What are the guidelines for post spinal cord injury (SCI) bladder management?

Guidelines for Post Spinal Cord Injury Bladder Management

Intermittent catheterization is the gold standard for bladder management after spinal cord injury, as it reduces urinary tract infections, urolithiasis, and increases probability of urination continence compared to other methods. 1

Primary Bladder Management Approach

• Implement intermittent catheterization as soon as the patient is medically stable 2, 1
• Remove indwelling catheters as early as possible to minimize urological risks 1
• Establish a regular catheterization schedule, typically every 4-6 hours, maintaining urine volume below 500 mL per collection 2
• Use clean catheterization technique as standard practice, with sterile technique reserved for patients with recurrent symptomatic infections 2
• Consider hydrophilic catheters as they are associated with fewer UTIs and less hematuria 2, 3

Proper Catheterization Technique

• Teach proper hand hygiene using antibacterial soap or alcohol-based cleaners before and after catheter insertion 2
• Use catheters for single use only as per manufacturer guidelines; reuse increases UTI frequency 2
• Perform daily catheter hygiene, including cleaning of the perineal region and proximal catheter with soap and water for patients with indwelling catheters 2
• Maintain a micturition calendar to adapt frequency and schedule of intermittent catheterization 2

Infection Prevention and Management

• Maintain adequate hydration with recommended fluid intake of 2-3 L per day unless contraindicated 2
• Do not routinely prescribe antibiotic prophylaxis to prevent symptomatic UTI 2
• Consider antibiotic prophylaxis only for patients with recurrent UTIs (defined as three or more UTIs per year with positive culture and symptoms) 2
• Do not use cranberry products, methenamine salts, or acidification/alkalinization products for UTI prevention as they lack proven efficacy 2
• During acute UTIs, lower bladder pressure by increasing frequency of bladder emptying and consider anticholinergic drugs 2

Pharmacological Management

• Consider anticholinergic medications and clean intermittent catheterization as first-line management for individuals with SCI who cannot empty their bladder 2
• For neuropathic pain management, consider gabapentinoid treatment for more than 6 months, potentially in combination with tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient 2

Monitoring and Follow-up

• Perform regular assessment of bladder function to ensure adequate emptying and prevent complications 4
• Monitor for signs of UTI, but recognize that asymptomatic bacteriuria is common and should not be treated with antibiotics 1
• Avoid relying on urine odor, cloudiness, or pyuria alone to diagnose UTI in asymptomatic patients 1
• Be vigilant for urethral complications such as strictures and false passages, which may increase with length of follow-up 3

Common Pitfalls to Avoid

• Delaying removal of indwelling catheters, which increases risk of urological complications 1
• Treating asymptomatic bacteriuria, which can lead to antimicrobial resistance 1
• Catheterizing too frequently (increases risk of cross-infection) or too infrequently (results in high bladder storage volumes) 2
• Reusing catheters, which significantly increases UTI frequency 2
• Inadequate hand hygiene or perineal care, which increases infection risk 2