Long-Term Intermittent Catheterization in the Spinal Cord Injury Patient

0022-5347 /82/1284-0760$02.00/0 Vol. 128, October Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright© 1982 by The Williams & Wilkins Co.

Urological Neurology and U rod ynamics LONG-TERM INTERMITTENT CATHETERIZATION IN THE SPINAL CORD INJURY PATIENT JOHN B. NANNINGA, Y. WU

AND

BYRON HAMILTON

From the Departments of Urology and Rehabilitation Medicine, Northwestern University Medical School and Rehabilitation Institute of Chicago, Chicago, Illinois

ABSTRACT

Intermittent catheterization was used as a means of long-term bladder management in 85 patients with spinal cord injury. Of these patients followup data revealed that 28 (33 per cent) had reflux and/or hydronephrosis. Treatment in 15 patients consisted of increasing the frequency of catheterization to every 4 hours and avoiding high fluid intake during a relatively short interval. Sphincterotomy was done in 3 patients, while 10 were placed on an indwelling catheter because of an inability to adapt to or refusal of other forms of treatment. The upper urinary tract changes noted seemed to be related to increased intravesical pressure, either from too long an interval between catheterizations or from marked detrusor hyperreflexia with sphincter obstruction. Close followup seems necessary in these patients. Intermittent catheterization has been used as a means of draining the paralyzed bladder. 1• 2 The urinary tract is believed to be less likely to become infected with elimination of the indwelling urethral catheter, which also has been shown to decrease the incidence of bladder calculus, urethral fistula and epididymitis. Recently, intermittent catheterization has been used as a nonsterile technique to achieve long-term bladder emptying. 3 The nonsterile technique is less expensive and also allows the patient to learn catheterization more easily. Although the risk of urinary infection seems higher with the nonsterile technique, the frequency of catheterization every 4 hours seems to achieve an acceptable incidence of clinical urinary infection. 3 •4 Also, the use of intermittent catheterization has spared patients with neurogenic bladder dysfunction from diversion of the urinary tract into a bowel conduit. Finally, reflux in patients with neurogenic bladder dysfunction has been shown to disappear with the use of intermittent catheterization as a method of long-term management. 5 Thus, the advantages of intermittent catheterization have been documented. We have followed 85 patients with neurogenic bladder dysfunction after spinal cord injury who have been managed by intermittent catheterization for an extended interval. We herein document what changes, if any, occurred in the urinary tract during this interval. From our study it appears that not all patients are suitable candidates for prolonged intermittent catheterization. The reasons for this finding are discussed.

was consistently > 150 ml. Followup ranged from 6 months to 5 years, with a mean of 11 months. Of the patients about twothirds were paraplegic, approximately 75 per cent with complete lesions, and a third were quadriplegic, approximately 40 per cent with complete lesions. Female patients comprised 16 per cent of the total population. Some of the male patients were offered sphincterotomy but they elected to continue on longterm intermittent catheterization. Early in the study some patients would perform catheterization 2 to 3 times per 24 hours. This frequency subsequently was increased to every 4 to 6 hours for all patients based on evidence that bacterial doubling time is such that the bacterial colony count in the bladder can be kept down by more frequent catheterizations. 6 With the development of smaller, portable catheter kits the patients found that catheterizations could be performed relatively easily and inexpensively in a sterile manner. 7 Followup evaluation consisted of an excretory urogram (IVP) and cystogram done at 6-month intervals unless clinical problems indicated a more immediate evaluation. Urine cultures were obtained at least once within the first 6 months or when indicated clinically by signs of fever, cloudy urine or hematuria. In a few selected patients monitoring of bacteriuria was by the dip slide method, which, if positive, was followed by standard urine culture. Serum blood urea nitrogen and creatinine were obtained at 6-month intervals.

