The burst catheter balloon: A comparison of fragmentation rates and overinflation burst volumes in Foley catheters with special considerations in SCI.

OBJECTIVE: The primary aim was to determine Foley catheter balloon burst volumes and the effect of latex Foley catheter size on balloon burst volume. The secondary aim was to measure the effect of Foley catheter material on free fragment formation rate. This study also focused on special considerations for those with neurogenic bladder and spinal cord injury at or above T6. METHODS: This study analyzed 83 various sized silicone (n = 14) and latex (n = 69) Foley catheters. All catheters had 5 mL balloons. Each catheter was overinflated in vitro with water until the balloon ruptured, with volume (mL) and fragment formation recorded upon rupture. The effect of catheter size on the number of free fragments and burst volume was measured with linear regression. The likelihood of free fragment formation was compared between silicone and latex catheters with significance measured using Fisher's Exact Test. RESULTS: Free fragment formation occurred in 90% (62/69) of the latex catheters compared to 0% (0/14) of the silicone catheters. A higher proportion of free fragment formation occurred in latex catheters when compared to silicone catheters (P < 0.001). There was a positive effect of catheter size on burst volume (P < 0.001). CONCLUSION: Balloon rupture by overdistention is an effective way to remove a retained catheter due to a non-deflating balloon. Post-bursting free fragment formation is common in latex balloons. This highlights the need for cystoscopy. Additionally, due to large fluid volumes needed to burst the balloon, this method should be discouraged in those at risk for autonomic dysreflexia.

Comparing the role of renal ultrasound vs MAG3 renal scans for evaluation of neurogenic bladder after spinal cord injury.

OBJECTIVE: Compare ability of renal ultrasound and Tc-99m mercaptoacetyltriglycine (MAG3) renal scan to identify upper urinary tract stasis. DESIGN: Retrospective chart review. SETTING: Outpatient Neuro-urology clinic serving a large SCI population. PARTICIPANTS: One hundred and sixty-five individuals with spinal cord injury, presenting for annual evaluation. INTERVENTIONS: Renal ultrasound, MAG3 renal scan. OUTCOME MEASURES: Radiologic evidence of upper urinary tract stasis as reviewed by independent radiologist. For renal ultrasounds, this included: mild hydronephrosis, dilation of collecting systems, pelviectasis, or caliectasis. For MAG3 renal scans, this included evidence of slow drainage of radioisotope, dilation of collecting systems, or reverse peristalsis. RESULTS: Forty-five individuals with spinal cord injury demonstrated upper tract stasis, with 12 identified by renal ultrasound and 43 identified by MAG3 renal scan. There was a strong relative correlation between test results (Yule's Q = 0.90), though MAG3 renal scan identified a significantly higher rate of upper tract stasis within the same patients (P < 0.0001). The odds ratio of improved identification using MAG3 renal scan was 16.5 (95% CI 3.96-68.76). CONCLUSIONS: While renal ultrasound is more effective at evaluating renal anatomy, MAG3 renal scan identifies significantly more upper urinary tract stasis than renal ultrasound and should be considered for SCI individuals with risk factors of upper tract injury.

Onset of the action of intravesical lidocaine after spinal cord injury.

AIMS: To obtain objective evidence for the time to onset of action for intravesical lidocaine utilizing exaggerated sympathetic blood-pressure responsiveness in patients with spinal cord injuries (SCI). METHODS: This prospective observational cohort study analyzed blood pressure responses in individuals with SCI at or above T6 who did (lidocaine-instillation group) or did not (control group) receive 10 ml of 2% lidocaine gel instilled through their catheters before routine suprapubic catheter change. Care was taken to minimize any potentially confounding position change or catheter manipulation. Given the potential for C-fiber mediated systolic blood pressure (SBP) increases after SCI, the time to lidocaine's onset of action for blocking these C-fibers (as seen by the decrease in SBP more than and equal to 10 mm Hg) was assessed with serial blood pressures for 4 to 6 minutes. RESULTS: Blood pressures were evaluated in 32 individuals with SCI (lidocaine-instillation group n = 22, control group n = 10). In the lidocaine-instillation group, 45% individuals demonstrated a sustained decrease in SBP more than and equal to 10 mm Hg, which occurred at a mean of 98.1 seconds (SD 59 seconds) after lidocaine instillation. Despite up to 6 minutes of serial monitoring, the remainder of the lidocaine-instillation group and the entire control group had SBP fluctuations less than 10 mm Hg. The serial mean SBPs of those who responded to lidocaine were significantly less than the remaining groups (P < .001 for both comparisons). CONCLUSION: Utilizing lidocaine's properties to decrease sympathetic-inducing afferents after SCI, the time to onset of action for intravesical lidocaine was found to be approximately 90 seconds. This relatively rapid initial onset on action is especially pertinent when managing autonomic dysreflexia.

