Special considerations in the urological management of the older spinal cord injury patient

PURPOSE

This paper reports the key findings of Committee 8 of the Joint SIU-ICUD Consultation on Urologic Management of the Spinal Cord Injured Patient and address issues pertaining to the older person with a SCI and the time-related changes relevant to their urological, gastrointestinal and functional management.

METHODS

A literature review using the Pubmed and Ovid search engines was performed examining pertinent literature regarding SCI in the older patient.

RESULTS

There is a rising incidence of both traumatic and non-traumatic spinal cord injury (SCI) in older people and improvements in healthcare and nutrition mean patients with SCI are living longer. Outcomes after a SCI in the older person are a sum of the effects of injury and its management compounded by specific effects of ageing and the emergence of unrelated comorbidities. Changes in health, comorbidities, cognition and dexterity with ageing have an impact on function and are important considerations in the management of the older patient with SCI. Treatment decisions are thus increasingly complex due to the need to take into account these changes and accompanying polypharmacy. For the person living with a SCI, changes in circumstances (social and financial) have an impact on quality of life and influence management and support strategies.

CONCLUSIONS

Older patients with SCI face additional challenges both in the acute setting and with ageing. Clinicians should take into account comorbid conditions, mental health, physical function, cognition and social support in making management decisions. With the global ageing population, health services planning will need to allow for increase in resources required to care for older patients with SCI.

Symptoms of bowel dysfunction and their management after spinal cord injury in a New Zealand centre

AIM

To document the symptoms of bowel dysfunction, and how the bowels are managed, in a cohort of patients following a spinal cord injury. To relate these to the level of the spinal injury and to examine the relationship between bowel symptoms and bladder dysfunction.

METHOD

Participants were identified from the discharge data from the Burwood Spinal Unit, one of two national Spinal Units in New Zealand, in two two-year sets from 1-3 years post-injury and from 20-21 years post-injury. With informed consent, they completed a survey developed for symptoms and management using Survey Monkey. This was cross-related to the level of cord injury and the AIS Scale, and then to the latest urodynamic analysis.

RESULTS

A total of 54 patients were included; data was incomplete in five patients. No specific relation was found between bowel sensation, bowel continence, bowel management, nor with bladder function.

CONCLUSION

Lack of correlation of patterns of bowel function with the level and severity of the cord lesion indicates the need to continue to individualise advice on bowel care according to symptoms.

Sacral neuromodulation with implanted devices for urinary storage and voiding dysfunction in adults

BACKGROUND

The neural control of storage and voiding of urine is complex and dysfunction can be difficult to treat. One treatment for people with refractory symptoms is continuous electrical nerve stimulation of the sacral nerve roots using implanted electrodes and an implanted pulse generator.

OBJECTIVES

To determine the effects of implantable electrical stimulation devices in the treatment of urine storage and voiding problems.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 10 February 2009), CENTRAL (The Cochrane Library 2008, Issue 1), MEDLINE (January 1980 to March 2008), EMBASE (January 1980 to March 2008), CINAHL (January 1982 to March 2008) and the reference lists of relevant articles.

SELECTION CRITERIA

Trials that tested implanted electronic stimulators connected to electrodes attached to the nerves and providing continuous electrical stimulation for neuromodulation.

DATA COLLECTION AND ANALYSIS

Both authors selected studies, assessed quality, and extracted data.

MAIN RESULTS

Eight reports of randomised studies that evaluated implants which provided continuous stimulation were included. It was unclear whether some reports included patients who also appeared in other reports, so no data were pooled. In spite of this, it seems clear that continuous stimulation offers benefits for carefully selected people with overactive bladder syndrome and for those with urinary retention but no structural obstruction.Many of the implants did not work and many required revision operations. Many questions remain about patient selection and the best way to use these devices.

AUTHORS' CONCLUSIONS

In spite of methodological problems, it would appear that some people benefit from implants which provide continuous nerve stimulation. More research is needed on the best way to improve patient selection, carry out the implant, and to find why so many fail. The effectiveness of implants should be tested against other interventions, particularly in people with an overactive bladder.

A successful nurse-led model in the elective orthopaedic admissions process

AIM

To document a nurse-led admissions process for same day orthopaedic surgery, on relatively fit patients under 70 years of age.

