Drake et al. 2005
UK/USA
Downs & Black score=21
Case series
N=222

Population: Mean age = 57.4 yrs; Gender: male = 171; females = 51. Years post-injury: 33.
Treatment: Patients were divided according to their bladder management method: balanced reflex voiding; intermittent catheterization; indwelling urethral or suprapubic catheter; normal micturition. 
Outcome Measures: Risk of UTI, other complications. Patients were prospectively followed for 6 years.

• Complications including renal failure were significantly related to both age and years post injury.
• No significant difference in risk of a urinary tract infection* was seen for the different bladder management methods (IDUC, p=-.17; IC, p=0.45; straining, p=0.87; normal voiding, p=0.30. *UTI incidence = 1 or more UTI’s in year prior to assessment.
• 28.8% changed bladder management method during the study period, particularly those in balanced reflex voiding group.
• Urodynamic studies were not done routinely

Gallien et al. 1998
France
Downs & Black score=20
Case series
N=182

Population: Mean age = 41.45 yrs; Gender: males = 129, females = 53; Severity of injury: complete = 69, incomplete = 113; Mean time since injury = 8y.
Treatment: Bladder management method relative to UTI and other complications was retrospectively reviewed and a questionnaire was sent to all patients and attending physicians.
Outcome Measures: Method of bladder management; complication:  lithiasis, urinary infections, orchiepidymitis, urethral trauma, vesicorenal reflux, renal failure.

• Prevalence of complications was related to:
  • Type of bladder management at discharge: 71% of patients using CIC, 75% using percussion and all patients using indwelling catheters had at least one urologic complication.
  • Gender, with males having a higher probability than females (p<0.0001).
• Urinary infections were significantly higher in:
  • Patients with complete lesions (p=0.0001).
  • Use of a protection or a urine collector (p=0.0022).
• Urinary infections were not significantly related to:
  • Time since injury.
  • Method of bladder management (those on indwelling catheters were not part of UTI analysis).
• Intermittent catheterization was the main method of bladder management.

Groah et al. 2002
USA
Downs & Black score=18
Case series
N=21

Population: SCI with bladder cancer: Mean age = 48 yrs; Time since injury = 20 yrs.
Treatment: SCI bladder cancer patients' data was analyzed to determine risk factors for bladder cancer.
Outcome Measures: Bladder management methods, prevalence of bladder cancer, risk for bladder cancer, mortality rate due to bladder cancer.

• Bladder management methods included:
  • Indwelling catheters (IDC), 15 patients.
  • Non indwelling catheters (NIDC) spon. Void, condom, IC: 3 patients.
  • Both indwelling and nonindwelling catheters (Multi) duration of IDC use 20 years, 3 patients.
• Development of bladder calculi was significantly higher in patients using IDC than NIDC (p<0.001) 46% vs 10% but bore no relationship to incidence of CA.
• SCI patients were 15.2 times (95% CI, 9.2-23.3) more likely to develop bladder cancer than the general population. IDC 4.9 x more likely to develop bladder cancer than NIDC
• Bladder management method (p<0.02) and age at SCI (p<0.01) significantly predicted bladder cancer.
• SCI patients using IDC have a risk factor of 77 per 100,000 person years of bladder cancer, starting at 12 years post injury.
• Of the 13 patients that died, 12 were due to bladder cancer.  Of these 12 patients, 10 used IDC methods while 2 used Multi method.
• No mortality rate was found in the NIDC group.

Giannantoni et al. 1998
Italy
Downs & Black Score=16
Retrospective Study
N=78

Population: SCI: Age: 35 yrs; Gender: males = 57, females = 21; Severity of injury: AIS: A/B = 68, C/D = 10; Time since injury = 89 months.
Treatment: Group 1: Patients using clean intermittent catheterisation (CIC). Group 2: Patients using other methods of emptying (31 using Abdominal straining, tapping, or Crede manoeuvre, 5 indwelling catheter, 7 sponataneous voiding)
Outcome Measures: Urodynamic studies (UDS) (all anticholinergics were held); renal function (BUN, creatinine, creatinine clearance), ultrasound, IVP and/or VCUG.

• Both groups had similar clinical and UDS characteristics, and length of time treated with a foley catheter (67.9 vs 75 months)
• There were significantly more abnormalities on US or Cystourethrography in Group 2(22 vs 36 patients) p = 0.03
• Upper urinary tract damage (hydronepphrosis, renal stones, reflux) occurred more commonly in group 2 (n=13) vs. group 1 (n=4) p=0.03.
• CIC was believed to be the only explanation for the improved outcome in group 1

Ord et al. 2003
England
Downs & Black score=15
Case Series
N=457

Population: SCI with > 6 months on any 1 form of management: Mean Age: 29-40 years for various groups; Gender: males = 88%, females = 12%; Level of injury: T3 – T9; Severity of injury: complete, incomplete; Follow-up time = 48-107 mnths.
Treatment: Assessment of various bladder management methods (i.e., sphincterotomy, condom, IC, indwelling urethral catheter, suprapubic catheter, + combinations of each).
Outcome measures: Bladder stone formation rate.

