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REVIEW ARTICLE
Year : 2023 | Volume
: 34
| Issue : 1 | Page : 3-9
Clinical guidelines of patient-centered bladder management of neurogenic lower urinary tract dysfunction due to chronic spinal cord injury-part 1: Pathophysiology, treatment strategy, and priority
Yi-Jhou Chen1, Shih-Hsiu Lo2, En Meng3, Jing-Dung Shen4, Eric Chieh-Lung Chou5, Sheng-Fu Chen6, Ming-Huei Lee7, Chao-Yu Hsu8, Hueih-Ling Ong9, Jian-Ting Chen10, Sung-Lang Chen11, Yun-An Tsai12, Chih-Chieh Lin13, Shu-Yu Wu14, Bin Chiu15, Hann-Chorng Kuo15
1 Department of Urology, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
2 Department of Urology, Taipei Medical University Hospital, Taipei, Taiwan
3 Division of Urology, Department of Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
4 Division of Urology, Department of Surgery, Taichung Armed Forces General Hospital, Taichung; National Defense Medical Center, Taipei, Taiwan
5 Department of Urology, School of Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
6 Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
7 Department of Urology, Miaoli General Hospital, Ministry of Health and Welfare, Miaoli, Taiwan
8 Division of Urology, Department of Surgery, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan
9 Department of Urology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
10 Division of Urology, Department of Surgery, Yuanlin Christian Hospital, Changhua, Taiwan
11 Department of Urology, School of Medicine, Chung Shan Medical University Hospital, Chung Shan Medical University, Taichung, Taiwan
12 Division of Neural Regeneration and Repair, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
13 Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan
14 Department of Urology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei; Department of Urology, School of Medicine, Tzu Chi University, Hualien, Taiwan
15 Department of Urology, Far Eastern Memorial Hospital, New Taipei City, 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_115_22
This article presents the current evidence and expert opinions on the patient-centered bladder management of neurogenic lower urinary tract dysfunction (NLUTD) for patients with chronic spinal cord injury (SCI) in Taiwan. This review article focuses on the pathophysiology, treatment strategies, and priorities of bladder management in patients with chronic SCI. The main problems of SCI-NLUTD are storage failure, voiding failure, and combined retention and voiding failure. The priorities in the management of SCI-NLUTD are as follows in order of importance: (1) preserving renal function, (2) preventing urinary tract infection, (3) achieving efficient bladder emptying, (4) avoiding indwelling catheter use, (5) obtaining patient agreement with management, and (6) avoiding medication after proper management. Management of NLUTD in SCI patients should be based on urodynamic study findings rather than inferences from neurologic evaluations. Conservative treatment and bladder management by clean intermittent catheterization should be the first-line option. When surgical intervention is necessary, less invasive types of surgery and reversible procedures should be considered first and any unnecessary surgery in the lower urinary tract should be avoided.
Keywords: Guidelines, lower urinary tract dysfunction, neurogenic bladder, spinal cord injury
Neurogenic lower urinary tract dysfunction (NLUTD) refers to conditions in which damage to the central nervous system or peripheral nerves causes the urine bladder and urethra to malfunction. NLUTD in patients with chronic spinal cord injury (SCI) is notably difficult to manage. Patients with SCI may have had a problem emptying their urine due to detrusor overactivity or urethral sphincter incompetence; failure to empty the bladder due to detrusor areflexia, detrusor underactivity, bladder neck dysfunction (BND), or detrusor sphincter dyssynergia (DSD); or a combined failure to retain and void urine as a result of to DSD/detrusor hyperreflexia and inadequate contractility.[1],[2] Autonomic dysreflexia, reduced bladder compliance, upper urinary tract injury, considerable morbidity, and sporadic mortality are all results of NLUTD in SCI patients. NLUTD in SCI patients not only imposes a considerable disease burden on patients but also negatively affects their quality of life (QoL), self-esteem, and family relationships.[3]
The main objectives of therapy and treatment for NLUTD have been well discussed, including protection of the kidneys from progressive damage, preservation of renal function, and reduction of urinary incontinence to enhance the patient's QoL.[4],[5] Based on the results of urodynamic examinations, each patient's course of treatment should be unique and take into account their level of disability, physical and mental health, and urinary tract function.[6],[7] The purpose of these clinical guidelines is to provide information on the pathophysiology, treatment strategy, and priority of bladder management for chronic SCI patients with NLUTD. These recommendations should help doctors manage patients with chronic SCI and NLUTD using a patient-centered approach.
