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.
| Author Year
Country Score Research Design Total Sample Size |
Methods | Outcome |
|---|---|---|
| McGee et al. 2017
USA Pre-Post N=17 |
Population:
Mean age=49.71±14.29yr; Gender: males=13; female=4; Etiology: SCI=17; Time since injury=12.76±9.13yr. Intervention: A custom silicone 12-Fr Foley-stimulating catheter with stainless steel electrode contacts was inserted into individuals’ urethra such that the balloon lay in the bladder neck to allow for the electrodes to target the proximal and distal urethra. Multiple electrodes were present along the length of the electrode to allow for stimulation to be customized to each individual. Battery-powered electrical stimulators delivered charge-balanced, asymmetric biphasic current pulses with a pulse width of 0.2 ms for a duration of 20 seconds. Blocks of 16 randomized combinations of single-site or 2-site co-stimulation (proximal and distal) were presented at different frequencies (2,10,20, and 40 Hz), as well as different amplitudes (2x threshold (T) and 4T) under isovolumetric conditions. Outcome measures were assessed at baseline and during stimulation. Outcome Measures: Mean detrusor pressures (Pdet); pelvic floor electromyographic activity (EMG) |
1. There was a significant effect of stimulation frequency on stimulation-evoked mean Pdet when stimulation was applied to both the proximal and distal urethra (p<0.001).
2. There were combinations of of proximal and distal intraurethral stimulation that produced significantly different effects on mean Pdet (e.g. stimulating proximal region at 10 hz produced inhibitory effects, whereas stimulating the distal region at 10 Hz produced excitatory effects) (p<0.001). 3. Changing one of the frequencies during co-stimulation resulted in significant effects to mean Pdet (p<0.05). 4. Specific patterns of co-stimulation were more effective than others (e.g. 2 Hz proximal-2 Hz distal and 30 Hz proximal-40 Hz distal were more effective and 10Hz distal was least effective). 5. There was a significant difference in normalized EMG activity between periods with stimulation on compared to periods with stimulation off 6. A significant interaction between normalized EMG, stimulation frequency, and stimulation-on periods indicated that changes in rectified and integrated EMG activity were dependent upon stimulation frequency (p<0.01). |
| Locke et al. 1985
USA Pre-Post N=25 |
Population:
SCI individuals with indwelling catheters: Length of indwelling catherization=17.6 yr. Intervention: SCI individuals with indwelling catheters were evaluated for presence of bladder malignancy. Outcome Measures: Urinalysis, urine culture, cytology, serum urea, creatinine, white cell count, hematocrit. Excretory urography results, cystoscopy results. |
|
| El Masri et al. 2014
United Kingdom Case Series N=262 |
Population:
Level of injury: cervical=168, thoracic-lumbar=94; Severity of injury: complete=153, incomplete=109; Injury etiology: traumatic spinal cord injury. Intervention: The positive findings from cystourethroscopic surveillance were reviewed for individuals using a suprapubic catheter or urethral catheter, comparing symptomatic vs. asymptomatic groups. Outcome Measures: Number of procedures, indications for cystourethroscopy. |
|
| Katsumi et al. 2010
USA Case Series N=179 |
Population:
SCI individuals: Urethral Catheter (UC; n=133): Mean Age: 63.1 yr; Gender: males=132, females=47; Level of injury: C=60, T=63, L=5, MS=5; Time post-injury: 35.5 yr; Suprapubic Catheter (SPC; n=46): Mean age: 59.9 yr; Gender: males=46, females=0; Level of injury: C=30, T=12, L=3, MS=1; Time post-injury: 31.2 yr. Intervention: Retrospective chart review of individuals using either UC or SPC. Outcome Measures: Urinary tract infection (UTI), presence of bladder stones, renal calculi, urethral complications, scrotal abscesses, epididymitis, gross hematuria and cancer. |
|
| Sugimura et al. 2008
New Zealand Case Series N=149 |
Population:
Gender: males=124, females=25; Level of injury: paraplegia=68, tetraplegia=96. Intervention: SCI individuals managed with SPC were retrospectively reviewed for complications. Outcome Measures: UTIs and other complications assessed over a mean follow-up period of 68 mo (range=3-179 mo). |
|
| MacDiarmid et al. 1995
USA Case Series N=44 |
Population:
Traumatic SCI with indwelling suprapubic catheter for>1 yr: Mean age: 36 yr; Gender: males=31, females=13; Level of injury: paraplegia, tetraplegia; Follow-up time=69 mo; Duration of catheterization=58 mo. Intervention: Assessment of urological/renal complication rate associated with suprapubic cystostomy drainage. (35 individuals had videourodynamic studies) Outcome Measures: Incidence of urological and renal complications. |
|
| Peatfield et al. 1983
England Case Series N=41 |
Population:
SCI: Level of injury: paraplegia=15, tetraplegia=25. Intervention: Long-term follow-up (>8 yr) of those managed originally by subrapubic catheter as reported in 1976. Outcome Measures: Mortality, renal function. |
|
| Hackler 1982
USA Case Series N=31 |
Population:
SCI: Level of injury: all above T11; Time since injury=>5 yr. Intervention: Assessment of urological/renal complication rate associated with suprapubic cystostomy drainage of ≥5 yr versus condom or Foley catheter drainage. Outcome Measures: Intravenous urography (IVU) and cystourethrogram (CUG) evaluated at ≥5 yr post-injury. |
|
| Kaufman et al. 1977
USA Case Series N=62 |
Population:
SCI; 4 groups: Group 1 (n=25): permanent bladder catheters >10 yr, Group 2 (n=24): permanent catheters <10 yr, Group 3 (n=11): short-term (post injury only) catheter drainage, Group 4 (n=2): bladder diversions. Intervention: Urinalysis and urine cultures, Cystoscopy and bladder biopsies on all individuals. Urethral biopsies in 29 individuals Outcome Measures: Incidence of squamous metaplasia of bladder or urethra, and bladder cancer. |
|
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.
