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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).

Table 11 Comparison Studies of Conservative Bladder Emptying

Author YearCountry
Research Design
Score
Total Sample Size
MethodsOutcome
Gu et al. 2015

China

RCT

PEDro=7

N=107

Population: Urinary retention; Mean age: 35.7 yr; Gender: males=80, females=27; ASIA classification: B=37, C=53, D=17.

Intervention: Individuals were randomized to Clean intermittent catheterization (CIC) (group 1) (n=35), Electroacupuncture combined with CIC (group 2) (n=38), or Sham acupuncture combined with CIC (group 3).

Outcome Measures: Residual urine volume, voided volume, bladder balance, frequency of CIC.

1.     At 1 mo follow-up, group 2 had a significantly higher number of bladder balance participants compared to group 1 (p=0.019) or group 3 (p=0.019).

2.     At 1 mo follow-up, group 2 participants had significantly lower frequency of CIC compared to group 1 (p<0.001) or group 3 (p<0.001), and group 3 was also significantly lower than group 1 (p<0.01).

3.     In terms of residual urine volume at 1 mo follow-up, group 2 was significantly lower than group 3 (p<0.001) and group 3 was significantly lower than group 1 (p=0.018).

4.     At 1 mo follow-up, group 2 had a significantly higher voided volume compared to group 1 (p<0.001) and group 3 (p<0.001), with no significant differences between groups 1 and 3.

5.     At 3 mo follow-up, significant differences were found between groups in terms of residual urine volume (p<0.001), with groups ordered as 1, 3, and 2 in terms of decreasing volume.

6.     At 3 mo follow-up, significant differences were found between groups in terms of voided volume (p<0.001), with groups ordered as 1, 3, and 2 in terms of increasing volume.

Giannantoni et al. 1998

Italy

Case Control

N=78

Population: SCI: Age: 35 yr; Gender: males=57, females=21; Severity of injury: AIS: A/B=68, C/D=10; Mean time post-injury=89 mo.

Intervention: Group 1: Individuals using clean intermittent catheterisation (IC). Group 2: Individuals using other methods of emptying (31 using Abdominal straining, tapping, or Crede manoeuvre, 5 indwelling catheter, 7 sponataneous voiding)

Outcome Measures: Urodynamic studies (UDS) (all anticholinergics were held); renal function (BUN, creatinine, creatinine clearance), ultrasound, intravenous pyelogram (IVP) and/or voiding cystourethrogram (VCUG).

1.     Both groups had similar clinical and UDS characteristics, and length of time treated with a foley catheter (67.9 versus 75 mo)

2.     There were significantly more abnormalities on US or Cystourethrography in Group 2(22 versus 36 individuals) p=0.03

3.     Upper urinary tract damage (hydronepphrosis, renal stones, reflux) occurred more commonly in group 2 (n=13) vs. group 1 (n=4) p=0.03.

4.     Clean IC was believed to be the only explanation for the improved outcome in group 1

Drake et al. 2005

UK/USA

Pre-Post

N=222

Population: Mean age: 57.4 yr; Gender: male=171; females=51. Mean time post-injury=33 yr.

Intervention: Individuals were divided according to their bladder management method: balanced reflex voiding; intermittent catheterization; indwelling urethral or suprapubic catheter; normal micturition.

Outcome Measures: Risk of urinary tract infection (UTI), other complications. Individuals were prospectively followed for 6 yr.

1.     Complications including renal failure were significantly related to both age and yr post injury.

2.     No significant difference in risk of a urinary tract infection* was seen for the different bladder management methods (IDUC, p=-0.17; IC, p=0.45; straining, p=0.87; normal voiding, p=0.30. *UTI incidence=1 or more UTIs in yr prior to assessment.

3.     28.8% changed bladder management method during the study period, particularly those in balanced reflex voiding group.

4.     Urodynamic studies were not done routinely

Bartel et al. 2014

Switzerland

Case Series

N=2825

Population: Bladder stone group (n=93): Mean age: 50 yr; Gender: males=69, females=24; Level of injury: cervical=34, thoracic=49, lumbar=9, sacral=1; Severity of injury: complete=75, incomplete=18; ASIA classification: A=53, B=22, C=13, D=5; Injury etiology: trauma=74, multiple sclerosis=10, other=9; Mean time post-injury: 9.5 yr.

