Primary Care and Bladder

Spinal cord injury often results in a condition called Neurogenic bladder, and it is a common problem (affecting up to 80-85% of people with SCI). Research from the USA (Model Systems Database, 2009) suggests 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 the skin (e.g., pressure sores).

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 have other severe complications.

Neurogenic bladder causes problems with the storage and release of urine. 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.

Improper management can result in significant kidney damage, kidney stones, recurrent infections, or autonomic dysreflexia.

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 with your physician).
  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.  Most patients with indwelling catheters should get a cystoscopy annually after 5-10 years of use (though with some patients, you might want to start ordering after 1 year if other indicators suggest it, e.g., younger males).

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

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

Reprinted with permission from Topics in Spinal Cord Injury Rehabilitation American Spinal Injury Association

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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.

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