Hydrophilic versus non-coated catheters for intermittent catheterization

Hydrophilic catheters for intermittent catheterization and occurrence of urinary tract infections. A retrospective comparative study in patients with spinal cord Injury

BACKGROUND

Neurogenic bladder dysfunction is a major problem for spinal cord injury (SCI) patients not only due to the risk of serious complications but also because of the impact on quality of life. The main aim of this study is to compare the rate of urinary tract infection (UTI) associated with hydrophilic-coated catheters versus uncoated polyvinyl chloride (PVC) catheters among SCI patients presenting with functional neurogenic bladder sphincter disorders.

METHODOLOGY

This was a retrospective cohort study from 2005 to 2020 including adult male or female patients who have an SCI at least more than 1 month ago with neurogenic bladder dysfunction and were using intermittent catheterization (single-use hydrophilic-coated or the standard-of-care polyvinyl chloride uncoated standard catheters) at least 3 times a day to maintain bladder emptying.

RESULTS

A total of 1000 patients were selected and recruited through a stratified random sampling technique with 467 (47.60%) patients in the uncoated catheter arm and 524 (52.60%) in the coated catheter groups. The three outcome measures, namely: symptomatic UTI, Bacteriuria, and pyuria were significantly higher in the group using uncoated polyvinyl chloride (PVC) catheters compared to hydrophilic-coated catheters at the rate of 79.60% vs.46.60%, 81.10% vs. 64.69, and 53.57% versus 41.79% respectively. Males, elder patients, longer duration, and severity of SCI were associated with increased risk of symptomatic UTI.

CONCLUSIONS

The results indicate a beneficial effect regarding clinical UTI when using hydrophilic-coated catheters in terms of fewer cases of symptomatic UTI. Bacteriuria is inevitable in patients with long-term catheterization, however, treatment should not be started unless the clinical symptoms exist. More attention should be given to the high-risk group for symptomatic UTIs.

Urinary Catheters: Materials, Coatings, and Recommendations for Selection

Urinary catheters have been used for more than 3000 years, although materials have changed from wood to silver to rubber. Research continues to try and find the optimal catheter materials, which improve safety and quality of life. Advantages when comparing newer catheter materials are not always obvious but catheters coated with a hydrophilic layer may reduce urethral trauma and the incidence of urinary tract infections. However, extrapolation of the data is limited by lack of end-point standardization and heterogenous populations.

Hygiene management of intermittent self-catheterization using reusable silicone catheters in people with spinal cord lesions: A cross-sectional Internet survey in Japan

OBJECTIVES

To investigate hygiene management and catheter maintenance of reusable silicone catheters for intermittent self-catheterization (ISC) in Japan and examine their relationship with symptomatic urinary tract infection (sUTI).

METHODS

We conducted a cross-sectional Internet survey of people performing ISC using reusable silicone catheters owing to spinal cord lesions in Japan. Hygiene management and catheter maintenance of reusable silicone catheters and the incidence and frequency of sUTI were evaluated. We also examined the significant risk factors for sUTI.

RESULTS

Of 136 respondents, 62 (46%), 41 (30%), and 58 (43%) washed hands with water, washed hands with soap, and cleaned or disinfected the urethral meatus every time or most of the time before ISC, respectively. No significant difference was observed in the incidence and frequency of sUTI between respondents who adhered to these procedures and those who did not. There were no significant differences in the incidence and frequency of sUTI in respondents who changed their catheters every month and in those who changed their preservation solution within 2 days compared with those who did not. In multivariate analysis, pain during ISC, inconvenience of indoor mobility, bowel management problems, and participants' feeling of never having received instruction on catheter replacement were significant risk factors for sUTI.

CONCLUSIONS

There are individual differences in hygiene management and catheter maintenance of reusable silicone catheters, but the influence of these differences on the incidence and frequency of sUTI is not clear. Pain during ISC, bowel management problems, and inadequate instruction on catheter maintenance procedures are factors associated with sUTI.

A scoping review on the impact of hydrophilic versus non-hydrophilic intermittent catheters on UTI, QoL, satisfaction, preference, and other outcomes in neurogenic and non-neurogenic patients suffering from urinary retention

Background

For patients suffering from urinary retention due to neurogenic [e.g., spinal cord injury (SCI), spina bifida (SB), multiple sclerosis (MS)] or non-neurogenic [e.g., cancer, benign prostate hypertrophy (BPH)] causes, intermittent catheterization is the primary choice for bladder emptying. This scoping review compared hydrophilic-coated intermittent catheters (HCICs) with non-hydrophilic (uncoated) catheters in neurogenic and non-neurogenic patients with respect to satisfaction, preference, adverse events, urinary tract infection (UTI), quality of life (QoL), cost effectiveness, pain, and discomfort.

Methods

A systematic literature search was conducted using PubMed, Cochrane Library, Google Scholar, Embase, and available clinical practice guidelines and was limited to systematic reviews/meta-analysis and clinical studies (randomized trials, cohort and case–control studies) published in English between 2000 and 2020. A narrative synthesis was performed, comparing HCIC with non-hydrophilic catheters in each pathology. The articles where critically appraised and weighted according to their level of evidence based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence grading.

Results

Thirty seven original articles and 40 reviews were included. The comparison of HCICs versus non-hydrophilic catheters was well-documented in patients with mixed pathology, SCI, and to some extent SB. The available evidence predominantly indicates better outcomes with HCICs as reported by study authors, particularly, greater UTI reduction and improved satisfaction, cost-effectiveness, and QoL. However, SB studies in children did not report reduction in UTIs. Children complained about slippery catheters, indicating possible touching of the surface during insertion, which may compromise cleanliness of the procedure and affect outcomes such as UTI. Limited studies were available exclusively on BPH and none on MS; however, most studies performed on mixed pathologies, including BPH and MS, indicated strong preference for HCICs compared to non-hydrophilic catheters.

