Bladder management is an essential element in the care of over 75% of individuals with spinal cord injury (SCI).¹ Common management strategies include indwelling catheters, clean intermittent catheterization (CIC), surgery (such as bladder augmentation, catheterizable channel or diversion) and external collection devices or volitional voiding. CIC is associated with fewer complications than indwelling catheters, while chronic indwelling catheters are associated with an increased morbidity and mortality risk when compared to other bladder management methods.^2,3 Despite CIC being the gold standard for bladder management for patients with SCI, only about 50% of patients use it as the initial management, and 50% of SCI patients on CIC have been shown to drop out after 5 years.¹ This discrepancy in physician-established goals for this population and the real-world results can be best explained by the differences in bladder-related quality of life seen for each group. A large multicenter cohort study of 1,479 patients from the Neurogenic Bladder Research Group found that patients managed with indwelling catheters or those having surgery had a much higher overall quality of life as compared to those managed with CIC.⁴

So why do patients dislike CIC so much if clinically it is the safest option for them? Turns out this is a rather complex question that encompasses not only clinical and physiological factors, but also psychosocial elements. Physical factors that drive bladder management have been shown to be elevated body mass index, age, female sex, severity of neurological injury and limited upper extremity function, thus requiring caregiver assistance with CIC.^5,6 CIC is significantly more challenging and more time-consuming as compared to an indwelling catheter or surgery due to these physical limitations. Patients with indwelling catheters spend a third of the time on bladder care daily.⁷ CIC can be particularly challenging for female patients and their caregivers as urethral access is more difficult compared to their male counterparts. CIC is time-consuming, particularly for women requiring caregiver assistance and obese women, adding 15–20 additional minutes for each catheterization.⁷

With time, bladder-related quality of life does improve as patients develop social structure to allow for safe and effective bladder management.⁸ For instance, patients develop routines, adapt assistive devices and caregiver relationships that allow them to reliably empty their bladder on a schedule. In the long term, the true drivers of poor bladder-related quality of life are those that cannot be modified and adapted–while a patient may be able to find reliable caregiver support or an assistive device, anatomical limitations relating to gender continue to be an issue. In our study evaluating 753 SCI individuals on CIC who were on average about 10 years from injury, we found that female gender was a persistent driver of poor bladder-related quality of life.⁹ Additionally, patients experiencing complications such as recurrent infections or bowel dysfunction tended to be much less satisfied with their bladder management.⁹ Notably, level of injury, caregiver-performed CIC and upper extremity function did not affect bladder-related quality of life for patients on average 10 years from injury.⁹ These data should be considered to support the decision for early reconstructive surgery, especially in female patients and those experiencing complications, as patients who have had surgery consistently report high bladder-related quality of life.⁴

Effective bladder management is key in maximizing SCI patients’ quality of life after injury. Many factors influence bladder quality of life, and while physical disability and caregiver availability may be important factors in the short term, these can be mitigated with time. In the long term, patient sex and complications such as urinary tract and bowel management ultimately impact the bladder-related quality of life.⁹ Shared decision making should be employed to determine the best bladder management strategy for individual patients, and early reconstructive surgery should be considered for those at high risk for complications or poor bladder-related quality of life.