Bladder management practices in spinal cord injury patients: A single center experience from a developing country

Abstract

Context/Objective: Inadequate bladder management in spinal cord injury (SCI) patients results in significant morbidity and even mortality. Clean intermittent catheterization (CIC) is the recommended option for SCI patients. The objective of the study was to document the bladder management practices of SCI patients in a developing country.

Design: Questionnaire based cross sectional survey

Setting: Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan

Participants: All patients with SCI (irrespective of duration, level and etiology)

Interventions: Data documentation included demographics, level, severity and time since injury, bladder management techniques used, details of CIC, results of Urodynamic studies (if available), complications resulting from bladder management technique and patient awareness of the yearly follow up. SPSS V 20 was used for analysis.

Outcome Measures: Not applicable

Results: Thirty four consenting patients were enrolled. All were males. Mean age was 31.24 ± 10.9. Most (17) of the patients were thoracic level paraplegics, while 12 patients had sustained a cervical SCI. Majority (23) had complete injury (ASIA A). Fifteen patients used CIC for bladder management followed by in dwelling Foley catheters in thirteen patients. Those using CIC performed the procedure every four hours and used disposable catheters. The same ‘disposable’ catheter was used for 5-7 days by half of these patients. Only Six patients independently performed CIC. Three patients on CIC reported urinary tract infection.

Conclusions: In the largest spinal rehabilitation unit of a developing country; Pakistan CIC was the preferred method of bladder management followed by indwelling catheter. Re-use of disposable catheters is a common practice due to cost issues. The rate of UTI was significantly lower in patients on CIC.

Introduction

Inadequate bladder management of spinal cord injury (SCI) results in significant morbidity including medical complications and social problems. It may even result in mortality. Young active males sustain a SCI more frequently than females (4:1).¹ The frequent leakage of urine, causing soiling of clothes and smell, can lead to psychosocial stress, cause skin breakdown and pressure ulcers. Bladder evaluation and an appropriate voiding program requires implementation to ensure a safe and complication free rehabilitation plan. Patient education, preferences and compliance are equally important when devising a bladder management plan.

Most of the SCI patients develop a neurogenic bladder.² The main aim of managing a neurogenic bladder in spinal cord injury is to maintain continence, avoiding or minimizing urinary infections and to avoid renal damage by maintaining a low bladder pressure.³ An areflexic bladder responds well to the intermittent catheterization. Urodynamic studies are recommended to determine the type of neurogenic bladder, its function and capacity. Different bladder management options available include clean intermittent catheterization (CIC), supra public catheterization, indwelling catheterization, use of external condom catheter for men, timed voiding, Creeds manoeuvre, bladder augmentation cystoplasty, urinary diversion and drug treatment.⁴ Patients choose different bladder management depending upon ease of use, comfort, cost, availability and complications.⁵ Selection of a bladder management option may be challenging for the treating physician due to the patient’s physical and/or psychosocial issues; two patients with the same level of SCI may end up with different bladder management options.

CIC is the preferred choice for neurogenic bladder management in SCI patients. It is considered life saving as it decreases the risk of urinary tract infections and renal damage.⁶ This method requires the patient to have good hand function and dexterity in order to self catheterize every four to six hours. However some patients are not comfortable with this technique and resort to other methods due to complications or their personal ease of use.⁷ Yearly follow up to determine renal status of patients with SCI is recommended by different guidelines on bladder management in SCI patients. The follow up protocol includes renal scanning, blood testing (for renal profile) and a urologist consultation.⁸

Published research on urological management of SCI is lacking in Pakistan. We were unable to locate any published manuscript in the English biomedical literature specifically addressing bladder management practices of SCI patients in Pakistan. The objective of this study was to document different bladder management options practiced by SCI patients at the largest spinal rehabilitation unit of a developing country; Pakistan.