Classification of Neurogenic Lower Urinary Tract Dysfunction and Spinal Cord Injury SeverityPrevious classifications of NLUTD included the Bors and Comarr neurological classifications.[8],[9] In the storage and voiding stages, detrusor and urethral dysfunction are similarly classified as NLUTD by the International Continence Society.[10] Most of the presently used classifications of SCI-NLUTD are based on bladder and urethral dysfunction. A clinically useful classification of NLUTD should help physicians in the management of patients. Chen et al. observed a large group of chronic SCI patients in a clinical setting and discovered that detrusor areflexia might occur at any degree of SCI, while detrusor overactivity and DSD were only observed in thoracic or lumbar SCI.[11] The incidences of neurogenic detrusor overactivity, DSD, and autonomic dysreflexia are significantly higher in patients with higher SCI levels, whereas detrusor underactivity or areflexia is more frequently observed in lumbar SCI than in thoracic SCI [Table 1].[12],[13] Lower urinary tract dysfunction cannot be classified using neurological classification systems like the International Criteria for the Neurological Classification of SCI.[14] As a result, in any particular patient, the description of NLUTD should be individualized. The most popularly used classification is the EAU-Madersbacher classification system, which categorizes NLUTD based on the combination of detrusor dysfunction (normoactive, overactive, or underactive) and urethral sphincter dysfunction (normoactive, overactive, or underactive).[15] When deciding on treatment objectives and plans, practitioners can use this classification of NLUTD to better understand bladder and bladder outlet abnormalities.
Table 1: The level of spinal cord injury and vesicourethral dysfunction[11]Recommendations
The classification of chronic SCI patients should be based on different bladder and bladder outlet dysfunctions, rather than simply by anatomical level or completeness of SCI.Clinicians' decisions for bladder treatment and long-term surveillance will be aided by the classification of SCI. Pathophysiology of Neurogenic Lower Urinary Tract Dysfunction in Patients with Chronic Spinal Cord Injury of Different Levels and CompletenessIn addition to urinary incontinence due to neurogenic detrusor overactivity, SCI patients typically have voiding dysfunction due to BND when the injury level is above T6–T8, DSD when the level is above S2, and detrusor areflexia if the level is below S4 and at the cauda equina.[15] Urinary urgency or incontinence, difficulties voiding or retention, decreased bladder compliance, and upper urinary tract injury are all frequently linked to NLUTD.[3] SCI patients may experience lower urinary tract symptoms such as urgency and urgency urinary incontinence. Urinary retention and challenging bladder emptying may also be seen in some BND and DSD individuals.[16],[17],[18] In patients with a complete SCI at T6-S2 levels, involuntary detrusor overactivity without sensation and DSD usually develop.[19] Detrusor areflexia with persistent residual urethral sphincter tone that is not under voluntary control results in difficult urination in the majority of patients with SCI below S2.[20] To urinate and empty their bladders, patients must use abdominal straining, the Crede maneuver, or clean intermittent catheterization (CIC).[21] Patients with suprasacral cord lesions may have neurogenic detrusor overactivity and DSD causing dysuria and retention, whereas patients with lesions of the sacral conus medullaris have detrusor areflexia and low urethral sphincter tone, leading to urinary incontinence.[22] The vesicourethral dysfunction in chronic SCI patients also demonstrated the same trend in our previous study[23][Table 2]. When there are lesions at any level in a chronic SCI patient, low bladder compliance may emerge. Patients with complete SCI are likely to have smaller maximum cystometric capacity and volume at the first involuntary contraction.[24]
Table 2: The videourodynamic study diagnosis among patients with spinal cord injury and different injury levels[23]Recommendations
Patients with NLUTD and SCI may encounter various detrusor and external sphincter dysfunctions, which can cause symptoms of the lower urinary tract, a small bladder capacity, and involuntary detrusor contractions.
