Single-use catheters: evidence and environmental impact

OBJECTIVE

To explore the data comparing single- vs multi-use catheters for clean intermittent catheterisation (CIC), consider if the widespread use of single-use catheters is warranted given the cost and environmental impact, and put forth ideas for future consideration.

METHODS

A primary literature review was performed in PubMed over the past 50 years. Studies that performed comparative analysis of single- and multi-use catheters were included in our review. All studies that reported on primary data were narratively summarised.

RESULTS

A total of 11 studies were identified that reported on primary data comparing single- and multi-use catheters. There was no appreciable evidence suggesting reusable multi-use catheters were inferior to single-use catheters from an infection or usability standpoint. In addition, the environmental and monetary burden of single-use catheters is significant.

CONCLUSIONS

The intermittent catheter landscape in the USA has a complex past: defined by policy, shaped by industry, yet characterised by a paucity of data demonstrating superiority of single-use over multi-use catheters. We believe that the aversion to reusable catheters by many patients and healthcare professionals is unwarranted, especially given the cost and environmental impact. Moving forward, better comparative data and more sustainable practices are needed.

Investigation of anxiety levels in caregivers who perform clean intermittent catheterization on their children and affecting factors

PURPOSE

The study aimed to determine the anxiety levels of caregivers who performed clean intermittent catheterization (CIC) on their children and the factors affecting them.

METHODS

This descriptive study was conducted between January 6, and May 29, 2023 with caregivers of 42 patients who were followed up by the pediatric nephrology outpatient clinic of a university for CIC. The study data were collected using the "Participant Information Form" and the "State and Trait Anxiety Scale."

RESULTS

According to the results, of the children included in the study, 73.8% were female, 64.3% were diagnosed with spina bifida (SB), and 76.2% received CIC applications 4-6 times a day. All the caregivers were mothers, and 76.2% received CIC training from a doctor. However, 78.6% of them found the training insufficient, leading them to rely on self-experimentation when applying CIC to their own children. None of the caregivers received information or training on the CIC application from nurses, and there were no home visits or telephone counseling provided after the hospital discharge. The mean score for the state anxiety scale among the caregivers was 45.90 ± 10.57, while the mean score for the trait anxiety scale was 46.92 ± 8.43. Significantly higher mean trait anxiety scores were observed among caregivers with chronic diseases who did not receive training on the CIC application (p < 0.05). Additionally, caregivers of children who experienced 3-4 urinary tract infections (UTIs) within the last 3 months also had significantly higher mean trait anxiety scores (p < 0.05). The mean trait anxiety level scores of caregivers of children who had 3-4 UTIs in the last 3 months were significantly higher (p < 0.05).

CONCLUSIONS

It was concluded that caregivers' lack of training on CIC implementation, having chronic disease, and having frequent UTIs in their children were effective on anxiety levels.

Improved emptying performance with a new micro-hole zone catheter in adult male intermittent catheter users: A comparative multi-center randomized controlled cross-over study

AIMS

To confirm the improved performance of the micro-hole zone catheter (MHZC) compared to a conventional eyelet catheter (CEC) in male users of clean intermittent catheterizations (CICs).

METHODS

Male self-catheterizing subjects, who used hydrophilic sleeved soft/flexible CIC as the only bladder emptying method, were enrolled into a multi-center, randomized, cross-over study performed across six European sites. Subjects tested the MHZC, featuring a drainage zone with 120 micro-holes and a CEC with two eyelets. The study consisted of four study visits (V0-V3), during which endpoints related to catheter performance (urinary flow-stops, bladder emptying, and intra-catheter pressure) were measured and two 4-week test periods at home (T1 and T2) where dipstick hematuria and user perception between catheters were evaluated.

