Your Bladder

Know about your bladder and kidneys

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How the bladder normally works

Urine forms as the blood filters through the kidneys. The urine drains down through tubes called ureters for storage in the bladder.

When your bladder is full of urine, it causes the bladder wall muscles to stretch. Nerve impulses or messages travel from your bladder to your brain via your spinal cord. You become aware of how full your bladder is and can decide whether to urinate or to wait until later. You have control over when you go to the toilet.

If you choose to pass urine, your brain sends a message down the spinal cord to the bladder to contract its muscles. As the bladder contracts, the bladder outlet or sphincter muscles relax for coordinated emptying. The urine passes through the urethra to outside of the body.

If you choose not to pass urine, your bladder will keep holding urine until you decide to go to the toilet.This is how your bladder works to store and then pass urine when you do not have a spinal cord injury.

An illustration of the kidneys with labels
Illustration of the bladder with labels

Effects of a spinal cord injury

After injury, spinal nerves carrying messages from the brain to your bladder do not work in the usual way. This type of bladder is often referred to as a neurogenic bladder.

There are two main types of neurogenic bladder depending on where your injury is:

diagram of skeleton showing T12

T12

Overactive or spastic (hyperrefeflexic) bladder

At and above T12 vertebral level (sacral nerves are intact)

diagram of an overactive or spastic (hyperreflexic) bladder

  • Bladder muscles get very excited due to lack of control by the brain.
  • Bladder holds less urine and bladder muscle spasms as bladder fills up.
  • Results in high pressure as the bladder fills with more frequent but poorer urination.

Underactive or flaccid (areflexic) bladder

Below T12 vertebral level (sacral nerves are damaged)

diagram of an underachieve or flaccid (areflexic) bladder

  • Bladder muscles are sluggish or do not work due to damage to the sacral nerves. 
  • Loss of the ability to contract and bladder is easily stretched. 
  • Bladder can overfill and leak. 

Note: Due to the level of spinal cord injury, some bladders may have a mixed pattern, with some features of both main types.

When you have a neurogenic bladder, you may experience problems with storing urine and/or completely emptying your bladder.

This is a common problem in an overactive bladder that empties too soon and often without any warning as it fills with urine. This usually occurs in people with spinal cord injury above the T12 level.

It can cause:

  • Urine to leak (incontinence)
  • Passing urine more often
  • A strong sense of need to pass urine (urgency)
  • High back pressure on the kidneys as the bladder is filling up.

Leakage of urine can also occur in an underactive bladder due to overflow (see ‘Problems with emptying your bladder’).

Your doctor may recommend taking an oral tablet to relax your bladder. The most common anticholinergic medication is Oxybutynin (sold as Ditropan). If tablets do not work, a Botulinum toxin injection into the bladder wall may help. This aims to increase the urine storing capacity of an overactive bladder. 

This is a common problem in an underactive bladder that does not empty well and retains urine. It can stretch and fill up too much, causing urine to leak when it overflows.

Failure to empty well can also occur in an overactive bladder. This is due to the bladder outlet or sphincter muscles spasming as the bladder empties. This can cause difficulty inserting a catheter or prevent emptying of the bladder completely. There is an increased chance of infection if the amount of urine remaining in the bladder is 100ml or more.

Your specialist may recommend taking an oral tablet (alpha-adrenergic blocker) to relax your sphincter muscles. Botulinum toxin injection into the sphincter muscle or surgery called a sphincterotomy are other options.

How Does Spinal Cord Injury Effect the Bladder?

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How people manage their bladder

In 2015 the Rural Spinal Cord Injury Project surveyed 681 people living with spinal cord injury in rural NSW.  These were their findings on the most common methods people used for managing their bladder.

Ways people manage their bladder

Suprapubic catheter
45%
Intermittent self-catheterisation
22%
Voluntary control
13%
Indwelling catheter
7%
Other
13%
ison of person with a suprapubic catheter

Ways to empty your bladder

There are three common ways to empty your bladder:

  1. Intermittent catheterisation
  2. Permanent catheterisation
  3. Reflex voidingreflex voiding is no longer recommended due to associated risks.

The choice of method depends on factors such as level of injury, lifestyle and gender.

The two most common methods are explained below.

Intermittent catheterisation

  • This is the preferred method for people with enough hand function.
  • Using this method, drain the bladder for 5 minutes or so by inserting a catheter at regular intervals.
  • Drain the bladder every 4 to 6 hours, but this depends on the amount and type of fluid you drink.
  • Recommended catheter size is 14, but for people with prostrate problems, use 16 gauge instead.
diagram on how to insert a catheter correctly

Important Notes

Intermittent catheterisation is not recommended when you have:

  • Abnormal urethral anatomy (such as stricture, false passages, and bladder neck obstruction)
  • Reduced bladder capacity (less than 200ml)
  • Poor decision-making, lack of motivation, inability or unwillingness to adhere to the catheterisation time schedule
  • Persistently high fluid intake
  • Adverse reaction to passing a catheter into the genital area multiple times per day
  • Tendency to develop episodes of autonomic dysreflexia with bladder filling despite treatment.

What does research tell you?

