Patterns of neurogenic lower urinary tract dysfunction management and associated factors among Chinese community … – Nature.com

In the present study, we leveraged LCA to identify the distinct patterns of NLUTD management among individuals with SCI living in the community, and explored the association of latent classes with socio-demographic and disease-related factors. Our findings indicate that almost 82.8% (2582/3120) of community-dwelling individuals with SCI could not fully control their urination and required supplemental methods to manage NLUTD. This prevalence is consistent with previous research on NLUTD in SCI patients3. Given the high prevalence of NLUTD in this population, it is crucial for rehabilitation and urology professionals to provide more attention and interventions.

The LCA results identified a 4-class model. 40.3% of our participants (Class 1) tended to use the urinal collecting apparatus (condom catheter or incontinence pad) for NLUTD management. The multinomial logistic regression showed that urinary incontinence was significantly associated with Class 1. The finding was similar to the study in Denmark, which found the most common combination of the bladder-emptying method was IC and the use of urinal collecting apparatus due to the incontinence not being easy to overcome10. However, the urinal collecting apparatus dominated pattern is too passive which means that patients rely primarily on incontinence to urinate and may bring high risk of UTI and high intravesical pressure4. Persons suffered from urinary incontinence should adjust their medication to control DO, or change the IC protocol to accommodate the increased urine leaks under medical guidance. The urinal collecting apparatus should be utilized as an auxiliary method to combat incontinence rather than being the main approach for NLUTD management.

Class 2 represented 30.7% of the sample consisted of individuals who relied on bladder compression such as Cred or Valsalva maneuver to void. This approach may lead to increased intravesical pressure and bladder outlet resistance due to reflex sphincter contraction4,17, which might cause urological complications such as structural bladder damage, vesicoureteral reflux (VUR), hydronephrosis, and renal insufficiency4,18. Another manually assisted voiding method, triggered reflex voiding, which is not always achievable and the maneuvers are unique to each person and too difficult to master19, showed a low usage rate among participants (13.1%) and was highest in Class 2. This indicates that when individuals are unable to successfully urinate using the triggered reflex, they resort to bladder compression techniques. It is important to note that these manually assisted voiding methods should only be attempted in patients with confirmed safe urodynamic parameters. Due to the associated complications with UUT, these methods are no longer routinely recommended.

Only 19.3% of our participants belonged to Class 3 (IC dominated pattern), who tended to use IC for NLUTD management. As the mainstream NLUTD management method worldwide, IC has a low complication rate and improves continence, leading to greater community participation and decreasing home confinement19. However, our results suggest that the penetration rate of IC remains low in China. Class 4 (IUC dominated pattern) represented 9.6% of our participants. IUC is generally reserved for patients who are unable or unwilling to perform IC and have contraindications to other options like SPIC19. However, in general, IUC should only be used as a last resort due to its high complication rate, including urethral erosion, fistula, epididymitis, and periurethral abscess19.

It is well known that IC is the safest NLUTD management method for patients with SCI in terms of urological complications4. The results of LCA indicated that the majority of community-dwelling individuals with NLUTD after SCI were still using non-recommended NLUTD management methods. Understanding the differences between Class 3 and the other classes will aid in promoting the adoption of IC and reducing the risk of urinary complications among community-dwelling individuals with SCI.

Multinomial logistic regression analysis revealed that impaired hand function and longer duration of SCI were associated with Classes 1, 2, and 4. Apparently, impaired hand function will make it more difficult for persons to self-catheter. For these people, SPIC may be more recommended than IUC, bladder compression, and urinal collecting apparatus in the absence of contraindications because its long-term outcomes are comparable with IC20. Regarding the duration of SCI, due to the late promotion of IC in China, people with a long course of SCI have less access to the IC. Therefore, the standardization process for IC should not be limited to hospitals but extended to community settings.

Unemployment was associated with Classes 1 and 4 compared to Class 3. Compared to urinal collecting apparatus and IUC, IC is more expensive due to the cost of consumed catheters6,21. In Class 1 and Class 2, self-supporting payment for catheterization products was a negative predictor of IC usage. Although some catheters are reused by patients after sterilization and lubrication, IC catheters still impose a significant financial burden on patients7. This suggests that reimbursements for intermittently used catheters could promote the use of IC by individuals with SCI. Despite potential burdens on medical insurance funding, IC remains highly cost-effective as it reduces long-term complications and related healthcare costs6. In Class 2 and Class 4, people would tend to use IC if the urination problems affected their social interaction. As previously mentioned, IC enables greater community participation, making it the best choice for individuals who value social interactions19. The lack of such differences in Class 1 may be attributed to the fact that the urinal collecting apparatus also allows for social continence. Combining urinal collecting apparatus with IC may be a viable solution for individuals who prioritize social interaction but also experience incontinence10.

In Class 2, individuals requiring nursing assistance showed a preference for IC over bladder compression techniques. This may be because people can seek assistance from paramedics with IC in the presence of nursing personnel. Living in northeast China or western China was associated with Class 1 or Class 4, respectively. Western China's socio-economic development lags behind that of eastern China22. Inadequate healthcare spending and material scarcity may explain that the people who lived in western China tended to use IUC compared with IC. However, these factors may not completely account for the increased use of urinal collecting apparatus in northeast China. Other regional differences, such as medical insurance policies, may contribute to this discrepancy.

There are some limitations in this study. First, our study had a cross-sectional design that prevented us from identifying causal relationships between variables. And the bladder emptying method could be changed over time according to the health condition or patients/caregivers preference. In future research, longitudinal data should be collected to determine the causal relationships between these variables and to determine the trajectory of change in bladder management patterns. Second, due to the limited resources and manpower, we had not yet collected comprehensive data on the disease-related factors, such as neurogenic bladder symptom score and catheter-associated UTIs. Future studies should aim to collect this data in order to explore the best management strategies for NLUTD in community-dwelling individuals with SCI. Third, we did not collect the data on the classification of NLUTD and medications. Because the questionnaires in our study were self-reported, considering that the classification of NLUTD is highly specialized, it may be difficult for patients to accurately respond to such specialized data. And the participants in our study were spinal cord injury patients who often take multiple medications. Therefore, these data were not collected in order to ensure the accuracy of the results. Fourth, our study used a convenient sampling method, so generalizations about conclusions need to be made with caution.

In conclusion, the present study identified four classes of NLUTD management patterns in community-dwelling individuals with SCI. The most prevalent pattern was the use of urinal collecting apparatus, while only 19.3% of participants preferred IC. Factors such as impaired hand function, longer time since SCI, and availability of self-supporting catheterization products influenced individuals decision to use IC as their primary NLUTD management method. Those who were bothered by urinary incontinence tended to use urinal collecting apparatus, while individuals who faced social challenges related to urination and retired individuals were more inclined to use IC. These findings can guide tailored interventions aimed at improving NLUTD management in community-dwelling individuals with SCI.

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