Evaluation of 3 methods of bladder irrigation to treat bacteriuria in persons with neurogenic bladder

BACKGROUND/OBJECTIVE: We conducted a randomized, double-blind comparison of twice daily bladder irrigation using 1 of 3 different solutions in community-residing persons with neurogenic bladder who used indwelling catheters to evaluate efficacy in treatment of bacteriuria. METHODS: Eighty-nine persons with bacteriuria were randomized to irrigate their bladders twice daily for 8 weeks with 30 mL of (a) sterile saline, (b) acetic acid, or (c) neomycin-polymyxin solution. Urinalysis, cultures, and antimicrobial susceptibility tests were performed at baseline and weeks 2, 4, and 8 to determine the extent to which each of the solutions affected numbers and types of bacteria, urinary pH, urinary leukocytes, and generation of antimicrobial-resistant organisms. RESULTS: Bladder irrigation was well tolerated with the exception of 3 participants who had bladder spasms. None of the 3 irrigants had a detectable effect on the degree of bacteriuria or pyuria in 52 persons who completed the study protocol. A significant increase in urinary pH occurred in all 3 groups. No significant development of resistance to oral antimicrobials beyond what was observed at baseline was detected. CONCLUSIONS: Bladder irrigation was generally well tolerated for 8 weeks. No advantages were detected for neomycin-polymyxin or acetic acid over saline in terms of reducing the urinary bacterial load and inflammation. We cannot recommend bladder irrigation as a means of treatment for bacteriuria in persons with neurogenic bladder.     

Genital nerve stimulation is tolerable and effective for bladder inhibition in sensate individuals with incomplete SCI

Background: Neurogenic detrusor overactivity after spinal cord injury (SCI) causes urinary incontinence and reduces bladder capacity. Surface electrical genital nerve stimulation (GNS) acutely inhibits reflex bladder contractions. The stimulation amplitude selected for GNS is typically twice the amplitude that is required to evoke the pudendal-anal reflex. There is concern about the ability of persons with sensation to comfortably tolerate effective levels of GNS. The objective of this work is to determine if persons with incomplete SCI are able to tolerate acute GNS for bladder inhibition.

Methods: Twenty-four subjects with neurogenic detrusor overactivity, SCI, and pelvic sensation were enrolled in this case series. The setting was the Spinal Cord Injury Service of a Veterans Affairs Medical Center. Primary outcome measures were sensation threshold and tolerable stimulation amplitude; secondary outcome measures were bladder capacity and bladder contraction inhibition.

Results: GNS was tolerable up to 30±16?mA (range 8?mA to ≥60?mA) at amplitudes greater than twice the pudendal-anal (PA) reflex threshold, which was 8±5?mA (range 4?mA to 20?mA). Twelve subjects tolerated GNS at greater than twice the PA, six tolerated 1–1.5 times the PA, and five had no identifiable PA. GNS at tolerable amplitudes inhibited reflexive bladder contractions or increased bladder capacity 135±109?mL (n=23). GNS did not cause autonomic dysreflexia or intolerable spasticity.

Conclusions: GNS is tolerable at amplitudes that effectively inhibit neurogenic detrusor overactivity in individuals with pelvic sensation. GNS therefore is a tool with potential clinical applications for persons with preserved sensation.     

Bladder calculi formed over a hair nidus in spinal injury cases

Abstract

Clean intermittent catheterization has been demonstrated to be a safe and effective method of bladder drainage in patients with neurogenic bladder dysfunction. However, breakdowns in technique may allow the introduction of foreign matter into the bladder and thereby result in bladder calculi. The three cases reported herein demonstrate this potential problem in persons with spinal cord injury (SCI) with hair nidus as the source of bladder calculi causing neurogenic bladder. In each situation, the problem was identified, calculi were removed cystoscopically and the patient and/or the ancillary aid were reinstructed. We recommend annual renal function tests, ultrasound and cytoscopic screening in high suspicion cases to allow early detection of bladder calculi in persons with SCI and prevent further urinary tract infections. This report also emphasizes the need for patient education and a careful follow-up preventing bladder calculi and thus, minimizing the morbidity in persons with SCI.     

