The online Community for people with spinal cord injury, their relatives and friends
cancel

Bladder & Bowel

Sort by:
What is catheterization? Catheterization (emptying of the bladder by using a catheter) is mostly applied in people with spinal cord injury with a flaccid bladder. A local medical sedation can sometimes enable catheterization in patients with a spastic bladder. In order to live as independently as possible, it is important to learn self-catheterization – this is also feasible for tetraplegics with a low level of spinal cord injury. How often do I have to catheterize? At the beginning, self-catheterization is required every 3-4 hours – also at night. The intervals between catheterizations are determined by the fullness of the bladder. To avoid the risk of bladder distention, the maximum filling should not exceed 500ml of urine. By observing and adjusting one's drinking habits, the frequency of catheterization can be adapted individually – this generally enables a longer break at night. Hygiene Catheterization must be carried out under clean conditions. Therefore, a careful personal hygiene is of utmost importance. If the catheterization does not take place at home, but e.g. in a public toilet, it is important to comply with the hygiene standards. The bladder emptying might require other material than at home. The right product There is a variety of catheters (with or without surface coating), separate lubricants and urine pouches available on the market that can be purchased from distinct suppliers. There are numerous alternatives in the event of material problems. Accessories, such as pant holders for bladder emptying while sitting in a wheelchair or cathing mirrors for women make catheterization easier. The material needed can be obtained from companies specialized in incontinence articles or medical stores. It is important to bear in mind that insurance companies do not pay for all products available on the market. In Switzerland all products covered by the insurance companies can be found on the “equipment and material list" issued by the Federal Office of Public Health. For all other countries we recommend to contact the respective insurance company. FAQs Do I have to stick to the products presented to me once or can I try other products at home? There is a variety of products available. Please consult your urologist before making any changes with regard to procedure or product. Where do I get the products from after being discharged from hospital? Before leaving the rehabilitation facility, the person in charge will order together with you all the material you need. This will be sufficient for the first days at home. You can also order the necessary material at home via telephone or internet from companies specialized in incontinence articles or medical stores. Is catheterization at home as time-consuming as it is in hospital? No. The risk of cystitis is reduced with catheterization at home, because people with spinal cord injury are used to the bacteria in their domestic environment. It is important to disinfect your hands before and after the catheterization and to disinfect the urethra. What if I go on a trip? Self-catheterization is also possible when you are on a trip. The risk of infection won't increase if you stick to the hygiene requirements, just as you do at home. If self-catheterization is not possible, e.g. during a flight, there is also the possibility to use a permanent catheter for the time being. What should I do if I notice blood at the tip of the catheter, in the urine bag or coming out of the urethra? The bleeding is probably caused by mucous membrane injuries. These might happen when inserting the catheter tip or they might be caused by an increased suction that occurs if the catheter is not clamped when removing it. Speak to your GP or urologist if the bleeding is continuous or heavy. What if I cannot get the catheter to go into my bladder? Men are particularly likely to be affected by a contraction of the sphincter muscle. Do not pull back the catheter, wait a few minutes, and then try again to insert it - without force. In case you do not succeed, stop trying and try again later. In case of repeated difficulties please contact your urologist. About the authors: Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1997. She is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" and "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch). The article is the result of a collaboration with the panel of experts in bladder management of the Swiss Paraplegic Centre. updated: December 2013
View full article
What is a condom catheter? A condom catheter is a condom-like urine drainage system. The condom part is then attached to a tube with a urinary storage bag. The urine is drained into the bag using reflexes - this means rhythmical tapping (triggering) on the lower abdominal region above the pubic bone triggers the emptying of the bladder. How does triggering work? Triggering enables a stimulation of the reflex arc – thus the emptying of the bladder can be controlled manually. This drainage technique stimulates the stretch receptors situated in the bladder walls. This activates the reflex arc and causes the emptying of the bladder. No mechanical pressure is required to stimulate the stretch receptors – a rhythmical tapping is sufficient. The triggering continues until the bladder begins to empty and starts again as soon as the urine stops to flow. This might take up to ten minutes. How effectively the bladder is emptied, depends on the contraction of the bladder, the opening of the neck of the bladder, but also on the relaxation of the sphincter. Initially, the bladder should be emptied in regular intervals of 3-4 hours. Later, the emptying can be adapted individually if you feel that your bladder is full or if your body shows signs of a full bladder, such as goose bumps, sweating, headache, spasms or certain – individually different – sensations in the abdominal area. The right product Before the first application of a condom catheter, the right size hast to be determined using a measuring tape, in order to make sure the condom is not too big or too small. There is a variety of adhesives, condoms, self-adhesive condoms