The neurogenic bladder in spinal cord injury--pattern and management

This study describes the various types of neurogenic bladder in spinal cord injury in relation to the level of lesion, defines the aims of bladder management, and discusses the importance of highly individualised management strategies and long-term follow-up. Urodynamic studies were done on 47 new patients with traumatic spinal cord injury when they had return of reflexic bladder activity. This study was conducted over a one-year period. Fifty-five per cent (n = 26) sustained cervical injuries (38.5% complete, 61.5% incomplete), 12.8% (n = 6) had thoracic injuries, 29.8% (n = 14) had lumbar injuries, and 2.1% (n = 1) had sacral injury. The urodynamic patterns according to injury level are shown in Table I. In patients with complete cervical injuries, 80% had detrusor sphincter dyssynergia (DSD), and areflexia was seen in 20% (n = 2). Of those with incomplete cervical injury, 7 (43.8%) had DSD, 5 (31.3%) had detrusor hyperrflexia without DSD, and 2 (12.5%) had areflexia or hyporeflexia. Normal urodynamic studies were only found in patients with incomplete cervical injury (n = 2). Of the 6 patients with thoracic injury, 4 (66.6%) had detrusor areflexia and 2 had DSD. The 2 patients with DSD had injury levels at T4/T6 and T5 respectively. Eleven (78.6%) patients with lumbar injury had detrusor areflexia, one (7.1%) had detrusor hyperreflexia (without DSD), and 2 (14.3%) had a normal urodynamic study. The various patterns of bladder management are shown in Table II. In total, there were 17 patients with DSD. Of these, 9 (52.9%) elected for intermittent catheterisation together with pharmacological therapy, 5 (29.4%) passed urine via spontaneous voiding/tapping, one (5.9%) had an in-dwelling catheter by virtue of his lack of manual dexterity and no care-giver, and 2 (11.8%) patients opted for sacral anterior root stimulator (SARS) or the Brindley device. Of the 6 patients with detrusor hyperreflexia, 4 (66.7%) passed urine spontaneously and 2 (33.3%) patients choose intermittent catheterisation together with pharmacologic therapy. There were 20 patients with detrusor areflexia/hyporeflexia; 15 (75%) were on clean intermittent catheterisation, 4 (20%) voided via straining and 1 (5%) had a suprapubic catheter inserted. The re-discovery of intermittent self-catheterisation, improved medical care, bladder training and surgical advances have enabled the goals of bladder management to be realised; namely safe bladder pressures, low residual urine volume and the attainment of continence.