Bladder Managment for Adults with Spinal Cord Injury - 30

BLADDER MANAGEMENT FOR ADULTS WITH SPINAL CORD INJURY

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.
(Scientific evidence–None; Grade of recommendation–None; Strength of panel opinion–Strong)

the muscle activity of the sphincter mechanism or an overactive bladder. Studies indicate that botulinum toxin injected into the bladder wall (100 to 300 units) can suppress an overactive bladder, which has been confirmed by cystometry (Schurch et al., 1996, 2005). As in the sphincter, the effects wear off after 3 to 6 months so the injections need to be repeated. Botulinum toxin injection into the bladder can be used for both males and females because it does not require use of an external condom catheter as a collection device. NOTE: This technique is not presently approved by the U.S. Food and Drug Administration for this indication.

Nursing Considerations for B o t u l i n u m To x i n I n j e c t i o n
This procedure is typically performed as sameday surgery. Toileting issues—including the ability to transfer to the toilet, access the genital area easily, and collect and contain urine—need to be addressed prior to surgery. The temporary nature of this treatment is an important consideration. Pretreatment baseline data. Baseline data are needed to evaluate postoperative outcomes and to determine the need for further treatment. Bladder diaries and urodynamics can provide subjective and objective evidence that will assist the health-care provider in evaluating the degree of improvement in function of the bladder and external sphincter. A diary of fluid intake, incontinence, voiding, and catheterization times and amounts will provide a record of actual occurrences. Baseline urodynamics will provide objective evidence of bladder and external sphincter function. Postprocedure. It usually takes about 2 weeks for the botulinum toxin to begin working, and 4 weeks to have its maximal effect. Therefore, the prebotulinum toxin method of bladder management will need to be maintained for several weeks after the injections. Applications for males. Botox injected into the external urethral sphincter facilitates urine emptying and requires a continuous collection device to contain urine. Assistance required, cosmesis, and interference with social/sexual function. See Nursing Considerations for Reflex Voiding.

Rationale: Botulinum toxin has the potential to exacerbate a neuromuscular disease. It also can have an increased effect if a person is undergoing aminoglycoside antibiotic treatment since aminoglycosides have been implicated in the induction and/or exacerbation of neuromuscular blockade. Another reason to avoid botulinum toxin injection is the inability to put on a condom catheter or to have one stay in place, since a condom catheter is needed for reflex voiding. 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.
(Scientific evidence–None; Grade of recommendation–None; Strength of panel opinion–Strong)

Rationale: Botulinum toxin is usually injected into the sphincter under direct visualization through a cystoscope. Both the injection and the cystoscopy have the potential to cause autonomic dysreflexia and/or hematuria during the procedure. 5. Consider injecting botulinum toxin into the detrusor muscle of individuals on intermittent catheterization with detrusor overactivity.
(Scientific evidence–I/III; Grade of recommendation– A/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. Therefore, botulinum toxin can suppress

Bladder Managment for Adults with Spinal Cord Injury

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