Q. I’m 28, in my fourth year as a C5-6 quad and have had a suprapubic catheter since rehab. It works well, so I thought it enabled me to dodge taking anticholinergic drugs like Ditropan that control bladder spasms. At a recent SCI support meeting, I heard that long term use of an indwelling catheter causes permanent bladder shrinkage and that bladder spasms makes this worse. The discussion also brought up two equipment options, a “dual-balloon” Foley called the Duette, and a catheter valve called the BioFlo that can help reduce bladder shrinkage. What can you tell me about these two products?
A. According to Paralyzed Veterans of America’s Bladder Management Guidelines for Adults with Spinal Cord Injury, long term bladder management with indwelling catheters — urethral or suprapubic — tends to cause decreased bladder compliance (elasticity and size), which is irreversible and can cause other problems, including formation of stones, reflux and an increase in UTIs. The guidelines say that regular use of medication to manage bladder spasms may be associated with better bladder compliance. The Duette and BioFlo are newer indwelling management methods that may help mitigate bladder shrinkage, but are not mentioned in the guidelines.
To understand how indwelling catheter use affects the bladder, I turned to Dr. Michael Kennelly, director of urology at Carolinas Rehab in Charlotte, North Carolina. He explains that a normal bladder expands as it fills with urine and contracts when it empties. When this cycle is interrupted by nerve damage (as with SCI), it can still expand and contract if managed with intermittent catheterization. But with an indwelling catheter, rather than expanding, the bladder stays contracted around the Foley balloon. Over the course of 15-25 years, it loses elasticity and shrinks. “We still aren’t sure of the exact mechanism that causes this, but we suspect it is a combination of bladder spasticity and irritation resulting in inflammation that, over time, leads to loss of bladder capacity and causes it to become fibrotic — scarred — and scar tissue doesn’t stretch.”
The good news is that incorporating methods to minimize bladder spasms, as well as bladder irritation, which leads to inflammation, can help mitigate the bladder shrinkage associated with long term indwelling catheter use.
“Even though an indwelling catheter is ‘free-flowing,’ it is still important to manage bladder spasticity,” says Kennelly. Fortunately, there are a variety of newer medications to quiet the bladder that don’t have the detrimental side effects of older anticholinergics, like Ditropan (oxybutynin). “I discuss managing bladder spasticity with my patients that have indwelling catheters. A lot of them have found that Botox therapy is beneficial to them.” In addition to helping mitigate bladder shrinkage and fibrosis, Botox quiets the bladder and helps eliminate leakage at the urethral or suprapubic opening.
Make sure to leave some slack in your extension tubing and properly secure it with straps to avoid any tension. Pulling on a Foley catheter will cause the balloon to scrape against the bladder wall and can trigger bladder spasms and cause inflammation. Also, if a Foley is chronically tight, it can cause pressure necrosis — skin breakdown. And be mindful that extension tubing doesn’t get tugged or pulled during transfers. This is especially important for people with higher level injuries relying on attendant help for transfers to secure their extension tubing and collection bag before, during and after the transfer, explains Kennelly.
Another source of inflammation is the catheter itself. “This is where a new type of Foley catheter called the Duette seems to help preserve the bladder,” says Kennelly. The Duette, made by Poiesis Medical and introduced in 2014, has a dual-balloon design (the second balloon inflates over the catheter tip, and along with the primary balloon creates a small, protected area around the lumens — catheter drain holes). “With an indwelling system, the collection bag sits lower than the catheter, creating negative pressure and suction in the bladder. In a standard Foley, the suction can pull the fragile lining of the bladder into the lumens, which causes polypoid cystitis — elongations of the bladder — which are areas of inflammation.”
The Duette’s dual-balloon design reduces inflammation by preventing the bladder wall from contacting the lumens and protects the bladder wall from contact with the catheter tip. An 11-month-long study (see resources) concluded that using the Duette Foley catheter reduces trauma to the bladder wall and reduces UTIs, compared to traditional Foley catheters. Duette Foley catheters are covered under Medicare. Online retail prices range from $12.70 to $16.99 per catheter.
Another product that can reduce inflammation is the BioFlo AutoValve (see resources), explains Kennelly. The AutoValve fits into the drain end of a Foley tube and has a magnetic closure valve that lets 20 cm of pressure (approximately 20 ml of urine) build up in the bladder; then the magnets separate and allow the bladder to empty. “By allowing fluid to build in the bladder, the system prevents the Foley balloon and tip of the catheter from rubbing against the wall of the bladder, which helps avoid inflammation,” says Kennelly. Another benefit of the BioFlo AutoValve is its Quick Disconnect, which includes a spring-loaded closure that snaps shut when changing collection bags, making it a closed system that keeps out bacteria. Studies show this reduces UTIs. BioFlo General Manager Eric Freer says BioFlo systems are reimbursable under Medicare. Suggested retail for the AutoValve is $198. Freer adds that BioFlo has a hardship program for people on limited budgets (contact the company for info).
Another option from BioFlo is the ActiValve, a small manually-operated flip-to-open drain valve that can be operated with limited hand function and connects to the AutoValve. This gives the user the option to “cycle” — go without a leg bag and let the bladder fill, then drain it on a schedule, similar to an intermittent cathing schedule. Kennelly says there haven’t been any long-term studies on bladder cycling, but it is reasonable to project that it will preserve bladder capacity since it mimics the bladder’s expanding and contracting with intermittent cathing. He cautions that bladder cycling should only be done under the guidance of a urologist, and only after a full urodynamic study to test for volume, control of bladder spasms — from Botox or other medication — and some type of “body clue” that lets a person know it’s time to drain (not autonomic dysreflexia). If a person doesn’t have a body clue to tell if their bladder is getting full, they would need to have a naturally large bladder capacity and the commitment to empty every three hours. They must also have the ability to release the drain lever and be highly motivated to do so on a regular basis. Suggested retail for the ActiValve is $25.
A word of warning: Kennelly says that bladder cycling should never be done without a thorough evaluation and discussion with your urologist. Never clamp or plug a Foley for more than 20 minutes without this discussion. Doing so can cause severe problems, including autonomic dysreflexia and permanent kidney damage.
“I customize volume recommendations and times between drainage for every person based on their urodynamic study,” he says.
• BioFlo, bioflo.us
• Duette Foley Catheter, poiesismedical.com/products/duette/
• Duette study, Journal of Urology, jurology.com/article/S0022-5347(16)01063-6/pdf
• Para/Medic: Bioflo, A New Option for Indwelling Catheter Users, newmobility.com/2015/03/bioflo-indwelling-catheter/
• Para/Medic: Options to Manage Bladder Spasms, newmobility.com/2015/05/manage-bladder-spasms/
• PVA Bladder Management Guidelines, pva.org/media/pdf/CPGBladderManageme_1AC7B4.pdf
Editor: In response to readers’ concerns, New Mobility’s policy is to disclose author-product relationships when appropriate. Accordingly, NM senior correspondent Bob Vogel works twice annually at an Abilities Expo booth in California promoting Peristeen, a bowel management product made by Coloplast, which also makes urological and ostomy products.