Conclusions

The findings generally support HCICs over non-hydrophilic catheters; however, most studies were fairly small, often used a mix of pathologies, and the conclusions were often based on studies with high drop-out rates that were therefore underpowered. Larger studies are needed to support the general finding that HCICs are the preferred choice in most populations. Additional training in children or redesigned catheters may be necessary for this age-group to fully benefit from the advantages of HCICs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-022-01102-8.

Effects of hydrophilic coated catheters on urethral trauma, microtrauma and adverse events with intermittent catheterization in patients with bladder dysfunction: a systematic review and meta-analysis

Background

Hydrophilic coated catheters are recommended to reduce the side effects of intermittent catheterization (IC) in patients with bladder dysfunction. However, there is lack of Level one evidence to support the use of this intervention.

Search methods

Several electronic databases were systematically searched to evaluate complication incidences for hydrophilic coated (HC) and non-hydrophilic catheters (NHC).

Results

Twelve studies were eligible for inclusion in the review. The meta-analyses exploring microscopic hematuria frequencies (RR = 0.69; 95% CI 0.52–0.90) and urethral stricture frequencies (RR = 0.28; 95% CI 0.13–0.60) showed a lower risk ratio associated with HC in comparison to NHC, whereas gross hematuria was no statistically significant difference in two groups. Subgroup analyses of gross hematuria which was grouped according to "catheterization frequency", "single/multiple catheterization" and "self/other catheterization” were performed and the values of combined RR were also no statistically significant difference.

Conclusions

Compared with non-hydrophilic catheters, the hydrophilic coated catheters have positive significance in reducing the incidence of urethral microtrauma and the urethral stricture. However, more studies are warranted for evaluating effects of hydrophilic coated catheters on the incidence of gross hematuria.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11255-022-03172-x.

The evidence supporting single-use intermittent catheters in people with spinal cord injury

Intermittent catheterization (IMC) is the accepted evidence-based best practice for bladder management in people with voiding dysfunction due to neurogenic bladder. The two methods for performing IMC over the decades since this practice was introduced are reuse and single-use catheters. There are perceived advantages and disadvantages of each method of performing IMC. There is considerable evidence that single-use IMC is associated with better health outcomes, including reduced risk of urinary tract infection, urethral trauma, and quality of life. People performing IMC also indicate a preference for single-use, although there are advantages of reuse that need to be acknowledged. Ideally, further research is needed in this area, particularly around the washing and storage of reuse catheters, as well as an adequately powered multicenter RCT comparing reuse with single-use IMC, but there are numerous challenges associated with progressing this research.

Intermittent catheterization with single- or multiple-reuse catheters: clinical study on safety and impact on quality of life

PURPOSE

Intermittent catheterization (IC) is a proven effective long-term bladder management strategy for individuals who have lower urinary tract dysfunction. This study provides clinical evidence about multiple-reuse versus single-use catheterization techniques and if catheter choice can have an impact on health-related quality of life (HRQoL).

METHOD

A prospective, multi-center, clinical trial studied patients who currently practiced catheter reuse, and who agreed to prospectively evaluate single-use hydrophilic-coated (HC) (i.e. LoFric) catheters for 4 weeks. A validated Intermittent Self-Catheterization Questionnaire (ISC-Q) was used to obtain HRQoL. Reused catheters were collected and studied with regard to microbial and debris contamination.

RESULTS

The study included 39 patients who had practiced IC for a mean of 10 years, 6 times daily. At inclusion, all patients reused catheters for a mean of 21 days (SD = 48) per catheter. 36 patients completed the prospective test period and the mean ISC-Q score increased from 58.0 (SD = 22.6) to 67.2 (SD = 17.7) when patients switched to the single-use HC catheters (p = 0.0101). At the end of the study, 83% (95% CI [67-94%]) preferred to continue using single-use HC catheters. All collected reused catheters (100%) were contaminated by debris and 74% (95% CI [58-87%]) were contaminated by microorganisms, some with biofilm.

CONCLUSION

Single-use HC catheters improved HRQoL and were preferred over catheter reuse among people practicing IC. Catheter multiple-reuse may pose a potential safety concern due to colonization by microorganisms as well as having reduced acceptance compared to single use.

TRIAL REGISTRY NUMBER

ClinicalTrials.gov NCT02129738.

Recent Updates in Urinary Catheter Products for the Neurogenic Bladder Patients with Spinal Cord Injury

Clean intermittent catheterization (CIC) is one of the core elements of neurogenic bladder management in the patients with spinal cord injury and is effective and safe to maintain low intra-bladder pressure and achieve urinary continence. Until now, the most notable development in urinary catheter products for CIC is the introduction of hydrophilic coating. Fortunately, in Korea, the national medical insurance has recently covered the cost for urinary catheters in this patient group. The purpose of this review is to summarize the history of CIC and the recent development of urinary catheter products. From our review, we would like to suggest a way of thinking that is the way forward for the future to improve the implementation of CIC with minimal morbidity.

Intermittent Catheterization and Urinary Tract Infection: A Comparative Study Between Germany and Brazil

PURPOSE

The purpose of this study was to describe and compare factors that affect urinary tract infection (UTI) rates in people with spina bifida (SB) and neurogenic bladder dysfunction before and following initiation of intermittent catheterization (IC).