  • Clean intermittent self-catheterisation is the preferred method of bladder management for people with spinal cord injury who have enough hand function.
  • The use of single-use hydrophilic catheters lowers the risk of a urinary tract infection.

Permanent catheterisation

  • There are two types of permanent catheterisation:

    • Indwelling catheter (IDC): this catheter drains urine from your bladder via the urethra. Recommended catheter size is 12 to 16 gauge.
    • Suprapubic catheter (SPC): this type of catheter is inserted into the bladder through a small cut in the lower abdominal wall. Recommended catheter size is 18 to 24 gauge.

    In both types, there is continuous drainage with the urine draining into a urinary drainage bag.

Indwelling-catheter-diagram-with-labels

Important Notes

Reflex voiding involves passing urine by triggering an automatic response using a technique like tapping over the bladder or stroking the inner thigh.

Reflex voiding is no longer recommended because of the long-term risk of high pressure being placed on the kidneys as the bladder fills against resistance which may lead to kidney failure in the long term.

Reflex voiding may also lead to other potential problems such as catheter leakage or skin breakdown of the penis. Using a condom catheter may result in recurrent symptomatic UTI, poor bladder emptying, and autonomic dysreflexia.

Do you know?Some people use a flip-flo valve attached to their permanent catheter and/or bag, which is not continuous and NOT recommended for people at risk of autonomic dysreflexia.

What does research tell you?

  • People with an overactive bladder using a permanent suprapubic or indwelling urethral catheter are recommended to take an anticholinergic medication.
  • Reflex voiding should no longer be used because it can cause too much pressure in the bladder and damage to the kidneys.

Selecting a catheter

When selecting a catheter that works best for you, consider the following:
  • Your level of injury
  • Degree of hand function and dexterity
  • Your lifestyle (includes school, work and social activities)
  • Cost and ease of use
  • Other existing medical conditions
  • The availability and expertise of your caregiver.

Do you know?

A single-use, disposable catheter may help reduce the chances of bladder infection, especially with a catheter tip that remains sterile (closed ‘no touch’ system). This type of catheter may be preferred, particularly when you are experiencing frequent urinary tract infections.

Advantages and disadvantages of different types of catheters

Type of management
Advantage
Disadvantage
Intermittent catheterisation
Reduced infection.
Usually need to take anticholinergic medications which are costly and you may require assistance with insertion.
Permanent catheter
Reduces pressure in your bladder and often recommended with limited hand function. Convenience and less caregiver assistance.
Increased risk of infection, problems with blockage. May need to access external providers for catheter changes.
Type of management
Intermittent catheterisation
Advantage
Reduced infection.
Disadvantage
Usually need to take anticholinergic medications which are costly and you may require assistance with insertion.
Type of management
Permanent catheter
Advantage
Reduces pressure in your bladder and often recommended with limited hand function. Convenience and less caregiver assistance.
Disadvantage
Increased risk of infection, problems with blockage. May need to access external providers for catheter changes.

Bladder management supplies

Eligibility for continence supplies

You may be eligible (certain criteria apply) for continence supplies under various schemes, as summarised in the table below:

Schemes/ Programs
Under 65 years
65 years and over
National Disability Insurance Scheme (NDIS)
$
My Aged Care
*
Continence Aids Payment Scheme (CAPS)
EnableNSW
icare NSW#

$ Unless you have accessed scheme prior to turning 65 years.

* Your package may not include your bladder supplies.

# For eligible participants only. 

Please talk to the relevant organisation/s or your healthcare provider for details about eligibility and further information.

Schemes/ Programs
Website
Contact details
National Disability Insurance Scheme (NDIS)
www.ndis.gov.au/people-disability
1800 800 110
My Aged Care
www.myagedcare.gov.au
1800 200 422
Continence Aids Payment Scheme (CAPS)
www.bladderbowel.gov.au/caps
1800 239 309
EnableNSW
www.enable.health.nsw.gov.au
1800 362 253
icare NSW
www.icare.nsw.gov.au
1300 738 586
Schemes/ Programs
Contact Details
National Disability Insurance Scheme (NDIS)
www.ndis.gov.au/people-disability
1800 800 110
My Aged Care
www.myagedcare.gov.au
1800 200 422
Continence Aids Payment Scheme (CAPS)
www.bladderbowel.gov.au/caps
1800 239 309
EnableNSW
www.enable.health.nsw.gov.au
1800 362 253
icare NSW
www.icare.nsw.gov.au
1300 738 586

The details in this table were last verified on 28th April 2022

Quick Bladder Check

Bladder Check

How do you empty your bladder?

Please select one answer below

Have you been experiencing any recent problems or changes in bladder emptying/ drainage?

Please select one answer below

 

bladder icon

Difficulty passing catheters into your bladder or bleeding afterwards?

Please select one answer below

 

Illustration of inserting a catheter

Frequent catheter blockages requiring catheter changes. Is this getting worse?

Please select one answer below

Difficulties passing urine (taking longer or needing to strain more)?

Please select one answer below

Have you been experiencing any problems with leakage of urine (incontinence) or less warning before leaking (an increased sense of urgency)?

