Epidural Stimulation

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Authors: Dominik Zbogar and Sharon Jang | Reviewer: Susan Harkema | Published: 14 February 2022 | Updated: ~

Key Points

  • Epidural stimulation is a treatment that sends electrical signals to the spinal cord.
  • Epidural stimulation requires a surgical procedure to implant electrodes close to the spinal cord.
  • One of the ways epidural stimulation works is by replacing the signals that would normally be sent from the brain to the spinal cord before spinal cord injury (SCI).
  • Epidural stimulation affects numerous systems. Stimulation aimed at activating leg muscles may potentially also affect bowel, bladder, sexual, and cardiovascular function.
  • Studies of epidural stimulation in spinal cord injury (SCI) generally do not include a comparison group without stimulation. The benefits of epidural stimulation that have been reported have been in small numbers of participants. So, while reports thus far are encouraging, more research is necessary.
  • Because it is in the research and development phase, epidural stimulation for spinal cord injury is not part of standard care nor is it a readily available treatment.

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Neuromodulation is a general term for any treatment that changes or improves nerve pathways. Different types of neuromodulation can work at different sites along the nervous system (e.g., brain, nerves, spinal cord) and may or may not be invasive (i.e., involve surgery). Epidural stimulation (also known as epidural spinal cord stimulation or direct spinal cord stimulation) is a type of invasive neuromodulation that stimulates the spinal cord using electrical currents. This is done by placing an electrode on the dura (the protective covering around the spinal cord).

To read more about other types of neuromodulation used in SCI, access these SCIRE Community articles: Functional Electrical Stimulation (FES), Transcutaneous Electrical Nerve Stimulation (TENS), sacral nerve stimulation, and intrathecal Baclofen.

Watch our neuromodulation series videos! Our experts explain experimental to more commonplace applications, and individuals with SCI describe how neuromodulation has affected their lives.

 

 

 

What is “an Epidural”?

Epi- is a prefix and means “upon”, and the dura (full name: dura mater) is a protective covering of the spinal cord. So epidural means “upon the dura”, and in the context of epidural stimulation, this is where the electrodes that stimulate the spinal cord are placed. Yes, it is also possible to have sub-dural (under the dura) or endo-dural (within the dura) electrode placement. And, there are more layers between the dura and the spinal cord, not to mention the spinal cord itself where electrodes could be placed in what is called intraspinal microstimulation. The benefit of being beneath the dura and closer to the spinal cord is that there is a more direct stimulation. Having the electrode closer to the spinal cord allows more precision with the signal going more directly to the neurons.

The drawback is that more complications can arise with closer placement because the electrodes are in the spinal cord tissue. Such placement is currently rare, experimental, or non-existent but that will change as the technology advances. Intraspinal microstimulation has been tested in animal models and is in the process of being translated to humans.

You are probably familiar with the term “epidural” already, as it is often mentioned in relation to childbirth. If a new mother says she had an epidural, what she usually means is that she had pain medication injected into the epidural space for the purpose of managing pain during birth.

We specifically discuss epidural spinal cord stimulation in this article. Spinal cord stimulation can also be applied transcutaneously. This type of spinal cord stimulation is non-invasive as the stimulating electrodes are placed on the skin. With transcutaneous stimulation, the signal has to travel a greater distance through muscle, fat, and other tissues, which means the ability to be precise with stimulation is hampered. However, it does allow for more flexibility in electrode placement and does not require surgery. There is research published or underway investigating the impact of transcutaneous stimulation in some of the areas discussed above, including hand, leg, and cardiovascular function.

Normally, input from your senses travels in the form of electrical signals through the nerves, up the spinal cord, and reaches the brain. The brain then tells the muscles or organs what to do by sending electrical signals back down the spinal cord. After a spinal cord injury, this pathway is disrupted, preventing electrical signals from traveling below the level of injury to reach where they need to go. However, the nerves, muscles, and organs can still respond below the injury to electrical signals.

Epidural stimulation works by helping the network of nerves in the spinal cord below the injury function better and take advantage of any leftover signals from the spinal cord. To do so, the stimulation must be fine-tuned to make sure the amount of stimulation is optimal for each person and a specific function, such as moving the legs.

Recent studies of the role of epidural stimulation on standing and walking have noted unexpected beneficial changes in some participants’ bowel, bladder, sexual, and temperature regulation function This highlights both the potential for epidural stimulation to improve quality of life in multiple ways and that much research remains to be done to understand how epidural stimulation affects the body.


There may still be spared connections in the spinal cord with a complete injury.

How can someone with a complete injury regain movement control with epidural stimulation?

Being assessed with a complete injury implies that there is no spared function below the injury. However, scientists are finding that this may not be the case. Studies have found that even with a complete loss of sensory and motor function, there may be some inactive connections that are still intact across the injury site. These remaining pathways may be important for regaining movement or other functions. Another hypothesis is that epidural stimulation in combination with training may encourage stronger connections across the level of injury. Although these pathways may provide some substitution for the injured ones, they are not as effective as non-injured pathways across the injury level.

When it is decided that an individual will receive epidural stimulation, a health professional, such as a neurosurgeon, will perform an assessment of the spinal cord using magnetic resonance imaging (MRI) to determine the best place to implant the electrodes.

In most of the studies mentioned in this article, the electrodes were placed between the T9-L1 levels, though researchers are investigating the impact of epidural stimulation on hand function.


Xray image of wires connecting power and signal to electrodes (red circle) placed on a spinal cord.

There are two possible procedures. One approach is to have two surgeries. During the initial surgery, a hollow needle is inserted through the skin into the epidural space, guided using fluoroscopy, a type of X-ray that allows the surgeon to see where the needle is in real time. Potential spots on the spinal cord are tested using a stimulator. A clinician will look to see if stimulation over those areas of the spinal cord leads to a desired response. Once found, the electrode array is properly positioned over the dura and the surgery is completed. This begins a trial period where the response to epidural stimulation is monitored. During this time the electrode array is attached to an electrical generator and power supply, which is worn on a belt outside of the body. When it is shown that things are working as desired, the generator is implanted underneath the skin in the abdomen or buttocks. The generator can be rechargeable or non-rechargeable. A remote control allows one to turn the generator on or off and control the frequency and intensity of stimulation.

The second method is to only have one surgery and no trial period. This is possible due to increased knowledge in how to stimulate the spinal cord. Soon after surgery, the individual will be taught how and when to use the epidural stimulation system at home. If needed, the frequency (how often) and intensity (how strong) of the stimulation will be adjusted at follow-up appointments with the physician. In other cases, many practice sessions of learning the right way to stimulate may be needed before a person can stimulate at home.

If the epidural stimulation is used for leg control, movement training, standing, and stepping will be required to learn how to coordinate and control movement during stimulation. This is required for the recovery of voluntary movements, standing and/or walking.

Epidural stimulation can be used in all people with SCI, regardless of the level or completeness of injury. However, certain situations can make it an unsafe treatment in some. It is important to speak to a health professional about your health history before beginning any new treatment.

Epidural stimulation should not be used in the following situations:

  • By people with implanted medical devices like cardiac pacemakers
  • By people who are unable to follow instructions or provide accurate feedback
  • By people with an active infection
  • By people with psychological or psychiatric conditions (e.g., depression, schizophrenia, substance abuse)
  • By people who are unable to form clots (anticoagulopathy)
  • Near areas of spinal stenosis (narrowing of the spinal canal)

Epidural stimulation should be used with caution in the following situations:

  • By children or pregnant women
  • By people who require frequent imaging tests like ultrasound or MRI (some epidural stimulation systems are compatible)
  • By people using anticoagulant medications (blood thinners)

Epidural stimulation is generally well-tolerated, but there is a risk of experiencing negative effects.

The most common risks and side effects of epidural stimulation include:

  • Technical difficulties with equipment, such as malfunction or shifting of the electrodes that may require surgery to fix
  • Unpleasant sensations of jolting, tingling, burning, stinging, etc. (from improper remote settings)

Other less common risks and side effects of epidural stimulation include:

  • Damage to the nervous system
  • Leakage of cerebrospinal fluid
  • Increased pain or discomfort
  • Broken bones
  • Masses/lumps growing around the site of the implanted electrode

Risks specific to the surgery which involves the removal of part of the vertebral bone (laminectomy) include:

  • bleeding and/or infection at the surgical site
  • spinal deformity and instability

Proper training on how to use the equipment and using the stimulation according to the directions of your health provider can help decrease the risks of experiencing these side effects.

Neuromodulation methods to manage bladder function have usually involved stimulation of the sacral nerves (which are outside of the spinal cord), not with epidural spinal cord stimulation. This is reflected in the fact that almost no research exists regarding the effects of epidural stimulation on bowel and bladder function in the previous century.

New information on epidural stimulation relating to bladder function is coming. In the last several years, several studies (weak evidence) from a very small group of participants of participants (who were AIS A or B) have found consistent improvements in bladder function. Participants in these reports were fitted with epidural stimulators for reactivation of paralyzed leg muscles for walking and reported additional benefits of improvements in bladder and/or bowel function. However, other studies have shown small changes to bladder function and no changes to bowel function. Negative changes, such as decreased control over the bladder, have even been noticed by some participants in another study. These findings suggest that epidural stimulation may improve quality of life by safely increasing the required time between catheterizations. Fewer catheterizations and reduced pressure in the bladder would preserve lower and upper urinary tract health. More research is required, especially with respect to bowel function. It must be noted that walk training alone has been shown to improve bladder and bowel function. Epidural stimulation may provide additional improvement to bladder function in comparison to walk training alone. Neuromodulation methods to manage bladder function have usually involved stimulation of the sacral nerves (which are outside of the spinal cord), not with epidural spinal cord stimulation. This is reflected in the fact that almost no research exists regarding the effects of epidural stimulation on bowel and bladder function in the previous century.

Why does walk/stand training alone have a beneficial effect on bladder, bowel, and sexual function?

Relationships between the leg movement and nerves in the low back regions have been identified.

Some evidence suggests that walk/step training alone can create improvements on bladder/bowel function. Researchers hypothesize that the sensory information created through walking or standing provides stimulation to the nerves in the low back region, which contains the nerves to stimulate bowel, bladder, and sexual function. Research has shown that bending and straightening the legs can been enhanced by how full the bladder is and the voiding of urine.

One of the consequences of SCI is the loss of muscle mass below the injury and a tendency to accumulate fat inside the abdomen (abdominal fat or visceral fat) and under the skin (subcutaneous fat). These changes and lower physical activity after SCI increase the risk for several diseases.

A single (weak-evidence) study measured body composition in four young males with complete injuries. Participants underwent 80 sessions of stand and step training without epidural stimulation, followed by another 160 sessions of stand/step training with epidural stimulation. This involved one hour of standing and one hour of stepping five days a week. After all training was complete, all four participants had a small reduction in their body fat, and all participants but one experienced an increase in their fat free body mass (i.e., the weight of their bones, muscles, organs, and water in the body) in comparison to their initial values prior to stimulation. While all participants experienced a reduction of fat, the amount of fat loss was minimal, ranging from 0.8 to 2.4 kg over a period of a year.

The first use of epidural stimulation was as a treatment for chronic pain in the 1960s. Since then, it has been widely used for chronic pain management in persons without SCI. However, it is important to recognize that the chronic pain experienced by those without SCI is different from the chronic neuropathic pain experienced after SCI. This may explain, to some extent, why epidural stimulation has not been as successful in pain treatment for SCI. The mechanism by which electrical stimulation of the spinal cord can help with pain relief is unclear. Some research suggests that special nerve cells that block pain signals to the brain may be activated by epidural stimulation.

There are a few studies focused on the role of epidural stimulation in managing pain after SCI. A number of other studies included a mix of different people with and without SCI. Because chronic neuropathic pain after SCI may not be the same as the chronic pain others experience, studies that do not separate mixed groups raise questions about the validity of findings. The number of individuals with SCI in these studies is often small, most were published in the 1980s and 1990s and so are quite dated, and the research is classified as weak evidence.

The results of this body of research show that some people may receive some pain reduction. Those who saw the most reduction in pain were individuals with an incomplete SCI. Also, satisfaction with pain reduction drops off over time. One study showed only 18% were satisfied 3 years after implantation. A different study looking at the long-term use of epidural stimulation for pain reduction found seven of nine individuals stopped using this method.

In the only recent study in this area, one woman with complete paraplegia (weak evidence) experienced a reduction in neuropathic pain frequency and intensity, and a reduction in average pain from 7 to 4 out of 10, with 0 being no pain and 10 being the worst imaginable pain. This improvement remained up to three months later after implantation of the epidural stimulation device.

It should be noted that the studies for pain place electrodes in different parts of the spinal cord compared to the more recent studies for voluntary movement, standing and stepping.

Using epidural stimulation to improve respiratory function is useful because it contracts the diaphragm and other muscles that help with breathing. Also, these muscles are stimulated in a way that imitates a natural pattern of breathing, reducing muscle fatigue. More common methods of improving respiratory function do not use epidural stimulation, but rather, directly stimulate the nerves that innervate the respiratory muscles. While such methods significantly improve quality of life and function in numerous ways, they are not without issues, including muscle fatigue from directly stimulating the nerves.

To date, most research into using epidural stimulation to improve respiratory function has been in animals. Recently, research has been done in humans and weak evidence suggests that epidural stimulation may:

  • help produce a cough strong enough to clear secretions independently.
  • reduce frequency of respiratory tract infections.
  • reduce the time required caregiver support.
  • help individuals project their voice better and communicate more effectively.

Long term use of epidural stimulation shows that improvements remain over years and that minimal supervision is needed, making it suitable for use in the community.

The impact of epidural stimulation on sexual function has been a secondary focus in research studies looking at standing and walking. Currently, there are reports from one male and two females.

After a training program of walk training with epidural stimulation, one young adult male reported stronger, more frequent erections and the ability to reach full orgasm occasionally, which was not possible before epidural stimulation. However, this study looked at effects of walk training and epidural stimulation together, which took place after several months of walk training without stimulation. Because the researchers did not describe what the individual’s sexual function was like after walk training, it is difficult to say how much benefit is attributed to epidural stimulation versus walk training.

In another study with two middle-aged females 5-10 years post-injury, one reported no change in sexual function and the other reported the ability to experience orgasms with epidural stimulation, which was not possible since her injury.

Botulinum toxin (Botox) injections and surgically implanted intrathecal Baclofen pumps are the most common ways to manage spasticity. Baclofen pumps are not without issues, however. Many individuals do not qualify for this treatment if they have seizures or blood pressure instability, and pumps require regular refilling.

Research in the 80s and 90s on the use of epidural stimulation for spasticity did not report very positive findings. It was noted that greater benefits were found in those with incomplete injury compared to those who were complete. Another paper concluded that (weak evidence) the beneficial effects of epidural stimulation on spasticity may subside for most users over a short period of time. This, combined with the potential for equipment failure and adverse events, suggested that epidural stimulation was not a feasible approach for ongoing management of spasticity.

More recently, positive results with epidural stimulation have been observed (weak evidence). This is likely due to improvements in technology, electrode placement, and stimulation parameters. Positive findings show that participants:

  • reported fewer spasms over 2 years
  • reported a reduction in severe spasms over 2 years
  • reported a reduction in spasticity
  • reported an improvement in spasticity over 1 year
  • were able to stop or reduce the dose of antispastic medication

For more information, visit our page on Botulinum Toxin and Spasticity!

In a study with a single participant (weak evidence) investigating walking, an individual implanted with an epidural stimulator also reported improvement in body temperature control, however details were not provided. More research is required to understand the role of epidural stimulation for temperature regulation.

In severe SCI, individuals may suffer from chronic low blood pressure and orthostatic hypotension (fall in blood pressure when moving to more upright postures). These conditions can have significant effects on health and quality of life. Some recent studies have looked at how epidural stimulation affects cardiovascular  function to improve orthostatic hypotension. Overall, they show (weak evidence) that epidural stimulation immediately increases blood pressure in individuals with low blood pressure while not affecting those who have normal blood pressure. They also showed that there is a training effect with repeated stimulation. This means that after consistently using stimulation for a while, normal blood pressure can occur even without stimulation when moving from lying to sitting.

Moreover, researchers are starting to believe that changes in orthostatic hypotension and blood pressure can promote changes in the immune system (Bloom et al., 2020). In the body, the blood helps to circulate immune cells so they are able to fight infections in various areas. One case study found that after 97 sessions of epidural stimulation, the participant had less precursors for inflammation and more precursors for immune responses. Although these changes are exciting, researchers are still unsure why this happens, and whether these effects occur with all people who are implanted with an epidural stimulator.

For individuals with tetraplegia, even some recovery of hand function can mean a big improvement in quality of life. Research into using epidural stimulation to improve hand function consists of one case study (weak evidence) involving two young adult males who sustained motor complete cervical spinal cord injury over 18 months prior.

The researchers reported improvements in voluntary movement and hand function with training while using epidural stimulation implanted in the neck. Training involved grasping and moving a handgrip while receiving stimulation. For 2 months, one man engaged in weekly sessions while the other trained daily for seven days. One participant was tested for a longer time as a permanent electrode was implanted, while the other participant only received a temporary implant. Both participants increased hand strength over the course of one session. Additional sessions brought additional gradual improvements in hand strength as well as hand control (i.e., the ability to move the hand precisely). These improvements carried over to everyday activities, such as feeding, bathing, dressing, grooming, transferring in and out of bed and moving in bed. Notably, these improvements were maintained when participants were not using epidural stimulation.

Being able to control your trunk (or torso) is important for performing everyday activities such as picking things up or reaching for items. One study found that using epidural stimulation can increase the amount of distance you are able to lean forward. The improvement in forward reach occurred immediately when the stimulation was turned on. The two participants in this study were also able to reach more side to side as well, but the improvement was minor.

Learning to make voluntary movements

Voluntary movements (i.e., being able to move your body when you want to) of affected limbs can occur with the use of epidural stimulation. Researchers are still unsure of the right training regimen to optimize results. For example, one study found that many sessions of step training with epidural stimulation are required for participants to slowly regain voluntary movement of the leg and foot with epidural stimulation when lying down. However, another study found that participants were able to voluntarily move their legs with stimulation and no stand training.

Voluntary movements (i.e., being able to move your body when you want to) of affected limbs can occur with the use of epidural stimulation. Researchers are still unsure of the right training regimen to optimize results. For example, one study found that many sessions of step and stand training with epidural stimulation are required for participants to slowly regain voluntary movement of the leg and foot with epidural stimulation when lying down. However, another study found that participants were able to voluntarily move their legs with stimulation and no stand training though the amount each participant was able to move their legs with epidural stimulation varied greatly. For example, one participant was able to voluntarily move their leg without any stimulation after over 500 hours of stand training with epidural stimulation while another participant from the same study was not able to voluntarily move their leg without stimulation after training. Overall, more than 25 people can move some or all of their leg joints voluntarily from the first time they receive epidural stimulation.

More recently, research shows that some with epidural stimulators can produce voluntary movements without stimulation on and without any intensive training program. In one study, participants did not do a consistent intensive training program, although many of them attended out-patient therapy or did therapy at home. Over the period of a year, 3 of 7 participants were able to voluntarily bend their knee, and bend and straighten their hips. Additionally, of those 3 participants, 2 were able to point their toes up and down. While the number of people able to make voluntary movements without stimulation is small, many more studies are underway.

Recent research indicates that epidural stimulation can influence walking function in individuals with limited or no motor function. While these findings are exciting, researchers are still learning how to use stimulation effectively to produce walking motions. Before being able to walk again, people must be able to make voluntary movements and be able to stand.

Learning to stand

Some studies have also found that with extensive practice (e.g., 80 sessions), independent standing (i.e., standing without the help of another person, but holding onto a bar) may be achieved without epidural stimulation. Gaining the ability to stand may also occur with stand training combined with epidural stimulation. However, the findings in regards to the effect of stand training with epidural stimulation have been mixed. For example, one study showed that stand training for 5 days a week over a 4 month period with epidural stimulation resulted in independent standing for up to 10 minutes in an individual with a complete C7 injury, while another study has suggested that independent standing for 1.5 minute can be achieved with epidural stimulation and 2 weeks of non-step specific training in an individual with complete T6 injury.

