How empty should the bladder be???

[sassyj]

I know someone who has a SCI and is set up on a self cath program every 6 hours. I've been told only to empty 500cc at a time. (In one setting I can empty 500cc wait 10 minutes and empty the rest.) This has become very time consuming and he empties very slowly.

I was also told if I were to empty the whole bladder, I could cause the bladder to collapse. (They told me this was very common practice in SCI people.) I believe it is a "nursing" decision to empty only every 6 hrs and only take out 500cc at a time. CAN anyone direct me to where I can find out if SCI should not have their bladder completly emptied and how much should be taken out??? (oh, and I was told to push on his bladder to get the urine to come out, because he drains so slow, I've seen people push pretty hard as if they were trying to get water out of a ball. It just didn't seem right...... please give me help and suggestions........

thanks!!

[SCI-Nurse]

The hazards of emptying a very full bladder are 98% old wives tales, with no scientific foundation, even though beliefs in the harmful effects are wide-spread amoung both physicians and nurses. I was involved in a research project about these beliefs several years ago (physician and nurse questionnaires), and we as part of this study we were unable to find a single valid and reliable scientific publication that proved there were ill effects, and the rationale given for why there were ill-effects (given by nurses and physicians) were nearly all physiologically impossible.

Given than, there are a few comments:

1) It is inadvisable for anyone with SCI to allow more than 500 cc. to be in their bladder at one time. The current recommendations, based on research, are for 425-450 cc. maximum. Above this amount, the blood supply to the bladder wall is compromised, making the bladder more vulnerable to infection. In addition, above 500 cc. the risks for reflux of urine from the bladder to the kidneys goes up significantly, and the risks for leakage and AD also go up.

The only except for this is if the person has AD when they are cathed, and have a very distended bladder. Under these circumstances, rapid drainage is desired, but can also cause some bladder spasm, which can make the AD worse. Only under this circumstance do we clamp the catheter for 5 minutes between every 500 cc. of urine drained, but we always do drain the bladder completely, even if it takes 2-3 clamping times to achieve this.

2) Catheterization should be done often enough (usually every 4 hours during the day, every 6 at night) to allow the person to drink 2400 cc. daily WITHOUT allowing their bladder to get over distended, and also to help keep the total bacterial count inside the bladder low. Since bacteria in the urine have a geometric progression of doubling, and with some bacteria the doubling time is a short as 15-20 minutes, 4 hours is preferred by most knowledgeable urologist as the maximum time you should have your bladder undrained.

3) Whenever emptying the bladder either by urination or catheterization, the bladder should be emptied completely. Leaving residual urine behind is a set-up for stones and urinary tract infections.

4) Pushing on the bladder (Crede's maneuver) while a catheter is in place is safe since during that time the "path of least resistance" for the urine is out the catheter. I always teach to Crede at the end of the catheterization to get out the last little bit of urine. Crede when there is no catheter in place is discouraged due to the significant risk of this causing reflux of urine to the kidneys. I don't advising using Crede for the entire catheterization. Drainage by gravity is best.

In 30 years of SCI nursing practice I have never seen a patient with a "collapsed" bladder...and have not found anyone who could tell me what a "collapsed" bladder would look like or how it would occur anatomically.

(KLD)

[nicotico]

sitting up and leaning forward will give me the jet stream effect i sorely miss. makes me pee out 500cc in under a minute.

[Wise Young]

I agree with KLD that it is usually quite safe to drain bladders completely and rapidly but want to point out that one should be careful about over-rapid drainage of the bladder when chronic urinary retention is suspected. Several reviews of the subject that suggested that there is little or no risk to rapid decompression of the bladder, i.e.

Mayo Clin Proc. 1997 Oct;72(10):951-6. Related Articles, Links

Management of urinary retention: rapid versus gradual decompression and risk of complications.

Nyman MA, Schwenk NM, Silverstein MD.

Division of Area General Internal Medicine, Mayo Clinic Rochester, Minnesota 55905, USA.

