Skip to main content

Non-surgical urologic management of neurogenic bladder after spinal cord injury

World Journal of Urology volume 36, pages 1555–1568 (2018)Cite this article

Abstract

Purpose

To review the available data on non-surgical management for neurogenic bladder in patients with spinal cord injury (SCI). Before the introduction of urinary catheters and antibiotics, neurogenic bladder was one of the main culprits for death in those patients with SCI. Currently, the management of neurogenic bladder is focused in improving quality of life and preserving renal function.

Methods

A literature review was performed and therapeutic management for neurogenic bladder was divided in six sections: (1) intermittent bladder catheterization; (2) indwelling catheters; (3) condom catheter drainage; (4) reflex voiding and bladder expression with Valsalva or Credé; (5) oral drug therapy of the spinal cord injured bladder; and (6) botulinum neurotoxin (BoNT).

Results

Intermittent catheterization is recommended as the preferable method for management of neurogenic bladder in patients with SCI based on limited high-quality data. However, this may not be feasible or available to all and other alternative options include condom catheter drainage or indwelling catheters such as urethral catheters or suprapubic tube, reflex voiding, and bladder expression with Valsalva or Credé. Non-invasive medical therapies are the key to improve incontinence, urodynamic parameters, and quality of life in this population. Botulinum neurotoxin has revolutionized the management of neurogenic bladder in the last two decades decreasing the need for reconstruction or diversion.

Conclusion

The Joint SIU-ICUD (Société Internationale d’Urologie) (International Consultation on Urological Diseases) International Consultation reviewed the available presented data and provided specific conclusions and recommendations for each non-surgical urologic method to address neurogenic bladder after SCI.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1

References

  1. Hackler RH (1977) A 25-year prospective mortality study in the spinal cord injured patient: comparison with the long-term living paraplegic. J Urol 117(4):486–488

    CAS  PubMed  Article  Google Scholar 

  2. Frankel HL, Coll JR, Charlifue SW et al (1998) Long-term survival in spinal cord injury: a fifty year investigation. Spinal Cord 36(4):266–274

    CAS  PubMed  Article  Google Scholar 

  3. Abrams P, Agarwal M, Drake M et al (2008) A proposed guideline for the urological management of patients with spinal cord injury. BJU Int 101(8):989–994

    Article  PubMed  Google Scholar 

  4. Consortium for Spinal Cord M (2006) Bladder management for adults with spinal cord injury: a clinical practice guideline for health-care providers. J Spinal Cord Med 29(5):527–573

    Google Scholar 

  5. Esclarin De Ruz A, Garcia Leoni E, Herruzo Cabrera R (2000) Epidemiology and risk factors for urinary tract infection in patients with spinal cord injury. J Urol 164(4):1285–1289

    CAS  PubMed  Article  Google Scholar 

  6. Schurch B, Schmid DM, Stöhrer M (2000) Treatment of neurogenic incontinence with botulinum toxin A. N Engl J Med 342(9):665

    CAS  PubMed  Article  Google Scholar 

  7. Oxford Centre for Evidence-based Medicine, Levels of evidence (2009). http://www.cebm.net. Accessed 6 Sept 2017

  8. Guttmann L, Frankel H (1966) The value of intermittent catheterisation in the early management of traumatic paraplegia and tetraplegia. Paraplegia 4(2):63–84

    CAS  PubMed  Google Scholar 

  9. Lapides J, Diokno AC, Silber SJ, Lowe BS (1971) Clean, intermittent self-catheterization in the treatment of urinary tract disease. Trans Am Assoc Genitourin Surg 63:92–96

    CAS  PubMed  Google Scholar 

  10. Wyndaele JJ (2002) Intermittent catheterization: which is the optimal technique? Spinal Cord 40(9):432–437

    CAS  PubMed  Article  Google Scholar 

  11. De Ridder DJ, Everaert K, Fernández LG et al (2005) Intermittent catheterisation with hydrophilic-coated catheters (SpeediCath) reduces the risk of clinical urinary tract infection in spinal cord injured patients: a prospective randomised parallel comparative trial. Eur Urol 48(6):991–995

