Prevention of AD During Bladder Procedures

Urinary bladder irritation or stimulation is a major trigger of AD following SCI (McGuire & Kumar, 1986; Linsenmeyer et al. 1996; Giannantoni et al. 1998; Teasell et al. 2000; Mathias & Frankel 2002). Thus, a bladder management program and continuous urological follow-up are important elements in the medical care of people with SCI (Waites et al. 1993a; Vaidyanathan et al. 1994; Vaidyanathan et al. 2004). An established bladder management program with intermittent catheterization or an indwelling Foley catheter allows people with SCI to plan for bladder emptying when convenient or necessary (Consortium for Spinal Cord Medicine, 2006). A study by Furusawa et al. (2011) found that the highest incidence of symptomatic AD was diagnosed in participants using reflex voiding as a bladder management method, while the lowest incidence of symptomatic AD was seen in participants using continent spontaneous voiding followed by intermittent catheterization.

In the past years, urological follow-up including annual urodynamic evaluations and cystoscopy (depending on the bladder management program) have decreased the frequency of urinary tract infections and the development of renal failure in people with SCI (Waites et al. 1993a; Waites et al. 1993b; DeVivo et al. 1999). However, conservative management is not always successful and alternative strategies (e.g., application of Botulinum toxin, capsaicin, anticholinergics, sacral denervation, and bladder or urethral sphincter surgery) may be needed to decrease afferent stimulation from the bladder to prevent development of AD. In addition, urodynamic procedures and cystoscopy are associated with significant activation of urinary bladder afferents and have the potential to trigger AD (Linsenmeyer et al. 1996; Dykstra et al. 1987; Snow et al. 1978; Chancellor et al. 1993). Therefore, strategies are also required during these procedures to reduce afferent stimulation.

Discussion

One case series (Xiong et al. 2015) revealed that individuals experiencing AD during cystolitholapaxy had larger bladder stones, a higher number of bladder stones, and longer operation times. Spinal anesthesia may be the most effective way to prevent incidences of AD in cystolitholapaxy procedures as only 2.5% of participants with spinal anesthesia experienced AD. Furthermore, the bladder management method that an individual uses may contribute to the prevalence of AD episodes. A study by Furusawa et al. (2011) found that participants who used reflex voiding experienced the highest incidence of symptomatic AD, while participants who used continent spontaneous voiding followed by intermittent catheterization experienced the least.

Conclusion

There is level 3 evidence (from one case control) (Furusawa et al. 2011) that reflex voiding as a bladder management method resulted in the highest incidence of symptomatic AD while continent spontaneous voiding followed by intermittent catheterization resulted in the lowest.

There is level 4 evidence (from one case series) (Xiong et al. 2015) that spinal anaesthesia may be more effective at preventing incidence of AD during cystolitholapaxy compared to local or general anesthesia.