Suprapubic Cystostomy vs. Urethral Catheterization
Wise Young, Ph.D., M.D.
W. M. Keck Center for Collaborative Neuroscience
Rutgers University, Piscataway, New Jersey
Intermittent urethral catheterization (inserting the catheter through the urethra) has long been the standard of bladder care for people with spinal cord injury. In recent years, suprapubic catheterization has become popular because it is easier technique for people with cervical spinal cord injury and limited hand dexterity to do catheterization. Suprapubic cystostomy creates tunnel from the abdomenal wall to the bladder. A catheter can be inserted into the bladder through this tunnel. The catheter drains urine into a bag. The catheter is irrigated daily and can be left in place for several weeks before replacement. It does not require catheterization every 4-6 hours and provide greater independence.
I review below several recent studies comparing urethral and suprapubic catheterization in people with SCI. These studies indicate that suprapubic catheterization is superior to both chronic indwelling and intermittent urethral catheterization for reducing bladder infections and kidney damage. While suprapubic catheterization is associated with a higher incidence of bladder stones, it is not associated with more bladder cancer. It, however, does not eliminate the need for anti-cholinergic bladder spasticity medication. Combined with oxybutinin, long-term suprapubic catheterization markedly reduces recurrent bladder infections and kidney damage, and is well-tolerated with minimal complications when the catheters are regularly irrigated and changed.
Urinary Tract Infection and Bladder Stones
Sterile catheterization is necessary to avoid introducing bacteria that can cause urinary tract infections. For people with cervical spinal cord injury, urethral catheterization is often not only difficult to do but often is not sterile unless it is done by somebody else. This is particularly true for women where sterile urethral catheterization is more difficult than in males. A suprapubic cystotomy allows people with limited hand use to do the catheterization themselves, allowing greater independence. Does suprapubic catheterization really reduce urinary tract infections?
Mitsui, et al. (2000) compared 34 and 27 patients managed with suprapubic cystotomy (SC) and intermittent catheterization (IC) respectively for 8.6-9.9 years. Neither group had any kidney problems but only 12% of SC patients had urinary tract infection compared to 26% of IC patients. However, kidney stones occurred in 9% of the SC group compared to 4% of the IC group. Bladder stones occurred in 65% of the SC group compared to 30% of the IC group. SC appears to be associated higher incidence of kidney and bladder stones than IC.
Nomura, et al. (2000) reported that the main complication from suprapubic cystostomy (SC) is bladder stone formation. Apparently 77% of the people did not have bladder stones after 5 years and 64% did not have stones after 10 years. Thus, about a third of people who have suprapubic cystotomies develop bladder stones sometimes during the first 10 years after placement.
Escalarin, et al. (2000) studied the incidence of urinary tract infection in patients with spinal cord injury. The overall incidence of urinary tract infection was 0.68 per 100 patient•days, while for male indwelling, clean intermittent, condom and female suprapubic catheterization, and normal voiding, the rate was 2.72, 0.41, 0.36, 0. 34 and 0.06, respectively.
Thus, suprapubic catheterization appears to be associated with significantly lower incidences of urinary tract infections than chronic indwelling urethral catheters and even intermittent catheterization. However, it seems to increase the incidence bladder stones and possibly kidney stones. As much as a third of people with long-term suprapubic catheterization will develop bladder stones over a 10-year period.
Indwelling catheters, i.e. catheters that are left in place for long periods, may cause bladder cancer by increasing urinary tract infections and irritating the bladder wall. Although suprapubic catheters reduce bladder infections, they appear to be associated with higher incidences of bladder stone. Do suprapubic catheters cause bladder cancer?
West, et al. (1998) examined the incidence of bladder cancer in U.S. veterans with spinal cord injury from 1988-1992. Out of 33,000 patients identified to have spinal cord injury, they found 130 (0.39%) with bladder cancer. Those who developed bladder cancer had only a 38% 5-year survival rate. The average age of onset was 57 years. In 42 patient where such information was available, bladder management was an indwelling urethral catheter in 18 (43%), suprapubic catheter in 8 (19%), clean intermittent catheterization in 8 (19%), and condom catheter in 6 (14%). Risk of bladder cancer in patients managed with suprapubic and intermittent did not differ from each other and lower than in patients managed with indwelling catheters.