Learning to walk

Earlier research has found that epidural stimulation can help with the development of walking-like movements, but these movements do not resemble “normal” walking. Instead, they resemble slight up and down movements of the leg. Recent studies have shown that with 10 months of practicing activities while lying down on the back and on the side, in addition to standing and stepping training, people are able to take a step without assistance from another person or body weight support. While some individuals in these studies have been able to regain some walking function, they are walking at a very slow pace, ranging from 0.19 meters per second to 0.22 meters per second. This is much slower than the 0.66 meters per second required for community walking. For example, of the 4 participants in one study, two were able to walk on the ground with a walker, one was only able to walk on a treadmill, and one was able to walk on the ground while holding the hands of another person. These differences in walking abilities gained by participants were not expected.

In late 2018, one researcher demonstrated that constant epidural stimulation was interfering with proprioception, or the body’s ability to know where your limbs are in space, which ultimately hinders the walking relearning process. The solution to this problem involves activating the stimulation in a specific sequence, rather than having it continuously on. With this method and a years’ worth of training, participants were able to begin walking with an assistive device (such as a walker or poles) without stimulation. However, these individuals had to intensively practice standing and walking with stimulation for many months to produce these results. In these studies, one case of injury was reported where a participant sustained a hip fracture during walking with a body weight support. Further studies on how to individualize therapy will be necessary as the response to treatment in these studies varied greatly from person to person depending on the frequency and intensity of the stimulation.

Is it the training or the epidural stimulation?

Most of the stand/walk training conducted in the studies is with the use of a body weight support treadmill.


Arm and leg movement and blood pressure have been seen to improve with epidural stimulation, but the role of rehabilitation in these recoveries is unclear. Rehabilitation techniques can have an effect on regaining motor function. For example, step/walk training alone can help improve the ability to make voluntary movements, walking and blood pressure among individuals with incomplete injuries.  In much of the current research, epidural stimulation is paired with extensive training (typically around 80 sessions) before and after the epidural stimulator is implanted. Furthermore, these studies do not compare the effects of epidural stimulation to a control group who receives a fake stimulation (a placebo) which would help to see if stimulation truly has an effect. Without this comparison, we are unable to clearly understand the extent of recovery that is attributable to epidural stimulation versus the effects of training. However, evidence now shows that voluntary movement and cardiovascular function can be improve from the first time epidural stimulation is used, if the stimulation parameters are specific for the function and person, which supports the role of epidural stimulation in improving function.

Access to new medical treatment for those requiring it cannot come soon enough. Experimental therapies are typically expensive and not covered by health care. Rigorous and sufficient testing is required before treatments become standard practice and receive health care coverage. Epidural stimulation for improving function in SCI is a unique example because epidural stimulation technology has been used widely to treat intractable back pain in individuals without SCI. The benefit of this is that, if/when epidural stimulation for individuals with SCI is shown to be safe and effective, the move from experimental clinical practice could happen relatively quickly as a number of hurdles from regulatory bodies have already been overcome. That said, current barriers to accessing epidural stimulation noted in a survey study of doctors include a lack of strong evidence research showing benefits, a lack of guidelines for the right stimulation settings, and an inability to determine who will benefit from it.

In Canada, the cost for an institution to install an epidural stimulation system for back pain in those without spinal cord injury, which is a common procedure, was $21,595 CAD. The cost incurred by a Canadian citizen undergoing implantation in Canada is $0 as it is covered by publicly funded health care.

 

In the United States, the cost for an institution to install an epidural stimulation system for back pain in those without spinal cord injury ranged between $32,882 USD (Medicare) and $57,896 USD (Blue Cross Blue Shield). The cost incurred for American citizens in the US will vary widely depending on their insurance coverage.

In contrast, for individuals with SCI, an epidural stimulation system is reported to cost over $100,000 USD in Thailand, and higher in other countries. Prospective clients should be aware that the epidural stimulation offered by these clinics may not be the same as that in the research reported in this article.

The recommended course for those wishing to try epidural stimulation is to register in a clinical trial. Regardless, persons interested in pursuing surgery at a private clinic or registering for clinical trials will find it useful to refer to the clinical trial guidelines published by ICORD (https://icord.org/research/iccp-clinical-trials-information/) for information on what they should be aware of when considering having an epidural stimulator implanted. Research studies that involve epidural stimulation can be found by searching the clinicaltrials.gov database.

Overall, there is evidence that epidural stimulation can improve function and health after SCI in numerous ways. However, because of the invasive nature of epidural stimulator implantation, research in this area involves few participants, no control groups, and no randomization, so it is classified as weak evidence. It is therefore important to keep in mind that while these recent reports are encouraging, more rigorous studies with more participants are needed to confirm the benefits and risks of this treatment to determine its place in SCI symptom management.

Epidural stimulation is not “plug and play” technology. Each implanted device needs to be tailored to the spine of the recipient. Some individuals respond to certain stimulation settings while others may respond better to other settings. Furthermore, over time, the need to change stimulation settings or even reposition the implant to maintain effectiveness may be required. Extensive physical training appears to be required for epidural stimulation to be most effective in improving standing or walking. The additional benefit of epidural stimulation to walk training is not always clear from the literature.

 

For a list of included studies, please see the Reference List. For a review of what we mean by “strong”, “moderate”, and “weak” evidence, refer to the SCIRE Community Evidence Ratings.


Parts of this page have been adapted from the SCIRE Project (Professional) “Spasticity”, “Bladder Management”, and “Pain Management” chapters:

Hsieh JTC, Connolly SJ, McIntyre A, Townson AF, Short C, Mills P, Vu V, Benton B, Wolfe DL (2016). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Curt A, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0.

Available from: scireproject.com/evidence/rehabilitation-evidence/spasticity/

Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, Wolfe D, Teasell R. (2014). Bladder Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-196.

Available from: scireproject.com/evidence/rehabilitation-evidence/bladder-management/

Mehta S, Teasell RW, Loh E, Short C, Wolfe DL, Benton B, Hsieh JTC (2016). Pain Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, McIntyre A, Querée M, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0: p 1-92.

Available from: scireproject.com/evidence/rehabilitation-evidence/pain-management/


Evidence for “What is epidural stimulation” is based on the following studies:

International Neuromodulation Society. (2010). Neuromodulation: An Emerging Field.

Toossi, A., Everaert, D. G., Azar, A., Dennison, C. R., & Mushahwar, V. K. (2017). Mechanically Stable Intraspinal Microstimulation Implants for Human Translation. Annals of Biomedical Engineering, 45(3), 681–694. Retrieved from http://link.springer.com/10.1007/s10439-016-1709-0

Evidence for “How does epidural stimulation work?” is based on the following studies:

Evidence for “How are epidural stimulation electrodes implanted?” is based on the following studies:

Lu, D. C., Edgerton, V. R., Modaber, M., AuYong, N., Morikawa, E., Zdunowski, S., … Gerasimenko, Y. (2016a). Engaging Cervical Spinal Cord Networks to Reenable Volitional Control of Hand Function in Tetraplegic Patients. Neurorehabilitation & Neural Repair, 30(10), 951–962. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27198185

Lu, D. C., Edgerton, V. R., Modaber, M., AuYong, N., Morikawa, E., Zdunowski, S., … Gerasimenko, Y. (2016b). Engaging Cervical Spinal Cord Networks to Reenable Volitional Control of Hand Function in Tetraplegic Patients. Neurorehabilitation & Neural Repair, 30(10), 951–962.

Evidence for “Are there restrictions or precautions for using epidural stimulation?” is based on the following studies:

Moore, D. M., & McCrory, C. (2016). Spinal cord stimulation. BJA Education, 16(8), 258–263. Retrieved from https://linkinghub.elsevier.com/retrieve/pii/S2058534917300975

Wolter, T. (2014). Spinal cord stimulation for neuropathic pain: current perspectives. Journal of Pain Research, 7, 651–663.

Evidence for “Are there risks and side effects of epidural stimulation?” is based on the following studies:

Eldabe, S., Buchser, E., & Duarte, R. V. (2015). Complications of Spinal Cord Stimulation and Peripheral Nerve Stimulation Techniques: A Review of the Literature. Pain Medicine, 17(2), pnv025. Retrieved from https://academic.oup.com/painmedicine/article-lookup/doi/10.1093/pm/pnv025

Taccola, G., Barber, S., Horner, P. J., Bazo, H. A. C., & Sayenko, D. (2020). Complications of epidural spinal stimulation: lessons from the past and alternatives for the future. Spinal Cord, 58(10), 1049–1059. Retrieved from http://dx.doi.org/10.1038/s41393-020-0505-8

Evidence for “Epidural stimulation and bladder and bowel function” is based on the following studies:

Herrity, A. N., Williams, C. S., Angeli, C. A., Harkema, S. J., & Hubscher, C. H. (2018). Lumbosacral spinal cord epidural stimulation improves voiding function after human spinal cord injury. Scientific Reports, 8(1), 1–11. Retrieved from http://dx.doi.org/10.1038/s41598-018-26602-2

Herrity, April N., Aslan, S. C., Ugiliweneza, B., Mohamed, A. Z., Hubscher, C. H., & Harkema, S. J. (2021). Improvements in Bladder Function Following Activity-Based Recovery Training With Epidural Stimulation After Chronic Spinal Cord Injury. Frontiers in Systems Neuroscience, 14(January), 1–14.

Hubscher, C. H., Herrity, A. N., Williams, C. S., Montgomery, L. R., Willhite, A. M., Angeli, C. A., & Harkema, S. J. (2018). Improvements in bladder, bowel and sexual outcomes following task-specific locomotor training in human spinal cord injury. Plos One, 1–26.

Darrow, D., Balser, D., Netoff, T. I., Krassioukov, A., Phillips, A., Parr, A., & Samadani, U. (2019). Epidural Spinal Cord Stimulation Facilitates Immediate Restoration of Dormant Motor and Autonomic Supraspinal Pathways after Chronic Neurologically Complete Spinal Cord Injury. Journal of Neurotrauma, 2336, neu.2018.6006. Retrieved from https://www.liebertpub.com/doi/10.1089/neu.2018.6006

Beck, L., Veith, D., Linde, M., Gill, M., Calvert, J., Grahn, P., … Zhao, K. (2020). Impact of long-term epidural electrical stimulation enabled task-specific training on secondary conditions of chronic paraplegia in two humans. Journal of Spinal Cord Medicine, 0(0), 1–6. Retrieved from https://doi.org/10.1080/10790268.2020.1739894

Evidence for “Epidural stimulation and body composition” is based on the following studies:

Terson de Paleville, D. G. L., Harkema, S. J., & Angeli, C. A. (2019). Epidural stimulation with locomotor training improves body composition in individuals with cervical or upper thoracic motor complete spinal cord injury: A series of case studies. The Journal of Spinal Cord Medicine, 42(1), 32–38.

Evidence for “Epidural stimulation and pain” is based on the following studies:

Guan, Y. (2012). Spinal cord stimulation: neurophysiological and neurochemical mechanisms of action. Current Pain and Headache Reports, 16(3), 217–225.

Marchand, S. (2015). Spinal cord stimulation analgesia. PAIN, 156(3), 364–365.

Tasker, R. R., DeCarvalho, G. T., & Dolan, E. J. (1992). Intractable pain of spinal cord origin: clinical features and implications for surgery. Journal of Neurosurgery.

Cioni, B., Meglio, M., Pentimalli, L., & Visocchi, M. (1995). Spinal cord stimulation in the treatment of paraplegic pain. Journal of Neurosurgery, 82(1), 35–39.

Warms, C. A., Turner, J. A., Marshall, H. M., & Cardenas, D. D. (2002). Treatments for chronic pain associated with spinal cord injuries: many are tried, few are helpful. Clinical Journal of Pain, 18(3), 154–163.

Reck, T. A., & Landmann, G. (2017). Successful spinal cord stimulation for neuropathic below-level spinal cord injury pain following complete paraplegia: a case report. Spinal Cord Series and Cases, 3, 17049.

Evidence for “Epidural stimulation and respiratory function” is based on the following studies:

Hachmann, J. T., Grahn, P. J., Calvert, J. S., Drubach, D. I., Lee, K. H., & Lavrov, I. A. (2017). Electrical Neuromodulation of the Respiratory System After Spinal Cord Injury. Mayo Clinic Proceedings, 92(9), 1401–1414. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/28781176

DiMarco, A. F., Kowalski, K. E., Geertman, R. T., & Hromyak, D. R. (2006). Spinal cord stimulation: a new method to produce an effective cough in patients with spinal cord injury. American Journal of Respiratory and Critical Care Medicine, 173(12), 1386–1389.

DiMarco, A. F., Kowalski, K. E., Geertman, R. T., & Hromyak, D. R. (2009). Lower thoracic spinal cord stimulation to restore cough in patients with spinal cord injury: results of a National Institutes of Health-sponsored clinical trial. Part I: methodology and effectiveness of expiratory muscle activation. Archives of Physical Medicine & Rehabilitation, 90(5), 717–725.

Harkema, S. J., Wang, S., Angeli, C. A., Chen, Y., Boakye, M., Ugiliweneza, B., & Hirsch, G. A. (2018). Normalization of Blood Pressure With Spinal Cord Epidural Stimulation After Severe Spinal Cord Injury. Frontiers in Human Neuroscience, 12, 83.

DiMarco, A. F., Kowalski, K. E., Hromyak, D. R., & Geertman, R. T. (2014). Long-term follow-up of spinal cord stimulation to restore cough in subjects with spinal cord injury. The Journal of Spinal Cord Medicine, 37(4), 380–388.

Evidence for “Epidural stimulation and sexual function” is based on the following studies:

Harkema, S., Gerasimenko, Y., Hodes, J., Burdick, J., Angeli, C., Chen, Y., … Edgerton, V. R. (2011). Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: A case study. The Lancet, 377(9781), 1938–1947.

Darrow, D., Balser, D., Netoff, T. I., Krassioukov, A., Phillips, A., Parr, A., & Samadani, U. (2019). Epidural Spinal Cord Stimulation Facilitates Immediate Restoration of Dormant Motor and Autonomic Supraspinal Pathways after Chronic Neurologically Complete Spinal Cord Injury. Journal of Neurotrauma, 2336, neu.2018.6006. Retrieved from https://www.liebertpub.com/doi/10.1089/neu.2018.600

Evidence for “Epidural stimulation and spasticity” is based on the following studies:

Nagel, S. J., Wilson, S., Johnson, M. D., Machado, A., Frizon, L., Chardon, M. K., … Howard, M. A. 3rd. (2017). Spinal Cord Stimulation for Spasticity: Historical Approaches, Current Status, and Future Directions. Neuromodulation: Journal of the International Neuromodulation Society, 20(4), 307–321.

Dekopov, A. V., Shabalov, V. A., Tomsky, A. A., Hit, M. V., & Salova, E. M. (2015). Chronic spinal cord stimulation in the treatment of cerebral and spinal spasticity. Stereotactic and Functional Neurosurgery.

Dimitrijevic, M. R., Illis, L. S., Nakajima, K., Sharkey, P. C., & Sherwood, A. M. (1986). Spinal cord stimulation for the control of spasticity in patients with chronic spinal cord injury: II. Neurophysiologic observations. Central Nervous System Trauma, 3(2), 145–152. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med2&AN=3490313

Midha, M., & Schmitt, J. K. (1998). Epidural spinal cord stimulation for the control of spasticity in spinal cord injury patients lacks long-term efficacy and is not cost-effective. Spinal Cord, 36(3), 190–192. Retrieved from https://www.nature.com/articles/3100532

Barolat, G., Singh-Sahni, K., Staas, W. E. J., Shatin, D., Ketcik, B., & Allen, K. (1995). Epidural spinal cord stimulation in the management of spasms in spinal cord injury: a prospective study. Stereotactic & Functional Neurosurgery, 64(3), 153–164.

Dekopov, A. V., Shabalov, V. A., Tomsky, A. A., Hit, M. V., & Salova, E. M. (2015). Chronic spinal cord stimulation in the treatment of cerebral and spinal spasticity. Stereotactic and Functional Neurosurgery.

Pinter, M. M., Gerstenbrand, F., & Dimitrijevic, M. R. (2000). Epidural electrical stimulation of posterior structures of the human lumbosacral cord: 3. Control Of spasticity. Spinal Cord, 38(9), 524–531. Retrieved from https://www.nature.com/articles/3101040

Evidence for “Epidural stimulation and temperature regulation” is based on the following studies:

Edgerton, V. R., & Harkema, S. (2011). Epidural stimulation of the spinal cord in spinal cord injury: current status and future challenges. Expert Review of Neurotherapeutics, 11(10), 1351–1353. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med7&AN=21955190

Harkema, S. J., Gerasimenko, Y., Hodes, J., Burdick, J., Angeli, C., Chen, Y., … Edgerton, V. R. (2011). Supplementary index: Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: A case study. The Lancet, 377(9781), 1938–1947. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21601270

Evidence for “Epidural stimulation and cardiovascular function” is based on the following studies:

Bloom, O., Wecht, J. M., Legg Ditterline, B. E., Wang, S., Ovechkin, A. V., Angeli, C. A., … Harkema, S. J. (2020). Prolonged Targeted Cardiovascular Epidural Stimulation Improves Immunological Molecular Profile: A Case Report in Chronic Severe Spinal Cord Injury. Frontiers in Systems Neuroscience, 14(October), 1–11.

Evidence for “Epidural stimulation and hand function” is based on the following study:

Lu, D. C., Edgerton, V. R., Modaber, M., AuYong, N., Morikawa, E., Zdunowski, S., … Gerasimenko, Y. (2016a). Engaging Cervical Spinal Cord Networks to Reenable Volitional Control of Hand Function in Tetraplegic Patients. Neurorehabilitation & Neural Repair, 30(10), 951–962. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27198185

Evidence for “Epidural stimulation and movement: trunk control” is based on the following studies:

Evidence for “Epidural stimulation and movement: voluntary movements” is based on the following studies:

Rejc, E., Angeli, C. A., Bryant, N., & Harkema, S. J. (2017). Effects of Stand and Step Training with Epidural Stimulation on Motor Function for Standing in Chronic Complete Paraplegics. Journal of Neurotrauma, 34, 1787–18023. Retrieved from www.liebertpub.com

Angeli, C. A., Edgerton, V. R., Gerasimenko, Y. P., & Harkema, S. J. (2014). Altering spinal cord excitability enables voluntary movements after chronic complete paralysis in humans. Brain, 137(Pt 5), 1394–1409. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999714/

Peña Pino, I., Hoover, C., Venkatesh, S., Ahmadi, A., Sturtevant, D., Patrick, N., Freeman, D., Parr, A., Samadani, U., Balser, D., Krassioukov, A., Phillips, A., Netoff, T. I., & Darrow, D. (2020). Long-Term Spinal Cord Stimulation After Chronic Complete Spinal Cord Injury Enables Volitional Movement in the Absence of Stimulation. Frontiers in systems neuroscience14, 35. https://doi.org/10.3389/fnsys.2020.00035

Evidence for “Epidural stimulation and movement: walking and standing” is based on the following studies:

Grahn, P. J., Lavrov, I. A., Sayenko, D. G., Straaten, M. G. Van, Gill, M. L., Strommen, J. A., … Lee, K. H. (2017). Enabling Task-Specific Volitional Motor Functions via Spinal Cord Neuromodulation in a Human with Paraplegia. Mayo Clinic Proceedings, 92(4), 544–554. Retrieved from http://dx.doi.org/10.1016/j.mayocp.2017.02.014

Harkema, S. J., Gerasimenko, Y., Hodes, J., Burdick, J., Angeli, C., Chen, Y., … Edgerton, V. R. (2011). Supplementary index: Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: A case study. The Lancet, 377(9781), 1938–1947. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21601270

Rejc, E., Angeli, C. A., Atkinson, D., & Harkema, S. J. (2017). Motor recovery after activity-based training with spinal cord epidural stimulation in a chronic motor complete paraplegic. Scientific Reports, 7(1), 13476. Retrieved from www.nature.com/scientificreports

Rejc, E., Angeli, C., & Harkema, S. (2015). Effects of Lumbosacral Spinal Cord Epidural Stimulation for Standing after Chronic Complete Paralysis in Humans. PLoS ONE [Electronic Resource], 10(7), e0133998. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med8&AN=26207623

Grahn, P. J., Lavrov, I. A., Sayenko, D. G., Straaten, M. G. Van, Gill, M. L., Strommen, J. A., … Lee, K. H. (2017). Enabling Task-Specific Volitional Motor Functions via Spinal Cord Neuromodulation in a Human with Paraplegia. Mayo Clinic Proceedings, 92(4), 544–554. Retrieved from http://dx.doi.org/10.1016/j.mayocp.2017.02.014

Gill, M. L., Grahn, P. J., Calvert, J. S., Linde, M. B., Lavrov, I. A., Strommen, J. A., … Zhao, K. D. (2018). Neuromodulation of lumbosacral spinal networks enables independent stepping after complete paraplegia. Nature Medicine, 24(11), 1677–1682. Retrieved from https://doi.org/10.1038/s41591-018-0175-7

Angeli, C. A., Boakye, M., Morton, R. A., Vogt, J., Benton, K., Chen, Y., … Harkema, S. J. (2018). Recovery of Over-Ground Walking after Chronic Motor Complete Spinal Cord Injury. New England Journal of Medicine, 379(13), 1244–1250. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=medl&AN=30247091

van de Port, I. G., Kwakkel, G., & Lindeman, E. (2008). Community ambulation in patients with chronic stroke: How is it related to gait speed? Journal of Rehabilitation Medicine, 40(1), 23–27.

