Rehabilitation Evidence > Bladder Management > Summary

Summary

Submitted by admin on Mon, 05/17/2010 - 13:31
  • Level 1 evidence from a single RCT supports the use of propiverine to treat detrusor hyperreflexia by significantly improving bladder capacity.
  • Level 1 evidence from a single RCT supports the use of tolterodine vs placebo to significantly increase intermittent catheterization volumes and decrease incontinence in neurogenic detrusor overactivity.
  • There is level 2 evidence from a single open label prospective controlled trial that  tolterodine and oxybutynin are equally efficacious in SCI patients with neurogenic detrusor overactivity except that tolterodine results in less dry mouth.
  • Level 4 evidence from a single pre-post trial supports the potential benefits of controlled-release oxybutynin. 
  • Level 1 evidence from a single RCT supports the use of trospium chloride to increase bladder capacity and compliance, and decrease bladder pressure with very few side effects in SCI individuals with neurogenic bladder.
  • Level 1 evidence based on two RCTs supports the use of Botox A injections into the detrusor muscle to provide targeted treatment for detrusor hyperreflexia and urge incontinence resistant to high-dose oral anticholinergic treatments with intermittent self-catheterization in SCI. 
  • Level 1 evidence supports the use of vanillanoid compounds such as capsaicin or resiniferatoxin to increase maximum bladder capacity and decrease urinary frequency and leakages in neurogenic detrusor overactivity of spinal origin.
  • Level 4 evidence exists to suggest that intravesical capsaicin instillation in bladders of SCI individuals does not increase the rate of common bladder cancers after 5 years of use. 
  • Level 1 evidence supports the use of N/OFG, a nociceptin orphan peptide receptor agonist for the treatment of neurogenic bladder in SCI.
  • There is level 4 evidence from 3 studies that instillations with oxybutinun or propantheline have equivocal benefits for neurogenic bladder in people with SCI. This lack of effect may be compounded by level 4 evidence suggesting systemic absorption may occur with this therapy, resulting in systemic side effects.
  • There is level 1 evidence from a single small RCT (n=10) that intrathecal baclofen may be beneficial for bladder function improvement in individuals with SCI when oral pharmacological interventions are insufficient.
  • Level 4 evidence is available from a single, small (n=9), case series study for the use of intra-thecal clonidine to improve detrussor hyperreflexia in individuals with SCI when a combination of oral treatment and sterile intermittent catheterization are insufficient.
  • There is level 4 evidence from three studies that surgical augmentation of bladder (ileocystoplasty) may result in enhanced bladder capacity under lower filling pressure and improved continence in persons with SCI who previously did not respond well to conservative approaches for overactive bladder.
  • Level 1 evidence suggests that moxisylyte decreases maximum urethral closure pressure by 47.6% at 10 minutes after an optimum dose of 0.75mg/kg in individuals with SCI.
  • There is level 1 evidence from a single study that suggests that tamsulosin may improve bladder neck relaxation and subsequent urine flow in SCI individuals. 
  • There is level 4 evidence (two studies, n=28 & 9) that  supports terazosin as an alternative treatment for bladder neck dysfunction in SCI individuals provided that side effects and drug tolerance are monitored.
  • There is level 4 evidence derived from a single, case series study involving 46 subjects (41 completers) that indicates some potential for phenoxybenzamine as an adjunct treatment for neuropathic bladder following SCI, when tapping or crede is insufficient to achieve residual urine volume of <100mL. Further evidence in required.
  • Level 4 evidence from 1 small retrospective chart review suggests that 6 months of alpha 1-blocker therapy may improve upper tract stasis secondary to SCI in men by decreasing the duration of involuntary contractions.
  • There is level 1 evidence from a single RCT with support from several additional controlled and uncontrolled trials that botulinum toxin injected into the external urinary sphincter may be effective in improving outcomes associated with bladder emptying in persons with neurogenic bladder due to SCI
  • There is level 2 evidence from a single trial that transurethral botulinum toxin injections were significantly more effective in reducing maximum urethral pressure than transperineal injections in persons with neurogenic bladder due to SCI.
  • There is level 4 evidence that indwelling urethral catheterization is associated with a higher rate of acute urological complications than intermittent catheterization.
  • There is level 4 evidence that prolonged indwelling catheterization, whether suprapubic or urethral, may result in a higher long-term rate of urological and renal complications than intermittent catheterization, condom catheterization or triggered spontaneous voiding.
