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Acute urologic management of the patient with spinal cord injury. Initial hospitalization.

The early urologic management of the patient with spinal cord injury can be straight-forward. Intermittent catheterization is the most acceptable therapy until final urologic decisions have been made based on appropriate urodynamic studies. The intermittent catheterization should be aggressive and periodic to empty the bladder, and the patients should be encouraged to do this independently when they are able to. Should any changes occur during this management, such as fever, infection, or dysreflexia, urodynamic studies should be done to identify high-pressure voiding with a high (40-60 cm H2O) leak-point pressure. Then, appropriate therapy should be instituted to lower the bladder pressure, including, initially, anticholinergic drugs and, ultimately, maybe another method such as a sphincterotomy. We usually reserve aggressive invasive therapy for patients whose spinal cord injury has totally evolved and who are rehabilitating, usually no less than 6 months after spinal cord injury, except in severe cases. There is controversy about the initial and long-term treatment of patients with intermittent catheterization, antibiotics, or both. This controversy will continue. Upper urinary tract complications associated with spinal cord injury have been virtually eliminated with better urologic therapy, and the incidence should continue to be negligible if proper therapy is given. Patients who have maintained good bladder management and who are doing well physically with good nutritional habits and medical care since their spinal cord injury will have a much better outcome than those who have more severe urologic and medical problems.