Bladder Managment for Adults with Spinal Cord Injury - 35

CLINICAL PRACTICE GUIDELINE

Preoperative. The focus of care is on the individual’s physical and emotional well-being and on the person’s ability to alter care to facilitate the surgical intervention. Postoperative. The focus of care is on maintaining homeostasis through adequate hydration and fluid elimination (Joseph et al., 1998). Care of equipment, assistance required, and cosmesis. See Nursing Considerations for Reflex Voiding. Interference with social/sexual function. A decrease in erectile function and in the ability to be urine-free during sexual activities may be observed. Although the risk of impotence is reported in the literature (Zedjdlik, 1992), a lower pressure system and removal of the indwelling catheter may improve fertility. Medications. Alpha-blockers may be given to open the bladder neck to facilitate emptying. Reversibility. This procedure is permanent and cannot be reversed.
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.

and/or sphincter, and this hyperreflexia can be abolished by posterior sacral rhizotomy. The implant usually is combined with a rhizotomy to reduce reflex incontinence, increase bladder capacity and compliance, protect the upper tracts, and reduce autonomic dysreflexia. However, rhizotomy also abolishes reflex erection, reflex ejaculation, and sacral sensation, if these are present, and can reduce reflex defecation. The rhizotomy is an irreversible procedure. NOTE: As of March 2006, the electrical stimulation system was awaiting reapproval by the U.S. Food and Drug Administration, although the device is available in other countries. The combination of implantation and rhizotomy in appropriate individuals can reduce urological complications and the long-term costs of bladder management (Creasey and Dahlberg, 2001). 1. Consider electrical stimulation and posterior sacral rhizotomy in individuals with: High post-void residual volumes. Chronic or recurrent urinary tract infection. Problems with catheters. Reflex incontinence.

Electrical Stimulation and Posterior Sacral Rhizotomy
Electrical stimulation of the sacral parasympathetic nerves (S2–4) produces bladder contraction. Stimulation of these segmental nerves also activates somatic motor nerves causing sphincter contraction, which might be expected to prevent micturition. However, the smooth muscle of the bladder and the striated muscle of the external sphincter have different rates of contraction and relaxation and can be made to contract alternately by an intermittent pattern of stimulation, producing safe and effective voiding of the neurogenic bladder. Electrodes are implanted surgically on the sacral nerves or nerve roots in the spinal canal and attached by subcutaneous wires to a stimulator placed under the skin of the abdomen or chest. The stimulator is powered and controlled by radio transmission from a battery-powered remote control operated by the user when voiding is desired. Many of the complications of the neurogenic bladder are due to hyperreflexia of the detrusor

Reduced bladder capacity and compliance, due to detrusor hyperreflexia. Intolerance of anticholinergic medication. Detrusor sphincter dyssynergia. Autonomic dysreflexia.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Electrical stimulation of sacral efferent nerves produces voiding with consistently low residual volumes (Schurch, Rodic, and Jeanmonod, 1997; van der Aa et al., 1999). This results in low rates of urinary tract infection and a reduced need for indwelling and intermittent catheterization (Creasey and Dahlberg, 2001; Egon et al., 1998; van Kerrebroeck, Koldewijn, and Debruyne, 1993; van Kerrebroeck et al., 1997). Posterior rhizotomy from S2–4 greatly reduces reflex incontinence (van Kerrebroeck et al., 1997; Schurch, Rodic, and Jeanmonod, 1997) and increases bladder capacity and compliance (Egon et al., 1998; Koldewijn et al., 1994; van Kerre-

Bladder Managment for Adults with Spinal Cord Injury

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