DESIGN

A quantitative, descriptive, correlational study.

SUBJECTS AND SETTING

The study included people who were from Germany, a high-income nation, and Brazil, a middle-income nation. Brazilian participants were recruited from a public rehabilitation hospital in the state of Minas Gerais. German participants were drawn from different regions of the country. The study sample included 200 participants; participants were either individuals diagnosed with SB and neurogenic bladder dysfunction and using IC, or caregivers of persons using IC for bladder management.

METHODS

Data were collected through a survey questionnaire developed for urological follow-up of SB patients. A translated and validated version of the form was used to collect data in Germany. To evaluate annual episodes of UTI, we considered the number of symptomatic UTI before and after IC.

RESULTS

Participants from Brazil were significantly younger than German patients (median age 9 vs 20 years, P < .001). Brazilians predominately used assisted catheterization (63.0%), whereas most Germans performed self-catheterization (61.0%). Use of IC greatly reduced the incidence of UTI in both groups (mean 2.8 episodes per year before IC vs mean 1.1 episodes after starting IC, P < .001). Women had a higher number of UTI, both before and after IC, but enjoyed greater reduction in UTI after initiating IC than men. Self-catheterization also promoted a greater reduction of UTI than assisted IC (P = .022).

CONCLUSIONS

Intermittent catheterization reduced annual episodes of UTI in both samples despite differences in catheterization technique. Patients practicing and performing self-catheterization achieved a greater reduction than those who relied on assisted IC. Comparative studies among additional countries with varying median income levels are needed to better understand the needs of individuals with SB and their families, and to plan and implement safe nursing interventions.

User perception of a new hydrophilic-coated male urinary catheter for intermittent use

AIMS

This study investigated user perception and adherence related to a hydrophilic-coated urinary catheter (LoFric® Origo™), available for male patients who practice intermittent catheterization.

DESIGN

The study had a prospective observational design, including patients from 19 European hospitals.

METHODS

A total of 416 patients were eligible for the study; 179 experienced catheter users and 237 de novo. Two questionnaires were filled out, one describing background data and a second, 8 weeks later, evaluating catheter features.

RESULTS

The response rate for the second questionnaire was 88% (365 patients). Patients evaluating the new catheter showed a general satisfaction rate of 81% and 72% kept using it. The hygienic grip of the catheter was appreciated by 85% and the foldable feature by 67%. The results show that convenience, ease of use, and hygienic factors are patient-preferred features for a urinary catheter. These factors were confirmed for the evaluated hydrophilic-coated catheter.

Active agents, biomaterials, and technologies to improve biolubrication and strengthen soft tissues

Normal functioning of articulating tissues is required for many physiological processes occurring across length scales from the molecular to whole organism. Lubricating biopolymers are present natively on tissue surfaces at various sites of biological articulation, including eyelid, mouth, and synovial joints. The range of operating conditions at these disparate interfaces yields a variety of tribological mechanisms through which compressive and shear forces are dissipated to protect tissues from material wear and fatigue. This review focuses on recent advances in active agents and biomaterials for therapeutic augmentation of friction, lubrication, and wear in disease and injured states. Various small-molecule, biological, and gene delivery therapies are described, as are tribosupplementation with naturally-occurring and synthetic biolubricants and polymer reinforcements. While reintroduction of a diseased tissue's native lubricant received significant attention in the past, recent discoveries and pre-clinical research are capitalizing on concurrent advances in the molecular sciences and bioengineering fields, with an understanding of the underlying tissue structure and physiology, to afford a desired, and potentially patient-specific, tissue mechanical response for restoration of normal function. Small and large molecule drugs targeting recently elucidated pathways as well as synthetic and hybrid natural/synthetic biomaterials for restoring a desired tissue mechanical response are being investigated for treatment of, for example, keratoconjunctivitis sicca, xeroderma, and osteoarthritis.

Hydrophilic-coated catheter appreciation study in a pediatric population

OBJECTIVE

The objective of the paper was to compare the satisfaction of hydrophilic-coated catheters (HC) (SpeediCath, Coloplast Canada, Mississauga, ON) versus uncoated catheters in a pediatric neurogenic bladder population, in order to identify a target group for HC. The main hypothesis was that our patients, with regard to their limitations, might have difficulties using the HC.

MATERIAL AND METHODS

A comparative prospective study was initiated in one pediatric rehabilitation centre. Out of the 39 patients who tried the HC during a routine clinic visit, 31 patients/parents accepted to participate in a 1-week trial and to answer a satisfaction questionnaire. Their medical records were reviewed for age, neurological disease, intellectual deficit, impaired dexterity and method of catheterization (Mitrofanoff/urethra).

RESULTS

Thirty of the 31 patients answered the satisfaction questionnaire. The median age for the 30 patients was 13.5 years (range 6-20 years). Of these patients, 19 were females (63%), 26 performed self-catheterization (87%), and 6 had Mitrofanoff (20%). Ten children (33%) would be ready to proceed with HC and all 10 children would receive catheterization by the urethra. Of these, 9 were females (90%), 8 used compact-HC (80%) and all were self-sufficient. Patients using compact-HC would continue with this catheter. In the patient comments, males catheterizing per-urethra and patients using a continent stoma requiring long catheters had problems with the excess of lubricant.

CONCLUSION

Most children preferred their usual uncoated catheter and would not change for HC. Female patients catheterizing per-urethra with a compact-HC seem to benefit most from this catheter.

