Validation of Upper Extremity Motor Function as a Key Predictor of Bladder Management After Spinal Cord Injury

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.

Bladder-Related Quality of Life After Spinal Cord Injury: Findings from the Neurogenic Bladder Research Group Spinal Cord Injury Registry

The Neurogenic Bladder Research Group (NBRG) was formed with the mission to optimize quality of life (QoL), surgical outcomes, and clinical care of patients with neurogenic lower urinary tract dysfunction. One of the original priorities of the organization was to support creation of the NBRG Spinal Cord Injury (SCI) Registry. The aim of this Registry was to establish a prospective database, in order to study bladder-related QoL after SCI. The study enrolled close to 1500 participants from across North America over an 18 month time-period (January 2016-July 2017).

Do improvements in upper extremity motor function affect changes in bladder management after cervical spinal cord injury?

INTRODUCTION

One of the most important predictors of clean intermittent catheterization (CIC) adoption after spinal cord injury (SCI) is upper extremity (UE) motor function at discharge from rehabilitation. It is not clear however if post-discharge improvements in UE motor function affect future bladder management decisions.

METHODS

We assessed persons with cervical SCI in the National Spinal Cord Injury Dataset for the years 2000-2016 who underwent motor examination at discharge from rehabilitation and again at 1-year follow-up. Individuals were stratified based on a previously described algorithm which categorizes the ability to independently perform CIC based upon UE motor scores. Improvements in the predicted ability to self-catheterize over the first year after rehabilitation discharge were evaluated in relation to bladder management.

RESULTS

Despite 15% of our SCI cohort improving from "less than able to independently catheterize" to "able to independently catheterize", more patients in the overall cohort dropped out of CIC (175/643 = 27.2%) than adopted CIC (68/548 = 12.4%) (P < .001). We found that in those initially categorized as "less than able to independently catheterize" at the time of rehabilitation discharge, CIC adoption was not significantly different at 1-year follow-up whether or not there was motor improvement to "able to independently catheterize" (12.7% vs 9.2% respectively, P = 0.665). Between these two groups, CIC dropout was also equivalent (34.3% vs 30.0% respectively, P = 0.559).

CONCLUSIONS

In the first year after rehabilitation, more overall SCI patients transition away from CIC than convert to CIC. Significant improvements in UE motor function during the first year after rehabilitation discharge do not appear to affect bladder management decisions.

Quality of life aspects of intermittent catheterization in neurogenic and non-neurogenic patients: a systematic review on heterogeneity in the measurements used

Background

Clean intermittent catheterization (CIC) is the golden standard in patients with lower urinary tract dysfunction, leading to bladder emptying problems, due to neurogenic or non-neurogenic causes. CIC affects patient Quality of Life (QoL) both positively and negatively.

Objectives

The aim of this systematic review is to determine which measurements are used to report on the QoL of patients who are on CIC in the currently available literature, to determine the overall QoL of patients who are on CIC and lastly, to determine whether QoL in patients who are on CIC is dependent on the underlying cause (neurogenic vs non-neurogenic).

Design

This systematic review was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

Data sources and methods

The Embase, Medline, Web of Science Core Collection, CINAHL, Google Scholar, and the Cochrane CENTRAL register of trials databases were systematically searched for relevant publications until March 2023.

Results

A total of 4430 abstracts were screened and 43 studies were included. Studies were published between 1993 and 2022 and consisted of only neurogenic patients in 22 studies, the others included a mixed population. The included patient populations and the used measurements/tools were heterogeneous. There were 21 measurements/tools used to measure QoL, of which 3 were not validated. One questionnaire was developed to measure QoL in patients on CIC (intermittent self-catheterization questionnaire). Other measurements were suitable for general health-related QoL, to evaluate neurogenic bladder symptoms or incontinence oriented.

Conclusion

The 43 included studies showed a great variety of used tools to measure QoL in patients on CIC due to neurogenic and non-neurogenic causes. Because of lacking uniformity of the measured aspects of QoL, the different included studies could not be compared and subgroup analysis was not performed. Recommendations for future research and practice are provided.

Trial registration

This systematic review was registered and published beforehand at Prospero (CRD42020181777; https://www.crd.york.ac.uk/prospero).

A Scoping Literature Review on Patient Education in Intermittent Catheterization

PURPOSE

To summarize evidence related to (1) research studies examining patient/caregiver educational interventions related to intermittent self/caregiver catheterization (ISC), (2) studies examining issues related to teaching ISC, and (3) evidence-based clinical practice guidelines addressing ISC.

PROBLEM

Avoiding lower urinary tract trauma during catheter insertion, adequate frequency of catheterization, and complete emptying of the bladder are essential to prevent and reduce complications associated with ISC. Consequently, proper patient/caregiver education is essential to achieving good outcomes.

METHODS

Scoping review of literature.

SEARCH STRATEGY

We searched PubMed, EMBASE, and CINAHL databases, and the reference lists of background and included studies for quantitative and qualitative research studies and professional and healthcare organization-generated evidence-based clinical practice guidelines published between 2005 and September 2021. Eleven studies and 2 clinical practice guidelines met our eligibility criteria and are included in the review.

