Hypothesis / aims of study
Life expectancy of patients with spinal cord injury (SCI) has not improved since the 1980’s. Nevertheless, attention for and preservation of renal function, introduction of and improvements in antibiotics, and the increased awareness of the options for bladder management have made the complications of neurogenic bladder to become a rare cause of death in patients with SCI. Bladder management in neurogenic bladder can still lead to debilitating complications: urinary stones, urinary tract infections, urinary tract fistulae, strictures and erosions, and cancer. These complications are more prevalent in patients with an indwelling catheter compared to patients emptying through clean intermittent (self) catheterisation [CI(S)C] (1). Apart from limiting the risk of complications, the bladder management plan in patients with SCI is aimed at safe and efficient storage of urine (continence) and independence, thereby allowing full social participation. The percentage of patients with SCI aged over 60 has risen sharply in developed countries, which may influence both lesion characteristics and choice for or ability to perform certain methods of bladder management.
Despite its importance in patients with SCI, little is known about the changes made in bladder management during first inpatient rehabilitation. The aim of this study is to describe the methods of bladder management in patients with recently acquired SCI at both admission to and discharge from a rehabilitation centre and to evaluate the factors that are associated with each method of bladder management at discharge.
Study design, materials and methods
In this multicentre prospective observational study, data from the Dutch Spinal Cord Injury Database (2) were used. Patients with SCI admitted to one of the eight specialized rehabilitation centres in the Netherlands for their first inpatient rehabilitation between 2015 and 2019 were included.
According to the International SCI Lower Urinary Tract Basic Data Set (3), standardized data were collected at admission and discharge, including demographics, lesion characteristics [level and American Spinal Injury Association Impairment Scale (AIS)] and method of bladder management. Independence was measured through the Spinal Cord Independence Measure (SCIM) score. Presence of urinary incontinence, and use of containment devices and medication were also recorded.
The level of statistical significance was set at p<0.05 and was corrected for multiple testing when using post-hoc analyses. The McNemar-Bowker test was used for paired testing of categorical variables, and Chi-square for non-paired analysis of categorical data. One Way ANOVA was used for continuous variables and the Games Howell test or Tukey for post-hoc analysis. Data are presented as N (number), percentage, median (range) or mean ± standard deviation.
A total of 1403 SCI patients were included, 905 (65%) were male, mean age was 56.8±16.3 years, and 544 (39%) had a traumatic aetiology. The level of SCI was cervical in 44%, thoracic in 38% and lumbosacral in 18%. AIS scale was A in 12%, B in 9%, C in 15% and D in 64%. The median time between date of SCI and admission to the rehabilitation centre was 22 (14-40) days and the median duration of admission was 71 (44-115) days.
The method of bladder management at discharge changed significantly compared to admission (Table 1 – p<0.001). Specifically there was a transition from assisted CIC and indwelling catheter to normal voiding (both p<0.001) and to CISC (both p<0.001).
The method of bladder management at discharge differed significantly based on age, gender, SCI level, AIS classification and SCIM score (all p<0.001).
Compared to patients discharged with an indwelling catheter (65.5±13.7 years), patients who void normally (56.9±15.3 years), use CISC (50.9±17.3 years) or assisted CIC (55.6±17.3 years) are significantly younger (all p<0.001). Patients using CISC are also significantly younger than SCI patients voiding normally (p<0.001).
Men more often perform CISC (27% vs 14% in women, p<0.001) and women more often are discharged with an indwelling catheter (22% vs 13% in men, p<0.001).
The method of bladder management at discharge in relation to SCI level and AIS classification is presented in Table 2. Patients with a cervical lesion more often void normally, whereas patients with a thoracic and lumbosacral more often perform CISC in comparison to patients with a cervical lesion. There is an inverse relation between normal voiding and completeness of injury. The relation between CISC and completeness of injury is direct on the other hand.
Finally, patients discharged with normal voiding (12.0±5.6) and CISC (11.9±5.3) had a higher SCIM score than patients discharged with assisted CIC (5.4±5.5) and with indwelling catheter (6.1±5.2) (all p<0.001).
At discharge 13% of the patients had urinary incontinence of which 37% used incontinence pads, 34% used a condom catheter, 1% used a different type of containment and 27% did not use any type of containment.
Out of the total patient population 12% used bladder relaxant drugs (antimuscarinics or beta3-agonists), 4% used alpha blockers, 2% used antibiotics for a urinary tract infection and 0.2% used prophylactic antibiotics at discharge.
Interpretation of results
The large population in this multicentre prospective observational study on the changes in methods of bladder management during first inpatient rehabilitation after SCI has the characteristics of a SCI population in a developed country, as indicated by the age, level and AIS classification of the cohort.
In line with current principles of best practice there is a transition from assisted CIC and indwelling catheter use at admission to CISC and normal voiding at discharge. These latter methods of bladder management reduce the risk of complications and increase the patients’ independence. Nevertheless, 16% of patients are discharged with an indwelling catheter.
Age and gender are associated with method of bladder management if normal voiding is not possible: patients using CISC are younger, whereas age increases in patients with assisted CIC and indwelling catheters. Men more often perform CISC than women and women more often have an indwelling catheter than men, possibly due to anatomical and functional barriers as women need to transfer to perform CISC.
If normal voiding is not possible, patients with thoracic and lumbosacral lesions, and with more complete lesions more often perform CISC. Patients with cervical lesions perform CISC significantly less, possibly due to limitations caused by hand function and transfer capability.
Remarkably, 13% of patients were discharged with urinary incontinence. This may be explained by the setting of first inpatient rehabilitation and these patients may suffer from refractory neurogenic detrusor overactivity or sphincter deficiency requiring more invasive treatment. Urology review in the Netherlands usually occurs 3-6 months after SCI (unless indicated otherwise) with (video-)urodynamic studies to evaluate bladder (dys)function and therefore often takes place after discharge from first inpatient rehabilitation.