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Effects of long term foley use on bladder capacity

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    Thanks Kimmy

    I've been using the inswelling because I cant manage to independently IC in my chair which makes drinking enough yet still having a life without getting high pressures next to impossible. I was hoping to get a Mitrofanoff this spring but now I have to wait until after I have the baby. Can you independently IC in your chair?

    "Learn from yesterday, live for today, hope for tomorrow"
    ~ Anon
    Emily, C-8 sensory incomplete mom to a 8 year old and a preschooler. TEN! years post.


      sci-nurse...i read that suprapubic is causing cancer and i brought this up to the urologist. he said i was right. so what is the best method?


        DA, I tried to find some papers reporting the incidence of bladder cancer associated with indwelling foley and suprapubic, as well as reasons why they might cause bladder cancer. Groah, et al., (2002) examined 3670 patients with spinal cord injury and who had cystoscopy to rule out bladder cancer. Only 21 cases of bladder cancer were found and a risk analysis suggests a 77 per 100,000 person-year risk of bladder cancer. However, a larger percentage of those who developed bladder cancer used indwelling catheters; approximately 4.9 times greater risk when the population was controlled for age, gender, smoking, and other factors.

        The general population of people with spinal cord injury, however, did not show an increased risk. Pannek (2002) reviewed the charts of 43,561 patients in European SCI centers, finding only 48 cases (0.11%) who developed bladder cancer at a mean age of 22.6 years, at an average of 22.6 years after spinal cord injury. Wall, et al. (2001) suggests that chronic inflammation associated with the catheters may result in the production of nitrosamines that may stimulate bladder cancer.

        Delnay, et al. (1999) biopsied the bladders of 208 patients with indwelling urethral or suprapubic catheters, showing that 23% had premalignant changes and 17% had malignancies. West, et al. (1999) examined the VA databases and found 131 patients with bladder cancer from a population of 33,565 patients with SCI; 43% of the 131 patients had indwelling urethral catheter, 19% had suprapubic catheters, 19% used clean intermittent catheterization, 14% used condom catheters. Vereczkey, et al. (1998) did a multiple risk model and found 31 variables that predicted 9 of 11 cases of bladder cancer; showing that indwelling catheterization for at least 10 years most significantly predicted bladder cancer. In an older study of 81 patients with SCI > 20 years Chao, et al. (1993) found that 6 developed bladder cancer. Of these 6 patients, 2 were spontaneous voiders, 3 had indwelling catheters, and 1 had a mitrafanoff.

        In summary, the data indicate a 3-5 fold increase in risk of bladder cancer associated with urethral catheters. Although suprapubic catheters had a slightly higher risk, at least one study suggests that suprapubic catethers do not pose a much greater risk than condom or intermittent catheterizations. So, given the choice between suprapubic or urethral indwelling catheters, I would choose suprapubic. Given the choice of suprapubic and intermittent catheterization, I would probably opt for the latter.