Sheriff, et al. (1998) examined the clinical outcome and patients satisfaction with long term SC. They assessed 185 patients with suprapubic catheters. Those with bladder spasticity received anti-cholinergic oxybutynin (Ditropan). The catheters were clamped daily for 2 hours and changed every 6 weeks for 3-68 months. SC was associated with a 50% reduction in bladder pressure and improved bladder morphology in 85%, and abolishment of ureteral reflux in a third of the cases. Although patients complained of recurrent catheter blockage, persistent urinary leakage, urinary tract infections [note, perhaps because they changed the catheters every 6 weeks!], and 2.7% had small bowel injury from the procedure, the authors conclude that SC is well tolerated.
Kim, et al. (1997) examined the role of oxybutinin in 109 male patients treated for 11.9 years with chronic indwelling catheters: 80 had transurethral catheters (foley) while 29 had suprapubic catheters. The 38 (35%) patients who used oxybutinin regularly had lower bladder leak point pressures and only 3% hydronephrosis (kidney damage) compared to 23% not taking oxybutinin. The authors conclude that oxybutinin use is justified in patients using chronic indwelling catheters.
Grundy, et al. (1996) reported using suprapubic catheters in 3 male patients with with closure of the urethra. They showed that the procedure was possible in men and suggest that it is worth considering in men, particularly in cases where continence was not achievable by more conventional means.
MacDiamid, SA, et al. (1995) in New Zealand reviewed urological complications in 44 patients who had suprapubic catheters for 12-150 months. The catheters were irrigated weekly and changed every 2 weeks. They found no kidney damage, vesicoureteral reflux (urine returning into the tubes leading to the kidney), or bladder cancer. The incidences of bladder cancer, UTI, and stones were “acceptable”.
In people with spinal cord injury, suprapubic catheterization is associated with significantly lower incidence of urinary tract infection than intermittent catheterization, i.e. 12% vs. 26% (Mitsui, et al, 2000). Indwelling urethral catheters were associated a high incidences of bladder infection, i.e. 2.73 infections compared to only 0.34 for suprapubic catheterization per 100 patient•day (Escalarin, et al. 2000). However, suprapubic catheters were associated with a higher incidence of bladder stones than intermittent catheterization, i.e. 9% vs. 4% over 9 years (Mitsui, et al. 2000). Another study indicates that 36% of people with suprapubic catheters developed bladder stones over 10 years (Nomura, et al. 2000). Despite the high incidence of bladder stones, bladder cancer was not more higher in patients who use suprapubic catheters compared to those who use intermittent urethral catheterization, i.e. 0.07% in patients managed with either suprapubic or intermittent urethral catheterization, compared to 0.17% in those managed with indwelling uretheral catheters (West, et al, 1998). SC markedly lowered bladder pressure, improved bladder morphology, and abolished ureteral reflux but was associated with a 2.7% incidence of small bowel injury, catheter leakage, and urinary tract infection in an English rehabilitation center (Sheriff, et al. 1998). Indwelling catheters, however, do not eliminate the need to take bladder spasticity medication. The anti-cholinergic oxybutinin (Ditropan) treatment in patients with chronic indwelling catheters signicantly reduced the incidence of kidney damage, i.e. 3% compared to 23% in patients not taking oxybutinin (Kim, et al. 1997). Male patients who have chronic leakage can have urethral closure combined with SC (Grundy, et al. 1996). Long-term suprapubic catheterization is well tolerated with minimal complications (MacDiamid, et al. 1995). Thus, superpubic catheterization offers many major advantages over indwelling and even intermittent urethral catheterization, particularly for people with cervical spinal cord injury.
