John A. Horton

Effect Of Controlled-Release Oxybutynin On Neurogenic Bladder Function In Spinal Cord Injury

Abstract Objective: This study evaluated the effects and tolerability of extended-release oxybutynin chloride on the frequency of voiding and catheterization and urodynamic capacity in spinal cord injury (SCI) patients with defined detrusor hyperreflexia. Methods: This was a 1 2-week, prospective, dose-titration study of extended-release oxybutynin (oxybutynin XL) . SCI patients with urodynamically defined detrusor hyperreflexia were recruited for this study. Following a 7 -day washout period, patients were evaluated via video-urodynamic study and then treatment was initiated at a dosage of 1 0 mg per day. Dosage was increased in weekly intervals to a maximum of 30 mg per day. Micturation frequency diaries and urodynamics were completed at baseline and repeated at week 1 2. Tolerability information was collected at each follow-up visit. Results: Ten patients (mean age = 49 years) with complete or incomplete SCI were enrolled. Participants reported clinical improvement (decreased urinary frequency and fewer incontinence episodes) with oxybutynin therapy following titration to 30 mg per day. All patients chose a final effective dosage of greater than 1 0 mg, with 4 patients taking the maximum of 3 0 mg per day. Mean cystometric bladder capacity increased from 2 7 4 mL to 3 80 mL (P = 0.008). No patient experienced serious adverse events during the 12-week study. Conclusion: Oxybutynin XL is safe and effective in patients with detrusor hyperreflexia secondary to SCI. The onset of clinical efficacy occurs within 1 week, and daily dosages up to 30 mg are well tole rated.

Medical and Psychosocial Complications Associated With Method of Bladder Management After Traumatic Spinal Cord Injury

OBJECTIVES To determine the relationships between bladder management method and medical complications (renal calculi or decubitus ulcers), number of hospital days, and psychosocial factors. We hypothesized that indwelling catheterization would be associated with more complications, more hospitalizations, and worse psychosocial outcomes compared with other bladder management methods. DESIGN Inception cohort study. SETTING Model spinal cord injury (SCI) centers funded by the National Institute on Disability and Rehabilitation Research from 1973 to 2005. PARTICIPANTS Persons with new traumatic SCI (N=24,762) enrolled in the National SCI Database entire data set forms I and II. Patients were stratified according to the bladder management method recorded at each time of data collection into 1 of 4 groups as follows: indwelling catheterization, spontaneous voiding, condom catheterization, and intermittent catheterization. Those who reported no management method or errors in reporting were excluded (n=1564). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Medical complications, including pressure ulcer number and grade of worst ulcer, kidney stones, and hospitalizations, as well as psychosocial factors (satisfaction with life, perceived health status, societal participation), were stratified by bladder management method. Results were adjusted for level and completeness of neurologic injury and other confounding and modifying factors. RESULTS Compared with other forms of bladder management, use of an indwelling catheter was associated with more pressure ulcers and longer and more hospitalizations for all causes and urology-specific causes. Indwelling catheter use was associated with the lowest levels of participation, but similar satisfaction with life and perceived health status. CONCLUSIONS Indwelling catheterization was associated with more medical complications and lower levels of participation than other bladder management methods, but more research is required to ascertain the causality of these complications.

Impact Of α-Blockers In Men With Spinal Cord Injury And Upper Tract Stasis

Abstract Objective: Our objective was to determine the effectiveness of α1-blockers on upper tract stasis in men with spinal cord injury (SCI) who use reflex voiding for bladder management. Methods: A retrospective chart review of men with SCI at or above T6, who used reflex voiding for bladder management and had upper tract stasis diagnosed by renal scan. Inclusion was based on the availability of the following tests both before and after α1-receptor blockade: renal scan, urodynamic studies, and arterial pressures. Part I evaluated the impact of α1-blockers on upper tract stasis. Part II evaluated the impact of α1-blockers on urodynamic parameters in those with and without resolution of stasis. Statistical methods: Chi-square test was used to determine the statistical significance of resolution of upper tract stasis. Students t test for 2-paired samples was used to evaluate whether urodynamic parameters differed significantly before and after treatment with α1-blockers. Main Outcome Measures: Urodynamic parameters evaluated included mean changes in opening pressure, maximum detrusor voiding pressure, and duration of uninhibited contraction. Results: Ten men with uppertract stasis were identified (15 renal units). After >6 months on α1-receptor antagonist therapy, upper tract stasis resolved in 8 of the 10 men (11 renal units) and persisted in 2 men (4 renal units). (P = .00026). The only urodynamic parameter that significantly changed in those with resolution of upper tract stasis was the duration of the uninhibited contraction (resolution of stasis: – 57 seconds; P < .001), persistence of stasis: +12 seconds (P < .05). No significant change in opening pressures occurred in either those with resolution of stasis or persistent stasis (P < .78). Maximum arterial pressures during voiding statistically decreased with the use of α1-blockers (152 mmHg vs 135 mmHg; P < .01). Conclusions: α1-Receptor-antagonist therapy improved uppertract stasis in men with SCI. The urodynamic parameter that changed in those with resolution of upper tract stasis was the duration of uninhibited contractions, which decreased significantly.

