“Will he ever walk again?” This is inevitably the first question I am asked by family members outside the hospital room of a newly injured spinal cord patient. For a variety of reasons the injured will not ask the significance of my neurological exam as it pertains to prognosis early during their hospitalization. It is only after meaningful interactions between the newly injured and the rehabilitation team will the necessary trust be established that the injured begin to tip toe into the reality relating to their functional prognosis and life after a spinal cord injury (SCI). Interestingly, quadriplegics and paraplegics will ask first, “Dr. Vigna, will I ever urinate on my own again?”
It is not surprising that the SCI community reports lower quality of life compared to those who are not disabled, but what is surprising to most is that they would rather regain bowel and bladder function over the ability to walk. In other words, living life dependent on a wheelchair is superior to the current medical management options available for those with a neurogenic bladder caused by a SCI. Chronically injured paraplegics rank their priorities for attaining function as the following (in order of highest priority): 1) sexual function, 2) continence of bowel and bladder, and 3) walking. Chronically injured quadriplegics rank their priorities for attaining function as the following: 1) use of their upper extremities, 2) sexual function, 4) continence of bowel and bladder, and then 5) walking.
Forty years ago kidney failure and urinary sepsis was the leading cause of death in those with a SCI. Much has changed regarding the medical management of the neurogenic bladder caused by SCI that has preserved kidney function, decreased kidney related complications, and improved the quality of life of those with spinal cord injuries. In fact, every rehabilitation plan of care for an acutely injured spinal cord patient will be tailored to ensure that patients are managed to avoid urinary tract complications. Despite significant advancement in the medical management of the neurogenic bladder much more needs to be done considering SCI patients would rather be continent of urine rather than regain the ability to walk.
The ‘modern’ management of SCI related neurogenic bladder centers on the intermittent catheterization procedure (ICP), whereby the patient or a caregiver inserts a catheter four to six times a day to empty the bladder completely. This is based on the fact that the normal bladder volume is 500 milliliters, and by ICP of volumes between 400 and 450 milliliters the pressures within the bladder will generally remain low preventing the urine from ‘refluxing’ back up towards the kidneys and preventing embarrassing urinary leaking. Also, understanding that ICP will inevitably cause the bladder to be colonized by bacteria, by emptying the bladder with its contained bacteria every six hours the concentrations of the bacteria will remain in concentrations below levels thought to cause infection. Studies indicate that not only will the morbidity and mortality decrease in those who are managed with ICP, but also these individuals have improved body image, improved self-esteem, and enhanced sexuality.
Despite providing medical education regarding the risk of indwelling catheters patients and families often decide that ICP is not feasible and they elect on utilizing indwelling catheters to attain urinary drainage. Reasons are varied and often relates to socioeconomic factors, level of injury, and the sex of the patient.
An Academic Physician Life Care Planner is in the best position to provide the foundation for the management of the neurogenic bladder of a SCI patient. A well planned interview of the patient with and without their family, the Academic Physician Life Care Planner will be in position to understand if the decision related to the use of a chronic indwelling catheter was made because of socioeconomic pressures to the injured person’s detriment of health. By interpreting the available urodynamic studies and by educating the injured on the various management options the injured will be empowered to make a knowing decision relating to their care.
Only after the injured has decided on their future management plan for their neurogenic bladder, will the Academic Physician Life Care Planner be able to understand the likelihood of foreseeable complications and account for those complications in the life care plan. In addition, the routine medical goods and services will be tailored for the chosen medical management which will include physician follow up care, urodynamic testing, renal ultrasounds, renal scans, catheters, gloves, and other ancillaries.
Dr. Greg Vigna, MD, JD Academic Physician Life Care Planner
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