Anxiety masquerading as autonomic dysreflexia.

Context: Autonomic dysreflexia (AD) is characterized by a sudden onset of hypertension in those with spinal cord injuries (SCI) at T6 or above. Prompt recognition and treatment of AD is important. Herein are two individuals with SCI and acute hypertension due to anxiety that may easily have been confused for AD. Findings: Case 1: A 77-year-old male with C4 AIS D SCI and a history of anxiety and AD presented for urodynamics to evaluate the effectiveness of onabotulinumtoxinA injections into his urethral sphincter. After lying down on the urodynamics table, his systolic blood pressure (SBP) was noted to rise, from 138 to 170 mmHg over six minutes without any instrumentation or position change. Upon announcing urodynamics would be postponed and preparing for AD management, his SBP returned to below baseline within two minutes. Case 2: A 57-year-old male with T12 AIS A SCI and a history of anxiety presented for routine urodynamics. His baseline SBP was 140 mmHg. During bladder filling, incidental SBP was elevated to 170 mmHg. Filling was stopped and he was told the study was complete. One minute later, prior to draining his bladder, SBP decreased to 150 mmHg. Conclusions: An individual's psychological state should be considered in addition to traditional management of AD when an individual with SCI presents with hypertension. Moreover, Case 2 may possibly explain reports of individuals presenting with AD with injuries below T6.

Intravesical lidocaine decreases autonomic dysreflexia when administered prior to catheter change.

OBJECTIVE: To evaluate the role of intravesical lidocaine in preventing autonomic dysreflexia (AD) during routine catheter changes in individuals with spinal cord injury (SCI) at T6 or above. DESIGN: Prospective observational cohort study. SETTING: Outpatient urology clinic. PARTICIPANTS: Fifty consecutive individuals with SCI at or above T6 and a history of AD having a routine indwelling catheter change. INTERVENTIONS: A treatment group of individuals received 10 ml of 2% lidocaine administered into the existing catheter 4-6 minutes prior to catheter change. The control group had the same amount of lidocaine administered into the urethra or suprapubic tract after removing the old catheter and immediately prior to inserting the new catheter (due to the delayed onset of action of the anesthetic, this was assumed to have no initial effect). Systolic blood pressures (SBP) were measured immediately after catheter insertion and then every 30-45 seconds for 5 minutes. OUTCOME MEASURES: Incidence and magnitude of AD as determined by SBP following catheter change. RESULTS: The incidence of AD in the lidocaine treatment group was 14.8% vs 47.8% in the control group (P = .011). Pretreatment with lidocaine also demonstrated a significantly attenuated rise in SBP immediately after the catheter change (9.5 mmHg vs 26.9 mmHg for post-treatment, P = .014) relative to baseline SBP. CONCLUSION: In individuals with SCI at risk of AD, pretreatment with intravesical lidocaine prior to catheter change significantly decreased both the incidence and magnitude of AD. This suggests that pretreatment with intravesical lidocaine is helpful in individuals with SCI who are prone to AD.

Catheter-associated urinary tract infections in persons with neurogenic bladders.

This review is based on the author's Donald Munro Lecture given at the annual conference of the Academy of Spinal Cord Injury Professionals in New Orleans, LA. Indwelling catheters play an important role in bladder management following SCI for many individuals with neurogenic bladders. There is an increased risk of UTI compared to other types of bladder management with indwelling urethral catheters but not SP catheters. To minimize the risk of symptomatic UTI, the following steps are essential: prevent bladder wall distention and resulting ischemia, maintain colonization with "good" bacteria, and prevent bladder stones. For individuals with recurrent symptomatic UTIs, try to change the environment, prevent bladder over distention, and make sure the bladder is "quiet" by using strategies such as adequate dosages of anticholinergics, onabotulinum toxin A, and preventing catheter blockage. Bacterial colonization of the bladder is common. However, bacterial colonization may have a positive effect by inhibition of colonization of pathogenic bacteria. Judicious use of antibiotics is important since antibiotics hasten the evolution of more resistant organisms. Potential prevention and treatment strategies include killing the offending organisms, changing the environment (such as urinary acidification), and modifying virulence factors and the bacterial microbiome.