The literature was reviewed to quantify the risk of complications related to the relief of obstruction in urinary retention. We also sought to determine whether the risk of complications is higher with rapid or gradual decompression (or "clamping") of the obstructed urinary bladder. The medical literature was identified by a search of the MEDLINE database and a manual review of the bibliographies of the identified articles. Studies show that, after quick, complete relief of obstruction, hematuria occurs in 2 to 16% of patients; however, clinically significant hematuria is rare. After relief of obstruction, blood pressure often decreases, but it usually normalizes and does not progress to clinically significant hypotension. Postobstructive diuresis occurs after relief of obstruction in 0.5 to 52% of patients; however, it is easily managed and rarely of clinical significance. We were unable to identify any randomized controlled studies that directly compared quick, complete emptying with gradual emptying of the obstructed bladder. Moreover, we identified no studies supporting the practice of gradual emptying of the obstructed bladder. The available published studies support quick, complete emptying for relief of the obstructed urinary bladder. We conclude that hematuria, hypotension, and postobstructive diuresis may occur after decompression of the obstructed urinary bladder, but these complications are rarely clinically significant. Quick, complete emptying of the obstructed bladder is safe, simple, and effective and is recommended as the optimal method for decompressing the obstructed urinary bladder. Prudent, supportive care is needed for all patients, with special attention to elderly patients and those with hypovolemia.

The above is true for acute urinary retention. On the other hand, rapid drainage the bladder in a situation of chronic urinary retention should be carefully done. When I was in medical school, I took care of a young woman who had Hirschsprung's disease and showed up in the emergency room with a huge (over 4 liters) that occupied most of her abdomenal cavity. Even though we slowly drained the bladder over several days, she developed significant diuresis, leading to severe hypokalemia (low blood potassium). The mechanism is unclear but may be related to the kidneys becoming insensitive to ADH (anti-diuretic hormone) in situatons of chronic urinary retention.

According to http://www.patient.co.uk/showdoc/40024504/

In acute retention the catheter can be left to drain freely, producing a very grateful patient. In chronic retention there is dilatation of blood vessels that can bleed profusely if deflation is too fast. In chronic retention the bladder must be drained slowly. Authorities differ as to the exact speed but the larger the bladder the slower it must be drained.

Some people develop acute urinary retention on top of a chronic urinary retention, due to obstruction by stones or prostate, or even medication. In such cases, care should be taken not to drain the bladder too rapidly and all at once. Differentiation between chronic and acute urinary retention may not be easy for a doctor who is seeing a patient for the first time, particularly in somebody with spinal cord injury. Acute retention is usually associated with tenderness or palpation and the bladder volume is a liter or less. If there is no tenderness on palpation and ultrasound scans or other imaging modalities suggest a bladder volume greater than a liter, chronic urinary retention may be present. In people with spinal cord injury who have loss of sensation, the diagnosis is more difficult but palpation of the abdomen may result in increased spasticity or spasms. While rapid decompression of large bladders can result in hematuria (blood in the urine), this occurs in 10-15% of cases and is usually self-limited.

Thus, I recommend the following. If a person has acute urinary retention, a bladder volume of less than a liter, and tenderness or increased spasticity to bladder palpation, it is reasonable to insert a catheter and let the urine drain freely. However, if there is a history of chronic unrelieved urinary retention, a bladder volume greater than a liter, suspicion of renal damage, and high intravesicular pressure encountered when the catheter is inserted, I suggest admitting the patient and draining the bladder in steps with monitoring of the patient for blood pressure and blood potassium, with intravenous fluid replacement if necessary. It is better to be safe than sorry.

Wise.

[bob clark]

Wow, over 4 liters. As I wrote before, I once had about 1 & 1/2 liters in me and thought I was gonna pop. I wonder how she was able to retain that much urine without getting a severe or even deadly case of AD and/or rupturing her bladder or making her kidneys bleed? Heebie-jeebie time.

[SCI-Nurse]

Thanks, Dr. Young. Of course I should have added the caveat about chronic urinary retention vs. acute or just doing a regular cath too late and being too full. The first one can cause problems with too rapid decompression, but it is very unlikely with the latter.

(KLD)

[sassyj]

Thank you soooooo much. That information really helps me. I had searched for hours and I couldn't find any information on it. I am a new nurse and the more experienced nurses at my place of employment told me it was "common knowlege" not to drain over 500 cc out of a bladder. I was taught to drain the bladder completely so I thought I was going a little crazy. So, you've really helped me so I can help someone else! Thanks!!

