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>> Hello and welcome to the Spinal Cord Injury Forum.
I'm Stephen Burns, medical co-director
of the Northwest Regional Spinal Cord Injury System.
The forums, the video recordings,
and our online media content are made possible by a grant
from the National Institute on Disability
and Rehabilitation Research.
Tonight, I will be talking about managing neurogenic bladder.
After my presentation, we will hear from two individuals
with SCI about the bladder management methods they use,
Todd Stabelfeldt and Tammy Wilber.
We will have questions after the presentation.
So with that, I'll get started here, a little change of title.
And I'll start with the disclaimer.
I was at a VA meeting last week
and all the speakers were giving disclaimers saying, "Oh,
you know, this is just my personal opinion,
it might not reflect the VA,"
and I was kind of laughing at them.
And then as I put this presentation together I was
thinking, well, I will put something in here
because there are guidelines that we have at the VA,
VA policies about what's done and some
of it very sensible stuff.
I'll leave it at that, but this is kind of a mix of things based
on my experience for the last 13 years treating people with SCI
at the Seattle VA Hospital.
So just starting with a little bit of the history
and why this is all important.
So, going back 60 years or so, 70 years or so,
people with spinal cord injuries did not live long.
Most people died in the first month, or definitely
in the first year and one of the leading causes
of death was urinary tract infections.
Of course there were no antibiotics available then.
So during the 1940's, antibiotics were introduced
and people started surviving for longer,
but what became apparent is
that renal complications were still occurring.
People were developing kidney failure
and it was a leading cause of death early on.
Now, with current management for bladder
and the periodic testing that's recommended,
I would say this is success.
It's a very small percentage of people who die due
to complications like renal failure.
And this is in spite of the fact that there's really no agreement
on the best way to manage things.
Different centers think that one thing is the best
and that's what they push everyone to do,
another place has a different opinion.
And really we see pretty universally
with just a few exceptions,
all of these things are making a big difference
that people are not suffering the same long-term complications
as far as having a shortened life expectancy.
So we're doing things much better now even though we're not
quite sure what's the ideal way to do it.
So, just starting with a bit on the anatomy,
so the upper urinary tract refers to the kidneys
and then the tubes that are connecting
down from there, the ureters.
In this part of the urinary tract, it's really unaffected
by spinal cord injury.
It's not greatly affected at all.
The kidneys of course do the filtering of the blood
and produce the urine.
Now the lower urinary tract has muscles which are affected
by the spinal cord injury.
So the bladder muscle which is also known as the detrusor,
and then the valve muscle or muscles that are at the bottom
of the bladder, so the sphincter muscles.
And then there is the urethra which connects to the outside
of the body, so where the urine passes through.
Now how it works starting from the bottom, the urinary tract
down and forgetting about the nerves,
it's actually pretty simple what the bladder does.
We just really have to think about the two parts, the bladder
and sphincter and then what they do.
They just do two different things.
The bladder can be in its filling mode
where the bladder muscle is just relaxed and it allows itself
to expand and expand as urine is-- urine is made.
The sphincter is staying close
so that the urine doesn't leak out.
And then if you move into the emptying phase,
the opposite thing happens.
The bladder muscle starts contracting
and the sphincter opens up.
So this is normal urination,
you're either filling or you're emptying.
Most of the time you're filling.
There are a whole bunch of nerves
and it's all pretty complicated, what's going on.
So I'm not going to dwell on the details.
It's more than most of us need to think about at a basic level
but it's coming in off the spinal cord at different levels
and arriving at the bladder by all different, different routes
and it's autonomic and it's somatic.
It's quite complicated.
Now keep in mind, so this is different parts
of the nervous system.
They each have a little different nerve supply
and different neurotransmitters.
And because of that, we can selectively affect one part
or another of the system with different medications.
So, trying to change the muscle activity,
increasing it or decreasing it.
And to some degree, there are medicines to do all
of those things somewhat better than others.
So an example would be something like the
so called anticholinergic medicine like Ditropan.
So that relaxes the bladder muscle and that's the spot
where it's acting in the system.
So with normal urine collection and then urine emptying,
there's got to be coordination going on,
that the bladder muscle,
the sphincter muscles are doing something in a coordinated way.
And the way that this works,
it's really hardwired into the spinal cord.
So in a normal situation without a spinal cord injury,
everything works the way it should.
The bladder is relaxing and then filling while the sphincter is
closed and then the opposite will happen
when you want to empty.
So all of that, it's really working just
like a reflex the same way we think that some
of walking is hardwired into the spinal cord.
So if the spinal cord is injured,
a few things can happen to these muscles.
So, they could be weakened, they're not contracting
to a normal degree or they could be so called overactive,
something that-- some of the medicines that are advertised
on TV for overactive bladder,
so a bladder muscle that's contracting too much.
Or the other thing that could be going on is
that there's just very poor coordination of the muscles.
For example, the bladder is contracting and trying to empty,
at the same time the sphincter is contracting and trying
to hold urine in, which is not a good thing.
Now, the actual pattern that someone will have,
it really depends on the level of the spinal cord injury,
how complete the injury is, and which of the nerves and which
of the reflexes are affected.
And it's going to vary from person to person.
Something to keep in mind is
that a stable pattern can take a few months to form,
especially in somebody with a complete spinal cord injury.
So early on, there might not be much muscle activity at all.
But going out a couple of months, there could be more.
So, when we do test early on,
it doesn't always tell us what things will be
like further down the road.
So I mentioned the two things going on, filling and emptying.
It's a good way to think about the different problems
that can occur after spinal cord injury.
So thinking of filling problems,
so the bladder could be contracting inappropriately
and not allowing filling to happen,
the sphincter might not be contracting enough
to keep the urine from coming out.
Or you could think of emptying problems,
the bladder is not contracting hard enough
to empty the urine out,
or the sphincter just won't, won't relax.
So that's basically the problems that can be occurring
and what we think about when we're trying to problem solve
to get the urine out when we want it to.
Now, when we approach trying to figure out what's going on,
we don't automatically jump
to the most expensive, invasive test.
We can get a lot of the information just starting
with the history, when is there incontinence,
what are the circumstances going on there.
Going to the neurological exam deciding what is happening
with the whole nervous system, what's happening
with the muscles in the legs, are there reflexes down there,
does it seem that there's-- that there is spasticity going on,
how much is sensation affected.
That gives us a good picture of what is likely to be happening
with the nerves, what is working
and what's contracting and what's not.
