Bladder Managment for Adults with Spinal Cord Injury - 29

CLINICAL PRACTICE GUIDELINE

Precautions. Alpha-blockers may affect positioning, urgency, urge incontinence, and stress urinary incontinence. The individual is instructed to take the medication at night when lying down, to dangle the feet and sit up slowly to allow time for the body to accommodate to changes in blood pressure, to avoid driving or the use of heavy machinery when the drug is first administered, and to report any side effects to the physician. Medication system. To ensure that all medications are taken as prescribed, a medication dispenser or similar system should be developed. Bladder diary. A record of all bladder activity can be useful in some settings to evaluate emptying and fluid intake. Assistance required. Specific considerations for the individual and caregiver include: (a) adequate hand function to open the medication bottle; (b) the ability to remember to take the medication as prescribed; (c) the ability to transfer quickly to the toilet; and (d) the ability to access the genital area. Individuals who experience a decrease in level of energy should find that this side effect lessens over time as the body accommodates to the medication. Cosmesis. Standing or transferring will require more time as the individual adjusts to changes in blood pressure. Interference with social/sexual function. Some individuals have noted a change in ejaculatory function, in which case dosing or medication may need to be altered. Medications. To prevent drug interactions or overdosing, the urologist should be aware of all other medications being taken. Reversibility. Alpha-blockers can be stopped at any time and the body will return to its normal function.
Adapted from Joseph, A.C., A. Hixon, J. Giroux, D. Briggs, M. Gardenhire, D. Diaz, and J. Wells. Nursing clinical practice guideline: neurogenic bladder management. Spinal Cord Injury Nursing 15 (2) (1998): 21–56.

Botulinum Toxin Injection
Coordinated relaxation of the sphincter mechanism may be absent in individuals with SCI. Consequently, detrusor sphincter dyssynergia usually is present. Other interventions frequently are needed to allow the bladder to empty effectively and to prevent upper tract complications. One modality is the transurethral or transperineal injection of botulinum toxin into the urinary sphincter mechanism. Botulinum can also be used to treat the neurogenic overactive bladder, by injecting it directly into the bladder wall proper. Botulinum toxin inhibits acetylcholine release at the neuromuscular junction, which in turn blocks neuromuscular contraction and relaxes muscles that are either spastic or overactive. It can, therefore, relax sphincter spasticity in those with detrusor sphincter dyssynergia. Lack of permanence is both an advantage and a disadvantage of botulinum toxin injections, which frequently lose effectiveness after 3 to 6 months when the nerve endings resprout. Thus, reinjections usually are necessary. There is no limit to the number of reinjections that may be required. 1. Consider the use of botulinum toxin injections into the sphincter to help improve voiding in individuals with SCI with detrusor sphincter dyssynergia.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Schurch et al. (1996) reported that after botulinum toxin was injected into 21 individuals with detrusor sphincter dyssynergia, urethral pressures were significantly reduced with a concomitant decrease in post-void residual volumes in 38 percent of individuals. 2. Monitor and inform individuals after botulinum toxin injections that onset is delayed up to 1 week and that the drug may lose its effectiveness in 3 to 6 months.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Botulinum toxin inhibits acetylcholine release at the neuromuscular junction, which in turn blocks neuromuscular contraction and relaxes muscles that are either spastic or overactive. Over time, reinnervation of the neuromuscular junction occurs. For detrusor sphincter dyssynergia, botulinum toxin injected into the external sphincter has been reported to remain effective for 2 to 3 months (Dyksra et al., 1990).

Bladder Managment for Adults with Spinal Cord Injury

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