Paraplegia 31 (1993) 320-329 © 1993 International Medical Society of Paraplegia The morbidity due to lower urinary tract function in spinal cord injury patients P E V Van Kerrebroeck MD PhD, E L Koldewijn MD, S Scherpcnhuizen, F M J Debruyne MD PhD Department of Urology, Unit for Neurourology and Urodynamics, University Hospital St Radboud, Geert Grooteplein Zuid 16, PO Box 9101, NL-6500 HB Nijmegen, The Netherlands. A review is given of 105 patients with a traumatic spinal cord injury. In 93 patients with a minimum follow up of one year the morbidity due to lower urinary tract function was evaluated, based on the situation at their last control visit. The relation was studied between bladder behaviour and the type of urine evacuation and their influence on upper urinary tract problems, urinary tract infections, stone formation and incontinence. Based on the results of this study the most appropriate method for control of bladder behaviour and urine evacuation in spinal cord injured patients is discussed in view of new treatment modalities such as dorsal rhizotomies and the implantation of an anterior sacral root stimulator. Keywords: spinal cord injuries; neurogenic lower urinary tract dysfunction; morbidity. Introduction daily practice proves that the control of individual patients tends to be less scrupul­ Great progress has been made during the ous with time. Even in the published pros­ last 25 years in the urological rehabilitation pective series the incidence of urological of patients with a spinal cord injury. problems varies much depending on the Nevertheless these patients continue to follow up, the composition of the patient develop complications such as urinary groups and the treatment(s) that were prop­ tract infections, stones of the upper and osed. the lower urinary tract and deterioration of In an important study on the 25-year the bladder. Furthermore upper urinary prospective mortality in veterans of the tract problems can develop due to reflux Korean and the second world war the and/or obstruction and these, with or with­ mortality rate was 49% after 25 years, with out urinary tract infections as additional renal disease as the major cause of death in complications, can lead to deterioration of 43% of those who died.! In this group, 44% kidney function. Incontinence remains of the patients had a Foley catheter at the another important problem for these handi­ time of evaluation. Vesicourethral reflux capped people. was present in 14.2% of the whole group However no consensus exists on the real and hydronephrosis in 14%. The group with incidence of morbidity due to lower urinary the most important renal deterioration com­ tract function in spinal cord injury patients. prised patients with upper motor neuron Although a number of interesting articles lesions who were maintained on a Foley review the urological problems following catheter. The high morbidity rate can prob­ spinal cord injury, most authors present a ably be explained by the fact that in this prospective study of consecutive patient study only 3 out of 175 patients were female. groups that had a strict follow up. Such A British study presents a survey of 406 follow up is not always achieved and, even traumatic spinal cord injury patients ad­ when the medical care is well organised, the mitted from 1967 to 1982.2 In this group Paraplegia 31 (1993) 320-329 Lower urinary tract morbidity 321 only 0.5% of the patients died from renal Table I Follow up status of all patients complications, being 5% of all deaths. At the last review 46% of the patients were Years Number Control 1991 appliance free and only 5.5% used perman­ 4 ent catheter drainage. Upper tract abnor­ > 20 9 15-20 12 11 malities were found in 14% of the patients 10-15 9 6 and stones in 8%. In this series 84% were 5-10 28 23 male and 16% female. The most striking 1-5 35 25 feature of this study is the low incidence of <1 12 12 death from renal failure. Total patients 105 81 Since there is a difference in the risk for Total> 1 93 69 upper tract problems between the male and the female population and since incontin­ ence is a more difficult problem in women, problem were excluded from this study. some series deal especially with the female However 7 patients with a spinal cord injury population with spinal cord injury. due to an arteriovenous malformation were In another British study a difference was included. The patient of 0 year at the found in the mortality between males and moment of the injury had a birth injury but females.3 In a group of 86 females no single was controlled till the age of 20. patient died from urological causes whereas The mean follow up was 93.7 months (7.8 13 (1.7%) in a group of 775 males died from years) with a range between 1 and 456 renal failure. In the female group 3 patients months. In 12 patients (11.4%) the follow underwent a urinary diversion and 28 were up was less than one year. An overview of managed with a permanent catheter drain­ the follow up is given in Table I. age. In a group of 124 Irish women with a Patients with complete and incomplete spinal cord injury, 22% had a permanent lesions at all different levels, from cervical catheter drainage and 2 had undergone a to sacral, are represented in this series. urinary diversion because of intractable However since the classification of the incontinence. 