1. Nomura S, Ishido T, Teranishi J and Makiyama K (2000). Long-term analysis of suprapubic cystostomy drainage in patients with neurogenic bladder. Urol Int. 65 (4): 185-9. Summary: OBJECTIVE: We assessed the roles of suprapubic cystostomy in patients with neurogenic bladder and analyzed the complications and their courses. PATIENTS AND METHODS: We reviewed 118 patients with neurogenic bladder managed with suprapubic cystostomy. The original diseases were spinal cord injury in 90, degenerative disease of the central nervous system in 15, spina bifida in 6, cerebral palsy in 3, pontine bleeding in 1, Parkinson's disease in 1, brain tumor in 1, and dysgenesis of the external sphincter in 1. Fifty-six (62.2%) of spinal cord-injured patients demonstrated cervical damage. Renal function, urinary pH and white blood cell values were measured and evaluated after insertion. The stone-free rate after insertion was estimated by the Kaplan-Meier method. RESULTS: Indications for cystostomy were failure of clean intermittent catheterization in 62 (52.5%) and Crede's maneuver in 2, severe urethral damage in 30 (25.4%), replacement of urethral catheter in 3, worsening of the original disease in 15 (12.7%), deterioration of the general condition in 2, mental retardation in 2, and traumatic vesical rupture in 1. Frequent complications were formation of the bladder calculi in 30 (25%) and urinary leakage through the urethra in 11 (10%). No fatal complications occurred. The stone-free rates 5 and 10 years after insertion were 77 and 64%, respectively. The urinary pH of the stone-forming group was significantly higher than that of the stone-free group. The high urinary pH group (>7.24) had a higher risk of stone formation. CONCLUSIONS: Although continuous cystostomy drainage is not considered to be ideal management for bladder emptying, some patients with neurogenic bladder may benefit from this procedure. Department of Urology, Kanagawa Rehabilitation Hospital, Atsugi-city, Japan.
2. Mitsui T, Minami K, Furuno T, Morita H and Koyanagi T (2000). Is suprapubic cystostomy an optimal urinary management in high quadriplegics?. A comparative study of suprapubic cystostomy and clean intermittent catheterization. Eur Urol. 38 (4): 434-8. Summary: INTRODUCTION: Long-term outcome of spinal cord injury (SCI) patients was compared between those managed by suprapubic cystostomy (SPC) and clean intermittent catheterization (CIC) with particular emphasis on an incidence of urinary tract complications and patients perception for urinary management. MATERIALS AND METHODS: The study comprised 61 SCI patients; 34 patients managed with SPC (group A), while 27 with CIC (group B). After stabilization of their condition, all were followed annually on an outpatient basis with clinical history, urinalysis, urinary imaging and renal function studies. Mean follow-up periods were 8.6 and 9.9 years for groups A and B, respectively. Between groups, a comparative study was performed on the incidence of urinary complications such as renal dysfunction, hydronephrosis, vesicoureteral reflux, symptomatic genitourinary infection and urinary stone. Satisfaction with urinary management was also estimated using the questionnaires during follow-up. RESULTS: Renal dysfunction, hydronephrosis and vesicoureteral reflux were not found in either group. Symptomatic genitourinary infection was seen in 4 (12%) of group A and 7 (26%) of group B, respectively. The incidence of renal stone was 3 (9%) in group A and 1 (4%) in group B. A significant difference was not found between two groups in these urinary complications. On the contrary, bladder stone was seen more frequently in group A (65%) than in group B (30%) with a significant difference (p<0.001). The degrees of incontinence, bother score of daily activities, and overall satisfaction showed no significant difference between the two groups. CONCLUSION: Except for bladder stones, SPC is a valuable option of urinary management for quadriplegic patients, the results of which were comparable to paraplegic SCI patients managed with CIC. Department of Urology, Hokkaido University School of Medicine, Hokkaido, Japan. firstname.lastname@example.org
3. Esclarin De Ruz A, Garcia Leoni E and Herruzo Cabrera R (2000). Epidemiology and risk factors for urinary tract infection in patients with spinal cord injury. J Urol. 164 (4): 1285-9. Summary: PURPOSE: To our knowledge risk factors for urinary tract infection associated with various drainage methods in patients with spinal cord injury have never been evaluated overall in the acute period. We identified the incidence and risk factors associated with urinary tract infection in spinal cord injured patients. MATERIALS AND METHODS: We prospectively followed 128 patients at our spinal cord injury reference hospital for 38 months and obtained certain data, including demographic characteristics, associated factors, methods of urinary drainage, bladder type, urological complications and predisposing factors of each infection episode. Logistic regression modeling was done to analyze variables and identify risk factors that predicted urinary tract infection. RESULTS: Of 128 patients 100 (78%) were male with a mean age plus or minus standard deviation of 32 +/- 14.52 years. All patients had a nonfatal condition by McCabe and Jackson guidelines, and 47% presented with associated factors. The incidence of urinary tract infection was expressed as number episodes per 100 patients daily or person-days. The overall incidence of urinary tract infection was 0.68, while for male indwelling, clean intermittent, condom and female suprapubic catheterization, and normal voiding the rate was 2.72, 0.41, 0.36, 0. 34 and 0.06, respectively. The risk factors associated with urinary tract infection were invasive procedures without antibiotic prophylaxis, cervical injury and chronic catheterization (odds ratio 2.62, 3 and 4, respectively). Risk factors associated with repeat infection were a functional independence measure score of less than 74 and vesicoureteral reflux (odds ratio 10 and 23, respectively). CONCLUSIONS: Spinal cord injured patients with complete dependence and vesicoureteral reflux are at highest risk for urinary tract infection. Departments of Physical Medicine and Rehabilitation, and Medicine, Hospital Nacional de Paraplejicos, Toledo and Department of Preventive Medicine, Universidad Autonoma de Madrid, Madrid, Spain.