Priority and Principles of Bladder Management in Chronic Spinal Cord Injury PatientsThe priorities in the management of SCI-NLUTD should be the following in order of importance: (1) preservation of renal function, (2) prevention of urinary tract infection (UTI), (3) effective bladder emptying, (4) avoidance of indwelling catheters, (5) patient agreement with management, and (6) avoidance of medication after proper management.[25] Urinary incontinence can further lower QoL, which is linked to a considerable decline in QoL in neurogenic disorders.[26] SCI patients have higher degrees of depression than the healthy population, and this is closely related to gender and the ability to perform self-catheterization.[27] After discharge, less than half of SCI patients are thought to have adequate bladder management abilities.[28] As a result, there is a need to increase patient awareness of the urological complications of NLUTD, and to educate physicians about treatment strategies for NLUTD. It is crucial to understand the patient's voiding function before selecting a certain bladder management strategy or surgical procedure.
Recommendations
The principal goals of managing NLUTD in SCI patients are preserving renal function and keeping good QoL by reducing urological complications.Treatment of SCI patients should take into account the patient's acceptance and expectations in addition to the disease.An urodynamic study at baseline is essential and regular follow-up is needed. Changes in Bladder Function over Time in Chronic Spinal Cord Injury PatientsThe bladder function in patients with chronic SCI will change with time.[29] In patients with chronic SCI, an increase in injury duration was related to better satisfaction and fewer bladder symptoms.[30] Urothelial dysfunction after SCI may have hampered the permeability of the urothelial barrier and its sensory function. Changes in the morphology of the urothelium have also been identified, including the disappearance of apical cell disorganization of cell layers, and reduction of cellular volume.[31] The urothelium of SCI patients has higher levels of sensory receptors such as the transient receptor potential vanilloid receptor 1 and purinergic receptor (P2 × 2), which improves responses to adenosine triphosphate.[32] The barrier function proteins, E-cadherin and uroplakin III, are significantly reduced in SCI involving the bladder.[33]
Annual follow-up of renal function through blood tests and sonography is necessary. High-risk patients, such as those with hydronephrosis, recurrent pyelonephritis, and severe urine incontinence, require urodynamic investigations, particularly videourodynamic studies.
Recommendations
The bladder function of patients with chronic SCI changes with time.Additionally, SCI patients' bladder urothelium changes over time and reduced barrier function may make them more susceptible to bacterial infection.Annual follow-ups of the bladder function and upper urinary tract condition are essential. Management Goals Regarding Voiding Dysfunction in Neurogenic Lower Urinary Tract Dysfunction of Chronic Spinal Cord Injury PatientsThe main issues associated with NLUTD in chronic SCI patients are storage failure, voiding failure, and combined storage and voiding failure. As a result, there is a decrease in bladder compliance in the lower urinary tract, associated with upper urinary system injury, severe morbidity, and infrequently, fatality. NLUTD imposes a considerable disease burden on patients and adversely affects their QoL, self-esteem, and family relationships.[3] Treatment priorities and tactics should be adaptable and focused on reducing NLUTD, addressing issues, and enhancing the QoL. The ability of the patient to store and empty urine, as well as the absence of long-term urological sequelae, must be satisfied with the treatment's outcomes.