Please select one answer below

 

illustration of a man with hands in front of groin area

Have you been experiencing signs or symptoms, including:

General – fever, chills, nausea, vomiting, feeling unwell, cloudy or smelly urine, discomfort/burning when urinating or blood in urine,

along with

Specific to SCI – leakage of urine (incontinence), increased spasms, lower abdominal pain or autonomic dysreflexia?

Please select one answer below

Have you been experiencing a dull aching pain and tenderness in one or both flanks (lower back below ribcage at side) where your kidneys are located?

Please select one answer below

woman holding her back with red indicating pain in her lower back area

Have you been noticing an increase in sediment, sand, grit or hard calcified matter in your urine?

Please select one answer below

a urine test kit with ph indicator strips and a urine sample

Have you seen any blood in your urine recently?

Please select one answer below

two sample jars of urine showing the difference between visible and microscopic haematuria

Severity scale

To check the severity of your problem, consider the intensity, duration and frequency of your signs and symptoms by using this scale.

Please select one answer below

Are you experiencing high urine volumes (more than 600ml), increased frequency of bladder voiding or passing more catheters overnight?

Please select one answer below

Have you been experiencing frequent episodes of pounding headache, profuse sweating, blotchy skin/rashes or blurred vision related to your bladder (e.g., distended bladder, blocked catheter), which may indicate autonomic dysreflexia?

Please select one answer below

Alert! icon  Important notice

Any bladder-related symptoms of any severity associated with autonomic dysreflexia are considered severe and require urgent medical attention.

Severity scale

To check the severity of your problem, consider the intensity, duration and frequency of your signs and symptoms by using this scale.

Please select one answer below

Interference scale

To determine to what extent does your problem interfere with participating in everyday activities, use the scale below.

Please select one answer below

Managing your problem

Based on your selections, we use the assessment ratings on both severity and interference scales to help you decide what level of support you may need to most effectively manage your problem.

Managing your problem

This Quick Health Check asks questions based on the most common health problems that people living with a spinal cord injury experience, but not all. It is important that you consult with your healthcare professional to identify your problem and how best to treat it.

Please note, keeping a Bladder Diary for several weeks prior to consultation will help your healthcare professional to better understand the problem.

Difficulty inserting a catheter

Your condition is: Mild (with little or no interference) 

Recommended management pathway: Self-manage without support

Care plan: You can download a care plan for difficulty inserting a catheter here

Your condition is: Mild (with little or no interference)

Recommended management pathway: Self-manage without support

Care plan: You can download a care plan for difficulty inserting a catheter here

Your condition is: Mild (with some or a lot of interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for difficulty inserting a catheter here that you can share with your GP or other healthcare professional

Your condition is: Mild (with some or a lot of interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for difficulty inserting a catheter here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for difficulty inserting a catheter here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for difficulty inserting a catheter here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for difficulty inserting a catheter here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with a lot of interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for difficulty inserting a catheter here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for difficulty inserting a catheter here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for difficulty inserting a catheter here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for difficulty inserting a catheter here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for difficulty inserting a catheter here that you can share with your GP and/or spinal specialist

Catheter blockage

Your condition is: Mild (with little or no interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for catheter blockage here 

Your condition is: Mild (with little or no interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for catheter blockage here 

Your condition is: Mild (with some or a lot of interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for catheter blockage here that you can share with your GP or other healthcare professional

Your condition is: Mild (with some or a lot of interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for catheter blockage here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for catheter blockage here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for catheter blockage here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for catheter blockage here that you can share with your GP or other healthcare professional 

Your condition is: Moderate (with a lot of interference) 

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for catheter blockage here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for catheter blockage here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for catheter blockage here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for catheter blockage here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for catheter blockage here that you can share with your GP and/or spinal specialist

Difficulty passing urine

Your condition is: Mild

Recommended management pathway: Self-manage without support

Your condition is: Mild

Recommended management pathway: Self-manage without support

Your condition is: Mild

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Your condition is: Moderate

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Your condition is: Moderate

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Your condition is: Moderate

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Your condition is: Moderate

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Your condition is: Moderate

Recommended management pathway: Manage with specialist support

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Urine leakage

Your condition is: Mild (with little or no interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urine leakage here 

Your condition is: Mild (with little or no interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urine leakage here 

Your condition is: Mild (with some or a lot of interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urine leakage here that you can share with your GP or other healthcare professional

Your condition is: Mild (with some or a lot of interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urine leakage here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urine leakage here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urine leakage here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urine leakage here that you can share with your GP or other healthcare professional 

Your condition is: Moderate (with a lot of interference) 

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for urine leakage here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for urine leakage here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for urine leakage here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for urine leakage here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for urine leakage here that you can share with your GP and/or spinal specialist

Urinary tract infection (UTI)

Your condition is: Mild (with little or no interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urinary tract infection here 

Your condition is: Mild (with little or no interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urinary tract infection here 

Your condition is: Mild (with some or a lot of interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urinary tract infection here that you can share with your GP or other healthcare professional

Your condition is: Mild (with some or a lot of interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urinary tract infection here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urinary tract infection here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urinary tract infection here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for urinary tract infection here that you can share with your GP or other healthcare professional 

Your condition is: Moderate (with a lot of interference) 

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for urinary tract infection here that you can share with your GP or other healthcare professional 

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for urinary tract infection here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for urinary tract infection here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for urinary tract infection here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for urinary tract infection here that you can share with your GP and/or spinal specialist

Prostatitis

Prostatitis refers to swelling and inflammation of the prostate gland. This can develop gradually or suddenly. It often affects young or middle- aged men.