        • Groah SL, Weitzenkamp DA, Lammertse DP, Whiteneck GG, Lezotte DC and Hamman RF (2002). Excess risk of bladder cancer in spinal cord injury: evidence for an association between indwelling catheter use and bladder cancer. Arch Phys Med Rehabil 83:346-51. Summary: OBJECTIVES: To evaluate whether the risk of bladder cancer is greater in individuals with spinal cord injury (SCI) than in the general population and whether indwelling catheter (IDC) use is a significant independent risk factor for bladder cancer. DESIGN: Historical cohort study in which subjects with SCI were stratified according to bladder management method and followed for the development of bladder cancer. SETTING: A large rehabilitation hospital in the Spinal Cord Injury Model Systems. PARTICIPANTS: A total of 3670 patients with SCI who were evaluated for bladder cancer on at least 1 occasion by cystoscopy over a period of 1 to 47 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Bladder cancer occurring after SCI determined by diagnosis at our facility, by subject report, or by report of next of kin. RESULTS: Twenty-one cases of bladder cancer were found in the 3670 study participants. The risk of bladder cancer for subjects with SCI using IDC is 77 per 100,000 person-years, corresponding to an age- and gender-adjusted standardized morbidity ratio (SMR) of 25.4 (95% confidence interval [CI], 14.0--41.9) when compared with the general population. After controlling for age at injury, gender, level and completeness of SCI, history of bladder calculi, and smoking, those using solely IDC had a significantly greater risk of bladder cancer (relative risk [RR] = 4.9; 95% CI, 1.3--13.8) than those using nonindwelling methods. Mortality caused by bladder cancer in individuals with SCI was significantly greater than that of the US population (SMR = 70.6; 95% CI, 36.9--123.3). CONCLUSIONS: Bladder cancer risk and mortality are heightened in SCI compared with the general population. IDC is a significant independent risk factor for the increased risk of and mortality caused by bladder cancer in the SCI population. Department of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, 751 S Bascom Avenue, San Jose, CA 95128, USA.

        • Pannek J (2002). Transitional cell carcinoma in patients with spinal cord injury: a high risk malignancy? Urology 59:240-4. Summary: OBJECTIVES: To study bladder cancer incidence in patients with spinal cord injury (SCI) in Germany, Switzerland, and Austria. SCI is associated with neurogenic bladder dysfunction. These patients are at an increased risk of developing bladder malignancies. METHODS: A questionnaire was mailed to all SCI centers in these countries. The number of patients with SCI treated between 1995 and 1999, and the data of all patients with SCI with bladder cancer were recorded. RESULTS: The charts of 43,561 patients were reviewed. Of these, 48 patients (0.11%) developed bladder cancer. The data of 8 female and 29 male patients were fully available. The mean age was 53.3 years. Bladder management was reflex voiding in 18 patients, intermittent catheterization in 12 patients, and an indwelling catheter in 7 patients. Twelve patients were smokers. The mean time between SCI and the first bladder cancer diagnosis was 22.6 years. Thirty-two percent had superficial cancers, 8% had carcinoma in situ, and 60% presented with muscle-infiltrating tumors; 81% had urothelial cancer and 19% squamous cell cancer. Thirteen patients rarely had urinary tract infections (UTIs), 9 had more than 10 UTIs annually, and 15 had chronic UTIs. CONCLUSIONS: The bladder cancer incidence in patients with SCI and in the general population is comparable. More than 60% of the patients with SCI, however, initially presented with muscle-infiltrating bladder cancer. Indwelling catheters and chronic UTIs were common in patients with bladder cancer. Immunologic pathologic mechanisms and a prolonged exposure to carcinogens may be involved in bladder cancer carcinogenesis in patients with SCI. Department of Urology, Ruhr-Universitat Bochum, Herne, Germany.

        • Wall BM, Dmochowski RR, Malecha M, Mangold T, Bobal MA and Cooke CR (2001). Inducible nitric oxide synthase in the bladder of spinal cord injured patients with a chronic indwelling urinary catheter. J Urol 165:1457-61. Summary: PURPOSE: Spinal cord injured patients are at increased risk for bladder carcinoma. Nitric oxide production in areas of chronic inflammation may provide a stimulus for carcinogenesis by serving as a source of nitrosating agents that generate potentially carcinogenic nitrosamines from secondary amines normally present in urine. MATERIALS AND METHODS: To determine whether inducible nitric oxide synthase is expressed as a catalyst for sustained nitric oxide production by cellular elements in chronically inflamed bladder mucosa immunohistochemical studies were performed on mucosal biopsies obtained from 37 adults with spinal cord injury. All participants had required a chronic indwelling urethral or suprapubic catheter for greater than 8 years. RESULTS: Histopathological studies revealed active inflammatory infiltrates in all 37 biopsy specimens, squamous metaplasia in 20, epithelial dysplasia in 3 and carcinoma in 1. Inducible nitric oxide synthase was detected in inflammatory cells localized to the lamina propria. Inducible nitric oxide synthase positive cells were identified as macrophages using monoclonal antibodies to macrophage antigen. There was no inducible nitric oxide synthase expression in the urothelial cell layers. Immunostaining for inducible nitric oxide synthase was not detected in bladder mucosal biopsy specimens obtained from cadaveric organ donors. CONCLUSIONS: Inducible nitric oxide synthase is expressed in inflammatory macrophages in areas of chronic inflammation in the bladder mucosa of spinal cord injured patients with a chronic indwelling bladder catheter. The expression of inducible nitric oxide synthase may potentially lead to the sustained production of nitric oxide and its oxidative products, the nitrosation of urinary amines and the formation of potentially carcinogenic nitrosamines in the bladder. Division of Nephrology, Department of Medicine, Veterans Affairs Medical Center, Memphis, Tennessee, USA.

