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REVIEW ARTICLE
Year : 2023 | Volume
: 34
| Issue : 4 | Page : 170-175
Clinical guidelines of patient-centered bladder management of neurogenic lower urinary tract dysfunction due to chronic spinal cord injury – Part 4: Patient risk, bladder management, and active surveillance
Lin-Nei Hsu1, Jia-Fong Jhang2, Yin-Chien Ou3, Yao-Chi Chuang4, Mei-Yu Jang5, Cheih-Wen Chin6, Yung-Shun Juan7, Min-Hsin Yang8, Wei-Yu Lin9, Hsin-Ho Liu10, Jian-Ri Li11, Hann-Chorng Kuo2
1 Department of Urology, An Nan Hospital, China Medical University, Tainan, Taiwan
2 Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
3 Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
4 Department of Urology, Kaohsiung Chang Gang Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
5 Department of Urology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
6 Department of Urology, Feng Shan Lee Chia Wen Urologic Clinic, Kaohsiung, Taiwan
7 Department of Urology, Kaohsiung Medical University Hospital and College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
8 Department of Urology, Chung Shan Medical University Hospital, Taichung, Taiwan
9 Department of Urology, Chung Gung Memorial Hospital, Chiayi, Taiwan
10 Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
11 Department of Urology, Taichung Veterans General Hospital, Taichung, Taiwan
Correspondence Address:
Hann-Chorng Kuo
Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 707, Section 3, Chung-Yang Road, Hualien 97002
Taiwan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_117_22
Urological complications are common in patients with chronic spinal cord injury (SCI). Inappropriate bladder management may result in high voiding pressure, low bladder compliance, large postvoid residual urine volume, and recurrent urinary tract infections. Thus, long-term surveillance of high-risk patients with SCI is required to avoid urological complications and improve the quality of life. Herein, the current evidence and expert opinions on patient-centered bladder management of neurogenic lower urinary tract dysfunction (NLUTD) in patients with chronic SCI in Taiwan are presented. Regular physical and urological examinations should be performed in patients with SCI depending on their risk of upper urinary tract deterioration. For patient with SCI who have received different bladder management and surgical intervention, education on proper bladder emptying and regular surveillance are mandatory. It is critical to identify high-risk patients to prevent renal functional deterioration in those with chronic SCI-induced NLUTD. Thus, annual active surveillance of bladder and renal function is required, particularly in high-risk patients with SCI.
Keywords: Guidelines, lower urinary tract dysfunction, neurogenic bladder, spinal cord injury
Neurogenic lower urinary tract dysfunction (NLUTD) refers to the urinary bladder or urethral dysfunction caused by lesions of the central nervous system or peripheral nerve. NLUTD is the most difficult disorder to manage in patients with spinal cord injury (SCI).[1] Patients with SCI might have urinary incontinence due to detrusor overactivity (DO) or urethral sphincter incompetence; urinary retention due to detrusor areflexia (DA), detrusor underactivity, bladder neck dysfunction or detrusor sphincter dyssynergia (DSD); or combined urinary incontinence and retention due to DSD or detrusor hyperreflexia and inadequate contractility.[2],[3] Although NLUTD in SCI may not always cause decreased bladder compliance, it may result in upper tract damage, significant morbidity, and occasionally death. NLUTD imposes a significant disease burden on patients with SCI and negatively impacts their quality of life (QoL), self-esteem, and family relationships.[4]
The main goals of NLUTD treatment are protection from kidney injury, improvement of renal function, elimination of recurrent urinary tract infection (UTI), facilitation of complete bladder emptying, and reduction of urinary incontinence severity to improve patients' QoL.[5],[6] Bladder management or surgical intervention should be based on urodynamic findings and tailored to each patient's disability, mental and physical conditions, urinary tract dysfunction status, and preferences.[7],[8]
Herein, the clinical guidelines have been elaborated to aid in the selection of patients with high-risk SCI, selection of appropriate bladder management to avoid urological complications, the management of bladder overactivity, and monitoring of patients with NLUTD who have chronic SCI. These guidelines may help physicians manage patients with chronic SCI and NLUTD by determining the patient's clinical condition and preference.
