Knowledge Gaps in Urologic Care of Female Spinal Cord Injury Patients

  • Seth Teplitsky
  • Alana Murphy
  • Patrick J. ShenotEmail author
Female Urology (L Cox, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Female Urology


Purpose of Review

We highlight the substantial gaps in knowledge on urologic care of female spinal cord injury (SCI) patients.

Recent Findings

Males account for approximately 80% of people living with SCI in developed nations. Although there is a robust body of literature in some aspects of urologic care of individuals with SCI, such as treatments for neurogenic detrusor overactivity, there are relatively few studies focusing specifically on females. There are also few studies focusing on other aspects of urologic care of women with SCI such as sexual dysfunction, pelvic organ prolapse, and bladder cancer. Established guidelines for bladder management exist, generally recommending intermittent catheterization, but the fact remains that a substantial number of women with SCI utilize indwelling catheters for bladder management. There remains a paucity of literature using patient-reported measures regarding both outcomes and experiences of urologic management in the SCI population.


Bladder management is challenging for many women with SCI. There are few studies on other urologic concerns in women with SCI.


Female Spinal cord injury Urologic management 


Compliance with Ethical Standards

Conflict of Interest

Seth Teplitsky and Alana Murphy each declare no potential conflicts of interest.

Patrick J. Shenot reports a grant from Ipsen and consulting fees from Merck.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Consortium for Spinal Cord Medicine. Bladder management for adults with spinal cord injury: a clinical practice guideline for health-care providers. J Spinal Cord Med. 2006;29(5):527–73.Google Scholar
  2. 2.
    Groen J, Pannek J, Castro Diaz D, Del Popolo G, Gross T, Hamid R, et al. Summary of European Association of Urology (EAU) Guidelines on Neuro-Urology. Eur Urol. 2016;69(2):324–33.PubMedCrossRefGoogle Scholar
  3. 3.
    Drake MJ, Apostolidis A, Cocci A, Emmanuel A, Gajewski JB, Harrison SC, et al. Neurogenic lower urinary tract dysfunction: clinical management recommendations of the Neurologic Incontinence committee of the fifth International Consultation on Incontinence 2013. Neurourol Urodyn. 2016;35(6):657–65.PubMedCrossRefGoogle Scholar
  4. 4.
    Shackelford M, Farley T, Vines CL. A comparison of women and men with spinal cord injury. Spinal Cord. 1998;36(5):337–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Biering-Sørensen F, Bickenbach JE, El Masry WS, Officer A, von Groote PM. ISCoS-WHO collaboration. International Perspectives of Spinal Cord Injury (IPSCI) report. Spinal Cord. 2011;49(6):679–83.PubMedCrossRefGoogle Scholar
  6. 6.
    National Spinal Cord Injury Statistical Center. Facts and figures at a glance. Birmingham: University of Alabama at Birmingham; 2018.Google Scholar
  7. 7.
    Lenehan B, Street J, Kwon BK, Noonan V, Zhang H, Fisher CG, et al. The epidemiology of traumatic spinal cord injury in British Columbia, Canada. Spine (Phila Pa 1976). 2012;37(4):321–9.CrossRefGoogle Scholar
  8. 8.
    Burke DA, Linden RD, Zhang YP, Maiste AC, Shields CB. Incidence rates and populations at risk for spinal cord injury: a regional study. Spinal Cord. 2001;39(5):274–8.PubMedCrossRefGoogle Scholar
  9. 9.
    • Savic G, DeVivo MJ, Frankel HL, Jamous MA, Soni BM, Charlifue S. Causes of death after traumatic spinal cord injury-a 70-year British study. Spinal Cord. 2017;55(10):891–7. This is a large observational study illustrating how the causes of mortality and morbidity in patients with chronic SCI have changed over the past 70 years. PubMedCrossRefGoogle Scholar
  10. 10.
    • Nahm LS, Chen Y, DeVivo MJ, Lloyd LK. Bladder cancer mortality after spinal cord injury over 4 decades. J Urol. 2015;193(6):1923–8. This study highlights the increased risk of development and high mortality rate of bladder cancer in women with SCI. PubMedCrossRefGoogle Scholar
