Game of Thrones has become a focus of American pop culture over the last eight years. Even now, almost a year after the finale aired, people are still discussing the impact of the show and the controversial last season. Many of us were hoping to finally get answers to questions we have been asking since the beginning, and the final season provided us with some answers, although not necessarily satisfying ones.

As urologists — doctors specializing in treating conditions of the urinary system — there is one question that was never addressed: How does Bran pee?

We’ve seen Bran carried, fed, even warg into another human, but not once was there a reference to him urinating. Since the writers have not taken the liberty to discuss his urological issues, we felt compelled to relieve (no pun intended) our own frustrations and finally address it.

To understand how Bran maintains his bladder, we have to understand:

1. How we pee
2. Bran’s injury
3. How Bran’s injury interrupts normal bladder function

Let’s begin with how we pee.

The bladder does two things — it stores and empties urine. In order to properly fill, the bladder must stay relaxed, and a normally functioning nervous system must keep it from emptying prematurely. Also, the outlet of the bladder must stay closed when the bladder wants to store urine, and it must open when it’s time to empty. Think of it like a sink tap that we can turn on/off. A functioning nervous system is key in keeping this system running.

When Bran was pushed out of the tower by Jamie Lannister, his life and fate were irreparably changed. Based on his injury and ability to move his arms, we’ll hypothesize that Bran’s spinal cord was damaged somewhere between the thoracic and lumbar regions (about halfway down the spine), rendering him paraplegic.

Early on, while Ned was still in King’s Landing, Bran was likely experiencing the early phase of what is known as “spinal shock,” which results from decreased input to spinal segments below the area of a spinal cord injury (SCI). Spinal shock occurs for approximately two to three months after a SCI and results in a floppy bladder that cannot squeeze and empty urine adequately. During this time, Bran’s “neurogenic bladder” was basically a wet noodle, unable to contract, and therefore he was unable to pee as we normally do. Once spinal shock resolves, SCI patients like Bran develop bladders that are overactive, constantly in spasm, while at the same time squeezing against an uncoordinated, closed sphincter.

I know what you’re thinking, “What’s the big deal?”

Well, if you can’t relieve your bladder properly, urine trouble — the pressure transmits to your kidneys, and over time leads to kidney failure. Kidney failure, especially in an age without dialysis, would have been fatal.

With a newfound understanding of Bran’s neurogenic bladder, the natural next question for us is, could his issues have been managed in Westeros, and if so, how?

Although Westeros and the Game of Thrones series exist in a fantasy universe with a completely different concept of time, we know that George R. R. Martin loosely based some of his story on England’s 15th Century War of the Roses, so we can assume that medical knowledge was similar in both worlds.

So what was the medical prowess of those living in the 15th century? Well, it wasn’t good. At this point in history, we were still several hundred years away from local and general anesthesia, let alone antibiotics and the concept of sterility. The art of surgery was anything but — it was brutal and incredibly painful, with high morbidity and mortality.

This leads us back to Bran. The list of comorbidities secondary to Bran’s injury would be long, but as urologists, we have a one-“tract” mind.

Unable to urinate properly, Bran would require intermittent catheterization, which involves the insertion of an instrument into his urethra to drain his bladder. He would need to do this multiple times a day to prevent damage to his kidneys.

Fortunately, catheters existed, and had existed for over one thousand years at that point. Some of the earliest documented catheters were made out of hollowed onion plant leaves that were coated with lacquer in China in 100 BC. By the 15th century, catheters were typically made of silver, gold, or brass.

Bran’s management would have faced other obstacles. Up until the 20th century, catheters were mainly used for the treatment of bladder stones, enlarged prostates causing urinary obstruction, and urethral inflammation. SCI patients were rarely managed, simply because they were few and far between. The start of the 20th century brought war and advanced weaponry, and with this, more SCI patients requiring physicians to manage them. By 1901 physicians were acknowledging the voiding issues of SCI patients and finally advocating catheterization of their bladders.

So let’s put it all together. Bran is paraplegic with the inability to pee on his own. In order to alleviate his bladder and prevent kidney failure, he would have been catheterized by gold rods at least four times a day. Since SCI at the time was rare, Bran’s neurogenic bladder would have been mismanaged.

In the Game of Thrones universe, Bran’s injury leads him to be the Three-Eyed Raven and eventually the King of Westeros. In real life, would he have made it that long? Probably not. He probably would have died of kidney failure, if sepsis or some other mismanaged SCI complication didn’t kill him first.

Even after the show’s conclusion, Bran still remains one of the most mysterious characters in Game of Thrones. He had overcome many obstacles on his journey, including the White Walkers and the Night King, to ultimately become the King of Westeros (to the chagrin of many viewers). Shedding light on his urinary issues leads us to conclude, however, that the most miraculous thing Bran had done was to survive, nay thrive, after his SCI, which would have surely killed almost anyone else.

Justin Dubin and Daniel Furlong are urology residents.

Image credit: Shutterstock.com