Question Title: SupraPubic Catheter for Urinary Incontinence????

Hoping you can give me your opinion and perhaps some suggestions for guiding me in the right direction. Im a 32 yr old female with a neurogenic bladder of unknown reasons. Started getting chronic UTIs about 8 months ago. Urologist found that I was retaining urine which was causing the infections. it was taking 6-7 courses of antibiotics before I could get rid of infection. She put me on self cath 3 x's per day and said a week of this should bring bladder function back to normal. This didnt help and my bladder problems and they have progressively and rapidly gotten worse. I self cath about 8 times per day and have no urgency and cant go on my own. Was at Mayo Scottsdale and found that I have no sensation until about 1200 CC full. My goal during self cath is to have less than 400 cc each time. I have had an incredible amount of UTI's during thios time and even a few kidney infections. I dont respond well at all to antibiotics. Last round was 7 orals in succession and also 2 antibiotic injections and 2 rounds of IV antibiotics. I also have a large amount of blood in urine and have had this microscopic hematuria the whole time. Sometimes i can visually see the blood. Right back kidney pain is excruciating as well as bladder pain and pain in abdomen. One IVP showed a small kidney stone but when they went to remove it they didnt find it and said that the dye had gotten trapped and this made a shadow on the IVP. I had a foley cath put on yesterday because I was unable to empty myself at all. It has been very painful, but also the urine just does not come out. I know how to self cath..8 times a day for 7 months..Im good at it, so Im unsure what the problem is. This has happened another time a few months ago and I had the foley on for a week. This almost completely wipes out the pain, and no problems emptying at all. My PCP told me today that the Urologist and he recommend a suprapubic catheter for me. Im pretty nervous about this...seems so final. he said we've tried everything else and now it is time to either go with this or live my life the way I have been...pain, discomfort, not working, infections, etc. I wonder what your opinion of these suprapubic caths are. My questions are as follows:
1. Any idea why my bladder stopped working all of a sudden. (they dont think I have MS but will retest every 12 months)
2. Any hope it can go back to normal on its own?
3. Are the suprapubic caths a good alternative to self cath as far as cutting down on infections?
4. Any major risks that go along with this new cath?
5. Would you recommend this to one of your patients in my situation?
Dr. wants to go ahead with this as soon as possible. Thanks for your time and expertise....it is greatly appreciated.

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Dear DD,

It sounds like you have had quite a difficult time with what you've been going through. I am certain it hasn't been easy and you would like to resolve the issues. It is, however, a difficult problem. Absolute or relative failure to empty the bladder results from decreased bladder contractility, or increased bladder outlet resistance, or both. This may be due to a temporary OR permanent change in the neuromuscular mechanisms which help initiate and maintain bladder emptying. It could also be due to inhibition of a voiding reflex. Furthermore, the problem could be due to the impairment of the bladder muscle itself, caused by infection, fibrosis, or overdistention.
Intermittent catheterization is an effective treatment. Some of the diseases that could lead to such dysfunction of the bladder include MS, (as you mentioned), diabetes, herpes zoster, Guillan-Barre syndrome, spinal stenosis, disc disease/spinal cord injury, and polio. It is unclear from your letter whether or not you have any underlying medical conditions which predispose you to this problem.

Aside from clean intermittent catheterization (CIC), which is a very commonly utilized approach for treatment of a nonfunctional bladder, there are other potential treatment options which may or may not be appropriate, practical, or effective in your case. These include:

Valsalva maneuver (bearing down)
Crede maneuver (manually pushing on the bladder through the abdomen)
Promotion of a reflex contraction to help bladder empty (stimulation of different areas that promote
bladder contraction)
Pharmacologic therapy, which may include bathanechol (Urecholine--which is only minimally
effective); metoclopramide (Reglan); and prostaglandins
Surgical and other treatments, such as electrical nerve stimulation.

As for your question about this returning to normal on its own, it is difficult to make this prediction. However, in certain of the diseases mentioned above, such as herpes, the problem may resolve within a couple of months of the resolution of the primary infection (namely herpes).

Before any treatment course, however, it is important for you to have had a urodynamic study, which is performed by a urologist, to identify and profile the bladder dysfunction you experience. The option of a suprapubic tube, especially in a young otherwise healthy functional woman, is not the treatment of choice. There is no reason to believe that a suprapubic tube would decrease your incidence of infection(s). The use of CIC, which you have used, is a much better option. You may need to refine the technique and use a less traumatic catheter, as well as make sure that you are doing the procedure correctly and not introducing any infection(s) in the bladder. You will want to discuss the above-mentioned options with your urologist, and consider a second opinion with a urologist who specializes in patients with neurogenic bladder disease.

This information is provided for general medical educational purposes only. Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition. More individualized care is available at the Henry Ford Hospital and its satellites (1 800 653-6568).

Sincerely,
HFHS M.D.-BE
*keyword: neurogenic bladder

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