Intermittent catheterization and recurrent urinary tract infection in spinal cord injury

Management of Systemic Anti-psoriatic Drugs in Psoriasis Patients with Concurrent Paraplegia or Tetraplegia: Insights From a 6-Year Multicenter, Retrospective Observational Study

INTRODUCTION

Patients with psoriasis (PsO) and permanent spinal cord injuries (SCI) resulting in paraplegia and tetraplegia may experience a higher rate of infections compared to patients with PsO without SCI. It can result in further challenges for therapeutic management with immunosuppressants (biological and non-biological treatments). Thus,  we aimed to evaluate the rate of infections in patients with PsO and SCI treated with systemic immunosuppressants.

METHODS

This multicenter, retrospective observational study enrolled patients with PsO and traumatic SCI undergoing systemic immunosuppressive treatments for at least 5 years. All patients were evaluated by experienced, board-certified dermatologists and neurologists. Demographic and clinical data were collected.

RESULTS

We enrolled 23 patients with SCI (16 with paraplegia and 7 with tetraplegia) treated with methotrexate (MTX) and different biologics (tumor necrosis factor (TNF) inhibitors (i) and interleukin (IL)-17i/IL-23i). Globally, patients with SCI treated with MTX displayed higher rates of infection compared to those treated with biologics. Patients with paraplegia had lower rates of infection compared to patients with tetraplegia during anti-psoriatic therapies (p < 0.05). Those treated with TNFi had greater rates of infection than those treated with IL-17i/IL-23i (p < 0.001). Patients with psoriatic arthritis (PsA) experienced a significant diagnostic delay and clinical monitoring of PsA severity was challenging.

CONCLUSION

In patients with moderate-to-severe PsO and concurrent traumatic SCI, dermatologists should consider using IL-17i/IL-23i as first-line therapy.

Reusable Intermittent Catheters are Acceptable but Product Innovation is Needed: An Interview Study of Catheter Users' Experiences

PURPOSE

The purpose of this study was to explore the experiences of intermittent catheter users after using both reusable and single-use catheters, with a particular focus on factors that affected acceptability.

DESIGN

Qualitative descriptive study following a clinical trial.

PARTICIPANTS AND SETTING

Thirty-six participants who had used both reusable and single-use catheters in a clinical trial were interviewed between June 2022 and March 2024. All were living at home in England or Wales, UK.

METHODS

Participants were invited to interview following one-year's use of a reusable catheter as part of a clinical trial. The reusable catheter was used in combination with their usual single-use catheter. Semi-structured telephone and video interviews were used to enable participants to describe their experiences. Data were analyzed using inductive methods and framework analysis to develop themes and subthemes.

RESULTS

Data analysis identified 4 themes. Successful use of the reusable catheter depended on capacity, confidence and willingness of the individual to adapt. Most people found reuse easier to do at home but there were significant barriers when going out. The design of the catheter used in the trial and the process of reuse did not suit everyone. While there was a desire to continue reuse, this was conditional on the provision of single-use catheters to enable users to mix and match both types in different situations.

CONCLUSIONS

This study presents data from participants who were enthusiastic to try reusable catheters, mainly for environmental reasons, as part of a trial. For most there was a desire to mix and match, combining single use and reusable catheters for different situations. Innovation is needed to create a range of reusable catheter designs and cleaning processes that better meet individual needs.

The bacterial displacement test: an in vitro microbiological test for the evaluation of intermittent catheters and urinary tract infection

AIMS

Intermittent catheters (ICs) are commonly used in bladder management, but catheter-associated urinary tract infections (CAUTIs) remain challenging. Insertion tips may reduce the risk of CAUTIs by minimizing bacterial transfer along the urinary tract. However, there are few laboratory tests to evaluate such technologies. We describe the use of an adapted in vitro urethra agar model to assess bacterial displacement by ICs.

METHODS AND RESULTS

Simulated urethra agar channels (UACs) were prepared with catheter-specific sized channels in selective media specific to the challenge organisms. UACs were inoculated with Escherichia coli and Enterococcus faecalis before insertion of ICs, and enumeration of UAC sections was performed following insertion. Four ICs were evaluated: Cure Catheter® Closed System (CCS), VaPro Plus Pocket™, Bard® Touchless® Plus, and SpeediCath® Flex Set. CCS demonstrated significantly reduced bacterial displacement along the UACs compared to the other ICs and was also the only IC with undetectable levels of bacteria toward the end of the UAC (representing the proximal urethra).

CONCLUSION

The bacterial displacement test demonstrated significant differences in bacterial transfer between the test ICs with insertion tips, which may reflect their different designs. This method is useful for evaluating CAUTI prevention technology and may help guide future technology innovations.

Understanding the properties of intermittent catheters to inform future development

Despite the extensive use of intermittent catheters (ICs) in healthcare, various issues persist for long-term IC users, such as pain, discomfort, infection, and tissue damage, including strictures, scarring and micro-abrasions. A lubricous IC surface is considered necessary to reduce patient pain and trauma, and therefore is a primary focus of IC development to improve patient comfort. While an important consideration, other factors should be routinely investigated to inform future IC development. An array of in vitro tests should be employed to assess IC's lubricity, biocompatibility and the risk of urinary tract infection development associated with their use. Herein, we highlight the importance of current in vitro characterisation techniques, the demand for optimisation and an unmet need to develop a universal 'toolkit' to assess IC properties.

Incidence and risk factors of urinary tract infection in hospitalized patients with spinal cord injury in a hospital of China

Urinary tract infection (UTI) caused by spinal cord injury (SCI) can have significant morbidity. There is currently a lack of relevant data in China. This study explores incidence and risk factors of UTI in hospitalized patients with SCI in China, and will help healthcare professionals to make informed clinical decisions to reduce the incidence of UTI. This retrospective study analyzed the medical records of patients with SCI who were hospitalized at three campuses of a hospital in central China between August 2014 and August 2023. The files of patients with SCI were reviewed for demographics and clinical characteristics. Logistic regression analysis was performed to identify risk factors associated with UTI. A total of 538 patients were included in this study. The incidence of UTI was 49.8%. Sex, hypoproteinemia, urinary incontinence, bladder irrigation, timing of rehabilitation, duration of indwelling urinary catheter were risk factors of UTI. The implementation of specific preventive measures is anticipated to result in a decrease in the occurrence of UTI among individuals with SCI, consequently enhancing their overall quality of life and prognosis.