and urine bags available on the market. In case you have any problems with your material, alternatives can be found. The material needed can be obtained from companies specialized in incontinence articles or medical stores. Important points Make sure the urine bag is positioned below the bladder (bladder level) to ensure an unimpeded urine flow. The tube should never be bent or run above bladder level. As a precaution please ensure the proper fit of the condom and the seating of the urine bag after each transfer. Hygiene Whether you choose silicone or latex – the condom needs to be changed every 24 hours. Your personal hygiene is absolutely important with regard to keeping your skin healthy and thus enabling a long-term application of condom catheters. FAQs What do I need to do if no urine flows? Please make sure the condom is not twisted. Recap your fluid intake during the past hours. Try to feel whether your bladder is hard (= full) or not. If this is the case and there's still no urine flow after the next triggering, please empty the bladder using a disposable catheter or consult your GP. Triggering or a full bladder causes headache. What might be the cause? In most cases the headache results from an extremely elevated blood pressure, caused by the autonomic nervous system. This is also called autonomous dysreflexia or "Guttmann-Reflex". In case of severe headache or if no urine flows, it is important to empty the bladder immediately, possibly by means of a disposable catheter. In case of repeated headache, please consult your GP or urologist. What do I need to do in case of pain or burning in the urethra/bladder? This might be first signs of a urinary infection – do a Nephur test. If the test is positive and/or the pain does not go away, please consult your GP. The pain might possibly disappear when increasing the fluid intake. What can I do if the penis skin is reddened? In most cases this is a fungal skin infection. In case the skin is still reddened after a few days, despite good personal hygiene, please consult your GP. What can I do if the penis skin is open or injured? If the skin injury is not too big, a condom may still be applied using an extremely thin protective strapping. In case the open skin does not heal within a few days, please consult your GP. What can I do if the condom catheter suddenly does not fit any more? Make sure you still use the right condom size – you might need a smaller condom. Very scaly, dry skin might reduce the adhesive effect. Please note that there are different types of condoms with different adhesives. Check whether your penis "retracts into the abdominal area". This is called "retracted penis" – the condom might slip off. If this is the case, please consult a professional for condom products or your GP. About the authors: Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1997. She is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" and "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch). updated: December 2013
View full article
What is a transurethral urinary catheter? A transurethral urinary catheter is an indwelling catheter that is inserted into the bladder through the urethra. This enables a continuous drainage of urine. A small balloon is used to hold the catheter in the bladder. Transurethral catheters are inserted just like disposable catheters. The Transurethral Urinary Catheter (Source: jameda) What needs to be considered when using the catheter? An indwelling urethral catheter encourages the urethral mucosa to form secretions. This causes a small amount of constant discharge. The amounts may vary. These secretions are an ideal breeding ground for bacteria. A good personal hygiene is therefore extremely important. The secretion should be cleaned off at least once a day. Make sure the urine bag is positioned below the bladder (bladder level) to ensure complete drainage. The tube should never be bent or run above bladder level. FAQs What do I need to do, if no urine drains? The catheter could be blocked. Often, sediments are deposited in the catheter and do not allow the urine to drain. By kneading the catheter regularly, these sediments can mostly be avoided and/or removed. If not, the catheter needs to be rinsed. In case you are not able to perform the catheter rinsing on your own in accordance with the instructions, please contact your GP or a care service immediately. What do I need to do in case of pain or burning in the urethra or the bladder? This might be first signs of a urinary infection - do a Nephur-Test. If the test is positive and/or the pain does not go away, please consult your GP. The pain might possibly disappear when increasing the fluid intake. Urine is coming out of the urethra next to the catheter – how is that possible? Possible causes might include: Blockage of the catheter. Positioning of the drainage bag above bladder level. The tube could be bent or run above bladder level. In case you can rule out all of the above-mentioned options, and there is still urine coming out of your urethra, please contact your GP or urologist. What do I need to do if the secretion coming out of the entry site of the catheter smells bad or increases? These might be first signs of an inflammation or may be due to a mechanical irritation caused by the catheter. In case good hygiene leads to no improvement, please contact your GP. How often does the catheter need to be changed? Silicone catheters basically have to be changed every 3-4 weeks. It depends on the amount of sediments in the catheter and whether it blocks often or not. May I cap the catheter if I want to go swimming? Generally not. The risk of infection increases each time the drainage bag and the catheter are disconnected. Please consult your urologist. About the authors: Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1997. She is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" and "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch). updated: December 2013
View full article
