Q. I’m in my 10th year as a T8 complete para. While trading “locker room talk” among the friends I roll with, it’s not uncommon to hear tales of people that routinely have volumes of 1,000 cc or more when they intermittent cath! In rehab I was taught that bladder volumes of more than 600 cc can cause problems, but my friends don’t seem to think larger volumes are a big deal. Am I being overcautious? Are large bladder volumes really a big deal?
A. Craig, you aren’t being overcautious: Letting the bladder get too full can cause serious, permanent problems. Avoiding large bladder volumes is an often overlooked and/or misunderstood concept. Ideally the bladder should be emptied when the volume is 400 cc (about 1.5 cups) or less; a volume of 600 cc is considered a very full bladder. To put this in perspective, according to Medline Plus, the average person with normal sensation will feel the urge to urinate when bladder volume reaches around 200 cc. At 400 cc the urge to urinate becomes uncomfortable, as in “I gotta find a bathroom fast!” Between 550 cc and 600 cc the urge becomes so strong it is painful! One can imagine the stress of a bladder volume of 1000 cc or more is putting on the body.
A recent international study of 1,450 intermittent catheter users done by Coloplast found that 50 percent of U.S. catheter users are not catheterizing often enough. Reasons given for not catheterizing more often were expense and inconvenience — which shouldn’t be an issue given greatly improved reimbursement guidelines and the myriad of catheters and catheter systems available.
In terms of expense, Medicare now reimburses up to 200 catheters per month — guidelines include “one catheter (A4351, A4352) and an individual packet of lubricant (A4332) per catheterization episode.” These guidelines also cover Coudé catheters and hydrophilic catheters. Many people with SCI find hydrophilic catheters are more convenient and easier to use than non-hydrophilic coated catheters — a report that is backed up by a study published in the January 2011 edition of Neurology and Urodynamics. The study found, in addition to ease of use, hydrophilic catheters help reduce urinary tract infection and microhematuria (blood in the urine due to trauma from catheterization).
When it comes to intermittent catheterization and convenience, the key is finding out which catheter works best for your body and your lifestyle. To that end, check out United Spinal Association’s webinar on June 7, titled “Accessing the Catheter that Best Works for You!” Sign up or see the archived webinar after June 7 here.
Other ways to find which catheter works best for you include discussing it with your urologist and speaking to your urological supplier — they will be more than happy to send you samples of different types of catheters for to try.
Back to your question of large bladder volumes. Paula Wagner, a urology nurse practitioner from UC Davis Medical Center in Sacramento, Calif., explains that large bladder volumes can cause very serious, often permanent problems. An overfull bladder can cause autonomic dysreflexia. When a bladder gets too full it can cause reflux — urine backing up into the kidneys — which can cause serious, irreversible kidney damage. A full bladder can also can result in permanent scarring of the bladder, leaving it less flexible, and the scars create an area in the bladder where bacteria can grab on, hide and make a stronghold, resulting in more frequent bladder infections —which also increases the risk for bladder cancer. Again, it is important to keep bladder volumes under 400 cc. At the same time, it is important to drink enough water to stay hydrated. A rule of thumb is to try to drink enough water to keep urine in the clear to straw colored range.
When it comes to cathing, proper technique also important to make sure your bladder is completely emptying. When there is bacteria in the bladder, most of it gets flushed out each time the bladder empties — one of the reasons staying hydrated and cathing often helps avoid UTIs. When the bladder doesn’t completely empty, the urine left behind, called residual volume, is like a stagnant pond and gives bacteria a place to multiply and make a stronghold. Residual volume also allows minerals in the urine to crystallize and can lead to bladder stones. Making sure your bladder is completely empty gets back to basic cathing technique. Because the opening to the urethra is located at the bottom of the bladder, the best way to make sure you are completely empty is to cath while sitting upright. Also, when the catheter is in the bladder, the eyelets (drain holes) are probably higher than the opening, so when urine stops flowing, slowly pull the catheter out an inch or two, then stop — this will allow urine at the bottom of the bladder to empty. For people who cath lying down, use the same system of pulling the catheter out a few inches and roll side to side.
A few moments’ thought and taking the time to cath often enough to keep volumes low goes a long way to keeping your bladder and kidneys healthy and avoid major problems in the future. Stay with it, and perhaps share this column with your friends in hopes they keep their volumes low and keep their bladders healthy for the long haul as well.