Identifying and classifying quality of life tools for neurogenic bladder function after spinal cord injury: A systematic review

Objective: To identify and classify quality of life (QoL) tools for assessing the influence of neurogenic bladder after spinal cord injury/disease (SCI).

Design: Systematic Review

Methods: Medline/Pubmed, CINAHL, and PsycInfo were searched using terms related to SCI, neurogenic bladder and QoL. Studies that assessed the influence neurogenic bladder on QoL (or related construct) in samples consisting of?≥50% individuals with SCI were included. Two independent reviewers screened titles and abstracts of 368 identified references; 118 full-text articles were assessed for eligibility, and 42 studies were included. Two reviewers independently classified outcomes as objective (societal viewpoint) or subjective (patient perspective) using a QoL framework.

Results: Ten objective QoL measures were identified, with the Medical Outcomes Short Form (SF-36/SF-12) used most frequently. Fourteen subjective QoL measures were identified; 8 were specific to neurogenic bladder. Psychometric evidence for SCI-specific neurogenic bladder QoL tools was reported for the Quality of Life Index (QLI), Qualiveen, Bladder Complications Scale, Spinal Cord Injury-Quality of Life (SCI-QOL) Bladder Management Difficulties, and the SCI-QOL Bladder Management Difficulties-Short Form. The QLI and Qualiveen showed sensitivity to neurogenic bladder in experimental designs.

Conclusion: Several objective and subjective tools exist to assess the influence of neurogenic bladder on QoL in SCI. The QLI and Qualiveen, both subjective tools, were the only validated SCI-specific tools that showed sensitivity to neurogenic bladder. Further validation of existing subjective SCI-specific outcomes is needed. Research to validate objective measures of QoL would be useful for informing practice and policy related to resource allocation for bladder care post-SCI.     

Unexpected foreign body in the bladder of a spinal cord injured patient: A case report

Context: Bladder dysfunction is common in patients with spinal cord injuries. Clean intermittent catheterization is a preferred method of neurogenic bladder management among spinal cord injured patients. Some complications may occur due to the use of clean intermittent catheterization.

Findings: In this report, we presented a case with an unexpected foreign body detected in the bladder of a patient who used to perform clean intermittent catheterization for her neurogenic bladder management, to our knowledge, which has not been reported in the literature so far.

Conclusion/Clinical Relevance: In this case report, we want to emphasis the importance of different kind of foreign bodies remaining in the bladder during clean intermittent catheterization.     

Establishment of animal model manifested as bladder neurogenic changes generated by bilateral pelvic nerve injury in male rats

Purpose

To establish a male rat model of neurogenic bladder after bilateral pelvic nerve injury (BPNI) and investigate the factors associated with onset of neurogenic bladder.

Methods

Twenty-four 8-week-old male Sprague–Dawley rats were randomly divided into three groups (n?=?8 rats per group). Rats in 4-week and 8-week nerve injury group underwent BPNI, while rats in the sham group underwent a sham operation. Bladder functional analysis were performed and then bladders tissues were harvested for morphological examination and investigating the mRNA expression levels of target genes in all rats.

Results

The bladder weight significantly increased in rats following BPNI. Functional analysis revealed non-voiding contractions and decreased detrusor contractility following BPNI, manifested as elevated post-void residual and bladder capacity while reduced maximum voiding pressure and voiding efficiency. The collagen area in bladder tissue and mRNA expression levels of target genes significantly increased at 4 or 8 weeks post-BPNI except Smad3. At 4 weeks post-BPNI, expression levels of vesicular acetylcholine transporter were reduced, then returned to baseline at 8 weeks. Expression levels of tyrosine hydroxylase were reduced at both 4 and 8 weeks post-BPNI.

Conclusions

A neurogenic bladder animal model was successfully established by performing BPNI in male rats, characterized by impaired voiding function, bladder detrusor fibrosis, and reduced neurotransmitter release.

     

Bladder Stones Following Sci In The Sprague-Dawley Rat

Abstract

Objective: To develop a spinal cord injury (SCI) animal model for the study of bladder stones and compare this model with a non-SCI animal model.