Methods

A Cross sectional survey was carried out at the spinal unit of Armed forces institute of rehabilitation medicine (AFIRM), Rawalpindi, Pakistan (Feb 2013 to Feb 2014). Ethics review committee approval was obtained. AFIRM currently has the largest multidisciplinary SCI unit in the country which offers comprehensive SCI rehabilitation services under the leadership of a Rehabilitation Medicine Physician. Laboratory, urodynamics and ultrasound facilities are available for bladder evaluation. At the time of discharge, depending upon the injury level, motivation and social support, patients are put on one of the globally accepted bladder management protocols (timed voiding , supra-pubic catheterization, indwelling catheter placement and clean intermittent Catherization). Consecutive sampling was used for patient enrolment. Patients with SCI reporting to AFIRM outpatient department for routine yearly follow up visits or for three monthly medication refill visits were included in the study. This also included spinal cord injury patients reporting for the first time for consultation, irrespective of duration of injury. Patients with other neurological conditions such as Stroke, Multiple Sclerosis and traumatic brain injury, Parkinsons disease were excluded from the study.

Data was collected using a pre-piloted questionnaire developed by the authors after an in-depth literature search and discussion with SCI experts. Emphasis was to make it simple to administer, considering the local norms and the average educational level of SCI patients in Pakistan. It was not formally validated by statistics. The questionnaire had four parts: The first section was informed consent. The patient had to sign before enrolment in the current study. The second part related to demographic data including age, sex, level of injury and American spinal injury association (ASIA) scoring. The third section of the questionnaire was based on an unstructured interview with the patient and extracting data from the patient’s medical records. It included time since injury, bladder management technique used, frequency of catheterisation and other details related to CIC, results of Urodynamic (if available), complications resulting from bladder management technique and awareness of the yearly follow up. Data was entered in SPSS V 20 for analysis. Frequencies and proportions were calculated for descriptive statistics and means and t test was used for quantitative data analysis.

Results

Thirty four spinal cord injury patients were requested to participate in the study; all the patients consented and were enrolled. Mean age was 31.24 ± 10.99 years (age range 16-60 years). All the patients were males. Eleven patients sustained SCI in the last six months while 12 patients had sustained injury between 6-12months and eleven patients had SCI for more than 18 months. The majority of patients (17) had thoracic lesions, whilst 12 patients had cervical level of spinal injury. The majority (23) of injuries were complete (ASIA A) whilst 7 patients had ASIA C (table 1). Only 20 patients underwent urodynamic evaluation (easy-load Masterflex L/S model 7518-00 machine). Ten patients had acontractile bladders, 9 had Detrusor over activity and one patient had a normal urodynamic study. All the patients who had Detrusor over activity were using anticholinergics. CIC was the preferable (15) method for bladder management by patients, followed by indwelling Foley’s catheters (13 patients). Two patients had suprapubic catheters in place, one used the Creed’s manoeuvre and one used a condom catheter. Two of the patients were voiding normally. All the patients using CIC for their bladder management passed a catheter every 4 hours and were using reusable catheters. The same catheter was used for 6-7 days by 50% of the patients, whilst 14.3% used the same catheter for 2-3 days (table 1). Six patients were completely independent in performing CIC. Eight patients were dependent on their attendants for CIC and only one patient needed assistance in CIC. Among patients doing CIC only 3 patients reported urinary tract infection in the past six months. All patients were aware of the yearly follow up for bladder and renal status.

Table 1. Demographics profile of bladder management in spinal cord injury (n= 34).

