Bladder Managment for Adults with Spinal Cord Injury - 38

BLADDER MANAGEMENT FOR ADULTS WITH SPINAL CORD INJURY

2. Consider bladder augmentation for females with paraplegia.
(Scientific evidence–None; Grade of recommendation–None; Strength of panel opinion–Strong)

Rationale: No effective external collecting device exists for females. Long-term studies have demonstrated excellent continence rates with acceptable complications rates for females with paraplegia who have undergone bladder augmentation (Venn and Mundy, 1998). Augmentation procedures often can be combined with simultaneous procedures on the bladder outlet, preferably at the time of the original procedure. These procedures may include a fascial sling, closure of the bladder neck, or insertion of an artificial urinary sphincter (Khoury et al., 1992). Excellent continence rates have been achieved by constructing a continent abdominal stoma at the time of augmentation using the appendix (Mitrofanoff), tapered ileal cecal segments, or tapered ileum. This modification is especially adaptable to individuals who cannot access their native urethra because of congenital abnormalities, obesity, or spasticity, or who require closure of an incompetent bladder neck. It is equally adaptable to tetraplegics who retain pincer grip or who can be assisted with the aid of a hand brace (Cain, Casale, and Rink, 1998; Casale, 1999; Sutton et al., 1998). 3. Consider bladder augmentation for individuals who are at high risk for upper tract deterioration secondary to hydronephrosis and/or ureterovesical reflux as a result of high pressures, secondary to poor bladder wall compliance, and/or detrusor sphincter dyssynergia.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Individuals with creatinine greater than 3 mg/dL have been excluded from consideration for augmentation if the rise in creatinine was not attributed to obstruction but rather related to compromised renal function (Kuo, 1997). Individuals with compromised renal function will be prone to develop hyperchloremic acidosis secondary to profound fluid and electrolyte shifts through the bowel wall. An individual with renal insufficiency might be considered for a gastrocystoplasty because of decreased chloride reabsorption, mucus production, and a low incidence of perforation (Chancellor et al., 1993; Kurzrock, Baskin, and Kogan, 1998). 5. Advise individuals of both the early and late complications of reconstructive surgery using intestinal segments.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Possible perioperative complications include: • • • • • • • • • • Anesthetic complications. Postoperative ileus and small bowel obstruction. Wound separations and infections. Mucus production causing blockage. Bowel disturbances. Persistent urine leakage. Bladder perforation. Development of bladder stones. Vitamin B12 deficiencies. Potential or late development of bladder cancer.

Rationale: Vesicoureteral reflux resolves in the majority of cases following bladder augmentation alone. However, occasional reimplantation procedures may be required if there is severe hydronephrosis. Long-term studies have demonstrated stability of the upper tracts following augmentation as well as improvement in mild to moderate hydronephrosis (Khastgir et al., 2003; Kuo, 1997). 4. Avoid augmentation in individuals with: Inflammatory bowel disease. Pelvic irradiation. Severe abdominal adhesions from previous surgery. Compromised renal function.
(Scientific evidence–II/III; Grade of recommendation–B/C; Strength of panel opinion–Strong)

Increased mucus production is common and may cause blockage during catheterization, but this complication usually will resolve with time. Bowel disturbances, such as diarrhea, are fairly common in the first month, but have been shown to diminish in subsequent follow-up visits. Bladder complications include persistent leakage, bladder perforation, or the development of bladder stones requiring endoscopic removal. Pyuria in augmented segments is common; however, symptomatic infections are rare. There have been scattered reports of carcinoma in bladder augmentation, but as yet no causal relationship to bladder augmentation has been established. Long-term follow-up will be required to answer this question (Khastgir et al., 2003; Kuo, 1997).

Bladder Managment for Adults with Spinal Cord Injury

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