Wagner, F. B., Mignardot, J.-B., Le Goff-Mignardot, C. G., Demesmaeker, R., Komi, S., Capogrosso, M., … Courtine, G. (2018). Targeted neurotechnology restores walking in humans with spinal cord injury. Nature, 563(7729), 65–71. Retrieved from http://www.nature.com/articles/s41586-018-0649-2

Angeli, C. A., Edgerton, V. R., Gerasimenko, Y. P., & Harkema, S. J. (2014). Altering spinal cord excitability enables voluntary movements after chronic complete paralysis in humans. Brain, 137(Pt 5), 1394–1409. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999714/

Carhart, M. R., He, J., Herman, R., D’Luzansky, S., & Willis, W. T. (2004). Epidural spinal-cord stimulation facilitates recovery of functional walking following incomplete spinal-cord injury. IEEE Transactions on Neural Systems & Rehabilitation Engineering, 12(1), 32–42. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med5&AN=15068185

Harkema, S. J., Wang, S., Angeli, C. A., Chen, Y., Boakye, M., Ugiliweneza, B., & Hirsch, G. A. (2018). Normalization of Blood Pressure With Spinal Cord Epidural Stimulation After Severe Spinal Cord Injury. Frontiers in Human Neuroscience, 12, 83.

Legg Ditterline, B. E., Aslan, S. C., Wang, S., Ugiliweneza, B., Hirsch, G. A., Wecht, J. M., & Harkema, S. (2020). Restoration of autonomic cardiovascular regulation in spinal cord injury with epidural stimulation: a case series. Clinical Autonomic Research, (0123456789), 2–5. Retrieved from https://doi.org/10.1007/s10286-020-00693-2

Evidence for “Costs and availability of epidural stimulation” is based on the following studies:

Solinsky, R., Specker-Sullivan, L., & Wexler, A. (2020). Current barriers and ethical considerations for clinical implementation of epidural stimulation for functional improvement after spinal cord injury. Journal of Spinal Cord Medicine, 43(5), 653–656.

Kumar, K., & Bishop, S. (2009). Financial impact of spinal cord stimulation on the healthcare budget: a comparative analysis of costs in Canada and the United States. Journal of Neurosurgery: Spine.

Image credits
  1. Image by SCIRE Community Team
  2. Image by SCIRE Community Team
  3. Image by SCIRE Community Team
  4. Image by SCIRE Community Team
  5. Adapted from image made by Mysid Inkscape, based on plate 770 from Gray’s Anatomy (1918, public domain).
  6. Pregnant woman holding tummy. [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)] via Google Images.
  7. Edited from Nervous system, Musculature. ©Servier Medical Art. CC BY 3.0.
  8. Neurons ©NIH Image Gallery. CC BY-NC 2.0.
  9. Image by SCIRE Community
  10. bladder by fauzan akbar from the Noun Project
  11. Large Intestine by BomSymbols from the Noun Project
  12. Feet by Matt Brooks from the Noun Project
  13. hip by priyanka from the Noun Project
  14. visceral fat by Olena Panasovska from the Noun Project
  15. Lightning by FLPLF from the Noun Project
  16. Lungs by dDara from the Noun Project
  17. Love by Jake Dunham from the Noun Project
  18. Male by Centis MENANT from the Noun Project
  19. Female by Centis MENANT from the Noun Project
  20. Image by SCIRE Community
  21. Temperature by Adrien Coquet from the Noun Project
  22. Heart by Nick Bluth from the Noun Project
  23. Image by SCIRE Community
  24. Hand by Sergey Demushkin from the Noun Project
  25. Torso by Ronald Vermeijs from the Noun Project
  26. Yoga posture by Gan Khoon Lay from the Noun Project
  27. Standing by Rafo Barbosa from the Noun Project
  28. Walking by Samy Menai from the Noun Project
  29. Image by SCIRE Community
  30. Canada by Yohann Berger from the Noun Project
  31. United States of America by Yohann Berger from the Noun Project

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Acupuncture

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Author: SCIRE Community Team | Reviewer: Amrit Dhaliwal | Published: 5 July 2019 | Updated: ~

Acupuncture is a common complementary therapy used for various symptoms and conditions. This page outlines what acupuncture and dry needling are and their uses after spinal cord injury (SCI).

Key Points

  • Acupuncture is a treatment where small thin needles are inserted into specific points on the body to treat health conditions. Acupuncture is a complementary and alternative medicine treatment based on traditional Chinese medicine.
  • Acupuncture has been studied as a treatment for pain, bladder problems, and to aid functional recovery after SCI.
  • Scientists are not entirely sure how acupuncture might work. Its effects on pain, bladder function, and functional recovery after SCI are likely related to influences on the nervous system and/or circulation.
  • Overall, there is moderate evidence suggesting that acupuncture (including electroacupuncture) may be effective for treating neuropathic pain and bladder problems after SCI; and may aid functional recovery after SCI. The evidence for treating shoulder pain is unclear. Further studies are needed to confirm these findings.
Thin acupuncture needle inserted into cloth.

Acupuncture needles are thin needles that are inserted into acupuncture points on the body.1

Acupuncture is a complementary and alternative medicine (CAM) practice that has been used for thousands of years as a component of traditional Chinese medicine (TCM). Acupuncture involves the insertion of small thin needles into specific points on the body called acupuncture points or acupoints.

Acupuncture is used to treat many different symptoms and conditions. For people with SCI, acupuncture is used to treat pain, manage bladder problems, and possibly aid functional recovery.

 

Dry needling

Dry needling, also known as intramuscular stimulation (IMS), involves the use of similar thin needles that are inserted into trigger points. Trigger points are tight, irritable bands in the muscles and fascia that are a common cause of musculoskeletal pain. Dry needling typically elicits a small muscle twitch that may help to reduce muscle tension. Acupuncture and dry needling differ in both the theories that underlie their use and in how they are practiced.

Acupuncture is performed by health providers such as physiotherapists, physicians, chiropractors, and acupuncturists. In many regions, health providers need special training and a license to practice acupuncture.

Before the treatment

If you are considering trying an acupuncture treatment, it is important to discuss with your health providers to make sure that acupuncture is safe for you. Before starting a treatment, your health provider will perform an assessment and provide information about the treatment, its risks, and any other information you need to decide whether to proceed with an acupuncture treatment.

During the treatment

Person's lower leg with several acupuncture needles inserted into the skin

Acupuncture points are located at very specific points on the body.2

Acupuncture needles are thin, single-use, sterile needles that are solid and cannot be used to inject or withdraw fluids from the body. The needles are inserted into the surface of the skin at locations called acupuncture points. Acupuncture points are specific points on the body that are thought to influence the body systems. When the needles are inserted into the skin, they can cause minimal pain and/or bleeding.

Once the acupuncture needles are inserted, they may be left in for a specific amount of time determined by the therapist (usually 20 minutes or longer) before removal. Your response will be monitored during and after the treatment. While the needles are inserted, some practitioners choose to twist or shallowly plunge the needles into the skin or apply other stimulation in the form of heat or electricity to the needles. Acupuncture treatments are usually scheduled anywhere from a few days to a week apart.

Traditional Chinese medicine explanation

ancient illustration of man with acupuncture meridian labelled on his body

Ancient illustration of the acupuncture meridians based on Traditional Chinese Medicine.3

Traditional Chinese medicine (TCM) is based on the belief that illness happens because of imbalances in energy flow in the body. This energy flow is known as Qi (pronounced ‘chee’) and is thought to flow along lines of energy in the body called meridians. Traditional acupuncture points are located where these lines are believed to pass close to the surface of the skin. Thus, stimulating acupuncture points with needles is thought to promote balance of the body’s energy and treat health conditions.

Modern explanations

Traditional explanations for how acupuncture works do not align well with modern science. Scientists are not entirely sure how acupuncture might work, but its effects are likely related to influences on the nervous system and/or circulation.

Pain

Scientists have proposed several possible explanations for how acupuncture could work to reduce pain:

  • By blocking pain from traveling in the nerves
  • By causing the body to release substances that prevent pain (such as endorphins)
  • By altering blood circulation in important areas of the body
Bladder problems

Acupuncture may affect bladder function by influencing nerve signals or control centers for urination in the brain and spinal cord.

Functional recovery

Acupuncture has been proposed as a treatment to improve recovery of function after SCI. This is not well understood, but some scientists have proposed that it may be related to reducing damage caused by the after-effects of the injury.

There are certain situations in which acupuncture may not be safe to use. This is not a complete list; please consult a health provider for detailed safety information before using this treatment.

Acupuncture should be used with caution in the following situations:

Hand inserting a thin acupuncture needle into another person's arm.

It is important to consider whether acupuncture will be safe for you.4

  • By certain groups of people, such as children, pregnant women, and people with medical conditions (such as heart conditions, osteoporosis, or weakened immune systems)
  • Near major organs (such as certain places on the torso or neck)
  • By people who are prone to fainting or have a fear of needles
  • By people who are prone to autonomic dysreflexia
  • By people who are at risk of bleeding (including people taking anticoagulants)
  • By people who are unable to follow instructions or provide accurate feedback

Acupuncture should not be used in the following situations:

  • By people with metal allergies
  • In areas with open, infected, inflamed skin or recent surgery
  • Near tumors

Even for people who are not restricted from using acupuncture (see above), there may be risks and side effects with the use of this treatment. The common side effects of acupuncture are usually mild and serious complications are rare. However, it is important to discuss these possibilities in detail with your health provider before using this treatment.

Common risks and side effects of acupuncture may include:

  • Bruising, bleeding, and skin irritation
  • Nausea, vomiting, and diarrhea
  • Headaches
  • Sweating
  • Dizziness and fainting
  • Worsening of symptoms (like increased pain or muscles spasms)

For people with SCI (especially those with injuries above the level of T6), acupuncture needles may be a cause of irritation to the body if they are placed below the level of injury. This could increase the risk of autonomic dysreflexia in some people.

Rare complications of acupuncture may include:

  • Puncture of the lung (pneumothorax) or other internal organs
  • Nerve injury
  • Infection or spread of infectious diseases (such as Hepatitis B)
  • Needles breaking after they are inserted and becoming embedded in the skin
  • Convulsions

Many of the rare complications of acupuncture can result from improper acupuncture technique. Technique is a very important part of ensuring safety, and there can be major risks if acupuncture is performed incorrectly. For example, improper needle placement and not using properly sterilized needles or sterile technique can put a person at risk of complications. Because of these risks, it is important that acupuncture is only performed by a trained health provider.

Acupuncture for pain after SCI

White computer generated figure with a red spot representing pain over their back.

Acupuncture is a common alternative treatment for pain, although research is currently limited.5

Research has studied acupuncture for the treatment of several different types of pain after SCI, including neuropathic pain and shoulder pain.

Shoulder pain

The evidence is unclear about whether acupuncture helps to reduce shoulder pain after SCI. Two studies have compared acupuncture to other treatments, including a sham treatment and a movement therapy called Trager therapy. Although both of these studies found that acupuncture helped with shoulder pain after SCI, it was not more effective than the comparison treatments. Further research is needed to determine effectiveness.

Neuropathic pain

Moderate evidence from three studies suggests that acupuncture may reduce neuropathic pain after SCI. However, two of these studies were low quality so further research is needed to confirm this.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Acupuncture for bladder problems after SCI

Three studies have studied acupuncture as a treatment for bladder problems after SCI. These studies provide moderate evidence that electroacupuncture used together with conventional therapies may help people with SCI to develop effective bladder management earlier after injury.

Another small study provides weak evidence that regular needle acupuncture may help with bladder incontinence caused by hyperreflexic bladder.

Acupuncture for improving functional recovery after SCI

One study has investigated acupuncture for improving functional recovery after SCI. It provides moderate evidence that acupuncture helps to improve functional recovery early after SCI. However, other researchers have debated the quality of the study and whether its conclusions were accurate. More studies are needed to confirm whether acupuncture has any effects on the recovery of function after SCI.

Overall, there is moderate evidence suggesting that acupuncture (including electroacupuncture) may be effective for treating neuropathic pain, bladder problems, and possibly for improving functional recovery after SCI. The evidence for shoulder pain is unclear. Further studies are needed to confirm these findings.

There have not been any studies on whether dry needling is effective for treating people with SCI.

Acupuncture needs to be used with caution in certain situations, but overall is a safe treatment when performed by a trained practitioner. Until more research is done, it is best to discuss this treatment with your health provider to find out more about if it is a suitable treatment option for you.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Parts of this page has been adapted from SCIRE Project (Professional) “Pain Management”, “Bladder Management”, and “Upper Limb” Chapters:

Mehta S, Teasell RW, Loh E, Short C, Wolfe DL, Hsieh JTC (2014). Pain Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-79.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/pain-management/

Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, Wolfe D, Teasell R. (2014). Bladder Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-196.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/bladder-management/

Connolly SJ, McIntyre A, Mehta, S, Foulon BL, Teasell RW. (2014). Upper Limb Rehabilitation Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-77.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/upper-limb/

Evidence for “Acupuncture for pain after SCI” is based on:

Shoulder pain

[1] Dyson-Hudson TA, Shiflett SC, Kirshblum SC, Bowen JE, Druin EL. Acupuncture and trager psychophysical integration in the treatment of wheelchair user’s shoulder pain in individuals with spinal cord injury. Arch Phys Med Rehab 2001;82:1038-46.

[2] Dyson-Hudson TA, Kadar P, LaFountaine M, Emmons R, Kirshblum SC, Tulsky D et al. Acupuncture for chronic shoulder pain in persons with spinal cord injury: a small-scale clinical trial. Arch Phys Med Rehab 2007;88:1276-83.

Neuropathic pain

[1] Norrbrink C, Lundeberg T. Acupuncture and massage therapy for neuropathic pain following spinal cord injury: An exploratory study. Acupunc Med 2011;29:108-15.

[2] Rapson LM, Wells N, Pepper J, Majid N, Boon H. Acupuncture as a promising treatment for below-level central neuropathic pain: A retrospective study. J Spinal Cord Med 2003;26:21-6.

[3] Nayak S, Shiflett SC, Schoenberger NE, Agostinelli S, Kirshblum S, Averill A et al. Is acupuncture effective in treating chronic pain after spinal cord injury? Arch Phys Med Rehab 2001;82:1578-86.

References for Acupuncture for bladder problems after SCI:

[1] Cheng P-T, Wong M-K, Chang P-L. A therapeutic trial of acupuncture in neurogenic bladder of spinal cord injured patients-A preliminary report. Spinal Cord 1998;36(7):476-480.

[2] Honjo H, Naya Y, Ukimura O, Kojima M, Miki T. Acupuncture on clinical symptoms and urodynamic measurements in spinal-cord-injured patients with detrusor hyperreflexia. Urol Int. 2000;65(4):190-5.

[3] Liu Z, Wang W, Wu J, Zhou K, Liu B. Electroacupuncture improves bladder and bowel function in patients with traumatic spinal cord injury: results from a prospective observational study. Evid Based Complement Alternat Med. 2013;2013:543174

[4] Gu XD, Wang J, Yu P, Li JH, Yao YH, Fu JM, Wang ZL, Zeng M, Li L, Shi M, Pan WP. Effects of electroacupuncture combined with clean intermittent catheterization on urinary retention after spinal cord injury: a single blind randomized controlled clinical trial. Int J Clin Exp Med. 2015 Oct 15;8(10):19757-63.

References for Acupuncture for functional recovery after SCI:

[1] Wong AM, Leong CP, Su TY, Yu SW, Tsai WC, Chen CP. Clinical trial of acupuncture for patients with spinal cord injuries. Am J Phys Med Rehabil. 2003 Jan;82(1):21-7.

Other references:

Ma R, Liu X, Clark J, Williams GM, Doi SA. The Impact of Acupuncture on Neurological Recovery in Spinal Cord Injury: A Systematic Review and Meta-Analysis. J Neurotrauma. 2015 Dec 15;32(24):1943-57.

Dorsher PT, McIntosh PM. Acupuncture’s Effects in Treating the Sequelae of Acute and Chronic Spinal Cord Injuries: A Review of Allopathic and Traditional Chinese Medicine Literature. Evid Based Complement Alternat Med. 2011;2011:428108.

Wang J, Zhai Y, Wu J, Zhao S, Zhou J, Liu Z. Acupuncture for Chronic Urinary Retention due to Spinal Cord Injury: A Systematic Review. Evid Based Complement Alternat Med. 2016;2016:9245186.

Shin BC, Lee MS, Kong JC, Jang I, Park JJ. Acupuncture for spinal cord injury survivors in Chinese literature: a systematic review. Complement Ther Med. 2009 Oct-Dec;17(5-6):316-27.

NIH consensus conference. Acupunc JAMA 1998;280:1518-24.

Pomeran ZB. Scientific basis of acupuncture. In: Stux G, Pomeran (Eds.). Basis of acupuncture (pp. 6-72). 4 Rev Ed. Springh-Verlag. 1998.

Wong JY, Rapson LM. Acupuncture in the management of pain of musculoskeletal and neurologic origin. Phys Med Rehab Clin North Am 1999;10:531-45.

Zhang T, Liu H, Liu Z, Wang L. Acupuncture for neurogenic bladder due to spinal cord injury: a systematic review protocol. BMJ Open. 2014 Sep 10;4(9):e006249.

Lee MHM, Liao SJ. Acupuncture in physiatry, in Kottke FJ, Lehmann JF (eds). Krusens Handbook of Physical Medicine and Rehabilitation, ed. 4. Philadelphia: Saunders 1990:402-32.

Chung A, Bui L, Mills, E. Adverse effects of acupuncture. Which are clinically significant? Canadian Family Physician. 2003;49:985–989.

White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004 Sep;22(3):122-33.

Ansari NN, Naghdi S, Fakhari Z, Radinmehr H, Hasson S. Dry needling for the treatment of poststroke muscle spasticity: a prospective case report. NeuroRehabilitation. 2015;36(1):61-5.

Salom-Moreno J, Sánchez-Mila Z, Ortega-Santiago R, Palacios-Ceña M, Truyol-Domínguez S, Fernández-de-las-Peñas C. Changes in spasticity, widespread pressure pain sensitivity, and baropodometry after the application of dry needling in patients who have had a stroke: a randomized controlled trial. J Manipulative Physiol Ther. 2014 Oct;37(8):569-79.

Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014 Aug;19(4):252-265.

Averill A, Cotter AC, Nayak S, Matheis RJ, Shiflett SC. Blood pressure response to acupuncture in a population at risk for autonomic dysreflexia. Arch Phys Med Rehabil. 2000 Nov;81(11):1494-7.

Gattie E, Cleland JA, Snodgrass S. The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2017 Mar;47(3):133-149.