Selecting High-Risk Patients with Spinal Cord Injury in Health SurveillanceRenal function deterioration, vesicoureteral reflux (VUR), UTI, urolithiasis, urothelial cancer, and urethral injury are potential complications in patients with chronic SCI.[9],[10],[11],[12],[13] Urodynamic findings, rather than inferences from the anatomical level or lesion completeness, must be used to manage urinary tract complications in patients with SCI.[14],[15] Preservation of renal function, prevention of UTI, and efficient bladder emptying should be the top priorities in neurogenic voiding dysfunction management.[16] Patients with complete neurological lesions, cervical SCI-induced paraplegia, a prolonged indwelling catheter (>3 months), a high detrusor leak point pressure (DLPP), DSD and acontractile detrusor (ACD), large postvoid residual (PVR) volume (>400 mL), and VUR should be screened. The SCI level is not associated with VUR.[10] Furthermore, DLPP >40 cm H2O jeopardizes the upper urinary tract.[17],[18] Patients with SCI who have low bladder compliance, an indwelling urethral catheter, bladder deformity, comorbidities, a history of surgical intervention, or a different injury level may be at risk for urological complications. Thus, renal and bladder sonography and complete medical history should be obtained and urodynamic examination should be performed at the earliest. The main goals of NLUTD management are to correct urological complications, lower intravesical pressure, and improve the voiding-associated QoL. In addition, each patient should be evaluated and managed using an individualized strategy.[19]
Recommendations
Renal function deterioration, VUR, UTI, urolithiasis, urothelial cancer, and urethral injury are potential complications in patients with chronic SCI.Patients with SCI due to cervical cord lesions, chronic indwelling catheter, high DLPP, DSD, ACD, large PVR, and VUR are at a high risk of developing urological complications and thus, should be regularly screened.Renal function must be evaluated annually via blood tests and sonography. Urodynamic studies, particularly video urodynamic studies (VUDS), are required in patients with high-risk conditions, such as hydronephrosis, recurrent pyelonephritis, and severe urinary incontinence. Long-Term Urological Complications in Patients with Chronic Spinal Cord InjuryThe overall complication rate is high in patients with chronic SCI, and urological complications are common. The most common complication is symptomatic UTI (>1 episode/year) which is characterized by pyuria or positive urine cultures and symptoms such as fever, flank pain, hematuria, and exacerbated bladder symptoms.[19],[20],[21],[22] The other commonly reported complications include bladder stone, hydronephrosis, and VUR.[19],[20] Most complications initially occur during the first 25 years following injury. Complications, especially UTI and renal insufficiency, are linked to the male sex, cervical injury, and condom catheter use.[23] The occurrence of symptomatic UTI and hydronephrosis do not differ significantly across SCI levels.[19] However, severe urinary incontinence is common in patients with cervical and thoracic SCI than in those with lumbar SCI; urolithiasis is more common in patients with sacral SCI.[20] Patients with clean intermittent catheterization (CIC) or spontaneous voiding without catheter have a significantly lower rate of UTI than patients with indwelling urethral, suprapubic, or condom catheterization.[24] Old age, male sex, cervical SCI, and in-home support services are associated with high UTI rates. The most common cause of UTI is an indwelling catheter, followed by CIC, pads/condoms, and spontaneous voiding.[19],[21],[24] The risk of UTI-associated hospitalization is three times higher with an indwelling catheter than with spontaneous voiding.[22] In patients with traumatic SCI, botulinum toxin A (Botox) injection to the detrusor significantly reduces UTIs.[25],[26] There is a high risk of bladder stones developing in patients with indwelling catheters.[26] The type of voiding dysfunction and SCI level are closely, but not completely, correlated.[14],[27] DLPP >40 cmH2O endangers the upper urinary tract.[17],[18] Thus, it is critical to screen patients with SCI at high risk of developing urological complications. High-risk patients with SCI should undergo regular urodynamic studies; poor bladder compliance and high DLPP are risk factors for upper urinary tract deterioration. A DO period to filling phase period ratio of ≥33% may indicate rapidly progressing renal deterioration.[28]
Recommendations
UTI, upper urinary tract damage, and urolithiasis are common long-term urological complications in patients with chronic SCI.Compared to CIC or clean intermittent self-catheterization (CISC), an indwelling urethral catheter is associated with a higher risk of UTI.An indwelling catheter increases the risk of developing bladder stones. Relationship of Inappropriate Bladder Management with Urinary Tract Infection and HydronephrosisPatients with DSD, low bladder compliance, and high intravesical pressure at end-bladder filling are at an increased risk of developing renal failure.[29] Furthermore, chronic renal disease is more common in patients with paraplegia than in the general population.[30] In patients with DSD and an indwelling catheter, CIC should be performed or spontaneous urination should be monitored annually to prevent the development of renal failure. CIC is superior to other bladder management methods for preserving bladder compliance and preventing low-compliance-associated upper tract complications.[14] The safe bladder volume for CIC should be regularly measured through urodynamic studies to prevent the development of a low-compliance high-pressure bladder, which can cause recurrent UTI or hydronephrosis. Indwelling transurethral and suprapubic catheterization should be used only in exceptional cases and should be closely monitored; additionally, the catheter should be changed frequently. Suprapubic catheterization is superior to urethral catheterization in patients who require chronic indwelling catheters. The UTI and hydronephrosis frequency do not vary with disease duration, implying that urological complications can occur at any stage following SCI.[20] Inappropriate bladder management may lead to recurrent UTI and hydronephrosis; therefore, patients should be regularly assessed for lower urinary tract dysfunction.[22],[23] Appropriate antibiotics should be administered based on urine culture results in patients with febrile UTI. However, asymptomatic bacteriuria does not require treatment. If urodynamic studies in patients with recurrent UTI reveal a high intravesical pressure, large PVR, VUR, contracted bladder, or other lower urinary tract abnormalities, medications or surgical interventions that lower intravesical pressure and increase bladder capacity or an anti-reflux procedure should be implemented.