Bladder Management for the Evolving Spinal Cord Injury: Options and Considerations

Bladder management after a spinal cord injury is a critical consideration from the onset of the condition. Inadequate management resulted in a high incidence of morbidity and mortality in the past. As better awareness has been generated and more judicious use of the available management options has been used, a dramatic decline in associated pathologies has occurred. This review seeks to delineate the options for diagnosis and management of the neurogenic bladder. Clinical context is emphasized in the timing of interventions and testing. Suggestions for formulating a urological management plan for the individual patient are provided.

Pilot evaluation of functional questionnaire for predicting ability of patients with tetraplegia to self-catheterize after continent diversion

Abstract Background/Objectives: Creation of a continent catheterizable stoma has dramatically improved the ability of the patient with spinal cord injury to perform clean intermittent catheterization (CIC). However, not all patients are good candidates for this procedure. To aid in patient evaluation, we propose the use of a functional questionnaire to predict a candidates ability to negotiate a continent catheterizable stoma. Methods: A published functional questionnaire was adapted to assess the self-perceived ability to perform upper extremity tasks similar to those involved in the manipulation of catheter. Tetraplegie patients who had undergone creation of a content catheterizable stoma were given the questionnaire and asked to describe demographics, method of catheterization, motivational factors, and satisfaction with the procedure. Results: Subjects varied in age (23-36 years) and level of impairment (C4-C6). Functional scores correlated with level of injury. Of the 4 women and 1 man who responded, only 2 were able to self-catheterize before diversion. Their catheterization times decreased significantly after creation of a continent stoma. Two patients unable to perform CIC preoperatively were able to perform CIC postoperatively. The patient with the lowest score was unable to perform CIC preoperatively or postoperatively. All were satisfied with outcome after diversion. Conclusions: In our small cohort, a low functional score was associated with inability to perform CIC after continent diversion. Administration of this questionnaire to a larger spinal cord injury population should aid in selecting appropriate candidates for the creation of a continent catheterizable stoma.

Clinical Experience With Continuous Intrathecal Baclofen Trials Prior to Pump Implantation

To report our clinical experience using continuous intrathecal baclofen (ITB) trials prior to permanent pump implantation.

Active Lifestyle Is Associated With Reduced Dyspnea and Greater Life Satisfaction in Spinal Cord Injury

OBJECTIVE To assess the relations between measures of activity with dyspnea and satisfaction with life in chronic spinal cord injury (SCI). DESIGN Cross-sectional survey. SETTING Five SCI centers. PARTICIPANTS Between July 2012 and March 2015, subjects (N=347) with traumatic SCI ≥1 year after injury who used a manual wheelchair or walked with or without an assistive device reported hours spent away from home or yard on the previous 3 days, sports participation, and planned exercise. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Satisfaction with Life Scale (SWLS) and dyspnea. Dyspnea was defined as shortness of breath when hurrying on the level or going up a slight hill, going slower than people the same age on the level because of breathlessness, or stopping for breath when going at your own pace, or after about 100yd (or after a few minutes) on the level. RESULTS Dyspnea prevalence was 30%. Adjusting for asthma or chronic obstructive pulmonary disease, mobility mode, race, and season, there was a significant linear trend between greater SWLS scores and quartiles of time spent away from the home or yard (P=.0002). SWLS score was greater if participating in organized sports (P=.01), although was not significantly greater with planned exercise (P=.093). Planned exercise was associated with a reduced odds ratio (OR) of dyspnea (.57; 95% confidence interval [CI], .34-.95; P=.032), but organized sports was not (P=.265). Dyspnea was not significantly increased in persons who spent the fewest hours outside their home or yard (≤7h) compared with people who spent the most hours outside their home or yard (>23h) (OR=1.69; 95% CI, 0.83-3.44; P=.145). CONCLUSIONS In SCI, a planned exercise program is associated with less dyspnea. An active lifestyle characterized by greater time spent away from home or yard and sports participation is associated with greater SWLS scores.