Sex
• Males	34 (100%)
Time since Injury
Less than 6 months	11 (32.4%)
6months – 1 year	12 (35.3%)
More than 18 months	11 (32.4%)
Spinal level of injury
• Cervical	12 (35.3%)
• Thoracic	17 (50%)
• Lumbar	1 (2.9%)
• Cauda equina	4 (11.8%)
ASIA Classification
• ASIA A	23 (67.6%)
• ASIA B	1
• ASIA C	7 (20.6%)
• ASIA D	3 (8.8%)
Urodynamic evaluation Done
• Yes	20 (58.8%)
• No	14 (41.2%)
Urodynamic findings
• Acontractile bladder	10 (50%)
• Detrusor over activity	9 (45%)
• Normal Study	1 (5%)
Bladder management options used
• Clean intermittent catheterization	15 (44%)
• Indwelling Foleys catheter	13 (38%)
• Suprapubic catheter	2 (5.9%)
• Creed’s maneuver	2 (5.9%)
• External Condom catheter	1 (2.9%)
• Normal voiding	2 (11.8%)
Reuse frequency of CIC Catheter	15 (100%)
• 6-7 days	49%
• 4-5 days	35.7%
• 2-3 days	14.3%
Assistance required in CIC	4 (26.7%)
• Completely independent	6 (40%)
• Completely dependent	8 (53.3%)
• Assistance required	1 (6.7%)

Discussion

This is the first study documenting bladder management practices in SCI from Pakistan; a low resourced developing country with no national guidelines for management of SCI. All patients in the study were males. Since AFIRM is primarily a military health care institute and overwhelming majority of servicemen in the Pakistan military are males. This could be a reason that we were unable to find a female patient during the enrollment period. The mean age was 31.24 years which is slightly lower than the globally reported mean age for SCI patients.⁹ Most (15) of the patients were using CIC for bladder management. This is similar to international data where CIC is the preferred option amongst spinal cord injury patients.¹⁰ The key to prevent renal damage is to maintain a low intravesical pressure. Although CIC does not decrease the intravesical pressure directly, it helps in emptying the areflexic bladder. In addition CIC has long term advantages in terms of compliance and decreased infection rates. It is also reported to reduce the incidence of bladder calculi and renal scarring.¹¹ CIC decreases the incidence of fever, bacteremia and local infections such as epididymitis and prostatitis. CIC has shown to decrease the incidence of urethral strictures after optical internal urethrotomy.¹² Shekella et al. in 1999 compared different catheter options among spinal cord injury patients and reported that 7 out of 8 studies found that CIC had a reduced incidence of UTI’s compared to indwelling catheters.¹³ However a 2013 Cochrane review on this subject was inconclusive and found lack of evidence and studies comparing different catheter options of bladder management.¹⁴

Before considering long term use of CIC, the following factors must be kept in mind including type of neurogenic bladder, preferably based on urodynamic studies, incontinence of urine despite medication, prognosis of the injury, good hand function, and independence in CIC. However a patient’s preference and compliance are the most important considerations.¹⁵ CIC has very good results in motivated patients. Maynard and Glass (in their 5 year follow up study of 40 patients performing intermittent catheterization at the time of discharge) found that 80% continued to perform intermittent catheterization.¹⁶ Zlatev DV et al. retrospectively evaluated 4481 spinal cord injury patients and found that among patients discharged with indwelling catheters, 33.4% had adequate upper limb function for CIC.¹⁷ Similarly among patients performing CIC, 14.1% had inadequate upper limb function for CIC, demonstrating that there are many factors relating to option selection, in addition to upper limb function, when deciding on bladder management. Patients do shift between different bladder management options based on different factors. In a cross sectional study similar to ours, Lane GI et al.¹⁸ found that 14 out of 54 patients performing CIC had previous history of use of urethral catheter or supra pubic catheter, similarly up to 50% of patients using urethral catheters and supra pubic catheters had history of performing CIC and this transition was often made either by patients preference and physicians recommendation. Our study could not establish the change of bladder management options. The main reason could be the small duration of injury at the time of evaluation.

An important highlight of our study was the reuse frequency of the CIC catheters. Almost all the patients reused the same catheter. Fifty per cent of the patients were using the same catheter for 6-7 days, 35.7% for 4- days and 14.3% for 2-3 days. They washed the catheter after use and put it in a container filled with pyodine solution mixed with water. The major reason was affordability and availability of catheters. Similar results were recently reported by Chhabara et al. based on an online survey in the Indian and Asia spinal cord injury network region. They found an overall Nelaton catheter re-use frequency of 57% and 47% in patients having injury duration of more than one year.¹⁹ Some respondents suggested use of soap water and clean cloth storage of reusable catheter. The cervical and higher thoracic level patients (8) needed assistance in performing CIC while six patients were completely independent.