Methods: Small pieces of catheters were implanted into the bladders of Sprague-Dawley rats as a nidus for bladder stone formation. Three weeks later, the rats underwent an SCI surgery (SCI transection or sham SCI). Control rats had SCI surgery, but no catheters were implanted into their bladders.

Main Outcome Measures: Bladder stone number, weight, and composition were determined in two groups of SCI and sham SCI animals: Group A (recent spinal shock: 2 weeks post-SCI/sham SCI surgery) and Group B(out of spinal shock: 3 weeks to 3 months post-SCI/sham SCI surgery). AX2 test was used to compare the incidence of bladder stones in SCI vs sham SCI animals. AStudent t test was used to compare the weight of bladder stones in the 2 groups.

Results: Group A(recent spinal shock): Of the 20 SCI rats, 8 (40%) had stones. None of the sham SCI rats with implanted catheters (n = 5) had stones (0%). Group B(out of spinal shock): All 6 of the SCI rats with implanted catheters had stones (100%). Of the 10 sham SCI animals with implanted catheters, 3 (30%) had stones. Stones were more common in the SCI rats than in the sham SCI rats (X²., = 4.9, P < 0.05). The mean weight of the bladder stones in SCI rats (42.2 ± 16.3 mg) was greater than that in sham SCI rats (5.4 ± 1.5 mg) (P < 0.01). Group C (controls: SCI surgery, but no catheter implanted): At 3 weeks post-SCI, control rats had no stones (n = 7); control rats at 3 months post-SCI also had no stones (n = 9). Stone composition in the 3 sham SCI animals was calcium apatite (90%) and calcium oxylate (10%). In the 14 SCI rats, 10 had struvite stones (1 00%), 1 had struvite (70%) and carbonate apatite (30%) stones, 1 had brushite (100)% stones, and 2 had carbonate apatite (>90%) stones.

Conclusion: Bladder stones occurred earlier and more frequently and attained a larger size in SCI rats with catheters compared with sham SCI rats with catheters. There were no stones in SCI rats without catheter implants, even at 3-month follow-up. The bladder stone composition in SCI rats was similar to that in humans with SCI. The Sprague-Dawley rat model appears to be an excellent animal model for the study of bladder stones following SCI.

J Spinal Cord Med. 2003;26:65-68     

Transitional Cell Carcinoma of the Urethra in a Young Male with Neurogenic Bladder

ABSTRACT

We are reporting on a 23 year old white male with neurogenic bladder disease secondary to spinal cord injury, who recently was discovered as having a primary transitional cell carcinoma of the posterior urethra. He is the youngest patient with neurologic involvement of the lower urinary tract presenting a malignant urethral tumor.     

Bladder stone formation after sigmoidocolocystoplasty: statistical analysis of risk factors

Purpose

Bladder stone formation (BSF) after sigmoidocolocystoplasty (SCP) is a major source of morbidity. The authors identify risk factors and analyze them statistically.

Methods

Medical records of 106 patients who had SCP at our institute were reviewed to examine the incidence of post-SCP BSF, the stone removal method and length of follow-up. The primary underlying pathological conditions were myelomeningocele in 103 patients and other conditions in 3. Risk factors for BSF were statistically assessed by comparing cases with and without BSF.

Results

Bladder stone formation occurred in 20 (18.9%) of 106 patients (BSF group). The remaining 86 did not have stones (NBSF group). Mean age at SCP was 11.7 years in the BSF group and 10.2 years in the NBSF group. Mean follow-up was 12.0 years in the BSF group and 11.0 years in the NBSF group. BSF developed after a mean of 30.3 ± 25.6 months after SCP. Twenty-two stone removal procedures were performed in the BSF group and spontaneous evacuation occurred in 4 instances. Once stone free, BSF recurred in 4 patients. Although differences between the 2 groups with respect to sex, age at SCP, follow-up period, bladder capacity, bladder compliance, incidence of gram-negative bacteriuria, incidence of gram-positive coccus bacteriuria, electrolytes, frequency of urinary catheterization, post-SCP incidence of vesicoureteric reflux, and incidence of ureteric reimplantation were not statistically significant, differences in the incidence of spontaneous micturition, bladder neck tightening procedures, or gram-positive bacillus bacteriuria, or frequency of bladder irrigation were all statistically significant (P < .05 in all, Fisher's Exact test).