  • There is level 4 evidence that intermittent catheterization, whether performed acutely or chronically, has the lowest complication rate.
  • Results are conflicting about the complications associated with chronic use of a spontaneous triggered voiding but some authors present level 4 evidence that this method has comparable long-term complication rates to intermittent catheterization.
  • There is level 4 evidence that those who use intermittent catheterization at discharge from rehabilitation may have difficulty continuing, especially those with tetraplegia and complete injuries. To a lesser degree females also have more difficulty than males in maintaining compliance with IC procedures.
  • There is level 1 evidence based on 1 RCT that pre-lubricated hydrophilic catheters are associated with fewer UTIs and reduced incidence of urethral bleeding and microtrauma as compared to conventional Poly Vinyl Chloride catheters.
  • There is level 2 evidence based on 1 RCT that fewer UTIs, but not necessarily urethral bleeding may result with the use of hydrophilic catheters as compared to conventional PVC catheters.
  • There is level 4 evidence that urethral complications and epididymoorchitis occurs more frequently in those using IC programs for bladder emptying, but the advantages of improved upper tract outcome over those with indwelling catheters outweigh these disadvantages.
  • There is level 4 evidence that using a portable ultrasound device reduces the frequency and cost of intermittent catheterizations.
  • There is level 4 evidence that triggering mechanisms such as the Valsalva or Crede maneuvers may assist some individuals with neurogenic bladder in emptying their bladders without catheterization. However, high intra-vesical voiding pressures can occur which could conceivably lead to renal complications.
  • There is level 4 evidence that despite a significant incidence of urological and renal complications associated with acute and chronic indwelling suprapubic catheterization, this may still a reasonable choice for bladder management for people with poor hand function, lack of care-giver assistance, severe lower limb spasticity, urethral disease, and persistent incontinence with urethral catheterization.
  • There is level 4 evidence that those with indwelling catheters are at higher risk for bladder cancer than those with non-indwelling catheter management programs.  Screening for cancer may require routine biopsy as well as cystoscopy.
  • There is level 4 evidence that condom drainage can be associated with urinary tract infection and upper tract deterioration.
  • There is level 4 evidence that penile implants may allow easier use of condom catheters, thereby reducing incontinence and improving sexual function.
  • There is level 4 evidence that most individuals who receive catheterizable stomas become newly continent and can self-catheterize.  It appears possible that this surgical intervention could protect upper tract function.  Larger studies are needed to better evaluate true incidence of complications, and long-term bladder and renal outcome.
  • There is level 4 evidence that most individuals undergoing cutaneous ileal conduit (ileo-ureterostomy) diversion became newly continent and were more satisfied than with their previous bladder management method. Long-term follow-up demonstrated the presence of a high incidence of urological or renal complications.
  • There is level 4 evidence from eight studies that ongoing use of sacral anterior root stimulation (accompanied in most cases by posterior sacral rhizotomy) is an effective method of bladder emptying resulting in reduced incontinence for the majority of those implanted. This is associated with increased bladder capacity and reduced post-void residual volume.
  • There is level 4 evidence from five studies that sacral anterior root stimulation (accompanied in most cases by posterior sacral rhizotomy) may be associated with reducing UTIs and autonomic dysreflexia.
  • There is level 4 evidence from two studies that direct bladder stimulation may result in reduced incontinence, increased bladder capacity and reduced residual volumes but requires further study as to its potential clinical use.
  • There is level 4 evidence from various single studies that other forms of neuroanatomically-related stimulation (e.g., electrical stimulation to posterior sacral, dorsal penile or clitoral nerve or surface magnetic sacral stimulation or direct bladder stimulation) may result in increased bladder capacity but require further study as to their potential clinical use. Further development involving this approach may permit sacral anterior root stimulation without the need for posterior root ablation.
  • There is level 4 evidence from a single study that epidural dorsal spinal cord stimulation at T1 or T11 originally intended for reducing muscle spasticity may have little effect on bladder function.
  • There is level 4 evidence from a single study that a program of functional electrical stimulation exercise involving the quadriceps muscle originally intended for enhancing muscle function and reducing muscle spasticity has only marginal (if any) effects on bladder function.
