Comparing Methods of Conservative Bladder Emptying
Bladder emptying must be conducted under low pressure conditions in order to prevent upper urinary tract complications such as reflux, infections and even renal failure. The choice of SCI-related bladder management method depends on the type of bladder dysfunction (e.g., incomplete emptying, incontinence, dyssynergia) and other secondary aspects of the SCI such as the patient’s functional capabilities, health, resources and other concomitant conditions. Urodynamic assessment is likely to be necessary in most patients to fully understand the dysfunction in specific structures in the lower urinary tract. Thereafter, the chosen method of bladder management must result in continence, be acceptable to the individual with neurogenic bladder, and facilitate the greatest independence. During rehabilitation and after spinal shock has subsided, people with SCI are initiated with the most conservative treatment options first (Wyndaele 2008). Patients are then taught how to manage the chosen method, and are advised as to complications and alternatives. The section below reviews several papers that address the outcome of groups of patients treated with the spectrum of conservative bladder management methods.
Conservative methods for bladder management includes behaviour therapy (triggered reflex voiding, bladder expression through Crede and/or Valsalva maneuver, and toileting assistance; catheters (intermittent or indwelling, condom (males only) or other external applicances); pharmacotherapy; and finally electro stimulation (electrical neuromodulation, electrical stimulation of the pelvic floor or intravesically). If residual bladder function permits, spontaneously “triggered” or expression voiding without the need for an external drainage system may be an option, although there are a variety of complications that can result from high bladder pressures with these approaches (Wyndaele et al. 2001). Suprapubic catheterization (SPC) is occasionally chosen in the subacute period given that disturbance to the urethra can be avoided. However, the complication rate remains high for this invasive technique and thus should be chosen only when conservative methods are unsuccessful and must be accompanied by comprehensive education for daily care.
Urodynamic studies provide information on lower urinary tract health, storage and emptying pressure, reflux status, and are essential to the choice of bladder management method(s) individualized for each patient. Having access to urodynamic data can also assist later decision making if changes to management methods are required. Green (2004), Drake et al. (2005), and Yavuzer et al. (2000), address these issues, listing some of the common complications as reason for change of management methods: frequent UTI’s, upper tract deterioration, increased post void residual urine volume, bladder or kidney stones, functional decline and patient request. The section below presents data on studies which attempt to clarify the type and incidence of complications associated with the above methods of bladder management. For the most part, these approaches are considered in advance of more invasive options involving bladder augmentation surgery or stimulator implantation (covered in later sections).
Discussion
A retrospective analysis of 234 patients with incomplete cervical cord injuries (Gohbara et al. 2013) found that during initial rehabilitation, patients were managed by urethral catheterization, suprapubic cyststomy, self or assisted administration of clean IC, clean IC with occasional spontaneous voiding, or spontaneous voiding alone. The severity of paralysis (e.g., AIS score) and urinary sensation (presence/absence of desire to urinate) were found to be predictive parameters for improvement in voiding function over the course of rehabilitation. The majority of patients’ bladder function improved during rehabilitation and those patients who were admitted with catheterization and discharged with spontaneous voiding, did so on average by 85.2 days (range 16-142). An interesting finding in this Japanese study is the high rate of AIS D (80.2%) patients compared to published rates from other international SCI populations (46-59% in Europe (Hogel et al. 2012), 29-32% in the USA (DeVivo 2007), 28% in Canada (Pickett et al. 2006)).
In keeping with offering conservative management options first, El-Masri et al. (2012) found that supervised sequential management methods beginning with a brief period of indwelling urethral catheterization followed in IC and/or reflex voiding over the longer term of regular surveillance (8-21 years) and timely intervention, kept complication rates to 62% (compared to 93% reported by Weld & Dmochoswski 2000). Of the 62% of complications, only 22.6% were related to the upper urinary tract.