 

Image credits:

  1. ‘Acupuncture’, ©Magali M , CC BY-NC-ND 2.0
  2. By thepismire, ‘her handiwork’, CC BY-NC-ND 2.0
  3. Acupuncture meridian illustration: This image is in the public domain in its country of origin and other countries, and is identified as being free of known restrictions under copyright law, including all related and neighboring rights.
  4. Acupuncture on an arm: Released into the public domain (by the author). There is no copyright associated with this file, and the website has released all ownership to the public domain.
  5. Stock image of back pain, ©3dman_eu, CC0.

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Urinary Tract Infections

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Author: SCIRE Community Team | Reviewer: Bonnie Nybo | Published: 9 November 2018 | Updated: ~ Nov 9, 2018

Urinary tract infections (UTIs) are a common problem that can happen after spinal cord injury (SCI). This page discusses what urinary tract infections are and how they are treated following SCI.

Key Points

  • A urinary tract infection is an infection of the bladder, kidneys or their connecting tubes.
  • Urinary tract infections are common after SCI because of changes to how the bladder works, side effects of bladder treatments (such as use of urinary catheters), and other factors.
  • Common symptoms of urinary tract infections include cloudy, dark or bad-smelling urine and fever, chills, or fatigue. Symptoms may also involve increased muscle spasms which can cause leaking or autonomic dysreflexia. If you have sensation you may experience discomfort over the abdomen and back or when urinating.
  • Urinary tract infections should be treated with antibiotics only if symptomatic, not just for the presence of bacteria in the urine. There are several things that can be done to prevent urinary tract infections, such as maintaining an effective bladder routine, adequate water intake, seeking treatment for bladder problems, and staying healthy.
  • Urinary tract infections can be very serious and even become life-threatening. If you suspect you might have a urinary tract infection, see your doctor as soon as possible.
Image showing the urinary system. Bottom right image shows a person's abdomen with two bean-shaped kidneys connecting by tubes labelled 'ureters' to the bladder (just above the pubic bone). Enlargement top left shows the bladder surrounded by a smooth muscle labelled 'bladder wall muscle'. Urine is contained in the bladder. The bladder connect downward to a tube labelled 'urethra'. The exit of the bladder to the urethra has muscles surrounding it labelled 'bladder sphincter muscles'.

Urinary tract infections can happen in the kidneys, bladder, or their connecting tubes.1

urinary tract infection (commonly called a ‘UTI’) is an infection of part of the urinary tract. This may be the kidneys, the bladder, or the urinary tract’s connecting tubes (the ureters or urethra). Kidney infections are called pyelonephritis and bladder infections are called cystitis.

Urinary tract infections are common after SCI, affecting around 1 in 5 people early after injury, and as many as 7 in 10 people living with SCI long-term.

In severe cases, UTIs can progress to a life-threatening infection called sepsis. In the early days of SCI care, complications of UTIs were the most common cause of death after SCI.

Today, treatment and prevention of UTIs is much more effective and infections can be treated effectively in most cases. However, it is very important to take steps to prevent infections and to seek out treatment for new infections as soon as they are detected.

The symptoms of UTIs usually consist of whole body symptoms of infection (like fever), changes to urination (such as appearance or odour), or signs that indicate something is wrong below the injury (such as increased muscle spasms or autonomic dysreflexia).

However, UTIs are not always easy to recognize, especially if you don’t have sensation in the area. If you suspect you might have a UTI, contact a health provider as soon as possible.

 

Signs and symptoms of UTIs may include:

  • Cloudy urine (from pus), dark-coloured or red urine (from blood), or bad-smelling urine
  • Fever, chills, tiredness, or a feeling of unease
  • More frequent or severe muscle spasms
  • Autonomic dysreflexia (in people with injuries above T6)
  • Leaking of urine or leakage around the catheter
  • Reduced appetite

If you have sensation in the area, you may also experience:

  • An urge to urinate often
  • Pain or discomfort while emptying the bladder
  • Pain in the abdomen or back

Hear Liander’s personal experience with the signs and symptoms of UTIs.

 

Watch for changes to your bladder function

As a part of your regular bladder care, keep an eye out for changes that could indicate a UTI. For example, monitoring changes in the colour or volume of urine emptied may help you detect infections earlier.

Urinary tract infections happen when bacteria or other microorganisms enter the urinary tract and start to multiply and grow. Most UTIs are caused by bacteria like E. coli. However, fungi, viruses, and parasites can also cause infections.

Although anyone can experience a UTI, people with SCI have a greater risk of developing one because of changes to how the bladder works, catheterization which may be used to manage the bladder, and a number of other factors:

 

Learn the importance of cleanliness through Liander’s advice on hygiene.

 

What is E.coli?

Low-temperature electron micrograph of a cluster of E. coli bacteria, magnified 10,000 times.

Low-temperature electron micrograph of a cluster of E. coli bacteria, magnified 10,000 times.2

Escherichia coli (E. coli) is a species of bacteria which is commonly found in the lower intestine of mammals. There are many types of E.coli and most are harmless to us, or even beneficial, as they are part of the normal gut flora and can produce beneficial compounds that we absorb and by preventing pathogenic bacteria from moving in. However, while E. coli normally resides in the gut it does not normally reside in the bladder and is responsible for most UTIs.

 

Changes to how the bladder works

Incomplete emptying

If a person cannot fully empty the bladder, any bacteria that have entered into the urinary tract cannot be flushed out fully during emptying. The leftover urine in the bladder can create an environment that promotes growth of bacteria that can cause infection.

Bladder overfilling

Overstretching of the bladder due to overfilling can damage the bladder walls, which increases the risk of infection. Overfilling can also cause reflux which causes the urine to back up to the kidneys (see below).

Reflux

Reflux occurs when urine flows backwards from the bladder to the kidneys and can increase the risk of infection in the kidneys and ureters. It can be caused by detrusor sphincter dyssynergia, where the coordinated action of two muscles (the detrusor of the bladder and the sphincter of the urethra) is disrupted. Instead of relaxing when urinating, the sphincter muscle contracts. This interrupts the outflow of urine causing pressure in the bladder to rise, which can result in reflux.

Use of urinary catheters

Urinary catheters (thin tubes that can be inserted into the bladder) are often used to drain the bladder after an SCI. However, catheters can also increase risk of infections because they provide a pathway for bacteria to enter the urinary tract. A catheter can pick up bacteria from contact with skin and surfaces and bring it into the bladder when it is inserted. This is a greater risk if catheters are reused or techniques are not done hygienically.

Indwelling catheters can sometimes get blocked, which prevents urine flow and can cause urine to remain in the urinary tract for too long. This can allow bacteria to grow and multiply. Proper care of catheters is important to reduce contamination and avoid blockages. The indwelling catheter is a foreign object in the bladder and this can increase the risk of bacteria or bladder stone formation as well.

Changes to bowel function

Most people also experience changes to bowel function after SCI which can cause bowel accidents and the need to perform regular bowel routines. This can lead to bacteria (often E. coli) from feces entering the urinary tract and causing infections.

Poor hygiene

Poor hygiene when performing a bladder routine, such as not washing the hands or genitals before inserting a catheter, not using sterile technique when inserting an indwelling catheter, or wearing condom catheters for longer than 24 hours without cleaning the genitals, especially, can allow bacteria to enter the urinary tract. In addition, wetness from a poorly managed bladder can increase the risk of infections spreading.

Other factors

  • Women are at greater risk for developing UTIs because female anatomy increases the risk of the natural bacteria from the vagina or anus to enter the urinary tract
  • Older age (especially over 65) increases the risk of developing a UTI because of incomplete bladder emptying
  • Obstruction of the urinary tract from something like a kidney or bladder stone, enlarged prostate, or narrowing of the urethra
  • Sexual intercourse, including the use of protective equipment such as diaphragms or spermicides
  • Other health conditions such as diabetes or conditions that reduce ability to fight infections such as HIV (human immuodeficiency virus)
  • Reduced sensation, as sensation is one of the ways that early infections of the urinary tract are detected. This is usually experienced as pain when urinating or over the abdomen or back
  • Other infections, such as infected wounds, can sometimes travel into the urinary tract
  • Reduced functional abilities may result in difficulty performing clean technique in bladder management
  • Reduced economic resources may result in reusing catheters or unclean environments or decreased care support
  • Pregnancy
  • Menopause
  • Depression

Medical examination

Your doctor will ask you about your medical history and symptoms and perform a visual and physical inspection. If they suspect that you might have a UTI, they will likely take a urine sample and do additional testing, such as a dipstick test and urine culture. Since most people with SCI will have a positive dipstick test or urine culture, the inspection of the urine, physical examination and history is very important to assist with directing treatment.

Urine sample

Taking a urine sample can help to confirm whether there is a UTI. The sample is then tested for signs of infection, bacteria and other features.

Taking a good urine sample

Urine for a urine sample needs to be collected in a careful way to ensure that it provides accurate information. To take a good urine sample, the genital area should be washed first. Urine is collected in a sterile container midstream during urination or catheterization. If the sample is collected from an indwelling catheter, the catheter should be changed first. Samples are never taken from a urine drainage bag. These steps can help to prevent the sample from being contaminated.


Picture of dipstick test strip beside black storage bottle with label for interpreting results

The dipstick or urine test strip is a basic diagnostic tool for identifying presence of substances or infection in urine.3

Dipstick Test

A dipstick test is a standard urine test strip that provides results in minutes. A positive result for leukocytes and nitrites indicates the need for a urine culture. Antibiotics would not be prescribed based on this test alone.

Urine culture

A urine culture may be done to determine the amount and type of bacteria causing the infection. This test is done using a urine sample that is left in conditions where bacteria can grow if they are present. It can later be tested to determine what type of bacteria are present, and a suitable antibiotic for treatment.

Imaging

Various imaging tools can be used to visualize the urinary tract and detect structural abnormalities. Some examples are ultrasound or magnetic resonance imaging (MRI). A cystoscopy is a more invasive way to view the urinary tract in greater detail. It involves inserting a long thin camera through the urethra and up into the bladder.

Bacteria in the urine alone does not require treatment

Although the bacteria in the urine can show a UTI, antibiotic treatment is not recommended unless it is also accompanied by other symptoms. People who use catheters often have some bacteria in the urinary tract, which does not indicate an infection. This is important because frequent use of antibiotics when they are not necessary can create antibiotic resistance (where antibiotics become less effective).

However, people who are more vulnerable when they have an infection (such as pregnant women or young children) may still be treated in this situation.

Urinary tract infections are treated with antibiotic medications (antibiotics). Antibiotics help kill bacteria that cause infections. Antibiotics are usually taken orally, but in severe cases, may be delivered directly into the veins through an intravenous (IV) line.

There are a wide range of antibiotics that may be used to treat urinary tract infections after SCI. The most common antibiotics used to treat urinary tract infections after SCI include:

  • Fluorquinolones (such as Ciprofloxacin and Ofloxacin)
  • Trimethoprim/sulfamethoxazole (TMP-SMX)
  • Amoxicillin
  • Nitrofurantoin
  • Ampicillin

Fluorquinolones are the most common choice because they are effective for treating a wide range of different types of bacteria. The selection of antibiotic is individualized and based on various factors such as type of bacteria causing the infection, recent antibiotic use, allergies, and risk of side effects.

Length of treatment can vary depending on the health status of the individual and the severity of the infection. For catheter-related UTIs, the typical duration is about 2 weeks. Signs and symptoms should start to improve within a few days after starting treatment, but that does not mean the antibiotics should be stopped. The full course of treatment should be finished to prevent recurrent infections.  

While there are many studies to support the effectiveness of antibiotics for UTI treatment in people with SCI, there is a lack of research on what the optimal dose and length of treatment is.

A number of different practices may be used to prevent UTIs. A proper bladder routine and good hygiene is the first step. Some options such as antibiotics and bacterial interference are not usually encountered as a typical part of prevention, thought there is research in these areas. Some of these are part of self-care and others involve working together with your healthcare team.

The Bladder Routine

A bladder routine is a regular schedule of bladder techniques and treatments done every day to maintain bladder function and health. To decrease the risk of a UTI, a bladder routine will take into account a number of items:

Catheterization Method

Various studies on UTI prevention in SCI have been done on different types of catheterization with most research focusing on intermittent catheterization, which is one of the most common and preferred bladder-emptying methods for the neurogenic bladder.

Refer to our article on Urinary Catheters for the different types of methods available for individuals with SCI

Example of an indwelling catheter. Uncoupling the line above the ‘leg bag’ is not recommended. An optional ‘night drainage bag’ that attaches to the ‘leg bag’ may be attached and detached as needed.

Example of an indwelling catheter. Uncoupling the line above the “leg bag” is not recommended. An optional “night drainage bag” that attaches to the “leg bag” may be attached and detached as needed.4

There is moderate evidence that intermittent catheterization carries a lower risk of UTI than both urethral indwelling or suprapubic indwelling catheters. If an indwelling catheter is required, there is moderate evidence to show that a StatLock device to secure urethral and suprapubic catheters may lead to a lower rate of UTI.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Suprapubic catheters lead to a lower rate of UTIs than urethral catheters. There is weak evidence that where intermittent catheterization may not be viable as an approach to bladder management due to socioeconomic challenges, bladder management with a suprapubic as opposed to urethral catheter may lead to a lower rate of UTI.

Maintaining closed systems with indwelling catheters is recommended practice. This means not uncoupling links in the line where the catheter is connected to the urine collection bag as to do so creates an entry route for bacteria.

Specially coated catheters

There is strong evidence that using a pre-lubricated or hydrophilic catheter for intermittent catheterization is more effective in reducing the risk of UTI or need for antibiotic treatment compared to non-coated catheters.

Catheterization Hygiene

Washing your hands thoroughly with soap and hot water before catheterization is the first step regardless of whether you use the clean technique, the sterile technique, or something in between.

Clean Technique

More common and less expensive

Often performed in the community

Usually done for intermittent catheterization

Requires thoroughly washed hands

Intermittent catheterization is often done with a single-use sterile catheter

The genital area is cleaned with soap and water

 

 

 

Sterile Technique

Less common and more expensive

Often performed in the hospital/rehab centre

Usually done for indwelling catheterization

Requires thoroughly washed hands and sterile gloves to be worn.

Intermittent catheterization is done with a single-use sterile catheter

The genital area is cleaned with a disinfectant

Requires a sterile catheterization kit that will include gloves, draping, an underpad, lubricant, swabs, a syringe, and a urine collection receptacle

There is moderate evidence that intermittent catheterization using the clean technique or sterile technique is equally effective in reducing UTI risk during inpatient rehabilitation for SCI.

The use of single use catheters is recommended over multiple use catheters as there may be a lower incidence of UTI in people who use single use catheters. For those who still use multiple use catheters for intermittent catheterization, properly cleaning the catheter and allowing it to dry completely before reuse is important.

Do not apply a multiuse tube of lubricant directly to the catheter. To prevent contamination, dispense lubrication on to a sterile napkin included with the catheter, then apply it to the catheter. Alternatively, you can use a small one-time use tube of lubrication. If the catheter touches any unsterilized surfaces during the bladder routine, a new catheter must be used.

Catheterization schedule

Perform intermittent catheterization when necessary. Usually a person will catheterize four to six times a day and collect less than 500mL of urine each time. If there is more than 500mL collected, one should consider more frequent catheterizations or review their fluid intake. This reduces the risk of having an overfilled bladder which can damage the bladder and cause reflux of fluid up towards the kidneys. Both these factors increase the risk for UTI. The amount of urine left over after catheterization does not seem to play a role in UTI occurrence in individuals with SCI. However, emptying the bladder completely is desired as performing more catheterizations than required may increase UTI risk as each catheterization is an opportunity for bacteria to be introduced into the urinary tract.

Genital Hygiene

Keeping the genital and perineal area clean may reduce bacterial growth in that area that could contribute to a UTI.

This involves a bowel routine to minimize the occurrence of bowel accidents which can increase UTI risk as fecal matter may gain access to the urethra. When cleaning up after a bowel movement, wipe from front to back. Also, preventing bowel accidents and bladder leaks will keep the area dry and help keep the skin healthy.

Women should avoid using douches and similar feminine hygiene products.

Individuals who are able to urinate should empty their bladder after sexual activity. For those who catheterize, clean the genital and perineal area after sexual activity.

 

Fluid Intake and Diet

Research in the general population suggests that adequate hydration may contribute to the prevention of UTIs. There is no SCI specific research investigating the relationship between water intake and UTI risk.

Water being poured into a clear glass.What is known is that dehydration can have numerous short and long-term negative effects on one’s physical and mental health Therefore, (unless directed by your physician) decreasing fluid intake for the convenience of less catheterizations is unwise if doing so dehydrates you.

Listen to Liander speak about how he manages his daily water intake.

 


How much water do you need to prevent UTIs?

While there is some evidence that adequate hydration prevents UTIs, there is no guideline for how much is adequate. Even research in the general population for what constitutes adequate hydration is an unsettled question.

Based on the best evidence so far, guidelines for the general population indicate that adequate intake of water is between 2.2 Litres for women to 2.9 Litres for men. This includes water from all beverages and food. We get between ½ to 1 litre of water from the food we eat.

How do these guidelines change for individuals with SCI? It has been suggested that individuals with neurogenic bowel dysfunction require additional fluid compared to other people. For those who use intermittent catheterization 2 Litres per day is recommended. For those who have indwelling catheters, 3 Litres per day is recommended.

One way to easily gauge your hydration is to look at your urine colour. While no precise relationship between urine color and hydration level exists, dehydration creates concentrated urine which is darker in colour while adequate hydration usually yields light coloured urine, so aim to consistently produce light coloured urine. Note that diet, vitamin supplements, and medications may affect the colour to your urine independent of your hydration.

 

What should you drink to prevent UTI?

There is no SCI specific information regarding the role of choice of fluids in UTI prevention. There is also very little research regarding the role of choice of fluids in UTI prevention in the general population. From an overall health perspective, the optimal amount of soda and alcohol is none. Juices and blended drinks (frappucchino, etc) are best avoided because of the high amount of sugar and/or calories. If you are drinking coffee and tea for its health benefits, consider omitting dairy products from the beverage as milk blocks the absorption of phytonutrients into the body. Caffeinated beverages like coffee and tea can have a diuretic effect in people not used to drinking them, and this will need to be accounted for in how it may affect one’s catheterization schedule. Also, alcohol has a diuretic effect and hard alcohol has an additional dehydrating effect which will increase water requirements.

Green tea in a teacup with dry tea leaves on the sideConsider that what you eat can also affect your hydration levels. Whole foods like fruits and vegetables have high water content and will increase your hydration level more than processed foods. For information on cranberries for prevention of UTIs in SCI, see the oral antiseptic section below.

Finally, while there is no SCI specific information on these topics,
there is some evidence that compounds in green tea, which are
protective against E. coli that causes UTIs, make their way to the
bladder. Also, there is evidence in the general population that suggests poultry may be a source of
pathogenic E. coli that populates the gut and serves as a reservoir to infect the urinary tract.

Physical exercise

Based on one study with moderate evidence, regular moderate physical activity may prevent UTI following SCI. This may be due to strengthening of the immune system, one of the benefits of regular exercise.

Antibiotics as prevention

Certain antibiotics have been investigated for their role in preventing UTIs in SCI. However, there is evidence that taking antibiotics as a preventive measure cause an increase in antimicrobial resistant bacteria. With increasing antibiotic resistance becoming a major public health issue over the past decade, non-antibiotic strategies are recommended before considering antibiotics as a UTI prevention tool.

There is moderate evidence that ciprofloxacin, but not trimethoprim/sulfamethoxazole, may be an appropriate antibiotic for UTI prevention. There is weak evidence from one study which found that customizing therapy to the SCI individual and alternating between two antibiotics on a weekly basis is helpful in UTI prevention.

Antiseptics

Antiseptics rid bacteria differently than antibiotics. Many factors play a role in determining the effectiveness of antiseptics for UTI prevention such as the specific antiseptic, whether they are used in combination, and the methods of delivery. Antiseptics may be used during body washing, bladder irrigation, or by mouth in tablet form as described in more detail below.