Recommendations
To facilitate bladder emptying in patients with SCI and chronic urinary retention, CIC is superior to a suprapubic or indwelling urethral catheter.Inappropriate bladder management may lead to recurrent UTI and hydronephrosis. Therefore, patients should be regularly assessed for lower urinary tract dysfunction.Repeated urodynamic studies and constant urinary drainage should be considered for patients with impaired bladder storage and upper urinary tract deterioration. Education on Appropriate Self-Care and Bladder Management for Patients with Chronic Spinal Cord InjuryThe goals of bladder management are the protection of the upper urinary tract, maintenance of lower urinary tract function, achievement of urinary continence, and providing adequate bladder emptying.[31] QoL is also important in the treatment strategy for NLUTD in patients with chronic SCI. Patients with chronic SCI should be educated about the following issues: (1) NLUTD is one of the most troublesome complications that can lead to serious deterioration, such as renal failure, and negative impacts on the patient's QoL.[4] (2) Patients' agreement with the management modality, hand function, self-care capability, and social, economic, and family support, should be considered.[32] (3) Patients' life expectancy may reduce if optimal medical care is unavailable.[33] (4) Patients with SCI need long-term or even life-long care to maximize their life expectancy and QoL. (5) Early detection and proper treatment are essential to prevent upper and lower urinary tract damage. (6) Individualized multidisciplinary bladder management is required to meet patents' needs. (7) Advantages and disadvantages of each bladder management method and self-care issues should be explained.
Although intravesical Botox injection produces highly satisfactory results in patients with neurogenic DO, CIC is still required for bladder evacuation in > 70% of patients.[34] Patients in Asian countries may not accept this treatment modality because their living conditions and social support are not as good as those in Western countries.[35] Given that patients with NLUTD are relatively young, the morbidity and mortality associated with the disease could significantly impact patients, caregivers, and society in general. Adequate medical interventions and social support strategies are essential. Although the guidelines of the European Urological Association, American Urological Association, and International Continence Society provide bladder management strategies for patients with SCI, they should be tailored to the patient's socioeconomic adaptation, burden of self-care, and medical care resources.[36] To provide healthcare decision-makers the best approach to manage NLUTD, periodic and comprehensive updates of evidence from both traditional and novel interventions are required. In addition, the patient's sexual and reproductive functions should not be overlooked.
Recommendations
Bladder management following SCI is an ongoing set of treatments and practices. Regular urological examinations are necessary to determine the optimal bladder management.Patients with SCI should be counseled that optimal bladder management can keep the bladder and kidney healthy and free of UTI and other complications.Each type of bladder management has its advantages and disadvantages, and it should be selected in an individualized, holistic, and multidisciplinary manner. Active Bladder Management and Risk Factors of Patients With Spinal Cord Injury and Neurogenic Lower Urinary Tract DysfunctionPatients with chronic SCI may develop urological complications such as UTI, urolithiasis, hydronephrosis, VUR, bladder cancer, and renal failure.[23] In patients with NLUTD, bladder, and urethral dysfunction evolve. Changes in bladder management, such as switching from an indwelling urethral catheter to a CIC or CISC, may reduce the risk of urological complications.[21] If patients with complete neurological lesions, cervical SCI with tetraplegia, and prolonged indwelling catheters are not properly monitored, their renal function may deteriorate.[29] Thus, these patients should be regularly monitored for lower urinary tract dysfunction; any urological complications should be promptly treated appropriately. Avoiding the use of a chronic indwelling catheter can lower the risk of developing a low-compliance bladder. A long-term antimuscarinic therapy has been shown to reduce urinary incontinence and lower intravesical pressure. Intravesical instillation of vanilloid and Botox injections is alternative to bladder augmentation for refractory DO or low-compliance bladders.[37] When surgery is required, less invasive surgeries and reversible procedures should be considered first; unnecessary lower urinary tract surgeries should be avoided. Maintaining healthy bladders and urethras without interfering with the neuromuscular continuity allows patients with NLUTD to experiment with new technologies in the future. Improving the QoL in patients with NLUTD is the most important aspect of treatment. Patients with NLUTD should be classified as low-, moderate-, high-, or unknown-risk. Patients should be monitored at regular intervals after diagnosis and risk-based stratification.[38] Physicians should be cautious of patients with a high-risk of developing urological complications; active bladder management should be initiated to reduce the likelihood of such complications.