METHODS

RESULTS

We have used sterile intermittent catheterization as a method of long-term bladder management in 85 patients with spinal cord injury who had been on intermittent catheterization during the interval of spinal shock. The patients were continued on intermittent catheterization when it became apparent that there was persistent detrusor areflexia, or that residual urine

Followup data revealed that 28 of 85 patients (33 per cent) had either reflux (12 patients) or changes on the IVP ranging from ureterectasis to hydroureteronephrosis (16 patients) (figs. 1 and 2). Of these 28 patients 11 had an elevation of the serum creatinine to >1.5. Of the total 85 patients 64 (75 per cent) experienced at least 1 documented urinary tract infection (count > 10 5) while on intermittent catheterization and another 16 were found to have bacteriuria when an indwelling catheter was inserted because of hydronephrotic change on x-ray. Thus, in all likelihood >90 per cent of the patients had been or were

Accepted for publication February 5, 1982. Supported in part by National Institute of Handicapped Research Grant No. 13-59113-5, Office of Human Development Services, Department of Health, Education and Welfare, Washington, D. C.

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LONG-TERM I}•ITERMITTEN·T CATHETERIZATIOJ\T Il>J SPil\fA_L CORD INJURY PATIEl\Ff

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FIG. 1. IVP in 19-year-old male paraplegic. A, reflux on right side after approximately 8 months of intermittent self-catheterization. B reflux disappeared when patient followed strict schedule of catheterization every 4 hours. '

FIG. 2. A, IVP in patient with injury at TIO level. Detrusor reflex failed to develop after several months and patient was maintained on intermittent catheterization. Frequency between catheterizations was lengthened to 2 to 3 times per 24 hours during 6-month interval. Hydronephrotic changes are apparent. B, x-rays were improved dramatically within 2 months after frequency of catheterization was increased to every 4 to 6 hours.

infected. Bladder calculi were believed to be related to the longterm intermittent catheterization in 1 patient. Treatment in 15 patients consisted of increasing the frequency of catheterization to every 4 hours and avoiding high fluid intake during a relatively short interval (1 to 2 hours). It was found that these patients had decreased the frequency of catheterization for convenience or economic reasons. Transurethral sphincterotomy was performed in 3 patients who demonstrated marked obstruction at the level of the striated sphincter during a detrusor contraction. Indwelling urethral catheterization or suprapubic cystotomy was used in 10 patients because of an inability to adapt to or refusal of other forms of treatment.

DISCUSSION

The reason for the changes in the upper urinary tract noted on the IVP and cystogram would seem to be related to the onset of increased intravesical pressure. 8 Urodynamic studies demonstrated the increased intravesical pressure as the bladder filled or frequent detrusor contractions and sphincter dyssynergia (figs. 3 and 4). As a group, these patients had been continent between catheterizations when they began intermittent catheterization but had noticed the onset of voiding or at least passage of small amounts of urine. Pharmacological agents (propantheline or oxybutinin) were prescribed for these patients in an effort to keep them dry but these drugs were not effective

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NANNINGA, WU AND HAMILTON

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FIG. 3. Combined sphincter electromyogram (top line) and cystometrogram (bottom line) was done 6 months after injury because of ureterectasis on x-ray in male patient on intermittent catheterization with fracture to Tll. We believe that relatively high intravesical pressure between volumes of 200 to 300 ml. accounts for this finding. Patient was treated by regulating fluid intake and catheterization every 4 hours.

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as a rule in preventing the upper urinary tract changes seen on x-ray. Several studies have not noted any renal deterioration on the IVP while patients were on intermittent catheterization. 3• 5• 9 These reports did include patients with bladder dysfunction associated with meningomyelocele, who tend to have a more stable neurological lesion. However, 1 report did note renal deterioration in 3 of 12 patients evaluated by x-ray. 10 Thus, in patients with evolving neurologic lesions that produce bladder dysfunction the possibility of the bladder changing from a low to a high pressure type must be considered. If we had been more alert to those patients in whom increased detrusor pressure or detrusor hyperreflexia was developing we might have prevented the hydronephrotic changes and/or reflux in 15, thus making only 13 of 85 (15 per cent) who required other therapy. Also, our study, as others, does indicate that elimination of reflux or hydronephrotic changes will occur when catheterization is performed every 4 hours. Urinary infection remains a problem, although it may not be detrimental in these patients. As has been shown, there is fluctuation in the colony counts so that the patient is not necessarily in constant danger. 4 However, we hope to have a more detailed report on infection rates in the future. It would seem that close monitoring is necessary in patients on intermittent catheterization for an extended interval after spinal cord injury. Because bladder function is evolving the patient and physician must assume that the conditions under which intermittent catheterization was initiated will not necessarily remain constant. Also, those patients with lesions of the sacral cord and an areflexic bladder on initial evaluation may have increased intravesical pressure later in the recovery period and be at risk. Close followup seems necessary to avoid the changes described herein. REFERENCES

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FIG. 4. Sphincter electromyogram and cystometrogram 6 months after injury in 20-year-old male quadriplegic show detrusor contractions and coinciding bursts of sphincter activity. Patient had unilateral reflux 3 months later despite catheterizations every 4 hours. He presently wears indwelling urethral catheter.