  • There is level 4 evidence from a single case-series study that sphincterotomy is effective in reducing episodes of autonomic dysreflexia associated with inadequate voiding.
  • There is level 4 evidence from a single case-series study that sphincterotomy, as a staged intervention, can provide long-term satisfactory bladder function.
  • There is level 2 evidence from a single low-quality RCT but supported by level 4 studies that both sphincterotomy and implantation of a sphincteric stent are effective in reducing incontinence, with little need for subsequent catheterization, and both treatments are associated with reduced detrusor pressure and reduced post-void residual volume but not with changes in bladder capacity. The only significant difference in these 2 treatments was the reduced initial hospitalization associated with the stent, given the lesser degree of invasiveness.
  • There is level 4 evidence that implantation of a sphincteric stent may result in reduced incidence of UTIs and bladder-related autonomic dysreflexia over the short-term although several studies have demonstrated the potential for various complications and subsequent need for re-insertion or another approach over the long-term.
  • There is level 4 evidence from a single long-term follow-up study of those having a previous sphincterotomy that the incidence of various upper and lower tract urological complications may be quite high.
  • There is level 4 evidence from a single case-series study that advocates for placement of a temporary stent early after injury as a reversible option that allows patients to choose from the range of permanent stent placement to less invasive bladder management methods such as intermittent catheterization.
  • There is level 4 evidence based on a single study that transurethral balloon dilation of the external sphincter may permit removal of indwelling catheters in place of condom drainage, and also be associated with reduced detrusor pressure and post-void residual volume but not with changes in bladder capacity.
  • There is level 4 evidence based on a single study that implantation of artificial urinary sphincter may be useful in the treatment of incontinence in SCI but further study is required.
  • There is level 2 evidence from a single study that early treatment with electroacupuncture may shorten the time that it takes to develop low pressure voiding /emptying with minimal residual volume, when combined with conventional methods of bladder management. 
  • Level 4 evidence from two studies suggests that intranasal DDVAP may reduce nocturnal urine production with fewer night-time emissions and also may reduce the need for more frequent catheterizations in persons with SCI with neurogenic bladder that is otherwise unresponsive to conventional therapy.
  • There is level 4 evidence from four studies that nerve crossover surgery (anastomosis of more rostral ventral nerve roots to S2-S3 spinal nerve roots) may result in improved bladder function in chronic SCI. 
  • Level 1 evidence based on a single RCTon SCI inpatients suggests that both limited and full microbial investigation result in adequate clinical response to UTI treatment with antibiotics.  Therefore the cost savings attributed to a limited microbial investigation favours this practice in the investigation of UTI although more rigorous investigation of the patient outcomes and attributed costs is needed.
  • There is limited level 1 evidence from a single investigation that refrigeration (up to 24 hours) of urine samples prior to sample processing does not alter urinalysis or urine culture results in SCI patients.
  • There is limited level 2 evidence from a single investigation that fewer false positive tests showing bacteriuria occur if indwelling or suprapubic catheters are changed prior to collection for urine culture analysis.
    There is conflicting level 4 evidence from two investigations concerning whether dipstick testing for nitrates or leukocyte esterase is recommended to guide treatment decision-making.
  • Level 2 evidence based on two RCTs suggests no difference in UTI rates between sterile vs clean approaches to intermittent catheterization during inpatient rehabilitation, although using a sterile method is significantly more costly.
    There is limited level 4 evidence from a single study that there is no difference in UTI rates between intermittent catheterization conducted by the patients themselves or by a specialized team during inpatient rehabilitation.
  • There is limited level 4 evidence from a single study that similar rates of UTI may be seen for those using clean intermittent catheterization during inpatient rehabilitation as compared to those using similar technique over a much longer time when living in the community.
  • There is limited level 4 evidence from a single study that differences in residual urine volume ranging from 0-153 ml were not associated with differences in UTI during inpatient rehabilitation.
  • There is level 1 evidence based on 1 RCT that pre-lubricated nonhydrophilic catheters are associated with fewer UTIs as compared to conventional Poly Vinyl Chloride catheters.
  • There is level 2 evidence based on 1 RCT that fewer UTIs, but not necessarily urethral bleeding may result with the use of hydrophilic catheters as compared to conventional PVC catheters.
  • There is level 2 evidence based on a single prospective controlled trial and supported by a case control study that intermittent catheterization may lead to a lower rate of UTI as compared to other bladder management techniques such as use of indwelling or suprapubic catheter.