    PubMed  Article  Google Scholar 

  12. Wyndaele JJ (2002) Complications of intermittent catheterization: their prevention and treatment. Spinal Cord 40(10):536–541

    CAS  Article  PubMed  Google Scholar 

  13. Bakke A, Digranes A, Høisaeter PA (1997) Physical predictors of infection in patients treated with clean intermittent catheterization: a prospective 7-year study. Br J Urol 79(1):85–90

    CAS  PubMed  Article  Google Scholar 

  14. Wyndaele JJ, Maes D (1990) Clean intermittent self-catheterization: a 12-year followup. J Urol 143(5):906–908

    CAS  Article  PubMed  Google Scholar 

  15. Cox L, Cameron AP (2014) Prevention of urinary tract infection for patients with neurogenic bladder. Curr Bladder Dysfunct Rep 9(4):282–288

    Article  Google Scholar 

  16. Perrouin-Verbe B, Labat JJ, Richard I, Mauduyt de la Greve I, Buzelin JM, Mathe JF (1995) Clean intermittent catheterisation from the acute period in spinal cord injury patients. Long term evaluation of urethral and genital tolerance. Paraplegia 33(11):619–624

    CAS  PubMed  Google Scholar 

  17. Lewis RI, Carrion HM, Lockhart JL, Politano VA (1984) Significance of asymptomatic bacteriuria in neurogenic bladder disease. Urology 23(4):343–347

    CAS  PubMed  Article  Google Scholar 

  18. Nicolle LE, Bradley S, Colgan R et al (2005) Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 40(5):643–654

    Article  PubMed  Google Scholar 

  19. Vickrey BG, Shekelle P, Morton S, Clark K, Pathak M, Kamberg C (1999) Prevention and management of urinary tract infections in paralyzed persons. Evid Rep Technol Assess (Summ) 6:1–3

    Google Scholar 

  20. Barnes DG, Shaw PJ, Timoney AG, Tsokos N (1993) Management of the neuropathic bladder by suprapubic catheterisation. Br J Urol 72(2):169–172

    CAS  PubMed  Article  Google Scholar 

  21. MacDiarmid SA, Arnold EP, Palmer NB, Anthony A (1995) Management of spinal cord injured patients by indwelling suprapubic catheterization. J Urol 154(2 Pt 1):492–494

    CAS  PubMed  Article  Google Scholar 

  22. Nomura S, Ishido T, Teranishi J, Makiyama K (2000) Long-term analysis of suprapubic cystostomy drainage in patients with neurogenic bladder. Urol Int 65(4):185–189

    CAS  PubMed  Article  Google Scholar 

  23. Sugimura T, Arnold E, English S, Moore J (2008) Chronic suprapubic catheterization in the management of patients with spinal cord injuries: analysis of upper and lower urinary tract complications. BJU Int 101(11):1396–1400

    PubMed  Article  Google Scholar 

  24. Edokpolo LU, Foster HE Jr (2011) Suprapubic cystostomy for neurogenic bladder using Lowsley retractor method: a procedure revisited. Urology 78(5):1196–1198

    PubMed  Article  Google Scholar 

  25. Grundy DJ, Tromans AM, Cumming J (1996) Suprapubic catheterisation with urethral closure (the Feneley procedure) in spinal cord injured men. Paraplegia 34(2):93–94

    CAS  PubMed  Google Scholar 

  26. Lawrentschuk N, Lee D, Marriott P, Russell JM (2003) Suprapubic stab cystotomy: a safer technique. Urology 62(5):932–934

    PubMed  Article  Google Scholar 

  27. Hamid R, Peters J, Shah PJ (2002) Pitfall in insertion of suprapubic catheter in patients with spinal cord injuries. Spinal Cord 40(10):542–543