4. West DA, Cummings JM, Longo WE, Virgo KS, Johnson FE and Parra RO (1999). Role of chronic catheterization in the development of bladder cancer in patients with spinal cord injury. Urology. 53 (2): 292-7. Summary: OBJECTIVES: Patients with spinal cord injury (SCI) and chronic indwelling catheters are known to be at increased risk of bladder malignancy. "Decatheterization" by clean intermittent catheterization, external condom catheterization, or spontaneous voiding is thought to reduce the risk by decreasing the chronic mucosal irritation and rate of infection. We examined two Department of Veterans Affairs (DVA) data bases to test this theory. METHODS: A population-based retrospective analysis of invasive treatments for carcinoma of the bladder in all DVA hospitals was conducted using computerized inpatient files from fiscal years 1988 to 1992. RESULTS: One hundred thirty patients with bladder malignancy were identified from a pool of 33,565 patients with SCI (0.39%). All 130 patients underwent either radical cystectomy (n = 63, 48%) or transurethral resection of bladder tumor (n = 67, 52%). The 30-day perioperative mortality and overall 5-year survival rates were 2 (1.5%) and 49 (38%) of 130, respectively. Of the 130 patients analyzed, 42 (32%) had adequate data available regarding tumor pathologic findings and method of bladder management for analysis. The average age at diagnosis was 57.3 years. The histologic finding was transitional cell carcinoma in 23 (55%), squamous cell carcinoma in 14 (33%), and adenocarcinoma in 4 (10%) of 42. Bladder management was an indwelling urethral catheter in 18 (43%), suprapubic catheter in 8 (19%), clean intermittent catheterization in 8 (19%), and condom catheter in 6 (14%) of 42 patients. Squamous cell carcinoma was more common in patients with indwelling urethral catheters and suprapubic tubes (11 of 26, 42%) than in those using clean intermittent catheterization, condom catheterization, or spontaneous voiding (3 of 16, 19%). CONCLUSIONS: Bladder cancer was diagnosed in approximately 0.39% of this large SCI population during a 5-year period. Most cancers (55%) were transitional cell carcinomas. Squamous cell carcinoma was more common in patients with SCI and indwelling catheters than those without chronic catheterization. These data continue to suggest that avoidance of indwelling catheters, when feasible, is the preferred method of bladder management in patients with SCI. Department of Surgery, St. Louis University School of Medicine, and the John Cochran Veterans Affairs Medical Center, Missouri, USA.
5. Sheriff MK, Foley S, McFarlane J, Nauth-Misir R, Craggs M and Shah PJ (1998). Long-term suprapubic catheterisation: clinical outcome and satisfaction survey. Spinal Cord. 36 (3): 171-6. Summary: We report on the clinical outcome and satisfaction survey of long-term suprapubic catheterisation in patients with neuropathic bladder dysfunction. Between early 1988 and later 1995, 185 suprapubic catheters were inserted under direct cystoscopic vision. Anti-cholinergic therapy was given to all patients with significant detrusor hyper-reflexia; the catheters clamped daily for two hours and changed every six weeks. Ultrasonography and assessment of the serum creatinine were used to assess the upper renal tracts, and the results of the pre- and post-catheter video-cystometrography was used to evaluate bladder morphology, cystometric capacity, maximum detrusor pressure and the presence of vesico-ureteric reflux. There were equivalent numbers of males and females. The follow-up ranges from 3-68 months. Following catheterisation, there was a 50% reduction in the average maximum detrusor pressure, bladder morphology improved in 85% of the cases; the bladder capacity and upper renal tracts remained unchanged. Vesico-ureteric reflux was abolished in 33% of the cases. Complaints were common consisting of recurrent catheter blockage, persistent urinary leakage and recurrent urinary tract infections. There was a 2.7% incidence of small bowel injury with one fatality. However, the general level of satisfaction was high. It is concluded that suprapubic catheterisation is an effective and well tolerated method of management in selected patients with neuropathic bladder dysfunction for whom only major surgery would otherwise provide a solution to incontinence. We are encouraged to find preservation of renal function with maintained bladder volumes and reduced maximum detrusor pressures thus justifying the policy of catheter clamping and anti-cholinergic therapy in the presence of significant detrusor hyper-reflexia. However, even in expert hands this procedure is not without hazards. Spinal Injuries Unit, Royal National Orthopaedic Hospital, Stanmore, UK.