A very simple test we can do is something called a postvoid
residual or it could be just a random check
of the urine volume either putting a catheter
in the bladder to see how much urine is resting there.
Or if you have an ultrasound machine,
what's called a BVI machine, just doing a quick scan
to see what's in there.
Now, if we need to find out more precisely what are the nerves
doing and what is the bladder doing as it's filling,
we can do a group of tests that is called urodynamics.
And it answers questions like the ones listed here.
So is the bladder relaxing enough to allow it
to fill itself up with urine, is the sphincter opening
at the right time or is it closing at the time
when it should be open, and things like that.
This is a diagram of the setup and I'm not going to point
out everything that's on here.
But there's pressure catheter that's in the bladder
and some other measurements that go
on that tell us what the muscles are doing
and is it the bladder muscle, is it abdominal muscles,
what's producing the pressure.
The tracing, I'm not going
to explain everything that's going on here.
We just kind of trace out a bunch of different signals
over time as the bladder is filled and filled with urine,
what's happening with the pressures,
what's happening with the muscles.
So it's sort of a rapid filling of the bladder
to see what is the reaction of the nervous system,
what is the bladder, what is the sphincter trying to do
as filling is going on.
So it's a test that's sometimes needed
to sort out what's happening.
Now, the choice of method.
This is a common question.
What's the best thing to do for managing the bladder,
how to drain the urine out of there, what's going
to be the best, best thing over the long run.
So we start with really what the goals are,
starting with continence and how we're going
to collect, collect the urine.
So we want to keep the skin dry.
If the skin is always wet,
it's going to predispose somebody to skin breakdown.
>> Also just for general hygiene in community reintegration,
it's not socially acceptable to be smelling of urine
in our society and we don't--
we don't want to be having any incontinence.
We don't want to be interrupting our day.
We want something that's going to be convenient
where our life does not have to revolve
around managing our bladder and staying, staying dry.
Of course we also want to minimize complications.
We want to be doing something that gives us a low rate
of urinary tract infections
because nobody likes feeling sick with one.
And a serious one can really be life threatening.
We want to avoid some problems
that can affect the lower urinary tract,
especially the urethra, some nasty complications
that can happen associated with catheters for example.
And then really the bottom line, we want to prevent loss
of kidney function to whatever degree we can.
So this can happen from recurrent kidney infections,
it can happen from a stone that's up there
that directly damages the kidney.
We want to be avoiding kidney failure.
So what I want when I'm choosing this, I want the simplest thing,
I want it to be convenient.
I want it to be least expensive because that is a consideration.
We want to stay dry, we want to avoid the serious complications.
We also want to avoid the side effects of these treatments
and preserve the kidneys so that your kidneys last longer
than the rest of you.
We don't want people's lives to be shortened
by the kidneys running out of function.
We want the kidneys to last for your entire life.
So people have looked at this and saying,
what gives the lowest rate of complications,
what's the best way to go.
And there is an answer but unfortunately it's one
that we can't really do anything about.
So people with spinal cord injuries
who have a pretty much unaffected bladder,
people who have good control don't have abnormal contraction
of the bladder and sphincter but are, you know,
essentially normal control.
Surprise, surprise, they have the lowest rate
of complications, the lowest rate
of urinary tract infections, the lowest rate of forming stones.
So if you have a spinal cord injury and you're fortunate
to have good control over your bladder,
you have a very low rate of complications.
Of course we can't-- we can't do anything to steer people
in that direction if they're not fortunate enough
to have that function.
But then the good news is that as I mentioned at the beginning,
almost all of the other methods give good outcomes
with just a few exceptions.
So I'll start to run through some of the options.
So we'll start with options where no catheter is
in the bladder at all.
So, what I was mentioning there,
just voluntary voiding under normal control.
You might need some medications to sort of tamper
down the activity of the bladder muscle
if it's a little bit so called overactive.
Or there could be involuntary voiding.
So this could just go on spontaneously.
The bladder fills to a certain point, kicks off and empties.
That could be in response to some things
where you're generating a little pressure in the bladder
and that causes it to kick off and empty.
Maneuver is called a Crede, where there are some tapping
on the bladder, or a Valsalva where sort of bear down.
The problem is, these are not recommended.
This is the one thing where it seems
like there are more complications, more problems
that can happen with the kidney.
So it's something that we don't steer people toward.
For example, if the sphincter is not opening correctly
and the bladder is being triggered to squeeze,
that can cause high pressure that can damage the kidneys.
Of course, you know, involuntary voiding.
It will just be incontinence unless you can collect
it somehow.
So, for example in males
where the *** catheter is what would be done
if you are using that method.
Kind of a variation on this, not having a catheter that goes
into the bladder but using a *** catheter.
So this is an option for males having a sphincterotomy,
so the sphincter muscles are cut and opened up
and then this allows the urine to flow out more freely provided
that the bladder does contract.
So some people will just kind of continuously be draining urine.
Sometimes it will fill for a little while
and then the bladder starts contracting and it comes out.
Traditionally, this was done surgically
but there are other options.
This is being done with Botox.
It seems like everything is done with--
you can do anything with Botox these days.
It's not FDA approved for that but most of what Botox is used
for is not FDA approved.
You can put in a stent, so sort of a little steel tube
that will keep things open where the sphincter is.
Urolume was one of the brands that was on the market.
So for any of these to work well,
the bladder has to contract.
If it's a bladder muscle that doesn't really contract, well,
the urine is not going to drain out well and you're going
to be a setup for infections.
There's really no great advantage over having a catheter
in your-- that goes into you all the time, say a Foley catheter,
as far as infections go.
There is infected urine or colonized urine that will come
in through the *** catheter.
It is not a guarantee of not having a urinary infection just
because there's not a tube passing all the way
into the bladder.
And then with the sphincterotomies
and we do see complications.
So, urinary retention can develop over time, the bladder,
in a lot of people just over timet just loses its squeeze
and it's not effectively emptying anymore.
It can be hard to maintain a *** catheter in place.
Some patients will need to have a *** prosthesis put
in really just so there's enough *** there
to keep the *** attached on.
With the surgical sphincterotomies,
they tend to scar down over time and sometimes need
to be repeated because the urine flow is blocked off.
Erectile dysfunction is frequently worsened
by cutting in that area.
Those stents that I mentioned
to pop things open, they can block off.
Tissue can grow, grow into them.
They can move around.
If they have to be taken out, it can be challenging.
These Botox sphincterotomies,
probably 3 to 9 months is how often you would need it repeated
and you'd be going into some urinary retention
by the time it was being repeated possibly.