Use of botulinum toxin in individuals with neurogenic detrusor overactivity: state of the art review.

BACKGROUND: Botulinum neurotoxin (BoNT) injection into the bladder wall has been shown to be an effective alternative to anticholinergic (antimuscarinic) medications and more invasive surgery in those with multiple sclerosis and spinal cord injury with neurogenic detrusor overactivity (NDO) and urinary incontinence who are not tolerating anticholinergic medications. In August 2011, Botox(®) (onabotulinumtoxinA) received Food and Drug Administration (FDA) approval for this use. Clinically, intradetrusor injection of BoNT has been found to decrease urinary incontinence and improve quality of life. Its impact on urodynamic parameters is an increase in the maximum cystometric (bladder) capacity and decrease in the maximum detrusor pressures. The most common side effects are urinary tract infections and urinary retention. There have been rare reports and a black box warning of distant spread of BoNT. BoNT has gained popularity because of its effectiveness and long duration of action, relative ease of administration, easy learning curve, reproducibility of results on repeated administration, and low incidence of complications. OBJECTIVE: To discuss the structure and function, mechanisms of action, clinical and urodynamic studies, injection technique, potential beneficial and adverse effects, and potential areas of research of BoNT. METHODS: Literature search focused on botulinum toxin in MEDLINE/PubMed. Search terms included botulinum toxin, neurogenic bladder, NDO, botox bladder, botox spinal cord injury, botox, FDA, botox side effects. All papers identified were English language, full-text papers. In addition, English abstracts of non-English papers were noted. The reference list of identified articles was also searched for further papers. CONCLUSION: Botulinum toxin is an alternative treatment for individuals with NDO who fail to tolerate anticholinergic medications. Its popularity has increased because of the literature, which has supported its effectiveness, safety, easy use and learning curve, reproducibility of results on repeated use, and recent FDA approval of Botox(®) (onabotulinumtoxinA).

Impact of annual urodynamic evaluations on guiding bladder management in individuals with spinal cord injuries.

STUDY DESIGN: A single-center institutional review board-approved prospective cross-sectional observational study. CONTEXT: Urodynamic studies are essential to accurately direct bladder management following spinal cord injury (SCI). There is no consensus on how often testing should be performed. OBJECTIVE: To determine the impact of annual urodynamic studies on guiding bladder management following SCI. METHODS: Individuals with traumatic SCI undergoing annual urological evaluations were enrolled in this study. They had to be injured for at least 2 years so that urodynamic changes could be compared with their previous annual urodynamic evaluation. Changes in the urodynamic parameters and autonomic dysreflexia were determined by comparing this study with the previous year's study. All studies were done with the same physician and nursing staff. Demographic data, bladder management, urodynamic parameters, and the need and type of interventions based on the urodynamic study were obtained. The main outcome measure was whether or not there was a need for an intervention based on the urodynamics. Interventions were classified as urological intervention, non-urological intervention, or a combination of urological and non-urological intervention. The impact of the type of bladder management, length of injury, and level of injury was also evaluated. RESULTS: Ninety-six consecutive individuals with SCI undergoing annual urodynamic evaluations were enrolled over a 5-month period. Overall, 47.9% of individuals required at least one type of intervention based on urodynamic studies: 82.6% were urological interventions (medication changes were most common, comprising 54.3% of urological interventions); 13.0% were non-urological interventions; and 4.3% were a combination of non-urological and urological interventions. The need for interventions did not appear to be influenced by the type of bladder management, the length of time post-injury or level of injury. CONCLUSION: Annual urodynamic evaluation plays an important role in guiding bladder management following SCI.

Post-CVA voiding dysfunctions: clinical insights and literature review.

