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EDUBRIEFS in CCTC In spinal cord injury, bladder sphincter relaxation is absent, leading to urinary retention. As soon as hourly urine output is no longer necessary, the indwelling bladder catheter should be removed to reduce the risk of urinary tract infections (a life-threatening complication of acute spinal cord injury). Intermittent catheterization decreases the risk for urinary tract infections. Considerations Immediately following acute spinal cord injury, spinal shock develops. Spinal shock is characterized by: Flaccid paralysis (loss of bladder tone) below the level of the injury, and loss of spinal cord Spinal shock often coincides with neurogenic shock, which is evidenced by loss of autonomic control (bradycardia, vasodilation, Spinal shock can persist for several weeks, and is associated with an inability to retain urine or bowel contents. Although urinary incontinence may be present, bladder emptying is also dysfunctional, making some form of catheterization mandatory. When spinal shock ends, spinal reflexes begin to return. Bulbocavernal, bladder and rectal Sphincter reflex are amont the first responses to appear and are generally signs that the spinal shock phase is ending. The ability to retain urine is restored, and spastic movements of the paralyzed limbs may appear (care should be taken not to mistake these involuntary movements for a return of voluntary movement). Although bladder and bowel sphincter tone may allow the paralyzed individual to maintain continence of urine and feces, the cord injury prevents the individual from contracting the bladder and relaxing the sphincters to facilitate elimination. Retained urine or feces is the most common cause of autonomic dysreflexia. Autonomic dysreflexia is a life threatening complication that is most common in patients with injuries above T6. This is can occur as a result of any noxious stimulous AFTER the period of spinal shock ends. Patients who develop autonomic dysreflexia are at risk for the rest of their lives. Then hourly urine output is no longer needed, diuretic use has stopped and urine output stabilizes, routine intermittent catheterization can be considered. Catheterization should be performed q 4 h initially. The volume of urine with each catheterization should be less than 500 mL. Larger volumes can precipitate bladder spasm, autonomic dysreflexia, renal reflux and overflow incontinence. The goal for intermittent catheterization is a stable intake of ~2Litres per day and intermittent cathetrization Q 6 H with an output of less than or equal to 500 mL. Fluid restriction shoudl be avoided as it increases the risk for urinary tract infection, renal calculi and hypotension during mobilizaiton. Intermittent catheterization frequency is required for patient with spinal cord injury and intermittent catheterization who require diuretics. Indwelling catheterization may be more appropriate if diuretic use is required. Following catheter removal, incomplete bladder sphincter control may cause some urinary incontinence. Condom drainage can be used to protect skin and linen, however, it is important to continue to perform intermittent catheterization, as complete bladder emptying does not usually occur. Krassioukov, A., et. al. (2009). A Systematic Review of the Management of Autonomic Dysreflexia Following Spinal Cord Injury. Arch Phys Med Rehabil. April; 90(4): 682–695. Krassioukov, A., et. al. (2010). Neurogenic bowel management after spinal cord injury: A systematic review of the evidence. Spinal Cord. 2010 October; 48(10): 718–733.
After a spinal cord injury, the bladder will no longer work as it did before the injury. If the injury is above the T12 level, the bladder may empty by "reflex." Any injury in this area may be able to have a "reflex" bladder. For a reflex to occur, the bladder message needs to travel within the cord at any level but does not need to travel up to the brain. When the bladder empties by reflex, it is called a "Reflex Bladder." Reflex Bladder: Process of Urination The bladder fills with urine and stretches. The stretching bladder pushes out onto nearby nerves. The nerves send signals to the spinal cord. The message loops around in the cord (below the injury) and sets off the reflex. The message goes back down the cord to the bladder. The bladder contracts, the sphincter muscles open and the urine is let out. It may let the urine out at an inconvenient time because the brain it not involved to determine the "right time" to urinate. Therefore, the person could have bladder accidents at inappropriate times. If the spinal cord injury is below the T12 level, the bladder will probably not be able to empty by a reflex. Because the spinal cord ends at about L2, the signals of a full bladder have no place to travel. Since the injury is below the level of the cord, the signals cannot ever reach the cord to stimulate the reflex to