Intermittent catheterization with hydrophilic catheters as a treatment of chronic neurogenic urinary retention

AIMS

Neurogenic bladder can be effectively managed with intermittent catheterization (IC) to improve or restore continence, but there is no consensus on which type of catheter is preferred. Hydrophilic catheters were developed to reduce urethral friction, thereby minimizing trauma and sticking, and making them more acceptable to the patient, and easier and safer to use. The objective of this article was to review the literature on the benefits of hydrophilic catheters in patients with neurogenic bladder.

METHODS

A large body of experimental and observational evidence, including randomized controlled trials, was identified using PubMed.

RESULTS

Compared with plastic catheters that have been manually lubricated with gel, hydrophilic catheters reduce urinary tract infection and microhematuria. Hydrophilic catheters are also associated with high levels of patient satisfaction because they are comfortable to use.

CONCLUSIONS

There is a wealth of evidence, including randomized controlled trials, to support the benefits of hydrophilic catheters in terms of safety and quality of life, especially in men with spinal cord injury. More data are required for spina bifida, multiple sclerosis, and in women. Further research is warranted, especially large-scale and long-term robust comparisons of different types of catheter, and in well-defined and stratified populations.

Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America

Guidelines for the diagnosis, prevention, and management of persons with catheter-associated urinary tract infection (CA-UTI), both symptomatic and asymptomatic, were prepared by an Expert Panel of the Infectious Diseases Society of America. The evidence-based guidelines encompass diagnostic criteria, strategies to reduce the risk of CA-UTIs, strategies that have not been found to reduce the incidence of urinary infections, and management strategies for patients with catheter-associated asymptomatic bacteriuria or symptomatic urinary tract infection. These guidelines are intended for use by physicians in all medical specialties who perform direct patient care, with an emphasis on the care of patients in hospitals and long-term care facilities.

Hydrophilic catheters versus noncoated catheters for reducing the incidence of urinary tract infections: a randomized controlled trial

Cardenas DD, Hoffman JM. Hydrophilic catheters versus noncoated catheters for reducing the incidence of urinary tract infections: a randomized controlled trial.

OBJECTIVE

To test the hypotheses that hydrophilic catheters reduce the incidence of symptomatic urinary tract infections (UTIs) in persons with spinal cord injury on self-intermittent catheterization (IC).

DESIGN

Randomized controlled trial.

SETTING

Community.

PARTICIPANTS

Subjects (N=56) on IC with recurrent UTIs and who met eligibility criteria.

INTERVENTION

Use of hydrophilic catheters for IC.

MAIN OUTCOME MEASURE

Symptomatic UTIs treated with antibiotics.

RESULTS

Of the 56 subjects enrolled, 45 completed the study (22 in the treatment group, 23 in the control group). There were no significant differences in demographics, including sex, between the treatment group and the controls except for more tetraplegic subjects in the control group (P<.05). Seventy-one percent of the treatment group and 52% of the control group were men. The total number of symptomatic UTIs treated with antibiotics was significantly smaller in the treatment group than in the control group (P<.05). Seventy percent of the control group had at least 1 antibiotic treatment episode compared with only 50% of those with the hydrophilic catheter (P=.18). There was no significant difference in the incidence of bacteriuria or symptomatic UTIs among the 2 groups. Level of injury and years with injury were unrelated to symptomatic UTIs, but being female increased the risk of UTIs (P<.01).

CONCLUSIONS

Although there was no difference in the number of symptomatic UTIs in the 2 groups, hydrophilic catheter usage was associated with reduced numbers of treated UTIs as compared with standard nonhydrophilic catheters in persons with spinal cord injury who used self-IC; however, the study is limited by a small sample size. Women on self-IC were more likely to develop UTIs regardless of the catheter type, suggesting that the benefits of the lubrication may be more important in men.

Validity, accuracy, and predictive value of urinary tract infection signs and symptoms in individuals with spinal cord injury on intermittent catheterization

BACKGROUND/OBJECTIVE

To determine the validity, accuracy, and predictive value of the signs and symptoms of urinary tract infection (UTI) for individuals with spinal cord injury (SCI) using intermittent catheterization (IC) and the accuracy of individuals with SCI on IC at predicting their own UTI.

DESIGN

Prospective cohort based on data from the first 3 months of a 1-year randomized controlled trial to evaluate UTI prevention effectiveness of hydrophilic and standard catheters.

PARTICIPANTS

Fifty-six community-based individuals on IC.

MAIN OUTCOME MEASURES

Presence of UTI as defined as bacteriuria with a colony count of at least 10(5) colony-forming units/mL and at least 1 sign or symptom of UTI.

METHODS

Analysis of monthly urine culture and urinalysis data combined with analysis of monthly data collected using a questionnaire that asked subjects to self-report on UTI signs and symptoms and whether or not they felt they had a UTI.

RESULTS

Overall, "cloudy urine" had the highest accuracy (83.1%), and "leukocytes in the urine" had the highest sensitivity (82.8%). The highest specificity was for "fever" (99.0%); however, it had a very low sensitivity (6.9%). Subjects were able to predict their own UTI with an accuracy of 66.2%, and the negative predictive value (82.8%) was substantially higher than the positive predictive value (32.6%).

CONCLUSIONS

The UTI signs and symptoms can predict a UTI more accurately than individual subjects can by using subjective impressions of their own signs and symptoms. Subjects were better at predicting when they did not have a UTI than when they did have a UTI.

Patient experience with hydrophilic catheters used in clean intermittent catheterization

OBJECTIVE

To evaluate patient experience of hydrophilic catheters used for clean intermittent catheterization (CIC).

PATIENTS AND METHODS

Out of 107 consecutive patients on a CIC programme, 100 filled in a questionnaire concerning the hydrophilic catheters they were using for CIC.