  11. 11.
    Yang CC, Clowers DE. Screening cystoscopy in chronically catheterized spinal cord injury patients. Spinal Cord. 1999;37(3):204–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Gui-Zhong L, Li-Bo M. Bladder cancer in individuals with spinal cord injuries: a meta-analysis. Spinal Cord. 2017;55(4):341–5.PubMedCrossRefGoogle Scholar
  13. 13.
    Kalisvaart JF, Katsumi HK, Ronningen LD, Hovey RM. Bladder cancer in spinal cord injury patients. Spinal Cord. 2010;48(3):257–61.PubMedCrossRefGoogle Scholar
  14. 14.
    Groah SL, Weitzenkamp DA, Lammertse DP, Whiteneck GG, Lezotte DC, Hamman RF. Excess risk of bladder cancer in spinal cord injury: evidence for an association between indwelling catheter use and bladder cancer. Arch Phys Med Rehabil. 2002;83(3):346–51.PubMedCrossRefGoogle Scholar
  15. 15.
    Davies B, Chen JJ, McMurry T, Landsittel D, Lewis N, Brenes G, et al. Efficacy of BTA stat, cytology, and survivin in bladder cancer surveillance over 5 years in patients with spinal cord injury. Urology. 2005;66(4):908–11.PubMedCrossRefGoogle Scholar
  16. 16.
    Elmelund M, Klarskov N, Biering-Sørensen F. Prevalence of urinary incontinence in women with spinal cord injury. Spinal Cord. 2018;56(12):1124–33.PubMedCrossRefGoogle Scholar
  17. 17.
    Lewis RI, Lockhart JL, Politano VA. Periurethral polytetrafluoroethylene injections in incontinent female subjects with neurogenic bladder disease. J Urol. 1984;131(3):459–62.PubMedCrossRefGoogle Scholar
  18. 18.
    Bennett JK, Green BG, Foote JE, Gray M. Collagen injections for intrinsic sphincter deficiency in the neuropathic urethra. Paraplegia. 1995;33(12):697–700.PubMedGoogle Scholar
  19. 19.
    De Vocht TF, Chrzan R, Dik P, Klijn AJ, De Jong TP. Long-term results of bulking agent injection for persistent incontinence in cases of neurogenic bladder dysfunction. J Urol. 2010;183(2):719–23.PubMedCrossRefGoogle Scholar
  20. 20.
    Mcguire EJ, Lytton B. Pubovaginal sling procedure for stress incontinence. J Urol. 1978;119(1):82–4.PubMedCrossRefGoogle Scholar
  21. 21.
    Chancellor MB, Erhard MJ, Kiilholma PJ, Karasick S, Rivas DA. Functional urethral closure with pubovaginal sling for destroyed female urethra after long-term urethral catheterization. Urology. 1994;43(4):499–505.PubMedCrossRefGoogle Scholar
  22. 22.
    Athanasopoulos A, Gyftopoulos K, McGuire EJ. Treating stress urinary incontinence in female patients with neuropathic bladder: the value of the autologous fascia rectus sling. Int Urol Nephrol. 2012;44(5):1363–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Fontaine E, Bendaya S, Desert JF, Fakacs C, Le Mouel MA, Beurton D. Combined modified rectus fascial sling and augmentation ileocystoplasty for neurogenic incontinence in women. J Urol. 1997;157(1):109–12.PubMedCrossRefGoogle Scholar
  24. 24.
    Hamid R, Khastgir J, Arya M, Patel HR, Shah PJ. Experience of tension-free vaginal tape for the treatment of stress incontinence in females with neuropathic bladders. Spinal Cord. 2003;41(2):118–21.PubMedCrossRefGoogle Scholar
  25. 25.
    Pannek J, Bartel P, Gocking K. Clinical usefulness of the transobturator sub-urethral tape in the treatment of stress urinary incontinence in female patients with spinal cord lesion. J Spinal Cord Med. 2012;35(2):102–6.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Losco GS, Burki JR, Omar YA, Shah PJ, Hamid R. Long-term outcome of transobturator tape (TOT) for treatment of stress urinary incontinence in females with neuropathic bladders. Spinal Cord. 2015;53(7):544–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Abdul-Rahman A, Attar KH, Hamid R, Shah PJ. Long-term outcome of tension-free vaginal tape for treating stress incontinence in women with neuropathic bladders. BJU Int. 2010;106(6):827–30.PubMedCrossRefGoogle Scholar
  28. 28.