occur. When the bladder is not able to empty by a reflex, it is called an "areflexic Bladder." Areflexic Bladder: Process of Urination The bladder fills with urine and stretches. The stretching bladder pushes out onto nearby nerves. The nerves send signals to the spinal cord but they are not able to reach the cord. The signals are there but have no place to travel. Because the cord never received the signals, the bladder does not get a message to contract. The sphincters stay closed. The urine does not empty by reflex, nor does the brain instruct the bladder to empty at all since the signals are not able to reach the cord or the brain. The bladder becomes very full. When it becomes "too full," the urine will eventually leak out from the bladder, resulting in bladder accidents. In addition to the problems associated with nerve pathways up and down the cord, there are other problems that often affect bladder size, pressures and bladder muscle function. All of these affect the ability of the bladder to hold/store urine as well as properly release the urine. For example, some bladders may have a very tight sphincter muscle that makes it difficult to allow urine to pass. The bladder may empty incompletely, thus leaving residual urine in the bladder. The residual urine stays inside the bladder too long and is prone to causing urinary tract infections. Changes in bladder function after spinal cord injury require new ways of emptying the bladder. Bladder programs may vary from person to person depending on his/her particular needs. Some people may use intermittent catheterizations and/or wear a condom catheter. Others may require an indwelling catheter, suprapubic catheter or other types of surgical intervention. The lessons in this course will review common types of bladder emptying as well as bladder problems associated with spinal cord injury.
Epidemiological follow-up study. To evaluate urinary incontinence and its management in a population of individuals with long-term spinal cord injury (SCI). Clinic for Spinal Cord Injuries and Department of Urology, Copenhagen University Hospital, Rigshospitalet, Denmark. Retrospective data collection from the patient records and information from a follow-up questionnaire of traumatic SCI individuals at least 10 years after injury. A total of 236 patients participated (84.6% response), 82% males and 18% females, 47% tetraplegic and 53% paraplegic, injured between 1956 and 1990. Age at the time of follow-up was 28–84 years (mean 50.5 years). Years of follow-up were 10–45 years (mean 24.1 years). A total of 43% of the participants reported incontinence from less than once a week to daily. There was a significant linear trend across the groups of incontinence with more paraplegics reporting daily incontinence compared with tetraplegics. A higher proportion of participants using clean intermittent catheterization reported incontinence (56%) compared with participants using other bladder-emptying methods. Only 19% of the participants used medication for the management of incontinence. Urinary incontinence is a common problem in individuals with SCI. Only a minority of individuals used medication for the treatment of incontinence. This study was carried out as a part of the primary author's PhD study, financed by the Medicon Valley Academy and Coloplast A/S. A spinal cord injury (SCI) may impair the normal function of the urinary bladder and give rise to neurogenic bladder dysfunction. Lesions above the sacral micturition centre may cause urge and reflex incontinence, and lesions peripheral to the sacral micturition centre may cause overflow incontinence. Urinary incontinence is an important aspect of bladder management in individuals with SCI. From the view of the SCI individuals, it is a most unpleasant complication, which may disable the individuals socially. Earlier studies have shown impaired bladder control to be related to lower quality of life.1, 2 The aim of this study was to evaluate urinary incontinence and its management in a population of individuals with SCI, at least 10 years after injury, to elucidate the extent of the problem and how it is handled. The study included patients from the Clinic for Spinal Cord Injuries (CSCI) at Rigshospitalet, Denmark. The inclusion criteria were a traumatic SCI contracted before 1 January 1991 and the participant still alive at the time of mailing a follow-up questionnaire. The exclusion criteria were: (1) not immediately transferred to CSCI after the acute admission because of the SCI, (2) follow-up terminated from the CSCI, (3) not followed in CSCI since 1990 or (4) missing medical record/insufficient data. In all, 279 participants were included in the project. They all received a questionnaire by mail with a pre-stamped return envelope. Approximately 2 months after the first dispatch of questionnaires, a reminder with a new questionnaire was sent to those participants, who had not answered. All