Bladder Managment for Adults with Spinal Cord Injury - 21

CLINICAL PRACTICE GUIDELINE

often used by individuals with chronic SCI who are unable to perform intermittent catheterization or reflex voiding, have uncontrollable urinary incontinence, have difficulty wearing continence devices, or have an acute medical condition warranting catheterization, or by those who prefer indwelling catheterization because it offers greater expediency and compatibility with their lifestyle. 1. Consider indwelling catheterization for individuals with: Poor hand skills. High fluid intake. Cognitive impairment or active substance abuse. Elevated detrusor pressures managed with anticholinergic medications or other means. Lack of success with other, less invasive bladder management methods. Need for temporary management of vesicoureteral reflux. Limited assistance from a caregiver, making another type of bladder management not feasible.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Multiple factors influence choice of bladder management method and subsequent success with bladder management after SCI. These include but are not limited to age, gender, medical comorbidities, body habitus, decade of injury, level and completeness of SCI, hand function, need for and availability of caregiver assistance, and spasticity (Bennett et al., 1995; MacDiarmid et al., 1995; Mitsui et al., 2000; Singh and Thomas, 1997; Yavuzer et al., 2000). The lack of an adequate external collecting system for females eliminates some bladder management options that are available to males. Upper extremity impairment due to cervical SCI or other abnormality, obesity, and spasticity make intermittent catheterization challenging for both males and females. As a result, females with tetraplegia with complete injuries are more likely to use indwelling catheterization (Singh and Thomas, 1997). Individuals with tetraplegia, regardless of gender, report greater satisfaction with suprapubic catheter use compared to clean intermittent catheterization (Mitsui et al., 2000). When intermittent catheterization is attempted, continued long-term use is less common among females,

individuals with tetraplegia, and those with complete SCI because of the need for caregiver assistance, severe spasticity that interferes with intermittent catheterization, incontinence despite anticholinergic use, and lack of an external collecting device (Yavuzer et al., 2000). Therefore, it is common for females and individuals with high, complete tetraplegia either to choose indwelling catheterization or to have their health-care provider recommend it (Bennett et al., 1995). Each individual needs his or her choice of bladder management method individualized, based on the advantages and disadvantages of each method. Despite the additional complications associated with indwelling catheter use, this method—when well managed—is generally preferred over other methods if they cannot be performed properly. Risk of symptomatic infection is at least comparable to and may be more in individuals with indwelling catheters than those managing their bladders with clean intermittent catheterization. Although it is common for individuals using indwelling catheters to have asymptomatic bacteriuria, the significance of this is unknown. Conflicting data exist related to the risk of symptomatic infection in individuals using indwelling catheters versus other methods of bladder management. Reports indicate lower or relatively equal proportions of symptomatic urinary tract infection in individuals using indwelling catheterization compared with intermittent catheterization (Mitsui et al., 2000; Singh and Thomas, 1997). Retrospective studies report that individuals using indwelling catheterization tend to have more recurrent urinary tract infections (Larsen et al., 1997) and pyelonephritis (Weld and Dmochowski, 2000) than those using other bladder management methods. However, the proportion of symptomatic UTI is relatively low given the fairly universal bacteriuria in this population. For these reasons, the value of prophylactic antibiotics in this population remains unclear and is generally unwarranted except in select instances. Lastly, the use of indwelling catheterization is often effective as an initial and/or temporary treatment for vesicoureteral reflux. Further evaluation and follow-up is needed to determine the effectiveness of the indwelling catheter for this problem. 2. Consider using suprapubic catheterization for individuals with: Urethral abnormalities, such as stricture, false passages, bladder neck obstruction, or urethral fistula. Urethral discomfort.

Bladder Managment for Adults with Spinal Cord Injury

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