ORIGINAL ARTICLE Medical and Psychosocial Complications Associated With Method of Bladder Management After Traumatic Spinal Cord Injury Anne P. Cameron, MD, Lauren P. Wallner, MPH, Martin B. Forchheimer, MPP, J. Quentin Clemens, MD, Rodney L. Dunn, MS, Gianna Rodriguez, MD, David Chen, MD, John Horton III, MD, Denise G. Tate, PhD ABSTRACT. Cameron AP, Wallner LP, Forchheimer MB, Clemens JQ, Dunn RL, Rodriguez G, Chen D, Horton J III, Tate DG. Medical and psychosocial complications associated with method of bladder management after traumatic spinal cord injury. Arch Phys Med Rehabil 2011;92:449-56. Objectives: To determine the relationships between bladder management method and medical complications (renal calculi or decubitus ulcers), number of hospital days, and psychosocial factors. We hypothesized that indwelling catheterization would be associated with more complications, more hospitalizations, and worse psychosocial outcomes compared with other bladder management methods. Design: Inception cohort study. Setting: Model spinal cord injury (SCI) centers funded by the National Institute on Disability and Rehabilitation Research from 1973 to 2005. Participants: Persons with new traumatic SCI (N=24,762) enrolled in the National SCI Database entire data set forms I and II. Patients were stratified according to the bladder man- agement method recorded at each time of data collection into 1 of 4 groups as follows: indwelling catheterization, spontaneous voiding, condom catheterization, and intermittent catheteriza- tion. Those who reported no management method or errors in reporting were excluded (n=1564). Interventions: Not applicable. Main Outcome Measures: Medical complications, includ- ing pressure ulcer number and grade of worst ulcer, kidney stones, and hospitalizations, as well as psychosocial factors (satisfaction with life, perceived health status, societal partici- pation), were stratified by bladder management method. Re- sults were adjusted for level and completeness of neurologic injury and other confounding and modifying factors. Results: Compared with other forms of bladder manage- ment, use of an indwelling catheter was associated with more pressure ulcers and longer and more hospitalizations for all causes and urology-specific causes. Indwelling catheter use was associated with the lowest levels of participation, but similar satisfaction with life and perceived health status. Conclusions: Indwelling catheterization was associated with more medical complications and lower levels of participation than other bladder management methods, but more research is required to ascertain the causality of these complications. Key Words: Catheters, indwelling; Pressure ulcer; Quality of life; Rehabilitation; Spinal cord injuries; Urinary bladder, neurogenic. © 2011 by the American Congress of Rehabilitation Medicine W ITH IMPROVED MEDICAL CARE, persons with SCI are surviving at 70% to 92% of average life expectancy. 1 Therefore, the choice of bladder management and its impact on long-term medical outcomes and quality of life have become increasingly important. Published guidelines regard clean or aseptic IC as the criterion standard for bladder management if the patient is able and willing to perform the task. 2-4 Use of IC typically has been associated with fewer bladder calculi, 5 urinary tract infections, and urethral complications 6-10 and a lower risk for bladder cancer 11,12 than observed with indwelling cath- eterization. However, some studies have found little differ- ence in complications between various bladder management approaches, 13-15 and a recent Cochrane review 16 of catheter management in patients with neurogenic bladder could not find evidence robust enough to suggest one form of man- agement instead of another. Few studies have focused on the relationships of bladder management to psychosocial well-being in patients with SCI. These studies also often are limited by small sample size, inadequate outcome measures, and sample bias. A number of investigators have studied factors leading to psychosocial adjustment after SCI, with some focusing on losses related to bladder function, satisfaction, complica- tions, and mortality. 17-19 Most studies found depression to be related to urologic complications. Hicken et al 20 reported improved life satisfaction in patients with SCI who voided without the use of devices; however, other investigators have found little difference in patient satisfaction with an From the Departments of Urology (Cameron, Wallner, Clemens), Epidemiology (Wallner, Dunn), and Physical Medicine and Rehabilitation (Forchheimer, Rodriguez, Tate), University of Michigan, Ann Arbor, MI; Rehabilitation Institute of Chicago, Chicago, IL (Chen); and University of Pittsburgh, Pittsburgh, PA (Horton). Supported by the National Institute on Disability and Rehabilitation Research (grant no. H133N060032). A commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a financial benefit on the author or one or more of the authors. Clemens is an investigator and consultant with Pfizer and Lilly, a consultant with investment interest at Merck, and a proctor at Medtronic. Reprint requests to Anne P. Cameron, MD, 2875 Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI, 48169, e-mail: annepell@med.umich.edu. Published online January 31, 2011 at www.archives-pmr.org 0003-9993/11/9203-00100$36.00/0 doi:10.1016/j.apmr.2010.06.028 List of Abbreviations ASIA American Spinal Cord Injury Association CHART-SF Craig Handicap Assessment and Reporting Technique Short-Form CI confidence interval IC intermittent catheterization NSCIDB National Spinal Cord Injury Database OR odds ratio SCI spinal cord injury SWLS Satisfaction With Life Scale 449 Arch Phys Med Rehabil Vol 92, March 2011