Indwelling Catheterization (Urethral or Suprapubic)
Urethral catheterization may be the bladder management method of choice for a variety of reasons including the following: ease of management, inadequate hand function for intermediate catheterizations, severe spasticity, low bladder capacity with high detrusor pressures and/or persistent incontinence especially in women, and pressure ulcers (Yavuzer et al. 2000). Suprapubic catheterization, first described in SCI by Cook and Smith (1976), is the preferred choice for those patients who require an indwelling catheter but have severe urethral disease. Weld and Dmochowski (2000) presented data showing a lower overall complication rate from SPC use than from urethral catheter use (44.4% vs. 53% respectively). Since indwelling catheterization is sometimes unavoidable, becoming familiar with the various potential complications and appropriate monitoring is important for clinical and self-management of neurogenic bladder.
Based on a series of case review studies comparing various bladder management methods, long-term use of indwelling catheters is associated with generally higher rates of complications (Wyndaele et al. 1985; Gallien et al. 1998; Weld & Dmochowski, 2000) in contrast to other methods (especially intermediate catheterizations). For example, Ord et al. (2003) noted a significantly greater chance of having bladder stones with long-term SPC or urethral indwelling catheter use as indicated by hazard ratios of 10.5 and 12.8 relative to intermittent catheterization respectively. Indwelling catheterization has also been linked to significantly higher rates of bladder cancer development (Groah et al. 2002; Kaufman et al. 1977) and upper tract deterioration (Weld & Dmochowski, 2000) as compared to those who use long-term intermittent catheterization.
Discussion
Although intermittent catherizations are the first choice for neurogenic bladder management, some patients with subacute SCI are managed with indwelling catheters due to prolonged high urine output states, frequent medical illnesses or surgical complications, or severe incontinence. Suprapubic catheterization is occasionally considered during this early period if urethral damage has occurred as a result of prolonged urethral catheter use. Later, in chronic situations, SPC may also be favored by individuals with SCI who are obese, or have severe lower extremity spasticity, inadequate hand function, persistent incontinence, urethral stricture or erosion, or because of perceived increased ability to engage in sexual relations (Weld & Dmochowski, 2000; Peatfield et al. 1983). Prostatitis and orchiepidymitis occur less frequently in those with SPC but upper tract deterioration remains a concern (Gallien et al. 1998; Weld & Dmochowski 2000; Sugimura et al. 2008).
Hackler (1982) has suggested that upper tract deterioration may be reduced with concomitant use of anticholinergic medication. MacDiarmid et al. (1995) hypothesized that clinical factors may also reduce the complication rate. They attributed the low incidence of complications during the year-long data collection period to strict adherence to a catheter protocol with regular follow-up and close surveillance utilizing a dedicated medical and nursing team and informed primary care practitioners. Sugimura et al. (2008) also noted that upper tract complication rates resulting from SPC may be lower than earlier studies suggested and reported a 13.4% renal complication rate associated with a mean follow-up period of 68 months. Furthermore, Sherriff et al. (1998) conducted a satisfaction survey regarding SPC use which indicated 70-90% satisfaction based on questions such as impact on life, pleasure with the switch, and “would you do it again”, etc.
Several of the studies described above on SPC contain a relatively short follow-up period (<10 years). The specific concerns regarding indwelling catheter use centre on the potential for urological complications with long-term use. Many patients are injured as young adults, and may live for greater than 50 years and therefore the target for safety monitoring regarding bladder management choice should emulate SCI life expectancy. According to the prospective study by Kaufman et al. (1977), the risk of bladder cancer with indwelling urethral catheters increase significantly with duration of use. Interestingly, his data suggest that routine screening with bladder biopsy may be indicated in addition to cystoscopy for those at highest risk of bladder cancer. Research since this time suggests, however, that there is no good evidence for screening cystoscopy in this population; the requirements of a test to be a good screening tool have not met (Yang et al. 1999). Kaufman et al. (1977) did not include a significant number of SPC users, but Groah et al. (2002) did include both types of indwelling catheter users, and clearly showed a higher incidence of bladder cancer in such patients compared to those not managing their bladders with indwelling catheters. Stone disease, upper tract deterioration, reflux, and chronic infection remain additional long term concerns in those who resort to indwelling catheter use, with a slightly lower overall incidence reported in those with suprapubic versus urethral catheters (Weld & Dmochowski 2000).
A recent study by Katsumi et al. (2010) has shown that regardless of indwelling catheterization method, there were no significant differences in frequency of UTIs or other comparable bladder complications. While each method was correlated with unique complications, one type of catheterization was not superior over the other (Katsumi et al. 2010).
Conclusion
There is level 4 evidence (from four cases series studies, one observational study, and one pre-post study) that despite an associated significant incidence of urological and renal complications, acute and chronic indwelling catheterization may be a reasonable choice for bladder management for people with poor hand function, lack of caregiver assistance, severe lower limb spasticity, urethral disease, and persistent incontinence with intermittent catheterization.
There is level 4 evidence (from one cohort study: Groah et al. 2002) that those with indwelling catheters are at higher risk for bladder cancer compared to those with non-indwelling catheter management programs.