Intervention: Charts were reviewed for spinal cord injury individuals who had a bladder stone.

Outcome Measures: Bladder management method, period to stone development, bladder stone recurrence rate.

1.     Of the 2825 SCI individuals, 93 had bladder stones (2.8%).

2.     In terms of bladder management methods, bladder stones were observed in 11% of suprapubic catheter, 6.6% of transurethral catheter, 2% of intermittent catheterization, and 1.1% of reflex micturition.

3.     In terms of period to stone development, the mean for suprapubic catheter was 59 mo, transurethral catheter was 31 mo, intermittent catheterization was 116 mo, and reflex micturition was 211 mo.

4.     The bladder stone recurrence rate was 28% for suprapubic catheter, 40% for transurethral catheter, 22% for intermittent catheterization, and 0% for reflex micturition.

Afsar et al. 2013

Turkey

Case Series

N=164

Population: Mean age: 40.7 yr (range 23-65 yr); Gender: males=102, females=62; Level of injury: Tetraplegia=43, Paraplegia=87, Conus-Cauda Equina Syndrome=34; Time post-injury: 51.5 d (range 5-292 d).

Intervention: Retrospective review of bladder management and emptying methods.

Outcome Measures: Bladder management method, urinary tract infection (UTI) prevalence, functional independence measure (FIM) scores.

1.   Bladder emptying method at discharge was: indwelling catheter (n=16, 9.8%), clean intermittent catheterization (n=104, 63.4%), reflex voiding (n=25, 15.2%), and normal voiding (n=19, 11.6%). While at follow up emptying method was: indwelling catheter (n=21, 13.1%), clean intermittent catheterization (n=60, 37.5%), reflex voiding (n=57, 35.6%), and normal voiding (n=22, 13.8%).

2.   42% of individuals using clean intermittent catheterization changed their bladder emptying method. Also rate of reverting to urethral indwelling catheter usage was 21.4%.

3.   The number of UTIs was highest in individuals using indwelling catheters.

Gohbara et al. 2013

Japan

Case Series

N=234

Population: Mean age: 57.2±14 yr (range=13-87, median=61); Gender: males=195, females=39; Level of injury: Cervical; Etiology of injury: Traumatic=204, Non-traumatic=30.

Severity of Injury: ASIA B=23 (9.8%), C=90 (38.5%), D=120 (51.7%); Time post-injury: 1-10 mo.

Intervention: Chart review.

Outcome Measures: Urinary management, spontaneous voiding, urinary sensation, detrusor overactivity.

1.     Between admission and discharge, the number of individuals using:

·       urethral catheterization declined (48.3% vs. 9.4%, respectively)

·       suprapubic cystostomy with indwelling catheters increased (0.9% vs. 10.7%, respectively)

·       nursing care clean IC (5.5% vs. 2.6%, respectively)

·       self-IC increased (0.9% vs. 15.8%, respectively)

·       spontaneously voiding increased (42.7% vs. 57.2%, respectively)

2.     There was no difference in urinary management between the sexes.

3.     At discharge, the spontaneous voiding rates of individuals with ASIA B,C and D classification were 13.0, 37.8 and 80.2% resp. (p<0.001)

Of the 113 individuals who had urethral catheterization at admission, 35 were spontaneously voiding at discharge.

El-Masri et al. 2012

United Kingdom

Case Series

N=119

Population: Mean age: 29±12 yr (range=16-63); Gender: male=99, female=20 Level of injury: paraplegic=60, tetraplegic=50; Neurological level: ASIA A=63, B=8, C=14, D=34.

Intervention: N/A – Data analysis of bladder management and urinary complications divided into Phase 1: Preadmission to MCSI, Phase 2: During first hospitalization at MCSI, and Phase 3: Post discharge resp. Review of results from routine clinical assessment, urine analyses, ultrasound scans or intra venous urograms (IVU) that were completed every 1 or 2 yr (cystoscopies also performed in individuals with suprapubic or indwelling catheters).