So not an ideal approach, it's not one
that we pursue quite a bit.
But at other centers it's a method of choice.
Next we'll look at intermittent catheterization frequently known
as ICP, Intermittent Catheterization Program, CIC,
Clean Intermittent Catheterization, I and O,
In and Out Catheterization.
All of these are the same.
What it means is temporarily putting the catheter
into the bladder about every 4 to 6 hours
and when you put it in, you completely drain out the urine.
There's essentially nothing left.
We try to keep the urine volume anytime that you cath less
than 500 which is about as much
as anyone's normal bladder would like to hold.
So of course to do this,
you need to restrict your fluid intake.
Usually around 2 liters per day is what we recommend
or otherwise you might be cathing just too frequently
to make this practical.
Now, this is a preferred method
because it's really the closest thing
to the normal bladder function.
Usually what the bladder is doing is filling, filling,
filling, filling and then it empties all at once.
So that's really what you get
with intermittent catheterization.
And some people actually will maintain pretty sterile urine
with this.
Not everyone.
Some people are colonized very--
you know frequently people are colonized.
The theory why, why you don't get sick,
why you don't get symptomatic urinary tract infection as much.
So, when we empty the urine out,
maybe let's say there's just 1 milliliter of urine left
in there with some bacteria
and then you start filling and filling again.
The bacteria are doing their usual thing, they're doubling
and doubling and doubling but the bladder is filling with more
and more urine, so the bacteria
in there never become concentrated.
You never have concentrated bacteria in there and then
by the time the-- it would be time to cath again,
you empty things out and just leave a small number
of bacteria again.
So, it keeps things under control by clearing it
out all the way and the bacteria just never have a chance
to reproduce enough to get symptoms,
so it's not truly sterile in there.
There are bacteria but it's just not getting to a level
that would give most people symptoms.
Now, to do this yourself,
you need to have enough hand function to be able
to manipulate the catheter, as well as manage your clothing.
So, it said C7 or some people with a C6 level
if you have a motor complete injury,
that's really what's required.
For somebody with a C5 motor level with a complete,
usually will not have enough hand function
to do this your self.
So, you need to do more
than just the catheter very frequently,
so you might need one of these
so called anticholinergic medicines
to relax the bladder muscle
so that it's not contracting so much.
So, commonly used ones, oxybutynin known as Ditropan.
There's a gel form of this
that possibly has less side effects that's been
marketed recently.
I don't have any experience using it in my population.
Tolterodine or Detrol is another choice.
There're a number of medicines that do this.
You can inject Botox into the bladder muscle to relax it.
It's another non-FDA approved use of it.
So, at our center, we recommend doing intermittent cath really
only if it can performed independently.
If you're not able-- if you don't have the hand function
to do it independently,
typically your care needs are pretty high.
You have a lot of need for assistance during the day.
It can be complicated.
If you're going to go out and be working, you've got to arrange
for somebody to be able to come and cath you a couple
of times during the day.
It is an obstacle to being-- to being independent for time
that you're-- that you're up.
So-- and with other methods that give a similar benefit,
it's hard to-- hard to make an argument that this must be done
by everyone, but it's controversial
who it should be done with.
It's not without complications, so the urethra can get narrowed
from passing the catheter through frequently.
Epididymitis in males and infection of part
of the lower urinary tract, but it's not quite as common
as with an indwelling catheter.
>> Hydronephrosis and reflux, essentially urine that's backing
up or the bladder is contracting and the urine is going backwards
up toward the kidneys, it doesn't happen commonly
but we need to monitor for it.
So, because it's the closest thing to normal voiding
and can be maintaining pretty sterile urine,
it's really our goal that everyone should be doing
that provided that you have the hand function to do it
and provided you have the brain function to do it,
that you can remember to do this on schedule,
that you're not going to be letting the bladder fill
up with more than it should,
and that we're not having high pressure and that you're going
to have regular followup to make sure this is working for you.
So, it's potentially the best way to go
but it's not for everybody.
So, now we move to indwelling catheters,
the two types are Foley catheter, one that's going
in just through the urethra, or what's called an SP tube
which stands for suprapubic catheter,
so going in through a hole in your belly going directly
into the-- into the bladder instead of going
in through the urethra.
The advantages, well, this is always a good choice
in the sense that it treats essentially all the problems.
It doesn't matter what the bladder is doing,
it usually doesn't matter what the sphincter is doing,
it will-- it will collect the urine,
it will keep somebody dry.
So-- and it's also, it's a potential for somebody
to be completely independent during the day time.
Once you're set up with this,
even if you have a high level injury,
you could be using an electric leg bag opener to empty
out urine and not need assistance from anybody
for that time that you're up and about and outside.
So it's potentially a good way to go.
But there of course, there are disadvantages.
Having a catheter sitting in the urethra all the time,
it causes erosions, it can cause just some very nasty problems
where urine's leaking where it shouldn't be,
and that's often a reason why we switch to a suprapubic tube.
Just getting the catheter
out of the urethra entirely is often a good way to go if a--
indwelling catheters in the long-term plan.
Now, if you have suprapubic tube placed, it does require surgery.
Sometimes you need to have the bladder neck closed so it has
to be shut so that the urine won't keep leaking
out the urethra.
And you think that might be an easy surgery
but it's actually fairly complicated surgery to do.
It's not a minor procedure to do that.
So with either of these, you do have a bag of urine that's going
to be with you during the time that you're--
that you're, you know, up in your chair
and you have a night bag when you're down in bed.
You have a catheter coming out of your body.
So, some people want to avoid that and that's' enough
of a reason to do something different.
We know that there's an increased risk of bladder cancer
with anyone with an indwelling catheter probably
because of inflammation in the bladder.
And also an increased risk of developing bladder stones.
And there are more infections that need treatment
than doing intermittent catheterization.
So, little question for our talk here.
So males and females, for the purpose of this talk,
so what's the important difference, anyone?
So, it's in the slides.
Yes, the ***.
Females do not have a ***.
And a ***, yes, yes.
You were going to say that.
So, it tends to be something handy when it comes to managing,
managing the bladder and managing the urine.
So, females, unfortunately there's really no good external
collection device that works the same way
that a *** catheter does.
There's more difficulty maintaining continence
because the urethra is longer in a male because of the ***,
because it's going through the prostate,
it's easier for men to remain continent.
In people without spinal cord injuries,
it's women who are more likely to have, have incontinence
because the urethra is short.
And then complications, women get different complications
from having an indwelling Foley catheter for a long time.