RESULTS

Seventy-three male subjects with non-neurogenic and neurogenic bladder dysfunction (3:2) were enrolled. On average, catheterizations with the MHZC led to close to mean zero flow-stops compared to ≥1 flow-stops with the CEC, during both HCP- and self-led catheterizations (both p < 0.001). Residual urine at first flow-stop was significantly reduced for the MHZC compared to CEC (p = 0.001 and p = 0.004, for HCP- and self-led catheterizations, respectively). This was substantiated by a significantly smaller pressure peak at first flow-stop, a proxy for minimized mucosal suction (both HCP- and self-led catheterizations, p < 0.001). After home-use catheterizations, dipstick hematuria was comparable between catheters, whereas catheterizations were associated with significantly improved perception in favor of MHZC regarding bladder emptying, less blocking sensation, and improved hygienic catheterization compared to the CEC.

CONCLUSION

This study confirmed the evidence of improved bladder emptying with the MHZC compared to a CEC without the need to reposition the catheter. The MHZC therefore offers an enhanced benefit for the dependent CIC user securing complete bladder emptying in an uninterrupted free flow and reducing the need to reposition the catheter during emptying.

Efficacy and safety of an alternative onabotulinumtoxinA injection paradigm for refractory overactive bladder

AIMS

In studies utilizing a 20-injection-site paradigm of onabotulinumtoxinA treatment for overactive bladder (OAB), some patients performed clean intermittent catheterization (CIC). An alternative injection paradigm of fewer injections targeting the lower bladder may reduce the need for CIC by maintaining upper bladder function. This study evaluated the efficacy and safety of an unapproved alternative 10-injection-site paradigm targeting the lower bladder.

METHODS

In this phase 4, double-blind, parallel-group study, patients with OAB and urinary incontinence (UI) for ≥6 months with ≥3 episodes of urinary urgency incontinence (no more than 1 UI-free day) and ≥8 micturitions per day over 3 days during screening were randomized 2:1 to onabotulinumtoxinA 100 U or placebo injected at 10 sites in the lower bladder.

RESULTS

Of 120 patients, 78 in the onabotulinumtoxinA group and 39 in the placebo group had efficacy assessments. In the double-blind phase, mean change from baseline at week 12 in daily frequency of UI episodes was greater with onabotulinumtoxinA (-2.9) versus placebo (-0.3) (least squares mean difference [LSMD]: -2.99, p < 0.0001). Achievement of 100% (odds ratio [OR]: 6.15 [95% confidence interval, CI: 0.75-50.37]), ≥75% (OR: 7.25 [2.00-26.29]), and ≥50% improvement (OR: 4.79 [1.87-12.28]) from baseline in UI episodes was greater with onabotulinumtoxinA versus placebo. Reductions from baseline in the daily average number of micturitions (LSMD: -2.24, p < 0.0001), nocturia (LSMD: -0.71, p = 0.0004), and urgency (LSMD: -2.56, p < 0.0001) were greater with onabotulinumtoxinA than with placebo. Treatment benefit was improved or greatly improved in the onabotulinumtoxinA group (74.0% of patients) versus placebo (17.6%) (OR: 13.03 [95% CI: 3.23-52.57]). Mean change from baseline in Incontinence Quality of Life score was greater with onabotulinumtoxinA versus placebo (LSMD: 24.2, p = 0.0012). Two of 78 (2.6%) patients in the onabotulinumtoxinA group used CIC during the double-blind period; no females used CIC during the double-blind period. Commonly reported adverse events (≥5%) were urinary tract infection (UTI), dysuria, and productive cough for both groups; rate of UTI was higher with onabotulinumtoxinA versus placebo.

CONCLUSION

In patients treated with onabotulinumtoxinA for OAB with UI, an unapproved alternative injection paradigm targeting the lower bladder demonstrated efficacy over placebo, with a low incidence of CIC.