Normal bowel functions Defecation is a process that is controlled by reflexes but can, however, be influenced deliberately. If the rectum is sufficiently full and therefore stretched, an impulse is sent through the nerves to the defecation centre in the spinal cord. This triggers the sensation “urge to defecate" in the cerebrum. The defecation centre controls the rectum muscles and triggers relaxation of the anal sphincter and at the same time contraction of the outer muscles of the rectum. This moves the bowel contents outside. A continuing contraction of diaphragm and abdominal muscles, the so called abdominal press, supports this process. Delaying defecation over a certain period of time is possible because the external sphincter can be contracted deliberately and therefore defecation can be avoided. What are the differences between regular bowel functions and a flaccid bowel? Flaccid bowel Information on the degree of fullness is registered by stretch receptors on the intestinal wall (1). Normally, this information is forwarded via the defecation centre (2) to the brain. Due to the injury of the spinal cord (3), this information does not reach the spinal cord. Defecation can no longer be controlled deliberately. The intestinal wall (1) does not transport the stool; the external sphincter (4) stays relaxed. Normal defecation becomes impossible. Defecation A flaccid bowel often causes incontinence. To avoid this, it is necessary to take care of defecation on a daily basis. There are various defecation methods and aids to empty the bowel. Bowel movement is also influenced considerably by the dietary habits and the amount of fluid intake. About the authors: Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch) and "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1997. She is also co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung". The article is the result of a collaboration with the panel of experts in bowel management of the Swiss Paraplegic Centre. updated: December 2013
View full article
Flatulence is a common problem. People with spinal cord injury are frequently affected due to a disorder in bowel functions. Causes for flatulence in people with spinal cord injury Causes for flatulence Flatulence caused by nutrition Flatulence can occur right after eating, caused by the following foods, among others: Cabbage Onions and other bulbous plants High-fiber foods High-sugar foods Flatulence problems as a reaction to various foods differ from person to person. Also the way they are prepared may play an important role: Some foods may be easy to digest when they are cooked but can cause severe flatulence when eaten raw. Intolerances against certain foods or food groups may also cause flatulence. Among those are: Lactose intolerance (milk sugar) Fructose intolerance (fruit sugar) Gluten intolerance (gluten and grains) Histamine intolerance Fish and seafood Smoked meat Red wine, etc. Flatulence caused by constipation In case of constipation, the stool remains in the bowel longer than usual and bowel bacteria can digest it multiple times. This causes an increased bowel volume and therefore an increased formation of gas. What can be done to reduce flatulence? Remove constipation Identify foods that cause flatulence Reduce swallowing of air – learn how to avoid it: Eat slowly Chew well Avoid overly large portions Avoid stress when eating – no hurry or time pressure Eat regularly Reduce high level of coffee consumption Reduce or avoid highly carbonated drinks Avoid smoking and chewing gum Eat fennel, cumin and aniseeds (also available as tea) Take anti-foam preparations such as Flatulex, Sab Simplex, etc. FAQs Can flatulence also cause respiratory problems? Yes, especially for tetraplegics. Since their auxiliary respiratory muscles do not work or work only partially, they mainly respire into their abdominal cavity. If there is a lot of air in this area through flatulence, this may cause a subjective feeling of difficulties in breathing. Source: Geng, V.: Blähungen. In: Haas, U. (Eds.) (2012): Pflege von Menschen mit Querschnittlähmung – Probleme, Bedürfnisse, Ressourcen und Interventionen. Bern: Verlag Hans Huber, p. 146ff. About the authors: Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch) and "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1997. She is also co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung". The article is the result of a collaboration with the panel of experts in bowel management of the Swiss Paraplegic Centre. updated: December 2013
View full article
What is constipation? Constipation refers to bowel movements that are infrequent, hard to pass, small in quantity, and of hard and dry consistency. There are different forms of constipation: chronic constipation, traveler's constipation and acute constipation. The difference lies in the causes. Different forms of constipation Chronic constipation Due to a reduced bowel peristalsis and a decreased level of physical activity, people with spinal cord injury are particularly likely to be affected by chronic constipation. Traveler's constipation Traveler's constipation is a form of constipation that appears suddenly and is caused by a change of diet and unfamiliar surroundings while traveling. In most cases it is only temporary and occurs at the beginning of a journey. It can be caused by: unfamiliar food and spices dehydration caused by high temperatures and dry air changing the clocks during overseas trips unusual daily routine unfamiliar sanitary situations (toilets not equipped for wheelchair users, no shower wheelchair available etc.) Most of the causes mentioned above also apply to hospital stays. Unfamiliar food, unusual daily routine (e.g. confinement to bed) as well as the unfamiliar situation when using the toilet (time pressure, many other people in the room etc.) may cause constipation. The symptoms usually disappear at home. Acute constipation Acute constipation is relatively rare. In contrast to chronic constipation, acute constipation appears suddenly and must be medically investigated immediately. In case the typical constipation symptoms are accompanied by problems such as swollen abdomen severe abdominal pain (sensibility given) copremesis (medical emergency) shock (symptoms: high pulse, low blood pressure, cold sweat) this can be indicative of an intestinal obstruction that requires immediate medical attention. How to identify constipation in people with spinal cord injury: in 25% of all defecations