Quality of life with CIC has been scarcely studied. A study on Patient experience using CIC found that patients were initially worried, shocked, frightened and depressed when they heard about the methodology, but later some were satisfied and accepted CIC as a means to keep their dignity, whilst others considered CIC time consuming and affecting their family life and relationships.²⁰ A study from Iran compared health related quality of life among SCI patients using different bladder management options and found that individuals with indwelling catheters had the poorest scores in all domains of health related quality of life and recommended the use of intermittent catheterization.²¹

Indwelling Foley’s catheter use was the second commonest (13 patients) method of bladder management amongst our patients. The main reason for use included a higher level of injury and poor family/carer support along with patient preference. Two patients with higher cervical lesions were using supra pubic catheters for bladder management as they had been having multiple UTIs, frequent urine leakage and blockage when using indwelling urethral catheters. Ultimately, for the long term benefit of the patient, the bladder management option of chronic catheterization should be selected on the basis of patient comfort along with the physician’s treatment goals and expectations.

Turi MH et al. compared complications of CIC and indwelling catheters. They found that symptomatic infections such as pyelonephritis, epididymitis and uro-sepsis occurred in both groups however statistically significant and more frequent occurrence was in the indwelling catheter group.²³ In our study only 3 (8.8%) patients using CIC reported symptomatic UTI in the past six months, which is significantly lower, although asymptomatic bacteuria was not assessed in our study. Togan T et al. found symptomatic bacteuria in 22.6% of patients on CIC.⁹ Gao Y et al. in a 45 years retrospective study to find the urologic complications in spinal cord injury found that the male sex, cervical level of injury and the use of condom catheter have the greatest risk for urological complications.²⁴ They also observed that urologic complications continued throughout the follow up phase. Hence regular follow up for urological status for spinal cord injury patients is recommended. In our study, urodynamic studies were performed in 56% (19) of the patients to ensure an exact diagnosis, evaluation of the bladder and to provide a recommended management plan. Weld KJ found a significant association between the level of injury and the type of voiding dysfunction.²⁵ They found that patients having combined supra sacral and sacral injuries have unpredictable urodynamic findings. Regular follow up Urodynamic evaluation is recommended as it helps in early detection of bladder function issues and helps in preventing complications of the upper urinary tract and maintenance of continence.²⁶

There are some limitations of the study that warrant mention. The sample size was relatively small. All patients were enrolled from the largest rehabilitation center of the country with comprehensive rehabilitation care available, and so had access to better care and follow up. Therefore the results are difficult to generalize as other hospitals in the country lack a SCI unit, and SCI patients are sent home without any bladder evaluation or training programs. The majority of the spinal cord injury patients had an injury duration of less than one year hence long term compliance and preference for a particular bladder management option cannot be extrapolated.

There is a need to conduct research on bladder management practices in community dwelling SCI patients and patients being treated at other hospitals in the country to document the true magnitude of the problem. Further studies are needed to document the quality of life and satisfaction among spinal cord injury patients performing different bladder management procedures.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Conclusions

In the largest spinal rehabilitation unit of Pakistan CIC was the preferred method of bladder management followed by indwelling catheter. UTI was significantly lower in patients performing CIC. The majority of patients reuse the catheter for financial reasons.

Acknowledgments

Authors gratefully acknowledge the critical review of the manuscript by Fiona JVW Stephenson FRCN, RN Fellow of the Royal College of Nursing SCI Nurse Specialist Co-Founder International Network of SCI Nurses Member of the ISCoS Education and Disaster Committees We also acknowledge the valuable support of Dr Muhammad Fahim, Consultant at KRL Hospital, Islamabad during data collection.

Disclaimer statements

Conflict of Interest None

Source of funding and grants None.