Outcome Measures: Bladder management (i.e. indwelling urethral catheterization (IndUC), assisted clean intermittent catheterization (A-IC), clean intermittent self-IC (S-IC), reflex voiding (RV) resp.), Urinary complications, Length of stay.

Phase 1

1.     All individuals (119) were initially managed with IndUC; 81 had the method of urine drainage documented immediately before admission of which 56 (69%) had IndUC, 22 (27%) had A-IC, and 3 (4%) used RV and/or bladder expression resp.

2.     2 male individuals that were admitted 15 and 38 d post injury resp. were suspected of having UTI.

Phase 2

3.     Soon after admission, bladder management was changed from IndUC to A-IC.

4.     Of the 119 individuals, 45 (38%) had complications: UTI (31), UTI plus reflux or hydronephrosis (n=7), and other (n=7).

5.     There was no significant difference in complications by ASIA scores, length of stay or level of injury.

Phase 3

6.     Of the 119 individuals, 73 (61%) developed complications, most commonly UTI.

7.     All ASIA D (n=24) subjects did not require intervention for urinary drainage; only 3 had a mild UTI.

8.     60% of those individuals using RV with or without bladder expression developed complications.

9.     Of the 10 individuals who continued to use IndUC post-discharge, 6 had tetraplegia versus 4 with paraplegia.

10.   No significant difference in complications by level of injury but there was by severity of injury (p<0.01).

Böthig et al. 2012

Germany

Case Series

N=56

Population: Mean age: 45 yr (range=17-78 yr); Gender: male=40, female=16; Level of injury: C0=11, C1=0, C2=29, C3=14, C4=2; Neurological level: ASIA A=46, B=4, C=6. All individuals had long-term-ventilation and bladder drainage was obtained using either suprapubic catheter (SPC) (male=28, female=10, mean age: 49.9 yr), intermittent catheter (IC) performed by home caregivers (male=8, female=4, mean age: 31.8 yr), or other methods such as transurethral catheter (2), reflex voiding by suprapubic tapping (2) or and IC per umbilical stoma (2) resp.

Intervention: NA – Data analysis of a Quality of Life (QoL) questionnaire (ICIQ-SF) and urological morbidity of 3 groups: Suprapubic Catheter (SPC), Intermittent Catheter (IC) and Other resp.

Outcome Measures: Bladder management, Urological morbidity, Quality of Life (QoL).

1.     Only the data from SPC and IC individuals were used for analysis (N=50).

2.     The difference in mean age between the SPC group and IC group was statistically significant. (p=0.0035)

3.     There was no difference between the gender and method of bladder management (p=0.718).

4.     During the follow-up period, 7 of the 50 individuals changed from IC to SPC due to urethral complications.

5.     Of the SPC group, 10/38 had 15 urologicial interventions, while the other 28 had no complications or procedures.

6.     Of the IC group (now=12+7), 11 individuals had a total of 19 readmissions, while only 8 had no complications or procedures.

7.     The leading cause of readmission in the SPC versus IC groups was bladder stones versus urethral trauma resp.

8.     Individuals with IC experienced significantly more urological complications than with SPC. (p<0.05)

9.     47/56 (84%) individuals completed the QoL questionnaire of which 43 were included for analysis (SPC=32, IC=11).

10.   QoL scores for the SPC versus IC group were 3.06 versus 4.27 resp. which was not statistically significant (p=0.368) (ref: 0=best/16=worst)

Hansen et al. 2007

Denmark

Case Series

N=236

Population: Mean age: 50.5 yr; Gender: males=193, females=43; Mean follow-up time=24.1 yr; Level of injury: paraplegic=126, tetraplegic=110; Severity of injury: complete=102, incomplete=134.

Intervention: Retrospective analysis of renal calculi development associated with various factors including bladder management method (normal emptying, suprapubic tapping/crede, intermittent catheter (IC), indwelling catheter); individual questionnaire about kidney stones.

Outcome Measures: Prevalence of calculi, risk of calculi.