Urinary tract infections and intermittent catheterization among patients with spinal cord injury in Chinese community

We conducted a cross-sectional study using an online questionnaire to investigate the current status of urinary tract infections (UTIs) and the use of clean intermittent catheterization (CIC) in Chinese community-based SCI patients and to explore the risk factors for UTIs in patients using CIC. Our findings suggest that the prevalence of UTIS is higher in Chinese community-based SCI patients compared with patients in medically developed countries. In addition, we found that CIC had the lower incidence of UTIs than urinary indwelling catheter (UIC) and suprapubic catheter (SPC), and that SCI patients with CIC had low rates of use and poor compliance. Further analysis indicated that most of the risk factors for UTIs in CIC patients were associated with irregular use of CIC. Therefore, we call for not only the need to provide stronger caregiver support and financial assistance to improve CIC adherence in Chinese community SCI patients, but also the establishment of a database of Chinese SCI patients in order to enhance the management of bladder emptying methods and further standardize the CIC operation in such patients, thus reducing the risk of UTIs in Chinese community SCI patients.

Incidence of urinary tract infection following initiation of intermittent catheterization among patients with recent spinal cord injury in Germany and the Netherlands

Objective: To assess incidence of urinary tract infection (UTI) among patients with recent spinal cord injury (SCI) who initiated intermittent catheterization (IC).Design: Retrospective chart review.Setting: Two European SCI rehabilitation centers.Participants: Seventy-three consecutive patients with recent SCI who initiated IC.Outcome measures: Incidence of UTI, using six different definitions, each based on microbiology ± symptomatology ± mention of UTI . Rates were expressed in terms of numbers of UTIs per 100 patient-months (PMs). Attention was focused on first-noted UTI during the three-month follow-up, as assessed with each of the six definitions.Results: Fifty-eight percent of patients (n = 33) met ≥1 definitions for UTI during follow-up (rate: 31.5 UTIs per 100 PMs), ranging from 14% (5.3 per 100 PMs; definition requiring bacteriuria, pyuria, and presence of symptoms) to 45% (22.7 per 100 PMs; definition requiring "mention of UTI"). Ten cases were identified using the definition that required bacteriuria, pyuria, and symptoms, whereas definitions that required bacteriuria and either pyuria or symptoms resulted in the identification of 20-25 cases. Median time to UTI ranged from 42 days ("mention of UTI") to 81 days (definition requiring bacteriuria and ≥100 leukocytes/mm3).Conclusion: Depending on definition, 14% to 45% of patients with recent SCI experience UTI within three months of initiating IC. Definitions requiring bacteriuria and either pyuria or symptoms consistently identified about twice as many cases as those that required all three conditions. Standardizing definitions may help improve detection, treatment, and prevention of UTI within this vulnerable population.

Innate Bacteriostatic Mechanisms Defend the Urinary Tract

Urinary tract infection (UTI) is the most common type of urogenital disease. UTI affects the urethra, bladder, ureter, and kidney. A total of 13.3% of women, 2.3% of men, and 3.4% of children in the United States will require treatment for UTI. Traditionally, bladder (cystitis) and kidney (pyelonephritis) infections are considered independently. However, both infections induce host defenses that are either shared or coordinated across the urinary tract. Here, we review the chemical and biophysical mechanisms of bacteriostasis, which limit the duration and severity of the illness. Urinary bacteria attempt to overcome each of these defenses, complicating description of the natural history of UTI.

Antibiotic use for asymptomatic bacteriuria in children with neurogenic bladder

PURPOSE

Patients with neurogenic bladder (NB) often perform clean intermittent catheterization (CIC) and are predisposed to bladder colonization. Antibiotics are not routinely indicated in those with asymptomatic bacteriuria (ASB). The original purpose of this study was to compare patients that received antibiotics for ASB and those that did not. However, because the non-antibiotic group was very small, the final analysis evaluated treatment patterns of ASB in children with NB.

METHODS

A retrospective chart review was completed, including patients who presented with urinary tract infection (UTI) and NB managed by CIC. Patients with symptoms of UTI were excluded. Basic demographics, urinalysis, culture results, and antibiotic prescriptions were collected.

RESULTS

The sample included 272 patient encounters for 109 unique patients. Of these, 50.7% were female, and the median age was 10.25 years. More than half the urine cultures (56.2%) grew gram-negative organisms, and 31.3% contained 2 or more organisms. Nearly all encounters received treatment with antibiotics. Twenty-three encounters with no culture performed or the culture resulted in no growth received antibiotic therapy.

CONCLUSIONS

Antibiotic resistance and antibiotic stewardship are primary concerns in healthcare today. This organization's current practice pattern shows high antibiotic use for ASB in patients with NB. Future studies are required to identify outcomes associated with treatment versus non-treatment in these patients.

Intermittent catheter techniques, strategies and designs for managing long-term bladder conditions

BACKGROUND

Intermittent catheterisation (IC) is a commonly recommended procedure for people with incomplete bladder emptying. Frequent complications are urinary tract infection (UTI), urethral trauma and discomfort during catheter use. Despite the many designs of intermittent catheter, including different lengths, materials and coatings, it is unclear which catheter techniques, strategies or designs affect the incidence of UTI and other complications, measures of satisfaction/quality of life and cost-effectiveness. This is an update of a Cochrane Review first published in 2007.  OBJECTIVES: To assess the clinical and cost-effectiveness of different catheterisation techniques, strategies and catheter designs, and their impact, on UTI and other complications, and measures of satisfaction/quality of life among adults and children whose long-term bladder condition is managed by intermittent catheterisation.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 12 April 2021), 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 (RCTs) or randomised cross-over trials comparing at least two different catheterisation techniques, strategies or catheter designs.

DATA COLLECTION AND ANALYSIS

As per standard Cochrane methodological procedures, two review authors independently extracted data, assessed risk of bias and assessed the certainty of evidence using GRADE. Outcomes included the number of people with symptomatic urinary tract infections, complications such as urethral trauma/bleeding, comfort and ease of use of catheters, participant satisfaction and preference, quality of life measures and economic outcomes.