Conclusions

The authors are the first to statistically analyze a wide range of varying risk factors for BSF. BSF would appear to be common after SCP.     

Nursing Care of the Patient With Neurogenic Bladder After Kidney Transplantation: A Case Report

ObjectiveUrologic complications are among the most common complications after kidney transplantation. These complications are urinary retention, hematuria, hemorrhage, urinary leakage, vesicoureteral reflux, pyelonephritis, and nephrolithiasis. Although neurogenic bladder is one of the indications for kidney transplantation, it is not considered in the literature to be an expected complication after transplantation. In this case, we discuss the nursing care of a patient who underwent kidney transplantation from a living donor and developed neurogenic bladder.Case reportA 60-year-old woman underwent kidney transplantation from a living donor, and neurogenic bladder developed in the patient 1 year after kidney transplantation. Clear intermittent catheterization treatment was administered for the kidney transplant recipient with neurogenic bladder. Clear intermittent catheterization treatment was stopped in the patient who had frequent urinary tract infections and, alternatively, sacral neuromodulation treatment was administered to the patient.ConclusionsThe nursing care of a patient with neurogenic bladder after kidney transplantation aims to prevent excessive bladder distension, infection, stone formation, vesicoureteral reflux, renal failure, urinary tract damage, and incontinence, and to ensure regular and complete discharge of the bladder. The most common treatment modalities for these objectives are permanent or intermittent catheterization, sacral neuromodulation, and medical therapy. In the care of the patient with neurogenic bladder after kidney transplantation, nurses should provide appropriate care related to treatment options and bladder training, plan urination schedules of the patient, and monitor for possible complications.     

A Spinal Cord Injured Animal Model of Lower Urinary Tract Function: Observations Using Direct Bladder and Pelvic Plexus Stimulation With Model Microstimulators

Abstract

Background: Microstimulators are new devices that should be considered for managementof lower urinary tract problems following spinal cord injury (SCI) such as urinary retention. These devices are small(less than 25 mm by 5 mm) with the electrodes located on the ends of the stimulator. However, it is notknown whether the small electrodeson these devices would be effective in stimulating the plexus of nervesthat innervate thebladder. The aim of the present study was to provide preliminary observations with modelmicrostimulators (M-Micro) for inducing bladder contractions in an SCI animal model. Bladder wall andpelvic plexus stimulation sites were compared. Additional investigations evaluated parameters such asstimulation polarity, frequency, and period as well as bladder filling volume.

Methods: In an initial survival surgery, bilateral M-Micros were implanted on the bladderwall and the pelvic plexus along the urethra in 3 female cats. A second survival surgerywas conducted 3 to 5 weeks laterto produce a Tl 0 SCI. Studies are reportedfollowing the second survival surgery. These studies included the effects of stimulation and bladder filling.

Results: The postmortem location of the implanted pelvic plexus M-Micro was previouslydescribed asnear the bladder neck. Therefore, the pelvic plexus location is described in this reportas “pelvic plexus(bladder neck)”stimulation. The observations showed effective stimulation with pelvic plexus (bladder neck)stimulation andvoiding in some cases. Stimulation was limited byside effects of increased abdominalpressure and leg movement. Other factors also affected the response to stimulation, includingthe initial bladder volume and stimulating parameters. Fluoroscopy showed that when stimulation did not inducevoiding the striated urethral sphincter was closed.

Conclusions: This case series of 3 SCI animals showed that the small electrodes on the M-Micro could beused to stimulate the bladder with contractions and voidingin some cases. The pelvic plexus (bladder neck)location for the M-Micro may be a better location than higher on the bladder wall. Limiting side effects ofstimulation included legmovement and increased abdominal pressure. Additional important factors included the stimulation parameters, initial bladder volume, and the function of the skeletal urethral sphincter.     