1.     At least 1 episode of renal calculi was seen in 47 individuals and at least 1 episode of bladder calculi was seen in 33 of individuals.

2.     The first 6 mo after injury had the highest risk for getting renal and bladder calculus.

3.     No significant difference was seen between the type of bladder emptying method and the prevalence of calculi (trend was towards more stones in those with indwelling catheters).

Green 2004

USA

Case Series

N=479

Population: SCI: Mean age: 27 yr; Gender: males=383, females=96; Individuals admitted over a 10 yr period were chosen. 10 yr follow up data available for 426 individuals, 15 yr follow-up data available for 412 individuals.

Intervention: SCI individuals’ medical records were retrospectively reviewed to determine changes in bladder management techniques. Questionnaires were also sent.

Outcome Measures: Bladder management techniques.

1.     Of the individuals discharged with an intermittent catheterization program (ICP), 398 remained on the program at 1 yr follow-up.

2.     At 5 yr follow up, 80% of individuals were catheter free (50% used an ICP).

3.     At 15 yr follow up, of the 166 individuals, 42 changed to chronic indwelling catheters, while 111 were catheter-free state or used ICP.

Ord et al. 2003

England

Case Series

N=457

Population: SCI with>6 mo on any 1 form of management: Mean age: 29-40 yr for various groups; Gender: males=402, females=55; Level of injury: T3 – T9; Severity of injury: complete, incomplete; Follow-up time=48-107 mo.

Intervention: Assessment of various bladder management methods (i.e., sphincterotomy, condom, intermittent catheter (IC), indwelling urethral catheter, suprapubic catheter+combinations of each).

Outcome measures: Bladder stone formation rate.

1.   Both forms of indwelling catheterization had an increased risk of getting bladder stones and requiring hospitalization for bladder stones over IC and condom drainage with or without sphincterotomy.

2.   Relative to IC, hazard ratio was 10.5 for suprapubic catheters and 12.8 for indwelling urethral catheters.

3.   Incidence density ratio (like odds ratio) was 40.7 for developing bladder stones for indwelling catheters relative to IC. Condom incidence density ratio was 7.5 relative to IC.

4.   % Annual risk for stone formation: Condom & Sphincterotomy 0%; IC 0.2%; Expression voiding with or without condom 0.5%; Indwelling catheter 4% (first stone), 16% (subsequent stone).

Groah et al. 2002

USA

Case Series

N=21

Population: SCI with bladder cancer: Mean age: 48 yr; mean time post-injury=20 yr.

Intervention: SCI bladder cancer individuals’ data was analyzed to determine risk factors for bladder cancer.

Outcome Measures: Bladder management methods, prevalence of bladder cancer, risk for bladder cancer, mortality rate due to bladder cancer.

1.     Bladder management methods included:

·       Indwelling catheters (IDC), 15 individuals.

·       Non indwelling catheters (NIDC) spon. Void, condom, IC: 3 individuals.

·       Both indwelling and nonindwelling catheters (Multi) duration of IDC use 20 yr, 3 individuals.

2.     Development of bladder calculi was significantly higher in individuals using IDC than NIDC (p<0.001) 10 versus 2 individuals but bore no relationship to incidence of CA.

3.     SCI individuals were 15.2x (95% CI, 9.2-23.3) more likely to develop bladder cancer than the general population. IDC 4.9x more likely to develop bladder cancer than NIDC

4.     Bladder management method (p<0.02) and age at SCI (p<0.01) significantly predicted bladder cancer.

5.     SCI individuals using IDC have a risk factor of 77 per 100,000 person yr of bladder cancer, starting at 12 yr post injury.

6.     Of the 13 individuals that died, 12 were due to bladder cancer. Of these 12 individuals, 10 used IDC methods while 2 used Multi method.

7.     No mortality rate was found in the NIDC group.

Weld & Dmochowski 2000

USA

Case Series

N=316

Population: SCI: Mean age: 33.9-41.0 yr; Gender: males=313, females=3; Level of injury: suprasacral=269, sacaral=47; Severity of injury: complete=45, incomplete=271; Mean follow-up=17.8-19.3 yr for various groups.

