Abstract

Functional electrical stimulation (FES) in the form of the Vocare System™ can improve bladder emptying and aid bowel evacuation. The use of the Vocare System eliminates the need for urinary catheters enabling the patient micturition on demand. These case reports describe two patients who underwent implantation of the Vocare System™ and experienced episodes of urinary incontinence that were related to the presence of a urinary tract infection (UTI). Clinical evaluation included bladder/bowel history, urinalysis/culture, urodynamic evaluation and Vocare System assessment. After evaluation the outstanding similarity was the presence of a UTI. Both patients were treated with a ten-day course of antibiotic therapy. Following treatment both patients denied any further incontinent episodes. The results of these case reports suggest a possible relation between urinary incontinence and the presence of a UTI. Knowledge of this temporary problem can alleviate frustrations and concerns for both the patient and their healthcare provider.

Introduction/Background

One of the greatest barriers faced by a person with spinal cord injury (SCI) is the loss of bladder and bowel control. Functional electrical stimulation (FES) in the form of the Vocare System™ can improve bladder emptying and aid bowel evacuation. The use of the Vocare System™ eliminates the need for urinary catheters enabling the patient micturition on demand. The Vocare System™ a two channel totally implanted system obtained humanitarian device exemption from the United States Food and Drug Administration in early 1999. Surgical implantation of this device consists of insertion of two extradural electrodes on the anterior sacral roots 2,3 and 4. Electrode leads are tunneled to the abdominal region where they are connected to a receiver stimulator, which is placed subcutaneously in the abdomen. A dorsal rhizotomy is also performed on the posterior roots of 2 through 5. The main advantage for performing the rhizotomy is improved continence and protection of the upper tracts. Following implantation many patients report a marked decrease in the amount of urinary incontinence episodes with the regular use of this system for bladder emptying.

The purpose of these case reports is to evaluate the outcome of two female patients with SCI who have undergone implantation of the Vocare System™ and experienced urinary incontinence episodes that were related to the presence UTI. While there is published data (Creasey 1994) on the possibility of incontinence due to other etiologies there is no published data concerning the effects of UTI on continence following implantation with the Vocare System™.

Methods

Subject A is a 16 year old female with a diagnosis of T6 SCI (ASIA A). She underwent Vocare™ implantation on 4/1/97. Bladder emptying is accomplished with Vocare™ every six hours. Bowel evacuation with Vocare™ is achieved every other day.

Subject B is a 13 year old female with a diagnosis of C7 SCI (ASIA A). She underwent Vocare implantation™ on 8/9/99. Bladder emptying is accomplished with Vocare™ every six hours. Bowel evacuation with Vocare™ is achieved every other day.

A clinical evaluation of both patients included the following: bladder/bowel history (with attention to frequency of bladder emptying and episodes of incontinence) urinalysis/culture, urodynamic evaluation, Vocare System™ assessment for proper function, and radiographic films of the lower spine and pelvis.

Results

Subject A reported urinary incontinence four times a day. Bowel evacuation results were reported to be satisfactory. Subject A denied the use of any newly prescribed medications or over the counter medications. Radiographs of the lower spine and pelvis showed no evidence of breakage. The external control box was found to be functioning properly. Urinalysis revealed greater than 10,000 gram negative rods with bacteria and white blood cells present. No culture report was run due to the low colony count. Urodynamic evaluation revealed evidence of bladder hyperreflexia upon filling at 75 and 86cc’s. A ten-day course of antibiotics was prescribed. The patient was instructed to increase the frequency of bladder stimulation to every four hours as well as monitor post-void residuals after each bladder stimulation. At the two week follow-up Subject A had completed the prescribed antibiotics and reported no further episodes of incontinence. Urodynamic evaluation revealed no bladder hyperreflexia and the bladder was filled to 400cc.

Subject B was evaluated via telephone due to the extreme distance in which she lived. Subject B reported urinary incontinence four times per day. Bowel evacuation results were reported to be satisfactory. The subject denied use of any newly prescribed or over the counter medications. The external control box was found to be functioning properly. Urinalysis and culture revealed greater than 100,000 colony-forming units per milliliter (CFU/ML) along with the presence of bacteria and white blood cells. Urodynamics were unable to be performed as well as radiographic films of the spine and pelvis. A ten-day course of antibiotics was prescribed. The patient was instructed to increase the frequency of bladder stimulation to every four hours as well as monitor post-void residuals after each bladder stimulation. At the two week follow-up Subject B had completed the prescribed antibiotics and reported no further episodes of incontinence. A urodynamic evaluation could not be completed at the follow-up.

Discussion/Conclusions

The results of these case reports suggest a possible relationship between urinary incontinence and the presence of a urinary infection. To date both patients have remained continent since these reports and continue to use the Vocare System™ for bladder and bowel evacuation daily. While most patients who have undergone implantation with the Vocare System™ experience reductions in the episodes of incontinence and urinary tract infections there is still a possibility of urinary incontinence. A urinary infection may cause bladder hyperreflexia thus rendering the patient incontinent. Knowledge of this temporary problem can alleviate frustrations and concerns for both the patient and their healthcare provider. Prompt treatment with antibiotics has proven to restore continence in these cases described. Further research is needed to explore this possible relationship.

References

[1] Creasey G. Electrical stimulation of sacral roots for micturition after spinal cord injury. Urologic Clinics of North America 1994; (20) 3: 505-515.

Acknowledgments:

This project was funded by Shriners Hospitals for Children in Philadelphia, PA. We thank Dr. Michel Pontari for his assistance and insight.