METHODS

Patients undergoing minor surgery, under 70 years of age, and with a body mass index (BMI) of <35, were selected from the total of patients being admitted for elective orthopaedic surgery under the Accident Compensation Commission (ACC) contract. The nurse-led project relied primarily on an admission questionnaire, on physician consultation notes, and on previous clinical records.

RESULTS

During the 6-month study, 331 patients with a median age of 38 years were categorised into 3 streams. 252 patients (76%) underwent a nursing-admission process without the need for further consultation with a junior medical officer or an anaesthetist. The remaining patients not included in the study were admitted and clerked by a house officer. No safety issues arose and the surgeons and anaesthetists were satisfied with the process. The junior medical officers described improved job satisfaction by being able to attend theatre, other educational opportunities, and working more closely with the consultant.

SUMMARY

The process was safe; it improved the patient journey and job satisfaction among house surgeons; and it extended the skill base and job satisfaction of the nurses. It also allowed the hospital to cope better with the reduced number of house surgeons available. The process has now been incorporated into elective orthopaedic admissions at Burwood Hospital.

Propiverine Compared to Oxybutynin in Neurogenic Detrusor Overactivity – Results of a Randomized, Double-blind, Multicenter Clinical Study

OBJECTIVES

To compare the efficacy and tolerability of propiverine and oxybutynin in patients with neurogenic detrusor overactivity.

METHODS

Patients were eligible, if at least 18 years of age and suffering from neurogenic detrusor overactivity. Eligibility also required a maximum cystometric capacity less than 300 ml. After a one-week run-in period, propiverine 15 mg t.i.d. or oxybutynin 5mg t.i.d. were administered for 21 days. As primary efficacy outcomes urodynamic parameters were assessed. As tolerability outcome the percentage of patients with newly manifesting anticholinergic adverse events was taken.

RESULTS

131 patients were recruited at 20 study centers. The maximum cystometric capacity (ml) was increased significantly in the propiverine group from 198 (+/-110) to 309 (+/-166), and in the oxybutynin group from 164 (+/-64) to 298 (+/-125). Similarly, maximum detrusor pressure during the filling phase (cm H(2)O) was lowered significantly in the propiverine group from 56.8 (+/-36.2) to 37.8 (+/-31.6), and in the oxybutynin group from 68.6 (+/-34.5) to 43.1 (+/-29.2). No significant differences resulted between treatment groups. Anticholinergic adverse events were reported less frequently in the propiverine compared to the oxybutynin group (63.0% versus 77.8%). Dryness of the mouth, the most frequent adverse event, was reported significantly less (47.1% versus 67.2%; p=0.02) in the propiverine compared to the oxybutynin group.

CONCLUSION

Propiverine and oxybutynin are equally effective in increasing bladder capacity and lowering bladder pressure in patients with neurogenic detrusor overactivity. The trend for better tolerability of propiverine compared to oxybutynin achieved significance for dryness of the mouth.

Epidemiology and natural history of urinary incontinence

This paper examines or current state of knowledge of the epidemiology of urinary incontinence. The population studied was community-dwelling non-institutionalized persons. The review includes discussion of the prevalence, incidence, natural history and presence of racial and ethnic differences in the epidemiology of urinary incontinence. We also review correlates and potential risk factors that have been revealed in epidemiological studies. Differences between epidemiological and clinical approaches to a health problem, help-seeking behavior and methodological issues for research are also discussed. We have reviewed a large number of completed studies in the field of urinary incontinence, and have emphasized high-quality and population-based studies. We also wished to present studies from a variety of countries. Because of the abundance of studies, only a small fraction can be presented here. Other studies may have equal standards and useful information, but lack of space precludes their inclusion.

Tamsulosin in men with confirmed bladder outlet obstruction: a clinical and urodynamic analysis from a single centre in New Zealand

OBJECTIVE

To evaluate the clinical and pressure-flow effects of tamsulosin 0.4 mg once daily in patients with lower urinary tract symptoms (LUTS) caused by benign prostatic obstruction (BPO), as documented by pressure-flow studies performed according to a standardized protocol in one centre.

