DESD Therapy in SCI: Enhancing Bladder Volumes Pharmacologically

Anticholinergic Therapy for SCI-Related Detrusor Overactivity

Propiverine, oxybutynin, tolterodine and trospium chloride are efficacious anticholinergic agents for the treatment of SCI neurogenic bladder.

• Treatment with 2 of oxybutynin, tolterodine or trospium may be effective for the treatment of SCI neurogenic bladder in those not previously responding to one of these medications.
• Oxybutynin co-treatment with verapamil may enhance the standard formulation of oxybutynin in the treatment of SCI detrusor hyperreflexia.
• Oral Tolterodine, propiverine or transdermal application of oxybutinin likely results in less dry mouth but are similar in efficacy to oral oxybutynin in terms of improving neurogenic detrusor overactivity.

Toxin Therapy for SCI-Related Detrusor Overactivity

• Overall botulinum toxin for neurogenic detrusor overactivity in SCI is effective in reducing incontinence and excessive bladder pressure while improving bladder capacity for those resistant to, or intolerant of, oral anticholinergics.
• Capsaicin seems to have some clinical benefits but the side effects of pain and AD are concerning for clinical use. Resiniferotoxin seems to be tolerated much better and has similar improvements therapeutically. Pharmaceutical formulation difficulties make it non-existent for clinical use at present.

Intravesical Instillations for SCI-Related Detrusor Overactivity

• Intravesical instillations with oxybutinun or propantheline are ineffective for treating neurogenic bladder in people with SCI.

Other Pharmaceutical Treatments for SCI-Related Detrusor Overactivity

• Intrathecal baclofen and clonidine may be beneficial for bladder function improvement but further confirmatory evidence is needed.

DESD Therapy in SCI: Enhancing Bladder Volumes Non-Pharmacologically

Surgical Augmentation of the Bladder to Enhance Volume

• Surgical augmentation of bladder may result in enhanced bladder capacity under lower filling pressure and improved continence in persons with SCI.
• Extraperitoneal vs intraperitoneal augmentation enterocystoplasty may result in better postoperative recovery.

DESD Therapy in SCI: Enhancing Bladder Emptying Pharmacologically

Alpha-adrenergic Blockers for Bladder Emptying

• Tamsulosin is likely to improve urine flow in SCI individuals with bladder neck dysfunction.
• Mosixylyte is likely able to decrease maximum urethral closure pressure at a dose of 0.75mg/kg in individuals with SCI.
• Terazosin may be an alternative treatment for bladder neck dysfunction in individuals with SCI. but side effects and drug tolerance should be monitored.
• Phenoxybenzamine may be useful as an adjunct therapy for reducing residual urine volume in SCI neuropathic bladders maintained by crede or tapping.
• Six months of alpha 1-blocker therapy in male SCI patients may improve upper tract stasis.

Botulinum Toxin for Bladder Emptying

• Botulinum toxin injected into the sphincter is effective in assisting with bladder emptying for persons with neurogenic bladder due to SCI.

DESD Therapy in SCI: Enhancing Bladder Emptying Non-Pharmacologically

Comparing Methods of Conservative Bladder Emptying

• Intermittent catheterization, whether performed acutely or chronically, has the lowest complication rate.
• Indwelling catheterization, whether suprapubic or urethral or whether conducted acutely or chronically, may result in a higher long-term rate of urological and renal complications than other management methods.
• Persons with tetraplegia and complete injuries and to a lesser degree females may have difficulty in maintaining compliance with intermittent catheterization procedures following discharge from rehabilitation.

Intermittent Catheterization

• Although both pre-lubricated and hydrophilic catheters have been associated with reduced incidence of UTIs as compared to conventional Poly Vinyl Chloride catheters, less urethral microtrauma with their use may only be seen with pre-lubricated catheters.
• Urethral complications and epididymoorchitis occurs more frequently in those using IC programs.
• Portable ultrasound device can improve the scheduling of intermittent catheterizations.

Triggering-Type or Expression Voiding Methods of Bladder Management

• Valsalva or Crede maneuver may assist some individuals to void spontaneously but produce high intra-vesical pressure, increasing the risk for long-term complications.

Indwelling Catheterization (Indwelling or Suprapubic)

• With diligent care and ongoing medical follow-up, indwelling suprapubic catheterization may be an effective and satisfactory bladder management choice for some people, though there is insufficient evidence to report lifelong safety of such a regime.
• Indwelling catheter users are at higher risk of bladder cancer, especially in the second decade of use, though risk also increases during the first decade of use.

Condom Catheterization

• Patients using condom drainage should be monitored for complete emptying and for low pressure drainage, to reduce UTI and upper tract deterioration. Sphincterotomy may eventually be required. 
• Penile implants may allow easier use of condom catheters and reduce incontinence.

Continent Catheterizable Stoma and Incontinent Urinary Diversion

• Catheterizable abdominal stomas may increase the likelihood of achieving continence and independence in self-catherization, and may result in a bladder management program that offers more optimal upper tract protection.
• Cutaneous ileal conduit diversion may increase the likelihood of achieving continence but may also be associated with a high incidence of various long-term complications.

