According to international guidelines, bladder evacuation in individuals with neurogenic lower urinary tract dysfunction (NLUTD) should be changed to intermittent catheterization (IC) as soon as possible during primary rehabilitation after spinal cord injury / disease (SCI/D). The aim of this retrospective cohort study was to evaluate the implementation of this guideline-based demand in the clinical reality. Furthermore, predictors for IC in individuals with NLUTD during primary rehabilitation until the first few years after discharge were investigated.

In this retrospective cohort study, the electronic patient database of a single SCI/D rehabilitation center was screened for patients with NLUTD admitted for primary rehabilitation from January 2015 to December 2017. Patient and SCI/D characteristics, type and frequency of bladder evacuation method were collected from paper and electronic patient charts. Data were collected at the following time points: 1) first urodynamic examination during primary rehabilitation, 2) last urodynamic examination during rehabilitation, 3) first urodynamic examination after discharge from rehabilitation and 4) last available examination. Injury severity was classified as follows: 1) American Spinal Injury Association Impairment Scale (AIS) D, 2) AIS A-C paraplegia, 3) AIS A-C low-level tetraplegia (C8-C5) and 4) AIS A-C high-level tetraplegia (C4-C1).15 Bladder evacuation methods without catheter, i.e. reflex or quasi-normal voiding, were pooled for analysis. Quantitative data were calculated as mean and standard deviation (SD). For frequency data, 95% confidence intervals (Clopper-Pearson CI) were calculated. The effects of sex, age (≤65 / >65 years), injury severity, bladder evacuation method early during rehabilitation and above-average bladder capacity (≥400ml) on bladder evacuation by IC were investigated using binary logistic regression analysis. A p-value of ≤ 0.05 was considered significant.

The data of 255 men (74.3%) and 88 women (25.7%) with a mean age of 54 ± 19 years at admission to primary rehabilitation were analyzed. The mean duration of rehabilitation was 25.0 ± 11.9 weeks. 
At the time of the first urodynamic examination (8.1 ± 4.9 weeks after admission), IC (self-catheterization (ISC) 22% and assisted catheterization (AIC) 18%) had been established in approximately 40% of the evaluated patients (Fig. 1). In approximately 20%, the bladder was evacuated by transurethral catheterization (TUC). The proportion of TUC decreased during rehabilitation and was below 5% after rehabilitation. In contrast, the proportion of IC and SPC increased by almost 10% to 28% and 13%, respectively, until the end of rehabilitation (22.8 ± 8.4 weeks after admission). The proportion of patients using SPC for bladder evacuation increased further thereafter until the first examination after discharge (4.4 ± 3.2 months). The proportion of evacuation by SPC stayed stable at approximately 19% until the last available examination (2.5 ± 1.0 years after discharge). In contrast, there was a second increase in ISC to approximately 38% until the last examination. The reasons why ISC was not established was available from 63 individuals. The most common reason was insufficient hand or arm function (33.3% / 21).  
Age, injury severity and above-average bladder capacity were significant (p≤0.038) predictors for bladder evacuation by ISC both at the end of and after primary rehabilitation. At the end of primary rehabilitation, sex and initial voiding method were also significant (p≤0.048) predictors for bladder evacuation by ISC. Above-average bladder capacity increased the odds of bladder evacuation by ISC at the end of primary rehabilitation. Male gender and paraplegia increased the odds of ISC at the end of primary rehabilitation whereas high level tetraplegia decreased the odds of ISC after primary rehabilitation.

There is a shift towards bladder evacuation by ISC and SPC during and after primary rehabilitation. Bladder evacuation by IC, regarded as the gold-standard in persons with NLUTD, is affected by age, injury severity and above-average bladder capacity and may get initiated even at a later stage after primary rehabilitation. Bladder evacuation by ISC is not an optimal solution for all individuals with NLUTD. In selected individuals under close urological monitoring, SPC may represent an appropriate evacuation method. The optimal bladder evacuation method needs to be established individually and should be re-evaluated regularly.

Bladder management is a holistic rehabilitation process, aiming at preserving both renal function and quality of life, and therefore, ISC is not the best solution for all patients.