MAIN RESULTS

We included 23 trials (1339 randomised participants), including twelve RCTs and eleven cross-over trials. Most were small (fewer than 60 participants completed), although three trials had more than 100 participants. Length of follow-up ranged from one month to 12 months and there was considerable variation in definitions of UTI. Most of the data from cross-over trials were not presented in a useable form for this review. Risk of bias was unclear in many domains due to insufficient information in the trial reports and several trials were judged to have a high risk of performance bias due to lack of blinding and a high risk of attrition bias. The certainty of evidence was downgraded for risk of bias, and imprecision due to low numbers of participants.    Aseptic versus clean technique We are uncertain if there is any difference between aseptic and clean techniques in the risk of symptomatic UTI because the evidence is low-certainty and the 95% confidence interval (CI) is consistent with possible benefit and possible harm (RR 1.20 95% CI 0.54 to 2.66; one study; 36 participants). We identified no data relating to the risk of adverse events comparing aseptic and clean techniques or participant satisfaction or preference.  Single-use (sterile) catheter versus multiple-use (clean) We are uncertain if there is any difference between single-use and multiple-use catheters in terms of the risk of symptomatic UTI because the certainty of evidence is low and the 95% CI is consistent with possible benefit and possible harm (RR 0.98, 95% CI 0.55, 1.74; two studies; 97 participants). One study comparing single-use catheters to multiple-use catheters reported zero adverse events in either group; no other adverse event data were reported for this comparison. We identified no data for participant satisfaction or preference. Hydrophilic-coated catheters versus uncoated catheters We are uncertain if there is any difference between hydrophilic and uncoated catheters in terms of the number of people with symptomatic UTI because the certainty of evidence is low and the 95% CI is consistent with possible benefit and possible harm (RR 0.89, 95% CI 0.69 to 1.14; two studies; 98 participants). Uncoated catheters probably slightly reduce the risk of urethral trauma and bleeding compared to hydrophilic-coated catheters (RR 1.37, 95% CI 1.01 to 1.87; moderate-certainty evidence). The evidence is uncertain if hydrophilic-coated catheters compared with uncoated catheters has any effect on participant satisfaction measured on a 0-10 scale (MD 0.7 higher, 95% CI 0.19 to 1.21; very low-certainty evidence; one study; 114 participants). Due to the paucity of data, we could not assess the certainty of evidence relating to participant preference (one cross-over trial of 29 participants reported greater preference for a hydrophilic-coated catheter (19/29) compared to an uncoated catheter (10/29)).  AUTHORS' CONCLUSIONS: Despite a total of 23 trials, the paucity of useable data and uncertainty of the evidence means that it remains unclear whether the incidence of UTI or other complications is affected by use of aseptic or clean technique, single (sterile) or multiple-use (clean) catheters, coated or uncoated catheters or different catheter lengths. The current research evidence is uncertain and design and reporting issues are significant. More well-designed trials are needed. Such trials should include analysis of cost-effectiveness because there are likely to be substantial differences associated with the use of different catheterisation techniques and strategies, and catheter designs.

A Synthetic Overview of Preparation Protocols of Nonmetallic, Contact-Active Antimicrobial Quaternary Surfaces on Polymer Substrates

Antibacterial surfaces have been researched for more than 30 years and remain highly desirable. In particular, there is an interest in providing antimicrobial properties to commodity plastics, because these, in their native state, are excellent substrates for pathogens to adhere and proliferate on. Therefore, efficient strategies for converting surfaces of commodity plastics into contact-active antimicrobial surfaces are of significant interest. Many systems have been prepared and tested for their efficacy. Here, the synthetic approaches to such active surfaces are reviewed, with the restriction to only include systems with tested antibacterial properties. The review focuses on the synthetic approach to surface functionalization of the most common materials used and tested for biomedical applications, which effectively has limited the study to quaternary materials. For future developments in the field, it is evident that there is a need for development of simple methods that permit scalable production of active surfaces. Furthermore, in terms of efficacy, there is an outstanding concern of a lack of universal antimicrobial action as well as rapid deactivation of the antibacterial effect through surface fouling.

The frequency of urinary tract infections and the value of antiseptics in community-dwelling people who undertake intermittent urinary catheterization: A systematic review

BACKGROUND

This systematic review had 2 aims. First to identify the incidence of urinary tract infection (UTI) and bacteriuria in people undertaking intermittent catheterization (IC), second to determine the effectiveness of antiseptic cleaning of the meatal area prior to IC in reducing the incidence of UTI and bacteriuria.

METHODS

A systematic review was conducted. Medline and the Cumulative Index to Nursing and Allied Health Literature electronic databases were systematically searched between January 1, 1990 and January 31, 2020, to identify studies that reported either the incidence of UTI or bacteriuria or the impact of using antiseptics for meatal cleaning prior to IC on incidence of these same outcomes.

RESULTS

Twenty-five articles were identified for the first aim, 2 articles for the second. The proportion of participants experiencing ≥1 UTIs per year ranged from 15.4% to 86.6%. Synthesis of these studies suggest a combined incidence of 44.2% (95%CI 40.2%-48.5%) of participants having ≥1 UTIs per year. One of the 2 studies exploring the benefit of antiseptics in reducing UTI suggest some potential benefit of using chlorhexidine in reducing UTIs. Both studies have significant limitations, making interpretation difficult.

CONCLUSIONS

A large proportion of people undertaking IC in the community have UTIs each year. Evidence on the role of antiseptics in the prevention of UTI for people who undertake IC remains unclear.

Should We Delay Urodynamic Study When Patients With Spinal Cord Injury Have Asymptomatic Pyuria?

Objective

To assess the incidence of urinary tract infection (UTI) with post-urodynamic study (post-UDS) in patients with spinal cord injury (SCI) and study its relationship with pre-UDS pyuria.

Methods

Patients with SCI who were hospitalized and underwent UDS during a 4-year period were reviewed. Patients with pre-test lower urinary tract symptoms were excluded. Urinalysis and urine culture were performed before and 24 hours after UDS. Prophylactic antibiotics were administered for 5 days starting from the morning of the UDS. UTI was defined as bacteriuria with accompanying symptoms.

Results

Of 399 patients reviewed, 209 (52.4%) had pyuria in pre-UDS urinalysis, and 257 (64.4%) had bacteriuria in pre-UDS culture. Post-UDS UTI occurred in 6 (1.5%) individuals who all complained of fever: 5 (2.4%) of the post-UDS UTI cases occurred in patients with pre-UDS pyuria, and 1 (0.5%) in a person without. The differences between groups were not statistically significant (p=0.218). Of 221 patients with bacteriuria (gram-negative isolates) on pre-UDS culture, resistance to ciprofloxacin, cephalosporin, and trimethoprim/sulfamethoxazole (TMP/SMT) was noted in 52.9% (117 cases), 57.0% (126 cases), and 38.9% (86 cases), respectively.

