Archives of Physical Medicine and Rehabilitation
Volume 85, Issue 10 , Pages 1705-1707, October 2004

Twenty-seven years of complication-free life with clean intermittent self-catheterization in a patient with spinal cord injury: A case report

Presented in part to the 20th meeting in Kanto region of the Japanese Association of Rehabilitation Medicine, March 2001, Tokyo, Japan.

  • Katsuhiro Mizuno, MD

      Affiliations

    • Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
    • Corresponding Author InformationReprint requests to Katsuhiro Mizuno, MD, Dept of Rehabilitation Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, Japan 160-8582
    • ,
  • Tetsuya Tsuji, MD, DMSc

      Affiliations

    • Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
    • ,
  • Akio Kimura, MD, DMSc

      Affiliations

    • Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
    • ,
  • Meigen Liu, MD, DMSc

      Affiliations

    • Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
    • ,
  • Yoshihisa Masakado, MD, DMSc

      Affiliations

    • Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
    • ,
  • Naoichi Chino, MD, DMSc

      Affiliations

    • Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan

Article Outline

Abstract 

Mizuno K, Tsuji T, Kimura A, Liu M, Masakado Y, Chino N. Twenty-seven years of complication-free life with clean intermittent self-catheterization in a patient with spinal cord injury: a case report. Arch Phys Med Rehabil 2004;85:1705–7.

Currently, clean intermittent self-catheterization (CISC) is the most prevalent method of bladder management in patients with spinal cord injury (SCI) at discharge from rehabilitation centers. However, half of the patients discontinue using CISC and change to other methods of bladder management several months postdischarge despite the fact that it the best way to prevent urinary tract complications. Few studies, however, report the long-term consequences of CISC. In this case, we present a woman in her early fifties who had sustained thoracic SCI and had continued using CISC for 27 years without developing any complications. The possible reasons for her success were absence of incontinence because of underactive and normal capacity bladder; normal upper-extremity functions and absence of marked spasticity of lower extremities that facilitated CISC technique; and absence of sociovocational problems, enabling her to keep proper intervals between catheterizations each day. This case indicates that CISC is useful for long-term bladder management in patients with SCI, even for 25 years or more. Long-term outcomes of CISC and factors leading to success need to be delineated in future studies with larger samples.

Key words:  Bladder, neurogenic , Case management , Case report , Rehabilitation , Treatment outcome , Urinary tract infections

 

MANY REHABILITATION CENTERS now regard clean intermittent self-catheterization (CISC) as the best approach to bladder management in patients with spinal cord injury1, 2, 3 (SCI). About 40 years ago, however, most patients with SCI were taught to empty their bladder with tapping or the Credé maneuver. Many of them suffered from severe urinary tract complications such as pyelonephritis, hydronephrosis, and renal failure, and they eventually died from these complications.1, 4, 5 To overcome these devastating consequences, Lapides et al6 introduced the technique of CISC in 1972. Their rationale was that reducing residual urine as much as possible was more important than sterilizing catheters meticulously, because the bacteria introduced by the catheter are not the reason for infectious complications.6 Since its introduction, CISC has been widely accepted as a useful method of bladder management in patients with neurogenic bladder to prevent urinary tract complications. Today, CISC is the most commonly used method of bladder management among patients with SCI at discharge from rehabilitation centers, although some patients cannot continue to use it over the long-term for several reasons.1, 2, 3

There are several reports about the long-term consequences of CISC,5, 6, 7, 8, 9, 10, 11 but to our knowledge, no report with a follow-up period of more than 20 years. Recently, a patient presented to us with thoracic SCI who had performed CISC for 27 years without developing any urinary tract complications. We describe her case and discuss the possible reasons for her long-term success.

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Case description 

Our patient is a woman, now in her early fifties, who had fractured the T12 vertebra and sustained T10-level paraplegia in a traffic crash in 1975 when she was in her early twenties. One month postinjury, she had surgery for posterior fixation of the fractured thoracic vertebra and was transferred to a rehabilitation hospital. She was hospitalized there for 6 months and underwent a comprehensive SCI rehabilitation program including bladder management training with CISC. At discharge, she was completely independent in activities of daily living using a manual wheelchair.

After returning home, she managed her bladder function with CISC. She did not undergo a formal urinary function evaluation, except for intermittent follow-up by a family physician. In late 2001, she visited our hospital for evaluation of her health status, including bladder function after a 27-year interval.

On neurologic examination, muscle strength, light touch, and pinprick sensations were lacking below the level of T10. According to the American Spinal Injury Association (ASIA) and Internal Medical Society of Paraplegia standards,12 the patient had an ASIA Impairment Scale grade A-level injury, and she had scores of 50 on the motor scale and 34 on both the pinprick and light touch scales. Her lower-extremity muscle tone was hypotonic.

A detailed interview with her regarding bladder management revealed that, since she started using CISC, she had self-catheterized 5 or 6 times a day when she felt spasticity of her lower extremities as a substitute sensation for bladder fullness. On each catheterization, her urinary output ranged from 100 to 350mL. She had used the 20 catheters in turn that were given her at the time of discharge 27 years before. She usually washed them with unsterilized water and a kitchen detergent. Sometimes she sterilized her catheters by boiling them without any disinfectant. She had never experienced urinary incontinence nor used any medications for bladder management. During these 27 years, she had never suffered from overt urinary tract infections or taken antibiotics.

