Management of bladder and kidney problems
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.
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
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?
Urinary tract infection
67%
of individuals hospitalised were
admitted primarily for treatment of a urinary tract infection
Urine leakage
33%
of individuals performing intermittent self-catheterisation reported urine leakage
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.
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:
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.
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.
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.
Quick Links
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
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.
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)
(very rare)
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.
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.
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.
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.
- 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.
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.
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.