    Sakalis VI, Floyd MS, Caygill P, Price C, Hartwell B, Guy PJ, et al. Management of stress urinary incontinence in spinal cord injured female patients with a mid-urethral tape - a single center experience. J Spinal Cord Med. 2018;41(6):703–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Murphy S, Rea D, O'Mahony J, McDermott TE, Thornhill J, Butler M, et al. A comparison of the functional durability of the AMS 800 artificial urinary sphincter between cases with and without an underlying neurogenic aetiology. Ir J Med Sci. 2003;172(3):136–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Kavanagh A, Afshar K, Scott H, MacNeily AE. Bladder neck closure in conjunction with enterocystoplasty and Mitrofanoff diversion for complex incontinence: closing the door for good. J Urol. 2012;188(4 Suppl):1561–5.PubMedCrossRefGoogle Scholar
  31. 31.
    Kreuter M, Taft C, Siösteen A, Biering-Sørensen F. Women's sexual functioning and sex life after spinal cord injury. Spinal Cord. 2011;49(1):154–60.PubMedCrossRefGoogle Scholar
  32. 32.
    Saurí J, Chamarro A, Gilabert A, Gifre M, Rodriguez N, Lopez-Blazquez R, et al. Depression in individuals with traumatic and nontraumatic spinal cord injury living in the community. Arch Phys Med Rehabil. 2017;98(6):1165–73.PubMedCrossRefGoogle Scholar
  33. 33.
    Kreuter M, Siösteen A, Biering-Sørensen F. Sexuality and sexual life in women with spinal cord injury: a controlled study. J Rehabil Med. 2008;40(1):61–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Ferreiro-Velasco ME, Barca-Buyo A, de la Barrera SS, Montoto-Marqués A, Vázquez XM, Rodríguez-Sotillo A. Sexual issues in a sample of women with spinal cord injury. Spinal Cord. 2005;43(1):51–5.PubMedCrossRefGoogle Scholar
  35. 35.
    Matzaroglou C, Assimakopoulos K, Panagiotopoulos E, Kasimatis G, Dimakopoulos P, Lambiris E. Sexual function in females with severe cervical spinal cord injuries: a controlled study with the Female Sexual Function Index. Int J Rehabil Res. 2005;28(4):375–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Merghati-Khoei E, Emami-Razavi SH, Bakhtiyari M, Lamyian M, Hajmirzaei S, Ton-Tab Haghighi S, et al. Spinal cord injury and women's sexual life: case-control study. Spinal Cord. 2017;55(3):269–73.PubMedCrossRefGoogle Scholar
  37. 37.
    Fakhri A, Pakpour AH, Burri A, Morshedi H, Zeidi IM. The Female Sexual Function Index: translation and validation of an Iranian version. J Sex Med. 2012;9(2):514–23.PubMedCrossRefGoogle Scholar
  38. 38.
    Sipski ML, Alexander CJ, Rosen R. Sexual arousal and orgasm in women: effects of spinal cord injury. Ann Neurol. 2001;49(1):35–44.PubMedCrossRefGoogle Scholar
  39. 39.
    Courtois F, Alexander M, McLain ABJ. Women's sexual health and reproductive function after SCI. Top Spinal Cord Inj Rehabil. 2017;23(1):20–30.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Komisaruk BR, Whipple B, Crawford A, Liu WC, Kalnin A, Mosier K. Brain activation during vaginocervical self-stimulation and orgasm in women with complete spinal cord injury: fMRI evidence of mediation by the vagus nerves. Brain Res. 2004;1024(1–2):77–88.PubMedCrossRefGoogle Scholar
  41. 41.
    Hubscher CH. Ascending spinal pathways from sexual organs: effects of chronic spinal lesions. Prog Brain Res. 2006;152:401–14.PubMedCrossRefGoogle Scholar
  42. 42.
    Courtois F, Charvier K. Sexual dysfunction in patients with spinal cord lesions. Handb Clin Neurol. 2015;130:225–45.PubMedCrossRefGoogle Scholar
  43. 43.
    Alexander MS, Biering-Sørensen F, Elliott S, Kreuter M, Sønksen J. International spinal cord injury female sexual and reproductive function basic data set. Spinal Cord. 2011;49(7):787–90.PubMedCrossRefGoogle Scholar
  44. 44.
    Dasgupta R, Wiseman OJ, Kanabar G, Fowler CJ, Mikol D. Efficacy of sildenafil in the treatment of female sexual dysfunction due to multiple sclerosis. J Urol. 2004;171(3):1189–93 discussion 93. PubMedCrossRefGoogle Scholar
  45. 45.