The rationale for bladder washouts in children with neurogenic bladder

Children with a neurogenic bladder are at risk of developing recurrent urinary tract infections and long-term kidney failure. Due to an altered lower urinary tract, children may be overtreated for simple bacteriuria or undertreated for a potentially severe urinary tract infection. This group of patients represent high users of healthcare, and are at risk of colonization and development of antibiotic resistance. Bladder washouts with non-antibiotic electrochemically activated solutions are a potential new prophylactic option for patients with bladder dysfunction when clean intermittent catheterization has resulted in chronic bacteriuria.     

Bladder irrigation or irritation?

Exfoliation rates of urothelial cells following bladder irrigation were studied in patients with long-term indwelling catheters and chronic urinary tract infections (UTI). The irrigations were associated with an increased shedding of urothelial cells. Ultrastructural studies of these cells demonstrated increased disruption when compared with those obtained from normal subjects without catheters or chronic infection. The findings suggest that bladder irrigation further damages the already disrupted urothelium, which may in turn increase the predisposition of the bladder to the recurrent infections, commonly associated with patients who have indwelling urinary catheters. Bladder irrigation methods and the indications for their use require reassessment.     

Bladder lithiasis: from open surgery to lithotripsy

Bladder calculi account for 5% of urinary calculi and usually occur because of bladder outlet obstruction, neurogenic voiding dysfunction, infection, or foreign bodies. Children remain at high risk for developing bladder lithiasis in endemic areas. Males with prostate disease or relevant surgery and women who undergo anti-incontinence surgery are at a higher risk for developing vesical lithiasis. Open surgery remains the main treatment of bladder calculus in children. In adults, the classical treatment for bladder calculi is endoscopic transurethral disintegration with mechanical cystolithotripsy, ultrasound, electrohydraulic lithotripsy, Swiss Lithoclast, and holmium:YAG laser. Novel modifications of these treatment modalities have been used for large calculi. Open and endoscopic surgery requires anesthesia and hospitalization. Alternatively, extracorporeal shock wave lithotripsy has been demonstrated to be simple, effective, and well tolerated in high-risk patients. Recently, simultaneous percutaeous suprapubic and transurethral cystolithotripsy has been tested as well as percutaneous cystolithotomy by using a laparoscopic entrapment sac.     

Urodynamic Monitoring After Spinal Cord Injury

Abstract

Urinary tract infection (UTI) continues to be a major cause of mortality in patients with neurogenic bladders. Even patients who void reflexly and have unobstructed voiding with external condom drainage have a high incidence of chronic recurrent bacteriuria. Our recent studies have described the difficulty of diagnosing and localizing UTI in patients with neurogenic bladders. Symptoms correlated poorly with significant bacteriuria (> 10⁵ colonies/ml) and the use of the Fairley washout test gave less than optimal results in our studied population. Breakdown of endogenous host defenses, development of drug resistant organisms, and external contamination from urinary drainage appliances and fecal incontinence should be considered in diagnosis and management of these patients. Adequate bladder drainage is the most effective prophylactic measure against recurrent urinary tract infections. Our methods of bladder drainage include use of alpha blockers, transurethral sphincterotomy, and in selected paraplegics, long-term intermittent self-catheterization. We stress decreasing pathogenic bacterial skin colonization through daily perineal washing with soap and water, and cleaning drainage appliances at least once daily with 0.06% sodium hypochlorite. We treat the symptomatic patients and patients with positive urine cultures with potential stone forming organisms. Antibiotic therapy in asymptomatic patients should be guided by an inflammatory response with white blood cell count of > 10⁴ colonies/ml in the urine and positive bacterial culture of > 10⁵ colonies/ml.     

Minimally Invasive Techniques for Bladder Reconstruction

Purpose of Review

Bladder reconstruction surgery is a key component of neurogenic lower urinary tract dysfunction (nLUTD) management. Traditionally, given the complexity and unpredictable operative challenges of bladder reconstruction in this patient population, little consideration has been given to performing lower urinary tract reconstruction in a minimally invasive approach.

Recent Findings

We describe the innovative minimally invasive surgical techniques in four major categories of reconstructive procedures for nLUTD: (A) ileal bladder augmentation, the use of a low morbidity open Pfannenstiel incision and the use of laparoscopy and robotics; (B) creation of a catheterizable channel, the use of laparoscopy and robotics for Mitrofanoff procedures; (C) creation of both a bladder augmentation and catheterizable channel, the use of a hand-assisted approach for the creation of a continent cutaneous ileocystoplasty; and (D) bladder neck artificial urinary sphincter implantation: the use of a robotics.