RESULTS

Sixty-four out of 100 patients were females and 83 had a neurogenic reason for CIC. The programme was started at median age 4 (range 0-32) years. The handling and sliding properties of the catheters were usually good, although 26% felt that the hydrophilic catheters were too slippery in the hands and 11% felt some sticking during catheter removal. Catheter packages got the most criticism. Pain experiences were rare, although 87 performed CIC through the urethra. In general, there were no differences between brands of catheter (LoFric (Astratech) vs Easi/SpeediCath (Coloplast)), although the patients had preferences.

CONCLUSIONS

Patients have individual preferences, although the technical properties of hydrophilic catheters are in general quite good and similar. As CIC treatment is demanding, the patient is justified in selecting the best catheter for them.

Standard versus Hydrophilic Catheterization in the Adjuvant Treatment of Patients with Superficial Bladder Cancer

INTRODUCTION

The aim of the present study is to compare a hydrophilic catheter to the standard polyvinyl chloride catheter with regard to bacteriological safety and overall comfort in patients undergoing intravesical immuno- or chemotherapy for bladder cancer.

MATERIALS AND METHODS

One hundred patients (80 males, 20 females; median age 65.8 years, range 48-79 years) eligible for intravesical prophylaxis of superficial bladder cancer recurrences were randomized to receive intravesical therapy using a standard catheter (group A, n = 50) or a hydrophilic catheter (group B, n = 50). Urinalysis and urine culture were performed 2 days after catheterization. Comfort during catheterization was assessed by a 5-point visual analogue scale at the end of the first four instillations.

RESULTS

Urinary tract infection (UTI) was detected in 7.4% of catheterizations in group A, whereas it occurred in 3.5% of catheterizations in group B (p < 0.01). Escherichia coli was the most frequent pathogen regardless of the device used. At the end of each of the first four instillations, the mean score for discomfort was significantly higher in group A than in group B (p < 0.001), although catheterization was progressively better tolerated regardless of the device used (both p < 0.005). None of the patients were found to be suffering from orchitis, epididymitis or gross haematuria.

CONCLUSION

Hydrophilic catheters may be used safely and are well tolerated by patients undergoing intravesical immuno- or chemotherapy. The hydrophilic catheter was associated with a significantly lower occurrence of UTI and higher acceptability compared to the standard device. These data should be considered with regard to patient compliance with intravesical therapy.

Long-term bladder management by intermittent catheterisation in adults and children

BACKGROUND

Intermittent catheterisation (IC) is a commonly recommended procedure for people with incomplete bladder emptying not satisfactorily managed by other methods. The most frequent complication of IC is urinary tract infection (UTI). It is unclear which catheter types, techniques or strategies, affect the incidence of UTI. There is wide variation in practice and important cost implications for using different catheters, techniques or strategies.

OBJECTIVES

To compare sterile versus clean catheterisation technique, coated (pre-lubricated) versus uncoated (separate lubricant) catheters, single (sterile) or multiple use (clean) catheters, self-catheterisation versus catheterisation by others, and any other strategies designed to reduce UTIs in respect of incidence of symptomatic UTI, haematuria, other infections and user preference, in adults and children using intermittent catheterisation for incomplete bladder emptying.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 19 June 2006), MEDLINE (January 1966 to June 2007), EMBASE (January 1988 to June 2007), CINAHL (January 1982 to June 2007), ERIC (January 1984 to June 2007), the reference lists of relevant articles and conference proceedings, and we attempted to contact other investigators for unpublished data or for clarification.

SELECTION CRITERIA

Randomised controlled trials comparing at least two different catheterisation techniques, strategies or catheter types.

DATA COLLECTION AND ANALYSIS

Three reviewers assessed the methodological quality of trials and abstracted data. For dichotomous variables, relative risks and 95% confidence intervals (CI) were derived for each outcome where possible. For continuous variables, mean differences and 95% CI were calculated for each outcome. Because of trial heterogeneity, data were not combined to give an overall estimate of treatment effect.

MAIN RESULTS

Fourteen studies met the inclusion criteria; all were small (less than 60 participants). There was considerable variation in length of follow-up and definitions of UTI. Participant drop-out was a problem for several studies. Several studies were more than ten years old and outcome measures varied between studies. Where there were data, confidence intervals around estimates were wide and hence clinically important differences in UTI and other outcomes could neither be identified nor ruled out reliably.

AUTHORS' CONCLUSIONS

Intermittent catheterisation is a critical aspect of healthcare for individuals with incomplete emptying who are otherwise unable to void adequately to protect bladder and renal health. There is a lack of evidence to state that incidence of UTI is affected by use of sterile or clean technique, coated or uncoated catheters, single (sterile) or multiple use (clean) catheters, self-catheterisation or catheterisation by others, or by any other strategy. The current research evidence is weak and design issues are significant. In light of the current climate of infection control and antibiotic resistance, further, well-designed studies are strongly recommended. Based on the current data, it is not possible to state that one catheter type, technique or strategy is better than another.

A Novel Product for Intermittent Catheterisation: Its Impact on Compliance with Daily Life—International Multicentre Study

OBJECTIVES

This study was undertaken to evaluate patient openness to changing and satisfaction with catheters used in intermittent catheterisation (IC) for urinary retention from neurogenic bladder dysfunction, and to compare patient response to conventional catheters and a novel packaged hydrophilic catheter: LoFric Primo.