The urethra can become dilated.
Put in a larger catheter, it just dilates more.
It can just be a struggle to maintain continence that way,
and that's one reason why a suprapubic tube is actually a
very good option for a woman
who otherwise would be using a Foley catheter.
So, when we get to this choice, what's going to be best
for a patient over the long run?
These are the things we're considering.
So number 1, do they have the hand function
to do intermittent cath independently?
If they do, that's what we're going to try.
That would be the best way to go.
How much mobility does someone need here?
Transferring on to a toilet, is that required
for some of these techniques?
How much of the days is going to be devoted
to bladder management?
What happens if somebody doesn't do a hundred percent
of what we asked them to?
Is it going to cause a problem where it's going
to make them really sick or is this kind of a fail-safe method.
Are they living somewhere that's a very remote location
with no followup around, or are they in an area
where there's a lot of medical care available?
And what's the likelihood that they're going to really benefit
from one of the more complicated more time-intensive techniques?
Or are they going to do-- fine with something that's simpler?
So, that's what we'll consider
when we're making a recommendation on the way to go.
I want to briefly touch on some other surgical options.
There is an artificial urinary sphincter that can be placed
if someone is having trouble with incontinence that's due
to the sphincter being open.
In general, it's a bad idea having any foreign bodies near
the urinary tract in somebody with SCI because they tend
to get infected, but for some people this is a good way to go.
Bladder augmentation is a procedure that's been done
for quite a while and maybe being done a little less
frequently now.
So, this will be for somebody doing intermittent
catheterization and their bladder just cannot hold
enough volume.
You know, even in spite of medications being tried,
it just won't hold enough to make it practical.
What's done is a piece of bowel is sewed
on to the bladder essentially to give it more capacity
so that someone can hold more, more urine.
And then there are number of urinary diversion procedures.
I've kind of categorized these all together.
Let's say a non-continent one would be-- it's a urostomy.
It's essentially the same as someone who has a colostomy
for stool but it's bringing a connection from the bladder
to the outside of the body a large tube
where the urine will just drain out and be collected into a bag.
So, usually this is being used now just
when someone has had major complications
or they're having some-- like a cancer that needs treatment,
it's usually not done as a primary management strategy.
But if problems have occurred, it's something
that we can fall back on.
There's something called a continent catheterizable stoma,
and this is creating a tract
where somebody can do intermittent catheterization
through, but not doing it through the urethra,
putting it in a more convenient position on the belly,
and that's called a Mitrofanoff procedure.
And I've got a drawing here.
If anyone is sitting close, they can see that all of this is
in German and I don't speak German
but I can see the word stoma and navel here.
So, what it's showing is a little tube on the inside made
of part of your insides, bowel or appendix,
that comes out to the outside
and then a catheter would be placed through this
to empty the bladder instead of having to put it
in through the urethra.
I want to mention functional electrical stimulation.
This allows someone to empty without a catheter.
Of course you would need
to either be using a *** catheter or transfer
onto a toilet when the system is turned on.
It was on the market in the US for a fairly short time.
It was called the Vocare system.
A related device has been available in Europe and still is
and it's more than 2,000 people who've had one implanted.
It requires a surgery of course.
This is showing where the stimulator is placed.
They need to cut some of the sensory nerve roots,
the sacral nerve roots, to eliminate a reflex that happens
and then electrodes are put around the motor nerves
that are coming off essentially the sacral roots.
And that's the set up on the system.
And it's pretty easy to use one that it's in.
You have an external stimulator that you need to turn on.
You put it on setting number 1, and that's triggers a type
of stimulation that causes the bladder to empty.
So it sort of squirts the urine
out by giving the bladder an electrical squeeze.
Or you can do a more prolonged squeeze.
It's the same nerves that are going--
same nerve roots going to the bladder and the bowel
and it seems to help speed up the time of bowel care.
So it's a more prolonged squeeze when it's on setting number 2.
They removed it from the US market.
I think mostly based on the fact that they were not selling a lot
of them and it was expensive to be marketing.
One thing that's
under development now is using an electrode
to block those sacral sensory roots so that you wouldn't need
to cut the nerve roots.
Nobody is too keen on having nerve roots cut even
if they have a complete spinal cord injury
if they can avoid it.
And somebody with an incomplete spinal cord injury could
potentially use this, this method.
So it's under development at Case Western in Cleveland
and it really looks promising at this point.
But right now, the device is not on the market.
I mentioned Botox to the bladder a bit earlier.
This is being used more frequently.
So it's not an FDA approved use of it.
It will be done if oral medicines,
anticholinergic medicines just were not relaxing the bladder
muscle enough for somebody to be able to do intermittent cath
and hold enough urine in their bladder.
Up here it's showing 30 different spots
where Botox is injected into the bladder muscle.
It's effective for probably 6 to 9 months.
If it starts losing its effectiveness,
you would start having incontinence.
So, it's not so risky as far as it wearing off.
People would get a sense that they need to have it redone.
So, before we leave urinary management,
just to hit on some numbers here, what's most commonly used?
So I've got males and females over here.
So, suprapubic tube, 10 percent of males, 7 percent of females.
>> This is people who are 5 years out from injury,
exactly 5 years out,
and is people treated in the model systems.
Foley, 10 percent of males, 23 percent of females.
Kind of surprising to me that it's that high in females.
*** catheter, of course zero percent females
since there's no *** as we discussed earlier.
Intermittent catheterization, so a little over a quarter.
Normal voiding, also in that same sort of range.
So, it varies.
It's not everybody using one-- one method.
Different centers prefer different things.
Most centers should be individualizing the choice.
Now, I want to hit on some of the complications
and then the screening tests that we do
to try to pick up on them.
So, start with stones, kidney stones, bladder stones.
It's quite common.
It can happen actually early on.
There's such a great loss of calcium from the body
in the first couple of months after injury
that that can be the main thing forming stones.
Most people, that's not what causes them.
And most people with SCI, it's ones that develop more
in the chronic phase and it relates to infection,
often something called Proteus is the bacteria that does this,
but there's some others that do this too.
They break down the urea, something that's in urine
and it tends to precipitate out and start forming stones.
It's also something that can make people's urine look really
cloudy and milky all of a sudden.
So that stuff just starts gunking up the system
and turning into big stones.
This is a problem because it can be leading
to recurrent infections.
The antibiotics don't really penetrate the inside
of the stone well, so you never really clear
that bacteria out of there.
If they're large stones, they can damage the kidneys.
Smaller stones can move into the ureter and block it.