A plain spine radiograph revealed a fixation between the T10 and L2 vertebra with a metallic instrument. Her urinalysis was unremarkable, with a pH of 5.5 and neither hematuria nor pyuria. Urine culture yielded 1.0×105 of Escherichia coli. Blood chemistry results indicated normal renal function. On urodynamic study with carbon dioxide gas cystometry, she felt spasticity of her lower extremities when 154mL of carbon dioxide was infused reversely by urethral catheter, but a voiding reflex did not occur even when 497mL of carbon dioxide was infused. This indicated detrusor areflexia and normal bladder compliance. Maximum bladder pressure was 66cmH2O on urination with application of abdominal pressure, and surface electromyography of the external anal sphincter suggested that the urethral sphincters were relatively intact (fig 1). Cystography revealed normal bladder capacity, and there was no vesicoureteral reflux, diverticula, bladder deformity, or urinary stones (fig 2). Intravenous pyelography showed no dilation of renal pelvis, hydronephrosis, or renal stones. Thus, her bladder and renal status had remained healthy for 27 years since the introduction of CISC.

  • View full-size image.
  • Fig 1. 

    Urodynamic study results. Combined sphincter electromyogram (EMG) (top line) and cystometrogram (bottom line) were performed to examine bladder function. The patient felt substitute desire to urinate when 154mL of carbon dioxide was infused (downward arrow). Her bladder capacity was 497mL (upward arrow), and then the patient urinated by applying abdominal pressure.

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Discussion 

The treatment of neurogenic bladder has undergone significant changes in the past 40 years and dramatically decreased the incidence of urologic complications, once a leading cause of patient morbidity and mortality.5 Improved bladder management, including the CISC technique, the discovery of new antibiotics, and education for patients and caregivers, has reduced long-term renal complications. The CISC technique has been widely accepted in the United States and in Europe as a rational method of bladder management. This is supported by the data from the National Spinal Cord Injury Statistical Center,1 in which the percentage of persons discharged using CISC increased from 30% during the period from 1973 to 1985 to 52% during the period from 1986 to 1999. In Japan, this technique was first introduced by Chino and Asaba13 in 1975. Today, CISC is the most popular technique of bladder management for patients with SCI in Japan. It has also been shown that the incidence of urologic complications, such as vesicoureteral reflux, hydronephrosis, renal stones, and renal failure, is lower in patients with CISC than in those with pads or indwelling catheters.1, 4, 8, 10

In general, the preferred approach to prevent long-term complications in patients with SCI is uncertain. Several studies4, 8, 9, 11, 14, 15 have reported lower incidence of urinary complications with CISC during follow-up periods ranging from 1 to 10 years. However, the studies do not make it completely clear what the best approach is because none of this research was well controlled (ie, cohort studies, observation studies). How well CISC works depends on the patients and their social situations.

It is remarkable that the patient continued using CISC without developing any urinary complications. For 27 years, she had washed her catheters only with unsterilized water, without using any disinfectants. This outcome supports the idea that a more important component of a regimen to resist bacterial infection is emptying residual urine rather than preventing bacterial invasion through urethral tracts by using sterile catheters. Our case strongly suggests that CISC is a safe and useful method of bladder management that can be used for a long time in selected cases.

Although the percentage of patients with SCI discharged with CISC from rehabilitation centers is reported as between 52% and 76%,1, 4, 5 30% to 50% of these patients are known to discontinue CISC and to switch to other methods of bladder management several months after discharge.2, 16 The following reasons have been given for discontinuation of CISC: (1) persistent incontinence despite anticholinergic agents,2, 8, 17 especially in women; (2) severe spasticity of lower extremities, which interferes with catheterization; (3) trauma to the lower urinary tract and orchiepididymitis, especially in men4, 15, 18; (4) severe upper urinary tract complications, such as pyelonephritis and hydronephrosis, brought about by increased intravesical pressure because the interval between each catheterization is too long or because of detrusor hyperreflexia with sphincter obstruction.7

Considering the factors that lead to discontinuation of CISC, the remarkable long-term success without any accidents or complications seen in our patient may be attributed to (1) absence of urinary incontinence and absence of a need for external collective devices because of her normal bladder compliance, normal bladder functional capacity, and detrusor acontractility; (2) complete independence in CISC technique because of normal upper-extremity function, good sitting balance, and no interfering spasticity of lower extremities; (3) her ability to feel a substitute sensation of bladder fullness, which permitted her to know when her bladder needed to be emptied; and (4) the maintenance of a proper interval between each catheterization procedure every day for 27 years because she had spent most of the time at home as a housewife.

Lessons learned from our patient would be that when physiatrists try to introduce CISC to patients with SCI, we should consider their levels of injury, types of neurogenic bladder, upper-extremity functions, sitting balance, degree of lower-extremity spasticity, bladder sensation, and sociovocational factors. It would be necessary to reduce intravesical pressure with anticholinergics19 or nerve blocks in cases of overactive bladder and reduce spasticity with muscle relaxants or nerve or motor point blocks when lower-extremity spasticity is prominent. It is also important to instruct patients to observe proper intervals of CISC to keep their intravesical pressures low and to prevent urinary tract complications.

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Conclusions 

This single case indicates that CISC is useful for long-term bladder management in patients with SCI. Long-term outcomes of CISC and factors leading to long-term success need to be delineated in future studies with larger samples.

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References 

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 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated.

PII: S0003-9993(04)00433-2

doi:10.1016/j.apmr.2004.03.030

Archives of Physical Medicine and Rehabilitation
Volume 85, Issue 10 , Pages 1705-1707, October 2004

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