Conclusion

No difference was found in the prevalence of post-UDS UTI based on the presence of pyuria in pre-UDS urinalysis. UDS may be performed even in SCI cases of pre-UDS pyuria without increasing the prevalence of post-UDS UTI if prophylactic antibiotics are administered. TMP/SMT could be used as a first-line antibiotic for the prevention of post-UDS UTI in Korea.

The burden of illness in initiating intermittent catheterization: an analysis of German health care claims data

BACKGROUND

Intermittent catheterization (IC) is a common medical technique to drain urine from the bladder when this is no longer possible by natural means. The objective of this study was to evaluate the standard of care and the burden of illness in German individuals who perform intermittent catheterization and obtain recommendations for improvement of care.

METHODS

A descriptive study with a retrospective, longitudinal cohort design was conducted using the InGef research database from the German statutory health insurance claims data system. The study consisted of individuals with initial IC use in 2013-2015.

RESULTS

Within 3 years 1100 individuals with initial IC were identified in the database (~ 19,000 in the German population). The most common IC indications were urologic diseases, spinal cord injury, Multiple Sclerosis and Spina Bifida. Urinary tract infections (UTI) were the most frequent complication occurring 1 year before index (61%) and in follow-up (year 1 60%; year 2 50%). Resource use in pre-index including hospitalizations (65%), length of stay (12.8 ± 20.0 days), physician visits (general practitioner: 15.2 ± 29.1), prescriptions of antibiotics (71%) and healthcare costs (€17,950) were high. Comorbidities, complications, and healthcare resource use were highest 1 year before index, decreasing from first to second year after index.

CONCLUSIONS

The data demonstrated that prior to initial catheterization, IC users experienced UTIs and high healthcare utilization. While this demonstrates a potential high burden of illness prior to initial IC, UTIs also decreased over time, suggesting that IC use may have a positive influence. The findings also showed that after the first year of initial catheterization the cost decreased. Further studies are needed to better understand the extent of the burden for IC users compared to non-IC users.

Incidence and risk factors of urinary tract infections in hospitalised patients with spinal cord injury

AIMS AND OBJECTIVES

To investigate the incidence of urinary tract infection and analyse its risk factors among hospitalised patients with spinal cord injury.

BACKGROUND

While the incidence of urinary tract infection varies widely according to the healthcare setting and patients' clinical characteristics, formal reports are limited in quantity. There has been no consensus regarding the risk factors for urinary tract infection.

DESIGN

A retrospective descriptive study.

METHODS

Electronic medical records of 964 subjects between 2010-2017 were reviewed. Urinary tract infection status was examined to identify newly occurred cases. Data included demographic and clinical characteristics, hydration status and length of hospitalisation. The reporting of the study followed the EQUATOR Network's STROBE checklist.

RESULTS

Of the sample, 31.7% had urinary tract infection (95% confidence interval: 1.288 to 1.347, p < .001). Sex, completeness of injury, type of bladder emptying, detrusor function and urethral pressure were significant factors affecting urinary tract infection. Patients who were male and those with injury classifications A, B and C had higher risk of urinary tract infection. Patients with urinary or suprapubic indwelling catheters, as well as those with areflexic detrusor combined with normotonic urethral pressure or overactive detrusor combined with normotonic urethral pressure, showed higher risk. Length of hospitalisation in patients with urinary tract infection was greater than that in uninfected patients, which implies the importance of prevention of urinary tract infection.

CONCLUSIONS

Nurses should carefully assess risk factors to prevent urinary tract infection in patients with spinal cord injury in the acute and sub-acute stages of the disease trajectory and provide individualised nursing care.

RELEVANCE TO CLINICAL PRACTICE

This study contributes evidence for up-to-date clinical nursing practice for the comprehensive management of urinary tract infection. This can lead to improvements in nursing care quality and patient outcomes, including length of hospitalisation.

Bladder irrigation with povidone-iodine prevent recurrent urinary tract infections in neurogenic bladder patients on clean intermittent catheterization

AIMS

To determine if daily povidone-iodine (PI) bladder irrigation in neurogenic lower urinary tract dysfunction (NLUTD) patients doing clean intermittent catheterization (CIC) can reduce the rate of symptomatic urinary tract infections (UTIs), emergency department (ED) visit for UTIs, and hospitalization for UTIs.

METHODS

We prospectively reviewed the records of patients with NLUTD on CIC who had recurrent symptomatic UTIs and who were placed on daily intravesical instillations of PI. This trial was conducted from January 2014 to January 2020 on 119 patients.

RESULTS

After using daily PI bladder irrigation, the rate of symptomatic UTIs was reduced by 99.2% (incidence rate ratio [IRR]: 0.008, 95% confidence interval [CI]: 0.001-0.059; p < .001), the rate of ED visits was reduced by 99.2%% (IRR: 0.008, 95% CI: 0.001-0.059; p < .001), and the rate of inpatient hospitalizations for UTI was reduced by 99.9% (IRR: 0.0008, 95% CI: 0.0002-0.0035; p < .001). There was also a significant decrease in multidrug resistance in UTI organisms with the use of PI bladder instillation.

CONCLUSIONS

Daily intravesical PI instillation is a well-tolerated approach to prevent UTIs and related ED visits and hospitalizations in NLUTD patients doing CIC.

Urinary Self-Catheterization is Not Associated with Increased Risk of Major Complications Following Total Hip and Knee Arthroplasty

BACKGROUND

The objective of this study is to evaluate urinary self-catheterization as a potential risk factor for postoperative complications following total hip (THA) and knee (TKA) arthroplasty procedures.

METHODS

Self-catheterization patients who underwent total joint arthroplasty from 2005 to 2014 were identified in a national insurance database. Rates of death, hospital readmission, emergency room visit, infection, revision, and dislocation for THA or arthrofibrosis for TKA were calculated, as well as cost and length of stay. Self-catheterizing patients were then compared to a 4:1 matched control cohort using a logistic regression analysis to control for confounding factors.

RESULTS

Sixty-nine patients underwent THA, and 128 patients who underwent TKA and who actively self-catheterized at the time of surgery were identified. Self-catheterization was not associated with infection, emergency room visits, readmissions, revision surgery, arthrofibrosis, or cost compared to the 4:1 matched control cohort. However, self-catheterization was associated with significantly longer length of stay (difference for THA = 1.91 days, confidence interval = 0.97-2.86, P < .001; difference for TKA = 0.61, odds ratio = 0.16-1.06, P = .01).

