What is the recommended bladder training protocol at home for patients with transverse myelitis?

Bladder Training Protocol for Patients with Transverse Myelitis

Clean intermittent catheterization (CIC) every 4-6 hours while awake is the gold standard for managing neurogenic bladder in transverse myelitis patients, with each catheterization yielding less than 500mL to prevent bladder over-distension. 1

Assessment and Initial Management

• Evaluate bladder dysfunction type through urodynamic studies to determine:

  • Detrusor overactivity (most common, ~48% of cases)
  • Impaired detrusor contractility (~30%)
  • Poor bladder compliance (~15%)
  • Detrusor-sphincter dyssynergia
  • Post-void residual volume 1, 2

• Measure post-void residual (PVR) using portable ultrasound

  • PVR >100mL indicates need for intermittent catheterization 3
  • PVR should be assessed before initiating bladder training protocol

Bladder Training Protocol

For Patients with Detrusor Overactivity (Overactive Bladder)

1. Catheterization Schedule:

   • Begin with CIC every 4-6 hours while awake 1
   • Adjust frequency based on volumes obtained (target <500mL per catheterization)
   • Consider nighttime catheterization if significant overnight volumes

2. Pharmacological Management:

   • First-line: Antimuscarinic medications (e.g., oxybutynin 0.2 mg/kg three times daily) 3, 1
   • Alternative: Beta-3 adrenergic receptor agonists (e.g., mirabegron) if antimuscarinic side effects are problematic 1

3. Behavioral Techniques:

   • Timed voiding schedule every 2-3 hours during waking hours 3
   • Urgency suppression techniques (quick pelvic floor contractions when urgency occurs)
   • Fluid management (2-3L per day unless contraindicated, avoid evening fluids) 1
   • Avoid bladder irritants (caffeine, alcohol, acidic foods) 3

For Patients with Detrusor Underactivity (Retention)

1. Catheterization Schedule:

   • Begin with CIC every 4-6 hours while awake 1
   • If catheter volumes are consistently <30mL for 24 hours, increase interval to every 8 hours, then every 12 hours, then every 24 hours 3
   • May discontinue CIC if residuals remain <30mL and renal ultrasound shows no significant hydronephrosis 3

2. Pharmacological Management:

   • Consider alpha-blockers to improve bladder emptying by reducing outlet resistance 1
   • Avoid antimuscarinic medications unless there is concomitant detrusor overactivity

3. Voiding Techniques:

   • Double voiding (attempt to void, wait a few minutes, then try again)
   • Credé maneuver (gentle pressure on lower abdomen) if not contraindicated
   • Valsalva maneuver (bearing down) if not contraindicated

Monitoring and Follow-up

1. Regular Assessment:

   • Maintain a bladder diary documenting:
     • Fluid intake (amount and timing)
     • Voiding times and volumes
     • Incontinence episodes
     • Catheterization volumes 3

2. Renal Protection Monitoring:

   • Renal ultrasound every 6-12 months to assess for hydronephrosis 1, 4
   • Urodynamic studies at baseline and periodically (every 1-2 years) to assess for changes in bladder function 1, 2
   • Urinalysis and culture if symptoms of UTI develop 1

3. Protocol Adjustments:

   • If persistent incontinence despite antimuscarinic therapy, consider increasing dose or adding a second agent
   • For refractory cases, consider intradetrusor botulinum toxin injections (53% of transverse myelitis patients eventually require this) 2
   • Bladder augmentation surgery may be necessary in ~5% of cases with persistent high pressures 2

Cautions and Complications Prevention

• Maintain proper catheterization technique to prevent UTIs
• Avoid bladder over-distension (>500mL) which can lead to autonomic dysreflexia in patients with lesions above T6 1
• Monitor for upper tract changes, as 26% of patients may develop hydronephrosis if CIC is delayed beyond 2 years after disease onset 4
• Early institution of CIC appears to preserve bladder compliance and decrease upper tract disease 4

Special Considerations for Pediatric Patients

• All pediatric patients with transverse myelitis require baseline renal ultrasound and urodynamic evaluation regardless of symptoms 4
• Urodynamic abnormalities may be present despite normal neurological examination 4
• Early institution of CIC should be implemented at disease onset 4

This protocol should be adjusted based on individual urodynamic findings, as transverse myelitis can cause varying patterns of bladder dysfunction, with up to 86% of patients experiencing persistent bladder dysfunction despite recovery of motor and sensory function 2, 4.