together, 236 participants answered and returned the questionnaire after the first or second mailing corresponding to a response-rate of 84.6%. Among them, 193 were men and 43 women, injured from 1956 to 1990. The mean age of the participants at the time of the study was 50.5 years (range 28.4–84.5 years), and mean follow-up time was 24.1 years (range 10.7–45.1 years). Concerning level of injury, 126 participants were paraplegic and 110 tetraplegic, 102 complete and 134 incomplete according to the Frankel classification.3 The non-responder group consisted of 43 individuals, 35 men and 8 women injured from 1960 to 1990. Data concerning gender, time of injury, neurological level, Frankel classification3 and results from the latest urodynamic investigation carried out before follow-up were collected from the medical records. The neurological level and Frankel classification were recorded as defined at the time of discharge from the initial rehabilitation at CSCI, at which time the participants are expected to be neurologically stationary. The neurological level of the SCI was given as the most caudal normal spinal cord segment. The questionnaire concerned different aspects of late complications in individuals with SCI. The questions used in this study are seen in Table 1. Scales, questions and answer possibilities in the questionnaire were similar or comparable with earlier published standards.4 Experience from an earlier study of reproducibility and validity of a questionnaire filled in by spinal cord-lesioned individuals before regular follow-up5 has been used to optimize the questions. The questionnaire was further developed with the assistance of different professionals working with the treatment and rehabilitation of patients with SCI. Before the questionnaires were mailed to the participants in the main study, a pilot study was carried out including seven men with SCI (four tetraplegic and three paraplegic). The pilot study showed that the questionnaire was comprehensive and easy to answer. Owing to the experience from the pilot study, minor adjustments were made before sending the questionnaire to all the participants in the main study. Table 1 Questions used in the study To test the validity of the process of typing the answers to the questionnaire into the database, 10% (n=24) of the questionnaires were checked thoroughly a second time. The results showed that all data entries concerning the included data for this publication were correct. To investigate the reproducibility of the questionnaire, 38 participants received a second questionnaire 2 years after the initial emission of the questionnaire. A total of 33 participants returned the second questionnaire (86.8%). For each of the 33 participants, the answers of the first and second questionnaire were compared and it showed a reproducibility of 92–100% concerning questions, to which the answers are expected to be the same over time, and a reproducibility of 70–81% concerning questions wherein the answers depend on how the participant feels at the time of answering the questionnaire and therefore the answers are likely to change over time. Therefore, the reproducibility of the questions used in this presentation was concluded satisfactory and even stable over a period of 2 years. χ2-test was used for tables. χ2-test for trend was used for 2 × k tables with ordered categories.6 To compare the means, t-test was used for parametric data. Five percent was chosen as level of significance. The comparison between the responder and non-responder group with regard to gender, neurological level, para-/tetraplegia, Frankel classification, age at SCI, age at the time of follow-up, years since SCI and cause of SCI showed no statistically significant difference between the two groups. The frequency of incontinence within the last 3 months is seen in Figure 1. Figure 1 Frequency of incontinence within the last three months. (n=221). 15 participants did not answer the incontinence question. UTI, urinary tract infection. There was no statistically significant difference in frequencies of incontinence between groups with respect to gender, time of SCI (1956–1970,1971–1980,1981–1990) or age at follow-up (28–39 years, 40–49 years, 50–59 years, 60–84 years). Table 2 shows frequency of incontinence divided by para- and tetraplegics. There was a significant trend across the groups of incontinence with more paraplegics reporting daily incontinence compared with tetraplegics. Table 2 Frequency of incontinence divided by paraplegia or tetraplegia In the questionnaire, the participants estimated their present bladder-emptying function compared with that at the time of the initial discharge from CSCI (three categories: better, unchanged, worse). There was no statistically significant difference in the frequency of incontinence between the participants in the three categories. When analysing data, we found that significantly more participants, who found their bladder-emptying method to be a problem, experienced incontinence. Figure 2 shows the percentage of participants reporting incontinence from less than once a week to daily in each group of different bladder-emptying methods used at follow-up. Figure 2  Percent of participants reporting incontinence from less than once a week to daily in each group of the bladder-emptying methods used at follow-up. (n=221). 