Bladder Managment for Adults with Spinal Cord Injury - 26

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BLADDER MANAGEMENT FOR ADULTS WITH SPINAL CORD INJURY

noted that as the bladder develops reflex contractions to keep the bladder from getting distended, the bladder loses its capacity. This will make it very difficult to revert back to intermittent catheterization. Males can use external collecting devices very effectively, but no such device exists for females. In rare instances, reflex voiding may be used in females if they wear incontinence padding. However, incontinence padding has its own disadvantages. First, it requires frequent changing, thus making it both labor intensive and expensive (see appendix A), and, second, wearers risk skin breakdown. Reflex voiding is suited to those with poor hand function because there is no need to undress or catheterize with this technique. However, some help from a caregiver will be needed if a person does not have enough hand function to change a condom catheter or empty a leg bag. Leg bags need to be emptied periodically; however, there are electronic devices that will allow the bag to empty. Reflex voiding is also suited to those with poor compliance or unwillingness to limit fluid intake because the bladder will contract reflexively and empty whenever it reaches a certain volume. Finally, this method is suited to those with a small bladder capacity, since a large bladder capacity is needed for intermittent catheterization. 2. Conduct a thorough urodynamic evaluation to determine whether reflex voiding is a suitable method for a particular individual.
(Scientific evidence–None; Grade of recommendation–None; Strength of panel opinion–Strong)

Have incomplete bladder emptying despite treatment to facilitate voiding. Have high-pressure voiding despite treatment to facilitate voiding. Develop autonomic dysreflexia despite treatment to facilitate voiding.
(Scientific evidence–None; Grade of recommendation–None; Strength of panel opinion–Strong)

Rationale: An important requirement for reflex voiding is the ability to put on a condom catheter and have it stay in place. If this is not possible, another method of bladder management should be used. Unfortunately, there are no collecting devices for females, so reflex voiding is not a practical method for them. Detrusor sphincter dyssynergia frequently occurs in those who void reflexively. This results in a number of problems, such as autonomic dysreflexia, incomplete bladder emptying, and high voiding pressures. Both nonsurgical (see recommendation 4) and surgical (see recommendation 5) methods have been developed to treat detrusor sphincter dyssynergia. If problems continue despite treatment, then alternative methods of bladder management are needed. 4. Advise individuals of the potential for complications with reflex voiding, such as: Condom catheter leakage and/or failure. Penile skin breakdown from external condom catheter. Urethral fistula. Symptomatic UTI. Poor bladder emptying. High intravesical voiding pressures. Autonomic dysreflexia in those with injuries at T6 and above.
(Scientific evidence–None; Grade of recommendation–None; Strength of panel opinion–Strong)

Rationale: To void reflexively, a person needs to have uninhibited bladder contractions. However, individuals with spinal cord injury usually have detrusor sphincter dyssynergia. Problems can result, such as high voiding pressures (which can cause upper tract damage), autonomic dysreflexia, and high post-void residuals. A urodynamic evaluation will provide information on bladder and sphincter function and determine the need for any additional intervention prior to reflex voiding. 3. Consider not using reflex voiding as a method of bladder management in individuals who: Have insufficient hand skills or caregiver assistance. Are unable to maintain a condom catheter in place. Are female.

Rationale: Most complications from reflex voiding center on the external condom catheter and detrusor sphincter dyssynergia. One of the most common problems is condom catheter failure in which the condom catheter falls off. (This problem is discussed in more detail in the nursing considerations section.) Skin breakdowns may occur when a condom catheter is too tight or is taken off too frequently. A urethral fistula, which is extremely unusual, may occur for the same reasons. Other complications—symptomatic UTI,
Bladder Managment for Adults with Spinal Cord Injury

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