Recommendations
Patients with SCI who are at a high risk of developing urological complications should be carefully monitored and actively managed.The correlation of SCI lesions and urodynamic findings is not static.Bladder management should rely on clinical and urodynamic studies.When it comes to bladder management, choose a conservative or minimally invasive procedure first. Active Surveillance of Urinary Tract Function in Patients with Chronic Spinal Cord InjuryNLUTD should be diagnosed on the basis of neurological lesions and somatic and visceral dysfunction. Medical comorbidities can affect lower urinary tract functions.[39] The diagnostic procedures should include the following: (1) general, neurological, and systemic disease history; (2) specific, urinary, bowel, sexual, and neurological history; (3) physical, general, and neuro-urologic examination; (4) specific neuro-urologic examination, including bilateral sensations from S2-S5, reflexes, anal sphincter tone, and volitional contraction of the anal sphincter and pelvic floor; (5) laboratory tests; and (6) urodynamic study.
Urological surveillance aims to assess the urinary tract's functional and anatomical status following NLUTD. Laboratory tests such as urinalysis, urine culture, renal function tests, glomerular filtration rate, renal ultrasound to detect hydronephrosis or renal scarring, renal scans, voiding cystourethrography, cystoscopy, urodynamic studies, and VUDS should be performed. In patients with NLUTD, VUDS is the gold standard method for invasive urodynamics. VUDS can detect bladder and urethral dysfunction, as well as lower and upper urinary tract morphology.[17],[40],[41] DO is in significantly more patients with cervical and thoracic SCI than in those with lumbar or sacral SCI; DA is found in significantly more patients with lumbar SCI. DSD is found in 61% of patients with cervical SCI, whereas ACD is found in 38.7%.[19] Although patients with NLUTD can be appropriately diagnosed and treated, all patients should be monitored for the rest of their lives to avoid the development of urological complications and untoward lower urinary tract symptoms[42],[43],[44][Table 1].
Table 1: Classification of risk in patients with chronic spinal cord injuryRenal function is an important consideration in the treatment of NLUTD, particularly in patients with chronic SCI. Patients with DSD, hydronephrosis, trabeculated bladder, low-compliance bladder, VUR, high DLPP, recurrent UTI (>2 episodes/year), increased PVR, prolonged detrusor contraction, low reflex volume, and high intravesical pressure at end-bladder filling are at an increased risk of developing renal failure.[45] Chronic renal disease is more common in patients with paraplegia and neural tube defects than in the general population.[30] Bladder management has an impact on bladder compliance which evolves. Patients with CIC have a significantly higher rate of normal compliance than those with Foley's catheters. CIC is the best method for maintaining bladder compliance and avoiding low-compliance-associated upper urinary tract complications.[4] In patients with DSD and an indwelling catheter, CIC should be performed or spontaneous urination should be monitored for annually to avoid renal failure. In the long-term management of NLUTD, oral antimuscarinic agents or intravesical Botox injections may provide a low-pressure bladder and preserve renal function.[6] Urinary tract functions must be monitored annually in patients with chronic SCI.[45] Routine screening for asymptomatic bacteriuria in patients with chronic SCI has no benefit.[46] However, active monitoring of renal function through serum creatinine levels[47] and upper urinary tract through ultrasound, intravenous pyelography (IVP), or voiding cystourethrography is recommended annually.[48] Although urodynamic studies are not necessary as routine surveillance, they are recommended in high-risk patients with SCI.[45],[49]
Recommendations
Active surveillance of urinary tract function in patients with chronic SCI aims to prevent upper urinary tract deterioration, achieve or maintain urinary continence, restore lower urinary tract function, improve patient QoL, and avoid urological complicationsAnnual active surveillance of renal and bladder functions is recommended, including physical examination, ultrasound imaging of the upper urinary tract, estimation of serum creatinine levels, and regular follow-up urodynamic studies, for high-risk patientsRoutine urinalysis is not recommended for patients with asymptomatic bacteriuria. ConclusionThe lower urinary tract is at risk for complications in patients with chronic SCI due to NLUTD. Voiding dysfunction, recurrent UTI, VUR, urolithiasis, bladder cancer, and renal failure should be detected during follow-ups in patients with chronic SCI. These clinical guidelines demonstrate that patients with SCI should be stratified based on risk level and treated according to personalized evaluation of voiding and chosen method of bladder management. In addition, these guidelines can be added to the mandatory clinical patient care of the disease in Taiwan.
Data availability statement
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
Financial support and sponsorship
This study was funded by TCMF-MP 110-03-01 (111), Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.
Conflicts of interest
Dr. Yao-Chi Chuang, Yung-Shun Juan, Jian-Ri Li and Hann-Chorng Kuo, an editorial board member at Urological Science, had no role in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.
References
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