Bladder Managment for Adults with Spinal Cord Injury - 33

CLINICAL PRACTICE GUIDELINE

external sphincter will be intact after the stent is removed, creating continence. Other. If the stent is in place and an indwelling urethral catheter is needed, leakage will occur around the catheter. A #14FR urethral catheter is typically used to prevent de-epithializing the stent and causing irritation. If the stent is in place and a suprapubic catheter is placed, some leakage from the urethra will occur, especially during transfers and other activities that put strain on the body.
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.

1. Consider transurethral sphincterotomy to treat detrusor sphincter dyssynergia in males with SCI who want to use reflex voiding and who: Have insufficient hand skills or caregiver assistance to perform intermittent catheterization. Have a repeated history of autonomic dysreflexia with a noncompliant bladder. 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 reflex, and/or stone disease. Have prostate-ejaculatory reflux with the potential for repeated epididymoorchitis. Experience failure with or intolerance to anticholinergic medications for intermittent catheterization. Experience failure with or intolerance to alpha-blockers with reflex voiding.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Transurethral Sphincterotomy
Transurethral resection of the external urinary sphincter (TURS) is a reasonable option for adequately draining the bladder to prevent and manage urologic complications in males with SCI or myelopathic disorders who void reflexively and have detrusor sphincter dyssynergia. The procedure helps to decrease urinary outflow resistance due to detrusor sphincter dyssynergia. The objective is to reduce the intravesical voiding pressure mediated by bladder contractions against a contracted external urethral sphincter. The goals of sphincterotomy are to stabilize or improve renal function, prevent urosepsis, and ameliorate autonomic dysreflexia. This is considered to be an irreversible procedure. Following TURS, with lower detrusor leak point pressure, it is possible to stabilize or eliminate vesicoureteral reflux and thus eliminate the need for chronic indwelling catheterization in some males. After a successful sphincterotomy, an improvement in bladder emptying and stabilization of the upper urinary tract can be reasonably expected in 70 percent to 90 percent of individuals (Wein, Raezer, and Benson, 1976). Following TURS, the individual is expected to have urinary incontinence. Bladder drainage is provided with an external condom catheter connected to a leg bag, which needs changing and cleaning only once a day. This method reduces the amount of time a caregiver must devote to intermittent catheterization and gives much more independence to the individual. This method also eliminates the necessity for an indwelling catheter in individuals who have been unsuccessful with that device or who do not want to continue intermittent catheterization. Individuals can be up in a wheelchair most of the day and available to engage in a productive vocation.

Rationale: Tetraplegic males with poor hand function cannot self-catheterize their bladders. They also are prone to autonomic dysreflexia, which can create an emergency situation necessitating catheterization of the bladder at odd times, such as in the middle of night. Reflex voiding is easy following sphincterotomy. Gentle tapping in the suprapubic region also can trigger voiding and help bladder decompression. Following sphincterotomy, there is usually significant relief from autonomic dysreflexia (Perkash et al., 1992). 2. Consider avoiding sphincterotomy in males with a small retractable penis unable to hold an external collecting device unless a penile implant is planned following TURS.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Males with a small retractile penis cannot hold the external condom drainage device that is necessary to collect urine following TURS. A semirigid penile implant may be required (Perkash et al., 1992). The incidence of infection and implant failure has been much higher in persons with SCI than in those without. But in properly selected individuals, with adequate control of

Bladder Managment for Adults with Spinal Cord Injury

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