Bladder stones of unusual shape in a male with paraplegia due to spinal cord injury who has been performing self-catheterisation

Bladder calculi formed over a hair nidus in spinal injury cases

Clean intermittent catheterization has been demonstrated to be a safe and effective method of bladder drainage in patients with neurogenic bladder dysfunction. However, breakdowns in technique may allow the introduction of foreign matter into the bladder and thereby result in bladder calculi. The three cases reported herein demonstrate this potential problem in persons with spinal cord injury (SCI) with hair nidus as the source of bladder calculi causing neurogenic bladder. In each situation, the problem was identified, calculi were removed cystoscopically and the patient and/or the ancillary aid were reinstructed. We recommend annual renal function tests, ultrasound and cytoscopic screening in high suspicion cases to allow early detection of bladder calculi in persons with SCI and prevent further urinary tract infections. This report also emphasizes the need for patient education and a careful follow-up preventing bladder calculi and thus, minimizing the morbidity in persons with SCI.

Delayed complications of discontinuation of intrathecal baclofen therapy: resurgence of dyssynergic voiding, which triggered off autonomic dysreflexia and hydronephrosis

STUDY DESIGN

Case report.

OBJECTIVES

To report insidious development of autonomic dysreflexia and hydronephrosis due to dyssynergic voiding following discontinuation of intrathecal baclofen therapy.

SETTING

Regional Spinal Injuries Centre, Southport, UK.

METHODS

A male patient with paraplegia at T-5 (ASIA-A) had implantation of Medtronic Synchromed 8615 s programmable pump to control intractable spasms. After 4 years, the baclofen pump needed replacement because of battery exhaustion. At this time, he was taking oxybutynin 2.5 mg twice a day. He wore a penile sheath and performed intermittent catheterisation three times a day. Intravenous urography showed no dilatation of pelvicalyceal systems or ureters. During the course of the next 4 months, the dose of baclofen had to be increased gradually to 820 microg/day in order to control the spasms. Investigations revealed disconnection of the tube from the pump. The patient decided to undergo explantation of the pump and discontinue intrathecal baclofen therapy altogether. Following removal of the pump, he was prescribed baclofen 20 mg four times a day and diazepam 5 mg twice a day. He continued penile sheath drainage with oxybutynin 2.5 mg twice a day. Although spasms were controlled with oral baclofen and diazepam, he started getting transient, mild headache during reflex voiding. After nearly 2 years, he developed unbearable and pounding headache while passing urine.

RESULTS

The dose of oxybutynin was increased to modified release formulation, 20 mg, once daily. He was prescribed modified release alfuzosin 10 mg once a day. Indwelling urethral catheter drainage was instituted. Intravenous urography showed dilation of left renal pelvis and calyces, and left ureter. After a fortnight, the dose of modified release oxybutynin was increased further to 25 mg once a day. After a month, he started performing self-catheterisation every 3 h and symptoms of autonomic dysreflexia subsided completely. A follow-up intravenous urography performed 6 months later, showed normal appearances of the left kidney.

CONCLUSION

Spinal cord injury patients, in whom intrathecal baclofen therapy is terminated, need close monitoring of their urological status. Medications, which are prescribed for neuropathic bladder, and the method of bladder drainage, may need suitable changes, as discontinuation of intrathecal baclofen therapy can result in reappearance of detrusor-sphincter dyssynergia in previously susceptible patients.

Doctor-patient communication: do people with spinal cord injury wish to receive written information about their medical condition from the physicians after an outpatient visit or after a readmission in the spinal unit?

STUDY DESIGN

A survey of spinal cord injury patients attending a follow-up clinic in a Regional Spinal Injuries Centre.

OBJECTIVES

To investigate whether spinal cord injury patients wish to receive written information about any changes in their medical condition after an outpatient visit or, following readmission in a spinal unit.

SETTING

Regional Spinal Injuries Centre, Southport, United Kingdom.

METHODS

A questionnaire was developed to assess the following: (1) Whether spinal cord injury patients wished to receive written information about changes in their medical condition after an outpatient visit or following readmission in a spinal unit; and (2) Whether provision of such written information would cause needless anxiety to patients and/or their relatives/carers.

