiome. It may become possible to identify the good and bad bacteria in your gut and use specific probiotics (or treatments that facilitate growth of beneficial bacteria) to increase the good bacteria and inhibit harmful bacterial growth in the bladder;

2. Devices to control bladder function: New devices may take advantage of the intact peripheral nerves and muscle in the bladder. In the future, we may implant biosensors, which can measure pressure and distension, in the bladder, and electrical stimulators that coordinate opening of the urethral sphincter and contraction of the bladder;

3. Catheter material: Materials used for catheters may be improved to make it more difficult for bacteria to adhere and may even slowly release medicines or compounds that prevent bacterial colonization and growth. Currently, many catheters are made with silver in them, but its efficacy is limited.

There’s a powerful connection between your gastrointestinal system and your bladder, starting with periodontal health and ending with the bacteria in your colon. So it’s not surprising that many people encounter similar problems with their gut—which will be explored in the next chapter.

 

Everything You Need to Know

For many, maintaining a healthy bladder can be a challenge. Since your bladder health is crucial to your overall health and longevity, as well as your quality of life, it’s important to be vigilant in the areas that impact your bladder’s function and susceptibility to infection.

If you’re permanently incontinent, there are a number of options to consider, and it’s important to be as informed as possible when you and your doctor discuss which ones you might try. There are advantages and disadvantages to virtually all of them, so your decision will depend on your personal priorities and what can work well for you in the long term.

Urinary tract infections are not an “inconvenience”—they are serious threats to your health. They can be difficult to diagnose accurately, so be sure you learn to recognize your own symptoms. Treatments vary as well; keep in mind that it’s easy for a doctor to prescribe an antibiotic, but it’s also far too easy for that approach to have negative consequences on your overall health. An ounce of prevention is worth a pound of cure.

As always, keep a notebook to record your health achievements and setbacks so that you can see what works best for you.