  • There is level 3 evidence based on a single case control study that bladder management with a suprapubic as opposed to indwelling catheter may lead to a lower rate of UTI and reduced mortality in a poor, illiterate population where intermittent catheterization may not be viable as an approach to bladder management.
  • There is weak level 2 evidence based on a single low quality RCT that suggests that use of the Statlock device to secure indwelling and suprapubic catheters may lead to a lower rate of UTI.
  • There is level 2 evidence based on a single prospective controlled trial that suggests that removal of external condom drainage collection systems at night or for 24 hours/day might reduce perineal, urethral or rectal bacterial levels  but have no effect on bacteriuria.
  • There is level 4 evidence based on a single case series that no bladder management method is advantageous in preventing pyelonephritis (though indwelling urethral catheterization does have the highest incidence of upper tract deterioration). However, the presence of reflux results in a 2.8 fold higher incidence of pyelonephritis.
  • There is level 1 evidence based on a single RCT and supported by two level 4 investigations that bacterial interference in the form of E. coli 83972 bladder inoculation may prevent UTIs.
  • There is level 1 evidence from a single RCT that low-dose, long-term ciprofloxacin may prevent symptomatic UTI.
  • There is level 1 evidence from a single RCT that TMP-SMX as prophylaxis may reduce symptomatic UTI rates although conflicting findings were obtained from 2 prospective controlled trials. The potential for emergence of drug resistant bacteria and TMP-SMX related adverse events further limit the potential use of TMP-SMX for prophylaxis.
  • There is level 4 evidence from a single study that suggests weekly oral cyclic antibiotic use, customized as to individual allergy and antimicrobial susceptibility, may be effective for UTI prevention in SCI patients. 
  • There is level 1 evidence based on a single RCT that oral methenamine hippurate, either alone or in combination with cranberry, is not effective for UTI prevention.
  • There is level 2 evidence from separate studies that bladder irrigation with trisdine, kanamycin-colistin or a 5% hemiacidrin solution combined with oral methenamine mandelate (2 mg qid) may be effective for UTI prevention.
  • There are varying levels of evidence that bladder irrigation with neomycin/polymyxin (level 1), acetic acid (level 1), ascorbic acid (level 2) or phosphate supplementation (level 4) is not effective for UTI prevention.
  • There is level 2 evidence based on a single low quality RCT that supports the use of daily body washing with chlorohexidine and application of chlorhexidine cream to the penis after every catheterization versus using standard soap to reduce bacteriuria and perineal colonization.
  • There is conflicting level 1 evidence across 4 RCTs (1 +ive, 3 –ive) to support the effectiveness of cranberry in preventing UTI in patients with neurogenic bladder due to SCI.
  • There is level 1 evidence from a single RCT that a single educational session conducted by SCI specialist health professionals with accompanying written materials and a single follow-up telephone call can result in reduced urine bacterial colony counts in community-dwelling individuals with prior history of SCI.
  • The beneficial effects of education mediated by SCI specialist health professionals on reducing UTI risk in community-dwelling individuals with SCI are supported by a single level 2 study and two level 4 studies incorporating different features such as one-on one or group workshops, demonstrations, practice of techniques and written materials.
  • There is no evidence assessing the relative effectiveness of different educational approaches for reducing UTI risk. 
  • There is level 1 evidence from a single RCT that supports the use of 14 vs 3 days of Ciprofloxcin for improved clinical and microbiological outcomes in the treatment of UTI in persons with SCI. 
  • There is level 1 evidence from a single RCT suggesting that 3 or 7 day Ofloxacin treatment is more effective than trimethoprim-sulfamethoxazole in treating UTI and results in significant bladder bacterial biofilm eradication in persons with SCI patients. 
  • Level 4 evidence from a single study suggests that norfloxacin may be a reasonable treatment choice for UTI in SCI but subsequent resistance must be monitored.
  • A low success rate of aminoglycosides in the treatment of SCI UTI is supported by level 1 evidence from a single RCT.
  • Optimum antimicrobial treatment duration and dosage is uncertain due to the lack of comparative trials in persons with SCI.
  • Level 4 evidence is reported for intermittent neomycin/polymyxin bladder irrigation being effective in altering the resistance of the offending bladder organism(s) to allow for appropriate antibiotic treatment.