bowel movements, the stool is hard usually less than three defecations per week defecation takes longer than usual longer defecation intervals/less frequent manual discharge incomplete stool evacuation no discharge of stool even if trying severe flatulence (might cause respiratory problems) How to prevent constipation: A consistent individual bowel management reduces the risk of constipation: regular, sufficient defecation, each day at the same time if possible (defecation rhythm according to type of bowel paralysis, at least every other day) balanced diet high in fiber adequate fluid intake, in hot climate correspondingly more => rule of thumb: at least 1.5 liters of urine have to be excreted through the bladder each day physical activity within the realms of possibility How to treat constipation: Defecation can be accelerated by adapting the oral stool medication. Additional defecation might be necessary. If this is ineffective, a Microclist or Freka-Clyss stimulation might be necessary. In case this is also ineffective, a physician should be consulted. Important Constipation can cause severe complications. It is therefore absolutely indispensible to ensure a consistent bowel management and to react in case of changes. FAQs Do I have to see a doctor every time I suffer from constipation? No, you only need to see a doctor in case the constipation lasts for several days without improvement. Before taking any kind of new medication, you should consult your physician. Is it possible to suffer from constipation and diarrhea at the same time? Yes – this is called paradoxical diarrhea. Constipation needs to be treated first. Sources: URL: http://www.pflegewiki.de/wiki/Obstipation (retrieved August 7, 2013) Geng, V.: Obstipation. In: Haas, U. (Hrsg.) (2012): Pflege von Menschen mit Querschnittlähmung – Probleme, Bedürfnisse, Ressourcen und Interventionen. Bern: Verlag Hans Huber, S. 143f. About the authors: Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch) and "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1997. She is also co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung". The article is the result of a collaboration with the panel of experts in bowel management of the Swiss Paraplegic Centre. updated: December 2013
View full article
Emptying the bowel should occur periodically (every one or two days) possibly around the same time. Doing so trains the bowel and therefore allows you to maintain or regain control over defecation. Controlling defecation In order to support regular defecation, it is recommended to stick to certain habits; e.g. defecation should always occur during the same time of day (e.g. in the morning or in the evening). Drinks such as coffee, apple and grape juice as well as foods such as apples, stone fruit and sauerkraut have a laxative effect. Regular exercise is also important to regulate bowel movement. In order to decide whether laxative measures need to be taken, it is important to make sure there are no other causes for an irregular bowel movement. Causes may be due to issues with organs (e.g. diverticulum) but also periods of stress or travelling may cause changes within the digestive system. Taking laxatives should be taken into consideration as last option. If the problems recur, keeping record of the bowel movement may be helpful for the assessment of the situation (this can be recorded in My Diary). Techniques and methods of bowel management There are various techniques of how to empty the bowel. Important For all techniques that require a finger to manipulate around the anus, it is a must to use a gel since injuries may occur easily. Special attention is required in case of anal fissures and hemorrhoids. Digital stimulation of the rectum (only for the spastic bowel) The defecation reflex can be triggered through gently rotating movements and soft pressure against the rectal wall (min. 30 seconds), using the index or middle finger. Digital defecation (clearing of bowel) In case of digital defecation, the rectum is being cleared manually using the index or middle finger. Digital control of the rectum (checking with finger) Checking the rectum should be done to find out whether it is empty, usually after defecation. Due to loss of sensibility and therefore the incapability to feel the amount of fullness, the rectum should also be checked before defecation. Rotating movements should be avoided when checking the rectum since this may trigger the defecation reflex. Supporting measures Emptying the rectum should ideally be done in a sitting position on the toilet or shower wheelchair since gravity supports the process. It is important to be in a relaxed sitting position and that the feet are not dangling in the air but are placed on a supporting surface. The seats of a toilet or wheelchair should possibly be cushioned to avoid pressure sores. If defecation needs to be performed in bed, it is recommended to lie on your left side since the progression of the large intestine facilitates emptying in this position. Abdominal press Activating the abdominal muscles may be used supportively for the defecation procedure. Normal stool consistency is necessary however. If the abdominals cannot be activated due to the lesion level , the following options exist: Bending forward with the upper body Pressing with the hands on the lower abdomen Massaging the colon Colon massage is a massage of the abdominal cavity. It can be applied in a lying or sitting position and has a supportive effect after using a suppository or in case of digital stimulation of the rectum. Large intestine (Source: G-Netz) Procedure: Massage clockwise since this is the direction of the bowel movement. It begins on the lower left side of the abdomen in the descending large intestine. Through soft pressure with the flat hand, the stool is pushed towards the rectum. Go up slowly on the left side of the abdomen, across the horizontal part of the large intestine, to the ascending large intestine on the right side of the abdomen. Massaging the colon takes about 10 to 20 minutes. Giving a suppository Warm up suppository slightly through rubbing with the fingers or moisten with water (Lecicarbon) for better gliding. You should not use Vaseline or similar products