MEDICAL MANAGEMENT OF NEUROGENIC BLADDER IN SCI
Click on Bladder Management for Adults with Spinal Cord Injury for the current clinical practice guideline.
There are several methods of managing bladder dysfunction due to impaired innervation. An inability to retain or completely expel urine must be routinely managed, using one or more of these methods, to prevent incontinence and urinary retention, which can cause urinary tract infections (UTIs) and renal dysfunction. Proper bladder management not only achieves adequate bladder drainage, but low-pressure urine storage and low-pressure voiding, which also help prevent UTIs, bladder wall damage, bladder overdistention, vesicoureteral reflux, stone disease, urolithiasis, hydronephrosis, or vesicoureteral reflux in all SCI patients (Perkash, 1993; Levy and Resnick, 1993; Sekar, et al 1997; Bergman, et al 1997). Cranberry tablets can reduce the frequency of UTIs in SCI patients with neurogenic bladder, especially in patients with a high glomerular filtration rate. (Hess, et al 2008)
Contemporary management of the spinal cord-injured bladder has allowed for near-elimination of renal failure as the primary cause of long-term morbidity in these patients (Lightner, 1998; Jamil, 2001). The mainstay of treatment is the use of antimuscarinic medication and catheterization, but in those for whom this is not possible, external sphincterotomy has been the traditional management route (Ahmed, et al 2006). Combined high-dosage antimuscarnic medications are effective and do not increase side effects (Amend, et al 2008). Flexible dosing with an anticholinergic agent, with clean intermittent catherization when indicated, reduces the risks of urologic complications, improves levels of continence, and enhances patient quality of life in most children and adults (Chancellor, et al 2006).
- Crede or Valsalva maneuver or abdominal tapping are used by patients with incomplete SCI to achieve bladder evacuation by relaxing the external urethral sphincter and increasing pressure in the bladder. In patients with complete SCI, anal stretch (with two fingers) and the Valsalva maneuver performed simultaneously produce favorable conditions.
- Bladder training is possible if there is sufficient recovery of spinal cord neurophysiology. Intermittent catheterization should be avoided if return of bladder function is a possibility.
- Intermittent catheterization using sterile technique is commonly used following the acute phase of SCI in patients where there is inadequate bladder emptying. It protects bladder compliance regardless of the level or completeness of injury and prevents upper tract complications associated with low compliance (Weld, et al 2000). It is the safest bladder management method in terms of urological complications (Weld & Dmochowski, 2000). It is also recommended in early urologic management until urodynamic studies have been performed and final urologic decisions made (Wheeler and Walter, 1993) and in female patients following SCI given that other factors, such as independent hand function or the need for appropriate assistance, are considered (Bennett, et al 1995).
- Perform every 4 to 6 hours to prevent infection, or, whenever the bladder is full to prevent high intravesical pressure, bladder overdistension, incontinence, and urinary tract infection
- Perform more frequently, every 3 hours or less, if bacteriuria is present or to maintain sterile urine.
- Anticholinergic agents are recommended to reduce contractibility and increase bladder capacity, which will prevent incontinence between catheterizations
- Disposable and reusable catheters may be used
- Clean (long-term) intermittent catheterization using non-sterile technique may be done, every 4 to 6 hours or less often, to achieve complete bladder emptying and prevent intravesical pressure, bladder overdistension, and recurrent urinary tract infections
- Indwelling catheterization may be used in the acute phase of SCI, when fluid intake and output are carefully monitored. It may be used following the acute phase, if other measures fail and patients undergo regular upper urinary tract imaging and cystoscopy (Chao, et al 1993). To prevent bacteriuria and other complications:
Indwelling catheters, specifically (Konety, et al 2000) and SCI in general have been associated with a higher risk for bladder cancer (Konety, et al 2000; Groah, et al 2002), particularly patients using catheters for more than 10 years (Cravens & Zweig, 2000). Patients using indwelling catheters had more infections than those using intermittent catheterization (Shekelle, et al 1999).
