Page 3

D - Bladder Continence

Regaining bladder and bowel function is the top priority for just under 40% of individuals with spinal cord injury who were asked to rank the importance of these specific health issues.1 Neurogenic Bladder Services in Canada: Where Are We Now? The majority of the 12 participating E-Scan sites report that bladder management is achieved through the coordinated efforts of individuals, nurses, physicians (physiatrists, urologists and family practitioners) and occupational therapists (OTs), in descending order of contribution across sites (see Figure 2.0). Coordination of services among individuals, nurses, physiatrists and urologists is essential for effective bladder care. Figure 2.0 Number of Sites Reporting Sta ff Members Participating in Blader Management Services 0 2 4 6 8 10 12 Nurse (RN) Urologist Physiatrist Nurse (RNA/RPN) Occupational Therapist Family Practice Physician Nurse Aide/Healthcare Aide Number of Sites Typically, if an individual with SCI has a neurogenic bladder, and cannot voluntarily void, staff start him or her on an intermittent catheterization (IC) every four to six hours routinely, to keep volumes less than 600 cc (ideally ≤ 500 cc). This process is usually initiated in the first few weeks after SCI, often in acute care, prior to rehabilitation admission, and once the initial trauma phase and fluid management is under control. Generally, once urine output is less than 2600 cc daily, the IC routine will start. If an individual has good hand function, cognition and is enthusiastic, instruction to perform independent IC is started in acute care. Once in rehabilitation, the instruction continues until the individual has mastered the IC technique in different positions (e.g., in bed, in a wheelchair). For those who have little hand function, a tenodesis orthosis or catheter advancer may be introduced, by the OT. For those unable to learn self-catheterization, due to poor hand function, long-term plans are discussed with the physiatrist, individual, caregiver(s), spouse, etc., and the urologist about who will be responsible for the ongoing IC routine. If this is infeasible, an indwelling catheter is usually placed until a decision on other potential long-term management strategies (such as a sphincterotomy with condom drainage in men, or continent or incontinent stoma in women), is made. For those unable to perform self-catheterizations, the primary goal is teaching them to direct their own care, including prevention and recognition of Urinary Tract Infections (UTIs). When an individual is in hospital and being catheterized by staff, a sterile technique with a new catheter is used each time. Once self-catheterization is learned, individuals often switch to a “clean” technique once discharged from rehabilitaton - to wash (with soap and water). Unfortunately, individuals who have financial constraints often choose to reuse catheters for several days. Testing to describe neurogenic bladder function should be done in the first few months following injury. The optimal timeline for this varies, in Canada, but generally, the individual should be out of spinal shock. Therefore, some sites wait until the three month point, before baseline testing. This baseline testing includes urodynamics, ultrasound of kidney and bladder, and determination of creatinine clearance, with a 24-hour urine collection. After rehab discharge, an individual with SCI should ideally undergo bladder function testing - annually, for the first five years and then every second year, thereafter. Tests offered from site to site vary, depending on testing resources and any follow-up program. Minimally, ultrasound imaging (see Figure 5.0) and a kidney function test should be done. Monitoring for renal failure using serum creatinine testing is generally unreliable in individuals with SCI because less creatinine is made, as a result of reduced muscle mass. Even in the case of failing kidneys, serum creatinine may not be significantly elevated beyond the normal reference range. Thus, 24-hour urine collection for creatinine clearance is recommended. Regular follow-up urodynamic testing is preferably done as well, but may not be acceptable to individuals (with some preservation of sensation), who can perceive rectal and urethral catheter insertion as invasive. For those with long-term indwelling catheters, annual screening starting one decade, post-injury (or five years post-injury, for high risk individuals, such as smokers), should be done via cystoscopy to monitor for possible development of bladder cancer. Regular follow up should also include an inquiry for new onset of complications, bladder maintenance routine, frequency of UTIs, incidents of incontinence, urodynamic testing, and review of ongoing and available treatments. Significant symptoms of overactive bladder, such as problematic urgency, frequency and need for frequent catheterizations, should prompt investigations to rule out UTIs, followed by introduction of anticholinergic medications (as indicated). These two interventions are mainstays of first-line treatment for incontinence. If neither of these interventions are effective or tolerated, botulinum toxin injected in the bladder muscle (detrusor) can be used, or surgical bladder augmentation considered. Surgical considerations are generally deferred for at least one year, to observe natural recovery of bladder function. One site reports not having an RN dedicated to bladder management activities, and four sites report lacking specific physiatric and urologic relationships, for the bladder management program. The spectrum of service for management of overactive bladder is shown in Figure 3.0. 54 CAPTURING CAPACITY IN CANADIAN SCI REHABILITATION


D - Bladder Continence
To see the actual publication please follow the link above