It can leave a very serious infection behind there.
It needs to be treated as an emergency and have a tube put
in through your flank to drain-- drain out the urine from above
and then go in and treat the stone.
So, it's a very serious complication
and that's a main reason why we're screening for stones.
Hydronephrosis and reflux, these are referring to similar things,
either a blockage of urine or a backwards flow
of the urine up toward the kidney.
And it can be caused by multiple things.
The bladder is contracting a lot
and the sphincter isn't opening, for example.
This diagram on the bottom is just supposed
to show what's happening with the kidney.
It's refilling more and more.
All the fluid is backed up here.
There's less kidney to do any sort of filtering.
So, the treatment is to remove something that's blocking the
system and do whatever you need
to to reduce the bladder pressures.
Bladder cancer, I mentioned earlier.
We know that it's associated with chronic inflammations.
So for example an indwelling catheter,
it still is a fairly low risk.
And it's controversial,
some people do recommend periodic screening,
so putting a cystoscope, a little telescope
up in the bladder and taking a look.
The parts that are controversial is exactly who needs
to be screened, how soon
after injury should you start screening,
and how frequently should you screen if you're going to do it.
These tend to be really aggressive cancers and even
with the yearly screening, you may not catch all of them.
So, even in the course of a year they can go
from a normal bladder to having one that's very advanced.
The fortunate thing is that they're really not common.
So it's something we need to think about
but it shouldn't steer us away from a management solely
because there's an elevated risk of this.
Now, moving to screening test here.
There's some lab tests that we do looking at the kidney,
kidney filtering, imaging tests and then some fancier tests
like urodynamics or cystoscopy.
A bit on the lab tests, there's two things
that are commonly done, so a blood test or serum creatinine.
Creatinine is something that's filtered out by the kidneys.
So if you have a high level of that in your blood,
it means the kidneys are not filtering enough.
The caution really to healthcare providers is
that this could be elevated,
or you could be losing some kidney function even though this
is not very elevated on the test.
It has to do with where the creatinine is coming from
and people having less muscle mass.
What's really important is following this over time
and looking at the older results.
So suddenly it's rising,
that's a sign something is not right with the kidneys.
The creatinine clearance is a test
where we need the blood test done
but then we also collect 24 hours worth of urine.
What we end up estimating is how much filtering the kidneys are
doing over the course of 24 hours or over a minute,
however you want to calculate it.
So, a higher number is better,
the kidneys are doing more filtering.
The problem, and this is some research that we did
at my VA hospital, just to show.
I actually have done research in this area.
By the way, I'm not a urologist, I'm a physical medicine
and rehabilitation doctor but we have done some research on this.
We found so much variability year to year.
This test really didn't seem all that useful.
Somebody could have a normal one
and then it could be almost renal failure and then bump back
up to normal, so we didn't find it all that helpful.
We really look a lot at the blood test
and follow that over time.
So then, imaging tests.
Up on the top here is shown an ultrasound.
What's really nice about this, zero radiation,
it's a risk-free test.
It's very good for picking up on stones that are forming there
and blockage of fluid.
In the middle here is showing a CAT scan.
What's typically done is one that's called CT KUB.
KUB is an x-ray of the kidneys, ureter and bladder,
so it's a CAT scan version of that.
But it's kind of-- with any of these CAT scans,
there's really a whopping dose
of radiation compared to other things.
It might be as much as a 1 in 3,000 chance
of getting a fatal cancer from getting a CAT scan,
so I don't think it's such a hot test for doing
in somebody who's 20 years old, who might be having, you know,
50 of these over the course of their life.
So, it's not our screening test of choice.
If we need to see something in more detail, it's a great test
but I don't think it's great for screening
because of the radiation risk.
And then renal scans, this is a nuclear medicine study
or "nucular" if you're from Texas.
And it's kind of easy, sort of fuzzy pictures down here.
So it gets the-- the stuff that's injected,
it gets filtered out by the kidneys.
They see it in these fuzzy pictures.
And, you know, if there was a big hole in this,
then maybe there's a stone there.
It's not as-- it's not as pretty a picture as the other ones,
but it does give you an index of how much filtering is going
on so it's not-- I'm not saying that it's a bad test,
it's just-- if we're getting imaging, we want a picture,
you know, I think ultrasound is the way to go.
How often should the test be done?
So, there's no-- really no research to say what's the--
what's the best way of doing this,
and I really think it should probably depend on the patient.
We should do individualize it.
If you're having no symptoms, if you have fairly normal control
of bladder, if you have good sensation in your body,
doing it yearly is probably excessive.
If you're having problems, then doing it--
doing it frequently makes sense.
So, there is a VA policy
that essentially tells us everything we're supposed
to be doing bladder care and otherwise.
So what they recommend is a certain group of tests
that are done annually on everyone
with spinal cord injury.
That's nice in black and white and that's basically what we do.
There's a guideline for physicians from the Consortium
for Spinal Cord Medicine,
and what they say is it's usually performed annually,
then they just left it at that.
So, frequently done annually, it's not to say that it has
to be done annually for everyone.
Now, I want to hit infections versus colonization
and urinary tract infections.
So, if someone has a high number of bacteria in their urine,
the way we measure it in the lab, and they have symptoms
that are consistent with infection.
It might be spasticity.
It might be a fever.
We would say that that is a symptomatic infection.
But if you have bacteria in your urine on the test
but have absolutely no symptoms,
we would say that's colonization.
There are bacteria that are living inside the urine.
They're attaching themselves to the inside of the bladder
but they're not causing symptoms.
And if it's colonization, you really shouldn't be treating
that with antibiotics.
You're just chasing your tail.
You cannot maintain sterile urine in everyone.
And in fact, there are some bacteria
that just don't cause any symptoms, and having something
in there that's not giving you symptoms, that's better
than having another bacteria come in there
and then give you-- give you symptoms.
And this is actually a strategy that's being looked at as a way
to prevent urinary tract infections.
It's called bacterial interference
where a specific bacteria would be inoculated into you
and it would just sort of occupy all the real estate
in the bladder, keep anything else from moving in.
If you started to get sick with it,
it's one that would be very easy to treat because it's sensitive
to lots of antibiotics.
And so far, it seems like this is probably going
to be an effective-- effective strategy.
But, you know, keep in mind you know any bacteria that are
in there that are not causing--
causing any symptoms that might be doing the same thing for you.
So, when we're deciding to treat, it's got to be based
on signs and symptoms.
