Bladder management in individuals with spinal cord injury or disease during and after primary rehabilitation: a retrospective cohort study

Timing of urological management during post-acute spinal cord injury rehabilitation

OBJECTIVES

To provide a population-based description of the timing and indicators of bladder storage medication and method of bladder emptying during post-acute specialised spinal cord injury (SCI) rehabilitation.

PATIENTS AND METHODS

Data from patients undergoing inpatient specialised post-acute SCI rehabilitation were collected from 2013 to 2024 by the prospective, multicentre, longitudinal, Swiss Spinal Cord Injury Cohort Study (SwiSCI). Information on bladder storage medication use (antimuscarinics, β3 adrenergic agonists, intradetrusor onabotulinumtoxinA injections), bladder emptying method (spontaneous voiding, intermittent self-catheterisation [ISC], intermittent assisted catheterisation, suprapubic and transurethral catheterisation), demographic and SCI characteristics was collected at up to four time points (28, 84, and 168 days after SCI; 0-15 days before discharge). Multivariable time-to-event regression analyses were employed to describe time-to-first-reported medication or bladder emptying method use.

RESULTS

Bladder storage medication was used by 31% of the 1084 patients during rehabilitation (2% onabotulinumtoxinA injections), starting a median of 97 days after SCI and was associated with American Spinal Injury Association Impairment Scale (AIS) Grade A, B, C SCI. Spontaneous voiding, ISC, and suprapubic catheter were the main bladder emptying methods at discharge, starting a median of 42, 90, and 75 days after SCI. Age and SCI severity were associated with all bladder emptying methods, while sex was associated with suprapubic catheter and ISC use, but not with spontaneous voiding. Rehabilitation centre was associated with all outcomes.

CONCLUSIONS

This descriptive study revealed considerable between-centre variation in the individualised patient management regarding timing of bladder storage medication and bladder emptying method during inpatient SCI rehabilitation in a high-resource setting. These findings warrant future targeted prospective research to evaluate the impact of centre-specific patient management processes on long-term upper and lower urinary tract outcomes. Between-centre differences in timing of medication and bladder emptying method initiation also need consideration in the design of multicentre randomised controlled trials during post-acute SCI rehabilitation.

Profile of patients practicing clean intermittent catheterization and associated resource consumption. Multicenter study in Spain

INTRODUCTION

Clean intermittent catheterization (CIC) is a technique used for bladder emptying in patients with neurogenic or non-neurogenic lower urinary tract dysfunction. CIC is considered the best option for most patients with dysfunctional voiding, as it improves their quality of life with a low complication rate. However, there is considerable variability in the management of CIC across regions and countries, as well as a lack of standardized guidelines. This study aims to determine the patient profile, associated complications and resource utilization related to the procedure.

METHODS

This descriptive, multicenter, cross-sectional study was conducted in the functional urology and urodynamics units of 23 hospitals across Spain between April 2019 and April 2021. Patient characteristics were collected and stored in the Multicenter Studies Research Platform of the Spanish Urology Association.

RESULTS

This study included 573 CIC users, with a mean age of 54.1 years (SD: 19.1). Of the participants, 78.6% lived in urban areas, and 53.9% had additional comorbidities. The primary indication for CIC was spinal cord injury (29.5%), followed by hypocontractile neurogenic bladder (20.8%). Most patients performed one clean intermittent catheterization per day (87.3%), with a median of three. The most common complication observed was urinary tract infection (51.8%). Additionally, 95.3% of patients attended at least one urology consultation in the past year.

CONCLUSIONS

CIC is mostly indicated for neurological pathologies, and urinary tract infection is the most common associated complication. CIC is a fundamental procedure in functional urology units and is linked to significant healthcare resource consumption. Knowledge on the patient profile and the characteristics associated with CIC is crucial for comprehensive patient management, as it helps reduce and prevent potential complications while also informing healthcare strategies for more efficient resource management.

Impact of bladder management methods and other factors on sexual activity in women with chronic spinal cord injury/disease

Background

Spinal cord injury/disease (SCI/D) profoundly affects both sexuality and urinary function. Catheterization is often necessary to manage bladder voiding and it can interfere with sexual activity.

Aim

We aim to investigate the effect of the bladder evacuation method on sexual activity in women with chronic SCI/D.

Methods

This cross-sectional study at a specialized SCI/D rehabilitation center recruited women ≥18 years with chronic SCI/D using intermittent or suprapubic catheterization. We assessed sexual activity and sexual function with the German version of the Sexual Behaviour Questionnaire and the Female Sexual Function Index (FSFI) and a study-specific questionnaire.

Outcomes

The primary outcome was sexual activity and secondary outcomes included factors influencing sexual activity, such as age and SCI/D characteristics.