There can be pain in the lower abdomen or when passing urine (burning) if sensation is present. There may be problems with urination, difficulty passing catheters or painful ejaculation. Chronic prostatitis can also lead to recurring urinary tract infections.

Your doctor may recommend you to take antibiotics to treat the infection. Antibiotic treatment without symptoms is usually not necessary.

Bladder and kidney stones

Your condition is: Moderate (with some interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for bladder and kidney stones here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for bladder and kidney stones here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for bladder and kidney stones here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with a lot of interference) 

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for bladder and kidney stones here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for bladder and kidney stones here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for bladder and kidney stones here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for bladder and kidney stones here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for bladder and kidney stones here that you can share with your GP and/or spinal specialist

Blood in urine

Your condition is: Moderate (with some interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for blood in urine here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference)

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for blood in urine here that you can share with your GP or other healthcare professional

Your condition is: Moderate (with some interference) 

Recommended management pathway: Self-manage with support from your GP or other healthcare professional

Care plan: You can download a care plan for blood in urine here that you can share with your GP or other healthcare professional 

Your condition is: Moderate (with a lot of interference) 

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for blood in urine here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for blood in urine here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for blood in urine here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for blood in urine here that you can share with your GP and/or spinal specialist

Your condition is: Severe

Recommended management pathway: Manage with specialist support

Care plan: You can download a care plan for blood in urine here that you can share with your GP and/or spinal specialist

Alert! icon  Important notice

Any bladder-related symptoms of any severity associated with autonomic dysreflexia are considered severe and require urgent medical attention.

High urine output

High urine volume, called polyuria, occurs when you urinate more than normal (greater than 3 litres per day in an adult). Urine volume depends on how much you drink, your age and gender. A urine output of 2 litres or less per day is usually considered normal, passing 250-400mls each time.

Find out more about high urine output

Diaries

Diaries

Keeping a Bladder Diary will provide you and your healthcare professionals with a good understanding of your bladder function and factors affecting it to be able to manage it better.

Keeping a Fluid Diary will provide you and your healthcare professionals with a good understanding of your bladder or kidney problem and how fluid intake influences your bladder/kidney health. It also will help to monitor changes with treatment. For example, making changes to your medications or frequency of bladder emptying may result in less urine leakage.

It is recommended that you complete the diary for a minimum of 7 days to identify any pattern or trend. If completing the bladder and bowel diary, you only need to collect information on fluid intake once.

You can download editable pdf version of the diary or create a digital diary on your device using the SCI Health Toolkit app.

Please note: Diaries must be downloaded to be completed – they cannot be filled in online

The SCI Health Toolkit App

The SCI Health Toolkit app provides you with a bladder and fluid diary in your pocket, along with all of the other diaries available on The Health Maintenance Toolkit website.

You can quickly and easily track and monitor key bodily functions and activities using the interactive and simple to use diaries.

SCI Health Toolkit app showing diary on screen

Quiz

Know about your bladder and kidneys

You may wish to see how much your knowledge has grown by taking this quick quiz.


Manage problems

Management of bladder and kidney problems

Skip to...

Manage a problem ‘just-in-time’

Serious complications can arise if bladder and kidney problems are not managed in a timely way.

In the long term, these issues can lead to:

  • Recurrent infections
  • Stones in the bladder or kidneys
  • Kidney damage and chronic renal failure
  • Bladder cancer.
young-handsome-disabled-man-on-wheelchair-petting his dog

Just-in-time, or the right care at the right place at the right time, will reduce risk and prevent complications. As a result, you will maintain your quality of life, independence, health and wellbeing. 

Be proactive and take responsibility for managing your own health risks.

This involves:

  • Education about how your spinal cord injury affects your bladder and what research tells us.
  • Becoming a partner in decision-making with your doctor and health professionals.
  • Developing an individualised bladder plan
  • Engaging in ongoing health and wellness activities for a healthy bladder:
    • Exercising regularly 
    • Watching your weight 
    • Drinking more water 
    • Taking medications as directed 
    • Scheduling an annual check-up.

Managing your bladder

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Common problems

(this may be due to an overactive sphincter muscle, damage and narrowing of urethral passage or enlargement of prostate gland)

What does research tell you?

illustration of hospital waiting room icon with Petri dish

Urinary tract infection

67% 

of individuals hospitalised were
admitted primarily for treatment of a urinary tract infection

icon of person with drops emitting from them

Urine leakage

33% 

of individuals performing intermittent self-catheterisation reported urine leakage

illustration of catheter

Blocked catheters

20% 

of individuals using a permanent suprapubic or indwelling urethral catheter reported blocked catheters

2015 Rural Spinal Cord Injury Project survey of 681 people living with spinal cord injury in rural NSW

Urinary tract infection

Urinary tract infection (UTI) is an infection of the urinary system (including kidneys, ureters, bladder and urethra). It is a very common problem after spinal cord injury. Most infections involve the lower urinary tract — the bladder and the urethra. UTI occurs when bad bacteria enter and multiply in the bladder.