• Both forms of indwelling catheterization had an increased risk of getting bladder stones and requiring hospitalization for bladder stones over IC and condom drainage with or without sphincterotomy.
• Relative to IC, hazard ratio was 10.5 for suprapubic catheters and 12.8 for indwelling urethral catheters.
• Incidence density ratio (like odds ratio) was 40.7 for developing bladder stones for indwelling catheters relative to IC. Condom incidence density ratio was 7.5 relative to IC.
• % Annual risk for stone formation: Condom & Sphincterotomy 0%; IC 0.2%; Expression voiding with or without condom 0.5%; Indwelling catheter 4% (first stone), 16% (subsequent stone).

Weld & Dmochowski 2000
USA
Downs & Black score=15
Case Series
N=316

Population: SCI: Mean age = 33.9-41.0 yrs for various groups; Gender: males = 313, females = 3; Level of injury: suprasacral = 269, sacaral = 47; Severity of injury: complete = 45, incomplete = 271; Mean follow-up = 17.8-19.3 years for various groups.
Treatment: Assessment of various bladder management methods (i.e., IC, voiding spontaneously, indwelling urethral catheter, suprapubic catheter).
Outcome Measures: Urological complication rate (epididymitis, pyelonephritis, upper tract stone, bladder stone, urethral strictures, periurethral abscess, vesicoureteral reflux, abnormal upper tracts).

• Frequency of those managed by IC, voiding spontaneously, suprapubic and urethral catheterization was 92, 74, 36 and 114 subjects respectively.
• Complication rates for the above groups were 27.2%, 32.4%, 44.4% and 53.5% respectively.
• Urethral catheter users had the highest rates for epididymitis, pyelonephritis, upper tract stone, bladder stone, urethral strictures and periurethral abscess.
• Suprapubic catheter users had the highest rates for vesicoureteral reflux and abnormal upper tracts.

Hansen et al. 2007
Denmark
Downs & Black score=14
Case series
N=236

Population: Mean age = 50.5 yrs; Gender: males = 193, females = 43; Mean follow-up time was 24.1y; Level of injury: paraplegic = 126, tetraplegic = 110; Severity of injury: complete = 102, incomplete = 134.
Treatment: Retrospective analysis of renal calculi development associated with various factors including bladder management method (normal emptying, suprapubic tapping/crede, IC, indwelling cath); patient questionnaire about stones.
Outcome Measures: Prevalence of calculi, risk of calculi.

• At least 1 episode of renal calculi was seen in 20% of patients and at least 1 episode of bladder calculi was seen in 14% of patients.
• The first 6 months after injury had the highest risk for getting renal and bladder calculus.
• No significant difference was seen between the type of bladder emptying method and the prevalence of calculi (trend was towards more stones in those with indwelling catheters).

Green 2004
USA
Downs & Black score=12
Case series
N=479

Population: SCI: Mean age = 27 yrs; Gender: males = 80%, females = 20%; Patients admitted over a 10 year period were chosen. 10 year follow up data vailable for 89% of cohort, 15 year follow-up data available for 86% of cohort.
Treatment: SCI patients' medical records were retrospectively reviewed to determine changes in bladder management techniques.  Questionnaires were also sent.
Outcome Measures: Bladder management techniques.

• Of the patients discharged with an intermittent catheterization program (ICP), 83% remained on the program at 1 year follow-up.
• At 5 year follow up, 80% of patients were catheter free (50% used an ICP).
• At 15 year follow up, of the 166 patients 25% changed to chronic indwelling catheters, while 67% were catheter free state or used ICP.

Yavuzer et al. 2000
Turkey
Downs & Black score=11
Case Series
N=50

Population: SCI: Mean age = 38 yrs; Gender: males = 36, females = 14; Level of injury: paraplegia = 43, tetraplegia = 7; Severity of injury: AIS: A-D; Time since injury = 124 days; Rehabilitation LOS = 130 days; Follow-up time = 24 months.
Treatment: Follow-up of those with various bladder management methods.
Outcome Measures: Bladder management method, compliance.

• At admission 86% used indwelling catheter and by discharge from rehabilitation, IC was used by 74%.
• At 2 year follow-up, of 38 people using IC, 52% had reverted back to indwelling catheter by 24 months, 42% continued with IC.
• Tetraplegics had lower compliance with IC than paraplegics (p<0.05) - majority of tetraplegics (80%) reverted to indwelling catheter vs only 40% of paraplegics.
• More females (60% vs 50%) reverted to indwelling catheters but this was not significant.
• More with complete injuries reverted to indwelling catheters (68% vs 31%, p<0.01).
• Main reasons for changing method = dependence on care givers, severe spasticity, incontinence and inconvenience (females).