So, systemic infection, you are sick with a urinary infection,
you're feeling lousy, your spasticity has increased,
you're having dysreflexia, dysuria, uncomfortable sensation
when urine is passing, if you have sensation,
not just the change in the appearance and not just based
on the fact that there's something growing out of there.
Now, what about just putting people
on prophylactic antibiotics,
just taking antibiotics all the time?
Well, when people have looked at this in big studies,
it doesn't seem like this is beneficial.
You're selecting out for resistant bacteria
and you'll never maintain sterile urine.
On average, it's not an effective way to go.
Some other prophylactic things that have been looked
at are cranberry tablets, methenamine which turns
into formaldehyde in the bladder.
So, these are all things
that have been used from time to time.
And I'll get to this but it's really trial and error
when it comes to what's going to work
to keep my infection rate down.
>> So just to summarize what I went
through before we hear from our speakers.
So, I really feel like the choice of the way
to manage the bladder for anybody, it's really going
to be individualized considering a lot of factors.
ICP is not automatically the best choice.
Some people do have less infections
when they use something we don't think is necessarily effective
for everybody.
They switch to different type of catheter.
They take prophylactic antibiotics,
some dietary supplement.
So, when people do research on this in a big group of people,
it doesn't seem effective.
But I have certain patients where we found that this works
and something else works for them and that's what we--
what we recommend for that person.
It's just trial and error.
Then for the followup studies,
most people with spinal cord injury should have some sort
of periodic testing of their urinary tract
to detect problems before they become big problems.
But as far as what the testing should be
and how often, that's debatable.
Now, there will be a consumer guide coming very soon.
So it's a companion to that physician guide I mentioned.
Paralyzed Veterans of America will be publishing it.
It's supposed to be out in December 2009.
I just checked with Thomas Stripling from PVA yesterday.
And if you look at www.pva.org, it should be there
under publications some time in the-- in the next few months.
So, I just acknowledge the VA Puget Sound for giving me time
to work on this presentation and then the grant from NIDRR
that also support some of my time as well.
So, that concludes my part of the talk.
Now, I would like to hear from our two panelists.
Who would like to go first?
>> My name is Tammy Wilber and I've been--
I have a spinal cord injury.
I'm a T5 complete, and I was injured when I was 17.
And when I had my car accident, I also lost my right kidney.
So that was a big deal.
Obviously in the presentation he talked a lot about kidneys
and how they can affect your life with a spinal cord injury.
First couple of years after my injury,
I had a lot of problems with cathing.
Considering I have no ***, I had to learn how to, you know,
transfer onto the toilet, try to hit the right hole and--
and it was very frustrating but--
and when I was in the rehab hospital for 2 months,
by the time that I went home, I still was not independent
in cathing my self, which is very frustrating.
And on top of that, I also had an allergic reaction
to a medication called Macrodantin.
And I don't want to scare you from taking it,
but it made my hair fall out.
So when I left the rehab, I had bald spots
on my head and my hair fell out.
I was incontinent all the time.
No medications were working for me.
I wasn't drinking enough because I was just constantly--
as a woman we have smaller bladders
and mine was just completely spastic and--
So basically, a summary for my-- you know, I go back to my senior
in high school and I'm wearing diapers and peeing
in my pants all the time and it was just-- it was such a--
those first couple years was just--
I have said it was just-- it just sucked.
I mean just trying to wake up everyday like 4 hours,
couldn't even get through a night sleep, until I found
out about bladder augmentations.
A friend of mine got--
now I originally grew up in the East Coast, from New Hampshire.
And a friend of mine at Boston had looked
into getting a bladder augmentation.
So after she got her bladder augmentation done,
I kind of want to see-- did a research on it and see how--
how it changed her life.
And so it's a big procedure to get done,
in anyway that's nearly injured.
A lot more women get it than men do, the bladder augmentations,
but what I found is that, for me, it was a big surgery to have
and it's definitely something that you need to research
and make sure that it's going to be right thing.
But they did use part-- a piece of my intestines
to increase my bladder 10 times the size that it was.
They used my appendix to create a canal from a--
so I do have a stoma, I use a catheter,
a straight cath, 14 french long.
And it goes right into my-- and I--
and it just looks like a little second belly button.
And I don't leak out of it.
It kind of works as like a sphincter where once I--
the stoma which is down here insert the catheter
and nothings leaks out of the stoma.
I've heard other people say that they've gotten surgery done.
They've had issues with it.
I've been very lucky.
I'm on no bladder medication.
I am-- I don't leak.
Basically they just kind of rerouted everything,
and so basically I'm kind
of like a guy now, I can pee anywhere.
So, for me [laughter] it's increased my quality
of life a lot better because I mean if I have to,
like I just flew in from Boise.
If I'm kind of spacey tonight, I've been up for hours,
I was in Boise for 2 days for work.
So, I'm really tired but--
you know the biggest thing for me was that I need to figure
out what was going to be the best way for me
to improve my quality of life.
And with that fact that I only have one kidney.
And your kidney, when you do lose a kidney,
your other kidney can function-- it enlarges itself and it can--
it can do the work of two kidneys
but having spinal cord injury, I was really at risk
for bladder infections and I was not drinking enough those first
few years because I was so worried about peeing my pants.
And who wants to do that when you're, you know,
teenagers of 17 or 20.
And so I didn't drink enough water
and I was always dehydrated.
Now, I've-- I have maybe a couple
of bladder infections a year.
I have been hospitalized a couple of times
for kidney infections but that's when I've
like missed the bladder infection
and then it went to my kidney.
So-- but otherwise, I mean it's just really improved my quality
of life.
I-- when I cath, I just--
like I said, I just insert the catheter into my stomach.
I don't have to pull down my pants and transfer
onto the toilet or whatever.
For me, it just works-- it worked great.
I mean I can sleep through the entire night.
People often ask me like how much does your bladder hold?
And basically, well, here is easier way to--
give you a visualization.
I recycle, so I carry one of these around with me
and I can fill up like a bottle and a half of one of these.
Like if I sleep through the night and I drink a lot
of water, then-- and plus who wants-- you know.
One time I was carrying around a urinal and it fell out of my bag
and they're doing a bag check at this [inaudible].
Like I'm never using a--
I'm never using a urinal again 'cause it was just embarrassing
having them go through my bag.
But you know the thing is, is for me as a woman,
it really changed how I was able
to just get around and do things.
I didn't always have to seek out and plan where am I going
to go pee next, you know.
Whether that meant that I was getting up in the morning
and going somewhere, makes traveling a lot easier.