Summary

Patients with nLUTD need surgical solutions that can improve their quality of life over several decades. As experience with robotics increases and as technology provides us with new tools to ease minimally invasive bladder reconstruction, we can expect that the field will continue to grow and improve.

     

Electrical Stimulation of the Urethra Evokes Bladder Contractions in a Woman With Spinal Cord Injury

Abstract

Objective: Electrical stimulation of pudendal urethral afferents generates coordinated micturition in animals and bladder contractions in men after spinal cord injury (SCI), but there is no evidence of an analogous excitatory urethra-spinal-bladder reflex in women. The objective of this study was to determine whether electrical stimulation of the urethra could evoke bladder contractions in a woman with SCI.

Case Report: A 38-year-old woman with a C6 ASIA A SCI who managed her bladder with clean intermittent catheterization and oxybutynin demonstrated neurogenic detrusor overactivity on urodynamics. Oxybutynin was discontinued 2 days prior to urodynamic testing with a custom 12F balloon catheter mounted with ring-shaped electrodes located in the bladder neck, mid urethra, and distal urethra. The inflated balloon was placed against the bladder neck to stabilize the catheter electrodes in place along the urethra. However, the balloon limited emptying during contractions. Urodynamics were performed at a filling rate of 25 mL/minute until a distention-evoked bladder contraction was observed. The urethra was stimulated over a range of bladder volumes and stimulus parameters to determine whether electrical stimulation could evoke a bladder contraction.

Findings: Electrical stimulation via urethral electrodes evoked bladder contractions that were dependent on bladder volume (>70% capacity) and the intensity of stimulation.

Conclusions: This is the first report of an excitatory urethra-spinal-bladder reflex in a woman with SCI. Future studies will determine whether this reflex can produce bladder emptying.     

Direct Bladder Stimulation with Percutaneous Electrodes and Impedance Monitoring of Volume in an SCI Animal Model

Abstract

Bladder responses to percutaneous electrodes were investigated with stimulation in three male spinal cats. The animals had been spinalized (T1 level lesion) 10 weeks prior to these studies and had been instrumented with chronic bladder wall electrodes and suprapubic bladder catheters for filling and pressure recording. Percutaneous stimulation in tethered animals was conducted with hook electrodes inserted with a needle in the abdomen bilaterally adjacent to the bladder trigone. Stimulation was conducted with 40 Hz pulse trains of 10 to 30 mA for three seconds. Stimulation with both percutaneous and chronic electrodes induced high bladder pressures and voiding. In addition, with chronically implanted electrodes, impedance monitoring of bladder volume was found to be an effective recording technique. (J Spinal Cord Med; 18:98–102)     

Factors Influencing Bladder Stone Formation in Patients With Spinal Cord Injury

Abstract

Objective: Bladder stones that form in patients with spinal cord injury (SCI) can cause significant morbidity. This study sought dto analyze factors associated withbladder stone formation to determine which patients might be at increased risk to developbladder stones.

Methods: A review of 56 SCI patients treated for bladder calculi over a 10-year period at a single institution was performed. These patients were compared with a control population of general SCI patients known tobe stone free. The factors compared were patient age, duration of injury, Ievei of injury, completeness of injury, method of bladder management, and the presence of documentedurinary tract infections with urease -producing organisms.

Results: All patients with stones were male and had a median age of 5 8.5years. The median Ievei of injury was C6, the median time since injury was 21 years, 66% had complete injuries, 68% managed their bladders with in dwelling cathetersor suprapubic tubes,and 83% had a history of infections with urease-producing organisms. When compared with the control group, patients forming bladder stones were older (P = 0 .03), were more likely to have in dwelling catheters (P < 0.0001 ), had a history of infections with urease-producing organisms (P = 0 .04), and had complete injuries(P= 0 .018).

Conclusion: This information can be used to identify patients who have anincreased risk of bladder stones and measures can betaken to reduce their incidence and morbidity.