Oral antiseptics

Close up image of cranberriesCranberries contain a substance that reduces the ability of E. coli bacteria to initially stick to the wall of the bladder. There is conflicting evidence for the effectiveness of cranberry products in preventing UTI in patients with neurogenic blad due to SCI. It is worth noting that cranberry is relatively high in oxalate, a chemical that may raise the risk of kidney stones in some people. Also, cranberry may increase the risk of bleeding for those on anticoagulant medication like Warfarin.

purple bottle on side with white tablets spilling outD-mannose is a naturally occurring sugar similar to glucose. Only small amounts of d-mannose are used by the body and the rest is sent to the bladder to be excreted. Once in the bladder, D-mannose is believed to dislodge bacteria from the bladder wall. One study of able-bodied women and another in individuals with multiple sclerosis showed that D-mannose supplementation reduced UTI incidence. However, no research is yet published regarding D-Mannose and UTI incidence in individuals with spinal cord injury.

Dietary supplementation with vitamin C (ascorbic acid) is thought to reduce UTIs by increasing urine acidity. However, no clinical studies indicate that vitamin C improves symptoms or UTI incidence.

Moderate evidence from one study showed that an oral form of antiseptic known as methenamine was not effective for UTI prevention when used alone or in combination with cranberry.

Body washing

Moderate evidence from one study suggests that daily body washing with the application of chlorhexidine cream to the penis after every catheterization is more effective in reducing bacteria in the urine than standard soap, which may be helpful for UTI prevention.

Bladder irrigation

Antiseptics can be used to flush out the bladder through a process called bladder irrigation. However, only certain antiseptics have been shown to be effective in preventing UTIs, based on moderate evidence:

    • 5% hemiacidrin solution combined with oral methenamine
    • Trisdine
    • Kanamycin-colistin

Other agents delivered via bladder irrigation that are not effective in UTI prevention, based on moderate evidence or weak evidence, include:

    • Neomycin/polymyxin
    • Acetic acid
    • Ascorbic acid
    • Phosphate supplementation

Bacterial interference

Bacterial interference involves introducing harmless bacteria (usually a safe strain of E. coli) into the bladder to compete with and replace infection-causing bacteria. This is done via intravescical installation where the bacteria are pumped into the bladder via catheter. Although effectiveness depends on the specific type of bacteria used, there is moderate evidence that this method is useful for preventing UTIs. There is no evidence for the use of oral probiotics for the prevention of UTI in SCI.

Botulinum toxin injections

There is weak evidence from one study that botulinum toxin injected into the detrusor results in fewer UTIs. It is thought that this is a result of decreased detrusor pressure.

Electrical Stimulation

There is weak evidence showing that sacral anterior root stimulation achieved via an implanted electrical device may be associated with reduced UTIs. In most cases this was accompanied with posterior sacral rhizotomy.

There is moderate evidence from one study which shows that sacral nerve stimulation within the first half-year after injury results in improvements in urinary tract issues. These improvements included prevention of detrusor overactivity and urinary incontinence, normal bladder capacity, and reduced UTI rate. In this less invasive intervention, there was no accompanying rhizotomy.

Urinary tract infections are a common complication after SCI that require individualized antibiotic treatment.

Proper hygiene and a proper bladder management routine are the primary parts of UTI prevention.

In terms of bladder management for UTI prevention, intermittent catheterization with pre-lubricated or hydrophilic catheters and clean technique are most supported by research evidence.

Additional preventive techniques that are part of self-care include proper hydration and physical exercise.

Additional preventive techniques that require consulting with your healthcare team include antibiotics, some forms of antiseptics, bacterial interference, botulinum toxin, and electrical stimulation.

Further SCI-specific research is needed to better understand which techniques are most effective.

It is best to discuss all treatment options with your health providers to find out which treatments are suitable for you.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Parts of this page have been adapted from the SCIRE Project (Professional) “Bladder Management” Chapter:

Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, Wolfe D, Teasell R. (2014). Bladder Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-196.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/bladder-management/

How are urinary tract infections treated?

[1] Dow G, Rao P, Harding G, Brunka J, Kennedy J, Alfa M et al. A prospective, randomized trial of 3 or 14 days of ciprofloxacin treatment for acute urinary tract infection in patients with spinal cord injury. Clin Infect Dis 2004;39(5):658-664.

[2] Reid G, Potter P, Delaney G, Hsieh J, Nicosia S, Hayes K. Ofloxacin for the treatment of urinary tract infections and biofilms in spinal cord injury. Int J Antimicrob Agents 2000;13(4):305-307.

[3] Waites KB, Canupp KC, DeVivo MJ. Efficacy and tolerance of norfloxacin in treatment of complicated urinary tract infection in outpatients with neurogenic bladder secondary to spinal cord injury. Urology 1991;38(6):589-596.

[4] Linsenmeyer TA, Jain A, Thompson BW. Effectiveness of neomycin/polymyxin bladder irrigation to treat resistant urinary pathogens in those with spinal cord injury. J Spinal Cord Med 1999;22(4):252-257.

What can be done to prevent urinary tract infections?

Evidence for “The Bladder Routine” is based on the following studies:

[1] Moore KN, Burt J, Voaklander DC. Intermittent catheterization in the rehabilitation setting: A comparison of clean and sterile technique. Clin Rehabil 2006;20(6):461-468.

[2] Prieto-Fingerhut T, Banovac K, Lynne CM. A study comparing sterile and nonsterile urethral catheterization in patients with spinal cord injury. Rehabil Nurs 1997;22(6):299-302.

[3] Li L, Ye W, Ruan H, Yang B, Zhang S, Li L. Impact of hydrophilic catheters on urinary tract infections in people with spinal cord injury: Systematic review and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil 2013;94(4):782-787.

[4] Giannantoni A, Di Stasi SM, Scivoletto G, Virgili G, Dolci S, Porena M. Intermittent catheterization with a prelubricated catheter in spinal cord injured patients: A prospective randomized crossover study. J Urol 2001;166(1):130-133.

[5] De Ridder DJ, Everaert K, Fernandez LG, Valero JV, Duran AB, Abrisqueta ML et al. Intermittent catheterisation with hydrophilic-coated catheters (SpeediCath) reduces the risk of clinical urinary tract infection in spinal cord injured patients: A prospective randomised parallel comparative trial. Eur Urol 2005;48(6):991-995.

[6] Cardenas DD, Hoffman JM. Hydrophilic catheters versus noncoated catheters for reducing the incidence of urinary tract infections: A randomized controlled trial. Arch Phys Med Rehabil 2009;90:1668-1671.

[7] Cardenas DD, Moore KN, Dannels-McClure A, Scelza WM, Graves DE, Brooks M et al. Intermittent catheterization with a hydrophilic-coated catheter delays urinary tract infections in acute spinal cord injury: A prospective, randomized, multicenter trial. PM R 2011;3:408-417.

[8] Jensen AE, Hjeltnes N, Berstad J, Stanghelle JK. Residual urine following intermittent catheterisation in patients with spinal cord injuries. Paraplegia 1995;33(12):693-696.

[9] Krebs J1, Bartel P, Pannek J. Residual urine volumes after intermittent catheterization in men with spinal cord injury. Spinal Cord. 2013 Oct;51(10):776-9.

[10] Joshi A, Darouiche RO. Regression of pyuria during the treatment of symptomatic urinary tract infection in patients with spinal cord injury. Spinal Cord 1996;34(12):742-744.

[11] Nwadiaro HC, Nnamonu MI, Ramyil VM, Igun GO. Comparative analysis of urethral catheterization versus suprapubic cystostomy in management of neurogenic bladder in spinal injured patients. Niger J Med 2007;16(4):318-321.

[12] Darouiche RO, Goetz L, Kaldis T, Cerra-Stewart C, AlSharif A, Priebe M. Impact of StatLock securing device on symptomatic catheter-related urinary tract infection: A prospective, randomized, multicenter clinical trial. Am J Infect Control 2006;34(9):555-560.

[13] Gilmore DS, Schick DG, Young MN, Montgomerie JZ. Effect of external urinary collection system on colonization and urinary tract infections with Pseudomonas and Klebsiella in men with spinal cord injury. J Am Paraplegia Soc 1992;15(3):155-157.

[14] Christison K, Walter M, Wyndaele JJM, et al. Intermittent Catheterization: The Devil Is in the Details. J Neurotrauma. 2018;35(7):985–989.

Evidence for “Fluid Intake and Diet” is based on the following studies:

[1] “4 Water.” Institute of Medicine. 2005. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: The National Academies Press. doi: 10.17226/10925.

Evidence for “Physical Exercise” is based on the following studies:

[1] Lavado EL, Cardoso JR, Silva LG, ela Bela LF, Atallah AN. Effectiveness of aerobic physical training for treatment of chronic asymptomatic bacteriuria in subjects with spinal cord injury: A randomized controlled trial. Clin Rehabil 2013;27(2):142-149.

Evidence for “Antibiotics as Prevention” is based on the following studies:

[1] Morton SC, Shekelle PG, Adams JL, Bennett C, Dobkin BH, Montgomerie J, Vickrey BG. Antimicrobial prophylaxis for urinary tract infection in persons with spinal cord dysfunction. Arch Phys Med Rehabil. 2002 Jan;83(1):129-38.

[2] Bonkat G, Pickard R, Bartoletti R, et al. Urological infections. 2018. http://uroweb.org/guideline/urological­infections/

[3] Biering-Sorensen F, Hoiby N, Nordenbo A, Ravnborg M, Bruun B, Rahm V. Ciprofloxacin as prophylaxis for urinary tract infection: Prospective, randomized, cross-over, placebo controlled study in patients with spinal cord lesion. J Urol 1994;151(1):105-108.

[4] Sandock DS, Gothe BG, Bodner DR. Trimethoprim-sulfamethoxazole prophylaxis against urinary tract infection in the chronic spinal cord injury patient. Paraplegia 1995;33(3):156-160.

[5] Reid G, Sharma S, Advikolanu K, Tieszer C, Martin RA, Bruce AW. Effects of ciprofloxacin, norfloxacin, and ofloxacin on in vitro adhesion and survival of Pseudomonas aeruginosa AK1 on urinary catheters. Antimicrob Agents Chemother 1994;38(7):1490-1495.

[6] Salomon J, Denys P, Merle C, Chartier-Kastler E, Perronne C, Gaillard JL et al. Prevention of urinary tract infection in spinal cord-injured patients: Safety and efficacy of a weekly oral cyclic antibiotic (WOCA) programme with a 2 year follow-up–an observational prospective study. J Antimicrob Chemother 2006;57(4):784-788.

[7] Lee BB, Haran MJ, Hunt LM, Simpson JM, Marial O, Rutkowski SB et al. Spinal-injured neuropathic bladder antisepsis (SINBA) trial. Spinal Cord 2007;45(8):542-550.

[8] Sanderson PJ, Weissler S. The relation of colonization of the perineum to bacteriuria and environmental contamination in spinally injured patients. J Hosp Infect 1990a;15(3):229-234.

[9] Krebs M, Halvorsen RB, Fishman IJ, Santos-Mendoza N. Prevention of urinary tract infection during intermittent catheterization. Journal d’urologie 1984;131(1):82-85.

Evidence for “Antiseptics” is based on the following studies:

[1] Hess MJ, Hess PE, Sullivan MR, Nee M, Yalla SV. Evaluation of cranberry tablets for the

prevention of urinary tract infections in spinal cord injured patients with neurogenic bladder.

Spinal Cord 2008;46:622-626.

[2] Lee BB, Haran MJ, Hunt LM, Simpson JM, Marial O, Rutkowski SB et al. Spinal-injured neuropathic bladder antisepsis (SINBA) trial. Spinal Cord 2007;45(8):542-550.

[3] Linsenmeyer TA, Harrison B, Oakley A, Kirshblum S, Stock JA, Millis SR. Evaluation of cranberry supplement for reduction of urinary tract infections in individuals with neurogenic bladders secondary to spinal cord injury. A prospective, double-blinded, placebo-controlled, crossover study. J Spinal Cord Med 2004;27(1):29-34.

[4] Waites KB, Canupp KC, Armstrong S, DeVivo MJ. Effect of cranberry extract on bacteriuria and pyuria in persons with neurogenic bladder secondary to spinal cord injury. J Spinal Cord Med 2004;27(1):35-40.

[5] Pearman JW, Bailey M, Harper WE. Comparison of the efficacy of “Trisdine” and kanamycin-colistin bladder instillations in reducing bacteriuria during intermittent catheterisation of patients with acute spinal cord trauma. Br J Urol 1988;62(2):140-144.

[6] Waites KB, Canupp KC, Roper JF, Camp SM, Chen Y. Evaluation of 3 methods of bladder irrigation to treat bacteriuria in persons with neurogenic bladder. J Spinal Cord Med 2006;29(3):217-226.

[7] Castello T, Girona L, Gomez MR, Mena MA, Garcia L. The possible value of ascorbic acid as a prophylactic agent for urinary tract infection. Spinal Cord 1996;34(10):592-593.

[8] Schlager TA, Ashe K, Hendley JO. Effect of a phosphate supplement on urine pH in patients with neurogenic bladder receiving intermittent catheterization. Spinal Cord 2005;43(3):187-189.

Evidence for “Bacterial Interference” is based on the following studies:

[1] Darouiche RO, Thornby JI, Cerra-Stewart C, Donovan WH, Hull RA. Bacterial interference for prevention of urinary tract infection: A prospective, randomized, placebo-controlled, double-blind pilot trial. Clin Infect Dis 2005;41(10):1531-1534.

[2] Darouiche RO, Green BG, Donovan WH, Chen D, Schwartz M, Merritt J, et al. Multiceter randomized controlled trial of bacterial interference for prevention of urinary tract infection in patients with neurogenic bladder. Urology 2011;78(2):341-346.

[3] Hull R, Rudy D, Donovan W, Svanborg C, Wieser I, Stewart C, Darouiche R. Urinary tract infection prophylaxis using Escherichia coli 83972 in spinal cord injured patients. J Urol 2000;163(3):872-877.

[4] Prasad A, Cevallos ME, Riosa S, Darouiche RO, Trautner BW. A bacterial interference strategy for prevention of UTI in persons practicing intermittent catheterization. Spinal Cord 2009, 47, 565-569.

[5] Trautner BW, Hull RA, Thornby JL, Darouiche RO. Coating urinary catheters with an avirulent strain of Escherichia coli as a means to establish asymptomatic colonization. Infect Control hosp Epidemiol 2007;28(1):92-94.

Evidence for “Botulinum Toxin Injections” is based on the following studies:

[1] Jia C, Liao LM, Chen G, Sui Y. Detrusor botulinum toxin A injection significantly decreased urinary tract infection in patients with traumatic spinal cord injury. Spinal Cord. 2013 Jun;51(6):487-90.

Evidence for “Electrical Stimulation” is based on the following studies:

[1] Van Kerrebroeck PE1, Koldewijn EL, Rosier PF, Wijkstra H, Debruyne FM. Results of the treatment of neurogenic bladder dysfunction in spinal cord injury by sacral posterior root rhizotomy and anterior sacral root stimulation. J Urol. 1996 Apr;155(4):1378-81.

[2] Vastenholt JM, Snoek GJ, Buschman HP, van der Aa HE, Alleman ER, Ijzerman MJ. A 7-year follow-up of sacral anterior root stimulation for bladder control in patients with a spinal cord injury: quality of life and users’ experiences. Spinal Cord. 2003 Jul;41(7):397-402.

[3] Creasey GH, Grill JH, Korsten M, U HS, Betz R, Anderson R, Walter J; Implanted Neuroprosthesis Research Group. An implantable neuroprosthesis for restoring bladder and bowel control to patients with spinal cord injuries: a multicenter trial. Arch Phys Med Rehabil. 2001 Nov;82(11):1512-9.

[4] Kutzenberger J. Surgical therapy of neurogenic detrusor overactivity (hyperreflexia) in paraplegic patients by sacral deafferentation and implant driven micturition by sacral anterior root stimulation: methods, indications, results, complications, and future prospects. Acta Neurochir Suppl. 2007;97(Pt 1):333-9.

[5] Martens FM, den Hollander PP, Snoek GJ, Koldewijn EL, van Kerrebroeck PE, Heesakkers JP. Quality of life in complete spinal cord injury patients with a Brindley bladder stimulator compared to a matched control group. Neurourol Urodyn. 2011 Apr;30(4):551-5.

[6] Sievert KD, Amend B, Gakis G, Toomey P, Badke A, Kaps HP, Stenzl A. Early sacral neuromodulation prevents urinary incontinence after complete spinal cord injury. Ann Neurol. 2010 Jan;67(1):74-84.

Other references:

Biering-Sorensen F. Urinary tract infection in individuals with spinal cord lesion. Curr Opin Urol 2002;12(1):45-49.

Foxman B. Epidemiology of urinary tract infections: Incidence, morbidity, and economic costs. Dis Mon 2003; 49(2):53-70.

National Institute on Disability and Rehabilitation. The prevention and management of urinary tract infections among people with spinal cord injuries. National Institute on Disability and Rehabilitation Research Consensus Statement. January 27-29, 1992. J Am Paraplegia Soc 1992; 15(3): 194-204.

Harrington RD, Hooton TM. Urinary tract infection risk factors and gender. J Gend Specif Med 2000;3(8):27-34.

Garcia-Arguello LY, O’Horo JC, Farrell A, Blakney R, Sohail MR, Evans CT, Safdar N. Infections in the spinal cord-injured population: a systematic review. Spinal Cord. 2017 Jun;55(6):526-534.

Image credits:

  1. Modified from: Bladder ©BruceBlaus, CC BY-SA 4.0 
  2. E. Coli ©Eric Erbe, CC0 1.0
  3. Image by the SCIRE Community Team
  4. Image by the SCIRE Community Team
  5. Water, CC0 1.0
  6. Image by the SCIRE Community Team
  7. Green tea, CC0 1.0
  8. Cranberry, CC0 1.0
  9. Pills, CC0 1.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Bladder Care Treatments (Overview)

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Bladder Changes After Spinal Cord Injury

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Authors: SCIRE Community Team | Reviewer: Bonnie Nybo | Published: 18 January 2018 | Updated: ~

Bladder changes are common after spinal cord injury (SCI). This page provides an overview of the types of bladder changes that happen after SCI and the basics of bladder care.

Key Points

  • Most people with SCI experience some bladder changes after injury, but the type and symptoms depend on the characteristics of the injury.
  • There are two main types of bladder problems after SCI:
    • Spastic (reflex) bladder involves unpredictable emptying caused by overactive bladder muscles. It happens with injuries above T12.
    • Flaccid (non-reflex) bladder involves an inability to empty the bladder because of ‘floppy’ and underactive bladder muscles. It happens with injuries below T12.
  • People with SCI are also at risk of complications like urinary tract infections, autonomic dysreflexia (if above T6), kidney and bladder stones, and kidney damage.
  • Bladder care after SCI involves developing a regular bladder routine that meets your unique bladder needs. This may include a variety of treatments, such as catheters, medications and injections.

Neurogenic bladder is bladder dysfunction caused by damage to the nerves, brain or spinal cord. After a spinal cord injury, nerve signals that normally allow the brain and bladder to communicate with one another cannot get through. This can affect bladder sensation and control.

Bladder changes after SCI are different for everyone. Some people experience only mild changes to how the bladder works (such as greater sense of urgency when the bladder is full); while others experience total loss of bladder sensation and control.

The symptoms of neurogenic bladder depend on the characteristics of the SCI, such as the level and completeness of the injury. There are two main types of neurogenic bladder after SCI, spastic bladder and flaccid bladder (see below).

Neurogenic bladder is different from other bladder problems

There are many different types of bladder problems that are not caused by nerve damage. For example, bladder problems may be related to aging or problems with the pelvic floor muscles. However, neurogenic bladder is very different and needs to be treated with specialized care.

The urinary system

The urinary system helps the body filter and remove waste products and excess fluids. It consists of the kidneys, ureters, bladder, urethra, and bladder and sphincter muscles.

The kidneys filter the blood to produce urine, which is passed to the bladder through narrow tubes called ureters. The bladder is a sac that collects urine. It is connected to a tube called the urethra, through which urine passes out of the body.