since this lessens the effect Put suppository between stool and rectum wall. If the rectum is already filled with hard stool, first clear it digitally. Stick to the duration of effect of the suppository; defecation should take max. 30 minutes FAQs Massaging the colon only helps insufficiently – what can I do? Applying the colon massage is not very easy. It is recommended to get instructions from a professional. If I need to defecate in bed, what do I need to consider? Ideally you should lie on your left side. We do not recommend bedpans due to an increased decubitus hazard. Is it normal that it takes me more than one hour to defecate? No, it should not take longer than one hour. If changing medication or technique does not lead to success, we recommend you to contact a professional care service. References: BG Unfallklinik Murnau (2006): Ernährung, Verdauung und Darmentleerung bei Menschen mit einer Querschnittlähmung. Patienteninformation. Arbeitskreis Darmmanagement Querschnittgelähmter (2011): Neurogene Darmfunktionsstörung bei Querschnittlähmung. Kompendium. Lobbach: Manfred-Sauer-Stiftung. About the authors: Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch) and "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1997. She is also co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung". The article is the result of a collaboration with the panel of experts in bowel management of the Swiss Paraplegic Centre. updated: December 2013
View full article
What is a bladder stimulator? A bladder stimulator is an implant that is used to directly stimulate the bladder and bowel nerves, in order to promote the emptying of bladder and bowels. It can only be used for patients with a complete spinal cord injury and a spastic bladder. How does the bladder stimulator work? The controller (control unit) (A) sends electrical power and control signals through the transmission cable (B) to the transmitter (C). The implanted receiver (D) converts the electrical power and the control signals into electrical stimulation signals. These signals are transmitted in form of impulses via a cable (E) to the electrodes (F), in order to stimulate the bladder and bowel nerves. The signals cause a contraction of the bladder and sphincter muscle. In the intervals between the signals, the bladder remains compressed – but the sphincter muscle relaxes and thus enables the emptying of the bladder. Bladder stimulator (Source: Finetech Medical) What to do in case of complications What to do, if no urine flows? 1. Check if the plate of the controller is placed properly (correct transmitter and receiver points aligned?) 2. Check whether the controller is charged 3. Emptying of the bladder using a disposable catheter In case of assisted catheterization, designate a person to help you ahead of time: relative or friend home care (Spitex) GP etc. Don't forget to take a catheter with you when travelling in case any problems arise with the bladder stimulator 4. Contact the department of urology of a specialty hospital Maintenance Check battery charge every day (battery level indication in %) Charge as required When travelling: Take battery charger with you. The new generation of devices (all black devices) does not require an adapter in European countries. Take an adapter with you when travelling to non-European countries. Voltage will be adapted automatically. For older devices (gray devices), an adapter is needed when travelling abroad – the charger voltage might have to be switched to 110 volts. FAQ The bladder stimulator is a foreign body – is it possible to have an MRI scanning with it? Yes. This is no problem for the latest MRI scanners with 1.0 tesla or more. About the authors: Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1997. She is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" and "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch). The article is the result of a collaboration with the panel of experts in bladder management of the Swiss Paraplegic Centre. updated: December 2013
View full article
What is a suprapubic urinary catheter? A suprapubic urinary catheter is an indwelling catheter that is inserted into the bladder through the abdominal wall. This allows the urine to permanently flow out of the bladder without having to pass the urethra. There are different types of catheters and options to attach them. Often a small balloon is used to hold the catheter in the bladder. The procedure can be performed on an outpatient basis. Suprapubic catheter (Source: DocCheck Pictures) What do I need to consider if I have a catheter? A catheter can lead to the formation of secretions, i.e. discharge might come out of the entry site of the catheter. The amount of discharge may vary. Secretions are an ideal breeding ground for bacteria – however, a bandage can prevent bacteria from entering the body and therefore avoid inflammations. Nevertheless, it is important to make sure the secretion does not form incrustations. Therefore, the bandage needs to be changed regularly - at least once a week and immediately in case the bandage is wet (e.g. after showering) or comes off. Make sure the urine bag is positioned below the bladder (bladder level) to ensure a complete drainage. The tube should never be bent or run above bladder level. FAQs Is it a problem if the entry site of the catheter is reddened? What do I need to do if secretion smells bad or increases in quantity? These might be first signs of an inflammation or may be caused by a mechanical irritation caused by the catheter. In case regular change of the bandage, including thorough disinfection of the entry site, leads to no improvement, please contact your GP. What do I need to do, if no urine drains? The catheter could be blocked. Often sediments are deposited in the catheter and keep the urine from draining. By kneading the catheter regularly, these sediments can mostly be avoided and/or removed. If not, the catheter needs to be rinsed. In case you are not able to perform the catheter rinsing on your own in accordance with the instructions, please contact your GP or a care service immediately. What do I need to do in case of pain or burning in the bladder? These might be first signs of a urinary infection - do a