Risk stratification for renal deterioration in the neurogenic bladder patient: Should it be a prerequisite for patient selection in video-urodynamic studies?

Objective: The aim of this retrospective review is to determine whether risk stratification for renal deterioration in neuro-urology patients is supported by urodynamic findings in terms of bladder safety and whether urodynamic findings affect bladder management in this patient group. The primary endpoints are to determine any statistically significant differences between the high and low risk for renal deterioration groups in terms of urodynamic findings regarding bladder safety, and the frequency of changes in bladder management following video-urodynamics (VUDs). Methods: VUDs, which were performed between March 2015 and March 2021 in view of neurogenic lower urinary tract dysfunction, were included in the study. These were divided into those performed in patients with high risk and those in patients with low risk for renal deterioration categories according to criteria specified in the National Institute of Clinical Excellence (NICE) Urinary Incontinence in Neurological Disease guidelines. The two groups were then statistically compared in terms of urodynamic parameters for bladder safety and changes in management thereafter. Results: In total, 69 VUDs were included, 49.3% were classified as having been performed in high risk for renal deterioration patients, and 50.7% as low risk. 50% of those in the former group were found to have an unsafe bladder versus 31.4% in the latter group ( p = 0.12). Meanwhile, 65.2% of VUDs resulted in a change in bladder management, with no difference in change in management frequency between the two risk stratification groups ( p = 0.36). Conclusion: The lack of statistically significant difference in urodynamic bladder safety findings and change in frequency of bladder management for the low and high risk for renal deterioration categories in this cohort bring into question the need for risk stratification in the clinical decision to perform VUDs in the neurogenic bladder patient. Level of evidence: 2c

Satisfaction with Detrusor OnabotulinumtoxinA Injections and Conversion to Other Bladder Management in Patients with Chronic Spinal Cord Injury

This study investigated the satisfaction with continued detrusor Botox injections for urinary incontinence and conversion to other surgical procedures and bladder management procedures for neurogenic detrusor overactivity (NDO) in patients with chronic spinal cord injury (SCI). A total of 223 patients with chronic SCI underwent detrusor Botox 200U for urodynamically confirmed NDO and urinary incontinence. After initial detrusor Botox injections, patients opted to either continue detrusor Botox injections every six to nine months and on clean intermittent catheterization (CIC), switch to other bladder management procedures, or receive surgical procedures to improve their urinary incontinence, correct emergent complications, or have better voiding conditions without CIC. Urinary incontinence improvement rates and satisfaction with bladder management were assessed and compared between different subgroups, urodynamic parameters, and bladder management procedures. Finally, a total of 154 male and 69 female patients were included, among whom 56 (25.1%), 81 (36.3%), 51 (22.9%), and 35 (15.7%) showed a marked, moderate, mild, and no reduction in urinary incontinence, respectively. However, only 48.4% of the patients continued detrusor Botox injections over the mean follow-up period of seven years. Patients with cervical or thoracic SCI had fair incontinence improvement rates. The presence of high detrusor pressure and higher-grade bladder outlet resistance also predicted a decrease in incontinence. Although more than 50% of the patients switched to other bladder management procedures or received surgical treatment, 69.1% expressed satisfaction with their current status. This large cohort of patients with chronic SCI who received initial detrusor Botox injections revealed that only 48.4% continued with Botox injections. Those who received surgical procedures due to urological complications or demanded change in bladder management could achieve high satisfaction rates.

Real-World Data Regarding Satisfaction to Botulinum Toxin A Injection into the Urethral Sphincter and Further Bladder Management for Voiding Dysfunction among Patients with Spinal Cord Injury and Voiding Dysfunction