15 participants did not answer the incontinence question. Notice that each participant may use more than one method of bladder emptying. CIC, clean intermittent catheterization. SIC, sterile intermittent catheterization. Other methods used are reservoir bladder, ileal conduit a.m. Bricker, sacral-anterior-root-stimulation, haemodialysis. Number of participants using the different methods is given in brackets. In 55% of the participants (130), at least one urodynamic investigation was present in the medical file. There was no difference in the frequency of incontinence between participants with suprasacral and infrasacral neurogenic bladder dysfunction (Table 3). Table 3 Degree of incontinence divided by type of neurogenic bladder dysfunction found at the latest urodynamic investigation before follow-up Degree of incontinenceIn the questionnaire, the participants could report the degree of incontinence by four categories: small drips, minor leak, major leak and constant leak. It was possible to mark more than one degree. Table 4 shows the highest degree of incontinence reported by each participant as percentage of frequency of incontinence. We could not show a significant difference between frequency of incontinence and degree of incontinence. Table 4 Frequency of incontinence divided by degree of incontinence Management of the incontinenceFigure 3 shows how the participants reported management of incontinence. A total of 28 participants (19%) reported use of medication. Of these, 11 used anticholinergic drugs against neurogenic detrusor overactivity, 18 used antibiotics, 13 of whom specified the use of long-term prophylaxis against urinary tract infection. Two participants used an alpha-blocker. Only three participants used two types of medication. There was no statistically significant difference in management of incontinence between groups with respect to age at the time of follow-up and how the bladder-emptying method was perceived. Figure 3 Management of the incontinence. (n=151). Notice that the participants may use more than one management method. To our knowledge, only few papers have described urinary incontinence and long-term SCI. Therefore, this study provides new information about individuals with SCI. Urinary incontinence was reported by 54% of the participants in this study, which indicates the importance of more focus on this problem and possible solutions. An earlier study7 described self-reported problems among patients with SCI more than 10 years after injury. On the basis of calculations of the data presented in the article, only 24% of the patients reported urinary incontinence. One explanation of this difference could be that data were not collected in the same way. In this study a questionnaire was filled in. In the study by Walter et al.,7 the data were collected through a structured interview. Furthermore, they reported minor incontinence differently—with a single question for urinary incontinence. It is important to notice that, although data from the questionnaire in this study are self-administered, the reproducibility of the data was very high, when tested 2 years after the initial emission of the questionnaire. A cross-check of the answers in a self-administered questionnaire would obviously be desirable, but unfortunately not possible in this study. Furthermore, it was not possible to obtain consistent and valid data concerning additional causes of incontinence in the participants such as prostatic or gynaecological disorders. The majority (63%) experienced small drips or minor leak. Although there were no significant differences in frequency of incontinence in relation to degree of incontinence, there seems to be a trend towards more frequent incontinence related to a higher degree of incontinence. Concerning bladder-emptying methods and incontinence, Figure 2 shows that 56% of the participants using clean intermittent catheterization (CIC) reported some kind of incontinence. This is nearly the same as found by Gray et al.,8 who reported that 53% of individuals carrying out CIC experienced at least occasional leakage. CIC having the highest percentage of incontinence compared with the other bladder-emptying methods in this study could be because of selection, that is, those with severe incontinence problems are also those who change to CIC to decrease or eliminate the incontinence. Only 22% of participants using sterile intermittent catheterization reported some kind of incontinence compared with 56% of participants