Neurogenic LUTS and CIC: Nurses’ point of view

Future nursing research in CIC to address the need for an evidence-based educational protocol

On behalf of the EAUN SIG Continence: E. Wallace (IE), V. Lejay (FR), G. Villa (IT)

The general term Neurogenic Lower Urinary Tract Dysfunction (NLUTD) refers to the effects that a neurological condition can have on the urinary tract. The neurological regulation of the organs  and their voluntary and reflex control are controlled by different levels of the spinal cord. The risk of lower urinary tract dysfunction in individuals with neurological disease is considerable and can heavily impact on quality of life. [1] Many neurological diseases can affect the filling and/or voiding phase of the micturition cycle. Clean intermittent catheterisation (CIC) is commonly performed by patients and/or by nurses in case of neurogenic urinary retention; nurses have a major role in patient education and training. In this short paper we summarize some of the main characteristics that lead patients with common neurological conditions to developing NLUTD which might require CIC.

“During the patient’s lifespan, acute events such as stroke lead to different NLUTDs compared to progressive conditions such as multiple sclerosis stroke. [1,2]”

NLUTDs largely depend on the site, extent, and clinical history of the neurological lesion. For example, in case of congenital or perinatal dysfunction, normal lower urinary tract function will never be gained by the patient. [1,2] During the patient’s lifespan, acute events such as stroke lead to different NLUTDs compared to progressive conditions such as multiple sclerosis stroke. [1,2] Neurological disorders are divided in upper motor neuron lesions, which include supra-pontine (brain) and suprasacral (brainstem and spinal cord) lesions, and lower motor neuron lesions, which include sacral and subsacral lesions, i.e. cauda equina. [3] Usually, patients with suprapontine lesions usually still have detrusor contraction reflexes, although they may lose voluntary  control of urination, inhibition of bladder contractility, and/or sensation of  filling and voiding. This may occur in cases of stroke or head trauma, in which synergistic lower urinary tract function is usually preserved. [1,3] When a lesion is located below the pons in the spinal cord, detrusor sphincter dyssynergy is commonly present. Persons with lesions above T6 can also present autonomic dysreflexia, characterised by headache, bradycardia, hypertension, vaso-constriction in the skin below the lesion, and vasodilation above the lesion. [1,3] Overall, the clinical  presentation is variable and depends on the level and completeness of the lesion; in many patients with a lesion above T10 detrusor overactivity is found on urodynamic studies. A low thoracic or sacral injury may result in a contractile deficit of the bladder with an intact external urethral sphincter. Patients with an incomplete lesion may present with a variety of clinical pictures, including  impaired  compliance, which may result in upper urinary tract damage over time, even in the absence of obvious symptoms. Patients with a lesion above T6 have increased risk of autonomic dysreflexia, a potentially  fatal condition with hypertension and bradycardia. [4,5] Motor neuron diseases comprise a group of neurodegenerative diseases involving the upper and/or lower motor neurons. Neurogenic LUTS related to motor neuron diseases are classified based on urodynamic findings. The most frequent finding is detrusor sphincter dyssynergy, indicating supra-sacral lesions as causes of LUTS. [6]

Clean intermittent catheterisation
From nurses’ point of view, CIC has long been used as a method of managing urinary retention problems of various kinds (neurological, detrusor hypoactivity). Several international studies have shown the effectiveness of CIC, if correctly performed, in reducing urinary tract infections compared to permanent catheterisation; solutions proposed in the literature and by manufacturers to train patients include aids such as leg mirrors to make female self-catheterisation easier, sometimes provided with an inflatable leg spreader. Labia separators and special grips that can be  activated with wrist movements to grab the catheter and securely inserting it into the urethra are dedicated to patients with impaired hand dexterity, i.e. inability to oppose the thumb to the other  fingers. Several of these devices are mentioned and depicted in the EAUN guidelines on intermittent catheterisation (www.nurses.uroweb.org/guideline/catheterisationurethral-intermittent-in-adults/, Appendix H) which also provide a detailed procedure for catheterisation and documents such as a medical travel paper and a voiding diary for patients.

Several questionnaires dedicated to CIC have been developed over the years. One of these tools investigating patients’ difficulties in performing CIC has been developed [10] which takes into account local difficulties: transitory spasm of the striated urethral sphincter, local bleeding, patient’s high sensitivity to urethral pain, and disease complication/evolution such as transitory/increased limb spasticity with spasms and stiffness. Another one [9] is aimed at evaluating patients’ adherence to CIC, while a third one [10] investigates patients’ satisfaction.

Finally, in past years the literature has offered insights and shared experiences regarding strategies for teaching the current technique [11], which can sometimes be a difficult task as patients have  difficulty in learning the rationale for the manoeuvre and neglect the principles of hygiene, correct preparation of the technique and correct execution. The available evidence does not include studies comparing different training methods: the published studies have focused more on the principles than on the results of different training methods. Based on the abovementioned considerations, future nursing research in the important field of CIC should address the need for an evidence-based educational protocol, including adaptation of existing tools and criteria suggested by the existing literature.

1. 1. References
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Dr. Stefano Terzoni, Chair, SIG Continence, San Paolo Hospital, Bachelor School of Nursing, Milan (IT), s.terzoni@eaun.org