        • Delnay KM, Stonehill WH, Goldman H, Jukkola AF and Dmochowski RR (1999). Bladder histological changes associated with chronic indwelling urinary catheter. J Urol 161:1106-8; discussion 1108-9. Summary: PURPOSE: Chronic urinary catheters induce histological changes in the bladder with time. The exact etiology of these changes is postulated to arise from inflammation and local tissue response. We elucidate the incidence of nonmalignant histological change in bladder biopsies of patients with chronic indwelling urinary catheters. MATERIALS AND METHODS: During 7 years 208 spinal cord injured patients underwent bladder biopsies as part of a surveillance program for vesical malignancy. All patients had chronic (more than 8.5 years) indwelling urethral or suprapubic catheters as definitive management for neurogenic voiding dysfunction. Biopsies were obtained from 4 to 6 sites within the bladder, including areas that were visually abnormal. All samples were routinely fixed with hematoxylin and eosin staining, and interpreted by an experienced pathologist. RESULTS: A total of 17 patients were identified with malignancy, including 10 with squamous cell carcinoma, 5 with transitional cell carcinoma and 2 with adenocarcinoma. Nonmalignant changes occurred in 48 patients (23%) with keratinizing squamous metaplasia or cystitis glandularis, each of which is considered a premalignant lesion. CONCLUSIONS: To our knowledge our study represents the largest group of spinal cord injured patients to undergo biopsy evaluation after chronic catheter use. A spectrum of inflammatory and proliferative pathological conditions were identified, which were predominantly inflammatory and squamous. The need to survey ongoing transitional mucosal changes in this population is underscored by the spectrum of histological abnormalities and the significant occurrence of malignant pathologies in our patients. Department of Urology, University of Tennessee and Veterans Affairs Medical Center, Memphis, USA.

