Bladder Managment for Adults with Spinal Cord Injury - 23

CLINICAL PRACTICE GUIDELINE

Urethral erosions. Epididymitis. Recurrent symptomatic urinary tract infections. Incontinence. Pyelonephritis. Hydronephrosis from bladder wall thickening or fibrosis. Bladder cancer.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Multiple retrospective studies have shown that the complication rate is higher for someone using indwelling catheterization than other methods of bladder management (Larsen et al., 1997; Weld and Dmochowski, 2000; Weld et al., 2000). Specifically, strong evidence supports the increased risk of bladder stones (Mitsui et al., 2000; Larsen et al., 1997; MacDiarmid et al., 1995; Weld and Dmochowski, 2000) and renal stones (Mitsui et al., 2000; Larsen et al., 1997) in individuals using indwelling catheters, especially in the first six months after injury. The etiology of this phenomenon early after injury is likely multifactorial, with bladder management method, frequency of infection, and bone demineralization all playing roles. Recurrent bladder stones tend to be more common in females using indwelling catheters (Singh and Thomas, 1997). This could be due to the heightened inflammation and bacteriuria associated with indwelling catheter use. Several factors may play a role in the deterioration of upper tract function in those managing their bladders with indwelling catheters (Weld et al., 2000). Mean serum creatinine is higher and mean creatinine clearance is lower for individuals managing their bladders with indwelling catheters compared with clean intermittent catheterization or spontaneous voiding. Proteinuria is higher for individuals using indwelling catheters (Weld et al., 2000). Bladders managed with long-term indwelling catheters tend to have lower compliance than those managed with intermittent catheterization or spontaneous voiding (MacDiarmid et al., 1995; Weld, Graney, and Dmochowski, 2000). This lower compliance can contribute to the development of pyelonephritis, upper tract stones, and vesicoureteral reflux (Weld, Graney, and Dmochowski, 2000; Weld and Dmochowski, 2000), which can further compromise upper tract function.

Lower tract complications are also prevalent after indwelling urethral catheter use. Although both indwelling catheterization and intermittent catheterization increase the risk of symptomatic lower tract infection, epididymitis, recurrent symptomatic urinary tract infection, and pyelonephritis seem to be elevated in relation to indwelling catheter use (Weld and Dmochowski, 2000). Multiple retrospective studies have shown that the rate of bladder cancer is higher in individuals with SCI who manage their bladders with longterm indwelling catheters longer than 8 to 10 years (Groah et al., 2002; Stonehill et al., 1996; West et al., 1999). This risk could be due in part to the higher risk of recurrent infection, stones, and inflammation associated with catheter use. Although not necessarily the predominant histologic type of cancer, squamous cell carcinoma is more common in those using indwelling catheterization (Groah et al., 2002; Stonehill et al., 1996), and prognosis for survival after squamous cell cancer diagnosis is poor (Groah et al., 2002). However, it should also be noted that squamous cell cancer is rare, so even though there is a greater incidence in those with spinal cord injury, the number of individuals who develop squamous cell bladder cancer is actually low. The other type of bladder cancer—transitional cell—has known risk factors regardless of whether or not there is a spinal cord injury. For these reasons it is prudent to counsel individuals about the other risk factors for bladder cancer, such as smoking and certain occupational exposures, and then monitor them for this potential problem. 6. Conduct more frequent cystoscopic evaluations for individuals with chronic indwelling catheters than for those with nonindwelling methods of bladder management.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Recurrent urinary tract infection and bladder stones are risk factors for bladder cancer, and these complications tend to be more common in individuals using indwelling catheters. Often the neurogenic bladder uroepithelium has an abnormal appearance, characterized by mucosal erythema, edema, vascular telangiectasia, and histologic changes, which emphasizes the need for surveillance. Surveillance is therefore recommended for individuals with SCI using indwelling catheters long term. Options include cystoscopy, cytology, and random bladder biopsy. Other methods currently being developed may be options in the future.

Bladder Managment for Adults with Spinal Cord Injury

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