General signs and symptoms of UTI may include:

  • Fever and chills
  • Feeling unwell and lethargy
  • Nausea and vomiting
  • Blood in urine.

Note: Cloudy or smelly urine alone does not need antibiotics or urine testing. 

Spinal cord injury specific signs and symptoms of UTI may include:

  • Abdominal discomfort or flank pain, as well as
  • Increased spasms, autonomic dysreflexia or sense of unease.

Note: Due to your spinal cord injury, you may not experience common signs and symptoms of urinary tract infection such as a burning sensation when urinating. 

How to treat a urinary tract infection

  • Collect a urine sample from a fresh catheter change (or from an indwelling catheter if changed within a week). Do this before starting treatment.
  • Increase fluid intake as this helps to dilute urine and flush out bacteria.
  • Take antibiotics as prescribed – usually for 7-10 days and do not stop when feeling better. Send another urine specimen for analysis 48 hours after finishing your course of antibiotics to check if your urine infection has cleared.
  • You may need to take a second course of antibiotics if it takes a few days before you start to feel better.
  • If you are not feeling better, check with your doctor if you are taking the right antibiotic.
  • If you experience frequent infections, presence of grit or blood in your urine, you may need an ultrasound. You may also need a referral to a urologist or your spinal specialist for a medical review.
a urine test kit with ph indicator strips and a urine sample

What does research tell you?

Long-term use of antibiotics is not encouraged as it results in reduced effectiveness of that antibiotic.

Urine leakage

After spinal cord injury, leakage of urine can happen as the bladder fills and stores urine. This is also known as incontinence.

There are several different types of incontinence:

diagram showing stress incontinence
Stress incontinence occurs when the pelvic muscles cannot hold the urine as bladder pressure increases. For example, this may happen during a transfer, exercise, coughing or sneezing.

diagram showing stress incontinence
Stress incontinence occurs when the pelvic muscles cannot hold the urine as bladder pressure increases. For example, this may happen during a transfer, exercise, coughing or sneezing.

Overactivity incontinence occurs when the bladder automatically contracts while it is filling.

 

Urge incontinence can also occur in an overactive bladder. This happens when there is a sudden desire to pass urine and you can’t hold on long enough to get to the toilet.

diagram of overflow incontinence
Overflow incontinence occurs when urine leaks from a bladder that is always full.

How to treat urine leakage

The choice of treatment depends on the type of urine leakage problem and the severity. It can be helpful to keep a daily diary recording how much you drink, how often you pass urine and the amount of urine leakage.

The treatment may include:

  • Using medications to either:
    • calm an overactive bladder (anticholinergic) or 
    • tighten lax bladder neck/sphincter muscles (alpha-adrenergic).
  • To tighten lax bladder neck/sphincter muscles (alpha-adrenergic).
  • Losing weight and making lifestyle changes. This includes quitting smoking and reducing alcohol, coffee and tea. These are diuretics that promote urine production.
  • Managing your bowel care well to prevent constipation or straining to empty.
  • Injecting a substance called macro-plastique to bulk up the soft tissues around the urethra. This procedure is performed by a urologist and helps narrow the bladder opening.
  • Performing pelvic muscle exercises with biofeedback, if there is some muscle control.
  • Undergoing surgery to:
    • place a mesh strip or “sling” around your urethra to lift up and support the bladder neck or;
    • insert an artificial urinary sphincter.

Important Note

Keep a bladder diary to record fluid intake, frequency of bladder emptying (day and night), amounts emptied, episodes of leakage, amount of leakage/pad usage, and other information such as a sudden desire or urge to pass urine and medication use. 

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Catheter blockage

This problem occurs in people using suprapubic or indwelling urinary catheters. 

Flow of urine can be blocked by:

  • Kinks in the catheter
  • Kinks in the tube of the drainage bag
  • Debris or grit building up in the catheter.

Catheter blockage is an emergency and needs fixing as soon as possible.

What to do if there is no urine draining into your bag

Check and remove any kinks in the catheter or drainage bag tubing. Wearing loose fitting underwear may help.

Check that the drainage bag is always positioned below the level of your bladder.

Check that the leg bag straps are not obstructing drainage.

Unless you experience signs of a full bladder, such as abdominal discomfort, increased spasms or autonomic dysreflexia, drink 1-2 glasses of water to help your urine flow.

If there is still no urine draining after 30 minutes or you have an episode of autonomic dysreflexia, your situation has now become an emergency. Call 000 for an ambulance.

Note: Increasing the size of the balloon holding the catheter in place is not advised.

Another problem is urine leaking around the blocked catheter, also called bypassing. Bypassing can also result from bladder spasms.

Catheter management

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What does research tell you?

The most common cause of autonomic dysreflexia is a distended bladder. 