    Alexander MS, Rosen RC, Steinberg S, Symonds T, Haughie S, Hultling C. Sildenafil in women with sexual arousal disorder following spinal cord injury. Spinal Cord. 2011;49(2):273–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Mayer M, Stief CG, Truss MC, Uckert S. Phosphodiesterase inhibitors in female sexual dysfunction. World J Urol. 2005;23(6):393–7.PubMedCrossRefGoogle Scholar
  47. 47.
    Rosen RC. Sexual function assessment and the role of vasoactive drugs in female sexual dysfunction. Arch Sex Behav. 2002;31(5):439–43.PubMedCrossRefGoogle Scholar
  48. 48.
    Gao Z, Yang D, Yu L, Cui Y. Efficacy and safety of Flibanserin in women with hypoactive sexual desire disorder: a systematic review and meta-analysis. J Sex Med. 2015;12(11):2095–104.PubMedCrossRefGoogle Scholar
  49. 49.
    Jaspers L, Feys F, Bramer WM, Franco OH, Leusink P, Laan ET. Efficacy and safety of Flibanserin for the treatment of hypoactive sexual desire disorder in women: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(4):453–62.PubMedCrossRefGoogle Scholar
  50. 50.
    Alexander M, Bashir K, Alexander C, Marson L, Rosen R. Randomized trial of clitoral vacuum suction versus vibratory stimulation in neurogenic female orgasmic dysfunction. Arch Phys Med Rehabil. 2018;99(2):299–305.PubMedCrossRefGoogle Scholar
  51. 51.
    Guess MK, Connell KA, Chudnoff S, Adekoya O, Richmond C, Nixon KE, et al. The effects of a genital vibratory stimulation device on sexual function and genital sensation. Female Pelvic Med Reconstr Surg. 2017;23(4):256–62.PubMedCrossRefGoogle Scholar
  52. 52.
    Wan L, Liu X. Delayed-onset advanced pelvic organ prolapse after spinal cord injury in a young, nulliparous woman. Int Urogynecol J. 2016;27(5):825–7.PubMedCrossRefGoogle Scholar
  53. 53.
    • Dillon BE, Seideman CA, Lee D, Greenberg B, Frohman EM, Lemack GE. A surprisingly low prevalence of demonstrable stress urinary incontinence and pelvic organ prolapse in women with multiple sclerosis followed at a tertiary neurogenic bladder clinic. J Urol. 2013;189(3):976–9. This study confirms the low incidence of pelvic organ prolapse in a pure SCI population as with many studies of SCI individuals. In many areas of SCI research, studies of comorbidities prior to SCI are severely lacking. PubMedCrossRefGoogle Scholar
  54. 54.
    Elmelund M, Biering-Sørensen F, Bing MH, Klarskov N. Pelvic organ prolapse and urogynecological assessment in women with spinal cord injury. Spinal Cord. 2019;57(1):18–25.PubMedCrossRefGoogle Scholar
  55. 55.
    Cameron AP, Wallner LP, Tate DG, Sarma AV, Rodriguez GM, Clemens JQ. Bladder management after spinal cord injury in the United States 1972 to 2005. J Urol. 2010;184(1):213–7.PubMedCrossRefGoogle Scholar
  56. 56.
    •• Nevedal A, Kratz AL, Tate DG. Women's experiences of living with neurogenic bladder and bowel after spinal cord injury: life controlled by bladder and bowel. Disabil Rehabil. 2016;38(6):573–81. A large multi-institutional study using collaborative study using patient reported outcome measures showing high satisfaction with augmentation cystoplasty patients with neurogenic bladder. PubMedCrossRefGoogle Scholar
  57. 57.
    Myers JB, Lenherr SM, Stoffel JT, Elliott SP, Presson AP, Zhang C, et al. The effects of augmentation cystoplasty and botulinum toxin injection on patient-reported bladder function and quality of life among individuals with spinal cord injury performing clean intermittent catheterization. Neurourol Urodyn. 2019;38(1):285–94.PubMedCrossRefGoogle Scholar
  58. 58.
    Ginsberg D, Gousse A, Keppenne V, Sievert KD, Thompson C, Lam W, et al. Phase 3 efficacy and tolerability study of onabotulinumtoxinA for urinary incontinence from neurogenic detrusor overactivity. J Urol. 2012;187(6):2131–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Seth Teplitsky
    • 1
  • Alana Murphy
    • 1
  • Patrick J. Shenot
    • 1
    Email author
  1. 1.Department of Urology, Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaUSA

Personalised recommendations