    CAS  PubMed  Article  Google Scholar 

  28. Ahluwalia RS, Johal N, Kouriefs C, Kooiman G, Montgomery BS, Plail RO (2006) The surgical risk of suprapubic catheter insertion and long-term sequelae. Ann R Coll Surg Engl 88(2):210–213

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  29. Mitsui T, Minami K, Furuno T, Morita H, Koyanagi T (2000) Is suprapubic cystostomy an optimal urinary management in high quadriplegics? A comparative study of suprapubic cystostomy and clean intermittent catheterization. Eur Urol 38(4):434–438

    CAS  PubMed  Article  Google Scholar 

  30. Katsumi HK, Kalisvaart JF, Ronningen LD, Hovey RM (2010) Urethral versus suprapubic catheter: choosing the best bladder management for male spinal cord injury patients with indwelling catheters. Spinal Cord 48(4):325–329

    CAS  PubMed  Article  Google Scholar 

  31. Shekelle PG, Morton SC, Clark KA et al (1999) Systematic review of risk factors for urinary tract infection in adults with spinal cord dysfunction. J Spinal Cord Med 22(4):258–272

    CAS  PubMed  Article  Google Scholar 

  32. Weld KJ, Dmochowski RR (2000) Effect of bladder management on urological complications in spinal cord injured patients. J Urol 163(3):768–772

    CAS  PubMed  Article  Google Scholar 

  33. Ku JH, Jung TY, Lee JK et al (2006) Influence of bladder management on epididymo-orchitis in patients with spinal cord injury: clean intermittent catheterization is a risk factor for epididymo-orchitis. Spinal Cord 44(3):165–169

    CAS  PubMed  Article  Google Scholar 

  34. Smart C (2014) Urinary sheaths for male incontinence. Br J Nurs 23(12):650–652

    PubMed  Article  Google Scholar 

  35. Jamison J, Maguire S, McCann J (2013) Catheter policies for management of long term voiding problems in adults with neurogenic bladder disorders. Cochrane Database Syst Rev 11:CD004375

    Google Scholar 

  36. Bang RL (1994) Penile oedema induced by continuous condom catheter use and mimicking keloid scar. Scand J Urol Nephrol 28(3):333–335

    CAS  PubMed  Article  Google Scholar 

  37. Golji H (1981) Complications of external condom drainage. Paraplegia 19(3):189–197

    CAS  PubMed  Google Scholar 

  38. Kawoosa NU (2011) Isolated gangrene of the penis in a paraplegic patient secondary to a condom catheter. Indian J Surg 73(4):304–306

    PubMed  PubMed Central  Article  Google Scholar 

  39. Ozkan HS, Irkoren S, Sivrioglu N (2015) Penile strangulation and necrosis due to condom catheter. Int Wound J 12(3):248–249

    PubMed  Article  Google Scholar 

  40. Fetsch JF, Davis CJ Jr, Hallman JR, Chung LS, Lupton GP, Sesterhenn IA (2004) Lymphedematous fibroepithelial polyps of the glans penis and prepuce: a clinicopathologic study of 7 cases demonstrating a strong association with chronic condom catheter use. Hum Pathol 35(2):190–195

    PubMed  Article  Google Scholar 

  41. Virseda-Chamorro M, Salinas-Casado J, Rubio-Hidalgo E, Gutierrez-Martin P, Esteban-Fuertes M (2015) Risk factors of urethral diverticula in male patients with spinal cord injury. Spinal Cord 53(11):803–806

    CAS  PubMed  Article  Google Scholar 

  42. Pidde TJ, Little JW (1994) Hydronephrosis due to improper condom catheter use. J Am Paraplegia Soc 17(4):168–170

    CAS  PubMed  Article  Google Scholar 

  43. Vaidyanathan S, Selmi F, Hughes PL, Singh G, Soni BM (2015) Urinary retention and acute kidney injury in a tetraplegic patient using condom catheter after partying: a preventable complication. Int Med Case Rep J 8:241–245

