Urological Management of the Spinal Cord-Injured Patient: Suggestions for Improving Intermittent Catheterization and Reflex Voiding

Abstract

Spinal cord injury can either be complete with no neural communication across the injury level or incomplete with limited communication. Similarly, motor neuron injuries above the sacral spinal cord are classified as upper motor neuron injuries, while those inside the sacral cord are classified as lower motor neuron injuries. Specifically, we provide recommendations regarding the urological management of complete upper motor neuron spinal cord injuries; however, we also make limited comments related to other injuries. The individual with a complete upper motor neuron injury may encounter five lower urinary tract conditions: first, neurogenic detrusor overactivity causing urinary incontinence; second, neurogenic detrusor underactivity resulting in high post-void residual volumes; third, detrusor sphincter dyssynergia, which is contraction of striated and/or smooth muscle urethral sphincters during detrusor contractions; fourth, urinary tract infection; and fifth, autonomic dysreflexia during detrusor contractions, which produces high blood pressure as well as smooth muscle detrusor sphincter dyssynergia. Intermittent catheterization is the recommended urinary management method because it addresses the five lower urinary tract conditions and has good long-term outcomes. This method uses periodic catheterizations to drain the bladder, but also needs bladder inhibitory interventions to prevent urinary incontinence between catheterizations. Primary limitations associated with this management method include difficulties with the multiple catheterizations, side effects of bladder inhibitory medications, and urinary tract infections. Three suggestions to address these concerns include the use of low-friction catheters, wireless, genital-nerve neuromodulation for bladder inhibition, and consideration of urine egress into the urethra as a risk factor for UTI as well as egress treatment. The second management method is reflex voiding. This program uses external condoms for urine collection in males and diapers for females. Suprapubic tapping is used to promote bladder contractions. This method is not recommended because it has high rates of medical complications. In particular, it is associated with high detrusor pressure, which can lead to ureteral reflux and kidney pathology. Botulinum toxin injection into the urethral striated sphincter can manage detrusor sphincter dyssynergia, reduce voiding pressures, and risks to the kidney. We suggest a modified method for botulinum toxin injections as well as five additional methods to improve reflex voiding outcomes. Finally, the use of intermittent catheterization and reflex voiding for individuals with incomplete spinal injuries, lower motor neuron injuries and multiple scleroses are briefly discussed.