Primary Care and Bladder

Most people with SCI experience bladder dysfunction at some point. Research from the USA (Model Systems Database, 2009) suggests that diseases of the genitourinary system (including UTIs) were the leading cause of rehospitalization followed by diseases of the respiratory system and the skin.

Neurogenic bladder results in problems relating to the storage and release of urine. Achieving bladder control can be done via intermittent, indwelling, or condom catheterization, reflex voiding, anticholinergic medication, botulinum toxin or surgical methods.

Patients with SCI are at a higher risk of UTI than non-SCI individuals.

Consider referral to urologist if:
o >3 UTIs per year
o Concerns regarding pathology, e.g., hematuria in the absence of a UTI, either persistent
microscopic or gross
o Hydronephrosis or renal impairment
o Indwelling catheter >15 years (consideration of cystoscopy due to increased risk of
bladder cancer)
o Current methods of bladder management (catheterization and/or medications) are
ineffective, as other more invasive management strategies are available, including but
not limited to botulinum toxin, stent placement, and surgery

Key Recommendations:

• Maintain a high level of suspicion for a UTI because symptoms are often non-specific and may
include: fever, rigors, chills, nausea and vomiting, abdominal discomfort, sweating, muscular
spasms, fatigue, and autonomic dysreflexia. Classic symptoms, such as dysuria, frequency, and
urgency, are often absent.
• Do not order routine screening urinalysis or urine culture.
• Avoid antibiotic prophylaxis.
• Avoid antimicrobial treatment in asymptomatic patients.
• Refer patient to a urologist annually for an evaluation. An ultrasound may be required every 1-2
years, and urodynamic studies are recommended every 5 years or upon clinical changes. Perform
yearly urologic follow-up evaluations.
• Refer individuals with indwelling catheters for a cystoscopy annually after 5-10 years of use.
• Avoid prophylaxis in the form of cranberry tablets or mannose; neither has been well studied in
this population.

From Mishori et al. (2016) Improving your care of patients with spinal cord injury/disease – Journal of Family Practice

Recommendations
Details
Frequency
Review Patient’s Bladder Management Strategies • Assess method of bladder management, continence, satisfaction, complications (e.g., UTIs, hematuria) Annually (more often if there are frequent complications
Renal Function Tests • Assess serum markers of renal function such as creatinine.
• Creatinine may be unreliable or falsely low due to low muscle mass; watch for an upwardly trending creatinine.
Annually
Renal/Upper Tract Imaging • Assess for the presence of hydroureter/hydronephrosis, stones.

• Renal ultrasound is non-invasive and readily available. It may also assess for bladder stones, debris, or trabeculations (suggestive of high pressure over time).

Annually or biannually
Urodynamics • Perform at baseline and when indicated by changes such as increased UTIs, difficult catheter insertion, incontinence, or urinary calculi. Baseline
Cystoscopy • Assess as needed based on symptoms and clinical signs.
• There is increased prevalence of muscle invasive bladder cancer in patients with neuro-urological bladder
As needed, based on signs and symptoms

From Mishori et al. (2016) Improving your care of patients with spinal cord injury/disease – Journal of Family Practice

Further Information:

1. McKinley WO, Jackson AB, Cardenas DD, & DeVivo MJ. (1999). Long-term medical complications after traumatic spinal cord injury: a regional model systems analysis. Archives of Physical Medicine and Rehabilitation 80:1402.
2. Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, et al. (2014). Bladder Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, et al. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-196. https://scireproject.com/evidence/rehabilitation-evidence/bladder-management/
3. New South Wales Government. (2015). Adult urethral catheterization for acute care settings. Retrieved from www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_016.pdf
4. Consortium for Spinal Cord Medicine. (2006). Bladder management for adults with spinal cord injury: A clinical practice guideline for health-care providers. Washington, DC: Paralyzed Veterans of America.
6. McKinley WO, Jackson AB, Cardenas DD, DeVivo MJ. Long-term medical complications after traumatic spinal cord injury: A regional model systems analysis. Arch Phys Med Rehabil. 1999;80(11):1402-1410.
http://www.ncbi.nlm.nih.gov/pubmed/10569434
7. James Middleton, Kumaran Ramakrishnan IC. Management of the neurogenic bladder for adults with spinal cord injuries. 2013. https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0010/155179/Management-Neurogenic-Bladder.pdf. Accessed August 1, 2019.
8. Consortium for Spinal Cord Medicine. Bladder management for adults with spinal cord injury: A clinical practice guideline for health-care providers. J Spinal Cord Med. 2006;29(5):527-573. http://www.ncbi.nlm.nih.gov/pubmed/17274492

9. Cardenas DD, Hoffman JM, Kirshblum S, McKinley W. Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis. Arch Phys Med Rehabil. 2004;85(11):1757-1763