Q. I sustained a T12 incomplete spinal cord injury in 2003. I was trained on how to use intermittent catheters in the hospital. I also wear a condom catheter and a leg bag.

After being home for a while I found that I could empty my bladder into my leg bag by placing a fist low on my abdomen and leaning on it while standing on my leg braces. I tried to cath myself after urinating using the method I just described, and nothing came out — it seemed like I had fully emptied my bladder.

I wonder why I was never informed of this method of bladder management while in the hospital? Do other people use this method? Is this an approved method of emptying the bladder — and can I continue to use it without harming myself? It sure is a whole lot easier than using an intermittent catheter.

— Robert

A. Robert, you bring up a good and often misunderstood question. I have a friend — also a T12 incomplete para — who, when he needs to urinate, grabs onto something, stands and gives a slight push with his stomach muscles. This fills his leg bag, and he is done.

Voiding the way you describe can be done with two similar “external” techniques. The first is called Credé’s method — manually applying pressure to your lower abdomen just below the belly button using a hand or closed fist to push the urine out of the urethra.

The second, the Valsalva technique, is where you flex your abdominal muscles — if you have them — or lean forward to apply pressure to the bladder and cause it to empty.

According to Paula Wagner, a urology nurse practitioner from U.C. Davis Medical Center in Sacramento, Calif., these methods can work in the right circumstances, but should only be used after consulting with a urologist and getting a complete urological workup to see if one or both are the right form of bladder management for you.

The main risk, Wagner explains, is if the urethral sphincter muscle is tight — often the case with people with spinal cord injuries — you will end up with high bladder pressure. High bladder pressure is dangerous and can cause reflux — urine backing up in into the kidneys — which can cause serious and irreversible damage. It can also result in permanent scarring of the bladder, leaving it less flexible. Plus, the scars create areas where bacteria can hide, make a stronghold and cause urinary tract infections. These techniques can also leave a residual amount of urine in the bladder — forming the perfect Petri dish for UTIs to grow. Other potential complications of the Valsalva technique include hemorrhoids and rectal prolapse.

Wagner explains that Credé and Valsalva do have their place in bladder management — usually in people with incomplete SCI, MS and some other neurological conditions. The key in all of these in cases is the sphincter can be voluntarily relaxed enough — or is relaxed enough on its own — to allow full bladder emptying at low bladder pressure.

To see if this technique is right for you, it is important to discuss it with a urologist. Wagner says before to considering Credé and or Valsalva techniques, a urologist should run a urodynamics test — which measures how much liquid your bladder can hold, bladder pressures, involuntary bladder contractions, and the pressure required to urinate — to make sure you are not developing high bladder pressure and to make sure you are not leaving any residual urine in your bladder. She also says the urologist should do a serum blood creatinine test — a blood test to evaluate how well your kidneys are functioning — and an ultrasound to make sure your kidneys and bladder look good. Armed with all of this information, the urologist can make an educated decision whether this is a good bladder management option for you.
Q. I have been using an indwelling Foley catheter for nine years, and from time to time I get mucus in the catheter. I was wondering if it is OK to irrigate the bladder on a regular basis. And if so, how much saline or water should I put in and how often?

— Mike

A. Good question, Mike. Paula Wagner, urology nurse practitioner from U.C. Davis Medical comes to the rescue on this one as well. Wagner explains that mucus is the bladder’s response to having a foreign body in it — in this case a Foley catheter (the same holds true for suprapubic Foleys).

“If somebody comes in to our clinic and has a lot of mucus in their bladder, first we run them through tests to make sure they don’t have a

[bladder] stone,” says Wagner. “If things check out, we will put them on a normal saline flush. The thing that is kind of tricky is there has been less prescription insurance coverage for normal saline.” Wagner says there is a recipe for making your own saline flush but she discourages it because if mixed incorrectly and there is too much salt in the solution, the bladder will absorb the salt. If your insurance doesn’t cover saline and money is tight, you can use distilled water instead.

To reiterate, the first thing to do if you are getting an increase in mucus in your bladder is see your urologist and get checked for stones.

To flush the catheter, you take a 60cc syringe and draw 30cc-60ccs of saline (or distilled water). The best way to do this is to pour the saline or distilled water into a clean container to draw into the syringe; this way you don’t contaminate the bottle of saline or distilled water. Next, insert the end of the syringe into the open end of the Foley catheter and inject the solution — leave the syringe in and draw it back until you have sucked all the mucus out. If you get a lot of mucus, repeat the process, Wagner says. The point is to irrigate and draw out the mucus — through the tiny eyelet holes in the bladder-end of the catheter — again and again until you draw out clean solution.

Wagner says when a person comes into her center with mucus in an indwelling catheter — after being checked for stones — the nurses start them on the flushing regime once a day. As mucus decreases, they have them back it off to every third day. “If it looks like you are getting a bladder infection,” she says, “you can flush more often.”

Journal articles report that people who have been using indwelling urinary catheters — Foley or suprapubic — for long periods of time have a slightly higher incidence of bladder stones, and of bladder cancer. Wagner says if you have been using an indwelling catheter for five years or longer, her office recommends a yearly cystoscopy — which uses a catheter with a tiny camera on the end to look inside the bladder for abnormalities like sessions or stones. They also recommend a yearly ultrasound and KUB — kidney, ureters and bladder x-ray to check for stones.

Wagner stresses that flushing an indwelling Foley is different than flushing after bladder augmentation surgery — discussed in December 2008 Bladder Matters — in which part or all of the augmentation is built from part of the lower intestine and often has to be flushed on a daily basis.