CONCLUSION

Self-catheterization does not appear to be associated with increased risk of major complications following total joint arthroplasty with the numbers available in this study. Reassurance can be given regarding concerns for infection and other complications following surgery in this patient population.

Complications and patient satisfaction with urethral clean intermittent catheterization in spina bifida patients: comparing coated vs uncoated catheters

INTRODUCTION

Many types of catheters are available in market for clean intermittent catheterization (CIC). Each company claim superiority of their products, but strong evidence is lacking.

PURPOSE

To assess the complications due to CIC in spina bifida children and its possible relationship to hydrophilic-coated catheter (HCC) or uncoated catheters (UCCs), with a view to decrease catheter related complications, and improve patients experience and compliance.

MATERIALS AND METHODS

The authors retrospectively reviewed the spina bifida patients aged between 0 and 16 years, who had no surgical intervention, and were performing CIC urethrally for at least 6 months. General information was recorded from electronic patient record, followed by telephonic/outpatient interview. Patients were divided into two groups: UCC or HCC. Patients in both groups had also used catheter from the other group at times. This study recorded the type/size of catheter used, its duration, complications, and their possible relation to type of catheter. Carer/patients overall satisfaction was recorded on a scale of 1-10 and their preference about the type of catheter they wish. The data were analyzed using SPSS (P-value < 0.05 as significant).

RESULTS

One hundred one patients were included in the study: 53 UCC and 48 HCC. There was no significant difference between gender/associated conditions/age at start of CIC or duration of CIC. The mean time taken to perform the procedure was similar in both groups: UCC 9.7 min vs HCC 8.8 min. Difficulty in insertion was felt in 20, UCC 12 vs HCC 8 (P = 0.15), recurrent UTIs UCC 12 vs HCC 17 (P = 0.09), median patient satisfaction UCC 8/10 (3-10) and HCC 10/10 (7-10) (P = 0.63). Request for change of catheter was made by 10 from UCC group to HCC vs none from HCC (P ≤ 0.05).When given a choice, 28/53 (52.8%) in UCC and none (0%) in HCC group (P ≤ 0.0001) preferred to change to the other type of catheter, mainly for convenience of use of the product. Per year per patient cost was UCC US$ 389 vs HCC US$ 2820.

DISCUSSION

Many un-modifiable factors contribute to the outcome of CIC. Despite claims of superiority by manufactures of some catheters over others, strong evidence is lacking especially in children. This study has shown no difference in the complications between UCC and HCC.

CONCLUSION

There is no significant difference in complication rates with urethral CIC in patients using either UCC or HCC. A significant majority would prefer to use HCC mainly because of convenience of use of the product though at a seven times higher cost.

Continuous low-dose antibiotic prophylaxis to prevent urinary tract infection in adults who perform clean intermittent self-catheterisation: the AnTIC RCT

BACKGROUND

People carrying out clean intermittent self-catheterisation (CISC) to empty their bladder often suffer repeated urinary tract infections (UTIs). Continuous once-daily, low-dose antibiotic treatment (antibiotic prophylaxis) is commonly advised but knowledge of its effectiveness is lacking.

OBJECTIVE

To assess the benefit, harms and cost-effectiveness of antibiotic prophylaxis to prevent UTIs in people who perform CISC.

DESIGN

Parallel-group, open-label, patient-randomised 12-month trial of allocated intervention with 3-monthly follow-up. Outcome assessors were blind to allocation.

SETTING

UK NHS, with recruitment of patients from 51 sites.

PARTICIPANTS

Four hundred and four adults performing CISC and predicted to continue for ≥ 12 months who had suffered at least two UTIs in the previous year or had been hospitalised for a UTI in the previous year.

INTERVENTIONS

A central randomisation system using random block allocation set by an independent statistician allocated participants to the experimental group [once-daily oral antibiotic prophylaxis using either 50 mg of nitrofurantoin, 100 mg of trimethoprim (Kent Pharmaceuticals, Ashford, UK) or 250 mg of cefalexin (Sandoz Ltd, Holzkirchen, Germany); n = 203] or the control group of no prophylaxis (n = 201), both for 12 months.

MAIN OUTCOME MEASURES

The primary clinical outcome was relative frequency of symptomatic, antibiotic-treated UTI. Cost-effectiveness was assessed by cost per UTI avoided. The secondary measures were microbiologically proven UTI, antimicrobial resistance, health status and participants' attitudes to antibiotic use.

RESULTS

The frequency of symptomatic antibiotic-treated UTI was reduced by 48% using prophylaxis [incidence rate ratio (IRR) 0.52, 95% confidence interval (CI) 0.44 to 0.61; n = 361]. Reduction in microbiologically proven UTI was similar (IRR 0.49, 95% CI 0.39 to 0.60; n = 361). Absolute reduction in UTI episodes over 12 months was from a median (interquartile range) of 2 (1-4) in the no-prophylaxis group (n = 180) to 1 (0-2) in the prophylaxis group (n = 181). The results were unchanged by adjustment for days at risk of UTI and the presence of factors giving higher risk of UTI. Development of antimicrobial resistance was seen more frequently in pathogens isolated from urine and Escherichia coli from perianal swabs in participants allocated to antibiotic prophylaxis. The use of prophylaxis incurred an extra cost of £99 to prevent one UTI (not including costs related to increased antimicrobial resistance). The emotional and practical burden of CISC and UTI influenced well-being, but health status measured over 12 months was similar between groups and did not deteriorate significantly during UTI. Participants were generally unconcerned about using antibiotics, including the possible development of antimicrobial resistance.

LIMITATIONS

Lack of blinding may have led participants in each group to use different thresholds to trigger reporting and treatment-seeking for UTI.

CONCLUSIONS

The results of this large randomised trial, conducted in accordance with best practice, demonstrate clear benefit for antibiotic prophylaxis in terms of reducing the frequency of UTI for people carrying out CISC. Antibiotic prophylaxis use appears safe for individuals over 12 months, but the emergence of resistant urinary pathogens may prejudice longer-term management of recurrent UTI and is a public health concern. Future work includes longer-term studies of antimicrobial resistance and studies of non-antibiotic preventative strategies.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN67145101 and EudraCT 2013-002556-32.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment Vol. 22, No. 24. See the NIHR Journals Library website for further project information.

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.