PATIENTS AND METHODS

A single-centre study was conducted with an open-label design comprising a 2-week, single-blind, placebo run-in period and a 12-week active treatment period with tamsulosin 0.4 mg once daily. Eligible patients were men (aged > or = 45 years) with LUTS (total International Prostate Symptom Score, IPSS, > or = 13) with a free-flow maximum urinary flow rate (Qmax) of > or = 4 mL/s for a voided volume of > or = 120 mL. After the 2-week placebo run-in period, only patients with BPO (i.e. in the obstructed zone of the Abrams-Griffiths, AG, nomogram) received active treatment with tamsulosin. The two primary efficacy variables were the change in detrusor pressure at maximum flow (PdetQmax) and the total IPSS, from baseline to endpoint. A standardized protocol was used for all pressure-flow studies.

RESULTS

In all, 42 patients were enrolled into the 2-week placebo run-in period, after which 30 received active treatment with tamsulosin 0.4 mg once daily. All 12 patients (29%) who discontinued during the placebo run-in period failed to fulfil the pressure-flow entry criterion of confirmed obstruction. The 30 patients who received tamsulosin had a high mean PdetQmax (82.1 cm H2O) and high mean AG number (68.1) at baseline, as would be expected in obstructed patients. Tamsulosin produced a significant reduction in mean PdetQmax (-10.6 cm H2O or -13%; P = 0.005 vs baseline). The mean AG number decreased accordingly (-15.5 points or -23%; P < 0.001 vs baseline). The pressure-flow mean Qmax was increased by 2.5 mL/s (36%) from 7.0 mL/s at baseline (P = 0.002 vs baseline). Urodynamic improvements were accompanied by a good symptomatic response; the mean total IPSS was reduced by 6.7 points from a baseline value of 18.1 (-37%, P < 0.001 vs baseline). At the endpoint, 67% of patients had a clinically significant symptomatic response (defined as a decrease in total IPSS of > or = 25% from baseline). Twenty-six patients (87%) were either slightly improved (13) or were much improved (13) in the opinion of the investigator. Twelve patients with LUTS who were unobstructed after the 2-week placebo run-in (PdetQmax 44.1 cm H2O) received tamsulosin treatment outside of the study protocol. Although these patients had no decrease in mean PdetQmax, the magnitude of the symptomatic response (decrease in total IPSS -6.4 or -34%, P = 0.001) was comparable with that in unobstructed patients; the free-flow Qmax was also significantly improved. Possibly or probably drug-related adverse events were reported in nine patients; one discontinued tamsulosin treatment because of a serious adverse event.

CONCLUSION

Tamsulosin 0.4 mg once daily can produce a significant decrease in detrusor pressure, increase in flow rate and a symptomatic improvement in patients with LUTS and confirmed obstruction. Patients with LUTS who are unobstructed and have a low initial detrusor pressure appear to have no improvement in detrusor pressure, but have similar clinical responses to those in obstructed patients. Pressure-flow studies can be reserved for those patients with LUTS who fail to respond to these agents and in whom further diagnosis and management is warranted.

Total synthesis of (+/-)-cytisine

[reaction:see text] The nicotine partial agonist cytisine was prepared in five steps featuring an "in situ" Stille or Suzuki biaryl pyridine coupling. Differentiation of the pyridyl rings was accomplished via selective benzylation and then reduction of a pyridinium ring. The penultimate diazabicyclo[3.3.1]nonane intermediate was obtained with high diastereoselectivity. A similar sequence has been employed for the synthesis of novel derivative 9-methoxycytisine.

Monitoring of renal function in patients with spinal cord injury

OBJECTIVE

To assess the sensitivity of serum creatinine level in detecting clinically important and early deterioration of renal function in patients with spinal cord injury (SCI), and to evaluate the optimal method of determining creatinine clearance in these patients.

PATIENTS AND METHODS

The serum creatinine level of 36 patients (25 paraplegics and 11 quadriplegics) was evaluated and compared with the corresponding measured creatinine clearance rate. Correlations were also assessed between the creatinine clearance measured by 24-h endogenous clearance, single-shot 99mTc-labelled diethylenetriamine pentaacetic acid (99mTc-DTPA) clearance technique, and the Cockcroft-Gault formula, to test their validity.