    PubMed  PubMed Central  Article  Google Scholar 

  44. Stelling JD, Hale AM (1996) Protocol for changing condom catheters in males with spinal cord injury. SCI Nurs 13(2):28–34

    CAS  PubMed  Google Scholar 

  45. Newman E, Price M (1985) External catheters: hazards and benefits of their use by men with spinal cord lesions. Arch Phys Med Rehabil 66(5):310–313

    CAS  PubMed  Google Scholar 

  46. Stoffel JT (2016) Detrusor sphincter dyssynergia: a review of physiology, diagnosis, and treatment strategies. Transl Androl Urol 5(1):127–135

    PubMed  PubMed Central  Google Scholar 

  47. Utomo E, Groen J, Blok BF (2014) Surgical management of functional bladder outlet obstruction in adults with neurogenic bladder dysfunction. Cochrane Database Syst Rev 5:CD004927

    Google Scholar 

  48. Pan D, Troy A, Rogerson J, Bolton D, Brown D, Lawrentschuk N (2009) Long-term outcomes of external sphincterotomy in a spinal injured population. J Urol 181(2):705–709

    PubMed  Article  Google Scholar 

  49. Wyndaele JJ, Madersbacher H, Kovindha A (2001) Conservative treatment of the neuropathic bladder in spinal cord injured patients. Spinal Cord 39(6):294–300

    CAS  PubMed  Article  Google Scholar 

  50. Cardenas DD, Kelly E, Mayo ME (1985) Manual stimulation of reflex voiding after spinal cord injury. Arch Phys Med Rehabil 66(7):459–462

    CAS  PubMed  Google Scholar 

  51. Groen J, Pannek J, Castro Diaz D et al (2016) Summary of European Association of Urology (EAU) guidelines on neuro-urology. Eur Urol 69(2):324–333

    Article  PubMed  Google Scholar 

  52. (NICE) NIfHaCE. Urinary incontinence in neurological disease. 2012. https://www.nice.org.uk/guidance/cg148/chapter/1-guidance. Accessed 8 Aug 2017

  53. Pannek J, Blok J, Castro-Diaz D, et al. Neurogenic lower urinary tract dysfunction. European Association of urology EAU Guidelines. 2013

  54. Medicine CfSC. Bladder management for adults with spinal cord injury: a clinical practice guideline for health-care providers. Consortium for Spinal Cord Medicine. 2006

  55. Stöhrer M, Madersbacher H, Richter R, Wehnert J, Dreikorn K (1999) Efficacy and safety of propiverine in SCI-patients suffering from detrusor hyperreflexia—a double-blind, placebo-controlled clinical trial. Spinal Cord 37(3):196–200

    PubMed  Article  Google Scholar 

  56. Madhuvrata P, Singh M, Hasafa Z, Abdel-Fattah M (2012) Anticholinergic drugs for adult neurogenic detrusor overactivity: a systematic review and meta-analysis. Eur Urol 62(5):816–830

    CAS  PubMed  Article  Google Scholar 

  57. Abrams P, Jackson S, Mattiasson A, Krishnan K, Haendler L. A randomised, double-blind, placebo controlled, dose ranging study of the safety and efficacy of tolterodine in patients with hyperreflexia. Paper presented at: proceedings of the international continence society 26th annual meeting, 1996

  58. Wöllner J, Pannek J (2016) Initial experience with the treatment of neurogenic detrusor overactivity with a new β-3 agonist (mirabegron) in patients with spinal cord injury. Spinal Cord 54(1):78–82

    PubMed  Article  Google Scholar 

  59. Kakizaki H, Ameda K, Kobayashi S, Tanaka H, Shibata T, Koyanagi T (2003) Urodynamic effects of α1-blocker tamsulosin on voiding dysfunction in patients with neurogenic bladder. Int J Urol 10(11):576–581