I mean half the time I don't even have to get out of the car.
I could pee in the car, I can--
You know, on long flights if I have to,
I mean I can pee under-- you know I'll just take a--
my jacket or something and person sitting next
to me has no idea except for the fact that they may hear a stream
and go look at me and like, what's that noise?
But it's-- it's-- if anybody is ever looking
into having a bladder augmentation, do your research
on it and definitely research the doctors.
I had one of the best doctors in the country.
He had already-- when I had my surgery done in 1995 or '96,
this was a doctor that had already been doing bladder
augmentations for about 15 years.
I had my surgery done at [inaudible] Hospital.
To do the surgery, it is a big deal because of the fact
that from start to finish, I was on bed rest for a month
and a half and then I ended up-- I did have to--
have a like bag for walks.
I had to heal and-- you know,
it was a big surgery, basically overall.
But then result was that I have--
I'm healthier, my kidney is healthy,
and it's just been great.
>> I'm Todd Stabelfeldt.
I guess that real quick before I start.
I'm German and I'm southern
and your western medicine doesn't really line up with me.
So, I'm just sort of bit stubborn and do my own thing.
So, it's taken me many, many years to figure
out the right physician and the right facility to work with.
And so, I would again sort
of stress what the doctor said here and Tammy.
You got to find the right people to work with you, who can line
up with your quality of care.
So with that being said, I start with a joke.
I've been working out for 9 months.
That's what I do, I write jokes.
So it's all up at delivery
and the joke is simply two quads walk in a bar.
>> Alright, pretty funny.
No? Alright.
It's a quad joke.
You know, you all get it later.
I was paralyzed back in 1987 due to a gunshot wound.
I was 8 years old.
A cousin shot me by accident,
so the result was a C4 complete quadriplegia.
So I can move and feel, you know, from the shoulders up.
Anything else is just, you know, pretty much dead.
Started with the *** catheter approach,
I did that for a number of years and I could talk hours on,
you know, catheters but the bottom line is the ***
catheter added about 45 minutes to my morning routine,
making sure it would stay on correctly.
I also grew up in a really sort of independent household
where I was alone a lot and whatnot
and I just couldn't really rely on people to be around,
you know, to change you know wet pants, et cetera, et cetera.
And then when I got into my business, when I was about 16,
17 years old, most of my life was sitting down with clients
and physicians, you know, and it just doesn't really look good
when you're at a high-end restaurant
and get all your wool slacks are full of ***.
It just, it didn't happen.
And so I need to figure out something.
You know it was-- at that point in my life beginning
to have lots of bladder infections,
had the spastic bladder.
I couldn't really empty it all the way
and did all the different urodynamics and went
through all the urologists
and you know the list was-- went on a while.
It's actually to the point where I could smell just, you know,
the aroma of E. coli versus pseudomonas,
and I could tell the physician which bacteria was in my bladder
and then I could prescribe myself
which antibiotic I should be on.
And then after the 3-day sort of test they would come back with
"Hey, you're actually right," you know, go figure.
So, it was really those things where it begin to--
you know where I had to be always on antibiotics, you know,
sort of full strength and it just was not working.
Multiple urologists had, you know, sort of suggested the--
the sphincterotomy and then when I sort of read into that
and was very concerned about my life and then, you know,
marriage and things like that, and it just didn't line up.
So I got connected with a wonderful urologist
who was trained by the greatest man
who ever lived on this earth.
He was in that field as Michael Mayo, who retired--
trained up a wonderful woman named Elizabeth Miller
who spent some time here at UW but now is at Overlake.
And so, I now see her at the Overlake system,
and she put in a suprapubic catheter which got back
in October of like '07.
And it's been just one huge blessing from that point forward
to retire the-- you know, a dollar 80.
Every time I want the catheter, a 35-dollar bottle of adhesive,
an 18-dollar urine bag.
You know, it was just one of those things where you just go,
this is ridiculous people.
And I found that the SP thing was a huge, huge asset for me.
There were lots to learn, and it took me about 6 months
to get comfortable with my SP tube on, you know,
what's it like now and trying to understand how much water
to drink and, you know, leg bag straps and, you know,
whether it's going to be latex or silicon,
you know what size catheter do I put
in there, et cetera, et cetera.
And then I would say that, you know,
to understand me is I look at--
I look at life as a series of sort of manageable projects
and my life as a whole is a project.
And the different parts that make
up my life were the smaller projects and I use a sort
of a process of elimination, the very objective thinking
to isolate and then resolve a particular issue.
And the bladder for me was
yet this one more particular project to resolve.
And I feel very comfortable with it now.
I'm able to tell if my bladder becoming spastic.
I can tell if I'm symptomatic for an infection
if I need antibiotics for a couple days,
when my SP needs to be change.
You know, I sort of follow a very specific set
of algorithms everyday to make sure
that I'm always doing the same thing.
For me it's always independence, alone time and ensuring
that I'm never going to *** my self due to the fact, you know,
I sit down a lot and work with a lot of folks.
And my whole world this can't be me living a urine trail behind
me when I wheel around.
It's just not acceptable.
>> And now we'll move to some questions.
Any questions for any of us up here?
>> So the question has to do with urethral strictures
and intermittent catheterization.
So it is a relatively uncommon complication.
But it is more common in someone doing that than say somebody
who has a *** catheter on, so just the trauma
of passing the catheter in and out can do that.
So it's not something that most of us should worry about
but people can get some difficulty just passing
the catheter.
Another thing that can happen is a false passage
where the catheter is trying to go a way
that just doesn't go through.
And that can happen
with different bladder management as well.
Usually it can all be sorted out by urologist taking a look
up there with a cystoscope seeing what the problem is
and doing a little-- a little bit of repair.
So just something we need to monitor for, it's just,
I guess my point is
that intermittent cath is not complication free.
So the question is whether there is a medicine like Ditropan
that does the same thing, relax the bladder but doesn't have--
doesn't have side effects.
[ Inaudible Remark ]
>> Yes. So I would say, there is a medicine
that does the same thing without the dry mouth and constipation
and other side effects and that would be Botox,
because it's just acting directly on the bladder
if you put it in there.
The gel looks promising when you read the theory behind it.
It has to do with the way that medication is taken
up by the skin and the way it's processed by the liver
and how it metabolite.
Ditropan is what gives more the side effects.
But I would say time will tell.
The thought was that Detrol would definitely have way less
side effects than Ditropan when you sort
of look closely at the studies.
It seemed to me that they were comparing a sort of a low does
of Detrol with a high dose of Ditropan.