Nephur-Test. If the test is positive and/or the pain does not go away, please consult your GP. The pain might possibly disappear when increasing the fluid intake. Urine is coming out of the urethra – how is that possible? Possible causes might include: Blockage of the catheter. Positioning of the drainage bag above bladder level. The tube could be bent or run above bladder level. In case you can rule out all of the above-mentioned options and there is still urine coming out of your urethra, please contact your GP or urologist. How often does the catheter need to be changed? Silicone catheters basically have to be changed every 6-8 weeks. It depends on the amount of sediments in the catheter and whether it often blocks or not. May I cap the catheter if I want to go swimming? Generally not. The risk of infection increases each time the drainage bag and the catheter are disconnected. Please consult your urologist. About the authors: Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1997. She is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" and "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch). updated: December 2013
View full article
Normal bowel functions Defecation is a process that is controlled by reflexes but can, however, be influenced deliberately. If the rectum is sufficiently full and therefore stretched, an impulse is sent through the nerves to the defecation centre in the spinal cord. This triggers the sensation “urge to defecate" in the cerebrum. The defecation centre controls the rectum muscles and triggers relaxation of the internal anal sphincter and at the same time contraction of the external muscles of the rectum. This moves the bowel contents outside. A continuing contraction of diaphragm and abdominal muscles, the so called abdominal press, supports this process. Delaying defecation over a certain period of time is possible because the sphincter can be contracted consciously and therefore bowel movement can be avoided. What are the differences between regular bowel functions and a spastic bowel? Spastic bowel Information on the degree of fullness of the rectum is registered by stretch receptors on the intestinal wall (1). Normally, this information is forwarded via the defecation centre (2) to the cerebrum. Due to the spinal cord injury (3), this information does not reach the cerebrum. Instead, it is returned directly from the defecation centre to the intestinal muscles with the information “bowel full" (so called reflex arc). Defecation can no longer be controlled consciously. Due to the reflex arc, the intestinal wall (1) transports the stool but at the same time the external anal sphincter (4) stays closed. Instead of a regular defecation, incontinence or constipation may occur. Defecation In case of a spastic bowel, it is possible to train the bowel so that defecation is necessary only every two days. This varies, however, from person to person depending on the defecation habits. During rehabilitation it will show whether it is possible to empty the bowel only every 2 days. There are various defecation techniques and tools for defecation. The stool's consistency is also influenced considerably by the dietary and drinking habits. About the authors: Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch) and "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1997. She is also co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung". The article is the result of a collaboration with the panel of experts in bowel management of the Swiss Paraplegic Centre. updated: December 2013
View full article
Bowel incontinence is involuntary loss of bowel contents including flatus and feces. The causes may be of neurogenic, muscular or textural nature. People with spinal cord injury (SCI) mostly cannot control their bowel movement deliberately. However, an individually developed bowel management makes it possible to maintain continence and to mostly avoid incontinence issues. Specific forms of diarrhea Diarrhea is frequent defecation, often in liquid form. Diarrhea often causes incontinence. Paradoxical diarrhea In this form of diarrhea, the colon is blocked by an obstacle (collection of a large amount of hard stool, tumor) and only liquid stool can pass the obstacle. This means that liquid stool is excreted, even though the problem is constipation. Overflow diarrhea Overflow incontinence is caused if the rectum is emptied only insufficiently. The permanent filling of the rectum (fecal impaction) weakens the internal anal sphincter. Therefore the stool that liquefied above the fecal impaction can pass it. This results in uncontrolled defecation. What can I do in case of recurring incontinence? check your dietary habits increase consumption of fibers take notes of the foods you are eating to detect a possible reason for diarrhea optimize defecation management empty rectum manually more frequent defecation apply colon irrigation check and adjust medication use osmotic laxatives and swelling agents (e.g. Duphalac, Movicol, Transipeg) check whether medication has effects on the intestines (e.g. antibiotics, iron tablets) If these measures do not reduce the problem and the incontinence issues prevail, further diagnostics need to be considered to find out the exact cause. Important Incontinence can cause irritation and damage of the skin within a short time. Liquid stool can be very aggressive on the skin and lead to erythema and skin sores in the anal area. Assistive Devices There are various kinds of pads, depending on how severe the incontinence symptoms are. However, pads increase the likeliness to get pressure sores at the buttocks and it is better to not use them if possible. Tampon suppositories If incontinence cannot be fully controlled, tampon suppositories may be an alternative for doing sports activities, such as swimming. However, anal tampons can only be used for a limited time. Using them a whole day is not an alternative to pads since they may cause pressure sores in the anal area. Protection of the skin If severe skin irritations due to incontinence occur, it is important to protect the skin in the anal area. Only a thin layer of cream and ointment should be applied and removed completely in between. "Oxyplastine Wundpaste" (rash