Spinal cord injury (SCI) is a major health problem due to its physical, psychological, social and economic consequences. Most patients with SCI have neurogenic lower urinary tract dysfunction and may need different treatments to promote adequate bladder empting. Clean intermittent catheterization (CIC) is an established treatment modality for patients with different forms of lower urinary tract dysfunction who cannot empty their bladders properly. For patients with spinal cord injury (SCI), CIC is recommended as the method of choice to promote bladder emptying. However, discontinuation rates of CIC range from 20 to 52% and the rate of SCI patients performing CIC around the world is close to 50% in most series.1,2,3 Reasons for discontinuation may include discomfort during catheterization, complications such as recurrent urinary tract infection or urethral trauma, difficulties to obtain catheters and dependence on caregivers. In Brazil, the use of CIC by SCI patients and the predictors of successful CIC are not known. In this study we present the bladder management options used by a large cohort of patients with SCI and the impact of patient and spinal cord injury characteristics regarding the choice of bladder-emptying methods.

We evaluated a consecutive series of 348 patients (295 men and 53 women) with traumatic SCI from an academic referral specialty hospital. This study was approved by the Institutional Review Board of our hospital. Patients agreed to participate after full disclosure of its purposes and written consent was obtained from all participants. All subjects were older than 18 years of age and had SCI for more than one year. Patients were invited to participate when they presented for a routine medical visit with a physiatrist or for a physiotherapy session. The only exclusion criterion was the presence of associated traumatic brain injury with confirmed cognitive impairment. Clinical and epidemiological data such as gender, age, SCI duration, level and completeness of SCI, participation in a rehabilitation program and presence of pressure sores were evaluated. We investigated the method of bladder management in each patient and examined the factors that are associated with adherence to CIC.

The mean age at SCI was 35.2 ± 15.0 years. Mean time since SCI was 5.4 ± 5.0 years among men and 7.7 ± 10.6 years among women (p=0.564). Complete neurological SCI (ASIA A) comprised 233 (67.0%) patients. Incomplete lesions were observed in 115 (33.0%) patients. SCI level was cervical in 148 (42.5%) patients, thoracic in 161 (46.3%), lumbar in 37 (10.6%) and sacral in 2 (0.6%). A total of 235 (67.5%) patients were performing CIC as the method of bladder management, 97 (27.9%) used no catheters (maneuvers, condom catheter) and 16 (4.6%) used an indwelling catheter. Compared to the other patients, those performing CIC were younger (37.2 ± 12.9 vs 46.4 ± 15.8; p <0.001), had shorter time since SCI (4.9 ± 4.3 vs 7.7 ± 8.8; p <0.001) and increased prevalence of complete SCI [79.1% vs 41.2%; OR= 5.3, 95% CI 3.28 to 8.62] (p<0.001). Women and men had similar rates of CIC (64.2% vs 68.1%; p= 0.633) and the level of SCI (cervical vs non cervical) was not associated with the bladder management (p= 0.822). There was a trend towards higher rates of CIC for patients who participated in a rehabilitation program (p= 0.090).

Most patients in our series use CIC as the method for promoting bladder emptying. Our rate of almost 70% adherence to CIC after a mean time since SCI of 5.4 years is one of the highest in the world. Most patients in our cohort are inserted in a multidisciplinary rehabilitation program where CIC is implemented early since the acute phase of SCI and is strongly advocated for the long term bladder management. Since most patients did participate in a rehabilitation program, we were not able to show an association between adherence to CIC and having participated in a rehabilitation program. We did not explore the reasons why patients who did not adopt CIC opted for other forms of bladder management. Interestingly, we did not find a difference between the rates of CIC in patients with cervical vs non cervical SCI. As those with cervical SCI are more prone to need assisted CIC, it would be expected to see a lower rate of CIC in these patients. In fact, this has recently been shown in another series.3 Among patients who did not use any catheter for bladder emptying, we did not evaluate the use of suprapubic stimulation, Crede maneuvers and real spontaneous voiding.

The overall adherence to CIC in our population of SCI patients is one of the highest in the world and the factors associated with it are younger age, shorter time since SCI, having a complete SCI and participation in a rehabilitation program. With time, the rates of CIC decrease among SCI patients.

Manack A, Motsko SP, Haag-Molkenteller C, et al. Epidemiology and healthcare utilization of neurogenic bladder patients in a US claims database. Neurourol Urodyn. 2011;30:395-401.
Krebs J, Wöllner J, Pannek J, et al. Bladder management in individuals with chronic neurogenic lower urinary tract dysfunction.
Zlatev DV, Shem K, Elliott CS, et al. Predictors of long-term bladder management in spinal cord injury patients-Upper extremity function may matter most.