Autonomic Dysreflexia: Discussion on Urologic Concerns Part 2 - Todd Linsenmeyer

July 24, 2023

Diane Newman interviews Todd Linsenmeyer, an expert on the urological management of spinal cord injury patients. Dr. Linsenmeyer defines autonomic dysreflexia, a potentially life-threatening condition common in high-level spinal cord injuries, and shares how it can cause a sudden rise in blood pressure. They delve into the occurrence of autonomic dysreflexia during urodynamics, stating it does not cause the condition, but identifies those prone to it. Dr. Linsenmeyer also explains the role of bowel management, intermittent catheterizations, and suprapubic catheters in managing patients. Finally, he mentions that while they primarily deal with male patients, they also have a significant number of female patients, with the population aging due to advances in technology and care.


Todd Linsenmeyer, MD, Kessler Institute for Rehabilitation, West Orange, NJ

Diane K. Newman, DNP, ANP-BC, BCB-PMD, FAAN, Adjunct Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania, and Former Co-Director of the Penn Center for Continence and Pelvic Health, Philadelphia, PA

Read the Full Video Transcript

Diane Newman: Thank you so much. That was really informative and I didn't realize that there's so many urologic causes of this.

Todd Linsenmeyer: Yes.

Diane Newman: And so since these individuals of course have to catheterize or have a catheter, many times these episodes occur at home, is that true? With maybe someone catheterizing them?

Todd Linsenmeyer: They do, yes. And so-

Diane Newman: So your goal was to really teach caregivers and the patient about this, huh?

Todd Linsenmeyer: ... Yeah, in fact, one of the things that we do, in fact just this afternoon somebody came in with their mom and she was actually a nurse. She has a very high C3 injury. And I said, "Do you know about dysreflexia?" And she said, "No." And I went over it with them and gave them the guideline. And I said, "Now one of the big goals of rehab is not just getting better to go back in the community, but you have to learn how to teach your doctors and nurses how to take care of you. And you have to be able to tell them how to take care of dysreflexia." And so that consumer guide in some ways is sort of to help validate that yes, there is such a thing as dysreflexia and let them then look at the guideline and get some ideas.

Diane Newman: Well, and it's so very important because these individuals, even with a high core lesion, are living much longer. They're out there independently going outside their home and that. So you're right. I myself, I've been in neurology since the 80s, was not aware of this. And the other thing that you brought up is probably the second cause is constipation or fecal impaction, which is a really big problem in this population also, right?

Todd Linsenmeyer: Yes, it is. And in fact, when we're doing a procedure, going to do a procedure, we make sure that they have a good bowel program before they come for the procedure. And sometimes somebody will come in and their blood pressure will be like 140 or so, and the baseline's normally 90 to 110. And so we check and make sure everything's okay. And sometimes it's a full leg bag that just needs to be drained. But if it's not anything else, it's generally constipation. And it's interesting, we'll say go home, do a good bowel prep, and we'll see a in a day or so. Sure enough, they come back and it's 90 over 110 and we can do the cysto procedures without any problems.

Diane Newman: What you're referring then is these individuals have to be on some kind of bowel management. We have a lot more devices now on irrigation of the bowel and that helps. Now, do you find though, that when you do urodynamics, is this a big occurrence with these individuals undergoing urodynamics?

Todd Linsenmeyer: Yes, but one of the things that I'm glad you asked about that because one of the misconceptions I think is that urodynamics causes autonomic dysreflexia, and everywhere you see that. But in reality, the urodynamics picks up individuals who are prone to dysreflexia. So when we're filling up their bladder, we can in there, if their bladder starts to have a strong contraction, if they're reflex voiders for example, and their blood pressure goes up, well, okay, we need to give you an alpha blocker or do Botox in your sphincter, or somebody's doing ICs and their blood pressure is going up, okay, we can do Botox if we're already on anticholinergics or whatever. And as I say, that study actually with the 40% was a study we'd done years ago where we found that up to 40% or more people have silent dysreflexia. They were sitting, talking, chatting away, and their blood pressure was going up to 170. So the urodynamics study actually was an excellent way to detect and pick up the individuals and their dysreflexia.

And those who have silent dysreflexia, we tell them you need to make sure you always have your blood pressure checked if you're going to have an ingrown toenail taken out, or this, or that, or the other thing as well, not just count on if you don't have a headache, that doesn't mean your blood pressure's not high.

Diane Newman: So what you're saying is with urodynamics you can really identify those individuals that might be more prone to it, huh?

Todd Linsenmeyer: Exactly. It really does help us to figure that out. And then when it goes up, we just to a certain point, if they're having an involuntary contraction, the water fill, we stop that, we drain the bladder, and then the blood pressure just comes right back to where it had been when they come in.

Diane Newman: Yeah, tell me a little bit about your practice. So you're at Kessler, right? Kessler Rehabilitation, right?

Todd Linsenmeyer: Yes. Uh-huh.

Diane Newman: And can you give us a kind of an idea about your population then?