paste with zinc oxide) "Bepanthen Salbe" – may be applied as is or mixed 1:1 with Oxyplasinte rash paste 3M Cavilon long term skin protection lotion for healthy skin; for already damaged and sore skin use "3M Cavilon Reizfreier Hautschutz" FAQs How can zinc paste (e.g. Oxyplastine) be removed easily and without having to rub it off? The best thing to use is oil – either baby oil or cooking oil. Sources: URL: http://www.pflegewiki.de/wiki/Diarrhoe (retrieved August 7, 2013) Geng, V.: Inkontinenz. In: Haas, U. (Hrsg.) (2012): Pflege von Menschen mit Querschnittlähmung – Probleme, Bedürfnisse, Ressourcen und Interventionen. Bern: Verlag Hans Huber, S. 144ff. About the authors: Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch) and "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1997. She is also co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung". The article is the result of a collaboration with the panel of experts in bowel management of the Swiss Paraplegic Centre. updated: December 2013
View full article
Medical stimulation and the regulation of stool consistency are often necessary in order to control defecation in people with spinal cord injury (SCI). Laxatives can be hazardous to health, although many of them are herbal. The principle is: as little as possible – as much as necessary. Taking laxatives can induce a habituation effect – they are therefore not suitable for long-term use. Laxatives are chosen depending on how they work. A normal stool consistency (formed stools) supports defecation. A balanced diet, including high-fiber grains and a sufficient fluid intake help to regulate stool consistency; regular exercise also supports bowel movement. Traditional domestic remedies – useful or not? In case of constipation problems, people tend to try remedies with natural ingredients first. However, they are often not appropriate for long-term use or not suitable for people with spinal cord injury. Senna pods Many laxative teas, and sometimes also fig syrup, contain senna pods. However, sennas might reduce colon activity, lead to imbalances in intestinal fluid absorption and tend to be addictive. Wheat bran, flax seed, psyllium etc. These fibers are harmless with regard to the diet of healthy people, but only conditionally suitable for the bowel management in people with spinal cord injury. They can be deposited in mucosal skin folds or diverticula of the colon and thus cause inflammations. Measures to stimulate rectal defecation All measures to support rectal defecation, as well as all oral laxatives (see below), are drugs. Please read the package information leaflet before using the product and contact your GP in case you have any questions. Product Information Lecicarbon Agent: CO2 - Laxative formation of gas bubbles stimulates peristalsis dosage: 1-2 supp. onset of action: 15-30 minutes important: dip suppository into water before use suitable for long-term use Prontolax, Dulcolax Agent: Bisacodyl inhibition of water absorption in the intestines, stimulation of peristalsis dosage: 1-2 supp. onset of action: 20-60 minutes according to medical studies suitable for long-term use Bulboid Agent: Glycerol extraction of water from the surrounding areas, effect restricted to rectum dosage: 1 supp. onset of action: 30 minutes effect restricted to rectum, therefore not suitable for people with complete paraplegia Freka-Clyss, Clyssie Klistier Agent: Sodium phosphate Microklist Agent: sugars, sugar alcohols pulls water from the body into the bowel, which leads to an increased stool volume in the rectum and thus stimulates peristalsis dosage: 1 flask resp. 1 applicator onset of action: 5-20 minutes in case of constipation, not suitable for long-term use Oral laxatives Generally it is important to avoid taking laxatives whenever it is possible. The use of laxatives depends on the stool consistency. The effect usually starts after at least 24 hours. Oral laxatives are therefore not suitable for short-term use. Product Effect Duphalac Syrup Agent: Lactulose, Galactose Importal Sachet Agent: synthetic sugar pulls water from the body into the bowel, leads to an increased stool volume in the rectum and thus stimulates peristalsis dosage: max. 3 x 20 ml (Duphalac), 1-2 x 1 bag (Importal) onset of action: after 12-48 hours suitable for long-term use do not use Duphalac: for people with lactose intolerance Importal: for people with permanent colostomy Movicol Agent: Macrogol, salts accumulation of water softens stool dosage: max. 3 x 1 bag (1 bag corresponds to 25 ml concentrate) onset of action: after 24-72 hours suitable for long-term use Agiolax mite Agent: psyllium, psyllium husks Colosan mite Agent: Sterculia granules start to swell which leads to an increase in stool volume – this stimulates peristalsis and makes stools soft and smooth dosage: max. 3 x 20 ml it is important to drink a lot after intake – at least 1 glass per 5 ml Colosan/Agiolax onset of action: 12 hours (Colosan) up to several days suitable for long-term use Metamucil Regular Agent: Plantaginis-ovatae-seed coats, dextrose Metamucil N Mite Orange Agent: Plantaginis-ovatae-seed coats, sucrose start to swell due to water intake which leads to an increase in stool volume – this stimulates peristalsis and makes stools soft and smooth dosage: max. 3 x 20 ml drink plenty – 1 glass of water for dissolving plus 1 additional glass of water after intake onset of action: after 12-48 hours suitable for long-term use note for diabetics: 10 ml Metamucil contain about 13kcal Senna-free fig syrup fructose, mucins and fruit acids soften the stool dosage: max. 3 x 20 ml onset of action: after approx. 