Primary Care and Bladder

Spinal cord injury often (up to 80-85%) results in a condition called neurogenic bladder – disruption of the ability to store and void urine.

Research from the USA (Model Systems Database, 2009) shows that the Top 3 leading causes of re-hospitalization after SCI were diseases of the genitourinary system (including UTIs), diseases of the respiratory system (e.g., pneumonia), and skin malfunction (e.g., pressure sores).

Bladder control for people with SCI usually requires catheterization (either intermittent, indwelling, or condom) or reflex voiding, medication (e.g., anticholinergics or botox), or in some cases, surgery is done. The method(s) used depend on the patient’s anatomy, functional abilities, any medical co-morbidities, and social life. The best bladder management routine is typically determined by a physiatrist or urologist with the patient’s input. The goals of managing neurogenic bladder are continence, regular emptying, avoiding increased bladder pressure, and preventing complications.

Bladder function may change as patient’s age and medical circumstances change (i.e., they acquire secondary conditions). Improper bladder management can result in significant kidney damage, kidney stones, recurrent infections, or autonomic dysreflexia.

Patients with SCI are at a higher risk of UTI than people without SCI. Left untreated, UTIs can lead to sepsis, autonomic dysreflexia (life-threatening spikes in blood pressure), or other severe complications.

Key Recommendations:

  1. Maintain a high level of suspicion for a UTI because classic symptoms (painful urination, burning sensation, urgency to pee) may be absent in people with SCI. Symptoms indicating UTI in people with SCI are often non-specific and may include fever, rigors, chills, nausea and vomiting, abdominal discomfort, sweating, muscular spasms, fatigue, and autonomic dysreflexia.
  2. Screening (e.g., urinalysis or urine culture) should take place in presence of any of the symptoms in point 1.
  3. Avoid antibiotic prophylaxis and avoid antimicrobial treatment in patients without symptoms (unless discussed between physician/patient).
  4. Refer patient to a urologist every 1-2 years for an evaluation and an ultrasound. Urodynamic studies are recommended every 5 years or upon clinical changes. Perform yearly urologic follow-up evaluations.
  5.  Bladder cancer risk is relatively higher in people with SCI, particularly males. Risk factors for bladder cancer with SCI include: indwelling or suprapubic catheter use, chronic UTI, bladder stones, increased urine contact time, altered immunological function – in addition to the usual population risk factors — smoking, workplace exposure, pelvic radiation. Most patients with indwelling catheters should get a cystoscopy annually after 5-10 years of use (though if any of above risk factors are present, consider screening for bladder cancer as more urgent).

Reviewed by Dr. Rhonda Willms Nov.2.22, and Dr. Indira Lanig Nov.17.22.

Recommendations
Details
Frequency
Review Patient’s Bladder Management Strategies • Assess method of bladder management, continence, satisfaction, complications (e.g., UTIs, blood in urine). Annually (more often if there are frequent complications
Kidney Function Tests • Assess blood markers of kidney function such as creatinine.
• Creatinine may be unreliable or falsely low due to low muscle mass; watch for an upwardly trending creatinine. Creatinine values need to interpreted in context of the person’s SCI (though generally the higher the level of injury, the lower their normal levels of creatinine will be).
Annually
Kidney/Upper Tract Imaging • Assess for the presence of high pressure in bladder tract or stones (hydroureter/hydronephrosis).

• Kidney ultrasound is non-invasive and readily available. It may also assess for bladder stones, debris, or changes to bladder/muscle wall appearance (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, leaking or incontinence, or urinary stones. 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, especially after 10 years.
As needed, based on signs and symptoms

Source: Milligan et al. 2020 – A Primary Care Provider’s Guide to Management of Neurogenic Lower Urinary Tract Dysfunction and Urinary Tract Infection After Spinal Cord Injury. Top Spinal Cord Inj Rehabil. 2020 Spring;26(2):108-115. 

Reviewed by Dr. Rhonda Willms Nov.2.22

A urology referral should be considered in all patients with neurogenic bladder.

Absolute indications for urology referral include:
• three or more UTIs per year,
• upper tract dysfunction or presence of chronic kidney disease,
• kidney/bladder stones,
• persistent blood in the urine,
• urethral trauma, and
• ineffective current bladder management (e.g., uncontrolled incontinence or leaking).

Source: Milligan et al. 2020 – A Primary Care Provider’s Guide to Management of Neurogenic Lower Urinary Tract Dysfunction and Urinary Tract Infection After Spinal Cord Injury. Top Spinal Cord Inj Rehabil. 2020 Spring;26(2):108-115. 

Reviewed by Dr. Rhonda Willms Nov.2.22. Discussion with Dr. Jamie Milligan December 2022. 

*Access to specialists (Urology, Physiatry) may be limited, particularly if you do not live in or near a major city.

Advanced screening like cystoscopy as well as making recommendations re: a patient’s bladder routine may best be handled by a Urologist or Physiatrist with more experience in SCI.

If you or your patients with SCI are not already connected, please try to gain access to a Urologist or Physiatrist near you.

(Please email matthew.queree@ubc.ca if we do not have a list for your country)

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

10. Amaral DM, Pereira AMVC, Rodrigues MR, Gandarez MDFL, Cunha MR, Torres MSR. Urinary tract infection in patients with spinal cord injury after urodynamics under fosfomycin prophylaxis: a retrospective analysis. Porto Biomed. J. (2019) 4:6(e56).

11. Kim EY, Lee HJ, Kim O, Park IS, Lee BS. Should We Delay Urodynamic Study When Patients With Spinal Cord Injury Have Asymptomatic Pyuria? Ann Rehabil Med 2021;45(3):178-185.

12. National Institute on Disability and Rehabilitation: The prevention and management of urinary tract infections among people with spinal cord
injuries: National Institute on Disability and Rehabilitation Research Consensus Statement. J Am Paraplegia Soc. 1992;15:194–204.

13. Przydacz, M., Chlosta, P., & Corcos, J. (2018). Recommendations for urological follow-up of patients with neurogenic bladder secondary to spinal cord injury. International urology and nephrology, 50(6), 1005-1016.

14. Grabe, M., Bartoletti, R., Johansen, T. E. B., Associate, T. C. G., Çek, M., Associate, B. K. G., & Naber, K. G.(2015). Guidelines on urological Infections by European Association of Urology. Retrieved from http://uroweb.org/wp-content/uploads/19-Urological-infections_LR2.pdf

15. Hill, T. T. C., Baverstock, R., Carlson, K. V, Estey, E. P., Gray, G. J., Hill, D. C., … Parmar, R.(2013). Best practices for the treatment and prevention of urinary tract infection in the spinal cord injured population: The Alberta context. Canadian Urological Association Journal7(3-4), 122–30. http://doi.org/10.5489/cuaj.337

16. Qu, L. G., & Lawrentschuk, N.(2019). Bladder cancer surveillance in patients with spinal cord injuries. BJU International, 123(3), 379-380. doi:10.1111/bju.14582

17. Mishori R, Groah SL, Otubu O, Raffoul M, Stolarz K. Improving your care of patients with spinal cord injury/disease. J Fam Pract. 2016 May;65(5):302-9.

Key Resources
Patient Handouts