RESULTS

A total of 128 adults with spinal cord injury filled in this questionnaire. One hundred and six persons (83%) wished to receive written information about any changes in their medical condition after an outpatient visit, whereas eight (6%) felt that provision of such written information was not required. 115 individuals with spinal cord injury (90%) preferred to receive a copy of the MRI scan report, with interpretation of the findings, while 11 (9%) would be happy not to receive such information. 115 persons with spinal cord injury (90%) felt that written information about their medical condition would be valuable for showing to a locum General Practitioner (GP), if necessary, who may not be acquainted with their medical status. Only eight (6%) did not perceive a need for written information to appraise a locum GP. One hundred and twenty-two persons with spinal cord injury (95%) did not feel that provision of written information would cause needless anxiety to them; only four (3%) felt the other way. One hundred and nineteen (93%) individuals with spinal cord injury wished to receive written information about changes in their medical condition after a readmission to the spinal unit, while six (5%) did not wish to receive such information.

CONCLUSION

Although the vast majority of people with spinal cord injury reported they wished to receive written information, a small proportion of patients did not wish to receive such information. Acceptance of written information is not universal and clinicians must ensure that provision of written information to people with spinal cord injury should be tailored to the needs of individual patients.

Protocol of a prospective cohort study of the effect of different methods of drainage of neuropathic bladder on occurrence of symptomatic urinary infection, and adverse events related to the urinary drainage system in spinal cord injury patients

BACKGROUND

To present a protocol of a prospective, cohort study in which four groups of spinal cord injury (SCI) patients will participate. (Patients with indwelling urethral catheter; patients who perform intermittent catheterisation without wearing a penile sheath; patients who perform intermittent catheterisation and wear penile sheath as well; and patients with penile sheath drainage).

OBJECTIVES

(1) What is the incidence of symptomatic urinary infection in men with spinal cord injury who use different types of bladder drainage? (2) Which are predisposing factors for the occurrence of symptomatic urinary infection in men with spinal cord injury who practise different methods of bladder drainage? (3) What is the incidence of catheter and urinary drainage system-related adverse events in the four groups of SCI patients?

PATIENTS

The criteria for inclusion are as follow: (1) Male patients with neuropathic bladder due to spinal cord injury, who are registered with the Regional Spinal Injuries Centre, Southport, England. (2) Age: 18 years or above. (3) Patients who are willing to give informed consent for participation in the study. (4) Patients willing to be contacted every two weeks by a staff of the spinal unit for 36 months. (5) Patients who are willing to maintain an accurate record of adverse events related to urinary catheter and urinary drainage system and predisposing factors for the occurrence of symptomatic urinary infection. (6) Patients, who are stabilised in a particular method of bladder drainage, and therefore, unlikely to make a permanent change in the method of bladder drainage (e.g. from penile sheath drainage to the use of long-term indwelling catheter) during a foreseeable future.

METHODS

The participants will be observed for a period of 36 months. A staff of the spinal injuries unit will contact the participants by telephone every two weeks on a mutually agreed day and time. The information obtained during this standardised telephonic interview conducted once in two weeks will be entered in a database. When a participant develops symptom(s) suggestive of urinary infection, he will undergo urine and blood tests, and imaging studies of the urinary tract.

CONCLUSION

This study will provide information regarding the occurrence of symptomatic urinary infection, predisposing factors for development of urinary infection, and adverse events related to urinary catheter and urinary drainage system in SCI patients using different methods of bladder drainage.

Bladder stone incidence in persons with spinal cord injury: determinants and trends, 1973-1996

OBJECTIVES

To examine the current trend in the incidence of an initial bladder stone and the potential contributing factors among persons with spinal cord injury.

METHODS

A longitudinal cohort of 1336 patients with spinal cord injury who were injured between 1973 and 1996 and followed up on a yearly basis up to 1999 in a single institution was used to estimate bladder stone incidence. Multivariable analysis was performed to identify risk factors for an initial bladder stone.

RESULTS

During the study period, 229 incident bladder stone cases were documented. It is estimated that for those injured in 1973 to 1979, 1980 to 1984, 1985 to 1989, and 1990 to 1996, the 5-year cumulative incidence rate of an initial bladder stone was 29%, 23%, 14%, and 8%, respectively (P <0.0001). This decreasing trend was consistent for various demographic and clinical characteristics. During the first year after injury only, the bladder stone risk increased with decreasing age (P <0.0001) and was greater for whites. A neurologically complete lesion was associated with an increased bladder stone risk in later years (P = 0.008). Males and persons with indwelling and intermittent catheters had a higher risk during all the years after the injury.

CONCLUSIONS

With improvement in urologic rehabilitation, bladder stone incidence has declined during the past several decades. The study results, however, suggest that new strategic interventions may be required to further prevent stone occurrence in individuals with spinal cord injury and a complete neurologic lesion who are using indwelling catheterization, because these patients are still at a relatively higher risk.