Incidence and prevalence of urinary bladder dysfunction after cord injury

Most people, during the first days after spinal cord injury, have evidence of a neurogenic bladder. In people with incomplete injury, the majority of recovery of bladder function is evident in the first 6-9 months and improvement can continue for 2 years after injury. The negative consequences of the neurogenic bladder to the health and quality of life for cord-injured people are decreasing with current improvements in management and understanding of the causes of the problems. In one of the early papers on urological aspects of rehabilitation, Bors (1951), described up to 80% mortality of spinal cord injured soldiers in World War I, before they were able to return to the United States. By the time of World War II the survival rate had increased to 88%. Bors attributed this improvement to greater understanding of the pathophysiology of the neurogenic bladder and the advent of antibiotics. Mortality due to uro-logical causes is now estimated to be <3% (Jamil, 2001). The current focus of modern rehabilitation medicine and research is directed toward issues of morbidity and not mortality. The prevalence of a neurogenic bladder after spinal cord injury is high (Anson and Shepard, 1996; Noreau et al., 2000). A study by the Model Spinal Cord Injury Systems of Care determined that 81% of persons with spinal cord injury reported some degree of impaired bladder function (McKinley et al., 1999). Even more significant are the secondary sequelae, including frequent urinary tract infections, pain secondary to urinary tract infection and pain secondary to indwelling devices such as Foley catheters.

In a survey of Spinal Cord Injured persons (Wolfe et al., 2002; Potter et al., 2004) regarding the long-term sequelae of spinal cord injury, uro-logical problems had a high prevalence. The ''neurological impairment'' of bladder function does not appear to change with time, but time and aging result in secondary problems such as urethral strictures, bladder diverticuli, chronic cystitis and increased incidence of bladder cancer. These prevalence studies reveal that, although we are well aware of the high incidence of neurogenic bladder, we are still limited in our ability to manage its consequences. For example, incomplete emptying is associated with high residual urine volume, which is a risk factor for incontinence and infection (Shekelle et al., 1999; Trautner and Darouiche, 2002). Recognizing that continence is the first issue associated with a neurogenic bladder, pain and infection are equally important long-term sequelae (Post et al., 1998). Although continence may be controlled with devices, sepsis, pain and incontinence may result from recurrent urinary tract infections.

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