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Treatment

Treatment goals

• Protect upper tracts: avoid high-pressure bladder that refluxes to upper tracts
• Minimize UTIs: ensure adequate emptying/drainage, avoid unnecessary antibiotics
• Avoid leakage: provide acceptable and realistic urinary drainage, ensure patient/caregiver can perform
• NGB adjuncts: optimize bowel and sexual function

Low-risk patients

• Pelvic floor PT: beneficial in properly selected patients, low risk
• Passive voiding: only viable if low-pressure bladder and minimal outlet resistance, can void into diaper, use valsalva or crede
• Neuromodulation: sacral or posterior tibial, consider for low risk patients with storage symptoms who spontaneously void, not recommended for SCI or spina bifida (response too variable)

Retention

• Catheter: optimizes bladder drainage, can be urethral, suprapubic, or CIC via urethra or catheterizable channel
• Alpha blockers: decreases outlet resistance
• Botox: reduces bladder contractility, can use 200-300U, no specific injection location/pattern, transient effects
• Sphincterotomy: can perform for male patients managing with condom catheter, but high risk of failure and need for repeat procedures

Incontinence

• Anticholinergics and B-3 agonists: reduces detrusor overactivity, decreases leakage between CIC
• Outlet obstruction: manage SUI, can consider bulking agents (low overall efficacy), slings (avoid synthetic if needing CIC), or artificial sphincter
• Bladder neck closure: consider for refractory SUI, may be beneficial with simultaneous augment if poorly compliant or low capacity bladder, fistulization risk up to 25%

End-stage bladder (poor compliance, resistant to more conservative treatments)

• Augment: improves volume to reduce CIC frequency, best option for poorly compliant bladder, complications 15-17%, low risk for bladder cancer (0.6-4.5%)
• Catheterizable channel: recommended for bladder neck closure, urethral strictures, or female patients desiring CIC, stenosis occurs in 4-32%
• Diversion: last-resort for high pressure low volume contracted bladder
• Ileovesicostomy: alternative to augment and diversion if unable to CIC, no need for ureteral anastomosis, potentially reversible
• Simple cystectomy: avoids risk of pyocystis
• Spence procedure: iatrogenic vesicovaginal fistula to prevent pyocystis

Specific management issues

Urinary tract infections

• Difficult to accurately diagnose UTI in patients with catheter use, no clearly sensitive or specific signs
• Screening: not warranted, risks > benefits
• Ideal treatment criteria: bacteruria, suspicious signs/symptoms, and no other infectious source
• Collection: place new catheter, plug to have urine build up, do not collect form tubing or bag
• Imaging indications: persistent fevers despite antibiotics, no recent upper tract imaging in moderate/high risk patients
• "Recurrent" UTI: frequency not defined, perform non-contrast upper tract imaging and cystoscopy to assess for a source, consider UDS if workup otherwise negative
• Prophylaxis: not recommended for indwelling catheters to prevent UTI, not recommended for CIC in absence of rUTI, can consider for CIC with rUTI but risk for increased antibiotic resistance
• Irrigation: can consider saline or antibiotic irrigation or instillation, although unclear benefits

Catheterizatoin

• Intermittent catheterization (CIC): provides lower UTI risk compared to urethral catheter or SPT, no increased UTI risk for clean catheterization vs sterile catheterization, pre-lubricated tend to be easier and more comfortable
• Indwelling catheter: suprapubic catheter overall preferred for long-term management, overall low risks for placement and exchange, urethral vs suprapubic have same infectious risks
• Hydrophilic catheters: may provide some benefit for UTI and urethral trauma (specific benefits unclear)
• Potential benefit to volume-dependent catheterization compared to time-dependent catheterization

Autonomic Dysreflexia

• Cause: sympathetic response to stimulus if SCI above T6, presents with headache + HTN + bradycardia + flushing/sweating
• Stimuli: bladder/rectal distension, urethral stimulation (catheter, UDS probes)
• Treatments: remove stimulus, apply 1-2 inches of 2% nitroglycerin paste above level of lesion, IV nitroprusside or B-blockers if IV access available, terazosin/prazosin, nifedipine 10mg sublingual (risk of hypotension)
• Prevention: lidocaine gel for clinic procedures, use monitors