The goals of management are to achieve urinary continence, enhance QoL, prevent UTIs, control calculus formation, and maintain upper urinary tract function.[15] The primary goals of treatment for NLUTD include: (1) correcting urinary tract complications, such as hydronephrosis, vesicoureteral reflux (VUR), UTI, and a contracted bladder; (2) lowering storage intravesical pressure and controlling or alleviating symptoms, including incontinence and difficult urination;[21] and (3) enhancing QoL in urination, treating urinary incontinence and difficult urination, improving bladder emptying, and preventing indwelling catheters and UTI.[34],[35] Suprapubic cystostomy, indwelling urethral catheter, and CIC or clean intermittent self-catheterization (CISC) are all viable treatment choices.[36] For properly selected NLUTD patients who need a chronic indwelling catheter, clinicians should recommend suprapubic catheterization over an indwelling urethral catheter.[37] For SCI patients with NLUTD and failure to urinate, techniques such as triggered reflex voiding, alpha-blocker medication, botulinum toxin A (Botox) urethral sphincter injection, transurethral incision of the bladder neck (TUI-BN), and external sphincterotomy are appropriate.[15],[37] Patients with detrusor underactivity and chronic urine retention could also benefit from bladder outlet methods such as urethral sphincter Botox injection or TUI-BN.[38],[39] Detrusor and sphincter dysfunction must be identified using a videourodynamic investigation. An individualized strategy is mandatory for SCI patients with NLUTD.[40]
Recommendations
CIC, indwelling urethral Foley catheter, and suprapubic cystostomy are feasible management options for SCI patients with voiding dysfunction.In SCI patients with NLUTD, bladder outlet surgery or urethral sphincter Botox injection may help patients urinate on their own. Treatment Strategy for Neurogenic Lower Urinary Tract Dysfunction and Clean Intermittent Catheterization in Chronic Spinal Cord Injury PatientsUrinary catheterizations, including CIC, CISC, and indwelling catheters, are the most common treatments for NLUTD.[37] According to the recommendations, CIC is the most secure technique for managing the bladder in terms of protecting the kidneys.[41] In a study, approximately three-quarters of the SCI patients with NLUTD had indwelling catheters, showing that short- or long-term indwelling catheters were needed in a majority of patients who were unsuitable for CIC.[42] CIC is more effective at maintaining bladder compliance and avoiding upper urinary tract problems linked to low compliance.[43] The preferred technique is aseptic intermittent catheterization. However, it is impractical and inconvenient for SCI patients with NLUTD to conduct sterile CIC/CISC several times daily for bladder management. The urologist Jack Lapides first used the term “clean” to characterize intermittent catheterization in 1972. He detailed a clean approach for carrying out the treatment and hypothesized that reusing nonsterile but clean catheters would not raise the incidence of UTIs.[44] However, SCI patients should be well instructed on the correct clean method and the risks of CIC/CISC.
Less frequent catheterization results in higher catheterization volumes and a higher risk of UTI.[45],[46] The safe bladder volume for CIC should be assessed by urodynamic study. About 4–6 times per day on average, catheterizations are performed. Cross-infections and other problems may become more likely with more frequent catheterizations.[45],[47],[48] A recent survey revealed that there is a shift toward bladder evacuation by CISC during hospitalization, and suprapubic cystostomy after primary rehabilitation. The gold standard procedure for SCI patients, bladder evacuation by CISC, is less common in people > 65 or in those with severe tetraplegia.[48] In SCI patients who desire spontaneous voiding, the reduction of bladder outlet resistance should be considered. Although urine incontinence and concomitant detrusor overactivity are frequently unavoidable, patients should be made aware of the discomfort of wearing a condom catheter or diaper. Because the diagnosis and management of SCI-NLUTD are complex, clinical practice recommendations on the treatment of patients with NLUTD are mandatory. Additionally required for bladder treatment is a patient-centered guideline.[23]
Recommendations
Treatment strategies for SCI patients and priority should be flexible and aimed at relieving NLUTD, resolving complications, and enhancing QoL.CIC ought to be utilized as the first line of treatment for SCI patients who are unable to urinate.Patients should be instructed regarding the catheterization technique, associated behavior modifications, and risks related to CIC, using a multidisciplinary approach if possible. Modification of Bladder Management According to the Need and Ability of Spinal Cord Injury PatientsConservative management is the mainstay of urological treatment for NLUTD in chronic SCI patients. Abdominal stimulation (induced reflex voiding), the Crede maneuver, or abdominal straining can all be used to urge patients to urinate (Valsalva).[49],[50] In patients with poor hand function and urinary incontinence, an external appliance to collect urine is feasible. In patients with tetraplegia and those who are bedbound, an indwelling urethral Foley catheter or suprapubic cystostomy may be an option to long-term indwelling catheters.[43],[51],[52],[53],[54] Patients should be informed of the possibility of voiding function recovery, risk of UTI, and possible upper urinary tract damage of individual bladder management.[55] Additionally, the Crede and Valsalva maneuver ought to be avoided in SCI patients who have bladder outlet obstruction, DSD, VUR, hydronephrosis, etc., A multidisciplinary approach is warranted, which will involve: (1) the cooperation of the physician, nurses, occupational therapists, and social workers; (2) sufficient knowledge of SCI and NLUTD; (3) the ability to conduct neurological and urological assessment for the patient; (4) ability to identify risk factors for upper urinary tract damage; (5) allowing a patient-centered knowledge transfer; and (6) offering inpatient and outpatient bladder management and urinary tract surveillance programs.