Filling and emptying of the bladder is partly controlled by the bladder muscles:

  • The bladder wall muscle (detrusor muscle) is smooth muscle that covers the outside of the bladder. When it contracts, it squeezes the bladder and pushes urine out through the urethra. When it is relaxed, the bladder is loose and can be filled with urine.
  • The bladder sphincter muscles (urethral sphincter or valve muscles) are two muscles which surround the exit of the bladder like a ring. When they tighten, they close off the urethra and hold urine in the bladder. When they relax, they allow urine to drain. The internal sphincter muscle is controlled unconsciously and the external sphincter muscle is controlled consciously.
Image showing the urinary system. Bottom right image shows a person's abdomen with two bean-shaped kidneys connecting by tubes labelled 'ureters' to the bladder (just above the pubic bone). Enlargement top left shows the bladder surrounded by a smooth muscle labelled 'bladder wall muscle'. Urine is contained in the bladder. The bladder connect downward to a tube labelled 'urethra'. The exit of the bladder to the urethra has muscles surrounding it labelled 'bladder sphincter muscles'.

The components of the urinary system.1


 

How does the bladder work when the spinal cord is intact?

When the bladder is not full, the bladder wall muscle is relaxed and urine produced by the kidneys passes through the ureters to fill the bladder. The bladder sphincter muscles are tightened so urine does not leak out.

When there is enough urine to stretch the bladder walls, a nerve signal is sent up the spinal cord to tell the brain that the bladder is full. Because the brain controls the external sphincter muscle, urine can be held until an appropriate time to empty.

When the bladder is to be emptied, signals are sent from the brain down the spinal cord to cause the coordinated squeezing of the bladder wall muscle and relaxation of the bladder sphincter muscles to allow urine to pass through the urethra and out of the body. Control of urination involves both bladder reflexes (in which emptying is triggered when the bladder is full) and voluntary control (in which urine can be held until a socially appropriate time to empty).

The bladder after SCI

When the spinal cord is injured, nerve signals that normally allow the brain and bladder to communicate with one another cannot get through. This can lead to changes to bladder control and sensation.

Bladder control

Signals from the brain are needed for the bladder muscles to contract and relax properly. If these signals cannot get through, the bladder muscles may contract too much, too little, or at the wrong times, depending on whether the person has spastic or flaccid bladder.

Bladder sensation

When the bladder is full, the nerve signals that would normally be sent up the spinal cord to the brain are interrupted. This can lead to reduced ability to feel sensations from the bladder, such as when it is full.

Spastic bladder (also called ‘reflex bladder’ or ‘overactive bladder’) is when the bladder wall muscle is overactive. Spastic bladder happens because the brain can no longer control reflexes in the bladder muscles. This leads to tension in the bladder wall muscle when it is supposed to be relaxed and spasms of the bladder muscles which cause emptying. Spastic bladder happens when the spinal cord is injured above T12.

Usually, the bladder sphincter muscles are also overactive and cannot coordinate very well with the bladder wall muscle. This is called detrusor dyssynergia or detrusor sphincter dyssynergia (DSD). When this happens, the bladder sphincter muscle tightens while the bladder wall muscle contracts, like squeezing a balloon that is tied off. This can cause high pressures within the bladder that can damage the bladder and kidneys.

Symptoms of spastic bladder:

  • Loss of control of bladder emptying (incontinence), leading to random emptying (accidents), inability to empty when you want to and leaking
  • Reflex emptying in response to things like touching the thigh or abdomen
  • People who have some bladder sensation may experience sudden strong urges or a frequent need to urinate
  • Incomplete emptying of the bladder caused by poor coordination of the bladder wall muscle and bladder sphincter muscles (detrusor dyssynergia)
  • Reduced or complete loss of bladder sensation

Flaccid bladder (also called ‘non-reflex bladder’ or ‘underactive bladder’) occurs with injuries below T12-L1 (i.e., cauda equina injuries). In this situation, the bladder wall muscle is ‘floppy’ and cannot squeeze to empty the bladder.

Flaccid bladder happens because there is a loss of both input from the brain and reflexes from the spinal cord. This causes the bladder wall muscle to stay loose and ‘floppy’ all the time. When this happens, the bladder wall muscle cannot squeeze the bladder to empty urine.

Usually, the external sphincter muscle is also overly relaxed, causing leaking during activities like transfers and coughing. However, the internal sphincter muscle is often in spasm and does not relax enough to allow urine to pass out of the body easily.

Symptoms of flaccid bladder:

  • Inability to empty the bladder, including loss of reflex emptying
  • Incomplete bladder emptying, leading to some urine remaining in the bladder after emptying (urinary retention)
  • Damage to the walls of the bladder when they are overstretched
  • Backflow of urine back to the kidneys (reflux), which can damage the kidneys
  • Reduced or complete loss of bladder sensation

Bladder examination

Bladder changes are diagnosed primarily through a bladder examination. A bladder examination typically involves several components:

  • Your health provider will ask you questions about your medical history, symptoms, bladder routine, and current treatments.
  • You may be asked to complete a ‘urinary diary’ and/or detailed questionnaires about your bladder care. This often involves recording how often you empty your bladder, how much urine is produced each time, and details about your fluid intake (what you drink, when and how much).
  • A physical examination may involve an inspection of the abdominal, pelvic and genital areas, as well as neurological testing of your reflexes, muscle strength, and sensation.

Other testing

Other testing may also be done if your health providers need further information.

Picture of dipstick test strip beside black storage bottle with label for interpreting results

The dipstick or urine test strip is a basic diagnostic tool for identifying presence of substances or infection in urine.2

A urine culture and sensitivity test involves collecting urine in a sterile container to test for infection. Urine samples are usually collected mid-stream while emptying so the test is more accurate. If the sample is collected from an indwelling catheter, the catheter should be changed first. Samples are never taken from a urine drainage bag.

Blood tests may be used to identify if there is an infection or to test kidney function. This usually involves testing for blood urea nitrogen (BUN) and creatinine. This test may be done if there is concern about kidney function and possible kidney damage.

Ultrasound is an imaging technique that uses sound waves to visualize deep tissues. Ultrasound imaging may be done over the kidneys (called renal ultrasound) to detect possible damage, kidney stones and infections.

Urodynamic testing includes special tests that can be used to look at bladder pressures and urine flow. It can test how the bladder acts when it fills and empties, how well it coordinates, and the pressure within the bladder. This test may involve urinating into a special container that can measure the flow and volume of urine, insertion of a catheter to measure the leftover urine, and inserting water into the bladder to measure your ability to prevent emptying. It may also involve the use of electrical measurement of muscle activity by placing a small catheter into the rectum.

Typical urodynamic measures

Bladder Capacity: The amount of urine the bladder can hold.

Voiding Efficiency: The amount of urine voided compared to the amount in the bladder before voiding. More efficiency means less urine is left in the bladder.

Bladder Compliance: The ability of the bladder to stretch in response to an increased amount of urine in the bladder. Allowing the bladder to stretch as more urine accumulates there is desirable. Without the stretch there will be large increases in pressure, which is damaging to the urinary tract.

Other imaging, such as x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) are sometimes used for further investigation of bladder problems.

Cystoscopy (sometimes called a ‘bladder scope’) is the use of a very small camera that can be inserted into the urethra to look at the urinary tract. Cystoscopy can be used to identify bladder stones, bladder health issues or damage including bladder cancer. It can also perform therapeutic procedures if needed such as removing tissue or stones.

Early bladder care

In the early hospital phase right after injury, the circulatory system is stabilizing and the prevention of infections and other complications is the priority. During this phase, an indwelling catheter is placed in the bladder to constantly drain urine from the bladder. The catheter will be changed regularly and maintained in a sterile way by your nurse.

Bladder care in rehab and after

After the acute phase, bladder care will involve transitioning to more long-term bladder care techniques and developing a suitable bladder routine. Keep in mind that spastic bladder and flaccid bladder happen for different reasons and are managed differently.

Bladder routines

A bladder routine is a regular routine of bladder techniques and treatments that are done every day to maintain bladder function and health. This usually involves techniques to regularly empty the bladder, prevent leaks, and avoid serious complications long-term.

Every person’s routine is different and often involves trial and error to find the methods that best meet your unique symptoms, abilities, preferences, and lifestyle. There is a wide range of different techniques and treatments that may make up your routine, including catheters, medications, and methods of stimulation like electrical stimulation.

Other things to consider when developing a bladder routine:

  • Timing and amount of fluids
  • Caffeine and alcohol consumption
  • Scheduling of bladder emptying (such as how long between catheterizations, before going to bed or certain activities, after drinking fluids)
  • What type of equipment to use, such as type of catheter and collection bag for different situations
  • What to do if you have a bladder infection or other new health problem
  • Regular assessment of bladder care with your health team

Spastic bladder management

The goals of spastic bladder management are to reduce overactivity in the bladder wall muscle which causes accidents, leaking, and wetness; as well as preventing high pressures within the bladder. This may include treatments such as:

  • Indwelling catheters, condom catheters, and/or intermittent catheterization to drain the bladder
  • Reflex voiding may help to empty the bladder for some people
  • Anticholinergic medications may help to relax the bladder muscles
  • Botulinum toxin (Botox) injections to help relax the bladder muscles
  • Bladder augmentation surgery to increase the capacity of the bladder to hold urine

Flaccid bladder management

The goals of flaccid bladder management are to regularly empty the bladder to prevent overfilling and increased pressure in the bladder; and to prevent leaking and wetness. This may include treatments such as:

  • Intermittent catheterization or indwelling catheters
  • Condom catheters or pouches may be used to catch leaks but not for emptying
  • Alpha-adrenergic blockers may help to relax the bladder sphincter muscles
  • Botulinum toxin (Botox) injections
  • Surgical techniques such as sphincterotomy or stents

Urinary catheters are pieces of equipment that are used to drain urine from the bladder. There are many different ways that catheters are used.

Intermittent catheterization

Intermittent catheterization is when a catheter is inserted and removed through the urethra to drain the bladder at regular intervals throughout the day. Bladder emptying with intermittent catheterization must be done hygienically and on a regular schedule.

Intermittent catheterization is usually used by people who have enough hand function to perform the procedure independently. It is the closest method to normal bladder function, where the bladder fills continuously for a period of time and then empties all at once.

A diagram of a yellow indwelling (Foley) catheter labelling the drainage port, size, balloon port, and bladder opening

A diagram of an indwelling (Foley) catheter.3

Indwelling catheters

Indwelling catheters (such as Foley catheters) are catheters that are inserted directly into the bladder and remain in place to continually drain the bladder. Indwelling catheters may be inserted through the urethra (called urethral catheters) or through a surgically created hole through the abdomen (called suprapubic catheters).

An upright condom catheter

An example of a condom catheter, for male use.4

Indwelling catheters are usually used if inserting your own catheter independently is difficult or there are concerns about leaking between sessions of emptying.

Condom catheters (only for males)

Condom catheters are catheters that resemble a condom and are placed over the penis and connected through tubes to a collection device. Condom catheters are usually used by people that leak in between emptying or for individuals who have the ability to trigger emptying by causing a spasm of their bladder (called reflex voiding).

One of the main concerns of condom catheters is incomplete bladder drainage, which can cause kidney damage. A careful medical examination is needed to ensure that condom catheters are a safe option for use.

For more detailed information about catheters, see Urinary Catheters.

Catching leaks

Some people may use medical ‘penis pouches’ (loosely fitted bags that can be placed around the penis), pads, or other devices to catch small leaks in between catheterizations. These will depend on the person and their risk of other problems like pressure injuries, and should be discussed in detail with your health providers before using.

Reflex voiding is a technique that can be used by some people with spastic bladder to stimulate urination. Reflex voiding is usually done by tapping over the bladder lightly and repeatedly with the fingertips or the side of the hand to stimulate reflexes in the bladder muscles. This technique can be used to help improve bladder emptying during intermittent catheterization and when using condom catheters. However, only a small number of people can use this technique safely without increasing the pressure too high in the bladder. Speak to your health team for more information about this technique.

Many reflex voiding techniques are not recommended

Older techniques for reflex voiding such as the Valsalva maneuver (increasing abdominal pressure by holding the breath and bracing) and the Credé technique (applying manual pressure onto the bladder through the abdomen) are no longer recommended because they can cause too much pressure in the bladder, which can damage the kidneys.

Several medications may be used to help manage bladder problems after SCI. These may help to relax overactive muscles or cause the bladder muscles to contract, depending on the type of bladder change experienced. A number of other medications may also be used for different aspects of bladder treatment after SCI.

Inserting liquid medications into the bladder

Some medications may be dissolved in a liquid solution and introduced into the bladder through a catheter after emptying. The solution is then left in the bladder until the next urination. This is called an intravesical instillation. Intravesical instillations may be used because their effects are more specific to the bladder, instead of throughout the whole body like oral medications are.

 

Anticholinergic medications

A pill box labelled with all the days of the week with pills in it.Anticholinergic medications (sometimes called antimuscarinic medications) are used to relax muscle spasms in the bladder wall muscle. This can help to reduce pressure within the bladder, increase the ability of the bladder to hold urine, and help reduce incontinence.

There are many different types of anticholinergic medications, with the most common being oxybutynin (Ditropan, Ditropal XL, Oxytrol, Uromax), tolterodine (Detrol), fesoterodine (Toviaz), trospium chloride (TCL, Trosec), propiverine hydrochloride (Mictonorm), darifenacin (Enablex), and solifenacin (Vesicare). These can be taken by mouth or administered directly into the bladder in a liquid form.

Alpha-adrenergic blockers

Alpha-adrenergic blockers are medications that are used to encourage the bladder sphincter muscles to relax to allow urine to flow out of the body. This can help with bladder emptying and help prevent urinary retention. Common alpha-adrenergic blockers that may be used include tamulosin, mosixylyte, terazosin, and phenoxybenzamine.

Botulinum toxin injections

A fluid filled syringe with pills surrounding it.Injecting small doses of some strains of botulinum toxin (Botox) into muscles can help to reduce muscle spasms. Injections into the bladder wall muscle or the external sphincter muscle can help to relax these muscles to help prevent leaking and incontinence or to improve bladder emptying. The effects of these injections can last for 6 to 12 months.

 

Other medications

  • Capsaicin is commonly found in hot peppers.7

    Capsaicin, a chemical commonly found in hot peppers, and its derivative resiniferatoxin, may be administered as a liquid into the bladder to help increase bladder capacity and reduce urinary frequency, leaking, and bladder pressures related to bladder wall muscle

  • Nociceptin/orphanin phenylalanine glutamine is another medication with effects similar to capsaicin and resiniferatoxin. It may also be given into the bladder to reduce overactivity in the bladder wall muscle.
  • Medications that are normally used to treat spasticity may also help with bladder problems related to spastic bladder. For example, baclofen and clonidine may help with bladder function after SCI.
  • Phosphodiesterase-5 (PDE5) inhibitors such as tadalafil and vardenafil may help to reduce overactivity in the bladder wall muscle and increase bladder capacity.
  • 4-Aminopyridine (fampridine) improves the transfer of nerve signals, which may help individuals regain sensation and control of the bladder sphincter muscles to improve emptying.

Bladder surgery is usually only considered if other less-invasive treatments are not effective. Surgical procedures that may be used include:

Mitrofanoff procedure

A cartoon diagram of the surgical Mitrofanoff procedure, taking the appendix and connecting it to the bladder.

The Mitrofanoff procedure involves connecting parts of the intestine to the bladder.8

The Mitrofanoff procedure involves the use of the appendix or part of the intestine to create a channel between the abdomen and bladder. The channel self-seals shut when the catheter is removed. This channel can be used for insertion of a catheter for intermittent catheterization. The urine can then be drained into a cup or toilet. This may be useful for people who have difficulty self-catheterizing directly into the urethra, and is often used for women (who have greater difficulty inserting catheters).

Bladder augmentation

Bladder augmentation- A simplified step by step diagram of how parts of the intestine are taken to enlarge the bladder

Bladder augmentation is a surgical procedure done to enlarge the bladder by using parts of the intestine.9

Bladder augmentation (also called augmentation cystoplasty) is a procedure in which the bladder is made bigger to create more room to hold urine. This is done by removing a segment of the intestine and stitching this tissue to an incision into the bladder to make the bladder bigger. Bladder augmentation may help to reduce pressure in the bladder and help to prevent incontinence related to spastic bladder.

Sphincterotomy (for males)

Spincterotomy is a surgical procedure where the internal sphincter muscle (the circular muscle that surrounds the outlet of the bladder) is cut to weaken the muscle. This is done to improve bladder emptying if this muscle is causing difficulties emptying. After a spincterotomy, bladder emptying will happen; therefore, you must wear a collection device.

Urethral stents

Urethral stents are prosthetic tubes (usually coils of metal) with openings on both sides that are be inserted into the opening of the bladder to hold it open. This is done to allow for improved bladder emptying for people with difficulty emptying due to overactivity in the bladder sphincter muscles.

Electrical stimulation can be used to activate muscles. Electrical stimulation may be used to assist with bladder problems after SCI by stimulating activity in the bladder muscles to help control muscle function.

Electrical stimulation

A black and white cartoon diagram of a neural synapseElectrical stimulation can be used to stimulate the nerves to help normalize the activity of the bladder muscles. Stimulation of the sacral nerves through the implantation of a stimulator and electrodes may help to improve control of bladder emptying. This is sometimes referred to as neuromodulation.

Commercially available electrical bladder stimulation systems such as the Vocare system may be used for this purpose. However, these systems may not be available in all locations or for all individuals because of their cost.

Acupuncture

Acupuncture and electroacupuncture have also been suggested as treatment options to help with bladder function by influencing nerve signals related to bladder function.

Bladder changes are common after SCI. Bladder care is an important part of self-management after SCI to prevent complications and maintain good health and quality of life.

Bladder care after SCI involves developing a regular bladder routine that meets your unique bladder needs. This may include a variety of techniques and treatments, such as catheters, medications, injections and other treatments. Speak to your health team about which bladder management options are best for you. Regular follow up with your doctor is recommended yearly.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

This page has been adapted from SCIRE Project (Professional) “Bladder Management” Chapter:

Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, Wolfe D, Teasell R. (2014). Bladder Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-196.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/bladder-management/


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Groah SL, Weitzenkamp DA, Lammertse DP, Whiteneck GG, Lezotte DC, Hamman RF. Excess risk of bladder cancer in spinal cord injury: evidence for an association between indwelling catheter use and bladder cancer. Arch Phys Med Rehabil 2002;83(3):346-351.

Gurung PM, Attar KH, Abdul-Rahman A, Morris T, Hamid R, Shah PJ. Long-term outcomes of augmentation ileocystoplasty inpatients with spinal cord injury: A minimum of 10 years of follow-up. BJU Int 2012;109(8):1236-1242.

Hackler RH. Long-term Suprapubic cystostomy drainage in spinal cord injury patients. Br J Urol 1982;54(2):120-121.

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Hansen J, Media S, Nohr M, Biering-Sorensen F, Sinkjaer T, Rijkhoff NJ. Treatment of neurogenic detrusor overactivity in spinal cord injured patients by conditional electrical stimulation. J Urol 2005;173(6):2035-2039.

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Hikita K, Honda M, Kawamoto B, Panagiota T, Inoue S, Hinata N. Botulinum toxin type A injection for neurogenic detrusor overactivity: Clinical outcome in Japanese patients. International J Urol 2013;20(1):94-99.

Hohenfellner M, Humke J, Hampel C, Dahms S, Matzel K, Roth S, Thuroff JW, Schultz-Lampel D. Chronic sacral neuromodulation for treatment of neurogenic bladder dysfunction: Long-term results with unilateral implants. Urology 2001;58(6):887-892.

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Katsumi HK, Kalisvaart JF, Ronningen LD, Hovey Rm. Urethral versus suprapubic catheter: Choosing the best bladder management for male spinal cord injury patients with indwelling catheters. Spinal Cord 2010;48(4):325-329.

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Kaufman JM, Fam B, Jacobs SC, Gabilondo F, Yalla S, Kane JP et al. Bladder cancer and squamous metaplasia in spinal cord injury patients. J Urol 1977;118(6):967-971.

Kim JH, Rivas DA, Shenot PJ, Green B, Kennelly M, Erickson JR et al. Intravesical resiniferatoxin for refractory detrusor hyperreflexia: A multicenter, blinded, randomized, placebo-controlled trial. J Spinal Cord Med 2003;26(4):358-363.