And once you got somebody up on a high dose of the Detrol,
it had its side effects, too.
So that whole class of medicine is the
anticholinergic medications.
It's essentially is the side effect
of the medicine is what we're doing.
The side effect of the medicine is that it relaxes the bladder
so it's that whole group of side effects.
The thought is that it maybe more selective.
And there are host of things that are under development now
with that same goal trying to get more selective
for the bladder and less of the unwanted side effects.
So to be determined, I have no experience using it.
Since it's brand new, it means it's expensive.
If it's expensive then it's not going to be our first line
at the VA especially when there are other alternatives
that are just pennies a day.
But you know, we shouldn't discount, you know,
the side effects even giving people a dry mouth all the time
and having effects on your teeth over the long run.
It's not just, you know, a small inconvenience
to have serious dry mouth all the time from those medications.
So the question is whether there are side effects to Botox.
So rarely when someone has Botox injected somewhere
in their body, we see distant effects from that
where they develop weakness somewhere else.
It's quite rare.
It usually gets, you know, reported in a journal,
here is our interesting patient where this happened.
The FDA recently put out a warning to physicians saying,
"Oh, we think that this does happen maybe a little more
commonly than what, what we thought."
But you know, it's usually just sort of a local side effect,
things that are in that, in that same area
when it's been other parts of the body injecting muscles
in the neck area and getting more weakness than you wanted.
But from the bladder, for its spreading widely
and causing major side effects, that wouldn't be a reason
to be concerned about it.
You know, if anything has side effect from being injected is
that if it's done more than a few times,
the muscle will probably--
the bladder muscle will probably tend to stay weaker
for a little longer and a little longer.
That's what we'd seen when it's injected into limb muscles
to treat spasticity that usually
over time you do get a more lasting effect,
sort of more permanent effect
where the muscle doesn't come back quite as well.
But it's not to say that the bladder will react exactly the
same way.
The bladder is a little different muscle
than the limb muscles the way that it's put together,
so probably a very safe treatment.
It might be that people start getting problems
with antibodies forming overtime especially if it's going
to be injected, you know, that frequently.
But there's more than one type on the market now
and the antibody problem is specific for type.
So the question has to do with what other natural substances
or supplements can be used for preventing--
getting urinary tract infections.
So cranberry juice or especially the cranberry tablets is what's
been looked at the most.
There is a sort of active ingredient in that
that has direct action against bacteria.
The problem, with the plain juice,
is that cranberry juice has so much sugar.
People will just be taking in excess calories right there.
So most people who are finding that effective will switch
to the tablets where it's superconcentrated
with that substance that's active against them.
There is-- That's really the main supplement that's been
studied by western medicine and has some--
some evidence, some evidence for, some evidence against,
is actually the studies done in people
with spinal cord injuries are not all that convincing with--
that it's beneficial on average for everyone.
But as I said, it's really trial and error.
There are some people where, you know,
it sure seems to make a difference.
>> So I'm sure there are other supplements
that have been reported
but really the one that's got the most study is the
cranberry tablets.
Some people take vitamin C to acidify their urine.
That's often done in conjunction with other medicine that needs
to have an acid environment to work.
It's the only other one that really comes to mind
but it's a host of things that are reported
to have beneficial effects.
The question had to do with getting very frequent UTIs,
so that sounds like about 15 a year.
So, hardly off antibiotics before starting again.
So it sounds--
[ Inaudible Remark ]
>> Yeah. So it sounds like a lot
of the most likely things have been tried.
We would, you know, be looking for something that's source
of recurrent infection especially
if it's the same bacteria coming back,
something that might not be apparent
on just the screening test, but a small stone or something
where the bacteria never can clear out entirely.
Some people just tend to have symptoms
with a low grade infection as well and just seem to be more--
it's just more apparent to them when the bacteria are
in the bladder than someone else.
It really tends to be just a trial
and error approach unless there is--
unless we can pinpoint a cause.
You know, it turns out that people's bladders have a
different ability for the bacteria to stick to them.
Some people, the lining is just more sticky.
Other people, the bacteria don't adhere as well.
So it might just be that you're unfortunate
that you're somebody who sticks there.
You know, what I've seen most typically,
I'm not saying this is your case,
but typically someone who's getting treatment
that often once a month or even more frequently than that.
It's often been a misperception by their healthcare provider
or by the patient that any time there's a change
in the appearance of the urine
or any time the bacterial count is above a certain number
that it must be treated.
You know, also for you, maybe you're somebody
who would do well with that approach
of bacterial interference intentionally putting any E.
coli in there that doesn't seem to give people symptoms and see
if that will keep something else out.
That's a great strategy if it turns out that it works
when those studies are done because we wouldn't be running
into this problem with antibiotic resistance.
We could just always use that same bacteria in there
to keep something out.
So, you know, I'd say that's the most promising strategy
but it's not available at this time.
The studies are still coming out now.
>> What about acupuncture?
>> So the question is about acupuncture.
Well, I'm sure there are some people
where it would be beneficial.
It's not something where I've seen any studies
to report on it.
It obviously has effects
that are not very well understood by western medicine.
So you know, in the trial and error approach,
I wouldn't say don't try it, there's no chance it will work.
But I can't point to something that says that it does.
And one UTI a year, we would say that's success.
We would like to see two or less per year would really be ideal.
So you know, three in one year or four in one year,
that doesn't mean failure but, you know,
anything that's starting to be, you know, in that range,
we have to look at what else could be done to try.
The comment had to do with how many--
well, getting supplies approved
and specifically the number of catheters.
So this is really a national decision
that some people pointed
out that the FDA never approved the catheters for reuse
that people have been reusing and lots
of people are getting by, really getting by just fine
on four catheters a month with washing, you know,
washing them out, they'd have their pool of catheters.
They would kind of build up their stock,
clean them out with whatever method was working for them
and seem to be doing fine.
Some people would definitely benefit from single use.
But then people when they pointed out,
these devices aren't really approved that way.
It's a medical device, it's a potential issue
so suddenly a lot of-- a lot
of groups started supplying four or five a day.
And some patients initially refused that saying,
"Where am I going to put, you know,
the 2000 catheters you're sending me for the year?"
And maybe that at some point there is a catheter that's
approved for reuse but somebody will have to do the studies
to show that that's a safe strategy.
But in, you know, much of the world,
catheter reuse is standard and a lot
of people have been taught to do the reuse.
So for most people who reuse does work
but insurers should not be insisting on that at this point
until there is one that's approved for reuse.
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