    CAS  PubMed  Article  Google Scholar 

  60. Chancellor M, Erhard M, Hirsch I, Stass W Jr (1994) Prospective evaluation of terazosin for the treatment of autonomic dysreflexia. J Urol 151(1):111–113

    CAS  PubMed  Article  Google Scholar 

  61. Ueda S, Satake N, Shibata S (1984) α1-and α2-adrenoceptors in the smooth muscle of isolated rabbit urinary bladder and urethra. Eur J Pharmacol 103(3):249–254

    CAS  PubMed  Article  Google Scholar 

  62. Wada N, Shimizu T, Takai S et al (2017) Combinational effects of muscarinic receptor inhibition and β3-adrenoceptor stimulation on neurogenic bladder dysfunction in rats with spinal cord injury. Neurourol Urodyn 36(4):1039–1045

    CAS  PubMed  Article  Google Scholar 

  63. Behr-Roussel D, Oger S, Caisey S et al (2011) Vardenafil decreases bladder afferent nerve activity in unanesthetized, decerebrate, spinal cord—injured rats. Eur Urol 59(2):272–279

    CAS  PubMed  Article  Google Scholar 

  64. Chancellor MB, Rivas DA, Staas WE Jr (1994) DDAVP in the urological management of the difficult neurogenic bladder in spinal cord injury: preliminary report. J Am Paraplegia Soc 17(4):165–167

    CAS  PubMed  Article  Google Scholar 

  65. Schurch B, Stohrer M, Kramer G, Schmid DM, Gaul G, Hauri D (2000) Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results. J Urol 164(3 Pt 1):692–697

    CAS  Article  PubMed  Google Scholar 

  66. Schurch B, de Seze M, Denys P et al (2005) Botulinum toxin type a is a safe and effective treatment for neurogenic urinary incontinence: results of a single treatment, randomized, placebo controlled 6-month study. J Urol 174(1):196–200

    CAS  PubMed  Article  Google Scholar 

  67. Herschorn S, Gajewski J, Ethans K et al (2011) Efficacy of botulinum toxin A injection for neurogenic detrusor overactivity and urinary incontinence: a randomized, double-blind trial. J Urol 185(6):2229–2235

    CAS  PubMed  Article  Google Scholar 

  68. Cruz F, Herschorn S, Aliotta P et al (2011) Efficacy and safety of onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity: a randomised, double-blind, placebo-controlled trial. Eur Urol 60(4):742–750

    CAS  Article  PubMed  Google Scholar 

  69. Ginsberg D, Gousse A, Keppenne V et al (2012) Phase 3 efficacy and tolerability study of onabotulinumtoxinA for urinary incontinence from neurogenic detrusor overactivity. J Urol 187(6):2131–2139

    CAS  PubMed  Article  Google Scholar 

  70. Apostolidis A, Thompson C, Yan X, Mourad S (2013) An exploratory, placebo-controlled, dose-response study of the efficacy and safety of onabotulinumtoxinA in spinal cord injury patients with urinary incontinence due to neurogenic detrusor overactivity. World J Urol 31(6):1469–1474

    CAS  PubMed  Article  Google Scholar 

  71. Schulte-Baukloh H, Michael T, Schobert J, Stolze T, Knispel HH (2002) Efficacy of botulinum—a toxin in children with detrusor hyperreflexia due to myelomeningocele: preliminary results. Urology 59(3):325–327 (discussion 327–328)

    CAS  PubMed  Article  Google Scholar 

  72. Denys P, Del Popolo G, Amarenco G et al (2017) Efficacy and safety of two administration modes of an intra-detrusor injection of 750 units dysport(R) (abobotulinumtoxinA) in patients suffering from refractory neurogenic detrusor overactivity (NDO): a randomised placebo-controlled phase IIa study. Neurourol Urodyn 36(2):457–462

    CAS  PubMed  Article  Google Scholar 

  73. Dickson EC, Shevky E (1923) Botulism. Studies on the manner in which the toxin of clostridium botulinum acts upon the body: II. The effect upon the voluntary nervous system. J Exp Med 38(4):327–346