Difficulty inserting catheter

If you cannot get the catheter in, do not force it and follow the steps below:

  • Ensure adequate lubrication.
  • Try a slight cough or bear down as this may help to open the bladder neck.
  • Check you have inserted your catheter in the right place:
    For females: check you have not inserted the catheter into your vagina by mistake. If you have, discard this catheter and try again using a new catheter to avoid transferring germs from the vagina to the bladder. 
    For males: ensure you have inserted the catheter about 18-25cm into your penis.
  • Take an extra Oxybutynin tablet and try inserting the catheter again in about half an hour.
  • Use of anaesthetic gel (2% lignocaine) inserted into the urethra 5 minutes prior to passing a catheter may help.
  • If the catheter seems to be in the right place but not draining, the lubricating gel may be blocking the catheter drainage holes. Wait for several minutes as the gel is water-based and may take a little time to dissolve in the urine.
diagram on how to insert a catheter correctly

If your bladder is still full and you are feeling sick and uncomfortable, your situation has now become an emergency. Call 000 for an ambulance.

Important Note

If you have recurrent problems with inserting a catheter, other associated medical conditions may be the cause and must be ruled out by consulting your doctor. 

Medical conditions may include an overactive sphincter muscle, damage and narrowing of the urethral passage or enlargement of the prostate gland. 

Female specific problems

After a spinal cord injury, women report a significant increase in bladder and catheter-related problems associated with gynaecological and reproductive health issues.

A large survey reported women experience 4 times more urinary tract infections after their injury (86%) than before (22%), as well as an increase in vaginal yeast infections (59% versus 45%).

Other key findings from the survey include:

Complications related to pregnancy were uncommon except for a significant increase in urinary tract infections.

One quarter of the women reported they had to change their usual bladder management method during their pregnancy. Between 10-15% reported having new leakage around their indwelling urinary catheter and new bladder spasms. Among those women using intermittent catheterisation, 27% had to catheterise more frequently during the day.

Complications related to pregnancy were uncommon except for a significant increase in urinary tract infections.

One quarter of the women reported they had to change their usual bladder management method during their pregnancy. Between 10-15% reported having new leakage around their indwelling urinary catheter and new bladder spasms. Among those women using intermittent catheterisation, 27% had to catheterise more frequently during the day.

Around one fourth of all women had exacerbations of autonomic symptoms (i.e., sweating, headaches, flushing, or goose flush), bladder spasms, or muscle spasms, which were associated with a certain time in their cycle.

Difficulties can be associated with catheterisation, as well as the use of tampons and pads, which can press on the urethra and bladder and interfere with catheter drainage.

Conditions such as spasticity, autonomic dysreflexia and bladder spasms were reported by some women to increase during menopause.

Bladder incontinence was reported as a problem in 17% of women with spinal cord injury during sexual intercourse.

Problems with Foley catheters were described more often (12%) during sexual intercourse by women with a longer injury duration of 11 years or more.

What does research tell you?

Women with a spinal cord injury experience a range of problems related to pregnancy, menstruation, menopause and sexual activity, which are unique to this group of people. They require greater recognition by health professionals to provide self-management education and support for women adapting to a new life situation after a spinal cord injury.

Epididymitis and epididymo-orchitis

Epididymitis is the inflammation of the epididymis, the tube at the back of the testicle.

Epididymo-orchitis refers to inflammation of both the epididymis and testicle.

Signs and symptoms may include:

  • Swelling and tenderness of the affected epididymis, testicle or scrotum
  • Fluid around the testicle called a hydrocoele
  • Fever and generally feeling unwell.
  • The pain may become constant and severe.

If the cause is a sexually transmitted disease, a discharge from the penis may be present.

How to treat epididymitis and epididymo-orchitis

  • Bed rest
  • Oral antibiotics and pain killers
  • Ice packs applied to the scrotum
  • Immobilising scrotum with a jockstrap to decrease pain from movement
  • Drainage of pus by a qualified medical practitioner.

If not treated properly, this condition can lead to permanent infertility.

Prostatitis

Prostatitis refers to swelling and inflammation of the prostate gland.

This can develop gradually or suddenly. It often affects young or middle-aged men. There can be pain in the lower abdomen or when passing urine (burning) if sensation is present. There may be problems with urination, difficulty passing catheters or painful ejaculation.

Chronic prostatitis can also lead to recurring urinary tract infections. Your doctor may recommend you to take antibiotics to treat the infection. Antibiotic treatment without symptoms is usually not necessary.

Urethral stricture

A urethral stricture is a constriction or narrowing of the urethra. It occurs in a small number of men who perform intermittent self-catheterisation. Urethral stricture results from trauma, tissue inflammation and scarring.

Treatment usually involves:

  • Incision of the stricture in an operation called urethrotomy or 
  • Sometimes a repair of a defect within the urethral wall by urethroplasty surgery.

Other problems

in person with spinal cord injury at/or above T6 level

(known as pyelonephritis)

(known as hydronephrosis)

(in those using a permanent suprapubic or indwelling urethral catheter)

(risk is no different from general population, but may be picked up later)

Bladder and kidney stones

Bladder and kidney stones are hard crystals made up of minerals and proteins found in urine. They can cause serious problems, including blocking the flow of urine into or out of the bladder and recurring infections.