RESULTS

Of the 36 patients 11 (31%) had a measured creatinine clearance of < 100 mL/min (mean 84.8) and a corresponding normal serum creatinine level. Creatinine clearance calculated by the Cockcroft-Gault formula did not correlate well with that measured by the 24-h endogenous clearance (r = 0.426) and 99mTc-DTPA clearance (r = 0. 366), overestimating creatinine clearance in all but three patients. The mean (SD) difference between the creatinine clearance measured by the 24-h and DTPA clearance technique was 17.7 (16.5)% and the correlation between these techniques was good (r = 0.71).

CONCLUSION

Serum creatinine level is not sensitive in detecting early deterioration of renal function in patients with SCI. The Cockcroft-Gault formula generally significantly overestimates the true creatinine clearance and is not recommended. The 24-h endogenous creatinine clearance measured on appropriately collected urine samples is an acceptable accurate and practical method of determining glomerular filtration rate in patients with SCI.

Assessment and management of female urinary incontinence--a survey of current practice

A survey of conference delegates attending the Urogynaecology Day at the 1997 Annual Scientific Meeting of the Royal Australasian College of Surgeons indicated that practitioners are inconsistent in their approach to the use of preoperative urodynamics evaluation for women with stress incontinence and disagree about the significance of the low pressure urethra.

Desmopressin for nocturnal enuresis: urinary osmolality and response

OBJECTIVE

To measure the effect of intranasal desmopressin (l-deamino 8-D-arginine vasopressin, DDAVP) on urine osmolality in a group of patients with persistent primary enuresis, and to determine whether changes in osmolality can the predict response to treatment.

PATIENTS AND METHODS

Thirty-seven patients with persistent primary nocturnal enuresis were entered into a double-blind placebo-controlled crossover trial of 20 micrograms intranasal DDAVP spray. Morning urinary osmolality was measured on two occasions during each phase of treatment and the clinical response recorded in a diary.

RESULTS

Thirty-one patients (22 males and nine females) were evaluable at the end of the trial period. A good clinical response, defined as enuresis on two nights or fewer each week, occurred in 12 of 31 (39%) patients, but complete continence was attained in only two. The response was better in older patients and in those with less frequent enuresis. The mean and peak urinary osmolality of the morning urine samples were higher while on treatment with DDAVP compared with placebo, but this difference was not statistically significant and the response did not predict a good clinical outcome in improving the enuresis.

CONCLUSIONS

Treatment with DDAVP can produce a socially acceptable level of dryness in some patients with refractory nocturnal enuresis. However, the early morning urinary osmolality, as a reflection of changes in nocturnal osmolality, was not useful in distinguishing this group or in selecting those who will respond to treatment.

Management of spinal cord injured patients by indwelling suprapubic catheterization

PURPOSE

We review the urological complications in spinal cord injury patients treated with suprapubic catheterization.

MATERIALS AND METHODS

Suprapubic catheterization was used in 44 spinal cord injury patients. Followup ranged from 12 to 150 months (mean 58). The catheters were irrigated weekly and changed every 2 weeks. Patients were followed annually with urodynamic studies and ultrasound.

RESULTS

No patient had renal deterioration, vesicoureteral reflux or bladder carcinoma. The incidences of incontinence, urinary tract infections and calculi were acceptable.

CONCLUSIONS

Suprapubic catheterization is an effective and safe alternative form of bladder management in select patients with spinal cord injury.

Carcinoma in situ of the testis followed by an overt malignant teratoma of the testis within 12 months

A case of bilateral metachronous testicular non-seminomatous germ cell tumour (NSGCT) is presented. The second tumour was preceded by carcinoma in situ, diagnosed at the time of the first orchidectomy. The patient was placed under active surveillance and 1 year later the second testis tumour developed. A second orchidectomy was performed and testosterone replacement begun. Carcinoma in situ of the testis is discussed.

Sexual function after pelvic surgery in women

To assess the prevalence of sexual dysfunction after pelvic floor surgery for nonmalignant conditions, a retrospective survey was performed. Replies from a postal survey were received from 66 of the 200 women canvassed. Dyspareunia developed in 10 patients who had never had it before the operation, however of those who had it preoperatively the pain stopped completely in 12 of 23. Reduced libido was noted in 16 of 54 (29%), reduced lubrication in 21 (38%), and reduced genital sensation in 10 (18%). Lack of information about the potential effects of surgery on sexual function was identified as a major deficit and of considerable concern to 35 of the 66 women. Sexual function after surgery should be evaluated more intensively, and the subject discussed openly before any contemplated operation.