- Remove the catheter with proper precautions
- Prevent outlet obstruction, plugging and kinking of the catheter
- Increase fluid intake to maintain urinary flow and reduce sediment
- Empty the leg bag frequently to prevent overdistension and back pressure on the bladder
- Tape the catheter to the abdominal wall to prevent pressure sores at the penoscrotal angle and injuries to the urethra
Although the incidence of bladder stones following SCI has declined significantly, males and persons with indwelling and intermittent catheters have a higher risk during all the years after the injury (Chen, et al 2001). Long-term catheterization is associated with a substantial increased risk of bladder stone formation that occurs independently of age, sex, injury level, and catheter type (suprapubic or urethral) (Ord, et al 2003). In cases which cannot undergo intermittent catheterization, or when the bladder cannot empty spontaneously, a suprapubic catheter is better than a urethral catheter for reducing upper tract deterioration (Ku, et al 2005). Stone disease is still a significant cause of morbidity and concern, and early identification and treatment of urolithiasis in spinal cord injury patients is recommended to preserve renal function and minimize associated complications (Ost & Lee, 2006).
Many contemporary SCI patients have calculi of a metabolic etiology (Matlaga, et al 2006). Encrustation of a catheter is highly predictive of the presence of bladder stones. This suggests that cystoscopy should be scheduled in a person undergoing a catheter change if catheter encrustation is noted (Linsenmeyer & Linsenmeyer, 2006).
- Baclofen can reduce bladder hyperreflexia and sphincter activity and increase bladder capacity, enabling some patients to be free of an indwelling catheter.
- Botulinum-A toxin injections that treat detrusor-sphincter dyssynergia by paralyzing the external urethral sphincter for 3 - 9 months may be a valid alternative for patients who are unable to perform self-catheterization and who do not desire surgery (Schurch, et al 1996). Although patients may need repeat injections, botulinum toxin is minimally invasive and easy to administer, has no side effects, and is therefore an effective method of managing voiding in SCI patients, especially those on continuous external catheters and those who refuse or are not good candidates for surgery (Wheeler, et al 1998). Botulinum-A may also be safe and valuable in SCI patients with incontinence resistant to anticholinergic medication who perform clean intermittent self-catheterization (Schurch, et al 2000). Injection with Botulinum toxin-type A is an effective day-case treatment that bridges the gap between oral and invasive surgical treatment of drug-resistant NDO in patients with SCI. (Patki, et al 2006). It should be offered as a treatment option for detrusor overactivity and considered for detrusor sphincter dyssynergia after SCI. (Naumann, et al 2008). Following this intervention, the Incontinence Quality of Life questionnaire is a reliable measure of incontinence-related QOL in neurogenic patients (Schurch, et al 2007).
- Propiverine is effective in treating detrusor hyperreflexia in SCI. The increase in cystometric bladder capacity outweighs the side effects of anticholinergic agents, such as dryness of mouth and accommodation disorders (Stohrer, et al 1999).
- Oxybutynin may be beneficial in SCI patients, who require chronic indwelling catheters for bladder management to achieve better bladder compliance, lower bladder leak point pressures, and less hydronephrosis (Kim, et al 1997). Controlled-release oxybutynin is safe and effective in patients with detrusor hyperreflexia secondary to SCI. The onset of clinical efficacy occurs within one week, and daily dosages up to 30 mg are well tolerated (O'Leary, et al 2003).
- Terazosin can improve compliance and continence in SCI patients who previously demonstrated poor compliance despite clean intermittent catheterizaton (Swierzewski, et al 1994). It is well tolerated and effective in reducing bladder outlet obstruction in many SCI patients and should be considered for treatment of vesicosphincter dyssynergia before considering surgery (Bennett, et al 2000).
- Ciprofloxacin is efficacious in preventing urinary tract infections in SCI patients with neurogenic bladder dysfunction (Biering-Sorensen, et al 1994).
- Nitric oxide relaxes the urethral sphincter and may prove to be safe and effective for DSD in the future (Mamas, et al 2001).
- Tamsulosin - Long-term treatment (0.4 and 0.8 mg once daily) seems to be effective and well tolerated in patients with neurogenic lower urinary tract dysfunction. It may improve bladder storage and emptying, and decrease symptoms of autonomic dysreflexia (Abrams, et al 2003).
- Tolterodine at self-selected doses is comparable to oxybutynin at SSDs in enhancing bladder volume and improving continence, but with less dry mouth (Ethans, et al 2004). 2 mg twice daily is the usual starting dose, but a 1 mg twice daily dose might be equally effective with less risk of dry mouth. If extended release preparations of oxybutynin or tolterodine are available, these might be preferred to immediate release preparations because there is less risk of dry mouth (Hay-Smith, et al 2005).
- Vardenafil can improve urodynamic parameters in men with SCI (Gacci, et al 2007).
- Electroacupuncture at Baliao and Huiyang (BL 35) has therapeutic effect on retention of urine induced by spinal cord injury (Zhou, et al 2006).