PATIENTS AND METHODS

Of 409 patients recruited, 378 (283 males, 95 females; mean age: 43.5 yr) completed a 12-d trial of the novel catheter. The diagnoses were spinal cord lesion in 65.6%, multiple sclerosis in 9.6%, spina bifida in 2.3%, and other neurologic conditions in 22.5%; the mean duration of IC was 4.6 yr. Patients evaluated their current catheter at recruitment and the novel catheter after the 2-wk trial by questionnaire. Patient satisfaction was expressed on a Visual Analogue Scale for seven topics covering use and general satisfaction.

RESULTS

Of the 378 patients, 55.2% were happy to continue with the novel device, which was 74% of patients using standard polyvinyl chloride (PVC) catheters and 36% of those using prelubricated PVC (p=0.04). No individual patient factors were found to be significant in catheter choice. For the whole study population "ability to comply with daily life activities" was maintained with the novel product despite handling and general satisfaction being found more troublesome.

CONCLUSIONS

The main finding was that more than 50% of the patients wished to continue with the novel catheter and reported increased satisfaction regarding introduction of the catheter, handling, time spent, perception of IC, general satisfaction, and ability to cope with daily life.

Current Evidence on Intermittent Catheterization

PURPOSE

Intermittent catheterization is a commonly prescribed procedure for people with incomplete bladder emptying not managed by other methods. The most frequent complication of intermittent catheterization is urinary tract infection (UTI). It is unclear what strategies, including sterile vs clean catheters or coated vs uncoated PVC catheters, affect the incidence of UTIs. This systematic review summarizes current evidence on the relationship between sterile single-use catheters or clean reused catheters and the incidence of UTIs.

SEARCH STRATEGY

The Cochrane Incontinence Group trials register, Medline, EMBASE, CINAHL, and ERIC were searched, plus the reference lists of relevant articles and conference proceedings. Randomized controlled trials comparing at least two different products or methods for intermittent catheterization were included.

DATA COLLECTION AND ANALYSIS

Three reviewers assessed the methodological quality of trials and abstracted data.

MAIN RESULTS

Of the 13 trials that met the inclusion criteria on intermittent catheterization protocols, there was considerable variation in length of follow-up, definitions of UTI, and numbers of subjects. Attrition was a problem for several studies, and all were underpowered. Several studies were more than 10 years old, and outcome measures were imprecise, making it difficult to draw conclusions on the benefit of one catheterization method over another.

CONCLUSIONS

There are no definitive studies illustrating that incidence of UTIs is affected by sterile single-use or coated catheters compared to clean reused catheters. However the current research base is weak and design issues are significant. Based on the current data, it is not possible to state that one catheter method is better than another and further research on the topic is strongly recommended.

Patient-perceived discomfort with two coated urinary catheters

Intermittent catheterization is now the preferred method for urethral catheterization of the urinary bladder when an indwelling catheter is not required. Nevertheless, the procedure may cause discomfort or pain. This randomized, prospective study was done to compare patient-perceived discomfort between two commonly used hydrophilic, single-use catheters in women. A total of 196 women referred to the urogynaecology section in the outpatient department were randomized to be catheterized with either a LoFric (n=102) or a SpeediCath (n=94) catheter. Both catheters are hydrophilic, low friction, single-use, disposable catheters. Discomfort was measured using a visual analogue scale (VAS). The results showed no difference in degree of patient-perceived discomfort between the two groups. Median score was 0.75 VAS points in both groups, which indicates little discomfort. Half of all the patients stated that they experienced no discomfort at all.

Disordered control of the urinary bladder after human spinal cord injury: what are the problems?

Spinal cord injury has a profound impact on the storage and voiding functions of the urinary bladder. Loss of autonomic and somatic control mechanisms leads to hypo- or hyperactivity of the bladder wall and sphincters causing problems that range from incontinence to complete loss of the capacity to empty the bladder. This chapter outlines the types of bladder dysfunction that occur after spinal cord injury, their relative prevalence and current practices used to manage the problems. With all the interventions that are available, management of bladder function often still remains a compromise, as the medications and physical interventions available may stimulate or block components of the voiding reflex, but are often not fully restorative in this effort.

Hydrophilic-Coated Catheters for Intermittent Catheterisation Reduce Urethral Micro Trauma: A Prospective, Randomised, Participant-Blinded, Crossover Study of Three Different Types of Catheters

OBJECTIVE

To compare two hydrophilic-coated (SpeediCath and LoFric and one uncoated gel-lubricated catheter (InCare Advance Plus) concerning withdrawal friction force and urethral micro trauma.

METHODS

49 healthy male volunteers participated in this prospective, randomised, blinded, crossover study of three different bladder catheters. The withdrawal friction force was measured, and urine analysis of blood, nitrite and leucocytes, microbiological analysis of urine cultures and subjective evaluation of the catheters were performed.

RESULTS

40 participants completed the study and were included in the analysis. SpeediCath exerted a significantly lower mean withdrawal friction force and work than the gel-lubricated uncoated catheter, whereas LoFric exerted a significantly higher mean friction force than both of the other catheters. The hydrophilic catheters caused less microscopic haematuria and less pain than the gel-lubricated uncoated catheter. Furthermore, 93% of the participants preferred the hydrophilic catheters.

CONCLUSION

Hydrophilic-coated catheters perform better than uncoated catheters with regard to haematuria and preference. SpeediCath, but not LoFric, exerts less withdrawal friction force than InCare Advance Plus.

Influence of bladder management on epididymo-orchitis in patients with spinal cord injury: clean intermittent catheterization is a risk factor for epididymo-orchitis

STUDY DESIGN

Retrospective study, based on cases of spinal cord injury (SCI).