Clam cystoplasty for the overactive bladder: a review of 23 cases

A clam enterocystoplasty was performed for refractory urge incontinence due to either idiopathic instability (13 patients) or neuropathic hyperreflexia (10 patients). Twelve patients became dry and appliance free. Of the remaining 11 wet patients, seven developed low pressure reservoirs, of whom five had stress incontinence and two had overflow incontinence. The other four patients had persistent symptomatic involuntary phasic contractions and ongoing urge incontinence. The magnitude of the surgery and the voiding dysfunction associated with the relative lack of motivation of elderly patients made the operation less successful and more hazardous in those over the age of 65. Successful outcome could be improved by careful patient selection and by performing an antistress incontinence procedure, such as implantation of an artificial urinary sphincter cuff or a cystourethropexy, where there is associated bladder outlet incompetence.

Clinical significance of ureteric diameter on intravenous urography after spinal cord injury

The ureteric diameter on IVU was compared with the MCU findings of reflux or lower urinary tract dysfunction in a group of patients followed up after spinal cord injury. A wide ureter was associated with reflux in 20%, but 8 normal sized ureters on IVU also refluxed--5 of them to a significant degree. In the non-refluxing group, wide ureters were noted more often in patients whose bladder pressures were high and wildly fluctuating than in those with normal bladder pressures. Similarly, the incidence of reflux was higher in patients with high bladder pressures and wild fluctuations of bladder pressure than in those with normal pressures. While a wide ureter on IVU should arouse suspicion that reflux or lower urinary tract dysfunction might be present, these conditions are not necessarily excluded by the finding of a ureter of normal size.

Sacral anterior root stimulation of the bladder in paraplegics

A Brindley-Finetech sacral anterior root stimulator has been placed intradurally in the spinal canal around the S2, 3, 4 nerve roots in six paraplegics at the Burwood Spinal Injuries Unit, Christchurch, New Zealand. The apparatus developed by Professor G. S. Brindley and the Medical Research Council in London, UK, has proved very useful in driving micturition, in achieving a dry device-free interval between electromicturitions, in reducing the incidence of urinary tract infections, and in some males in achieving a sustained erection. The clinical results are presented with a urodynamic analysis of the outcome.

Trophoblastic metaplasia in urothelial carcinoma of the bladder

Trophoblastic differentiation in bladder carcinoma is reported in four patients. Plasma gonadotrophin (beta subunit of HCG), measured in three patients, was elevated. In one patient treated with cisplatin, vinblastine and bleomycin, the beta HCG level fell significantly but progression of malignant disease was not arrested.

Urethral syndrome (abacterial cystitis)--search for a pathogen

Thirty-one women with the recurrent urethral syndrome (abacterial cystitis) had extensive microbiological, cytological and histological investigations. A Streptococcus species was isolated from the bladder aspirate of one patient, a wall-deficient Streptococcus species from two others and both a Lactobacillus species and Ureaplasma urealyticum from another. A possible microbiological cause was therefore identified in the bladder in only 4 of the 31 patients. A Lactobacillus species was isolated from the bladder aspirate of one control subject. Lactobacilli were grown in the voided urine of the majority of patients and in seven of the eight control subjects. Chlamydia trachomatis and Herpes simplex were isolated from the cervix and the urethra of one patient. Urethral cytology was normal in all patients. Trigonitis was noted at cystoscopy in 26 of the 31 patients. Bladder biopsies showed squamous metaplasia in 15 and lymphocytic infiltration of the lamina propria in 29, giving support to an inflammatory aetiology of this enigmatic syndrome.

