Role of Medication Combined with CIC

Case: bladder management in a 49 year old male with erectile dysfunction

A 49-year-old C7 SCI gentleman had a motorcycle accident in 1986 which resulted erectile dysfunction, and a neurogenic bladder. He previously have tried CIC but failed due to leakage. Previous treatment with anticholinergic agents caused significant side effects. He typically has been wearing a condom catheter and catheterizing only once a day for high residuals.

He has a significant history of four previous attempts at insertion of a penile prosthesis, but each resulted in later and removal. He is anxious to get another artificial penile prosthesis implantation as soon as is feasible.

Optimal bladder management program was discussed to get him free of condom catheterization thereby to minimize further potential prosthesis infections. After placing him on a regimen of imipramine 10mg bid and oxybutynin, extended release formulation, he has remained dry and catheterizing every 4-5 hours without difficulty, discomfort, infections, or leaking. He is quite pleased with his regimen, and he is anxious to resume his quest for a penile prosthesis.  

Comments and Lessons: Generally condom catheter drainage is not very successful. In an effort to avoid leakage these devices may be very tightly secured, so that penile skin ulceration and obstructed voiding are produced. Urines collected from patients treated by condom catheter devices are always infected and the association of infected urine and a tightly compressed penile shaft are factors in failure of the penile prosthesis. This patient has a relatively low neural lesion, and one must do urodynamic study to be certain that the proximal urethra actually functions. The major reason for failure of patients to continue intermittent catheterization is incontinence. In those patients with incontinence related to detrusor pressure, i.e. a detrusor contraction of poor compliance medication usually will provide for interval continence. Where proximal urethral function is lost; as a result of a T12-L1 level injury, no drug therapy will resolve incontinence. To make that diagnosis, and upright (or nearly upright cystogram, or video urodynamic study will show a non-functional bladder outlet and severe stress incontinence. Obviously that will not be improved by anticholinergic medication. In these cases a perineal sling, a periprostatic sling or a bladder neck artificial genitourinary sphincter are required. These three choices all will permit long term intermittent catheterization.

 

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