Urinary incontinence and other voiding dysfunctions are common sequelae post CVA (cerebrovascualar accident). Urinary incontinence declines over time; however, other voiding issues appear. Voiding dysfunctions not only have a significant impact on a person's quality of life and mortality, but also impact the person's caregiver. Urodynamic studies are important to help further understand, develop and direct bladder management. However, studies evaluating urodynamic findings in those with urinary incontinence shortly after CVA (within 3 months) are limited. While uninhibited contractions are the most common urodynamic finding in post-CVA incontinence, a number of men and women have other urodynamic findings causing incontinence. The type, onset, resolution and urodynamics of post-CVA symptoms other than urinary incontinence are rarely discussed. A literature review emphasizes that further research is needed not only in the evaluation of the most effective bladder management strategies for urinary incontinence, but also in the area of post stroke voiding dysfunction as a whole.

Treatment of erectile dysfunction following spinal cord injury.

Spinal cord injury (SCI) has a significant impact on erectile dysfunction. Treatment modalities for individuals with SCI are similar to treatments for those without SCI. Some of the most common methods of management include penile implants, oral phosphodiesterase (PDE) inhibitors, vacuum devices, intraurethral prostaglandins, and intracavernous injections. In addition to the advantages and disadvantages of these various modalities for able-bodied men, there are special considerations for men with SCI. Penile implants may help to keep an external condom catheter in place and provide more penile stability for intermittent catheterization. However, they have an increased risk of infection. Semirigid rods have an increased risk of erosion. Although convenient to use, PDE inhibitors are usually not effective in lower motor injuries. The hypotensive effects of intraurethral prostaglandins and PDE inhibitors need to be considered in SCI men with injuries at or above T6. Intracavernous injections are very effective; however, men with SCI require much lower doses than able-bodied men.

Accuracy of predicting bladder stones based on catheter encrustation in individuals with spinal cord injury.

BACKGROUND: Bladder calculi are the second most common urological complication in those with spinal cord injury (SCI). Detection and removal of bladder stones are important to prevent possible complications. OBJECTIVE: To determine the accuracy of bladder stone detection based on catheter encrustation in asymptomatic individuals with SCI. DESIGN: Prospective cohort study. METHODS: Cystoscopy findings in persons with SCI who were noted to have catheter encrustation at the time of catheter removal for their scheduled cystoscopy were used in this prospective study. Indwelling catheters were examined for encrustation at the time of removal as they were being prepared for cystoscopy. Cystoscopy was performed, and the presence or absence of bladder stones was noted. MAIN OUTCOME MEASURES: Presence or absence of bladder stones detected with cystoscopy in those with precystoscopy catheter encrustation. RESULTS: Forty-nine individuals with indwelling catheters were evaluated. Overall, 17/49 (35%) individuals in this study had bladder stones. Catheter encrustation was noted in 13 patients. Of these 13 patients, 11 also had bladder stones. In other words, a positive result for catheter encrustation had a positive result for bladder stones 85% of the time. Thirty-six individuals had no catheter encrustation. Of these, 6 (16%) were found to have bladder stones. CONCLUSIONS: Encrustation of a catheter is highly predictive of the presence of bladder stones. This suggests that cystoscopy should be scheduled in a person undergoing a catheter change if catheter encrustation is noted.

Normal ranges of variability for urodynamic studies of neurogenic bladders in spinal cord injury.