        • West DA, Cummings JM, Longo WE, Virgo KS, Johnson FE and Parra RO (1999). Role of chronic catheterization in the development of bladder cancer in patients with spinal cord injury. Urology 53:292-7. Summary: OBJECTIVES: Patients with spinal cord injury (SCI) and chronic indwelling catheters are known to be at increased risk of bladder malignancy. "Decatheterization" by clean intermittent catheterization, external condom catheterization, or spontaneous voiding is thought to reduce the risk by decreasing the chronic mucosal irritation and rate of infection. We examined two Department of Veterans Affairs (DVA) data bases to test this theory. METHODS: A population-based retrospective analysis of invasive treatments for carcinoma of the bladder in all DVA hospitals was conducted using computerized inpatient files from fiscal years 1988 to 1992. RESULTS: One hundred thirty patients with bladder malignancy were identified from a pool of 33,565 patients with SCI (0.39%). All 130 patients underwent either radical cystectomy (n = 63, 48%) or transurethral resection of bladder tumor (n = 67, 52%). The 30-day perioperative mortality and overall 5-year survival rates were 2 (1.5%) and 49 (38%) of 130, respectively. Of the 130 patients analyzed, 42 (32%) had adequate data available regarding tumor pathologic findings and method of bladder management for analysis. The average age at diagnosis was 57.3 years. The histologic finding was transitional cell carcinoma in 23 (55%), squamous cell carcinoma in 14 (33%), and adenocarcinoma in 4 (10%) of 42. Bladder management was an indwelling urethral catheter in 18 (43%), suprapubic catheter in 8 (19%), clean intermittent catheterization in 8 (19%), and condom catheter in 6 (14%) of 42 patients. Squamous cell carcinoma was more common in patients with indwelling urethral catheters and suprapubic tubes (11 of 26, 42%) than in those using clean intermittent catheterization, condom catheterization, or spontaneous voiding (3 of 16, 19%). CONCLUSIONS: Bladder cancer was diagnosed in approximately 0.39% of this large SCI population during a 5-year period. Most cancers (55%) were transitional cell carcinomas. Squamous cell carcinoma was more common in patients with SCI and indwelling catheters than those without chronic catheterization. These data continue to suggest that avoidance of indwelling catheters, when feasible, is the preferred method of bladder management in patients with SCI. Department of Surgery, St. Louis University School of Medicine, and the John Cochran Veterans Affairs Medical Center, Missouri, USA.

        • Vereczkey ZA, Schmeidler J, Binard JE and Bauman WA (1998). Bladder cancer risk in patients with spinal cord injury. J Spinal Cord Med 21:230-9. Summary: Bladder cancer (BC) is the fourth most common cancer in men. It is associated with several risk factors (RF), of which only a few have been evaluated in previous studies. Models incorporating only one or a severely restricted number of RFs did not predict BC well. We employed 19 a priori RFs and 12 interactions in a multivariate logistic regression analysis for the prediction of BC in a sample of subjects with spinal cord injury (SCI), of whom 149 were outpatients (7 with BC) and 4 were inpatients with BC. We also replicated dichotomous predictions for 10 of the 19 RFs that have been most frequently associated with a higher BC risk in the literature. The overall test for 31 predictors was significant (p = 0.0038). A dichotomized predictor correctly identified 9 of 11 BC cases and all 142 but one of the cases without BC. A more parsimonious subset of 21 predictors satisfied a Scheffe-type multiple comparison criterion. Although duration of SCI satisfied a Bonferroni criterion for statistical significance, it did not satisfy a Scheffe criterion. In the replication studies, only dichotomized duration of indwelling catheterization for at least 10 years significantly replicated the previous findings. Results of this study suggest that using multiple risk factors and interactions in a comprehensive statistical model may provide useful screening of patients with SCI for BC risk. Since early identification of BC substantially improves prognosis, such a model may identify patients at highest risk who are most likely to benefit from bladder biopsy. Department of Medicine, Mount Sinai Medical Center, New York, NY, USA.

        • Chao R, Clowers D and Mayo ME (1993). Fate of upper urinary tracts in patients with indwelling catheters after spinal cord injury. Urology 42:259-62. Summary: Several modes of urinary tract drainage exist for the spinal cord-injured (SCI) patient, but the use of an indwelling catheter is discouraged. We retrospectively reviewed the charts of our traumatic SCI patients followed twenty years or more since initial injury to compare urinary tract preservation and the incidence of urologic complications in patients with neurogenic bladders voiding spontaneously with those using long-term indwelling catheters. Eighty-one patients with long-term injuries were identified; 73 of them fit the study criteria. Forty-one patients voided spontaneously having a balanced bladder or performing intermittent catheterization or have undergone sphincterotomy or vesicostomy, and 32 had indwelling suprapubic or Foley catheters. Renal function measured by creatinine clearance was similar in both groups: 81.3 +/- 20.2 mL/min for spontaneous voiders and 83.7 +/- 24.9 mL/min for catheterized patients. Review of urinary tract imaging and incidence of complications in both groups was very comparable, with the exception that the catheterized group had a higher prevalence of scarring and calicectasis on radiologic imaging of the upper urinary tracts which was statistically significant. Of the remaining population, in 6 of 81 patients, bladder cancer developed, and they underwent radical cystectomy and urinary diversion and 2 had proximal diversion alone. Of the 6 patients with bladder cancer, 2 were spontaneous voiders with transitional cell carcinoma (TCC) developing. Three of the 6 patients had indwelling catheters: in 1 patient TCC developed, in 1 adenocarcinoma, and in 1 squamous cell carcinoma. In 1 patient TCC developed in a defunctionalized bladder after ileal conduit formation. Based on this study, we can conclude that in select groups of SCI patients, the choice of an indwelling catheter may be made if other methods fail, provided patients undergo regular upper urinary tract imaging and cystoscopy. Department of Urology, University of Washington, Seattle.