Recommendations
Bladder management should be modified according to the need and abilities of SCI patients.Except in cases of tetraplegia, long-term indwelling catheterization should be avoided.Education and training regarding bladder management are necessary to obtain good bladder emptying.Regular long-term urinary tract surveillance is imperative even in those thought to be in “stable” condition. Patient Satisfaction with Bladder Management by DoctorsSpontaneous voiding with and without triggered voiding and/or bladder expression has shown to be less safe except in well-defined patients with regular urological follow-ups.[56] In a study, more patients used CIC/CISC to empty the bladder with SCI duration of fewer than 5 years, but more patients used an indwelling catheter or cystostomy when the SCI duration was more than 5 years.[57] Nearly one-third of the 1114 patients with SCI who underwent a 10-year follow-up were male and on CIC at the time of discharge, but only 8% and 5% of them were still on it at the end of those time periods.[58] In another study of 100 SCI patients with an 11-year follow-up, 47.8% of patients using CIC changed to urethral or suprapubic catheters.[59] The decision to use an indwelling catheter and cystostomy was made due to chronic urinary incontinence, recurrent UTIs and hydronephrosis, inconveniences in everyday life at work, tetraplegia, and the lack of a carer. A study demonstrated that CISC is associated with a lower UTI rate than the indwelling urethral catheter.[60] Patients with paraplegia and tetraplegia who void may have impaired bladder function, in contrast to SCI patients who showed improved bladder symptoms when using indwelling catheters. After surgery, SCI patients had enhanced satisfaction with urinary function compared to those who underwent CIC in the paraplegia and tetraplegia groups.[61]
Recommendations
There is no ideal bladder care, only what is most appropriate for each SCI patient's unique set of limitations.Surgical interventions to improve bladder storage and bladder emptying (including urinary diversion) are beneficial for reducing bladder symptoms and achieving patient satisfaction.Compared to the indwelling catheter, CIC is associated with a lower rate of UTIs. ConclusionPatients suffering from SCI would have a significant change in his or their life, and the associated complications also influence their economic burden. Although current medical technology could not help them to go back to their previous healthy life. The goals to help the SCI patients were to (1) prevent upper urinary tract damage, (2) control calculus formation, and (3) maintain good QoL by reducing the urological complications. As a result, numerous techniques have been created to improve the voiding condition of SCI patients, including catheterization, TUI-BN, external sphincterotomy, Botox injections, and more invasive procedures such augmentation enterocystoplasty. Although there are many methods to treat NLUTD for SCI patients, their methods focus on decreasing the damage to the upper urinary tract, and patients still require CIC to empty the bladder. Well communication with SCI patients about the benefit and drawbacks of treatment is crucial when we decide to treat NLUTD for them. If possible, long-term indwelling catheterization was recommended to avoid. Only the most suitable bladder management is given, SCI patients can have long-term benefits, fewer urological complications, and a good QoL.
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. En-Meng, Eric Chieh-Lung Chou, and Hann-Chorng Kuo, editorial board members at Urological Science, had no roles 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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