Electrical Stimulation for Bladder Emptying (and Enhancing Volumes)

• Sacral anterior root stimulation (accompanied in most cases by posterior sacral rhizotomy) enhances bladder function and is an effective bladder management technique, though the program (surgery and followup) requires significant expertise.
• Direct bladder stimulation may be effective in reducing incontinence and increasing bladder capacity but requires further study.
• Posterior sacral, pudenal, dorsal penile or clitoral nerve stimulation may be effective to increase bladder capacity but requires further study.
• Early sacral neural modulation may improve management of lower urinary tract dysfunction but requires further study.

Sphincterotomy, Artificial Sphincters, Stents and Related Approaches for Bladder Emptying

• Surgical and prosthetic approaches (with a sphincterotomy and stent respectively) to allow bladder emptying through a previously dysfunctional external sphincter both seem equally effective resulting in enhanced drainage although both may result in long-term upper and lower urinary tract complications.
• Artificial urinary sphincter implantation and transurethral balloon dilation of the external sphincter may be associated with improved bladder outcomes but require further study.

DESD Therapy in SCI: Other Miscellaneous Treatments

• Early electroacupuncture therapy as adjunctive therapy may result in decreased time to achieve desired outcomes.
• Intranasal DDVAP may reduce nocturnal urine emissions and decrease the frequency of voids (or catheterizations).
• Anastomosis of the T11, L5 or S1 roots to the S2-S3 spinal nerve roots may result in improved bladder function in chronic SCI.

Urinary Tract Infections: Detecting and Investigating UTIs

• Both limited and full microbial investigation may result in adequate clinical response to UTI treatment with antibiotics.
• Indwelling or suprapubic catheters should be changed just prior to urine collection so as to limit the amount of false positive urine tests.
• Urinalysis and urine culture results of SCI patients are not likely to be affected by sample refrigeration (up to 24 hours).
• It is uncertain if dipstick testing for nitrates or leukocyte esterase is useful in screening for bacteriuria to assist treatment decision-making.

Urinary Tract Infections: Non-Pharmacological Methods of Preventing UTIs

Intermittent Catheterization and Prevention of UTIs

• Sterile and clean approaches to intermittent catheterization seem equally effective in minimizing UTIs in inpatient rehabilitation.
• Similar rates of UTI may be seen with intermittent catheterization as conducted by the patients themselves or by a specialized team during inpatient rehabilitation.
• Similar rates of UTI may be seen with intermittent catheterization, whether conducted in the short-term during inpatient rehabilitation or in the long-term while living in the community.
• UTIs were not associated with differences in residual urine volumes after intermittent catheterization.

Intermittent Catheterization using Specially Coated Catheters for Preventing UTIs

• A reduced incidence of UTIs or reduced antibiotic treatment of symptomatic UTIs have been associated with pre-lubricated or hydrophilic catheters as compared to standard non-hydrophilic catheters.

Other Issues Associated with Bladder Management and UTI Prevention

• Intermittent catheterization is associated with a lower rate of UTI as compared to use of indwelling or suprapubic catheter.
• The Statlock device to secure indwelling and suprapubic catheters may lead to a lower rate of UTI.
• Removal of external condom drainage collection systems at night or for 24 hours/day may reduce perineal, urethral or rectal bacterial levels but have no effect on bacteriuria.
• The presence of vesicoureteral reflux likely has a greater impact on development of significant infections than the choice of bladder management.

Urinary Tract Infections: Pharmacological and Other Biological Methods of UTI Prevention

Bacterial Interference for Prevention of UTIs

• E. coli 83972 bladder inoculation may prevent UTIs.

Antibiotic Prophylaxis of UTIs

• Ciprofloxacin may be indicated for UTI prophylaxis in SCI but further research is needed to support its use.
• Long-term use of TMP-SMX is not recommended for sustained use as a suppressive therapy for UTI prevention.
• A weekly oral cyclic antibiotic, customized to the individual, may be beneficial in preventing UTI in SCI.

Antiseptic and Related Approaches for Preventing UTIs

• Oral methenamine hippurate, either alone or in combination with cranberry, is not effective for UTI prevention.
• The antiseptic agents delivered via bladder irrigation (5% hemiacidrin solution combined with oral methenamine mandelate) may be effective for UTI prevention, whereas others are not (i.e., trisdine, kanamycin-colistin, neomycin/polymyxin, acetic acid, ascorbic acid and phosphate supplementation).
• Daily body washing with chlorohexidine and application of chlorhexidine cream to the penis after every catheterization instead of using standard soap may reduce bacteriuria and perineal colonization.

Cranberry for Preventing UTIs

• It is uncertain if cranberry is effective in preventing UTIs in persons with SCI.

Urinary Tract Infections: Educational Interventions for Maintaining a Healthy Bladder and Preventing UTIs

• A variety of bladder management education programs are effective in reducing UTI risk in community-dwelling persons with SCI, although limited information exists as to the most effective approaches.

Urinary Tract Infections: Pharmacological Treatments of UTIs

Antibiotics in Treatment of UTIs

• Ciprofloxin administered over 14 (vs 3) days may result in improved clinical and microbiological SCI UTI treatment outcome.
• Ofloxacin administered over either a 3 or 7 day treatment regimen may result in significant SCI UTI cure and bladder bacterial biofilm eradication rate, moreso than trimethoprim-sulfamethoxazole.
• Norfloxacin may be a reasonable treatment choice for UTI in SCI but subsequent resistance must be monitored.
• Aminoglycosides have a low success rate in the treatment of SCI UTI.
• Intermittent neomycin/polymyxin bladder irrigation may be effective in altering the resistance of the offending bladder organism(s) to allow for appropriate antibiotic treatment.