        [This message was edited by Wise Young on Dec 18, 2002 at 07:42 PM.]


          Considering that cancer often has heriditary and environmental factors (including diet, smoking, etc.) involved, don't these things also neeed to be considered in any study regarding cancer?

          Proofread carefully to see if you any words out.


            well, emi, i had an indwelling for like 3 years before having the mitrofanoff. its not impossible. so have your baby, deal with the indwelling b/c you'll need it at the end of the pregnancy anyway... then after the pregnancy have the mitr.- its easier to deal w/than an indwelling. but after you give birth try not to let it go too long w/the indwelling. i swear to you it'll be a good move. but get a good urologist!


              Long term cathater use 12 yrs has put me in same place. Nurse urged me for a year to get suprapubic cath, then when I said ok, the dr. looked at test and said bladder to small, what do we do now. Getting immuned to drugs, changing cath once a week to avoid infections getting hold. Any suggestions also wanted.


                If the problem is bladder size, then it sounds as though you should look into a bladder augmentation to increase the size of your bladder. That could be combined with a Mitrofanoff procedure, which would allow you to ditch the indwelling catheter and instead intermittent cath through a small stoma that is often hidden in your belly button. Changing from an indwelling cath to IC should also cut back on the number of UTIs you get.

                But to be honest, I don't understand how your bladder can be too small to accommodate a SP catheter if it can handle a urethral catheter. Perhaps the nurse can explain this.
                It is easier to find men who will volunteer to die, than to find those who are willing to endure pain with patience.

                ~Julius Caesar


                  I can report this. After two years of continuous foley drainage, my bladder was down to about 300 cc. After about ten years with a condom cath when it was removed, it was up to about 500 cc. Back in those days, we were all experiments. Hope you benefit from that.
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                    Women have smaller bladders to begin with. Constant draining does not allow the bladder muscle to expand and contract, thus decreasing the size. One reason that doc might have said that is the catheters used with suprapubic's are usually larger in diameter - that with the balloon, and the bladder size, might not allow for a larger catheter.

                    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.


                      Thanks for the feed back on sp cathing and small bladders. My second urologist I see for noncancer tumor in kidney suggested mitrandorf ic but not sure I can do it with limited finger c/4 quad, did read another quads procedure, live in the country have help in morning than by myself 6 hrs, will concider it and will be talking to him just watching tumor to see growth or attaching to other organ, grew 1.5 cent. Thanks Karen


                        What's the typical bladder capacity after 3 years of Foley cath use?

                        I'm trying to determine what is a safe injection volume for cath irrigation.


                          Originally posted by C5Ski09 View Post
                          What's the typical bladder capacity after 3 years of Foley cath use?

                          I'm trying to determine what is a safe injection volume for cath irrigation.
                          This varies widely. Some only have 30-40 cc. of capacity. Why are you irrigating? If for a clogged catheter and you are having AD, the clinical practice guidelines suggest using only 25-30 cc. for this, and if you get no return, repeating no more than twice before changing the catheter instead, since if the irrigant does not drain, you just make things worse by using too much irrigation solution.

                          The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.