Acute Management of the Bladder in SCI/D

1. Pathophysiology in Acute Stage

  • Primary goal of bladder management from day 1 in acute SCI is to achieve low pressure storage, avoiding bladder overdistension and reducing urinary tract infection rate.
  • Spinal shock results in detrusor areflexia and retention. For some reason there is function of the internal sphincter and closure of the bladder neck which is the reason for the urinary retention. For more information, please refer to this
  • Occasionally one encounters a male patient whose spinal cord injury occurred after a transurethral prostatic resection. In that case crede voiding could be used in stead of intermittent catheterization until better function of the external sphincter evolves even though that is rarely done.
  • Spinal shock lasts a variable time but is generally longer in high complete injuries.
  • Retention is universal and continuous or intermittent catheterization must be employed to permit bladder emptying and protect the bladder from a superimposed over distention injury. The latter can be associated with permanent retention

2. Managements

  • Chief goal is preservation of urinary tract integrity both anatomically and functionally.
  • If no direct genitourinary trauma or flank hematuria is present or after urethral integrity has been ensured, the bladder should be decompressed with a Foley catheter [Fehlings 1996]. Generally patients are managed with Foley catheters in the very first stages of their injury. Repeated distention beyond 500ml may damage the bladder wall, causing fibrosis and aggravating an already dysfunctional bladder [Wheeler 1993].
  • When the general medical condition is stable, the catheter is removed and the patient is switched to intermittent catheterization [McBride 1994]. If the patients have good hand function, the patients can be trained to do their own intermittent catheterization, thus beginning early independent bladder care [Wheeler 1993]. Sterile intermittent catheterization can be performed in the hospital to avoid any nosocomial infection, but at home intermittent catheterization can be done by the clean technique [Wheeler 1993]. For more information, please refer to this
  • In cases where intermittent catheterization proves difficult to perform in acute stage because of pelvic bone fracture, penile, urethral or pelvic floor injuries, suprapubic tube may be an alternative option [Zermann 2000]
  • Prophylactic antibiotics are not given just for urethral catheter indwelling, and bladder colonization is permitted [McBride 1994]. For more information, please refer to this
  • Patient understanding and compliance are crucial to successful urological management. Early on, it is important for the patients to understand the goals of urological management and the problems that they are currently facing and will face in the future [Wheeler 1993]. For more information, please refer to this
  • For a case example, please refer to this

3. Bladder Drainage Issue

  • Virtually all would agree that CIC is best
  • Urethral indwelling
  • Suprapubic catheters
  • Few claimed no differences in outcome when a small-bore Foley catheter or suprapubic tube is used at this stage [Lloyd 1986]. However, outcomes here were short term and reported in terms of creatinine clearance and renal scan data.
Key Points of This Section
  • Spinal shock is associated with loss of reflex bladder contractility, but preservation of internal sphincter function and urinary retention. There is a general loss of visceral and somatic reflex function below the lesion. As somatic and visceral reflexes are recovered, reflex bladder contractility is also recovered.
  • Keep in mind that reflex functional recovery means incontinence in most circumstances. Anticholinergic therapy is probably best if started early, as bladder dysfunction will evolve toward higher voiding and storage pressures and increased risk. Anticholinergic treatment does not impair recovery of normal reflex activity if that occurs and impairs the bladder response to a dis-coordinate sphincter.

References

  • Lloyd LK, Kuhlemeier KV, Fine PR, Stover SL. Initial bladder management in spinal cord injury: does it make a difference? J Urol. 1986 Mar;135(3):523-7.
  • Fehlings MG, Louw D. Initial stabilization and medical management of acute spinal cord injury. Am Fam Physician. 1996 Jul;54(1):155-62.
  • McBride DQ, Rodts GE. Intensive care of patients with spinal trauma. Neurosurg Clin N Am. 1994 Oct;5(4):755-66.
  • Zermann D, Wunderlich H, Derry F, Schroder S, Schubert J. Audit of early bladder management complications after spinal cord injury in first-treating hospitals. Eur Urol. 2000 Feb;37(2):156-60.
  • Wheeler JS Jr, Walter JW. Acute urologic management of the patient with spinal cord injury. Initial hospitalization. Urol Clin North Am. 1993 Aug;20(3):403-11.

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