24 hours long-term use might be hazardous to health Important Oral laxatives dehydrate our body. It is important to drink a lot of water in order to compensate for the loss of fluid. FAQs Do I always need to consult a physician when making changes in the use of laxatives? Not necessarily. In case you know the respective drug and only want to change the dosage, you can do this without having to ask your physician. In case of problems, or if you are not satisfied with the dosage of your laxative, please contact your GP. It is not recommended to only consult a pharmacist, as laxatives often do have different effects on people with SCI, compared to the effects they have on people without bowel paralysis. Therefore, not all drugs are suitable for people with SCI. Do I have to take laxatives for the rest of my life? That depends on your diet and the amount of exercise. Basically, the overall aim is to find the right balance for soft and smooth stools. This way the risk of hemorrhoids and anal fissures can be reduced – however, this is only possible for people without fecal incontinence. If I have an artificial anus, is there anything I need to consider when choosing a laxative? Yes – depending on what kind of artificial anus you have, not all drugs are suitable for you, as the effect of many products is restricted to the colon. We therefore recommend consulting your GP or a specialist for intestinal diseases before choosing a laxative. Do insurance companies pay for laxatives in Switzerland? In most cases they don't. Different insurance companies pay for different preparations – please ask your insurance company. About the authors: Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch) and "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1997. She is also co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung". The article is the result of a collaboration with the panel of experts in bowel management of the Swiss Paraplegic Centre. updated: December 2013
View full article
Normal bladder function Storage- and emptying function of the urinary bladder (Source: APOGEPHA Arzneimittel GmbH) a) empty bladder b) filling of the bladder c) emptying of the bladder If the bladder is empty, the bladder muscle (detrusor) relaxes and the sphincters contract – the bladder is shut (see figure a). If the bladder fills with urine, the bladder muscle remains relaxed and the sphincter remains contracted. The bladder is still shut (see figure b). As it fills, the bladder stretches – this is registered by the nerves that are connected to the bladder wall. They carry messages from the bladder to the brain, letting the brain know when the bladder is full. During urination, the bladder muscle contracts deliberately, and the sphincter relaxes to allow urine to flow out. (see figure c). Our control centre - the brain (APOGEPHA Arzneimittel GmbH) 1) brain 2) spinal cord 3) urinary bladder 4) nerves 5) sphincter/pelvic floor muscles What is the difference with a spastic bladder? Any information concerning the filling of the bladder is registered by the stretch receptors at the bladder wall. If the bladder is full, these receptors send information through the bladder nerves (sacral nerves S2-5) to the spinal cord. These nerves enter the spinal cord below the twelfth thoracic vertebra – this area is called micturition centre. The information sent by the micturition centre does not reach the brain and thus the brain cannot send back signals to the micturition centre. In this case, the information “full bladder" is sent back immediately to the bladder muscle and thus triggers urination (so-called reflex arc). The bladder is emptied whenever the stretch receptors are stimulated enough to send the message. However, the point of stimulation varies: sometimes the the reflex arc is triggered at a level of 200ml, the next time at only 80ml. Therefore the maximum filling volume of the reflex bladder varies each time. Furthermore, the bladder muscle is stimulated to contract and thus start urination, but at the same time, the sphincter muscles will not relax. Result: bladder muscle and sphincter muscles do no longer work with each other, but against each other. This can lead to an overfull bladder, which could cause incontinence and over time kidney damage. About the authors: Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1997. She is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" and "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch). The article is the result of a collaboration with the panel of experts in bladder management of the Swiss Paraplegic Centre. updated: December 2013
View full article
Normal bladder function Storage- and emptying function of the urinary bladder (Source: APOGEPHA Arzneimittel GmbH) a) empty bladder b) filling of the bladder c) emptying of the bladder If the bladder is empty, the bladder muscle (detrusor) relaxes and the sphincters contract – the bladder is shut (see figure a). If the bladder fills with urine, the bladder muscle remains relaxed and the sphincter remains contracted. The bladder is still shut (see figure b). As it fills, the bladder stretches – this is registered by the nerves that are connected to the bladder wall. They carry messages from the bladder to the brain, letting the brain know when the bladder is full. During urination, the bladder muscle contracts deliberately, and the sphincters relax to allow urine to flow out (see figure c). Our control centre - the brain (Source: APOGEPHA Arzneimittel GmbH) 1) Brain 2) Spinal cord 3) Urinary bladder 4) Nerves 5) Sphincter/pelvic floor muscles What is the difference with a flaccid bladder? A spinal cord injury below the twelfth thoracic vertebra usually causes a flaccid bladder. Any information concerning the fullness of the bladder is registered by the stretch receptors on the bladder wall. If the bladder is full, these receptors send information through the bladder nerves (sacral nerves S2-5) to the spinal cord. If the spinal cord injury affects the nerves of the bladder, fewer or no information can be sent to the brain. No information can be sent from the bladder to the brain – as a result, urination can no longer be controlled. Although the bladder itself is intact, it can no longer react – it is flaccid. Sometimes, however, information manages to reach the brain through nerves that are still intact. In this case, the paralysis is incomplete – the urge to urinate is perceived completely, less intense or in a different way. About the authors: Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1997. She is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" and "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch). The article is the result of a collaboration with the panel of experts in bladder management of the Swiss Paraplegic Centre. updated: December 2013
View full article