4 Twenty-four patients (19%) patients was based on the urodynamic underwent operative procedures on their behaviour of the lower urinary tract (blad­ urinary tract, mostly because of bladder der and urethra) no separate classification stones. was done depending on either the degree or The aim of the present study is to eval­ the level of the injury. uate morbidity due to lower urinary tract All patients had a complete urodynamic function in consecutive patients with a evaluation during the first screening. The spinal cord injury, controlled in a urology urodynamic investigation was repeated department. The incidence of urological whenever the clinical situation altered or in morbidity was based on the rate of urinary case of problems persisting after treatment. tract infections, the presence of urinary tract Videocystography was performed, usually stones, the importance of incontinence in combination with the urodynamic problems and the incidence of upper urinary investigation. In addition, an intravenous tract deterioration. urogram was obtained at the initial screen­ ing. Further follow up of the urinary tract Patients and methods was based on regular ultrasonic examination of the kidneys. If any abnormalities ap­ Between January 1985 and January 1992, peared on the ultrasonic examination the 105 patients with a traumatic spinal cord intravenous urography was repeated. In injury were seen for urological evaluation. case of suspicion of obstruction of the upper There were 78 males (74.3%) and 27 fe­ tract, renal scintigraphy with I-Hippuran or males (25.7%). The age at the moment of Tc-99m-Mag 3 was performed. 5.6 This the spinal cord injury varied between 0 and examination allows one to distinguish dilata­ 77 years, with a mean age of 31.5 years. tion with or without obstruction based on Patients with a congenital spinal cord the efflux curve of the radioisotope after the 322 Van Kerrebroeck et al Paraplegia 31 (1993) 320-329 injection of furosemide. Kidney function dyssynergia and 15 without proven dys­ was estimated with a 24-hour creatinine synergia. clearance or with a Tc-99m-Mag 3 clear­ The Crede manoeuvre was performed by ance.6 22 patients (23.7%) of whom 6 had a In the group of 105 patients, 4 died of detrusor hyperreflexia which generated too nonurological causes (3 men, one woman). little pressure to empty the bladder with Of the total group of 105 patients 81 tapping and who refused intermittent cath­ (77.1%) had a regular urological control eterisation. The other 16 patients perform­ and 93 patients (88.6%) had a minimum ing the Crede manoeuvre had detrusor follow up of one year. In these 93 patients areflexia and a weak pelvic floor, and could morbidity due to the function of the lower express urine with low intravesical pressure. urinary tract was evaluated based on the Clean intermittent catheterisation (CJC) situation at their last control visit. was performed by 9 patients (9.7%), al­ The group of 93 patients with a minimum though 3 patients with a detrusor hyper­ control of one year consisted of 70 males reflexia and 2 of the 6 patients with a (75.3%) and 23 females (24.7%) of whom detrusor areflexia had used other evacu­ 69 (74.2%) had their last follow up control ation methods previously. in 1991. A combination of different forms of urine evacuation was present in 22 patients. The Results combination of suprapubic tapping with clean intermittent catheterisation was used Of 93 patients with a minimum follow up of in 16 patients (17.2%) with a detrusor one year, 48 (51.6%) presented a detrusor hyperreflexia, because of incomplete evacu­ hyperreflexia with a coordinate sphincter ation with tapping alone. For the same mechanism, 14 (15.1%) had a detrusor reason 4 patients used the combination of hyperreflexia with a proven discoordinate tapping with the Crede manoeuvre. In the sphincter mechanism and 31 (33.3%) pres­ group with a detrusor areflexia 2 patients ented a detrusor areflexia. (2.1 %) emptied their bladder with a combi­ The method of evacuation of urine was nation of Crede and intermittent catheter­ noted as on the last follow up visit (Table isation to reduce the number of catheter­ II).