Incontinence plays a large role in the daily lives of persons who suffer disability. There are always options when choosing a method of managing incontinence. When it comes to urinary incontinence, there are always a number of factors to take into account when deciding on the best option to make use of. Traditionally, the decision on how to manage the bladder when affected by loss of control has been made by the doctor. However, medical professionals often forget that, despite their best intentions, the real decision needs to be made by the individual after having been given all the options available to them.
This decision may be made based on a number of factors such as hand function, access to clean water, ease of obtaining appliances such as catheters or urisheaths etc. The decision needs to be made after recommendations of best medical practice have been given by the doctor.
In the acute phase after an acute disabling medical event such as a spinal cord injury, the paralysed bladder is normally managed on an indwelling catheter – i.e. a catheter passed into the bladder through the urethra, which remains in for up to 6 weeks. However, fairly early after injury, one can start to decide on options for management of the bladder. The following options are available.
- Permanent catheter. This is normally reserved for patients whose bladders do not empty naturally or where complications such as autonomic dysreflexia (see earlier edition) are evident. The catheter remains in the bladder and is normally changed on a 4 to 6 weekly basis. The catheter should be a good quality catheter (100% silicone) as this will reduce the chances of infection and complications such as stones. Catheters can be either inserted via the urethra (the narrow tube running from the bladder to the outside) or directly into the bladder from just above the pubic bone – this is known as a supra pubic catheter. This is the preferred means. A permanent catheter is not the best choice medically speaking, but once again the final decision should be made by the patient themselves after all information has been given by the medical team.
- Intermittent self-catheterisation. In this technique, the bladder is catheterised at regular timed intervals using a disposable or reusable silicone catheter. When it comes to a recommended method of bladder management, the gold standard is intermittent self-catheterisation. However this can only be done if the bladder “profile” is suited to this. This will be established during the acute post injury phase (normally after 3 months) where urodynamic testing will identify a bladder that is safe to manage on intermittent catheterisation. Even though this may be the preferred method for patients, it may not always be feasible due to poor hand function, lack of clean facilities such as running water or other reasons.
- Urisheath (condom) drainage (in males). This option is only available when the bladder is able to safely empty in a reflex manner. Again this will become evident after the baseline bladder tests done soon after injury. A person should never switch to using a urisheath unless it is deemed safe to do so. Bladders that do not empty adequately, or that empty with high pressures will result in long-term damage to the bladder and kidneys.
- Urostomy or other urinary type diversion such as a continent urinary diversion. This should always be the last resort. In this method, which requires extensive surgery, the urine is diverted away from the bladder to either a continent stoma on the abdominal wall or an incontinent stoma over which a bag is placed to collect the urine – much like a colostomy. As mentioned this method of bladder management is normally reserved for complicated bladders that cannot be managed in any other way.
- Diapers. This is the least acceptable means of managing incontinence. This method often leads to skin dampness and secondary infections with fungal infections for example. This can further lead to skin breakdown and pressure sores.
Whichever method is used it is important to remember that there are advantages and disadvantages to any method. At the end of the day it should be an informed decision made by the patient after all the information has been given to them explaining options and best medical practice. Remember too that bladders are not static and may change with time and therefore regular follow up is essential.