After a spinal cord injury, the chances of developing a stone increase because of:

  • Changes in how well your bladder drains
  • Use of catheters
  • Recurring urinary tract infections
  • Concentration of urine from not drinking enough
  • Higher levels of calcium from your bones. 
Kidney-stones-diagram-with-labels
Kidney-stones-diagram-with-labels

Signs and symptoms of a stone may include:

  • Pain in the lower abdomen or lower back, if some sensation is present
  • Recurrent urinary tract infections
  • Increased urge to pass urine or bladder overactivity
  • Increased spasms
  • Increased sweating
  • Blood in the urine
  • Seeing stones passed in the urine
  • Autonomic dysreflexia – in people with injury at T6 level or above, for more details see the Autonomic dysreflexia section.

How to treat bladder and kidney stones

  • Small stones may be passed by drinking a lot of water.

If this does not help, your doctor may refer you to a urologist for treatment.

  • A common treatment involves passing a telescope-like device, called a cystoscope, into the bladder. The stones are then crushed or broken up with a laser into smaller pieces and flushed out.
  • Another common treatment, called lithotripsy, uses shock waves to break up kidney stones.
  • Sometimes larger stones need removal with open surgery.

What does research tell you?

Ninety-eight percent of stones are less than 5mm in diameter and likely to be passed spontaneously. This percentage decreases as the stone diameter increases.

Blood in the urine

Blood in the urine, called haematuria, can be either visible to the eye or only seen through a microscope.

Blood that is visible can vary in appearance from light pink to deep red with clots. People who can see blood in their urine will visit their doctor with this obvious problem. However, people who have microscopic haematuria will not realise they have it until found on urine analysis during a routine health check. 

two sample jars of urine showing the difference between visible and microscopic haematuria
Visible haematuria vs microscopic haematuria

Visible and microscopic haematuria result from bleeding anywhere along the urinary tract. Your doctor should investigate any amount of blood in the urine. The causes of visible and microscopic haematuria are similar:

  • Urinary tract infection
  • Kidney and bladder stones cause irritation and abrasion of the urinary tract which leads to blood in the urine 
  • Trauma to the urethra, prostate or suprapubic tract, which is the opening to the bladder in the lower abdomen
  • Kidney disease
  • Use of certain medications such as aspirin that can increase the risk of bleeding
  • Cancer somewhere along the urinary system, though this is rare.

Treatment for haematuria will vary depending on the reason for the bleeding. Many episodes of haematuria will settle down without any specific treatment with no cause found. You can reduce the risk of haematuria by maintaining a healthy urinary tract as follows:

  • Drink about 6-8 glasses of water of fluid daily, more during hot weather.
  • Avoid smoking cigarettes, which increases the risk of bladder cancer.
  • For men over 50 years – check with your doctor for an annual prostate examination and prostate-specific antigen (PSA) blood test. This is important to rule out prostate cancer, which is sometimes associated with haematuria.
  • If your haematuria does not resolve within 1 or 2 days or recurs, a review is required.

Your urologist will be responsible for recommending any further investigations or treatment.

What does research tell you?

A urological referral is recommended for people with spinal cord injury presenting with visible haematuria, persistent microscopic haematuria, abnormal urine tests showing abnormal cells or recurrent urinary tract infections. 

Urinary retention

Urinary retention refers to the inability to completely empty your bladder of urine. Urinary retention can be sudden (acute) or more gradual and long-term (chronic). Acute retention is a serious problem that requires urgent medical review and treatment.

bladder icon

Signs and symptoms of urinary retention may include:

  • not completely emptying your bladder after urinating and leaving high residual urine volumes in the bladder (this increases the risk of urinary tract infections)
  • feeling an urgent need to pass urine (called urgency) but without good emptying
  • having difficulty starting the flow of urine (called hesitancy)
  • needing to use greater amounts of percussion (tapping over bladder) or straining to start voiding
  • needing to go to the toilet often or soon again after passing urine (called frequency)
  • passing small amounts of urine with a slow stream or weak flow.

Common causes of urinary retention:

  • An overactive bladder with spasming of the bladder outlet or sphincter muscles
  • An underactive or weakened (overstretched) bladder
  • In men, problems occur with emptying of your bladder when:
    • the prostate gland gets so big that it presses on the urethra (tube draining the bladder)
    • scar tissue from damage inserting a catheter cause narrowing (stricture) of the urethra.
  • In women, problems may occur with emptying of your bladder due to weakness of pelvic floor muscles related to spinal cord injury and overstretching (after childbirth), changes in hormone levels (with menopause) or increased abdominal pressure and straining from constipation with:
    • bladder becoming lower and pushing against the vagina causing obstruction (cystocele)
    • uterus sagging/dropping down from its normal position into the vagina (called a uterine prolapse).
  • Certain medications (antidepressants or alpha blockers) can cause urinary retention.

How to treat urinary retention

  • Some medications (alpha blockers) can help to relax muscles at the bladder outlet and prostate.
  • You may need to change the way you empty your bladder (e.g., learn self-catheterisation).
  • See your doctor for an assessment and physical examination (including rectal exam to check prostate if male), and to arrange appropriate blood tests and an ultrasound of your kidneys and bladder.
bottle of pills spilling out onto table
  • You may need to see a urologist, who may undertake further special investigations:
    • Video-urodynamic test (assessing how much your bladder holds, pressures inside bladder with filling and how well it empties) or
    • Cystoscopy (looking inside the urethra and bladder with a thin telescope). This test may show a stricture (scarring) of the urethra, an enlarged prostate, blockage caused by a stone, or unusual causes, such as a tumour.
  • You may need surgery to remove excess prostate tissue, divide a urethral stricture (scar tissue), inject Botulinum toxin into an overactive sphincter muscle, insert a tube (stent) in urethra or perform a repair of a uterine prolapse.

