BC-9. Complications of SCI/MS  

  • Urinary tract-related problems are the most frequent reason for hospital readmissions in persons with SCI/D [Savic 2000; Vaidyanathan 1995].
  • Depending on the level and completeness of the lesion, normal voluntary voiding is usually impossible after SCI/D.
  • Impaired bladder function cause a risk of developing various urological complications, for example, urinary incontinence, UTIs, urinary stones and impaired renal function.
  • Health care professionals for SCI/MS patients should be aware of possible complications of neurogenic voiding dysfunction. Below major categories of complications are selected:

1. Lower tract dysfunction

1) Incontinence

  • Urinary incontinence due to neurogenic detrusor overactivity is a common problem in patients with neurological pathology, such as SCI and MS.
  • Impact long-term health
    • UTI [Hu 2000; Hu 2004]
    • Skin problem [Hu 2000;Hu 2004]
  • Affecting the Quality of life (QOL):
    • Significant impact [Jackson 1997]
    • Serious social inconvenience in the lives [Oh 2005]
  • Major psychologic impact
    • Decreasing self-confidence and self-esteem
    • Depression
    • Socially disabling result [Nortvedt 2001]
  • Affecting patient compliance or decreasing treatment efficacy
    • Urinary incontinence constitutes a primary reason why patients do not continue safe management methods for bladder function. That is, control of pressure without control of incontinence usually leads to an unsafe method of management selected to obviate incontinence.
    • More details:
  • Economic consequences
    • Lifetime costs: substantial
    • Direct costs, such as those associated with:
      • Diagnosis
      • Routine care including incontinence products, diapers depends, condom catheter systems etc
      • Treatment includes: behavioral interventions (adjustment of voiding or intermittent catheterization schedules), drug therapies, and surgical procedures
      • Treatment of consequences secondary to urinary incontinence, for example, skin problems, UTI, skin breakdown and tissue loss, osteomyelitis, and more serious problems.
  • For more information, also please refer to this

2) Infection

  • For more information, please refer to this (link to the UTI-1. Significance of UTI in SCI) this (link to the Tx-6-1. Problems encountered during long-term followup.doc/ 2. Genitourinary tract infection)

3) Malignancy

  • Overview
    • Patients with SCI are at increased risk for bladder cancer compared with the general population [Delnay 1999] although there is some debate [Pannek 2002]. These risks are partly related to use of catheters, and smoking, but not entirely, and late malignancy remains a risk in any patient with a neurogenic bladder treated or untreated
      • Mean time between SCI and the first bladder cancer diagnosis: 22.6 years [Pannek 2002]
      • 0.39% of large SCI population during a 5-year period [West 1999]
    • Common types of bladder tumor:
      • Transitional cell carcinoma
      • Squamous cell carcinoma [Delnay 1999]
    • Advanced stage at initial diagnosis: in > 60% of the SCI patients [Pannek 2002]. Most cancers (55%) were transitional cell carcinomas. Squamous cell carcinoma was more common in patients with SCI. Late diagnosis, and squamous cell carcinomas are both associated with very low survival rates.
  • Risk factor for this condition
    • Indwelling catheter [Groah 2002]
      • Incidence of SCC in patients with a chronic indwelling catheter: 10% [Delnay 1999].
    • Chronic UTIs [Pannek 2002].
  • Carcinogenesis mechanism
    • Still debatable
    • Chronic mechanical irritation:
      • The most commonly accepted opinion in chronic catheter indwelling
      • Catheter balloon: causes epithelial proliferation [Delnay 1999].
    • Immunologic mechanism [Pannek 2002]
  • Additional Information:
  • Additional Information for the neoplasm after enterocystoplasty:

2. Kidney damage

  • Primary concern and reason for treating neurogenic bladder in SCI patients
  • More information:
    • Risk factors:
    • Long term followup:

1) Infection

2) Renal Stone

3) Hydronephrosis

  • Definition
    • Dilatation of the renal pelvis and calyces resulting from alteration of the urinary flow
    • Not always the same as ‘obstructive nephropathy’ because dilatation of the renal pelvis and calyces can occur without obstruction,
    • Thus a dilated ureter or renal pelvis does not prove obstruction is present.
  • Incidence of hydronephrosis in SCI neurogenic bladder: [Generao 2004]
    • 64% in SCI patients with low compliance
    • 21% in SCI patients with normal compliance
  • Pathophysiology: high intravesical pressure is the basic factor.
    • The main determinants of detrusor pressure are:
      • bladder outlet resistance (functional obstruction: DSD)
      • poor bladder compliance
      • hyperreflexic detrusor
    • High pressure can be transmitted to the upper tracts
    • Ultimately causing hydronephrosis and VUR
    • For more information, please refer to this (
  • Significance: damage to the renal parenchyma (decreased glomerular filtration rate)
  • Treatment: should be targeted at reducing intravesical pressure
    • Intermittent catheterization
    • Sphincterotomy, intraurethral stent
    • Relaxing the bladder (anticholinergic medication)
    • Augmentation cystoplasty
    • Other treatments include: Botulinum toxin injection, myectomy, sacral root modulation, peripheral neural stimulation to achieve modulation