OBJECTIVES

To establish hazard ratios for risk of epididymo-orchitis in SCI.

SETTING

South Korea.

METHODS

A total of 140 male patients injured before 1987 were eligible for this investigation and have been followed up on a yearly basis from January 1987 to December 2003.

RESULTS

The average age at which the lesion occurred was 24.8 years old (range, 18-53). The average time since SCI was 16.9 years (range, 1-37). A total of 34 lesions (24.3%) were complete and 106 (75.7%) were incomplete. Over the 17 years, 39 patients (27.9%) were diagnosed with epididymo-orchitis. Epididymo-orchitis was more common for patients with a history of urethral stricture (66.7 versus 25.2%, P=0.014). We also found that epididymo-orchitis was more common for patients on clean intermittent catheterization (CIC) than with indwelling urethral catheterization (42.2% versus 8.3%, P=0.030). In multivariate analysis, patients on CIC had a 7.0-fold higher risk (odds ratio, 6.96; 95% confidence interval, 1.26-38.53; P=0.026); however, a history of urethral stricture lost statistical significance (P=0.074). For other variables, no positive association with epididymo-orchitis was observed.

CONCLUSIONS

In this study, CIC was an independent risk factor for the development of epididymo-orchitis in patients with SCI. In addition, our findings suggest that urethral stricture may be a contributing factor for the development of epididymo-orchitis in these patients. Correct instructions about CIC are of utmost importance.

Intermittent catheterisation with hydrophilic-coated catheters (SpeediCath) reduces the risk of clinical urinary tract infection in spinal cord injured patients: a prospective randomised parallel comparative trial

OBJECTIVES

To compare the performance of SpeediCath hydrophilic-coated catheters versus uncoated polyvinyl chloride (PVC) catheters, in traumatic spinal cord injured patients presenting with functional neurogenic bladder-sphincter disorders.

METHODS

A 1-year, prospective, open, parallel, comparative, randomised, multi centre study included 123 male patients, > or =16 y and injured within the last 6 months. Primary endpoints were occurrence of symptomatic urinary tract infection (UTI) and hematuria. Secondary endpoints were development of urethral strictures and convenience of use. The main hypothesis was that coated catheters cause fewer complications in terms of symptomatic UTIs and hematuria.

RESULTS

57 out of 123 patients completed the 12-month study. Fewer patients using the SpeediCath hydrophilic-coated catheter (64%) experienced 1 or more UTIs compared to the uncoated PVC catheter group (82%) (p = 0.02). Thus, twice as many patients in the SpeediCath group were free of UTI. There was no significant difference in the number of patients experiencing bleeding episodes (38/55 SpeediCath; 32/59 PVC) and no overall difference in the occurrence of hematuria, leukocyturia and bacteriuria.

CONCLUSIONS

The results indicate that there is a beneficial effect regarding UTI when using hydrophilic-coated catheters.

The ‘no-touch’ method of intermittent urinary catheter insertion: can it reduce the risk of bacteria entering the bladder?

OBJECTIVE

This in vitro model was designed to determine whether using a no-touch method for catheter preparation and insertion would affect the degree of contamination transmitted to intermittent urinary catheters.

SETTING

Northview Laboratories, Northbrook, IL 60062, USA.

METHODS

This was a parallel experimental study conducted in vitro at an independent testing laboratory under Good Manufacturing Practices. Six different models of intermittent urinary catheter were tested in triplicate, in accordance with the manufacturer's Instructions For Use (IFU). Gloved hands were contaminated with a known amount of Staphylococcus aureus or Escherichia coli, preparation for insertion was mimicked according to the manufacturer's IFU. The number of bacteria transferred to the catheter was then quantified using a validated technique. The null hypothesis tested was that the bacterial contamination resulting from handling would be the same for all of the catheters. The primary outcome measure was the amount of bacteria, expressed as colony forming units (CFU), recovered from the catheters. The catheter wrappers were sampled to confirm that active transfer of microorganisms had taken place and nonhandled samples served as the negative controls.

RESULTS

For both test organisms, the number of bacteria recovered from the catheters was significantly lower (P < 0.05) for the catheters featuring the no-touch design (approximately 5 CFU/plate versus 2.1 x 10(2) to 4.4 x 10(2) for the traditional hydrophilic catheters). The bacterial recovery from those catheters with the no-touch design often fell below the nominal detection limit.

CONCLUSION

The results of this study allow the null hypothesis to be rejected; it can be concluded that the no-touch method provides a significant benefit in reducing the potential for external contamination of an intermittent urinary catheter. This result supports the recent recommendations for aseptic intermittent catheterization promoted within the guidelines issued by the European Association of Urologists (EAU).

COMPLICATIONS OF CLEAN INTERMITTENT CATHETERIZATION IN BOYS AND YOUNG MALES WITH NEUROGENIC BLADDER DYSFUNCTION

PURPOSE

We evaluate the risk for urethral lesions and epididymitis in boys with neurogenic bladder dysfunction treated by clean intermittent catheterization (CIC) for a minimum of 10 years.

MATERIALS AND METHODS

The medical records of 28 males with neurogenic bladder dysfunction followed from the start of CIC until the age of 15 to 20 years were reviewed.