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Image Credits:

  1. Modified from: Urinary Sphincter ©BruceBlaus, CC BY-SA 4.0
  2. Image by SCIRE Community Team
  3. Foley catheter EN ©Ikej Renesz, CC BY-SA 3.0
  4. Cewnik zewnetrzny 0211 ©Sobol2222 assumed (based on copyright claims), CC0 1.0
  5. Medications ©Steve Buissinne, CC0 1.0
  6. Syringe ©Arek Socha, CC0 1.0
  7. Chili ©PublicDomainPictures, CC0 1.0
  8. Mitrofanoff ©Aphelpsmd, CC BY-SA 4.0
  9. Ileocystoplasty JPEG ©Aphelpsmd, CC BY-SA 4.0
  10. Synapse ©Clker-Free-Vector-Images, CC0 1.0
  11. Modified from: Nephron Anatomy ©BruceBlaus, CC BY-SA 4.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Botulinum Toxin

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Author: SCIRE Community Team | Reviewer: Patricia Mills | Published: 10 November 2017 | Updated: ~

Botulinum toxin injections may be used as a treatment after spinal cord injury (SCI). This page provides an overview of the use of botulinum toxin after SCI.

Key Points

  • Botulinum toxin is a protein made by bacteria that can cause muscle weakness or paralysis.
  • Very small doses of certain strains of botulinum toxin may be injected into muscles as a treatment for various medical conditions.
  • Botulinum toxin injections are currently used to treat muscle spasticity and certain types of bladder problems after SCI.
  • Research evidence supports that botulinum toxin is effective to reduce spasticity in muscles and to manage certain types of bladder problems after SCI.
A structure of a botulinum toxin molecule

A structure of a botulinum toxin molecule.1

Botulinum toxin is a protein produced by bacteria. Although this protein can be toxic to humans, injections of very small amounts of certain strains of botulinum toxin are used in medicine. Botulinum toxin is well-known by the trade names Botox, Dysport, and Xeomin as a cosmetic procedure for reducing wrinkles. However, it is also used as a treatment for various other medical conditions.

Botulinum toxin injections may be used after SCI to treat:

  • Problematic spasticity that is located in specific muscles (widespread spasticity is usually treated with an oral medication instead)
  • Overactive (reflex) bladder problems after SCI

Botulinum toxin injections into the bladder may also help to prevent autonomic dysreflexia that is triggered by bladder problems after SCI.

Monochrome cartoon logo of bottle and injection needleBotulinum toxin is given with an injection into the affected spastic muscle or bladder. 

The exact procedures and dose provided will be different for each person. Consult your health provider for further information about how botulinum toxin procedures may be done.

Multiple injections may be given in one session to ensure enough of the toxin reaches the muscle. After the injections, it may take up to a week for you to notice an effect. Exercise and stretching are usually recommended after the injection to enhance the effects of botulinum toxin.

Botulinum toxin injections are not permanent, and their effects wear off in usually around 3 months (in the case of muscle injections) to 6 months (in the case of bladder injections). Sessions are scheduled on an ongoing basis to maintain the effects of the treatment.

A black and white cartoon diagram of a neural synapse

When botulinum toxin is injected into a muscle, it blocks the nerves to the muscles from releasing a chemical called acetylcholine. Acetylcholine makes muscles contract (tense). When its release is blocked, the muscles are unable to contract, causing weakness or paralysis. In a muscle with spasticity, botulinum toxin can help to decrease muscle spasms.

Botulinum toxin can be used to treat overactive (reflex) bladder problems for similar reasons. These bladder problems happen when the bladder muscle or the bladder sphincters spasm, preventing emptying or causing random emptying of urine (detrusor hyperreflexia). The injection of botulinum toxin into these muscles reduces muscle spasms, which may help to treat these problems.

Botulinum toxin is not suitable for everyone for medical reasons. It is also important to know that botulinum toxin treatments can be expensive depending on how your medications are funded. Consult your doctor for detailed information about whether this treatment is safe and appropriate for you.

Botulinum toxin should not be used in the following situations:

Silhouette cartoon of pregnant woman

  • By people with other neuromuscular disorders, such as myasthenia gravis
  • By people who have an allergy to any of the injection ingredients
  • By pregnant or nursing women
  • In areas of infection

Botulinum toxin should be used with caution in the following situations:

  • By people taking anticoagulants (blood thinners)

Additional precautions when botulinum toxin is used in the bladder:

  • By people who have a current or multiple recent bladder or kidney infections (urinary tract infections)
  • By people who are not willing or able to do clean intermittent catheterization or have a Foley catheter inserted. This is because there is a potential short term side effect of too much bladder muscle relaxation leading to an inability to fully empty the bladder (urinary retention) without a catheter.

Botulinum toxin injections are generally considered to have low risk of serious medical complications with their use. However, there are side effects and risks of this treatment that are important to discuss with your doctor. Side effects usually happen within the first few days after injection, but sometimes last longer. This is not a complete list; speak to your doctor for detailed information about botulinum toxin injections.

Risks and side effects of botulinum toxin injections may include:Stock image of figure experiencing knee pain

  • Muscle weakness – usually in the muscles that receive the injection, but may be generalized to other muscles, although this is a rare occurrence
  • Long-term use may lead to loss of muscle size and bulk that happens when the muscles are not used (muscle atrophy)

Risks and side effects of botulinum toxin used for bladder problems include:

  • Bladder and kidney infections (urinary tract infections)
  • Blood in the urine
  • An inability to fully empty the bladder (urinary retention)

For more information on urinary tract infections, check out our article here!

Risks and side effects related to injections of any kind:

In addition to the risks of botulinum toxin itself, injections of any kind may cause pain or tenderness, inflammation, changes to sensation, redness, infections, bleeding, bruising, light-headedness and fainting.

Important considerations when treating spasticity

Although we often focus on the negative effects of spasticity, it can also have benefits. For example, spasticity in the legs can sometimes help people transfer more effectively or stand and walk. For this reason, when treatments like botulinum toxin work the way they are supposed to, they can sometimes have negative effects, such as:

  • Reduced functional abilities, such as the ability to transfer, stand, or walk
  • Loss of health benefits of spasticity, such as better circulation, and muscle strength
  • Loss of spasticity as a warning sign of other health problems (such as infections or injuries below the level of injury)

The decision to treat spasticity needs to be made by you and your health team on a personal basis, taking into consideration function, symptoms, and the benefits and drawbacks of treatment.

Botulinum toxin has been studied thoroughly as a treatment for spasticity in other conditions like stroke and brain injury. There is strong evidence to support that it is effective for treating spasticity in these conditions. Fewer studies have looked at how effective botulinum toxin injections are after SCI.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Spasticity

There is moderate evidence that botulinum toxin injections can be used to improve muscle spasticity in the injected muscle after SCI. It may also help to improve problems related to spasticity, such as pain, sleep disturbances, and walking problems.

Overactive (reflex) bladder problems

There is strong evidence that botulinum toxin injections are an effective treatment option for reducing the symptoms of overactive (reflex) bladder problems after SCI. This includes both:

  • Injections into the bladder muscle to prevent leaking or incontinence
  • Injections into the sphincter muscles to improve bladder emptying
    Image showing the urinary system. Bottom right image shows a person's abdomen with two bean-shaped kidneys connecting by tubes labelled 'ureters' to the bladder (just above the pubic bone). Enlargement top left shows the bladder surrounded by a smooth muscle labelled 'bladder wall muscle'. Urine is contained in the bladder. The bladder connect downward to a tube labelled 'urethra'. The exit of the bladder to the urethra has muscles surrounding it labelled 'bladder sphincter muscles'.

    The components of the urinary system.7

Autonomic dysreflexia and the spastic bladder

Some of the studies that have looked at treating bladder problems after SCI have also found that some participants also had fewer episodes of autonomic dysreflexia after treatment. This was thought to be because bladder problems triggered autonomic dysreflexia in these individuals. However, there is not enough evidence to use botulinum toxin as a direct treatment for preventing autonomic dysreflexia at this time.

See our article on Autonomic Dysreflexia for more information! 

Botulinum toxin injections are a treatment option for spasticity and overactive (reflex) bladder problems after SCI. Botulinum toxin can be effective for reducing the symptoms related to these problems after SCI. It is important to discuss with your health provider about whether this treatment option is suitable for you.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Parts of this page have been adapted from the SCIRE Project (Professional) “Bladder Management”, “Autonomic Dysreflexia”, and “Spasticity” chapters:

Hsieh JTC, Connolly SJ, McIntyre A, Townson AF, Short C, Mills P, Vu V, Benton B, Wolfe DL (2016). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, McIntyre A, Querée M, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0: p 1-135.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/spasticity/

Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, Wolfe D, Teasell R. (2014). Bladder Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-196.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/bladder-management/

Krassioukov A, Blackmer J, Teasell RW, Eng JJ (2014). Autonomic Dysreflexia Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1- 35.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/autonomic-dysreflexia/

 

Evidence for “Is botulinum toxin effective?” is based on the following studies:

Spasticity:

[1] Richardson D, Sheean G, Werring D, Desai M, Edwards S, Greenwood R et al. Evaluating the role of botulinum toxin in the management of focal hypertonia in adults. J Neurol Neurosurg Psychi 2000;69:499-506.

[2] Spiegl U, Maier D, Gonschorek O, Heyde C, Buhren V. Antispastic therapy with botulinum toxin type A in patients with traumatic spinal cord lesion. GMS Interdiscip Plast Reconstr Surg 2014;3:1-5.

[3] Bernuz B, Genet F, Terrat P, et al. Botulinum toxin effect on voluntary and stretch reflex-related torque produced by the quadriceps: An isokinetic pilot study. Neurorehabil Neural Repair 2012;26:542-7.

[4] Hecht M, Stolze H, uf dem B, Giess R, Treig T, Winterholler M et al. Botulinum neurotoxin type A injections reduce spasticity in mild to moderate hereditary spastic paraplegia–report of 19 cases. Mov Disord 2008;23:228-33.

[5] Al-Khodairy A, Gobelet C, Rossier A. Has botulinum toxin type A a place in the treatment of spasticity in spinal cord injury patients? Spinal Cord 1998;36:854-8.

Bladder problems:

Detrusor overactivity

[1] Mehta S, Hill D, McIntyre A, Foley N, Hsieh J, Ethans K et al. Meta-analysis of botulinum toxin A detrusor injections in the treatment of neurogenic detrusor overactivity after spinal cord injury. Arch Phys Med Rehabil 2013;94(8):1473-1481.

[2] Schurch B, de SM, Denys P, Chartier-Kastler E, Haab F, Everaert K et al. Botulinum toxin type is a safe and effective treatment for neurogenic urinary incontinence: Results of a single treatment, randomized, placebo controlled 6-month study. J Urol 2005;174(1):196-200.

[3] Grosse J, Kramer G, Jakse G. Comparing two types of botulinum-A toxin detrusor injections in patients with severe neurogenic detrusor overactivity: A case-control study. BJU International 2009;104:651-656.

[4] Schurch B, Denys Pierre, Kozma CM, Reese PR, Slaton T, Barron RL. Botulinum toxin A improves the quality of life of patients with neurogenic urinary incontinence. European urology 2007:52(3):850-859.

[5] Del Popolo G, Filocamo MT, Li Marzi V, Macchiarella A, Cecconi F, Lombardi G, Nicita G. Neurogenic detrusor overactivity treated with english botulinum toxin a: 8-year experience of one single centre. Eur Urol. 2008 May;53(5):1013-19.

[6] Giannantoni A, Meatini E, Del Zingaro M, Porena M. Six-year follow-up of Botulinum Toxin A intradetrosrial injections in patients with refractory neurogenic detrusor overactivity: Clinical and urodynamic results. European Urology 2009;55:705-712.

[7] Klaphajone J, Kitisomprayoonkul W, Sriplakit S. Botulinum toxin type A injections for treating neurogenic detrusor overactivity combined with low-compliance bladder in patients with spinal cord lesions. Arch Phys Med Rehabil 2005;86:2114-2118.

[8] Kuo H. Therapeutic effects of suburothelial injection of botulinum a toxin for neurogenic detrusor overactivity due to chronic cerebrovascular accident and spinal cord lesions. Urology 2006;67:232-236.

[9] Kuo H. Satisfaction with urethral injection of botulinum toxin A for detrusor sphincter dyssynergia in patients with spinal cord lesion. Neurourol Urodyn 2008;27:793-796.

[10] Pannek J, Gocking K, Bersch U. Long-term effects of repeated intradetrusor botulinum neurotoxin A injections on detrusor function in patients with neurogenic bladder dysfunction. BJU International 2009;104:1246-1250.

[11] Tow AM, Toh KL, Chan SP, Consigliere D. Botulinum toxin type A for refractory neurogenic detrusor overactivity in spinal cord injured patients in Singapore. Ann Acad Med Singapore 2007;36(1):11-17.

[12] Wefer B, Ehlken B, Bremer J, Burgdörfer H, Domurath B, Hampel C. Treatment outcomes and resource use of patients with neurogenic detrusor overactivity receiving botulinum toxin A (BOTOX®) therapy in Germany. World J Urol 2010;28(3):385-390.

[13] Akbar M, Abel R, Seyler TM, Bedke J, Haferkamp A, Gerner HJ et al. Repeated botulinum-A toxin injections in the treatment of myelodysplastic children and patients with spinal cord injuries with neurogenic bladder dysfunction. BJU Int 2007;100(3):639-645.

[14] Patki P, Hamid R, Shah PJ, Craggs M. Long-term efficacy of AMS 800 artificial urinary sphincter in male patients with urodynamic stress incontinence due to spinal cord lesion. Spinal Cord 2006;44(5):297-300.

[15] Herschorn S, Gajewski J, Ethans K, Corcos J, Carlson K, Bailly G et al. Efficacy of botulinum toxin A injection for neurogenic detrusor overactivity and urinary incontinence: A randomized, double-blind trial. J urology 2011;185(6):2229-2235.

[16] Abdel-Meguid T. Botulinum toxin-A injections into neurogenic overactive bladder—to include or exclude the trigone? A prospective, randomized, controlled trial. J urology 2010;184(6):2423-2428.

[17] Krhut J, Samal V, Nemec D, Zvara P. Intradetrusor versus suburothelial onabotulinumtoxinA injections for neurogenic detrusor overactivity: A pilot study. Spinal cord 2012;50(12):904-907.

Sphincter overactivity

[1] Kuo H. Therapeutic outcome and quality of life between urethral and detrusor botulinum toxin treatment for patients with spinal cord lesions and detrusor sphincter dyssynergia. Inter J Clin Prac 2013;67(10):1044-1049.

[2] Kuo H. Satisfaction with urethral injection of botulinum toxin A for detrusor sphincter dyssynergia in patients with spinal cord lesion. Neurourol Urodyn 2008;27:793-796.

[3] Tsai SJ, Ying TH, Huang YH, Cheng JW, Bih LI, Lew HL. Transperineal injection of botulinum toxin A for treatment of detrusor sphincter dyssynergia: Localization with combined fluoroscopic and electromyographic guidance. Arch Phys Med Rehabil 2009;90:832-836

[4] DeSeze M, Petit H, Gallien P, de Seze MP, Joseph PA, Mazaux JM et al. Botulinum a toxin and detrusor sphincter dyssynergia: A double-blind lidocaine-controlled study in 13 patients with spinal cord disease. Eur Urol 2002;42(1):56-62.

[5] Chen SL, Bih LI, Chen GD, Huang YH, You YH, Lew HL. Transrectal ultrasound-guided transperineal botulinum toxin A injection to the external urethral sphincter for treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury. Arch Phys Med Rehabil 2010;91:340-344.

[6] Schurch B, Hauri D, Rodic B, Curt A, Meyer M, Rossier AB. Botulinum-A toxin as a treatment of detrusor-sphincter dyssynergia: A prospective study in 24 spinal cord injury patients. J Urol 1996;155(3):1023-1029.

[7] Phelan MW, Franks M, Somogyi GT, Yokoyama T, Fraser MO, Lavelle JP et al. Botulinum toxin urethral sphincter injection to restore bladder emptying in men and women with voiding dysfunction. J Urol 2001;165(4):1107-1110.

Other references:

Alvares R, Silva,J, Barboza A, Monteiro R. Botulinum toxin A in the treatment of spinal cord injury patients with refractory neurogenic detrusor overactivity. International braz j urol 2010;36(6):732-737.

Bagi P, Biering-Sørensen F. Botulinum toxin A for treatment of neurogenic detrusor overactivity and incontinence in patients with spinal cord lesions. Scandinavian J Urol and nephrology 2004;38(6):495-498.

Caremel R, Courtois F, Charvier K, Ruffion A, Journel N. Side effects of intradetrusor botulinum toxin injections on ejaculation and fertility in men with spinal cord injury: Preliminary findings. BJU international 2012;109(11):1698-1702.

Chang E, Ghosh N, Yanni D, Lee S, Alexandru D, Mozaffar T. A Review of Spasticity Treatments: Pharmacological and Interventional Approaches. Crit Rev Phys Rehabil Med. 2013;25(1-2):11-22.

Chen G, Liao L. Injections of botulinum toxin A into the detrusor to treat neurogenic detrusor overactivity secondary to spinal cord injury. Intern Urol Nephrol 2011;43(3):655-662.

Chen S, Kuo H. Therapeutic outcome and patient adherence to repeated onabotulinumtoxinA detrusor injections in chronic spinal cord-injured patients and neurogenic detrusor overactivity. Journal of the Formosan Medical Association 2013.

Cho YS, Kim KH. Botulinum toxin in spinal cord injury patients with neurogenic detrusor overactivity. J Exerc Rehabil. 2016 Dec 31;12(6):624-631.

CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2016 [cited 2017 Nov 2]. Available from: http://www.e-cps.ca or http://www.myrxtx.ca. Also available in paper copy from the publisher.

Del Popolo G, Filocamo M, Li Marzi V, Macchiarella A, Cecconi F, Lombardi G, et al. Intermittent self-catheterization habits and opinion on aspetic VaPro catheter in French neurogenic bladder population. Spinal Cord 2012;50(11):853-858.

Dykstra DD, Sidi AA, Scott AB, Pagel JM, Goldish GD. Effects of botulinum A toxin on detrusor-sphincter dyssynergia in spinal cord injury patients. J Urol 1988;139(5):919-922.

Dykstra DD, Sidi AA. Treatment of detrusor-sphincter dyssynergia with botulinum A toxin: A double-blind study. Arch Phys Med Rehabil 1990;71(1):24-26.

Ehren I, Volz D, Farrelly E, Berglund L, Brundin L, Hultling C et al. Efficacy and impact of botulinum toxin A on quality of life in patients with neurogenic detrusor overactivity: A randomised, placebo-controlled, double-blind study. Scand J Urol Nephrol 2007;41(4):335-340.

Fried G & Fried K. Spinal cord injury and use of botulinum toxin in reducing spasticity. Phys Med Rehabil Clin N Am 2003;14:901-10.

Fried GW, Fried KM. Spinal cord injury and use of botulinum toxin in reducing spasticity. Phys Med Rehabil Clin N Am. 2003 Nov;14(4):901-10. Review.

Game X, Chartier-Kastler E, Ayoub N, Even-Schneider A, Richard F, Denys P. Outcome after treatment of detrusor-sphincter dyssynergia by temporary stent. Spinal Cord 2008; 46:74-77.

Grosse J, Kramer G, Jakse G. Comparing two types of botulinum-A toxin detrusor injections in patients with severe neurogenic detrusor overactivity: A case-control study. BJU International 2009; 104:651-656.

Haar GT, Dyson M, Oakley EM. The use of ultrasound by physiotherapists in Britain, 1985. Ultrasound in Med & Biol 1987. 13(10): 659-663.

Haferkamp A, Schurch B, Reitz A, Krengel U, Grosse J, Kramer G. Lack of ultrastructural detrusor changes following endoscopic injection of botulinum toxin type A in overactive neurogenic bladder. European urology 2004;46(6):784-791.

Hajebrahimi S, Altaweel W, Cadoret J, Cohen E, Corcos J. Efficacy of botulinum-A toxin in adults with neurogenic overactive bladder: Initial results. Canadian J Urol 2005;12:2543-2546.

