Bladder management strategies do not fall into a “one size fits all” model. Instead, the choice of BMS should depend on various patient-specific factors, including mobility, degree of bladder dysfunction, and, most importantly, goals of care. Notably, females have been shown to have worse urinary quality of life following SCI compared to males.3,4 However, the sex-specific differences in BMS over time have been understudied. Therefore, we sought to define the long-term changes in bladder management in females with SCI and compare these to their male counterparts. Additionally, we aimed to better characterize factors related to conversion to urinary diversion in the female cohort.
We utilized the longitudinal National Spinal Cord Injury Model Systems (NSCIMS) Database to record BMS over a 30-year time period. Within the first year following injury, noninvasive strategies were most common in the entire cohort. However, females were less likely to volitionally void or use noninvasive strategies compared to males at all time points up to 30 years after SCI. In concordance with the recent AUA guidelines on management of neurogenic lower urinary tract dysfunction (NLUTD),5,6 clean intermittent catheterization (CIC) was the second most commonly used strategy, with higher rates of utilization in females compared to males at 10, 15, and 30 years after injury. However, when evaluating the use of indwelling catheters, females were nearly twice as likely to have urethral catheters compared to males at every follow-up interval. Long-term use of indwelling urethral catheters is not supported in the guidelines due to the higher risk of urethral erosion, and therefore, suprapubic catheters are recommended for long-term indwelling use.5
Although urinary diversion (i.e. augmentation cystoplasty, continent diversions, and urinary conduits) was the least common strategy overall, females were significantly more likely than males to pursue diversion at 5, 10, and 15 years after injury. Median time to diversion was estimated between 5-10 years after injury. Of the females undergoing urinary diversion, 81% had tried another bladder management strategy prior, and 67% reported transitioning to wheelchair use around the same time as pursuing urinary diversion. Cervical and thoracic injuries, as well as lower total motor scores at discharge following initial injury, were both associated with conversion to urinary diversion in the female cohort, highlighting the impact of functional status on choice of this more invasive strategy.
Choice of BMS after SCI is likely multifactorial and appears to be dynamic over time. Factors influencing this decision may be related to desires for independence, the time burden of specific strategies, and functional changes with time. Although our results demonstrate higher utilization of CIC and urethral catheters in females with SCI, longer-term follow-up is needed to evaluate the impact of recent AUA guidelines on practice patterns. Importantly, further studies are needed to evaluate the variables that govern the choice of BMS and the associated quality of life over time.
Written by: Bridget L. Findlay1 and Katherine T. Anderson2
- Department of Urology, Mayo Clinic, Phoenix, AZ, USA
- Department of Urology, Mayo Clinic, Rochester, MN, USA
- Anson CA, Shepherd C. Incidence of secondary complications in spinal cord injury. Int J Rehabil Res. 1996;19(1):55-66. DOI: 10.1097/00004356-199603000-00006
- McKinley WO, Jackson AB, Cardenas DD, et al. Long-term medical complications after traumatic spinal cord injury: a regional model systems analysis. Arch Phys Med Rehabil. 1999;80(11):1402-10. DOI: 10.1016/s0003-9993(99)90251-4
- Dekalo A, Myers JB, Kennelly M, et al. General and bladder-related quality of life: A focus on women living with spinal cord injury. Neurourology and Urodynamics. 2022;41(4):980-90. DOI: 10.1002/nau.24912
- Crescenze IM, Myers JB, Lenherr SM, et al. Predictors of low urinary quality of life in spinal cord injury patients on clean intermittent catheterization. Neurourol Urodyn. 2019;38(5):1332-8. DOI: 10.1002/nau.23983
- Ginsberg DA, Boone TB, Cameron AP, et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation. J Urol. 2021;206(5):1097-105 DOI: 10.1097/JU.0000000000002235
- Ginsberg DA, Boone TB, Cameron AP, et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Treatment and Follow-up. J Urol. 2021;206(5):1106-13. DOI: 10.1097/JU.0000000000002239