Change in urodynamic pattern and incidence of urinary tract infection in patients with traumatic spinal cord injury practicing clean self-intermittent catheterization

Objective: To observe changes in cystometric parameters in individuals with spinal cord injury (SCI) with neurogenic bladder practicing clean intermittent self-catheterization (CIC) and incidence of urinary tract infection (UTI) in such patients.Design: Prospective, observational study.Setting: Tertiary Urban Rehabilitation Hospital.Participants: Persons with neurogenic bladder caused by traumatic SCI and practicing CIC.Interventions: Clinical evaluation, complete urine analysis, urine culture and sensitivity, ultrasonography of the abdomen and urodynamic study were evaluated at baseline and at follow-up (6 months to 1 year).Outcome Measures: Detrusor pattern, cystometric capacity, detrusor compliance, detrusor leak point pressure, residual urine, incidence of UTI.Results: Thirty-one participants were included in the study. The baseline cystometric study showed that 15 had overactive detrusor and 16 had detrusor areflexia. The mean cystometric capacity decreased significantly between baseline and follow-up in both the groups but remained within the normal threshold limit, decline being more marked in the overactive detrusor group, who also had more marked decrease in compliance. Mean detrusor leak point pressure was below 40 cm H₂O in all participants in both groups at baseline and follow-up. Mean residual urine improved at follow-up in both groups. Incidence of UTI was 2.29 episodes per patient per year, and more frequent in the overactive detrusor group. Escherichia coli was the causative agent in 45%.Conclusion: The cystometric capacity and compliance decreased significantly though patients were doing regular CIC and managed on antimuscarinics for detrusor overactivity (DO). UTI is more common in individuals with SCI with DO and E. coli is the most common cause of UTI.

The impact of different scenarios for intermittent bladder catheterization on health state utilities: results from an internet-based time trade-off survey

AIMS

Intermittent catheterization (IC) is the gold standard for bladder management in patients with chronic urinary retention. Despite its medical benefits, IC users experience a negative impact on their quality of life (QoL). For health economics based decision making, this impact is normally measured using generic QoL measures (such as EQ-5D) that estimate a single utility score which can be used to calculate quality-adjusted life years (QALYs). But these generic measures may not be sensitive to all relevant aspects of QoL affected by intermittent catheters. This study used alternative methods to estimate the health state utilities associated with different scenarios: using a multiple-use catheter, one-time-use catheter, pre-lubricated one-time-use catheter and pre-lubricated one-time-use catheter with one less urinary tract infection (UTI) per year.

METHODS

Health state utilities were elicited through an internet-based time trade-off (TTO) survey in adult volunteers representing the general population in Canada and the UK. Health states were developed to represent the catheters based on the following four attributes: steps and time needed for IC process, pain and the frequency of UTIs.

RESULTS

The survey was completed by 956 respondents. One-time-use catheters, pre-lubricated one-time-use catheters and ready-to-use catheters were preferred to multiple-use catheters. The utility gains were associated with the following features: one time use (Canada: +0.013, UK: +0.021), ready to use (all: +0.017) and one less UTI/year (all: +0.011).

LIMITATIONS

Internet-based survey responders may have valued health states differently from the rest of the population: this might be a source of bias.

CONCLUSION

Steps and time needed for the IC process, pain related to IC and the frequency of UTIs have a significant impact on IC related utilities. These values could be incorporated into a cost utility analysis.

[Original strategy for prevention of recurrent symptomatic urinary tract infections in patients with neurogenic bladder: Bacterial interference, state of the art]

PURPOSE

Urinary tract infection (UTI) is the most common complication in patients with neurogenic bladder. The long-term use of antibiotic drugs induces an increase in antimicrobial resistance and adverse drug reactions. Bacterial interference is a new concept to prevent recurrent UTI which consists in a bladder colonization with low virulence bacteria. We performed a literature review on this emerging therapy.

MATERIALS AND METHODS

Literature review of bacterial interference to prevent symptomatic urinary tract infection in neurological population.

RESULTS

Seven prospectives study including 3 randomized, double-blind and placebo controlled trial were analyzed. The neurological population was spinal cord injured in most cases. The bladder colonization was performed with 2 non-pathogen strains of Escherichia coli: HU 2117 and 83972. At 1 month, 38 to 83% of patients were colonized. Mean duration of colonization was 48.5 days to 12.3 months. All studies showed that colonization might reduce the number of urinary tract infections and is safe with absence of serious side effects.

CONCLUSION

Bacterial interference is a promising alternative therapy for the prevention of recurrent symptomatic urinary tract infections in neurogenic patients. This therapy should have developments for a daily use practice and for a long-term efficacy.

Participant experiences of clean intermittent self-catheterisation, urinary tract infections and antibiotic use on the ANTIC trial - A qualitative study

BACKGROUND

Recurrent urinary tract infections are a commonly reported problem in people who use clean intermittent self-catheterisation. Yet there is a lack of knowledge regarding both the impact on people's lives, the use of prophylactic anti-biotics and perceptions of patients on their use.

AIMS

To explore the views and experiences of adults who use clean intermittent self-catheterisation for long-term bladder conditions, with a focus on urinary tract infection experience and prophylactic antibiotic use.

DESIGN

A qualitative descriptive study.

METHODS

Twenty-six semi-structured qualitative interviews were conducted with individuals recruited from the ANTIC Trial (Antibiotic treatment for intermittent bladder catheterisation: A randomised controlled trial of once daily prophylaxis). Participants were intermittent self-catheter users aged 18 years or older. Interviews took place between August 2015 and January 2016. Transcript data were analysed thematically.

FINDINGS

Three overarching topics were revealed with corresponding themes: the experiences of intermittent self-catheterisation and urinary tract infections (normalisation, perceived burden); attitudes towards antibiotics for urinary tract infection treatment (nonchalant attitudes, ambivalence towards antibiotic resistance); and experiences of low-dose prophylaxis antibiotics (habitual behaviour and supportive accountability).

CONCLUSION

The emotional and practical burden of catheter use and urinary tract infection was considerable. Beliefs pertaining to antibiotic use were based on utility, gravity of need and perceived efficacy. These opinions were often influenced by clinician recommendations.

Rehabilitation Nurses' Knowledge, Attitudes, and Behaviors for Preventing Urinary Tract Infections From Intermittent Catheterization

PURPOSE

The aim of this study was to develop and examine the reliability of a survey to assess knowledge, attitudes, and behaviors (KAB) of rehabilitation nurses for preventing urinary tract infections in persons requiring intermittent catheterization.

DESIGN

Cross-sectional survey with principal component analysis.

METHODS

Survey development and administration based on national guidelines.

