Fine Tuning the System


Q: I’m 34 years old and I’ve been a T9 complete para for 14 years. Right after my injury I had trouble with bladder spasms, high bladder pressures and leaking. I tried managing my bladder by balancing a condom catheter and intermittent internal catheterization. That wasn’t working so I had a sphincterotomy. For about two years following the sphincterotomy, things seemed to be fine. I felt healthy, was going to college and playing sports. But a routine ultrasound on my kidneys showed there were problems. A urodynamic test confirmed I had high bladder pressures and kidney reflux.

In 2000 I decided to have a bladder augmentation. Since I didn’t want to deal with taking a condom catheter off each time I needed to cath intermittently, I also decided to have a stoma added to drain the urine from my bladder.

I never understood why my sphincterotomy didn’t work. Now I’m getting tired of having my condom catheter blow off. I’m looking at options to stay dry. Any suggestions?
Josh

A: Josh, your story points out the importance of regular urology follow-up to keep your system healthy. A PubMed search on sphincterotomies suggests that although the surgery is generally effective, problems like scarring can restrict urine flow and require a repeat of the procedure.

As far as options, the first and easiest option is look for an external catheter that stays on. There is a relatively new external catheter on the market called the Liberty manufactured by BioDerm. The Liberty is unique in that it attaches to the head of the penis only, which makes it more discrete, and more importantly it won’t roll or peel off like condom catheters can. In addition, it has a short, relatively stiff neck (the area that the drainage tube fits into) which eliminates the possibility of the neck “kinking” and resulting in “blow-out.” The neck is also short and stiff enough to clean the inside with an antiseptic wipe and insert an internal catheter, eliminating the need to remove the external catheter to do an intermittent cathing procedure. Anecdotally, I use an external catheter for stress incontinence, but still need to cath intermittently four to six times a day. I tried the Liberty system two months ago and haven’t had a single leak or blow-out.

If your goal is to get rid of an external catheter all together, here are a couple of options you may want to run by your urologist. One option is pretty straightforward: You can ask your urologist about having your bladder neck sewn shut. Another option is to inquire about a male sling system. You can check this out online at American Medical Systems, www.americanmedicalsystems.com. The system consists of a “sling” made of synthetic mesh that is surgically placed so the sling puts pressure on the urethra and reduces the possibility of urine leakage. Results of a 2003 study of 12 incontinent men with SCI who underwent the sling surgery at Rancho Los Amigos show eight were fully dry and two more had significant improvement after the surgery. The conclusion is that the procedure can be an effective and safe way to treat urethral incontinence. With either of these procedures, your urologist will want to run a urodynamic test first to make sure your bladder pressures are low enough for these procedures.

Q: I’m a C6-C8 quad who intermittently caths himself. I use the Rusch/MMG closed system where the catheter is contained in a lubricated bag, and the urine drains directly into the bag and I never have to touch the catheter. It works great for me. My problem is sometimes the catheter goes right in and other times it gets “stuck” in my urethra. My urologist suggested I try having Botox injected into my sphincter to eliminate some resistance, making it easier to cath. I am concerned about “reflex voiding” or becoming “free flowing.” I don’t want to use a leg bag, I’m much more comfortable cathing intermittently. I asked my urologist about increased leakage between intermittent caths if I had this procedure, and she said it wouldn’t be a problem. Do you know anybody who has had this procedure who caths intermittently? Have they had an increase in leaking between caths?
— Tim

A: Tim, the folks I know of who have had their sphincters treated in this way did so to enable them to become “free flowing” and ditch the need for intermittent catheterization. They wanted to use an external catheter and leg bag instead.

I ran your question by a physical medicine and rehab doc, and although he hadn’t seen anyone choosing this treatment who still caths intermittently, he said it should be possible by titrating (using the smallest effective amount possible) the Botox injection. Just the right amount should relax the sphincter and still keep you dry. The doc cautioned that at this point, titrating Botox is not an exact science, so there will be no guarantee you will not leak. The good thing about the procedure is the effects are temporary. If you do end up leaking, wearing an external catheter and legbag for six to nine months isn’t a big deal.

Before going the Botox route, you might want to try a different type of internal catheter. When your catheter gets stuck, most likely it is either caught against the sphincter muscle, or the sphincter muscle is clamping in a tight spasm. A wheeler I interviewed for a previous article had the same problem. Jim Munson, 39, has been a T10 para for 20 years. He had used straight catheters for years with no problem. Then he started having trouble getting a catheter past the sphincter. It got so bad his urologist said the only option was to have surgery (a sphincterotomy). By chance he ran into a Coloplast rep who gave him some sample “Speedy Cath” hydrophilic catheters with a Coude tip.  He says the catheter worked great the first time he used it. He called and canceled the surgery, and he has been using the Speedy Cath for years with no problem.

In Munson’s case, the hydrophilic catheter and the Coude tip made all the difference. A hydrophilic catheter is coated with a substance that becomes extremely slippery when water is added. You open the catheter package, add water, wait a few seconds then use the catheter. A Coude is a catheter with a curve at the tip (Coude is French for elbow or curve). In the urethra there is a curve that a catheter needs to make to go around the sphincter muscle. When inserting a Coude, the curve should be pointed “at your chin”; the curve helps the catheter tip navigate around the sphincter muscle and into the bladder. Unfortunately, it is difficult to engineer a Coude tip catheter into a “closed system.” If the Coude catheter works, you may want to switch altogether. Or you may want to keep some Coude catheters on hand for the times when your closed system catheters don’t work. Best of luck, and let us know how things work out.


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