4 BLADDER MANAGEMENT FOR ADULTS WITH SPINAL CORD INJURY Endourethral Stents 1. Consider endourethral 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. 2. Consider the endourethral stent method of drainage as an alternative to transurethral sphincterotomy in individuals with SCI. 3. Consider avoiding endourethral stents in individuals who: Have insufficient hand skills or caregiver assistance to manage a condom catheter. Are unable to maintain a condom catheter. Are female. Have urethral abnormalities. 4. Advise individuals of the potential for complications of endourethral stents, such as: Stone encrustation. Stent migration. Persistence of autonomic dysreflexia. Possible need for removal or replacement. Difficulty with removal. Possible urethral stricture after removal of stent. Urethral trauma. Tissue growth into the stent blocking urine flow. Urethral pain. Transurethral Sphincterotomy 1. Consider transurethral sphincterotomy (TURS) 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 epididymo-orchitis. Experience failure with or intolerance to anticholinergic medications for intermittent catheterization. Experience failure with or intolerance to alpha-blockers with reflex voiding. 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. 3. Advise individuals with SCI of the potential for complications of a sphincterotomy, such as: Significant intraoperative and perioperative bleeding. Clot retention. Prolonged drainage with a large diameter catheter. Urethral stricture. Erectile dysfunction. Ejaculatory dysfunction. Reoperation in 30 to 60 percent of cases. 4. Consider laser sphincterotomy the procedure of choice for transurethral sphincterotomy, depending upon the availability of laser equipment.