FINDINGS

Principal component analysis produced three reliable components of KAB explaining 54.5% of response variance. Results indicate that nurses report adequate knowledge and training. Although the facility had an evidence-based online catheterization procedure, staff reported that the procedure was not helpful nor useable. Twenty-eight percent incorrectly identified the root cause of urinary tract infection, and 45% reported that other nurses always washed their hands. Barriers to using standard intermittent catheterization technique were staff, time, and patient variables.

CONCLUSION

The modified survey is a reliable measure of KAB.

CLINICAL RELEVANCE

The survey assists with identifying knowledge gaps, customizing education, and changing practice.

WITHDRAWN: Intermittent catheterisation for long-term bladder management

BACKGROUND

Intermittent catheterisation is a commonly recommended procedure for people with incomplete bladder emptying. There are now several designs of intermittent catheter (e.g. different lengths, 'ready to use' presentation) with different materials (e.g. PVC-free) and coatings (e.g. hydrophilic). The most frequent complication of intermittent catheterisation is urinary tract infection (UTI), but satisfaction, preference and ease of use are also important to users. It is unclear which catheter designs, techniques or strategies affect the incidence of UTI, which are preferable to users and which are most cost effective.

OBJECTIVES

To compare one type of catheter design versus another, one type of catheter material versus another, aseptic catheterisation technique versus clean technique, single-use (sterile) catheters versus multiple-use (clean) catheters, self-catheterisation versus catheterisation by others and any other strategies designed to reduce UTI and other complications or improve user-reported outcomes (user satisfaction, preference, ease of use) and cost effectiveness in adults and children using intermittent catheterisation for incomplete bladder emptying.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, and handsearching of journals and conference proceedings (searched 30 September 2013), 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 (RCTs) or randomised cross-over trials comparing at least two different catheter designs, catheterisation techniques or strategies.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the methodological quality of trials and abstracted data. For dichotomous variables, risk ratios and 95% confidence intervals were derived for each outcome where possible. For continuous variables, mean differences and 95% confidence intervals were calculated for each outcome. Because of trial heterogeneity, it was not always possible to combine data to give an overall estimate of treatment effect.

MAIN RESULTS

Thirty-one trials met the inclusion criteria, including 13 RCTs and 18 cross-over trials. Most were small (less than 60 participants completed), although five trials had more than 100 participants. There was considerable variation in length of follow-up and definitions of UTI. Participant dropout was a problem for several trials, particularly where there was long-term follow-up to measure incidence of UTI. Fifteen trials were more than 10 years old and focused mainly on comparing different catheterisation techniques (e.g. single versus multiple-use) on clinical outcomes whereas, several more recent trials have focused on comparing different types of catheter designs or materials, especially coatings, and user preference. It was not possible to combine data from some trials owing to variations in the catheters tested and in particular the catheter coatings. 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 reliably ruled out. No study assessed cost-effectiveness.

AUTHORS' CONCLUSIONS

Despite a total of 31 trials, there is still no convincing evidence that the incidence of UTI is affected by use of aseptic 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. Results from user-reported outcomes varied. The current research evidence is weak and design issues are significant. More well-designed trials are strongly recommended. Such trials should include analysis of cost-effectiveness because there are likely to be substantial differences associated with the use of different catheter designs, catheterisation techniques and strategies.

Is the CABIC Clean Intermittent Catheterization Patient Education Effective?

PURPOSE

This study examined the effectiveness of the consensus model (Clinical Advisory Board for Intermittent Catheterization [CABIC] method) for teaching clean intermittent self-catheterization (ISC). The primary hypothesis was that the CABIC method of teaching ISC would result in higher ISC knowledge and performance scores.

DESIGN

Prospective, non randomized, pre-post study of an educational intervention of ISC education with nursing students.

METHODS

Nursing students completed a self-report pre-/posttest, education of the CABIC method, and video recording of the CABIC method using same-gendered manikins. The Le Danseur Instrument (LDI) was used to grade the video-recorded demonstration.

FINDINGS

Fifty participants completed three phases of the study. Paired t test showed statistically significant improvement in ISC knowledge. A mean score of 92-93 demonstrated a high level of participant education retention.

CONCLUSIONS

The CABIC method of teaching clean ISC is associated with improvement in generalized clean ISC knowledge and performance scores.

CLINICAL RELEVANCE

The CABIC method can be integrated into clinical practice as an evidence-based approach to teaching ISC.

Urinary tract infections in multiple sclerosis

Background:

Urinary tract infections (UTIs) are commonly reported by people with multiple sclerosis (PwMS) and significantly impact quality of life.

Objective:

To provide an overview of the problem of UTIs in PwMS and offer a practical approach for the diagnosis and management.

Methods:

A review of the literature through a Pubmed search up to October 2015 was performed using the following keywords: multiple sclerosis, neurogenic bladder, urinary tract infections, relapse, dipsticks, culture, recurrent and prevention.

Results:

Noteworthy topics include the definition of a confirmed symptomatic UTI as a positive urine culture defined by >105 colony-forming units (CFU)/mL or >104 CFU/mL if a urethral catheter urine sample is taken, or any count of bacteria in a suprapubic bladder puncture specimen, both in addition to symptoms including fever, pain, changes in lower urinary tract symptoms or neurological status. Urinalysis is useful to exclude a UTI; however, on its own is insufficient to confirm a UTI, for which urine culture is required. Experts advise asymptomatic UTIs should not be treated except in the context of an acute relapse. From international guidelines, there is no validated strategy to prevent recurrent UTIs in PwMS.

Conclusion:

This review provides an overview of the diagnosis, treatment and prevention of UTIs in the setting of multiple sclerosis (MS).

Australian Institute of Sport and the Australian Paralympic Committee position statement: urinary tract infection in spinal cord injured athletes

Patients with spinal cord injuries are at increased risk of developing symptomatic urinary tract infections. Current evidence-based knowledge regarding prevention and treatment of urinary tract infection in the spinal cord injured population is limited. There are currently no urinary tract infection prevention and management guidelines specifically targeted towards elite spinal cord injured athletes. This position statement represents a set of recommendations intended to provide clinical guidelines for sport and exercise medicine physicians and other healthcare providers for the prevention and treatment of urinary tract infection in spinal cord injured athletes. It has been endorsed by the Australian Institute of Sport (AIS) and the Australian Paralympic Committee (APC).

