Limitation of CISC and How to Overcome the Problems 

1. Changing of Bladder-emptying Method

  • In most SCI cases after discharge, the definitive choice of voiding method is made within 2 years post injury [Perrouin-Verbe 1995]
  • Changing of bladder-emptying method among SCI individuals over time is common: Of patients on CIC at discharge 52% discontinued the method and reverted to indwelling catheter during follow-up [Yavuzer 2000]
  • The most common change in management is from CIC to chronic indwelling catheterization in quadriplegics [Weld 2000]
  • In general, CIC alone or in combination with another bladder-emptying method is the most frequently used method of bladder emptying [Hansen 2004]
  • Reasons for stopping CIC:
    • Continuing incontinence despite anticholinergic [Perkash 1993]
    • Poor hand function and spasticity interfering with catheterization
      • generally poor condition or difficulty to reach the meatus
  • Lack of availability of external collective devices for female patients
  • Psychological or emotional status [Bakke 1998]
    • Non-acceptance of their chronic disability: Young patients and females were more averse to CIC.
    • Lack of independence or lack of autonomy: Dependence on care givers especially in tetraplegics

2. The Limitation of Application of CIC

  • There are truly some limitations of application of CIC in the following population. CIC alone practically can not be practiced easily.
    • Those who can not perform CIC:
      • Severe spasm of the lower extremities: unable to pass a catheter through the urethral meatus, especially in women.
      • Poor hand dexterity: especially caregiver is not available
    • Those who are unwilling to perform CIC:
      • Lack of motivation or lack of information
      • persistent refractory incontinence despite CIC
    • Those who can not perform CIC for other reasons:
      • Incomplete SCI where some sensory function is intact: patients feels pain on catheter insertion through the urethra
      • Tightness in the striated sphincter: tend to cause urethra trauma and subsequent false passage or urethral stricture
  • The patient should be highly motivated to live independently. The care providers are expected to give plenty of information to the patients and try to motivate the patients.
  • For CISC, the patient has moderate hand function to manipulate appropriate technique. There are some assistant devices available

3. Adjunctive Therapy to Overcome Problems

  • In many cases these problems may be overcome with good treatment and education.
  • Adjunctive therapy

  • For persistence incontinence:
    • Causes:
      • low compliance bladder
      • uninhibited detrusor
      • excessive intake of fluid
    • Options:
      • Addition or dose adjustment of anticholinergics
      • Surgery (augmentation cystoplasty) [Mast 1995]
      • Botulinum toxin injection to the detrusor [Schurch 2000]
      • Control of fluid intake [Kilinc 1999], DDAVP can safely and effectively be used [Chancellor 1994].
  • Catheterization difficulty

    Causes:

  • Poor hand function
  • Spasticity interfering with catheterization
  • Difficulty passing through the striated sphincter
  • Options:

    • Urinary diversion

      • noncontinent diversion
      • continent diversion with catheterizable stoma
    • Decreasing urethral sphincter tone: Botulinum toxin injection at the striated sphincter [Wheeler 1998].
    • Reconstructive hand surgery: may be offered to individuals with tetraplegia [Kiyono 2000].
    • Assistive devices: might be useful for those with poor hand function or difficulty in reaching the meatus [Bakke 1993].
  • Lack of availability of external collective devices for female patients
    • Options: Urinary diversion
      • noncontinent diversion
      • continent diversion with catheterizable stoma
  • Psychological or emotional status
    • Options: Counseling the patient and their family
  • Key Points of This Section
    • The most effective method to manage the neurogenic bladder is intermittent catheterization.
    • Any adjunctive therapy which facilitates that treatment is a good idea.
    • Patients develop problems which are poorly understood by care providers and that leads to chronic catheterization and other problems which are best avoided.
    • Patients on CIC protocols need reinforcement and continued follow up by experienced care providers.

    References

    • Bakke A, Malt UF. Psychological predictors of symptoms of urinary tract infection and bacteriuria in patients treated with clean intermittent catheterization: a prospective 7 year study. Eur Urol 1998; 34: 30-36.
    • Bakke A, Vollset SE. Risk factors for bacteriuria and clinical urinary tract infection in patients treated with clean intermittent catheterization. J Urol 1993; 149: 527-531.
    • Chancellor MB, Rivas DA, Staas JrWE. DDAVP in the urological management of the difficult neurogenic bladder in spinal cord injury: preliminary report. J Am Paraplegia Soc 1994; 17: 165-167.
    • Hansen RB, Biering-Sorensen F, Kristensen JK. Bladder emptying over a period of 10-45 years after a traumatic spinal cord injury. Spinal Cord. 2004 Nov;42(11):631-7.
    • Kilinc S, Akman MN, Levendoglu F, Ozker R. Diurnal variation of antidiuretic hormone and urinary output in spinal cord injured. Spinal Cord 1999; 37: 332-335.
    • Kiyono Y, Hashizume C, Ohtsuka K, Igawa Y. Improvement of urological-management abilities in individuals with tetraplegia by reconstructive hand surgery. Spinal Cord. 2000 Sep;38(9):541-5.
    • Mast P et al. Experience with augmentation cystoplasty. A review. Paraplegia 1995; 33: 560-564.
    • Perkash I, Giroux J. Clean intermittent catheterization in spinal cord injury patients: a follow up study. J Urol 1993; 149: 1068-1071.
    • Perrouin-Verbe B et al. Clean intermittent catheterization from the acute period in spinal cord injury patients. Longterm evaluation of urethral and genital tolerance. Paraplegia 1995; 33: 619-624.
    • Schurch B et al. Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results. J Urol 2000; 164: 692-697.
    • Weld KJ, Dmochowski RR. Effect of bladder management on urological complications in spinal cord injured patients.J Urol. 2000 Mar;163(3):768-72.
    • Wheeler Jr JS, Walter JS, Chintam RS, Rao S. Botulinum toxin injections for voiding dysfunction following sci. J Spinal Cord Med 1998; 21: 227-229.
    • Yavuzer G et al. Compliance with bladder management in spinal cord injury patients. Spinal Cord 2000; 38: 762-765.

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