Rectus Urinoma Leading to Abscess Following Urethral Perforation From Self-Catheterization: A Case Report

Urinomas are an accumulation of urine in the perirenal or paraureteral space due to urinary tract leakage. Stimulation of an inflammatory response results in the formation of a thick wall that encapsulates the urine. Etiologies of urinomas include trauma, surgery, or spontaneous occurrence. Complications when untreated vary and include peritonitis, fibrosis, abscess formation, and septic shock. We present a 52-year-old male with a neurogenic bladder who developed a rectus urinoma from the thorax to the scrotum. This likely developed from urethral trauma from intermittent self-catheterization. The patient received antibiotic therapy and percutaneous drainage catheters were placed in the rectus and pelvis, resolving the urinoma. We conclude that patients who perform intermittent self-catheterization may be more susceptible to formation of urinomas due to improper catheter usage. The intricate fascial connections between the pelvis and abdomen make proper interventions for suspected urinary tract injury crucial in patients who self-catheterize.

Outcomes of HUD Versus CIC in Patients With Urethral Strictures

Treatment of urethral stricture is a complex reconstructive urology treatment. Previous surgery in the treatment of urethral stricture increases the risk of urinary incontinence. Therefore, this study aimed to assess the outcome of comparing two preservative or nonsurgical methods, clean intermittent catheterization (CIC) or hydraulic urethral dilatation (HUD). Forty-eight patients diagnosed with symptomatic urethral stricture were enrolled in the study. Patients were randomly divided into two groups: Nelaton-based dilatation and HUD treatment. Patients were assessed using patient-reported outcome measure for urethral stricture surgery (USS-PROM) through direct clinical interview and were followed up for 12 months. The rate of urinary infection, the need for surgical intervention, and the patient's quality of life were considered as outcomes of the interventions. SPSS software, version 20.0, was used for statistical analysis. Overall, 23 (47.9%) patients underwent HUD of stricture and Nelaton-based dilatation of stricture was done in 25 (52.1%) patients. We found that surgical intervention was required in four patients in the HUD group, but 15 patients in the CIC group required surgical intervention. Also, the need for surgical intervention and urinary tract infection (UTI) was significantly greater in the CIC group compared with the HUD group. With respect to the patient-reported outcomes, the mean Peeling's voiding picture (Q8) and EQ-VAS score (Q16) in the HUD group (p = .02) were significantly greater than those in the CIC group (p = .02). We obtained excellent results by using an HUD catheter. This safe, simple, well-tolerated, home-based procedure reduced the need for hospital admission to operate for repeat.

Risk factors associated with recurrent febrile urinary tract infection in children with neurogenic bladder who perform clean intermittent catheterization

OBJECTIVE

To identify the clinical and urodynamic risk factors associated with the development of recurrent febrile urinary tract infections (FUTIs) in children with neurogenic bladder (NB) who perform clean intermittent catheterization (CIC).

METHODS

Children with NB receiving CIC were prospectively enrolled from January to December 2019 and followed up prospectively for 2 years. All data were compared between occasional (0-1 FUTI) and recurrent FUTIs (≥2 FUTI) groups. In addition, the risk factors for recurrent FUTIs in children were evaluated.

RESULTS

Complete data from 321 children were analyzed. Occasional FUTIs occurred in 223 patients, and 98 patients experienced recurrent FUTIs. Univariate and multivariate analyses, showed late-initiation and low-frequency CIC, vesicoureteral reflux (VUR), small bladder capacity and low compliance, and detrusor overactivity were associated with an increased risk of recurrent FUTIs. Children with high-grade VUR (grades IV-V) had a higher risk of recurrent FUTIs than those with low-grade VUR (grades I-III) (odds ratio [OR]: 26.95 vs. OR: 4.78, p < 0.001).

CONCLUSIONS

Our study suggests that late-initiation and low-frequency CIC, VUR, small bladder capacity and low compliance, and detrusor overactivity were associated with recurrent FUTIs in patients with NB. In addition, high-grade VUR is a crucial risk factor for recurrent FUTIs.

Profiling the Urobiota in a Pediatric Population with Neurogenic Bladder Secondary to Spinal Dysraphism

The human bladder has been long thought to be sterile until that, only in the last decade, advances in molecular biology have shown that the human urinary tract is populated with microorganisms. The relationship between the urobiota and the development of urinary tract disorders is now of great interest. Patients with spina bifida (SB) can be born with (or develop over time) neurological deficits due to damaged nerves that originate in the lower part of the spinal cord, including the neurogenic bladder. This condition represents a predisposing factor for urinary tract infections so that the most frequently used approach to treat patients with neurogenic bladder is based on clean intermittent catheterization (CIC). In this study, we analyzed the urobiota composition in a pediatric cohort of patients with SB compared to healthy controls, as well as the urobiota characteristics based on whether patients received CIC or not.