6. Kim YH, Bird ET, Priebe M and Boone TB (1997). The role of oxybutynin in spinal cord injured patients with indwelling catheters. J Urol. 158 (6): 2083-6. Summary: PURPOSE: The long-term benefits of oral oxybutynin in spinal cord injured patients with indwelling catheters is unknown. We reviewed our experience with this population of men and present the results of our analysis. MATERIALS AND METHODS: A total of 109 male spinal cord injured patients at the Houston Veterans Affairs Medical Center have been treated with chronic indwelling catheters (80 transurethral and 29 suprapubic). Thirty-eight patients (35%) were identified as using oxybutynin on a regular basis. These patients were compared to those not using oxybutynin with regard to urodynamic parameters and upper tract deterioration. Specifically examined were bladder compliance, bladder leak point pressure, vesicoureteral reflux, hydronephrosis, urolithiasis, febrile urinary tract infections and serum creatinine greater than 2 mg./dl. RESULTS: The mean duration of indwelling catheter use was 11.9 years (12.4 without oxybutynin and 10.9 on oral oxybutynin). Of the 31 patients with normal compliance (greater than 20 ml./cm. water), 24 (77%) were using oxybutynin (p = 0.001). Bladder leak point pressures were abnormal (greater than 35 cm. water) in 5 of 32 patients (16%) on oxybutynin versus 34 of 60 (57%) without it (p <0.001). Hydronephrosis was present in 15 of 66 patients (23%) without oxybutynin versus 1 of 36 (3%) with oxybutynin (p = 0.009). Febrile urinary tract infections occurred in 4 of 35 patients (11%) versus 17 of 62 patients (27%) with or without oxybutynin, respectively (p = 0.077). No significant differences were found between the 2 groups with regard to reflux, renal scars, stones or elevated serum creatinine. CONCLUSIONS: It appears that regular use of oxybutynin may be beneficial in spinal cord injured patients who require chronic indwelling catheters for bladder management. Our analysis reveals that patients who take oxybutynin regularly have better bladder compliance, lower bladder leak point pressures and less hydronephrosis. Until a prospective, randomized trial reveals contradicting outcomes, empiric use of oxybutynin in all spinal cord injured patients requiring chronic indwelling catheters seems justified. Scott Department of Urology, Baylor College of Medicine, and Veterans Affairs Medical Center, Houston, Texas, USA.
7. Grundy DJ, Tromans AM and Cumming J (1996). Suprapubic catheterisation with urethral closure (the Feneley procedure) in spinal cord injured men. Paraplegia. 34 (2): 93-4. Summary: Three male spinal cord injured patients who underwent suprapubic catheterisation with urethral closure are reported. Although the procedure is well established in women, and has been mainly used in patients with multiple sclerosis, this simple procedure is also possible in men, and worth considering in difficult situations where continence has been impossible to achieve by more conventional means. Duke of Cornwall Spinal Treatment Centre, Salisbury District Hospital, Wilts.
8. MacDiarmid SA, Arnold EP, Palmer NB and Anthony A (1995). Management of spinal cord injured patients by indwelling suprapubic catheterization. J Urol. 154 (2 Pt 1): 492-4. Summary: PURPOSE: We review the urological complications in spinal cord injury patients treated with suprapubic catheterization. MATERIALS AND METHODS: Suprapubic catheterization was used in 44 spinal cord injury patients. Followup ranged from 12 to 150 months (mean 58). The catheters were irrigated weekly and changed every 2 weeks. Patients were followed annually with urodynamic studies and ultrasound. RESULTS: No patient had renal deterioration, vesicoureteral reflux or bladder carcinoma. The incidences of incontinence, urinary tract infections and calculi were acceptable. CONCLUSIONS: Suprapubic catheterization is an effective and safe alternative form of bladder management in select patients with spinal cord injury. Department of Urology, Christchurch Spinal Injuries Unit, New Zealand.