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  74. Wöllner J, Schmidig K, Gregorini F, Kessler TM, Zbinden R, Mehnert U (2012) Is there a direct antimicrobial effect of botulinum neurotoxin type A? BJU Int 110(11 Pt C):E886–E890

    PubMed  Article  CAS  Google Scholar 

  75. Comperat E, Reitz A, Delcourt A, Capron F, Denys P, Chartier-Kastler E (2006) Histologic features in the urinary bladder wall affected from neurogenic overactivity—a comparison of inflammation, oedema and fibrosis with and without injection of botulinum toxin type A. Eur Urol 50(5):1058–1064

    CAS  PubMed  Article  Google Scholar 

  76. Jankovic J, Vuong KD, Ahsan J (2003) Comparison of efficacy and immunogenicity of original versus current botulinum toxin in cervical dystonia. Neurology 60(7):1186–1188

    CAS  PubMed  Article  Google Scholar 

  77. Kennelly M, Dmochowski R, Schulte-Baukloh H et al (2017) Efficacy and safety of onabotulinumtoxinA therapy are sustained over 4 years of treatment in patients with neurogenic detrusor overactivity: final results of a long-term extension study. Neurourol Urodyn 36(2):368–375

    CAS  PubMed  Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. University of Michigan, Ann Arbor, MI, USA

    Paholo G. Barboglio Romo & Anne P. Cameron

  2. Baylor College of Medicine, Houston, TX, USA

    Christopher P. Smith

  3. Dalhousie University, Halifax, NS, Canada

    Ashley Cox

  4. Moinhos de Vento Hospital, Porto Alegre, Brazil

    Márcio A. Averbeck

  5. Royal Melbourne Hospital, Victoria, Australia

    Caroline Dowling

  6. Centro Médico Nacional, Panama, Panama

    Cleveland Beckford

  7. Monash Health, Victoria, Australia

    Paul Manohar

  8. National Institute of Rehabilitation, Mexico City, Mexico

    Sergio Duran

  9. Division of Neurourology and Pelvic Reconstructive Surgery, Department of Urology, The University of Michigan Medical Center, 1500 East Medical Center Drive, Taubman Center 3875, Ann Arbor, MI, 48109-5330, USA

    Anne P. Cameron

Authors
  1. Paholo G. Barboglio Romo
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christopher P. Smith
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ashley Cox
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Márcio A. Averbeck
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Caroline Dowling
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Cleveland Beckford
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Paul Manohar
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Sergio Duran
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Anne P. Cameron
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All the authors whose names appear on the submission have contributed sufficiently and consented to submit this article for publication as specified below: PGBR: data collection or management, data analysis, manuscript writing, and editing. CPS, AC, MAA, CD, CB, and PM: data collection or management, data analysis, and manuscript writing. SD: data management and analysis, and manuscript editing. APC: project development, data collection or management, data analysis, manuscript writing, and editing.

Corresponding author

Correspondence to Anne P. Cameron.

Ethics declarations

Conflict of interest

The authors who reported conflict of interests were: Paholo G. Barboglio Romo: Co-Investigator for Covance/Ipsen. Márcio A. Averbeck: co-investigator for Covance/Ipsen; honorarium/proctor for Coloplast, Medtronic, GSK.

Informed consent

Anne P. Cameron: principal investigator for Medtronic (unpaid); speaker for Wellspect. Research consisted in literature review, data collection did not involve human or animal participants, and no informed consent was utilized.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Romo, P.G.B., Smith, C.P., Cox, A. et al. Non-surgical urologic management of neurogenic bladder after spinal cord injury. World J Urol 36, 1555–1568 (2018). https://doi.org/10.1007/s00345-018-2419-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00345-018-2419-z

Keywords

  • Neurogenic bladder
  • Anticholinergics
  • Botulinum toxin
  • Self-catheterization