BLADDER MANAGEMENT IN SPINAL CORD INJURY

BLADDER MANAGEMENT IN SPINAL CORD INJURY

Indwelling catheterisation

• non latex catheters – silicon catheter for longer use
• suprapubic catheterisation – less traumatic
• leg bag is worn during day and night time collection device used in bed
• bladder capacity and compliance tend to decrease over time
• watch for autonomic dysreflexia

• regular use of anticholinergics
  • improve bladder compliance
  • lower bladder leak point pressure
  • less chance for hydronephrosis
  • prevent involuntary bladder contraction and urine leakage
• high fluid intake (>2L/day)
  • facilitate mechanical washout
  • decrease solute concentration and less chance of stone formation
• mainly used in atonic bladder and spinal shock

Intermittent self catheterisation

• by Lapides
• proper hand washing before the procedure – catheter cleaned with soap and water – air dried – placed in clean paper bag
• recurrent UTI – latex catheter used – can be sterilized by heating in microwave oven
• catheterized every 4-6hrs – amount of urine should be <500ml – may need to awaken at night to catheterize
• mainly used in automatic bladder
• Contraindications
  • inability or unwilling to self catheterize (care giver not willing)
  • abnormal urethral anatomy like strictures, false passages
  • bladder capacity <200ml
  • poor cognition, little motivation, not willing to strictly adhere to schedule
  • high fluid intake regimen
  • autonomic dysreflexia
• Complications
  • UTI
  • bladder over distension
  • urinary incontinence
  • urethral trauma and hematuria
  • urethral false passages
  • urethral strictures
  • autonomic dysreflexia
  • bladder stones
• in case of urine leakage and high pressure bladder : medications for overactive bladder

Crede and Valsalva

• used in LMN injuries with low outflow resistance or post sphincterotomy
• Crede
  • applying suprapubic pressure to express urine from bladder
  • augments the bladder contraction when bladder is flaccid
  • effectiveness limited by sphincter pressure
• Valsalva
  • increase intraabdominal pressure – do not ensure complete emptying
• avoid both these methods as primary techniques for bladder emptying : cause inguinal hernia, rectal prolapse
• mainly in atonic bladder
• contraindications
  • detrussor sphincter dyssynergia
  • bladder outlet obstruction
  • vesicourethral reflux
  • hydronephrosis

Reflex voiding

• sacral micturation reflex should be intact
• external collection device (condom catheter) to be used
• incomplete emptying
• mainly used in automatic bladder
• can cause autonomic dysreflexia or DESD

Management of Detrussor External Sphincter Dyssynergia (DESD)

• non surgical methods for dyssynergia
  • alpha blockers
    • lowers urethral resistance and improve voiding
    • contraindicated in symptomatic hypotension
    • to be taken in night to avoid orthostatic hypotension
    • phosphodiesterase can be used if patient already on alpha blockers – with caution
  • botulinum toxin injection into urinary sphincter mechanism
    • in DESD and detrussor over activity in intermittent catheterisation
• surgical
  • transurethral sphincterotomy with laser
    • procedure of choice
    • can also be done with diathermy knife
  • transurethral stent

Electrical stimulation and posterior sacral rhizotomy

• electrodes placed on sacral nerves or nerve roots (S2-4)
• stimulated by stimulator controlled by battery powered remote – operated by user
• combined with rhizotomy
  • reduce reflex incontinence
  • increase bladder capacity and compliance
  • protect upper nerve tracts
  • reduce autonomic dysreflexia
  • reduce reflex defecation
  • abolish reflex erection and reflex ejaculation
  • abolish sacral sensation

Augmentation cystoplasty

• ileum, colon or stomach – used to create intraabdominal low pressure reservoir

Urinary diversion

• secondary form of bladder management
• ureters transected – connected to segment of intestine (terminal ileum) – then brought to skin through lower abdominal wall
• external collection device placed over to stomach to collect urine
• continent urinary diversion
  • no collection device – continence achieved
  • emptied by self catheterisation

Mitrofanoff procedure

• appendix used to create a channel between abdominal wall and bladder
• in patients with inadequate access

Cholinergic agents

• Bethanechol hydrochloride

Anticholinergic agents

• mainly in atonic bladder
• oxybutynin, imipramine, flavoxate, darifenacin
• increases bladder capacity

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