Bladder Managment for Adults with Spinal Cord Injury - 40

BLADDER MANAGEMENT FOR ADULTS WITH SPINAL CORD INJURY

be created on the abdominal wall, which makes catheterization of the bladder possible for individuals with SCI who have questionable ability to catheterize their native urethra and who are motivated and able to access an abdominal stoma. Such individuals are good candidates for a continent diversion and have shown improved quality of life (Zomminck et al., 2003).

Urinary Diversion
Urinary diversion, which diverts the flow of urine from the bladder, is normally a secondary form of bladder management when primary methods have failed. The ureters are transected just above the bladder and connected to a segment of intestine, which is in turn brought to the skin of the lower abdominal wall. Different segments of the intestine have been used for this purpose, but a segment of terminal ileum remains the most popular. An external appliance is placed over the stoma to collect urine externally. The appliance can be connected to a leg bag during the day and a bed bag at night. Modern appliances stay in place well and often only have to be changed weekly. Urinary diversion is normally used when bladder complications prevent restoration of an adequate bladder. Diversion may be used as an alternative to augmentation cystoplasty or continent diversion when hand function does not permit self-catheterization. As with any form of bladder management, the primary goals are to preserve the upper urinary tract and prevent unacceptable incontinence. 1. Consider urinary diversion for individuals in the following circumstances: Lower urinary complications secondary to indwelling catheters. Urethrocutaneous fistulas. Perineal pressure ulcers. Urethral destruction in females. Hydronephrosis secondary to a thickened bladder wall. Hydronephrosis secondary to vesicoureteral reflux or failed reimplant. Bladder malignancy requiring cystectomy.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Indwelling catheters may result in urethral damage, which often is difficult to correct surgically. Urethral erosion in both males and females and urethrocutaneous fistulas in males all present challenges for reconstructive surgery. Urinary diversion can circumvent these problems and provide satisfactory continence. The method is preferable to continent diversion in individuals who have poor hand function and cannot perform self-catheterization. Poorly compliant or thickwalled bladders may result in obstruction at the ureterovesical junction. These bladders are not suitable for ureteral reimplantation, and diversion may be used to relieve upper tract obstruction and prevent further renal damage (Creasey and Dahlberg, 2001). An increased incidence of bladder tumors has been noted in individuals using indwelling catheters for a long period of time. Cystectomy is often required as these tumors may not be discovered until late in the course of the disease. These individuals are usually older and often not good candidates for intermittent catheterization after years of an indwelling catheter (Chua, Tow, and Tan, 1996; West et al., 1999). 2. Use urinary diversion with caution in individuals who are too debilitated to undergo a major surgical procedure or who have one of the following conditions: Inflammatory bowel disease. Pelvic irradiation. Severe abdominal adhesions from previous surgery. Compromised renal function.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Individuals who have bowel disease or who are in poor health generally should be excluded from urinary diversion, and alternate bladder management methods should be used (Creasey and Dahlberg, 2001). Inflammatory small bowel disease and prior pelvic irradiation both increase the risk of ureterointestinal stricture and urinary leak as well as postoperative bowel complications (McDougal, 2002.) 3. Advise individuals undergoing urinary diversion of the following potential complications: Early complications associated with any major intestinal surgery, including anesthetic complications.

Bladder Managment for Adults with Spinal Cord Injury

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