CLINICAL PRACTICE GUIDELINE 3 Are unable to maintain a condom catheter in place. Are female. 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. 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. 5. First consider the use of the following nonsurgical methods to help decrease detrusor sphincter dyssynergia in individuals who use reflex voiding as their method of bladder management: Alpha-blockers. Botulinum toxin injection into the urinary sphincter mechanism. 6. To ensure low-pressure voiding during reflex voiding, consider the use of two surgical methods: Transurethral sphincterotomy. Endourethral stents. als with high-level spinal cord injuries because of the potential for orthostatic hypotension. 4. Use phosphodiesterase inhibitors with caution in individuals with a high-level SCI who are on alphablockers. Particular caution should be used if alpha-blockers and PDE5 inhibitors are prescribed together. 5. Advise individuals of the potential for complications of alpha-blockers, such as orthostatic hypotension. Botulinum Toxin Injection 1. Consider the use of botulinum toxin injections into the sphincter to help improve voiding in individuals with SCI with detrusor sphincter dyssynergia. 2. Monitor individuals after botulinum toxin injections and inform them that onset may be delayed up to 1 week and that the drug may lose its effectiveness in 3 to 6 months. 3. Consider avoiding the injection of botulinum toxin into the sphincter of SCI individuals who: Have a neuromuscular disease. Have a known allergy to or previous adverse effect from botulinum toxin. Are currently on an aminoglycoside. Have insufficient hand skills or caregiver assistance. Are unable to maintain a condom catheter. Are female. 4. Advise individuals with SCI of the potential for complications of botulinum toxin injections into the sphincter, such as: Autonomic dysreflexia during the injection (T6 and above). Hematuria during the injection. 5. Consider injecting botulinum toxin into the detrusor muscle of individuals on intermittent catheterization with detrusor overactivity. Alpha-Blockers 1. Consider the use of alpha-blockers on their own or as a supplement to other forms of treatment, such as transurethral sphincterotomy. 2. Consider avoiding alpha-blockers in individuals who have symptomatic hypotension. 3. When first prescribing, instruct the individual to take alpha-blockers at night, when supine. These instructions are particularly important for individu-