High urine output

High urine volume, called polyuria, occurs when you urinate more than normal (greater than 3 litres per day in an adult). Urine volume depends on how much you drink, your age and gender. A urine output of 2 litres or less per day is usually considered normal, passing 250-400mls each time.

Causes of high urine output

  • High urine output can be due to use of certain medications (such as diuretics, which increase urine volume) or due to health problems, including:

    • urinary tract infection
    • urinary incontinence
    • diabetes
    • kidney problems, such as inflammation of the kidney, kidney stones or kidney failure
    • blood disorder, such as sickle cell anaemia
    • enlarged prostate (benign prostatic hyperplasia), most common in men over 50 years old
    • certain kinds of cancer.

Signs and symptoms of high urine output

High urine output or frequent urination can be due to many different problems from kidney disease to simply drinking too much fluid. Certain symptoms should prompt you to see your doctor right away, including:

  • fever
  • an urgent need to urinate
  • back pain or discomfort in the abdomen
  • leg weakness
  • sudden onset of polyuria
  • night sweats
  • weight loss

How to treat high urine output

High urine output not caused by underlying health issues can be addressed at home.

You can likely relieve your symptoms by changing actions that contribute to making excessive urine volumes, such as following:

  • watch your fluid intake
  • limit fluids before bedtime
  • limit the amount of caffeinated and alcoholic beverages you drink
  • understand the side effects of medications.

High urine output caused by health issues can be managed by treating the underlying issue. For example, treatment for diabetes through making changes in diet and medication will often relieve the side effect of high urine output.

glass of water and pills on table

Kidney infection

Pyelonephritis

Pyelonephritis is a severe kidney infection, which usually comes on suddenly.

It can start as an infection in the lower urinary tract. People with backflow of urine from the bladder, called reflux, are at greater risk.

Symptoms and signs may include:

  • Fever and chills
  • Pain in your back, side or groin
  • Nausea and vomiting
  • Cloudy, dark, bloody or foul-smelling urine.

How to treat pyelonephritis

Treatment often requires admission to hospital, involving intravenous antibiotics as well as an extended course of oral antibiotics for 10-14 days.

Surgery may be necessary to drain the pus that does not respond to antibiotics. 

Important Note

Infection of a kidney is a severe type of urinary tract infection that often begins in your bladder and moves upstream to one or both of your kidneys.

Swelling of kidneys

Hydronephrosis

Hydronephrosis is swelling of one or both kidneys from a build-up of urine.

This can be due to:

  • Obstruction of the tubes, called ureters, draining the kidney, or
  • Backflow of urine already in the bladder.

Common causes of hydronephrosis:

  • A kidney stone blocking the ureter
  • High pressure in an overactive bladder
  • An enlarged prostate.

In a person with a spinal cord injury, the usual signs and symptoms may not be obvious. An ultrasound of the kidneys can detect hydronephrosis at an early stage. 

How to treat hydronephrosis

Treatment involves addressing the cause, e.g. removing a stone from the ureter.

You may need to change the way you manage your bladder.

A temporary procedure to drain the kidney, known as nephrostomy, may be necessary.

Hydronephrosis labelled diagram

It is critical to deal with this problem as soon as possible. Severe urinary blockage and hydronephrosis can lead to kidney failure.

Bladder cancer

People with a long-term spinal cord injury have an increased risk of bladder cancer, 5 to 7 times higher than the general population.

The condition is considered rare among the general population. People using urethral or suprapubic catheters for more than 15 years are most at risk.

Cigarette smoking increases the risk by about 4 times compared to a non-smoker.

Other risk factors may include frequent urinary tract infections and bladder stones. Although the value of routine screening is still unknown, it is recommended for a regular cystoscopy and bladder biopsy to be performed by a urologist in people most at risk.

Prostate cancer

Prostate cancer occurs when abnormal cells grow in an uncontrolled way in the prostate gland, creating a malignant tumour. Men with spinal cord injury generally have a lower incidence of prostate cancer. However, prostate cancer when present may be detected at a later stage because of accessibility problems limiting prostate examination, as well as common symptoms (such as frequent urination, pain while urinating and pain in the back or pelvis) being masked by your spinal cord injury. More widespread disease can spread to the bones causing pain, unexplained weight loss and fatigue.

From the age of 50 years, all men should discuss prostate screening with their doctor, including individual level of prostate cancer risk, and potential benefits, harms and uncertainties of screening using a prostate-specific antigen (PSA) blood test. There is a higher risk in men with one or more first-degree relatives diagnosed under age of 65 years. Treatment will depend on the extent of the cancer. 

Purple urine bag syndrome

Purple urine bag syndrome is caused by a bacterial infection. The bacteria produces a chemical, called indoxyl phosphatase, causing purple discolouration of the urine within the bag. This can be of concern for people with spinal cord injury and their family members and carers.

The treatment involves drinking plenty of water to flush out bacteria, changing the catheter and taking appropriate antibiotics. 

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