Bladder management for patients with spinal cord injury (SCI) is of utmost importance since bladder dysfunction represents a major physical and psychological problem (1).
The primary aim of this study was to outline the different choices of bladder management during the acute and rehabilitation phases, and at the time of discharge. The secondary aim focused on gathering information regarding bladder emptying in patients with SCI with regards to gender, level of injury and cause of injury.

This was a descriptive, multicentric and international prospective observational study based in Italy and Spain, that took place between May 2018 and August 2020. Here, we present data concerning Italian patients only. The study design was approved by the local Ethical Committees. Centers involved in the study had a homogenous distribution in the territory.
Inclusion criteria comprised (1) first access to the spinal unit (SU) for patients with any traumatic or non-traumatic cord injury in the acute phase; (2) first access to the SU for patients with any traumatic or non-traumatic cord injury and who come from another unit or hospital but have not yet started any type of rehabilitation treatment; and (3) signed informed consent. Exclusion criteria included (1) coming from another SU and having already started a rehabilitation process; (2) having mental or consciousness alterations (e.g., severe brain trauma); and (3) other factors that are grounds for exclusion by the investigator's judgment.
Clinicians were asked to fill two questionnaires – the first, during the hospitalization of their patient (M1) and, the second, on discharge from the SU (M2). M1 assessed general patient information, date and duration of admission, etiology of injury, complications, bladder management, Spinal Cord Independence Measure (SCIM III scale) and clinicians’ expectations on the patients’ bladder management method at discharge time. M2 assessed general patient information, complications during hospitalization, functional independence measurement (SCIM III scale) and bladder management.
Lesion degree was assessed using the American Spinal Injury Association (ASIA) motor score, which ranks spinal injury from A (complete sensory or motor function loss below the level of injury) to E (normal sensation and motor functions).

A total of 123 patients were recruited; 85 (69.1%) were men. Mean age was 53.2 years. Lesion etiology was traumatic in 81 (65.9%) cases (62 males [76.5%]), and medical in 42 (34.1%) cases (23 men [54.8%]). Dorsal lesions were found in 58 (47.2%) cases, while 64 (52.8%) cases were cervical and lumbosacral. In total, 57 patients had a complete (ASIA A + B) lesion (14 cervical, 35 dorsal, eight lumbosacral), while 64 (32 cervical, 23 dorsal, nine lumbosacral) had just an incomplete (ASIA C + D) lesion. Upon arrival at the SU, 116 patients (94%) used indwelling catheter, two did not need any device and four had other forms of bladder management. Clinician expectation for bladder management at discharge was intermittent catherization (IC) for 83 patients (68%), indwelling catheterization for 15 (12.3%), spontaneous urination for 12 (9.8%), condom catheter for 8 (6.6%) or other forms of management for 4 (3.3%). In total, 79 (64.2%) patients started the IC regimen during hospitalization. On discharge, 53 (43.1%) patients had IC, while 40 (32.5%) had spontaneous urination and 30 (24.4%) had an indwelling catheter. In cervical lesions, patients with spontaneous urination were 23 (50%), 14 (30.4%) had an indwelling catheter, 8 (17.4%) had IC. In dorsal lesions, patients with spontaneous urination were 6 (11.1%), 14 (25.9%) had an indwelling catheter, 34 (63%) had IC. In lumbosacral lesions, 9 (40.9%) patients had spontaneous urination, 2 (9.1%) had an indwelling catheter and 11 (50%) had IC. The relationship between lesion severity and the necessity of urinating-assisting devices is presented in Table 1. Data regarding presence or absence of spontaneous urination and related to age, sex, lesion etiology, level and severity, and SCIM score are demonstrated in Table 2, alongside for IC patients.

Results from this study correlate with epidemiological data and their variations (2). Percentage of males and females is in line with data from literature, which show a ratio male-to-female of 4:1 (2).
Compared to a “best-case scenario”, where ~76% of patients with a SCI and who receive appropriate assistance could potentially perform IC (2), patients on IC are less numerous. This could be explained with both a rise in the number of patients with incomplete lesions who can recover spontaneous voiding, and a rise in elderly tetraplegic patients where methods such as reflex voiding and indwelling catherization are preferrable.
Eventually, no patients in acute phase had a suprapubic catheter. This is in contrast with data from UK, where suprapubic catheter is one of the most-used methods for bladder management (3).

IC is the most used method alternative to reflex voiding or indwelling catherization. The choice for bladder management correlates with lesion level and type, but the role played by age and comorbidities, which are becoming more and more frequent in relationship with the epidemiological variations, may be bigger than that played by level and degree of the lesion.

Tulsky, D. S., Kisala, P. A., Tate, D. G., Spungen, A. M., & Kirshblum, S. C. (2015). Development and psychometric characteristics of the SCI-QOL Bladder Management Difficulties and Bowel Management Difficulties item banks and short forms and the SCI-QOL Bladder Complications scale. The journal of spinal cord medicine, 38(3), 288–302. https://doi.org/10.1179/2045772315Y.0000000030
Zlatev, D., Shem, K. & Elliott, C. How many spinal cord injury patients can catheterize their own bladder? The epidemiology of upper extremity function as it affects bladder management. Spinal Cord 54, 287–291 (2016). https://doi.org/10.1038/sc.2015.169
Savic, G., Frankel, H.L., Jamous, M.A. et al. Long-term bladder and bowel management after spinal cord injury: a 20-year longitudinal study. Spinal Cord 56, 575–581 (2018). https://doi.org/10.1038/s41393-018-0072-4