Intervention: Assessment of various bladder management methods (i.e., intermittent catheterization (IC), voiding spontaneously, indwelling urethral catheter, suprapubic catheter).

Outcome Measures: Urological complication rate (epididymitis, pyelonephritis, upper tract stone, bladder stone, urethral strictures, periurethral abscess, vesicoureteral reflux, abnormal upper tracts).

1.     Frequency of those managed by IC, voiding spontaneously, suprapubic and urethral catheterization was 92, 74, 36 and 114 subjects respectively.

2.     Complication rates for the above groups were 27.2%, 32.4%, 44.4% and 53.5% respectively.

3.     Urethral catheter users had the highest rates for epididymitis, pyelonephritis, upper tract stone, bladder stone, urethral strictures and periurethral abscess.

4.     Suprapubic catheter users had the highest rates for vesicoureteral reflux and abnormal upper tracts.

Yavuzer et al. 2000

Turkey

Case Series

N=50

Population: SCI: Mean age: 38 yr; Gender: males=36, females=14; Level of injury: paraplegia=43, tetraplegia=7; Severity of injury: AIS: A-D; Time post- injury=124 d; Rehabilitation LOS=130 d; Follow-up time=24 mo.

Intervention: Follow-up of those with various bladder management methods.

Outcome Measures: Bladder management method, compliance.

1.     At admission 43 individuals used indwelling catheter and by discharge from rehabilitation, intermittent catheter (IC) was used by 37.

2.     At 2 yr follow-up, of 38 people using IC, 20 had reverted back to indwelling catheter by 24 mo, 16 continued with IC.

3.     Tetraplegics had lower compliance with IC than paraplegics (p<0.05) – majority of tetraplegics (80%) reverted to indwelling catheter versus only 40% of paraplegics.

4.     More females (60% versus 50%) reverted to indwelling catheters but this was not significant.

5.     More with complete injuries reverted to indwelling catheters (68% versus 31%, p<0.01).

6.     Main reasons for changing method=dependence on care givers, severe spasticity, incontinence and inconvenience (females).

Gallien et al. 1998

France

Case Series

N=182

Population: Mean age: 41.45 yr; Gender: males=129, females=53; Severity of injury: complete=69, incomplete=113; Mean time post- injury=8 yr.

Intervention: Bladder management method relative to urinary tract infection (UTI) and other complications was retrospectively reviewed and a questionnaire was sent to all individuals and attending physicians.

Outcome Measures: Method of bladder management; complication: lithiasis, urinary infections, orchiepidymitis, urethral trauma, vesicorenal reflux, renal failure.

1.     Prevalence of complications was related to:

·       Type of bladder management at discharge: 129 individuals using clean IC, 137 using percussion and all individuals using indwelling catheters had at least one urologic complication.

·       Gender, with males having a higher probability than females (p<0.0001).

2.     Urinary infections were significantly higher in:

·       Individuals with complete lesions (p=0.0001).

·       Use of a protection or a urine collector (p=0.0022).

3.     Urinary infections were not significantly related to:

·       Time since injury.

·       Method of bladder management (those on indwelling catheters were not part of UTI analysis).

4.     Intermittent catheterization was the main method of bladder management.

Note: AIS=ASIA Impairment Scale; IVP=Intravesicle Pressure; UTI=Urinary Tract Infection; VCUG=Voiding Cystourethrogram

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.

Supervised sequential conservative bladder management is may result in favourable urological complication rates.

Severity of injury and urinary sensation could be predictive parameters for future voiding function.

Intermittent catheterization, whether performed acutely or chronically, may have the lowest complication rate.

Indwelling catheterization, whether suprapubic or urethral or whether conducted acutely or chronically, may result in a higher long-term rate of urological and renal complications than other management methods.

Persons with tetraplegia and complete injuries, and to a lesser degree females, may have difficulty in maintaining compliance with intermittent catheterization procedures following discharge from rehabilitation.

Bladder management via suprapubic catheterization may be the better option for patients that are high tetraplegics and respirator-dependent.