RESULTS

CIC had been performed for a median of 16 years (range 10 to 21). Overall CIC was used for 438 years (265 before and 173 after puberty). During 76% of the years a noncoated polyvinyl chloride catheter with lubrication was used and in 24% of years a hydrophilic coated polyvinyl chloride catheter was used. The catheter size was 12C or greater in 43% of the cases. Independence from self-catheterization occurred during 37% of the CIC years. Of the patients 19 experienced at least 1 episode of difficulty inserting the catheter and/or had macroscopic hematuria on a total of 42 occasions. Major urethral lesions were seen on cystoscopy in 7 patients on 9 occasions (5 false passages, 1 superficial recess, 2 meatal stenoses, 1 urethral stricture). Major urethral lesions were not associated with puberty and did not occur during self-catheterization or with use of catheters 12C or greater. Epididymitis was seen in only a 12 year-old boy.

CONCLUSIONS

The overall rate of complications was low. The incidence of major urethral lesions did not increase during puberty. Self-catheterization and 12C catheter or greater seemed to be protective against major lesions.

COMPLICATIONS ASSOCIATED WITH CLEAN INTERMITTENT CATHETERIZATION IN CHILDREN WITH SPINA BIFIDA

PURPOSE

Clean intermittent catheterization (CIC) is commonly used in the management of voiding dysfunction associated with neurospinal dysraphism. We determined the incidence of genitourinary complications associated with this technique in a population of children with spina bifida.

MATERIALS AND METHODS

The charts of all children younger than 13 years attending a multi-disciplinary spina bifida clinic between 1987 and 2002 were reviewed. Children in whom CIC had been performed for a minimum of 5 years were identified. Catheterization was performed with a polyvinyl chloride catheter and a water-based lubricant. All genitourinary complications that had occurred in this group were recorded. The caregiver of each patient was then contacted by telephone to confirm the accuracy of our data.

RESULTS

There were 32 females and 27 males identified in whom CIC had been performed for a minimum of 5 years. Mean duration of CIC was 10.5 years (range 5 to 15). Of the patients 45 (76%) learned to perform CIC independently at a mean age of 8 years (range 4.7 to 15.3). Two complications were gross hematuria and a false passage in the bulbar urethra. Both complications occurred in males early in the course of CIC, and while being performed by a caregiver. Neither complication was associated with long-term sequelae.

CONCLUSIONS

The incidence of genitourinary complications associated with CIC in children with spina bifida is low. We identified 2 complications during a period of 570 patient-years for an incidence of 3.5 complications/1000 patient-years (95% confidence interval -1.3, 8.3) of observation.

A prospective randomized trial of the LoFric hydrophilic coated catheter versus conventional plastic catheter for clean intermittent catheterization

PURPOSE

We compared the incidence of hematuria, pyuria and clinical urinary tract infection in patients who performed intermittent self-catheterization using a hydrophilic coated LoFric (Astra Tech AB, Mölndal, Sweden) or standard plastic catheter.

MATERIALS AND METHODS

A total of 62 male patients who performed intermittent self-catheterization to manage neurogenic bladder were randomized into 2 treatment groups at 3 American study sites. Outcome measures included urinary tract infection, microhematuria, pyuria and satisfaction rates.

RESULTS

Of the 62 enrolled patients 49 completed the 12-month study. The withdrawal rate was not different in the 2 groups. At the end of the study there was statistically significantly less hematuria in the hydrophilic coated catheter group compared with controls. In addition, there was a significant decrease in the urinary tract infection rate from baseline in the hydrophilic coated catheter group but not in controls.

CONCLUSIONS

Use of the hydrophilic coated catheter by patients on intermittent self-catheterization is associated with less hematuria and a significant decrease in the incidence of urinary tract infections. Therefore, it may be preferable for some patients, especially those with a history of difficult catheterization, urethral trauma or a high rate of urinary tract infection.

How to manage acute urethral false passage due to intermittent catheterization in spinal cord injured patients who refused insertion of an indwelling catheter

PURPOSE

Acute urethral false passage is an important complication of clean intermittent catheterization in spinal cord injured patients. Temporary urethral stenting with an indwelling catheter is generally an excellent conventional therapeutic option to treat patients with acute false passage. However, how can acute false passage be managed in a patient who refuses insertion of an indwelling catheter?

MATERIALS AND METHODS

For 3 years 5 male patients with acute urethral false passage due to catheterization refused urethral stenting because indwelling catheter insertion would prevent sexual intercourse. We placed a nitinol prostatic stent successfully in the false urethral passage in all 5 patients. The stents were left in place for 3 to 6 months.

RESULTS

The stent migrated in 1 patient and it was replaced. During a retention period of 3 to 6 months all patients continued clean intermittent catheterization without any difficulty and achieved sexual intercourse. On urethral cystoscopy we observed that all false passages disappeared without a gross tissue reaction. The stents were then removed without any complications. During a mean followup of 11.8 months (range 4 to 25) none of these patients had another false passage. All continued to perform clean intermittent catheterization without any further difficulty.

CONCLUSIONS

Temporary placement of a removable endourethral stent is a safe and effective method for managing acute urethral false passage in patients on clean intermittent catheterization who refuse insertion of an indwelling catheter. This approach makes further clean intermittent catheterization possible and improves patient quality of life.

Intermittent catheterization: which is the optimal technique?

STUDY DESIGN

Literature review to evaluate the practical techniques used for intermittent catheterization (IC) and intermittent self-catheterization (ISC).

OBJECTIVES

To ascertain the requirements for proper IC and ISC. To evaluate if a best technique exists.

METHODS

Relevant articles on the subject are reviewed.

CONCLUSION

There is a wide variety of materials and techniques applied for IC and ISC. This does not seem to change the practical outcome much if the basic principles are used: good education and training, clean and atraumatic technique, good patient compliance in the long-term. There is neither one best technique nor one best material for IC. Both depend greatly on the patient's individual anatomic, social and economic state.