Bladder Managment for Adults with Spinal Cord Injury - 31

CLINICAL PRACTICE GUIDELINE

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Medications. Additional medications, such as an alpha-blocker for the bladder neck, may be needed to facilitate emptying. Applications for males and females. Botox injected into the bladder muscle facilitates urine storage and catheterization to empty the bladder. Assistance required. Adequate hand function and sufficient cognitive ability to be aware that the bladder needs emptying are needed, or a caregiver must be available to empty the bladder. Cosmesis and interference with social /sexual function. See Nursing Considerations for Intermittent Catheterization. Medications. Additional medications may be needed to provide effective storage at low pressure. Reversibility. The effects of botulinum toxin injection are not permanent.
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.

The requirements for anesthesia during stent placement vary among individuals. Individuals with severe spasticity and a history of autonomic dysreflexia require general or spinal anesthesia. The stent is inserted through a preloaded insertion device with a zero-degree cystoscopic lens and deployed with the proximal end extending to the caudal end of the verumontanum so that it does not completely block the ejaculatory ducts. The distal end of the prosthesis extends into the bulbous urethra. 1. Consider urethral stents to treat detrusor sphincter dyssynergia in individuals who want to reflex void and: Have insufficient hand skills or caregiver assistance to perform intermittent catheterization. Have a repeated history of autonomic dysreflexia. Experience difficult catheterization due to false passages in the urethra or secondary bladder neck obstruction. Have inadequate bladder drainage with severe bladder wall changes, drop in renal function, vesicoureteral reflux, and/or stone disease. Have prostate-ejaculatory reflux with the potential for repeated epididymo-orchitis. Experience failure with or intolerance to anticholinergic medications for intermittent catheterization. Experience failure with or intolerance to alpha-blockers with reflex voiding.
(Scientific evidence–None; Grade of recommendation–None; Strength of panel opinion–Strong)

Urethral Stents
Urethral strictures and benign prostatic hyperplasia were the initial indications for urethral stents—the endolumenal wire prosthesis. Urethral stents also have been used in males with spinal cord injury who reflexively void and have detrusorexternal sphincter dyssynergia (DSD), a condition in which bladder contractions are simultaneously associated with sphincter contractions resulting in an obstructed urethra. Despite the dyssynergic sphincter, urine leakage occurs because the sphincter relaxes intermittently. A urethral stent provides a treatment option for circumventing urethral obstruction without a surgical procedure, such as transurethral external sphincterotomy (TURS). One type of frequently used stent consists of a woven, self-expanding, tubular metallic mesh, which is available in lengths of 20, 25, and 30 mm. It is made of a super alloy that expands to an unconstrained diameter of 14 mm (42F) when deployed from the insertion tool. This feature allows continuous drainage of the bladder; therefore, individuals with SCI will require a urinary collecting device (external condom catheter and leg bag) at all times. The geometry, elastic property, and radial force of the metallic stent mesh allow it to maintain an in-situ position continuously and thus prevent obstruction due to the dyssynergic external urethral sphincter.

2. Consider the urethral stent method of drainage as an alternative to TURS in individuals with SCI.
(Scientific evidence–II; Grade of recommendation–B; Strength of panel opinion–Strong)

Rationale: In a study of 153 individuals at 15 medical centers, sphincter prosthesis placement had documented clinical success with up to 2 years of follow-up (Chancellor et al., 1999). The simplicity of its placement and its minimal surgical morbidity make it an attractive modality for treating DSD. Stent placement may be indicated in individuals with previous failed external sphincterotomy performed by less experienced urologists. Chancellor et al. (1999) reported reversible clinical outcomes after sphincter stent removal in
Bladder Managment for Adults with Spinal Cord Injury

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