Page 9 - Diagnosis, management, and surveillance of neurogenic lower urinary tract dysfunction – Full text

Guideline: Neurogenic bladder

Antimicrobial prophylaxis ing induces bladder drainage via an increase in abdominal
pressure that can overcome the external urethral sphincter.
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A meta-analysis of 15 randomized controlled trials did not It can be inefficient and risk high pressures and cause hem-
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support the use of oral antibiotic prophylaxis for NLUTD orrhoids, hernias, and VUR. Spontaneous reflex voiding
UTI. Three of the included studies reported an approximately can occur with stimulation of the sacral or lumbar derma-
two-fold increase in antimicrobial resistance with oral anti- tomes by suprapubic tapping in some patients with upper
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microbial prophylaxis. Therefore, at this time, routine anti- motor neuron lesions. Condom catheter drainage is often
microbial prophylaxis for NLUTD UTI is not recommended used to collect urine in these non-catheter methods and,
for most patients (GOR A, LOE 1). therefore, are more common in male patients. Additionally,
Currently, evidence is insufficient to recommend routine males with cervical level lesions without the dexterity for
use of any non-antimicrobial prophylaxis measure, includ- CIC may select condom drainage. For patients using these
ing phytotherapy (e.g., cranberry), probiotics, methenamine non-catheter methods, regular screening with ultrasound and
salts, urine acidification, D-Mannose, oral immunostimula- UDS should be done to avoid complications such as incom-
tion, or bacterial interference. plete emptying causing UTIs or stones, as well as dangerous
elevated detrusor pressures. 5,95
Autonomic dysreflexia
Catheter mechanisms
Autonomic dysreflexia (AD) a well-known clinical emergency
in subjects who have had an SCI. It typically occurs in patients The options for catheter mechanisms to provide bladder
with an injury at level T6 or above. Physiologically, AD is drainage include: CIC, indwelling urethral catheterization
caused by a massive sympathetic discharge triggered by either and SP. While every attempt should be made to use the
a noxious or non-noxious stimulus originating below the level gold standard of CIC introduced by Lapides in 1972, prac-
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of the SCI. Strategies for acute treatment of emergent AD titioners must understand the limitations of CIC outlined by
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events have been thoroughly addressed elsewhere. Recent Elliot, which include: 1) limited upper extremity motor
data suggests that intravesical injection of onabotulintoxinA function; 2) anatomic limitations (female or obese); and 3)
decreases the frequency and severity of AD episodes. 90 limited functional bladder capacity (poor compliance or
DO). In a review by Binard, the ideal person for CIC has a
Treatment of NLUTD low Pdet at capacity; a minimum volume of 350–400 cc;
an unobstructed urethra; and is compliant, understanding,
continent, and cooperative with adequate hand function.
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Assisted bladder drainage Practitioners may need to use medical means, such as anti-
cholinergics, beta-3 agonists, or onabotulinumtoxin A, or
NLUTD can result in impaired bladder emptying. Over 75% surgical means, such as augmentation cystoplasty or cath-
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of SCI patients are unable to void on their own. The best eterizable stoma, to facilitate successful CIC. While CIC is
method of bladder emptying, which preserves renal func- the gold standard, it isn’t without complications, including
tion and minimizes the risks of urinary tract complications pain for those with sensation, UTI, and stricture forma-
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such as UTIs and renal or bladder stones, must be balanced tion estimated at 4–13% from recent reports despite using
against QoL implications, such as comfort, convenience, hydrophilic catheters.
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and continence. QoL cannot be ignored, as highlighted The debate regarding the ideal catheter for those performing
in a review by McIntyre where SCI patients who could void CIC does not have a clear winner. Options for patients include:
normally had the highest QoL ratings followed by those who single-use disposable catheters that may be non-hydrophilic
could micturate with assistance or perform CIC themselves, (uncoated), hydrophilic (coated), or include a gel reservoir.
while the worst QoL came when an indwelling catheter Alternatively, due to financial limitations, many patients still
(IC or SP) or CIC by an attendant was required. This is reuse uncoated catheters by various unstudied cleaning pro-
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an important reminder to continuously re-evaluate NLUTD tocols (such as washing with warm soapy water and allowing
patients’ selected drainage method and balance the risks to air dry, and replacing the catheter after a week or when
and benefits of their choice. there is visible wear). A recent Cochrane review from 2014 on
the issue of catheter reuse was withdrawn after Christison et
Non-catheter mechanisms al identified several flaws in the data extraction and conclu-
sions; their revised analysis found that hydrophilic catheters
The non-catheter mechanisms rely on involuntary emptying offered a small but significantly lower incidence of UTI and
that is either induced or spontaneous. The Crede manoeu- they reported a trend that favours single-use catheters over
ver (external pressure on the bladder) and Valsalva void- repeated multiple use. The authors clearly state that, “until

CUAJ • June 2019 • Volume 13, Issue 6 E165