FINDINGS

Research conducted in the United States examining the effectiveness of educational interventions for patients needing ongoing ISC is extremely limited. The single study identified was a small pilot feasibility study. Eight studies examining issues potentially related to patient/caregiver ISC education were identified, suggesting that catheter characteristics, patient barriers, and complications, particularly urinary tract infections, adherence, and upper extremity function, are important considerations when developing education interventions. The small number of studies and limitations in the methodologies limit the current evidence base to support patient/caregiver education about ISC. We also identified 2 evidence-based guidelines generated by European professional organizations that included recommendations related to ISC education.

CONCLUSIONS

Additional research is needed to support the development of patient/caregiver educational interventions and to examine their effectiveness.

Internal and External Barriers to Bladder Management in Persons with Neurologic Disease Performing Intermittent Catheterization

People living with neurogenic lower urinary tract dysfunction (NLUTD) often have to use clean intermittent catheters (CIC) to manage their bladder function. The use of catheters presents multiple unique challenges, based on both the person's inherent characteristics and on the external limitations imposed by public toilets. We review the impact of age, sex, upper limb function, caregiver assistance, time required to perform CIC, and urinary incontinence on CIC in NLUTD, with special reference to their interaction with societal and public health factors. Public toilet limitations, such as lack of availability, adequate space and special accommodation for CIC, cleanliness, and catheter design are also reviewed. These potential barriers play a significant role in the perception and performance of bladder care in people living with NLUTD.

Urological Management at Discharge from Acute Spinal Cord Injury Rehabilitation: A Descriptive Analysis from a Population-based Prospective Cohort

Background

There is limited epidemiological evidence describing contemporary neuro-urological management of persons with acute spinal cord injury (SCI).

Objective

To describe neurogenic lower urinary tract dysfunction (NLUTD) management at discharge from SCI rehabilitation.

Design, setting, and participants

The population-based Swiss Spinal Cord Injury (SwiSCI) cohort study prospectively collected data from 602 adults undergoing specialized postacute SCI rehabilitation from 2013 to 2020. The management strategy was based on the European Association of Urology (EAU) Guidelines on Neuro-Urology.

Outcome measurements and statistical analysis

Data were collected at discharge using the International SCI Lower Urinary Tract Function Basic Data Set. Multivariable logistic regression adjusting for demographics, SCI characteristics, and center, with inverse probability weighting accounting for sampling bias, was used to produce prevalence estimates and identify predictors of lower urinary tract symptoms (LUTS) and NLUTD management outcomes.

Results and limitations

At discharge (median time after SCI: 5.0 mo [Q1-Q3: 3.0–7.2]), the prevalence of LUTS or managed NLUTD was 82% (95% confidence interval [CI]: 79–85%). SCI completeness was the main predictor of LUTS and managed NLUTD. The risk of urinary incontinence was elevated in females (odds ratio 1.98 [95% CI: 1.18–3.32]) and with complete lesions (odds ratio 4.71 [95% CI: 2.52–8.81]). Voiding dysfunction was most commonly managed with intermittent catheterization (prevalence 39% [95% CI: 35–42%]), followed by indwelling catheterization (prevalence 22% [95% CI: 18–25%]). The prevalence of antimuscarinic or mirabegron use was 29% (95% CI: 26–33%). Urodynamic and renal function data were not collected.

Conclusions

Our population-based description of urological management in Swiss SCI centers utilizing the EAU Guidelines on Neuro-Urology may be used as a reference for evaluation in other settings. Data further indicate a need for sex-specific neuro-urological management research.

Patient summary

At discharge from spinal cord injury (SCI) rehabilitation, a majority of patients have lower urinary tract problems, especially those with complete SCI. Women have a higher risk of urinary incontinence.

Time Burden of Bladder Management in Individuals With Spinal Cord Injury

Background

While clean intermittent catheterization (CIC) is the gold standard for bladder management after spinal cord injury (SCI), many individuals with SCI, for reasons not fully understood, choose alternative bladder management. We hypothesized that CIC is associated with an increased time burden in individuals with SCI.

Objectives

To investigate the time required to perform neurogenic bladder management in individuals with SCI.

Methods

An electronic nonvalidated questionnaire was designed to determine the self-reported time spent performing bladder management. It was sent to participants in the Neurogenic Bladder Research Group SCI Registry, a national quality of life study of individuals with SCI.

Results

Eighty-seven individuals responded to the survey. CIC was the most common bladder management (76%). Men and women performing independent CIC had similar average times with each catheterization episode (8.8 vs. 8.5 minutes, p = .864) as did women with a catheterizable stoma compared to women catheterizing per urethra (8.2 minutes, p = .913). Longer catheterization times were associated with cervical spine injury (mean 12.4 minutes per catheterization) and women requiring caregiver assistance (mean 20 minutes per catheterization). In addition, obese/overweight women had longer CIC times than normal weight women (14.5 minutes vs. 7 minutes; p = .036), while catheterization time was similar for all men regardless of body mass index. Individuals with indwelling catheters spent less than a third of the time on bladder management per day compared to those doing CIC (17 vs. 53 minutes per day, p < .001).

Conclusion

Management of neurogenic bladder after SCI, especially in those performing CIC, is time consuming. This time burden may play a role in long-term bladder management decisions.