4) Vesicoureteral Reflux

  • Definition:
    • the retrograde flow of urine from the bladder to the upper urinary tract
  • Pathophysiology
    • In normal condition, urine flows in antegrade fashion since peristaltic pressure of the ureter is higher than that of the bladder.
    • In neurogenic conditions VUR is always associated with elevated intravesical pressures. If ambient detrusor pressure reaches 40cmH2O, VUR is present, even if it is not seen on a cystogram.
    • In the following pathologic condition, VUR develops.
      • Elevated intravesical pressure during filling and emptying
      • UTI (cystitis)
    • UTI and its accompanying inflammation can reduce bladder compliance, elevating intravesical pressures, and ultimately distort UVJ and weaken valvular mechanism. But the adult ureter is much more resistant to the effects of infection that an infant ureter.
    • For more information, please refer to this (
  • Significance:
    • VUR is an important pathogenic mechanism in damage to the renal parenchyma.
    • A combination of UTI, VUR and intra-renal reflux cause renal scarring [Arnold 1993]
    • Persistent reflux can lead to chronic renal damage and may be an important factor in the long-term survival of SCI patients [Foley 1997]
  • Incidence:
    • 17%-25% of SCI patients [Thomas 1990]
      • 46% in SCI patients with low compliance [Generao 2004]
      • 6% in SCI patients with normal compliance [Generao 2004]
    • Most patients developed VUR within 4 years of SCI [Foley 1997]
    • Higher in patients with complete than incomplete lesion [Lamid 1988]
    • Higher in patients with suprasacral lesions than sacral lesions [Lamid 1988]
  • Treatment
    • Should be targeted at achieving a reduction in intravesical pressure. Any bladder storage pressure in excess of 35cmH2O needs treatment. Voiding pressure in excess of 50cmH2O, if sustained can lead to a gradual loss of bladder compliance and a progressive increase in storage pressure. Hence treatment is directed at both phases of bladder activity.
    • Similar to those in hydronephrosis (above)
Key Points of This Section
  • Complications of neurogenic vesical dysfunction are serious, cumulative, and may be life threatening. These include incontinence which is distressing, inconvenient, and life altering. Treatment of incontinence can be dangerous, and that problem alone can not be allowed to drive treatment. Catheters used primarily to treat incontinence are associated with VUR, damage to the bladder: fibrosis, and loss of storage activity, upper tract damage, chronic untreatable infection and a dramatically increased risk of bladder carcinoma. The latter is often lethal related to the cell type of the cancer, and to the late diagnosis of the condition.
  • Detrusor pressure is the variable most associated with early and late complications of neurogenic bladder dysfunction. Elevated detrusor pressures are associated with sepsis, VUR, renal damage, ureteral damage and incontinence. No treatment of the neurogenic bladder will succeed without control of bladder pressure.

 

References

  • Arnold AJ, Sunderland D, Hart CA, Rickwood AM. Reconsideration of the roles of urinary infection and vesicoureteric reflux in the pathogenesis of renal scarring. Br J Urol. 1993 Nov;72(5 Pt 1):554-6.
  • Delnay, K. M., Stonehill, W. H., Goldman, H., Jukkola, A. F. and Dmochowski, R. R.: Bladder histological changes associated with chronic indwelling urinary catheter. J Urol, 161: 1106, 1999.
  • Foley SJ, McFarlane JP, Shah PJ. Vesico-ureteric reflux in adult patients with spinal injury. Br J Urol. 1997 Jun;79(6):888-91.
  • Foley SJ, McFarlane JP, Shah PJ. Vesico-ureteric reflux in adult patients with spinal injury. Br J Urol. 1997 Jun;79(6):888-91.
  • Generao SE, Dall'era JP, Stone AR, Kurzrock EA. Spinal cord injury in children: long-term urodynamic and urological outcomes. J Urol. 2004 Sep;172(3):1092-4.
  • Groah, S. L., Weitzenkamp, D. A., Lammertse, D. P., Whiteneck, G. G., Lezotte, D. C. and Hamman, R. F.: Excess risk of bladder cancer in spinal cord injury: evidence for an association between indwelling catheter use and bladder cancer. Arch Phys Med Rehabil, 83: 346, 2002.
  • Hu TW, Wagner TH, Bentkover JD, Leblanc K, Zhou SZ, Hunt T. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. Urology. 2004 Mar;63(3):461-5.
  • Hu TW, Wagner TH. Economic considerations in overactive bladder.Am J Manag Care. 2000 Jul;6(11 Suppl):S591-8.
  • Jackson S.: The patient with an overactive bladder-symptoms and quality-of-life issues. Urology, suppl., 50: 18, 1997.
  • Lamid S. Long-term follow-up of spinal cord injury patients with vesicoureteral reflux. Paraplegia. 1988 Feb;26(1):27-34.
  • M.W. Nortvedt, T. Riise, K.M. Myhr, A.M. Landtblom, A. Bakke and H.I. Nyland, Reduced quality of life among multiple sclerosis patients with sexual disturbance and bladder dysfunction. Mult Scler 7 (2001), pp. 231–235.
  • Oh SJ, Ku JH, Jeon HG, Shin HI, Paik NJ, Yoo T. Health-related quality of life of patients using clean intermittent catheterization for neurogenic bladder secondary to spinal cord injury. Urology. 2005 Feb;65(2):306-10.
  • Pannek J. Transitional cell carcinoma in patients with spinal cord injury: a high risk malignancy? Urology. 2002 Feb;59(2):240-4.
  • Savic G, Short DJ, Weizenkamp D, Charlifue S, Gardner BP. Hospital readmissions in people with chronic spinal cord injury. Spinal Cord 2000;38:371-7.
  • Thomas DG, Lucas MG: The urinary tract following spinal cord injury. In Chisolm GD, Fair WR (eds): Scientific Foundations of Urology. Chicago, Year Book Medical, 1990:286–99.
  • Vaidyanathan S et al. A review of the readmissions of patients with tetraplegia to Regional Spinal Injuries Centre, Southport, United Kingdom, between January 1994 and December 1995. Spinal Cord 1998;36:838-46.
  • West DA, Cummings JM, Longo WE, Virgo KS, Johnson FE, Parra RO. Role of chronic catheterization in the development of bladder cancer in patients with spinal cord injury. Urology. 1999 Feb;53(2):292-7.

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