[sassyj]

Thank you for the information. This person is a recent (6 months ago) spinal cord injury. He is new to our facility and the charge nurse is having us straight cath him every six hours. When I cath'd him he drained 1050cc in about 25 minutes. When I told the experienced nurses they told me I should only drain 500cc out at a time, wait 10 minutes and drain the rest because his bladder could collapse. There is no documentation stated this, just word of mouth and what I have found is other nurses not draining him completely, they are stopping at 500cc or less because now they have this fear he is going to collapse. We do not have a bladder scanner but I would guess he is being left with urine in his bladder which I would think could lead to infection or kidney stones.....right???
The information you gave me is very helpful!!! I'm so glad I found this site it is going to be very informative to me.....THANKS!!!!!

[bob clark]

Originally Posted by sassyj

When I cath'd him he drained 1050cc in about 25 minutes.

Hi Sassyj,

That seems awfully slow. I can drain 1200ccs in about 5 minutes using a 14fr clear plastic self-cath catheter. I don't apply any pressure and my bladder is flacid.... it just drains by gravity. Maybe you're using those red rubber ones that drain slow. The size, in my case 14fr, is the outside diameter. And since those red rubber ones are so thick the inside diameter is a lot smaller so drain slower.

Or maybe he has a lot of sediment that's clogging the catheter. But as has already been written and reasons explained, he shouldn't have any more than 450ccs in him at any one time.

the charge nurse is having us straight cath him every six hours.

The charge nurse needs to be re-educated.

Catheterization shouldn't be determined by time but by volume. A patient having 1050ccs of urine in him could be considered neglect or at least bad medical care. Perhaps the Nurse here would like to comment on this.

[Wise Young]

Originally Posted by bob clark

Hi Sassyj,

That seems awfully slow. I can drain 1200ccs in about 5 minutes using a 14fr clear plastic self-cath catheter. I don't apply any pressure and my bladder is flacid.... it just drains by gravity. Maybe you're using those red rubber ones that drain slow. The size, in my case 14fr, is the outside diameter. And since those red rubber ones are so thick the inside diameter is a lot smaller so drain slower.

Or maybe he has a lot of sediment that's clogging the catheter. But as has already been written and reasons explained, he shouldn't have any more than 450ccs in him at any one time.

The charge nurse needs to be re-educated.

Catheterization shouldn't be determined by time but by volume. A patient having 1050ccs of urine in him could be considered neglect or at least bad medical care. Perhaps the Nurse here would like to comment on this.

Bob,

In hospitals it is hard to monitor bladder volumes as the criterion for catheterization. So, they usually estimated a 6-hour schedule for catheterization. The fact that the bladder became so big and the urine drained out slowly over 25 minutes probably means that the person has a flaccid bladder. The bladder may gain back some tone over time.

However, I agree with you and KLD that there is something wrong. The policy of draining 500 ml and leaving the rest in does not make sense.

Wise.

Thank you for the information. This person is a recent (6 months ago) spinal cord injury. He is new to our facility and the charge nurse is having us straight cath him every six hours. When I cath'd him he drained 1050cc in about 25 minutes. When I told the experienced nurses they told me I should only drain 500cc out at a time, wait 10 minutes and drain the rest because his bladder could collapse. There is no documentation stated this, just word of mouth and what I have found is other nurses not draining him completely, they are stopping at 500cc or less because now they have this fear he is going to collapse. We do not have a bladder scanner but I would guess he is being left with urine in his bladder which I would think could lead to infection or kidney stones.....right???
The information you gave me is very helpful!!! I'm so glad I found this site it is going to be very informative to me.....THANKS!!!!!

Sassyj,

You are of course very welcome.

I agree with KLD and Bob Clarke that it is okay to drain the bladder completely. As KLD points out, the concept of a "collapsed" bladder is probably myth There is no rationale to draining only 500 ml (cc) and leaving the rest in. It should simply be drained completely.

If he is getting catheterization every six hours and putting out a liter or more every time, he is putting out too much urine A normal person urinates between 1.2-1.7 liters per day. People with spinal cord injury can have 2 or even 2.5 liters of urine a day but 4 liters is too much.

Based on your description, if the nurses are indeed just draining 500 ml every six hours and leaving the rest in, they are draining only 2 liters out per day and allowing the excess to accumulate. That doesn't make sense.

Wise.