BACKGROUND/OBJECTIVE: Urodynamic studies are conducted on a regular basis to evaluate changes in bladder function after spinal cord injury. Often, differences in urodynamic parameters exist from one study or one year to the next. The objective of this study was to provide reference ranges for "normal" variability in urodynamic parameters that can be considered as "no real change" from one study to the next. DESIGN: Retrospective chart review. METHODS: Fifty consecutive individuals with spinal cord injury had 2 trials (trial 1 and trial 2) of urodynamic studies done 5 minutes apart, and the following data were collected: maximum cystometric capacity, opening pressure, maximum detrusor pressure, volume voided, and postvoid residual. The corresponding data were compared, and the frequency distribution for the change between consecutive studies was plotted. Because there is no standard, variability ranges for 5th to 95th, 10th to 90th, and 25th to 75th percentiles were calculated to give health care providers more choices. RESULTS: Ranges of variability are as follows in the following format (urodynamic parameter; mean value; +, maximum increase; -, maximum decrease)--5th to 95th percentile: cystometric capacity (234.63 mL, +213.50 mL, -158.05 mL); opening pressure (54.56 cmH2O, +30 cmH2O, -18.00 cmH2O); maximum detrusor pressure (60.82 cmH2O, +17.35 cmH2O, -27.80 cmH2O); volume voided (122.20 mL, +177.25 mL, -176.00 mL); postvoid residual (176.06 mL, +197.25 mL, -118.00 mL); 10th to 90th percentile: cystometric capacity (234.63 mL, +126.40 mL, -74.60 mL); opening pressure (54.56 cmH2O, +13.70 cmH2O, -12.00 cmH2O); maximum detrusor pressure (60.82 cmH2O, +10.00 cmH2O, -20.00 cmH2O); volume voided (122.20 mL, +105.60 mL, -82.00 mL); postvoid residual (176.06 mL, +131.00 mL, -86.00 mL); 25th to 75th percentile: cystometric capacity (234.63 mL, +72.00 mL, -27.00 mL); opening pressure (54.56 cmH2O, +4.00 cmH2O, -9.50 cmH2O; maximum detrusor pressure (60.82 cmH2O, +4.00 cmH2O, -10.00 cmH2O); volume voided (122.20 mL, +50.00 mL, -30.00 mL); postvoid residual (176.06 mL, +50.00 mL, -30.00 mL). CONCLUSIONS: Urodynamic studies have variability. Knowing these ranges of variability can be helpful in determining whether differences between filling trial 1 and filling trial 2 in a single study or year-to-year changes in urodynamic studies are significant or simply the normal variability of the urodynamic study.

Urolithiasis associated with indinavir in a patient with spinal cord injury.

OBJECTIVE: To report a case of indinavir-induced urolithiasis, and the greater risk of this occurrence in individuals with spinal cord injury (SCI) who require fluid restriction for an intermittent catheterization program (ICP). METHODS: Case report. RESULTS: A 38-year-old man with a T4 ASIA A SCI (according to the American Spinal Injury Association classification scale) and human immunodeficiency virus (HIV) infection was using an ICP and taking indinavir (a protease inhibitor) as part of his antiviral regimen. Cystoscopy was performed to rule out recurrent urethral condylomata. He was found to have a bladder stone measuring 0.5 cm x 0.5 cm x 0.3 cm, which, on analysis, was composed of indinavir (100% exterior, 90% interior). The bladder stone was removed under direct visualization. The plain abdominal radiograph did not reveal any stones. CONCLUSION: Indinavir is a frequently used drug for the treatment of HIV that has the potential to induce urinary lithiasis. This is particularly problematic for individuals with SCI who are on fluid restriction and an ICP. Therefore, cystoscopy and monitoring for indinavir-induced urolithiasis should be undertaken in individuals with SCI who are taking indinavir. Considerations include switching to a different protease inhibitor or choosing an entirely new HIV drug cocktail with less potential for urolithiasis.

Evaluation of cranberry supplement for reduction of urinary tract infections in individuals with neurogenic bladders secondary to spinal cord injury. A prospective, double-blinded, placebo-controlled, crossover study.

OBJECTIVE: To determine the effectiveness of cranberry supplement at preventing urinary tract infections (UTIs) in persons with spinal cord injury (SCI). DESIGN: A prospective, double-blinded, placebo-controlled, crossover study. PARTICIPANTS: 21 individuals with neurogenic bladders secondary to SCI. MAIN OUTCOME MEASURES: Favorable or unfavorable response of cranberry supplement vs placebo on urinary bacterial counts and white blood cell (WBC) counts and the combination of bacterial and WBC counts. METHODS: Individuals with neurogenic bladders due to SCI were recruited and randomly assigned to standardized 400-mg cranberry tablets or placebo 3 times a day for 4 weeks. After 4 weeks and an additional 1-week "washout period," participants were crossed over to the other group. Participants were seen weekly, during which a urine analysis was obtained. UTI was defined as significant bacterial or yeast colony counts in the urine and elevated WBC counts (WBC count > or = 10 per high power field) in centrifuged urine. Participants with symptomatic infections were treated with appropriate antibiotics for 7 days and restarted on the cranberry tablet/ placebo after a 7-day washout period. Urinary pH between the cranberry and placebo groups was compared weekly. Data were analyzed using the Ezzet and Whitehead's random effect approach. RESULTS: There was no statistically significant treatment (favorable) effect for cranberry supplement beyond placebo when evaluating the 2 treatment groups for bacterial count, WBC count, or WBC and bacterial counts in combination. Urinary pH did not differ between the placebo and cranberry groups. CONCLUSION: Cranberry tablets were not found to be effective at changing urinary pH or reducing bacterial counts, urinary WBC counts, or UTIs in individuals with neurogenic bladders. Further long-term studies evaluating specific types of bladder management and UTIs will help to determine whether there is any role for the use of cranberries in individuals with neurogenic bladders.

