- Keep the patient safe (protect the kidneys) and dry
- Manage their catheters
- Know when not to panic
- Keep the patient infection free
- Know when to “throw in the towel”
- Spinal cord injury patients: ~100% have bladder symptoms and 80% cannot void
- Multiple sclerosis patients: 80% have bladder symptoms, which increases to 96% at 10 years after disease onset
- Spina bifida patients: 90% have bladder symptoms
- Prevent upper tract deterioration – by keeping bladder pressure low
- Maintain continence – by keeping bladder pressure low and the bladder empty
- Maintain an empty bladder by voiding – which is easiest for the patient
Do not:
- Screen for cancer with a cystoscopy or cytology
- Screen for UTIs with routine cultures in asymptomatic patients
- Screen for kidney dysfunction with serum creatinine
- Obtain KUBs
- Upper tract screening with an ultrasound – this is appropriate for identifying stones in the bladder or kidney, and for assessing hydronephrosis (if hydronephrosis is present, obtain and nuclear medicine renal study)
- Perform urodynamics at presentation and at some point during follow-up. Dr. Pelletier-Cameron notes that the frequency of urodynamic evaluation in follow-up is somewhat unclear

When managing the patients who require catheterization, Dr. Pelletier-Cameron notes that it is important to develop a bladder management plan. She is a huge proponent of clean intermittent catheterization (CIC) rather than indwelling catheters, even though these are often placed for incontinence or difficulty with CIC. Several complications of indwelling catheters in spinal cord injury patients are as follows:
- 6x more likely to develop an infection
- 4.9 increased RR of malignancy
- 20x more likely to develop bladder stones, and 2x more likely to develop kidney stones
- Devastating cases of urethral erosion and decubitus ulceration
Dr. Pelletier-Cameron notes that it is not time to panic when assessing high post-void residual (PVR) volumes. No studies to date have been able to deem a PVR volume as worrisome, as these patients are no more likely to develop infections or upper tract deterioration. Bladder compliance is more important than a specific PVR number, according to Dr. Pelletier-Cameron.
It is also important to keep these patients infection free. Neurogenic bladder patients are more prone to infection for several reasons:
- Decreased bladder glycosaminoglycan layer
- Poor bladder compliance leading to less blood flow to the bladder
- Poor urine hydrokinetics
- Changes in urothelial immune response
- Vesicoureteral reflux
- Catheterization
- Perineal soiling and flora changes

Presented by: Anne Pelletier-Cameron, MD, University of Michigan, Ann Arbour, MI
Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, Twitter: @zklaassen_md, at the 73rd Canadian Urological Association Annual Meeting - June 23 - 26, 2018 - Halifax, Nova Scotia