using CIC. One possible explanation is the limited number of participants using sterile intermittent catheterization. Another explanation could be that if sterile intermittent catheterization is needed as bladder-emptying method, the reason is most likely limited hand function, indicating tetraplegia. As mentioned earlier, we found a trend across the groups of incontinence with more paraplegics reporting daily incontinence compared with tetraplegics. In this study, we found no difference in the frequencies of incontinence between participants with suprasacral and infrasacral bladder dysfunction. The suprasacral bladder dysfunction is most likely related to neurogenic detrusor overactivity resulting in urge or reflex incontinence. The infrasacral bladder dysfunction is known to be related to detrusor areflexia and results in overflow incontinence.9 A total of 16% of the participants with normal bladder emptying reported incontinence. This is possibly because normal bladder emptying is not the same as normal bladder function. The incontinence reported by participants using urethral indwelling catheter or suprapubic catheter could be because of the catheter blocks, or bypasses and leaks. The significant relation between perception of bladder-emptying method as a problem and incontinence was not unexpected. Earlier studies have shown neurogenic bowel and bladder problems to be associated with lower quality of life.1, 2, 10 The incontinence in this study is most often managed by condom-catheter (men only), frequent bladder emptying or the use of diaper/sanitary towel. Only 19% of the participants reported the use of medication, and in more than half of the cases the medicine was antibiotics as treatment or prophylaxis of urinary tract infection. An earlier study by Gray et al.8 found pharmacotherapy to be the most common method to prevent leakage among spinal cord injured. Another study11 showed the effect of anticholinergics in association with CIC or suprapubic catheters to avoid high intravesical pressure and upper tract damage. Both the high proportion of participants with incontinence and the limited percentage using pharmacotherapy against urinary incontinence in this study could be because of a reluctant or conservative approach by the health care professionals or insufficient urological follow-up of these patients. Individuals with SCI have urological investigations done routinely every second year, as part of their urological follow-up. It is possible that the focus of follow-up is on the results of these investigations, rather than the symptoms experienced by the patient. Urinary incontinence is common in both para- and tetraplegics, and in most methods of bladder management. Only a minority of individuals used medication against incontinence. The study indicates a need for larger attention towards incontinence to solve the problem. Hicken BL, Putzke JD, Richards JS . Bladder management and quality of life after spinal cord injury. Am J Phys Med Rehabil 2001; 80: 916–922. Westgren N, Levi R . Quality of life and traumatic spinal cord injury. Arch Phys Med Rehabil 1998; 79: 1433–1439. Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 1969; 7: 179–192. Levi R, Ertzgaard P . Quality indicators in spinal cord injury care: a Swedish collaborative project. The Swedish Spinal Cord Injury Council 1998. Scand J Rehabil Med Suppl 1998; 38: 1–80. Biering-Sorensen B, Egebart J, Hilden J, Biering-Sorensen F . Reproducibility and validity of a questionnaire filled in by spinal cord lesioned individuals before regular follow-up. Spinal Cord 2001; 39: 161–167. Altman DG . Practical Statistics For Medical Research. Chapman and Hall: London, 1991. Walter JS, Sacks J, Othman R, Rankin AZ, Nemchausky B, Chintam R et al. A database of self-reported secondary medical problems among VA spinal cord injury patients: its role in clinical care and management. J Rehabil Res Dev 2002; 39: 53–61. Gray M, Rayome R, Anson C . Incontinence and clean intermittent catheterization following spinal cord injury. Clin Nurs Res 1995; 4: 6–18. Wyndaele JJ, Madersbacher H, Kovindha A . Conservative treatment of the neuropathic bladder in spinal cord injured patients. Spinal Cord 2001; 39: 294–300. Lin KH, Chuang CC, Kao MJ, Lien IN, Tsauo JY . Quality of life of spinal cord injured patients in Taiwan: a subgroup study. Spinal Cord 1997; 35: 841–849. Vaidyanathan S, Soni BM, Sett P, Singh G, Oo T, Hughes PL et al. Flawed trial of micturition in cervical spinal cord injury patients: guidelines for trial of voiding in men with tetraplegia. Spinal Cord 2003; 41: 667–672. We wish to thank secretary Lisbeth Nielsen, Clinic for Spinal Cord Injuries, for all her technical and practical assistance during the project. This study was carried out as part of the primary author's PhD study, which was financed by the Medicon Valley Academy and Coloplast A/S.
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