A 34-year-old man with T8
paraplegia after trauma 3 years ago.
He self catheterises 5 times daily but
is now experiencing incontinence
between catheterizations.
How would you manage him?
AIMs of Management
• Preservation of renal function
• Achieve continence
• Improve quality of life
History
• Duration
• Incontinence
– Stress
– Urge
– Without sensation
• Compliance to self
catheterization
• Change in volume intake
• Amount each time self
catheter inserted
• Infection – signs / symptoms
• Hematuria
– Stricture
– Stones
• History regarding trauma
– Partial or complete T8 injury
– What was neurological deficit
– Associated neurogenic bowel
• Constipation
• How is this managed
– Recent surgery
– Previous urological assessment
• Urodynamic study
• Imaging
• Renal profile
– Current medications
• Anticholinergics
• Diuretics
• Degree of bother and
expectations
Examination
• Abdomen
– Palpable bladder
– Ballotable kidneys
• DRE
– Anal tone
– Faecal load
• Neurological
examination
• Assessment
– Post catheterization
scans
– Bladder diary
• Fluid intake
• Amount removed via self
catheterization
• Note when leak occurs
and frequency
Investigations
• Renal profile
• Urine analysis
• US KUB
– Hydronephrosis
– Bladder wall,
trabeculations,
diverticulum
– Renal / bladder stones
• Video Urodynamic study
– Filling phase
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•
•
•
•
Compliance
Capacity
Sensations
Detrusor overactivity
Incontinence
– Associated with
cough/valsalva
– Neurogenic detrusor
overactivity
– Detrusor leak point
pressure
• Video urodynamic
– Filling
• Reflux into upper tracts
– Voiding phase
• Detrusor contraction
• Detrusor sphincter
dyssynergia
Management
• Purely stress
incontinence
– Urethral sphincter
incompetence
• Bulking agents
• Artificial urethral sling
insertion
• Neurogenic detrusor
overactivity
– Anti-cholinergics
• Oral
• Intravesicle
– BOTOX intravesicle
– Bladder augmentation
• Detrusor sphincter
dyssynergia
– Urehtral sphincter
BOTOX
– Sphincterotomy and CBD
/ pads / external
collecting devices
– Urethral stents
• Small contracted
bladder with high
intravesicle pressures
– Anticholinergics
– BOTOX
– Augmentation
cystoplasty
Follow up
•
•
•
•
Re- assess symptoms
Check RP, Urine analysis
Ultrasound KUB
Uro dynamic assessment
Appendix
American Spinal Injury
Association
•
Autonomic dysreflexia
•
•
•
Exaggerated sympathetic output
that occurs in response to noxious
stimulus below level of injury in
patients who have spinal cord
injuries above T6.
Manifests as
hypertension,bradycardia,
headache, profuse sweating and
flushing
Life threatening event–
procedure shoud be stopped
immediately, bladder emptied, serve
antihypertensive- eg S/L nifedipine.
Autonomic Dysreflexia
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•
•
•
•
•
•
•
Systolic HT, sweating, paradoxical bradycardia.
Only in SCI above T6, a viable distal cord & intact thoracolumbar sympathetic outflow.
Significant in 30% - 85%.
Can be life threatening as SBP>200mmHg.
Pt c/o headache & sweating.
SBP ↑40mmHg, DBP ↑25mmHg over baseline.
Heart rate ↓60bpm or lower (mean ↓20bpm).
A/w bladder distension, fecal impaction, decubitus ulcer, UTI, stones or manipulation of
genito-urinary tract.
• Prevented by SAB but not GA (unless quite deep).