Two-year toxicity/carcinogenicity study of fresh-brewed coffee in rats initially exposed in utero

Fresh-brewed regular coffee at concentrations of 25, 50, and 100% was consumed ad libitum as the sole fluid intake of F1 Sprague-Dawley rats (55 male and 55 female/group), derived from P0-treated females which were provided 50% coffee for about 5 weeks prior to copulation and throughout gestation and lactation. P0 males, P0 control females, and two groups of F1 control rats received tap water. Ten rats/sex/level were killed and examined after 1 year; survivors were killed after 2 years. Smaller mean body weights (50 and 100% coffee concentrations) occurred with increased feed and liquid consumption. Mean serum alkaline phosphatase, bilirubin, BUN, and calcium values occasionally were elevated. Serum cholesterol levels at 2 years were elevated in males (25 and 100%) and at 1 and 2 years in females (100%). Bone calcium was slightly reduced in females consuming 25 or 100% coffee for 1 year, but not after 2 years. Treatment-related increases in relative weights of lungs, kidneys, liver, and epididymides were recorded. Significantly increased mortality was observed in females receiving 50 or 100% coffee. There also was some evidence of a relationship between coffee consumption and the number of primary tumor-bearing animals; however, this finding appeared ambiguous, dependent on the assumption that tumors were the probable cause of death.

Bladder function following spinal cord injury: a urodynamic analysis of the outcome

Repeated urodynamic testing was undertaken on a group of 58 consecutive patients admitted with acute spinal cord injury. Thirty-seven (64%) were able to void satisfactorily spontaneously, whereas 10 required bladder outlet surgery and 11 achieved emptying by either abdominal straining, intermittent self-catheterisation or an indwelling suprapubic catheter. The pattern of the initial cystometry soon after injury provided some idea of what possibilities could be expected of subsequent bladder function. Very high detrusor pressures exceeding 80 to 100 cm of water developed in a third of patients with supranuclear lesions. Six patients developed vesicoureteric reflux between 4 and 24 months after injury.

A national trial on the treatment of invasive bladder cancer

A new anti-cancer agent, misonidazole, is now available for investigational purposes. It is a radiation sensitiser, and a national trial is described for its use in the curative treatment of carcinoma of the bladder. The co-operation of doctors is sought in referring patients for this study.

The nature of the abnormality in bladder neck obstruction

There is no dispute that there exists, in men, a condition of obstruction at the bladder neck in the absence of fibrous stricture or prostatic enlargement. The condition was clearly described by Guthrie (1836) and Young (1913) reported the results ff punch resection operation in over 50 cases. The large measure of success now achieved following resection of the bladder neck in these patients has perhaps been allowed to mask our ignorance of the nature of the abnormality and thus discourage studies of its cause. It is perhaps most often thought to result from fibrosis but a number of studies--for example Baadenoch (1949)--have shown no associated increase in fibrous tissue. Certainly the condition is in no way similar to the hard fibrous stricture seen more often in the distal urethra, or at the bladder neck as an occasional complication of prostatectomy. Our study shows that the obstruction if functional in nature and is due to the tightening of the bladder neck as the detrusor contracts.

Persistent primary enuresis: a urodynamic assessment

Videocystourethrography with synchronous pressure and flow-rate recordings has been carried out on 50 patients referred for the investigation of persistent primary enuresis. Urodynamic studies showed nocturnal enuresis to be associated mainly with normal detrusor function and nocturnal plus diurnal enuresis mainly with abnormal detrusor function. Evidence is presented which suggests that these two distinct types of enuresis occur de novo and do not overlap. Out of 18 of formerly enuretic male patients nine with abnormal detrusor function showed persistent nocturnal plus diurnal symptoms.

Videocystography with synchronous detrusor pressure and flow rate recordings

The addition of pressure and flow rate recordings to conventional cystourethrography is relatively inexpensive in terms of cost and of radiologist's time, each investigation requiring approximately half an hour.The value of this investigation in males lies in assessing the severity and site of outlet obstruction, particularly when the prostate is not clinically enlarged. Its value in demonstrating detrusor instability in cases of obstruction and in patients with post-prostatectomy problems is discussed. It is essential to the adequate assessment of sphincter mechanisms in both males and females. The particular importance of this in the female lies in the poor results of routine surgery for incontinence where this is due to detrusor instability.Finally the importance in neurological patients of a urodynamic evaluation of continence mechanisms and voiding dysfunction, both as a preliminary assessment and as a guide to the efficacy of treatment, is outlined.Various criticisms of the technique are reviewed and appropriate rebuttals provided.