Hikita K, Honda M, Kawamoto B, Panagiota T, Inoue S, Hinata N. Botulinum toxin type A injection for neurogenic detrusor overactivity: Clinical outcome in Japanese patients. International J Urol 2013;20(1):94-99.

Hori S, Patki P, Attar K, Ismail S, Vasconcelos J, Shah P. Patients’ perspective of botulinum toxin-A as a long-term treatment option for neurogenic detrusor overactivity secondary to spinal cord injury. BJU International 2009;104,:216-220.

Karsenty G, Chartier-Kastler E, Mozer P, Even-Schneider A, Denys P, Richard F. A novel technique to achieve cutaneous continent urinary diversion in spinal cord-injured patients unable to catheterize through native urethra. Spinal Cord 2008;46(4):305-310.

Karsenty G, Reitz A, Lindemann G, Boy S, Schurch B. Persistence of therapeutic effect after repeated injections of botulinum toxin type A to treat incontinence due to neurogenic detrusor overactivity. Urology 2006;68(6):1193-1197.

Kaviani A, Khavari R. Disease-Specific Outcomes of Botulinum Toxin Injections for Neurogenic Detrusor Overactivity. Urol Clin North Am. 2017 Aug;44(3):463-474.

Kuo H. Satisfaction with urethral injection of botulinum toxin A for detrusor sphincter dyssynergia in patients with spinal cord lesion. Neurourol Urodyn 2008;27:793-796.

Kuo H. Therapeutic outcome and quality of life between urethral and detrusor botulinum toxin treatment for patients with spinal cord lesions and detrusor sphincter dyssynergia. Inter J Clin Prac 2013;67(10):1044-1049.

Kuo HC, Liu SH. Effect of repeated detrusor onabotulinumtoxinA injections on bladder and renal function in patients with chronic spinal cord injuries. Neurourol Urodyn 2011;30:1541–1545.

Lui J, Sarai M, Mills PB. Chemodenervation for treatment of limb spasticity following spinal cord injury: a systematic review. Spinal Cord. 2015 Apr;53(4):252-64. doi: 10.1038/sc.2014.241. Epub 2015 Jan 13. Review.

Lui J, Sarai M, Mills PB. Chemodenervation for treatment of limb spasticity following spinal cord injury: a systematic review. Spinal Cord. 2015 Apr;53(4):252-64. doi: 10.1038/sc.2014.241. Epub 2015 Jan 13. Review.

Marciniak C, Rader L, Gagnon C. The use of botulinum toxin for spasticity after spinal cord injury. Am J Phys Med Rehabil. 2008 Apr;87(4):312-7; quiz 318-20, 329.

Mascarenhas F, Cocuzza M, Gomes C, Leão N. Trigonal injection of botulinum toxin‐A does not cause vesicoureteral reflux in neurogenic patients. Neurourol Urodyn 2008;27(4):311-314.

Ni J, Wang X, Cao N, Si J, Gu B. Is repeat Botulinum Toxin A injection valuable for neurogenic detrusor overactivity-A systematic review and meta-analysis. Neurourol Urodyn. 2017 Jul 26. doi: 10.1002/nau.23354. [Epub ahead of print]

Nigam PK, Nigam A. Botulinum toxin. Indian J Dermatol 2010; 55(1):8-14.

Petit H, Wiart L, Gaujard E, Le BF, Ferriere JM, Lagueny A et al. Botulinum A toxin treatment for detrusor-sphincter dyssynergia in spinal cord disease. Spinal Cord 1998;36(2):91-94.

Reitz A, Denys P, Fermanian C, Schurch B, Comperat E, Chartier-Kastler E. Do repeat intradetrusor botulinum toxin type a injections yield valuable results? Clinical and urodynamic results after five injections in patients with neurogenic detrusor overactivity. Euro Urol 2007;52(6):1729-1735.

Reitz A, Stohrer M, Kramer G, Del Popolo G, Chartier-Kastler E, Pannek J et al. European experience of 200 cases treated with Botulinum-A Toxin injections into the detrusor muscle for urinary incontinence due to neurogenic detrusor overactivity. European Urology 2004;45:510-515.

Richardson D, Edwards S, Sheean GL, Greenwood RJ, Thompson AJ. The effect of botulinum toxin on hand function after incomplete spinal cord injury at the level of C5/6: a case report. Clin Rehabil 1997; 11(4):288-292.

Schurch B, Stohrer M, Kramer G, Schmid DM, Gaul G, Hauri D. Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: A new alternative to anticholinergic drugs? Preliminary results. J Urol 2000;164(3 Pt 1):692-697.

Image credits

  1. Botulinum toxin 3BTA ©Clr324, CC0 1.0
  2. Injection ©priyanka, CC BY 3.0 US
  3. Synapse ©Clker-Free-Vector-Images, CC0 1.0
  4. Injection ©Vectors Point, CC BY 3.0 US
  5. Pregnancy botox risk ©waldryano, CC0 1.0
  6. Pain botox ©3dman_eu, CC0 1.0
  7. Modified from: Urinary Sphincter ©BruceBlaus, CC BY-SA 4.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Urinary Catheters

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Author: SCIRE Community Team | Reviewer: Bonnie Nybo | Published: 24 October 2017 | Updated: ~

Urinary catheters are a common method of emptying the bladder after spinal cord injury (SCI). This page provides basic information about the use of catheters for bladder problems after SCI.

Key Points

  • Urinary catheters are pieces of equipment that are used to drain urine from the bladder for people who experience bladder problems after SCI.
  • There are several ways of using catheters, including intermittent catheterization (a catheter that is inserted and removed from the bladder several times each day), indwelling catheters (a catheter that is inserted into the bladder and remains in place), and condom catheters (external catheters that cover the penis).
  • Urinary catheters may have risks with their use, such as damage to the urethra, bladder stones, and urinary tract infections.
  • Choosing a type of catheter to use and developing a bladder management routine should happen together with your health team based on the type of bladder problems you have and your risk of complications, ability to use the equipment, and personal preferences.
  • Catheters are an essential standard treatment for emptying the bladder after SCI. The research evidence suggests that intermittent catheterization is associated with the lowest risk of complications after SCI, followed by condom catheters, and then indwelling catheters.
A urinary catheter with a balloon at one end

There are various types of urinary catheters such as balloon catheters (above).1

Urinary catheters (simply referred to as ‘catheters’ on this page) are pieces of equipment that are used to drain urine from the bladder

Most catheters are thin tubes that are inserted directly into the bladder through the urethra (the duct that leads urine out of the bladder), but can also be placed outside of the body in males (condom catheters). These tubes allow urine to drain out of the bladder into a collection device such as a collection bag. There are several different types of catheters that are available, including single-use catheters and lubricated (hydrophilic) catheters.

Urinary catheters are used after SCI to help drain urine from the bladder in those who have difficulty emptying the bladder due to neurogenic bladder.

Many people experience bladder problems after spinal cord injury. SCI can lead to a loss of coordination between the brain and bladder, which can lead to irregular draining and filling of the bladder known as neurogenic bladder

There are two main types of neurogenic bladder, which may involve either a bladder that does not have the reflexes to empty itself (flaccid bladder) or a bladder that has unpredictable reflexes that cause it to empty (spastic bladder). Neurogenic bladder can lead to leaking of urine, incomplete emptying, and overfilling of the bladder, which can stretch and damage the bladder and kidneys.

Urinary catheters are the main technique that is used to allow for bladder emptying in people with neurogenic bladder after SCI.

Complications of poor bladder management

Regularly draining the bladder is a very important part of taking care of the body after SCI. Several serious complications can happen if bladder management is not successful:

Image showing the urinary system. Bottom right image shows a person's abdomen with two bean-shaped kidneys connecting by tubes labelled 'ureters' to the bladder (just above the pubic bone). Enlargement top left shows the bladder surrounded by a smooth muscle labelled 'bladder wall muscle'. Urine is contained in the bladder. The bladder connect downward to a tube labelled 'urethra'. The exit of the bladder to the urethra has muscles surrounding it labelled 'bladder sphincter muscles'.

Urine may back up into the kidneys if the bladder overfills.2

• When the bladder is not emptied regularly, it can continue to fill and may back up into the kidneys, which can cause damage to the kidneys.

• Overfilling of the bladder can also trigger a dangerous blood pressure response in some people with injuries at T6 and above called autonomic dysreflexia.

• Poor bladder management can contribute to urinary tract infections, which, in severe cases can lead to a life-threatening blood infection called sepsis.

• Leakage of urine can also contribute to the development of pressure sores, which can also be susceptible to dangerous infections.

There are several different types of catheters that may be used for bladder problems after SCI. The type of catheter chosen depends on the type of bladder dysfunction that you have (i.e. flaccid bladder or spastic bladder), as well as other factors like other health conditions, your self-care routines at home, level of independence, funding and lifestyle. It is important that you discuss your unique situation with your health providers to find the best treatment options for you.

Intermittent catheterization

The most common method of emptying the bladder after SCI is intermittent catheterization. Intermittent catheterization involves inserting and removing a catheter into the bladder through the urethra on a regular schedule during the day (usually every 4 to 6 hours) to drain urine from the bladder.

A cartoon calendarThe timing of intermittent catheterization is important. Maintaining a regular schedule of bladder draining can help to prevent urine leakage and bladder overfilling. Your unique bladder schedule will depend on the type of bladder dysfunction you have and other factors like fluid intake.

Depending on the situation, intermittent catheterization may be performed by you, a caregiver, or a health provider. There are many different techniques that may be used to insert the catheter depending on level of hand function and whether you are a male or female.

However, it is very important for all individuals to maintain good hygiene each time intermittent catheterization is used, which includes washing your hands and genitals before inserting a new single use catheter and thoroughly cleaning and drying (moisture attracts bacteria) if reusing your catheters.  If funding allows – reusing catheters is not recommended.

Indwelling catheters

Indwelling catheters (or Foley catheters) are tubes that are inserted directly into the bladder and remain in place to continually drain urine from the bladder.

A thin tube (catheter) is shown travelling up the urethra to the bladder. A zoom in image shows a small balloon that is inflated to hold the tube in place.

An indwelling (Foley) catheter is inserted through the urethra and held in place in the bladder by a small balloon.4

In most cases, indwelling catheters are inserted in through the urethra and into the bladder (known as urethral catheters). Once in the bladder, the very end of the catheter has a small balloon around it, which can be inflated to hold the catheter in place.

Indwelling catheters can also be inserted through a surgically created hole through the abdomen just above the public bone into the bladder called a stoma. These are called suprapubic catheters. Suprapubic catheters may be recommended as a later option for people who have medical complications or other reasons that make it difficult to use urethral catheters, such as intimacy.

Indwelling catheters may be used as a treatment option for people who are not able to insert a catheter regularly to perform intermittent catheterization, to allow for constant drainage of the bladder, and for people who have too much leaking of urine between uses of intermittent catheterization. Indwelling catheters are typically changed and replaced using sterile technique about once per month. Securement straps are recommended to secure indwelling catheter tubing as well as urine drainage bag tubing.

However, there are risks of having a catheter in the bladder all the time, such as increased risk of infections, sediment and bladder stones.

Condom catheters

Image of a condom catheter. A condom-like bag is held over the penis which drains through a tube to a urine bag strapped to the thigh.

Condom catheter with drainage bag strapped to the thigh5

Condom catheters are catheters that are placed over the penis on males to collect urine. Condom catheters resemble a condom and are placed over the penis and connected through tubes to a collection device. Unlike indwelling catheters, condom catheters must be changed each day.

Condom catheters are usually used for people that either leak in between bladder emptying sessions or for individuals who have the ability to trigger emptying by causing a spasm of their bladder (called reflex voiding). Because they are used to collect urine as it passes out of the body rather than directly from the bladder, condom catheters are not usually used for people with difficulties causing the bladder to empty.

One of the main concerns of condom catheters is incomplete bladder drainage, which can cause kidney damage. Therefore, a careful medical examination is needed to ensure that use of condom catheters alone is an appropriate management technique. For people who can use them safely, condom catheters are often considered a safer long-term treatment option because they are less invasive than catheters that are inserted into the body.

Reflex voiding

Reflex voiding is a technique that can be used by some people with spastic bladder to cause urination. Reflex voiding is usually done by tapping over the bladder lightly and repeatedly with the fingertips or the side of the hand to stimulate reflex muscle contractions in the bladder that cause urination. This technique can be used to help improve bladder emptying during intermittent catheterization and when using condom catheters.

Older techniques for reflex voiding such as the Valsalva maneuver (increasing abdominal pressure by holding the breath and bracing) and the Crede technique (applying manual pressure onto the bladder through the abdomen) are NO longer used because they can cause too much pressure in the bladder, which can damage the kidneys.

Maintaining good hygiene

A person lying down on a bed with a urinary catheter and collection bag hanging on the bed frame (left). Emptying the collection bag into a glass beaker (right).


Catheter maintenance includes emptying and washing the collection bag regularly.6,7

Maintaining good hygiene and cleanliness is required when using all types of catheters. In addition to washing your hands and genitals before using catheters, it is important to clean the collection bag as well. The collection bag must be emptied once it is about ¾ full. This is essential to help prevent complications like infections and the weight of the bag causing the condom catheter to fall off or irritation to the urethra if using an indwelling catheter.

Although sterile technique (using medical grade techniques and equipment to reduce bacteria) may be used during catheterization, research suggests that clean technique (maintaining clean and hygienic, but not medical grade techniques) is sufficient to reduce risk of urinary tract infections.

Although use of urinary catheters is the standard of care for managing bladder emptying after SCI, there are risks and side effects that may be related to the use of catheters. This is not a complete list. Speak to your health provider for further information.

Risks and side effects of urinary catheterization may include:

  • Pain and discomfort
  • Inconvenience
  • Indwelling catheters may limit a person’s movement and activities
  • Indwelling catheters may be considered embarrassing
  • Damage to the urethra from insertion of catheter or irritation from excess movement of indwelling catheter
    X-ray of a large bladder stone

    X-ray of a large bladder stone8

  • If used improperly (not regularly enough), damage to the kidneys can happen when bladder overfilling or bladder pressures causes urine reflux back up to the kidneys
  • Allergic reaction to the catheter material (often latex)
  • Bladder stones (crystallization of minerals in the urine from poor bladder emptying, indwelling catheters and unclean catheterization technique)
  • Urinary tract infections (from unclean catheter technique and incomplete bladder emptying)
  • Bladder cancer is associated with long term use of catheterization

Some of the risks associated with using urinary catheters can result from improper use, such as using improper or unclean technique or waiting too long between catheterizations. It is important that you discuss your bladder routine with a knowledgeable health provider to determine the best schedule for you and to learn to use the equipment correctly.

The use of urinary catheters for emptying the bladder is considered an essential standard care for bladder problems after SCI. Because of this, most research studies have instead looked at answering important questions about the relationships between catheters and complications.

Which type of catheterization has the highest risk of complications?

Cartoon of the kidneys and bladderThere is weak evidence from two studies that intermittent catheterization has the lowest risk of complications (such as urinary tract infections), followed by condom catheters. The highest risk of complications is with the use of indwelling catheters. Another study provides weak evidence that indwelling catheters are also related to higher risk of bladder cancer compared to other types of catheters.

However, the choice of which type of catheterization to use is often related to many different factors, like level of injury and the type of bladder problems that a person has. For instance, another study found that for people with high-level tetraplegia, suprapubic catheters may lead to fewer complications than intermittent catheterization.

Additionally, the type of catheter equipment used for catheterization may also be important to reduce risk. There is strong evidence from a review of five studies that using lubricated (hydrophilic) catheters for intermittent catheterization reduces the risk of urinary tract infections compared to non-lubricated catheters.

Urinary catheters are the main method of emptying the bladder for people with bladder problems after SCI. There are several types of catheterization, with the most common being intermittent catheterization. The type of catheterization used depends on many factors, such as the type of neurogenic bladder, your risk of complications, level of independence, funding and lifestyle.

Research studies suggest that intermittent catheterization is the type of catheterization with the lowest risk of complications. For further information, it is important to discuss your treatment options with your health providers to find out which treatments are best for you.

For a list of included studies, please see the Reference List. For a review of what we mean by ‘strong’, ‘moderate’, and ‘weak’ evidence, please see SCIRE Community Evidence Ratings.

This page has been adapted from SCIRE Project (Professional) “Bladder Management” Chapter:

Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, Wolfe D, Teasell R. (2014). Bladder Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-196.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/bladder-management/

Evidence for ‘How effective are urinary catheters for managing bladder problems after SCI?’ is based on the following studies:

[1] Ord J, Lunn D, Reynard J. Bladder management and risk of bladder stone formation in spinal cord injured patients. Journal d’urologie 2003;170(5):1734-1737.

[2] Weld KJ, Dmochowski RR. Effect of bladder management on urological complications in spinal cord injured patients. J Urol 2000;163(3):768-772.

[3] Groah SL, Weitzenkamp DA, Lammertse DP, Whiteneck GG, Lezotte DC, Hamman RF. Excess risk of bladder cancer in spinal cord injury: evidence for an association between indwelling catheter use and bladder cancer. Arch Phys Med Rehabil 2002;83(3):346-351.

[4] Li L, Ye W, Ruan H, Yang B, Zhang S, Li L. Impact of hydrophilic catheters on urinary tract infections in people with spinal cord injury: Systematic review and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil 2013;94(4):782-787.

Other References:

Cardenas DD, Hoffman JM. Hydrophilic catheters versus noncoated catheters for reducing the incidence of urinary tract infections: A randomized controlled trial. Arch Phys Med Rehabil 2009; 90:1668-1671.

Cardenas DD, Moore KN, Dannels-McClure A, Scelza WM, Graves DE, Brooks M et al. Intermittent catheterization with a hydrophilic-coated catheter delays urinary tract infections in acute spinal cord injury: A prospective, randomized, multicenter trial. PM R 2011; 3:408-417.

De Ridder DJ, Everaert K, Fernandez LG, Valero JV, Duran AB, Abrisqueta ML et al. Intermittent catheterisation with hydrophilic-coated catheters (SpeediCath) reduces the risk of clinical urinary tract infection in spinal cord injured patients: A prospective randomised parallel comparative trial. Eur Urol 2005; 48(6):991-995.

Giannantoni A, Di Stasi SM, Scivoletto G, Virgili G, Dolci S, Porena M. Intermittent catheterization with a prelubricated catheter in spinal cord injured patients: A prospective randomized crossover study. J Urol 2001; 166(1):130-133.

Groah SL, Weitzenkamp DA, Lammertse DP, Whiteneck GG, Lezotte DC, Hamman RF. Excess risk of bladder cancer in spinal cord injury: evidence for an association between indwelling catheter use and bladder cancer. Arch Phys Med Rehabil 2002; 83(3):346-351.

Hackler RH. Long-term Suprapubic cystostomy drainage in spinal cord injury patients. Br J Urol 1982; 54(2):120-121.

Moore KN, Burt J, Voaklander DC. Intermittent catheterization in the rehabilitation setting: A comparison of clean and sterile technique. Clin Rehabil 2006;20(6):461-468.

Ord J, Lunn D, Reynard J. Bladder management and risk of bladder stone formation in spinal cord injured patients. Journal d’urologie 2003; 170(5):1734-1737.

Perkash I, Kabalin JN, Lennon S, Wolfe V. Use of penile prostheses to maintain external condom catheter drainage in spinal cord injury patients. Paraplegia 1992; 30(5):327-332.

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Image credits

  1. Urinary catheterization 01 ©Saltanat ebli, CC0 1.0
  2. Modified from: Urinary Sphincter ©BruceBlaus, CC BY-SA 4.0
  3. Calendar ©tezar tantular, CC BY 3.0 US
  4. Foley Catheter ©BruceBlaus, CC BY-SA 4.0
  5. Condom Cather Drainage ©BruceBlaus, CC BY-SA 4.0
  6. Modified from: Closed Urinary Drainage ©BruceBlaus, CC BY-SA 4.0
  7. Modified from: Empty the Urinary Drainage Bag ©BruceBlaus, CC BY-SA 4.0
  8. Bladder Stone 08783 ©Nevit Dilmen, CC BY-SA 3.0
  9. Excretory system ©Olena Panasovska, CC BY 3.0 US

 

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