Purpose: This study aimed to investigate improvement in voiding condition after the initial botulinum toxin A (BoNT-A) injection into the urethral sphincter among patients with chronic spinal cord injury (SCI) and voiding dysfunction. Moreover, subsequent surgical procedures and bladder management were evaluated. Materials and Methods: From 2011 to 2020, 118 patients with SCI and dysuria who wanted to void spontaneously received their first BoNT-A injection at a dose of 100 U into the urethral sphincter. Improvement in voiding and bladder conditions after BoNT-A treatment were assessed. Next, patients were encouraged to continually receive BoNT-A injections into the urethral sphincter, convert to other bladder managements, or undergo surgery. After undergoing bladder management and surgical procedures, the patients were requested to report improvement in voiding condition and overall satisfaction to bladder conditions. Then, data were compared. Results: In total, 94 male and 24 female participants were included in this analysis. Among them, 51 presented with cervical, 43 with thoracic, and 24 with lumbosacral SCI. After BoNT-A injections into the urethral sphincter, 71 (60.2%) patients, including 18 (15.3%) with excellent, and 53 (44.9%) with moderate improvement, had significant improvement in voiding condition. Patients with cervical SCI (66.6%), detrusor overactivity and detrusor sphincter dyssynergia (72.0%), partial hand function (80.0%), and incomplete SCI (68.4%) had a better improvement rate than the other subgroups. Only 42 (35.6%) patients continually received treatment with BoNT-A injections into the urethral sphincter. Meanwhile, more than 60% of patients who converted their treatment to augmentation enterocystoplasty (n = 5), bladder outlet surgery (n = 25), BoNT-A injections into the detrusor muscle (n = 20), and medical treatment (n = 55) had moderate and marked improvement in voiding dysfunction and overall satisfaction. Discussion: Although BoNT-A injections into the urethral sphincter could improve voiding condition, only patients with SCI who presented with voiding dysfunction were commonly satisfied. Those whose treatments were converted to other bladder managements, which can promote urinary continence, or to surgical procedures, which can facilitate spontaneous voiding, had favorable treatment outcomes.

Urodynamic utilization in the adult spina bifida patient: An institutional review

PURPOSE: To characterize common clinical indications for urodynamic, a bladder function test, in adults with spina bifida. METHODS: A retrospective chart review was performed for 215 patients seen in an adult multidisciplinary spina bifida clinic who were registered with the National Spina Bifida Patient Registry from October 2011 to October 2018. Descriptive statistics were used for statistical comparisons. RESULTS: A total of 52 of 215 patients developed a clinical indication for urodynamics. Of these, 71 (33%) patients (8 of whom underwent testing twice) had urodynamics performed, resulting in a total of 79 urodynamic study encounters that were analyzed. Thirty-four (43%) urodynamic testing cases were performed due to a symptomatic change in lower urinary tract function; 14 (18%) were due to declining renal function or concern for upper tract deterioration based on imaging. The data obtained from urodynamic investigation led to new recommendations for urinary tract management in 59 (75%) of the urodynamic studies performed. A total of 32 of the 90 (35%) recommendations made were surgical interventions and 30 (33%) were for a change in medical management. Interestingly, 8 of the 18 (44%) routine or baseline urodynamic tests performed led to new recommendations in urinary tract management. CONCLUSION: A total of 24%of patients in the multidisciplinary spina bifida clinic developed an indication for urodynamic testing over a 7-year period which resulted in new recommendations for urinary tract management in most. As more patients with spina bifida enter adulthood, the indications for urodynamic evaluation may become more defined, since the results often lead to alterations in bladder management.

Factors associated with self-management independence and quality of life for adolescents and young adults with spina bifida engaged in a guideline-based transition clinic

PURPOSE: To determine characteristics associated with self-management independence and quality of life (QOL) among adolescents and young adults with spina bifida (AYASB) engaged in a spina bifida (SB) health care transition clinic. METHODS: During SB transition visits, Eighty-eight AYASB ages 14-20 completed the Adolescent/Young Adult Self-management and Independence Scale II Self-Report/SB (AMIS II-SR/SB), scores ranging from 1–7 with 7 indicating full independence in activities, and the QUAlity of Life Assessment in Spina bifida for Teens (QUALAS-T), which has two subscales, family/independence (QFI) and bowel/bladder (QBB), with scores ranging from 0-100 with 100 indicating maximal QOL score. Demographic and clinical variables were collected from the electronic medical record. RESULTS: The baseline AMIS II-SR/SB score was 3.3 (SD 1.0). Baseline scores for QUALAS-T QFI and QBB subscales were 73.8 (SD 19.9) and 63.8 (SD 25.8). Older age was associated with a higher baseline AMIS II-SR/SB score (p = 0.017). Over time, AMIS II-SR/SB total significantly improved (p < 0.001), but QFI and QBB did not. AYASB not on chronic intermittent catheterization (CIC) and those using urethral CIC significantly improved in AMIS II-SR/SB total scores (p = 0.001), but those using abdominal channel CIC did not. CONCLUSION: Baseline bladder management method was associated with self-management improvement for AYASB engaged in a SB-specific transition clinic.

