What is the neurogenic bladder protocol for patients with spinal cord injuries?

From the Guidelines

The neurogenic bladder protocol for patients with spinal cord injuries involves a comprehensive management approach that typically begins with intermittent catheterization every 4-6 hours to prevent bladder overdistension and maintain pressures below 40 cmH2O, as recommended by the most recent guidelines 1. This approach is crucial in preventing upper urinary tract damage and maximizing quality of life and independence. The protocol should include:

• Intermittent catheterization every 4-6 hours to keep the amount of urine obtained to less than 500 mL per collection, as suggested by the European Association of Urology 1
• Anticholinergic medications such as oxybutynin or tolterodine to reduce detrusor overactivity and prevent high bladder pressures
• Alpha-blockers like tamsulosin may be added to decrease outlet resistance
• For patients with persistent incontinence, a combination of clean intermittent catheterization and anticholinergics is often necessary
• Urodynamic studies should be performed initially and repeated annually to assess bladder function and adjust management accordingly
• Patients should maintain adequate fluid intake (2-3 liters daily) while avoiding bladder irritants like caffeine and alcohol, as recommended by the Australian Institute of Sport and the Australian Paralympic Committee 1
• Regular monitoring for urinary tract infections is essential, though prophylactic antibiotics are not routinely recommended
• OnabotulinumtoxinA injections may be considered for patients with spinal cord injury or multiple sclerosis refractory to oral medications, as recommended by the AUA/SUFU guideline 1

Key considerations in the management of neurogenic bladder include:

• Hand hygiene and clean catheterization technique to minimize the risk of urinary tract infections 1
• Daily catheter hygiene, including cleaning of the perineal region and proximal catheter with soap and water for patients with an indwelling catheter
• Patients using intermittent catheterization should use catheters for single use only, as per manufacturer guidelines 1
• Adequate hydration may also decrease the risk of developing urinary tract infections 1

From the Research

Neurogenic Bladder Protocol

The neurogenic bladder protocol for patients with spinal cord injuries typically involves a combination of management strategies to ensure low pressure reservoir function of the bladder, complete emptying, and dryness.

• Management typically begins with anticholinergic medications and clean intermittent catheterization 2
• Patients who fail this treatment because of inefficacy or intolerability are candidates for a spectrum of more invasive procedures, including endoscopic management to relieve bladder outlet resistance, such as sphincterotomy, botulinum toxin injection, and stent insertion 2
• Coordinated bladder emptying is possible with neuromodulation in selected patients 2
• Bladder augmentation, usually with an intestinal segment, and urinary diversion are considered last resort options 2

Treatment and Follow-up

A multi-center, cross-sectional study found that the most frequently used technique for bladder rehabilitation in patients with spinal cord injury was intermittent catheterization (77.9%), and 63.2% of patients used anticholinergic drugs, with oxybutynin being the most commonly used drug 3

• The study also found that 77% of patients had regular control visits for neurogenic bladder, and 42.7% did not experience any urinary tract infections 3
• A phenotype-based approach to neurogenic bladder can help guide surgical management, categorizing patients by failure to store and failure to empty, with a focus on catheterizable channels, bladder augmentation, and bladder outlet procedures 4

Urodynamic Findings

A descriptive study of urodynamic findings in patients with spinal cord injury found that unfavorable urodynamic parameters, such as detrusor overactivity and detrusor sphincter dyssynergia, were observed in 90% of patients within the first year after injury 5

• The study highlights the importance of early treatment based on urodynamic findings to reduce the risk of deterioration of upper and lower urinary tract function, and improve long-term outcomes 5
• Another study investigated the effectiveness of early sacral nerve stimulation as an adjunct to standard neurogenic bladder management following acute spinal cord injury, and found that it may prevent neurogenic detrusor overactivity and preserve bladder capacity and compliance 6