The role of abnormal congenitally displaced ureteral orifices in causing reflux following spinal cord injury.

OBJECTIVE: To determine the role of congenitally displaced ureteral orifices in causing vesicoureteral reflux (VUR) in individuals with spinal cord injury (SCI). DESIGN: Retrospective chart review. PARTICIPANTS: Men and women with (UMN) neurogenic bladders secondary to SCI. MAIN OUTCOME MEASURES: Position of the ureteral orifice and urodynamic parameters in association with VUR. METHODS: A retrospective chart review was performed to identify SCI participants with and without reflux who had evaluation with cystoscopy, cystogram, and urodynamics. The position of ureteral orifice was compared in individuals with SCI who did and did not have ureteral reflex. All cystogram studies were interpreted by board-certified radiologists. The International Classification system was used to grade the severity of the reflux. Fisher exact test was used to evaluate the association of the posterior ureteral orifice and reflux. Analysis also was performed to evaluate the association of reflux with posterior-placed ureteral orifices and urodynamic parameters in the reflux group and nonreflux group. RESULTS: Fifteen participants were found to have reflux--11 had posterior-placed ureteral orifices, whereas 4 had normally positioned orifices. The 11 individuals with posterior-placed ureteral orifices had no bladder wall trabeculation. However, all 4 individuals with normally positioned ureteral orifices had severe trabeculation. Seventeen participants did not exhibit reflux--2 had posteriorly placed ureteral orifices and 15 had normally positioned orifices. Association of posterior position and reflux (P = 0.004). No differences were found with regard to bladder capacity, bladder wall compliance, or voiding pressures between the reflux group and nonreflux group. CONCLUSION: Congenitally displaced ureteral orifices are an important cause of VUR in individuals with SCI. Participants with normally positioned ureteral orifices only had reflux in the presence of severe trabeculation. This study suggests that annual screening with cystograms may not be necessary in individuals with normally positioned ureteral orifices and no significant trabeculation.

Accuracy of bladder stone detection using abdominal x-ray after spinal cord injury.

BACKGROUND: Bladder calculi are a common problem in those with spinal cord injury (SCI). Detection is important to prevent complications. OBJECTIVE: To determine the accuracy of bladder stone detection by abdominal x-rays. METHODS: X-ray reports from individuals with SCI with known bladder stones detected by cystoscopy were reviewed. MAIN OUTCOME MEASURES: X-ray reports noted the presence or absence of bladder stones. The stone variables evaluated were stone composition (crystallographic analysis), widest dimension of the largest stone (during cystoscopy), and the total volume (cm3) of the stone mass removed. RESULTS: Sixty-two consecutive x-ray reports from individuals with bladder stones were reviewed. The majority of stones were calcium phosphate (46.8%) or struvite (26.7%). Regarding stone composition, the detection by x-ray was 28.6% for struvite stones and 41.9% for calcium phosphate stones. Regarding diameter of largest stone, the detection by x-ray was 14% for stones < 0.5 cm, 0% for stones 0.5 cm to 0.9 cm, 33% for stones 1.0 cm to 1.49 cm, 33% for stones 1.5 cm to 1.9 cm, and 54% for stones > or = 2.0 cm. Regarding total volume of stones, the detection by x-ray was 0% for volumes < 0.2 cm3, 33% for volumes 0.2 cm3 to 0.39 cm3, 60% for volumes 0.40 cm3 to 0.59 cm3, 40% for volumes of 0.60 cm3 to 0.79 cm3, 0% for stones from 0.8 cm3 to 0.99 cm3, and 57% for volumes > or = 1.0 cm3. Overall, 13/62 (20.97%) of stones found during cystoscopy were detected by the x-ray. CONCLUSION: Abdominal x-ray is not a reliable method to detect bladder stones in individuals with SCI.