Results

Around half of the evaluated women were sexually active, regardless of bladder evacuation method. However, significantly (P = .018) more women using intermittent catheterization (IC) (66.7%, 20/30) were sexually active compared to those with a suprapubic catheter (SPC) (29.4%, 5/17). The main concern for women using IC was urinary incontinence during sex (43.3%, 13/30), while those with a SPC struggled with self-image due to the catheter (58.8%, 10/17). Not having a partner was the most common reason for sexual inactivity in both groups (59.1%). The median FSFI total score was significantly (P = .049) greater in the IC group (median 26.4, lower quartiles [LQ] 8.9/upper quartiles [UQ] 28.8) compared to the SPC group (median 11.5, LQ 5.4/UQ 25.5), which represents a lower grade of sexual dysfunction in women using IC.

Clinical Translation

Sexual education is crucial and should be adapted to the different types of bladder management.

Strength & Limitations

This study shows first data on the effect of catheter on sexual activity in women. Limitation of our study is the small sample size and response bias by the high rejection rate of women with SPC.

Conclusions

Few women with SPC remain sexually active after SCI/D, while the majority of women using IC do, highlighting issues around self-image and urinary incontinence.

[Importance of neuro-urological care in patients with spinal cord injuries/diseases]

Integrity, control and regulation of the urinary tract are subject to a complex neuronal regulation, in which portions of the sympathetic, parasympathetic and somatic nervous system are involved. The spinal cord plays a central role in regulation and serves as a transmitter for the motor and sensory pathways. Bladder dysfunction followed by renal dysfunction was the most frequent cause of death in patients with spinal cord injuries/diseases (paraplegia) as recently as half a decade ago. Thanks mainly to diagnostic and therapeutic advances made in neuro-urology, urological problems are no longer life-limiting. A vital role is played not only by the actual function of the urinary tract but also by the complex interactions in patients living with paraplegia. Issues such undertreated hyperactivity of the detrusor muscle with autonomous dysregulation, incontinence with secondary skin changes, or insufficient hand function to perform intermittent catheterisation must be evaluated in an interdisciplinary approach. Spinal cord injury/disease implies numerous functional disorders and secondary impairments of the organism. In addition to bladder function, sexual dysfunction also plays a crucial role. Especially in younger patients who sustain paraplegia before or during the family planning phase, this disruption and limitation is an essential reason for reduced quality of life. Neurogenic intestinal function plays an additional crucial role with regard to quality of life and management of everyday life. In recent years, the range of neuro-urological topics has expanded significantly. The focus of our work shifted from being merely on the urinary tract and urodynamics. In particular, the diagnostic investigation and treatment of neurogenic intestinal dysfunction is increasingly in the hands of neuro-urologists. The complex presentation of paraplegia involves an interaction of bladder, intestinal and sexual dysfunction in a way that these influence one another. Therefore, the sustained care and re-integration of these patients essentially includes lifelong and regular neuro-urological care in a paraplegia centre. Last but not least, it is exactly these neuro-urological topics such as urinary tract infections, urinary and intestinal incontinence and faecal impaction, which most commonly lead to re-hospitalisation.

Changes in bladder emptying during inpatient rehabilitation after spinal cord injury and predicting factors: data from the Dutch Spinal Cord Injury Database

STUDY DESIGN

Secondary analysis of multicentre prospective observational data.

OBJECTIVES

To describe methods of bladder emptying at admission and discharge in patients with recently acquired spinal cord injury (SCI) and to describe predictors of bladder emptying methods at discharge.

SETTING

First inpatient rehabilitation in specialised rehabilitation centres in the Netherlands.

METHODS

Data from the Dutch Spinal Cord Injury Database collected between 2015 and 2019 were used. McNemar-Bowker test was used to evaluate if bladder emptying methods differed over time; One-Way ANOVA and Chi-Square tests to see if bladder emptying methods differed by demographic and injury-related characteristics. Binary logistic regression was used to predict the type of bladder emptying at discharge with demographic and injury-related characteristics measured at admission.

RESULTS

Of 1403 patients, 44.1% had cervical, 38.4% thoracic and 17.5% lumbosacral lesions at admission. AIS classification was mostly D (63.8%). The method of bladder emptying changed significantly (p < 0.001) from admission to discharge: decrease of clean intermittent assisted catheterisation (17.1% to 4.1%) and indwelling catheter (33.4% to 16.3%) and increase in clean intermittent self-catheterisation (CISC, 7.8% to 22.2%) and normal voiding (40.2% to 56.1%). Age, sex, SCI level, AIS classification and level of independence predicted the method of bladder emptying at discharge (all p < 0.001).

CONCLUSIONS

During first inpatient rehabilitation, the method of bladder emptying changed resulting in more patients discharged with normal voiding and CISC. Age, sex, SCI level, AIS classification and level of independence in self-care were all confirmed as factors playing a role in this change.