1. Guiteras, R.: Urology: The Diseases of the Urinary Tract in Men and Women. New York: D. Appleton & Co., vol. 2, p. 255, 1912. 2. Guttmann, L. and Frankel, H.: The value of intermittent catheterization in the early management of traumatic paraplegia and tetraplegia. Paraplegia, 4: 63, 1966. 3. Lapides, J., Diokno, A. C., Gould, F. R. and Lowe, B. S.: Further observations on self-catheterization. J. Urol., 116: 169, 1976. 4. Anderson, R. U.: Non-sterile intermittent catheterization with antibiotic prophylaxis in the acute spinal cord injured male patient. J. Urol., 124: 392, 1980. 5. Kass, E. J., Koff, S. A. and Diokno, A. C.: Fate of vesicoureteral reflux in children with neuropathic bladders managed by intermittent catheterization. J. Urol., 125: 63, 1981.

LONG-TERM INTERMITTENT CATHETERIZATION IN SPINAL CORD INJURY PATIENT

6. Hinrnan, F., Jr.: Intermittent catheterization and vesical defense. J. Urol., 117: 57, 1977. 7. Wu, Y., King, R. B., Hamilton, B. B. and Betts, H. B.: RIC-Wu catheter kit: new device for an old problem. Arch. Phys. Med. Rehabil., 61: 455, 1980. 8. Butler, E. D., Jr., Friedland, G. W. and Govan, D. E.: Radiological study of the effect of elevated intravesical pressures on ureteral calibre and peristalsis in patients with neurogenic bladder dysfunction. Clin. Rad., 22: 198, 1971. 9. Wyndaele, J. J., Oosterlinck, W. and De Sy, W.: Clean intermittent self-catheterization in the chronic management of the neurogenic bladder. Eur. Urol., 6: 107, 1980. 10. Withycombe, J., Whitaker, R. and Hunt, G.: Intermittent catheterization in the management of children with neuropathic bladder. Lancet, 2: 981, 1978. EDITORIAL COMMENT This report, when read in conjunction with the study by Maynard and Diokno, 1 illustrates quite vividly the important facets of a successful regimen for clean, intermittent, self-catheterization. Catheteriz-ation must be frequent enough to prevent high intravesical pressures and overdistension, since these are the underlying causes of cystitis, ureteral reflux, hydroureteronephrosis and pyelonephritis. Although attempts to use a sterile catheterization technique are commendable in the milieu of an operating suite, it is definitely not useful in the self-catheterization program, since the additional effort and material required for an aseptic technique predispose to infrequent catheterization, marked increase in

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cost and abandonment of the method. One cannot overen1phasize that there is a great difference between bacteriuria and cystitis just as there is between bacteria on the skin and pyoderma, flora in the gut and colitis, pathogens in the oral cavity and pharyngitis and so forth. The difficulty in assigning a primary role to factors affecting host resistance, that is high intravesical pressures, vesical overdistension and relegating bacteria or bacteriuria to a secondary position, probably is responsible for the slow acceptance of the clean, self-catheterization program by physicians and a number of the failures of acceptable candidates placed on a regimen not incorporating the concept involving the importance of host resistance in the genesis of infection. In view of the excellent long-term results of the intermittent, clean, self-catheterization technique, the regimen should be presented to properly selected patients as the treatment of choice for management of bladder dysfunction. Operative procedures are last resort measures when viewed in the light of distortion of normal structure, operative risk and costs associated with surgery, that is professional fee, hospital charges, outpatient visits and so forth. Jack Lapides Department of Surgery Section of Urology University of Michigan Medical Center Ann Arbor, Michigan 1. Maynard, F. M. and Diokno, A. C.: Clean intermittent catheteri-

zation for spinal cord patients. J. Urol., 128: 477, 1982.