Todd Linsenmeyer: Well, I primarily have spinal cord patients. Kessler has a number of different facilities, but the Kessler West where I'm at primarily has spinal cord. And we have a lot of people actually, with vent dependent because we also have spinal cord. So we have some very high level injured individuals as well as the individuals that don't. And basically what we do is that we evaluate them. We used to when they were allowed to stay in the hospital longer, they came out of spinal shock usually at about three months and then we could evaluate them. But now we often have a lot of our patients coming as outpatients. And so they'll come in and we do the urodynamics evaluations, we monitor and give them the medications that they need. People who have stones in their bladder., We then can go in and they're usually the small eggshells and break those up and take those out using our special precautions for that.

And as I said, we do the urodynamics. Botox can also be given if somebody doesn't have a risk of the dysreflexia. Otherwise, that's done with anesthesia in the OR. But most of the things we do are in the outpatient setting.

Diane Newman: And do patients come from all over or do you just get them from the East Coast?

Todd Linsenmeyer: Yeah, well primarily we have the tri-state area people coming in from there. So occasionally we'll have somebody come from somewhere else, but it's primarily coming from our area and then they get their yearly evals and whatever else is needed as well.

Diane Newman: And you see all types of spinal cord injury, just not the high lesions, right? It's all different?

Todd Linsenmeyer: Right, exactly. We were sort of focusing on the bladder and things, but there's a lot of sexuality issues because that's another big area as well. We have both men and women, so they're issues as far as the type of bladder management, different things. So we do a lot of education as well for the various topics related to urologic care.

Diane Newman: And most of these patients, or most of these men and women are doing intermittent catheterizations, someone's catheterizing them. You're not seeing Foley catheters are you in this population? What is the mix there?

Todd Linsenmeyer: Well, the way we sort of do it is that the gold standard is intermittent cath. And so we try to have everybody doing intermittent cath, however there is an exception and we have a unique group of very high level injuries. Like that person I just told you about the C3, is on a ventilator and his mom's a nurse. Well, yes, we could say, okay, we want you to start catheterizing him every four to six hours from now on. But that's not very realistic for her or for him and even people who are able to get up in chairs if they don't have good hand function. So what we encourage these individuals to do is actually have a suprapubic catheter.

Diane Newman: Okay.

Todd Linsenmeyer: And we've in studies have shown that they have no higher risk of UTI than intermittent catheterization. We try to avoid the indwelling urethral catheters because those have a very high risk I think. So we do our best, but there are some people who can't cath nothing else and really just want to use that. So that's sort of our way we do that. We try our best to... I see. Unless you can't do it, you don't have hand function, and then we look at the suprapubic tube.

Diane Newman: Who's changing the suprapubic? Do they come back to you or that's doing in home care?

Todd Linsenmeyer: We actually let the patient and their family decide. We are able to teach them that they mark the catheter right at the skin level and then they can deflate the balloon and then put back the new one to exactly that same level. And it's actually much easier, they can do it sitting in the chair or whatever then. So a number of people say, "I'll just change my significant other's catheter." We have some people who don't have somebody else and they come and see us. But as I say, we try to teach and everyone who gets a suprapubic tube, when they come in and we do their change the first time after we do that, we let the person that's there do the second change and we watch them. And that seems to be great. I remember I had one person who said, "Dr. Linsenmeyer, you'd be so proud of me."

And I said, "Why's that?" And they said, they had their son there and they said, "Because remember eight years ago when you had me do that supra pubic cath change?" I said, "Yeah." They said, "well, last Sunday the catheter got blocked and I picked it up and I remembered what you said and it worked. So we didn't have to go to the emergency room." So it was very nice to hear that that happened. But yes, they can do it either way. And honestly I think the suprapubic catheter is so much safer that somebody's going to another country and somewhere else to use that.

Diane Newman: Yeah, I'm seeing it, even in non-spinal cord injury patients we're seeing a switch more to suprapubic. And I agree with you. I also have taught many family members or the patient themself to change it because you're right, over time they can really do that. Now your mix of genders, do you see mostly men in Kessler than women more injured than men?

Todd Linsenmeyer: Well, statistically there are more men than women that have spinal cord injuries. So for that reason, yes, we have a more men than women, but we certainly have our share of women as well.

Diane Newman: And of all ages. Are you seeing them live longer because of a lot of the technology we have? Right? We're seeing these as really aging population in the spinal cord injury.

Todd Linsenmeyer: Yeah. Everything has changed so much. I've been at Kessler now for about 33 years and I remember initially the person was injured and they'd go home and we're pretty isolated. And now with the internet and all the different things and with adapted devices and the ADD having everybody getting to go where they want to go, people are extremely active. They zip all over the place. So it's really worked out great. And yes, people are very active and able to do things and talk to each other about, hey, how'd you do this or that, traveling on an airplane and things. So you're right, people are much more mobile and active and doing things that they wouldn't be able to do before.

Diane Newman: Well, thank you so much. This was really so informative. So what we just had is a discussion with Dr. Todd Linsenmeyer, who's a urologist at Kessler Rehabilitation in New Jersey. And he spoke with us about autonomic dysreflexia. So thank you very much.

Todd Linsenmeyer: Well, thank you. It's certainly a great chance to get to talk and be with all of you.