Time needed to perform intermittent catheterization in adults with spinal cord injury: A pilot randomized controlled cross-over study

Background: Intermittent catheterization (IC), considered the gold standard for bladder management for individuals with spinal cord injury (SCI) with sufficient dexterity, is usually performed using hydrophilic (HPC) or non-hydrophilic (non-HPC) catheters. Currently, there is no evidence on the temporal burden associated with IC with either catheter. Objective: To compare both catheters regarding their time requirement for IC and participant satisfaction. Design, setting and participants: Twenty individuals with chronic (>1-year) SCI at any spinal segment were randomized to undergo two cross-over assessments within 10 days (i.e., either starting with HPC or non-HPC). We measured time taken to perform IC using a 13 step pre-determined IC protocol (e.g., enter bathroom, wash hands, transfer to toilet, etc.). Furthermore, we assessed user satisfaction of both catheters using a Likert scale (i.e., strongly agree=5, strongly disagree=1). Outcome measures and statistical analysis: Time (i.e., for each step and in total) to perform IC and participant satisfaction were compared between catheters using non-parametric statistics, i.e., Wilcoxon rank sign tests. Results are presented as median with interquartile range. Results and limitations: Participants using HPCs spent less time to prepare a catheter [15 s (10-20) vs. 41 (20-69), p=0.002] and overall to perform IC [283 s (242-352) vs. 373 (249-441), p=0.01] compared to non-HPCs. Moreover, participants rated the preparation of HPCs to be easier [5 (4-5) vs. 4 (2-4), p=0.047] compared to non-HPCs. The key limitation of this pilot study was the sample size. Conclusions: Preparation and usage of HPCs for IC is easier and faster compared to non-HPCs. IC can be a significant temporal burden for SCI individuals. Patient summary: We compared coated and uncoated catheters on time needed for intermittent catheterization and user satisfaction in individuals with spinal cord injury. Participants can manually empty their bladder quicker and easier with coated compared to uncoated catheters.

Time Burden of Bladder Management in Individuals With Spinal Cord Injury

Background: While clean intermittent catheterization (CIC) is the gold standard for bladder management after spinal cord injury (SCI), many individuals with SCI, for reasons not fully understood, choose alternative bladder management. We hypothesized that CIC is associated with an increased time burden in individuals with SCI. Objectives: To investigate the time required to perform neurogenic bladder management in individuals with SCI. Methods: An electronic nonvalidated questionnaire was designed to determine the self-reported time spent performing bladder management. It was sent to participants in the Neurogenic Bladder Research Group SCI Registry, a national quality of life study of individuals with SCI. Results: Eighty-seven individuals responded to the survey. CIC was the most common bladder management (76%). Men and women performing independent CIC had similar average times with each catheterization episode (8.8 vs. 8.5 minutes, p = .864) as did women with a catheterizable stoma compared to women catheterizing per urethra (8.2 minutes, p = .913). Longer catheterization times were associated with cervical spine injury (mean 12.4 minutes per catheterization) and women requiring caregiver assistance (mean 20 minutes per catheterization). In addition, obese/overweight women had longer CIC times than normal weight women (14.5 minutes vs. 7 minutes; p = .036), while catheterization time was similar for all men regardless of body mass index. Individuals with indwelling catheters spent less than a third of the time on bladder management per day compared to those doing CIC (17 vs. 53 minutes per day, p &lt; .001). Conclusion: Management of neurogenic bladder after SCI, especially in those performing CIC, is time consuming. This time burden may play a role in long-term bladder management decisions.