Several authors have examined the frequency of a variety of urological and renal complications associated with various forms of chronic bladder management (Ord et al. 2003; Weld & Dmochowski, 2000; Hackler 1982). These authors have all employed retrospective chart reviews to examine complication rates associated with long-term follow-up data. In general, these authors concur that the greatest numbers of complications occur with long-term use of indwelling suprapubic and urethral catheters. In particular, of these investigations, Weld and Dmochowski (2000) employed a large sample (N=357) and examined the greatest range of complications. These authors noted that long-term urethral catheterization was associated with the largest overall number of complications, with long-term SPC ranked next. Depending on the specific complication, one of these two methods was associated with the highest incidence. Urethral catheter users had the highest rates for epididymitis, pyelonephritis, upper tract stones, bladder stones, urethral strictures and periurethral abscess. Suprapubic catheter users had the highest rates for vesicoureteral reflux and abnormal upper tracts. It should be noted that these authors did not account for changing bladder management methods, preferring to simplify the analysis by classifying the results by the most predominate bladder management method.
Ord et al. (2003) examined a relatively large dataset (n=467) but examined all the combinations of changing methods. However, these authors limited their analysis to the effect of various bladder management techniques on the risk of bladder stone formation. Similar to Weld and Dmochowski (2000), these authors also found a slightly greater incidence of bladder stones for indwelling urethral catheters compared to SPC. Each of these methods, resulted in a greater incidence of bladder stones than IC. Ord et al. (2003) reported hazard ratios relative to IC of 10.5 for SPC and 12.8 for indwelling urethral catheters. In contrast, Hackler (1982) reported comparisons between long-term complication rates among those with condom (Texas), urethral (Foley) and SPC and found markedly higher rates for those managed with SPC even though the follow-up period for these patients was only 5 years as compared to 20 years for those managed with the other 2 methods. However, these findings reflected a much smaller series of patients (N=31) and the comparisons were made from patients from different time periods reflecting different “generations” of care.
It should be noted that even though the data favour IC or triggered spontaneous voiding, it is not always possible to use these methods. Lack of independence for catheterization can limit the use of IC in women and those with tetraplegia (Yavuzer et al. 2000). While every effort is made to start patients on IC programs, some patients change to other methods over time. Drake et al. (2005) reported a 28.8% incidence in change of bladder management method, while Yavuzer et al. (2000) found that up to 60% of patients changed from intermittent to indwelling catheter use. Green et al. (2004) found that only 25% changed to indwelling catheters over 15 years. The primary reasons indicated for changing methods were a greater dependence on care-givers than originally thought, presence of severe spasticity, incontinence and inconvenience with IC (females only). Thus, assisting patients in choosing the most optimal method of bladder management is important. If less optimal methods of management are used post-injury, appropriate or increased surveillance must continue, given the described complication rates.
In select groups of patients such as those with tetraplegia and who are respirator-dependent, use SPC (compared to IC or indwelling catheterization alone or combined with stoma or tapping) resulted in lower urological complications and better QoL, as long as close urological surveillance occurs at least annually (Bothig et al. 2012; n=56). SPC resulted in fewer instances (p<0.05) of ureteric reflux, bladder/kidney stones, or bleeding for high-tetraplegic patients with long-ter-ventilation. SPC was increasingly used with increasing age, regardless of gender.
Conclusion
There is level 4 evidence (from one case series study: El Masri et al. 2012) that severity of injury and urinary sensation could be predictive parameters of future voiding function.
There is level 4 evidence (from one case series study: Gohbara et al. 2013) that supervised, sequential conservative bladder management options result in favourable urological complication rates.
There is level 4 evidence (from two case series studies: Ord et al. 2003; Weld & Dmochowski 2000) that indwelling urethral catheterization is associated with a higher rate of acute urological complications than intermittent catheterization.
There is level 4 evidence (from one case series study: Weld & Dmochowski 2000) that prolonged indwelling catheterization, whether suprapubic or urethral, may result in a higher long-term rate of urological and renal complications than intermittent catheterization, condom catheterization or triggered spontaneous voiding.
There is level 4 evidence (from two case series studies: Ord et al. 2003; Weld & Dmochowski 2000) that intermittent catheterization, whether performed acutely or chronically, has the lowest complication rate.
There is level 4 evidence (from two case series studies: Yavuzer et al. 2000; Green 2004) that those who use intermittent catheterization at discharge from rehabilitation may have difficulty continuing, especially those with tetraplegia and complete injuries. Females also have more difficulty than males in maintaining compliance with IC procedures.
There is level 4 evidence (from one case series: Bothig et al. 2012) supporting significantly fewer urological complications and higher quality of life for high-tetraplegic respirator-dependent patients who use suprapubic catheters (versus intermittent catheterization) for bladder management.