UTIs in patients with neurogenic bladder

Urinary tract infections (UTI) remain one of the most prevalent and frustrating morbidities for neurogenic bladder patients, and death attributed to urosepsis in the spinal cord injury (SCI) patient is higher when compared to the general population. Risk factors include urinary stasis, high bladder pressures, bladder stones, and catheter use. While classic symptoms of UTI include dysuria, increased frequency and urgency, neurogenic bladder patients present differently with increased spasticity, autonomic dysreflexia, urinary incontinence, and vague pains. Multiple modalities have been assessed for prevention including catheter type, oral supplements, bladder irrigation, detrusor injections and prophylactic antimicrobials. Of these, bladder inoculation with E. coli HU2117, irrigation with iAluRil(®), detrusor injections, and weekly prophylaxis with alternating antibiotics appear to have a positive reduction in UTI but require further study. Ultimately, treatment for symptomatic UTI should account for the varied flora and possible antibiotic resistances including relying on urine cultures to guide antibiotic therapy.

Treatment of detrusor external sphincter dyssynergia using ultrasound-guided trocar catheter transurethral botulinum toxin a injection in men with spinal cord injury

OBJECTIVE

To evaluate the effects of transrectal ultrasound-guided trocar catheter transurethral botulinum toxin A (BTX-A) injection into the external urethral sphincter (EUS) for treating detrusor external sphincter dyssynergia (DESD) in men with spinal cord injury (SCI).

DESIGN

Descriptive study.

SETTING

Hospital rehabilitation department.

PARTICIPANTS

Patients (N=15; mean age, 40.5y; range, 22-64y) with suprasacral SCI with confirmed DESD determined by urodynamic study.

INTERVENTIONS

A single dose of 100U BTX-A was injected into the EUS via transrectal ultrasound-guided trocar catheter transurethral injection.

MAIN OUTCOME MEASURES

Maximal detrusor pressure, detrusor leak point pressure, maximal pressure on static urethral pressure profilometry, postvoid residual volume, and maximal flow rate.

RESULTS

After BTX-A transurethral injection, 4 (28.5%) patients showed an excellent result and 7 (46.7%) patients showed an improved result, whereas 4 (28.5%) patients experienced treatment failure. The overall success rate was 75.2%. We observed a significant decrease in static urethral pressure (P<.05) and detrusor leak point pressure after treatment (P<.05), but not in detrusor pressure. The postvoid residual volume were significantly decreased in the fourth week after treatment (P<.05).

CONCLUSIONS

Transrectal ultrasound-guided trocar catheter transurethral BTX-A injection into the EUS effectively suppresses or ameliorates DESD. A potential advantage of the method is that ultrasound guidance may not be necessary in the next injection.

Intermittent catheterisation for long-term bladder management

BACKGROUND

Intermittent catheterisation is a commonly recommended procedure for people with incomplete bladder emptying. There are now several designs of intermittent catheter (e.g. different lengths, 'ready to use' presentation) with different materials (e.g. PVC-free) and coatings (e.g. hydrophilic). The most frequent complication of intermittent catheterisation is urinary tract infection (UTI), but satisfaction, preference and ease of use are also important to users. It is unclear which catheter designs, techniques or strategies affect the incidence of UTI, which are preferable to users and which are most cost effective.

OBJECTIVES

To compare one type of catheter design versus another, one type of catheter material versus another, aseptic catheterisation technique versus clean technique, single-use (sterile) catheters versus multiple-use (clean) catheters, self-catheterisation versus catheterisation by others and any other strategies designed to reduce UTI and other complications or improve user-reported outcomes (user satisfaction, preference, ease of use) and cost effectiveness in adults and children using intermittent catheterisation for incomplete bladder emptying.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, and handsearching of journals and conference proceedings (searched 30 September 2013), 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 (RCTs) or randomised cross-over trials comparing at least two different catheter designs, catheterisation techniques or strategies.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the methodological quality of trials and abstracted data. For dichotomous variables, risk ratios and 95% confidence intervals were derived for each outcome where possible. For continuous variables, mean differences and 95% confidence intervals were calculated for each outcome. Because of trial heterogeneity, it was not always possible to combine data to give an overall estimate of treatment effect.

MAIN RESULTS

Thirty-one trials met the inclusion criteria, including 13 RCTs and 18 cross-over trials. Most were small (less than 60 participants completed), although five trials had more than 100 participants. There was considerable variation in length of follow-up and definitions of UTI. Participant dropout was a problem for several trials, particularly where there was long-term follow-up to measure incidence of UTI. Fifteen trials were more than 10 years old and focused mainly on comparing different catheterisation techniques (e.g. single versus multiple-use) on clinical outcomes whereas, several more recent trials have focused on comparing different types of catheter designs or materials, especially coatings, and user preference. It was not possible to combine data from some trials owing to variations in the catheters tested and in particular the catheter coatings. 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 reliably ruled out. No study assessed cost-effectiveness.

AUTHORS' CONCLUSIONS

Despite a total of 31 trials, there is still no convincing evidence that the incidence of UTI is affected by use of aseptic 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. Results from user-reported outcomes varied. The current research evidence is weak and design issues are significant. More well-designed trials are strongly recommended. Such trials should include analysis of cost-effectiveness because there are likely to be substantial differences associated with the use of different catheter designs, catheterisation techniques and strategies.

Management of bladder dysfunction and satisfaction of life after spinal cord injury in Norway

BACKGROUND

There is limited knowledge about bladder dysfunction and bladder management in persons with spinal cord injury (SCI) after discharge from the hospital in Norway. The impact of bladder dysfunction on satisfaction of life has been rarely explored.

SETTING

Community-based survey from Norway.

METHODS

An anonymous cross-sectional postal survey. A questionnaire was sent to the registered members of the Norwegian Spinal Cord Injuries Association. A total of 400 participants, with traumatic or non-traumatic SCI, received the questionnaire.

RESULTS

A total of 248 subjects (62%), 180 men and 68 women, answered the questionnaire. Mean age was 54 years and mean time since injury 13.4 years. A total of 164 participants (66.1%) used intermittent catheterization for bladder emptying (48.5% women versus 72.8% men); more paraplegics than tetraplegics (77.2% versus 55.7%). Recommendations given at the Spinal Cord Units were thoroughly followed by persons who had used catheters more than 5 years. Use of incontinence pads were associated with reduced satisfaction of life.

CONCLUSIONS

The most common method of management of bladder dysfunction is clean intermittent catheterization in Norway. Recommendations were followed more thoroughly by persons who have used intermittent catheterization for more than 5 years. Spinal Cord Units are important source for information and guidance.