Episodes of Febrile Urinary Tract Infections Occur More Often in the Winter in Patients with Spina Bifida

OBJECTIVE

Febrile urinary tract infections, which commonly occur in spina bifida patients, can cause renal dysfunction. To help prevent febrile urinary tract infection occurrence, a better understanding of any seasonal tendencies would be beneficial.

MATERIALS AND METHODS

Study points evaluated included: (i) with or without febrile urinary tract infections, (ii) type of urinary management in patients with febrile urinary tract infections, (iii) number of febrile urinary tract infection occurrences, and (iv) season associated with episode. Febrile urinary tract infection was defined by medical records specifically ascribing the term and clinical presentations consistent with the diagnosis. We evaluated febrile urinary tract infection incidence per 1 person, risk odds, expected values, and chi-square analysis.

RESULTS

This study examined 140 patients (79 males, 61 females). The patient's age at the first visit ranged from 2 days to 43.7 years old (median: 3.0 years old). The observation period was 0.6-43.7 years (median: 11.5 years). (i) Febrile urinary tract infection occurred in 68 cases, (ii) urinary management included: full clean intermittent catheterization: 49 cases, autoaugmented bladder: 15 cases, self-voiding: 8 cases, clean intermittent catheterization + indwelling catheter at night time: 5 cases, self-voiding + clean intermittent catheterization: 4 cases, vesicocutaneostomy: 2 cases, (iii) number of febrile urinary tract infection episodes: 2 times or less: 40 cases, 3-5 times: 20 cases, over 6 times: 8 cases, and (iv) total number of febrile urinary tract infection episodes was 183, with spring: 41, summer: 44, autumn: 37, and winter: 61. Risk odds of the incidence (one season vs. the other season) were spring: 0.870 (P = .425), summer: 0.954 (P = .784), autumn: 0.755 (P = .120), and winter 1.497 (P = .009).

Regional variation in urinary catheter use in the Netherlands from 2012 to 2021: a population-based cohort

Objectives

Our aim was to evaluate trends and regional differences in the use of indwelling and intermittent urinary catheters in the community setting in the Netherlands from 2012 to 2021.

Design and methods

For this population-based cohort study, data on catheter use was collected from the Drug and Medical Devices Information System of the National Healthcare Institute of the Netherlands. This database contains information on the Dutch insured population, which was 100% of the total population in 2018. Users were divided into 12 provinces according to the Nomenclature of Territorial Units for Statistics codes. The number of catheter users was adjusted for the total population of the provinces by sex and age, and was expressed by users per 100,000 people. Negative binomial regression (NBR) was used to test for differences in clean intermittent catheter (CIC) and indwelling catheter (IDC) users across Dutch provinces.

Results

Between 2012 and 2021, IDC users increased by 44.6% from 41,619 to 60,172, and CIC users increased by 27.3% from 34,204 to 43,528. The greatest increases were mainly observed among IDC users over 85 years old and male CIC users over 65 years old. NBR showed significant differences for IDC and CIC users between the 12 provinces. CIC incidence was higher in Drenthe and Groningen (Northern Netherlands) compared to Zuid-Holland (Southern Netherlands). IDC incidence was higher in seven provinces dispersed throughout the Netherlands compared to Noord-Holland.

Conclusion

CIC and IDC users have continued to increase in recent years; this was especially observed among older men. In addition, there were regional differences in the number of CIC and IDC users; CIC was more prominent in the northern region of the Netherlands, and IDC varied between multiple provinces. Practice variation in urinary catheterization may result from patient population differences or healthcare provider preferences and their alignment with guidelines.

Variation of diagnosis and treatment of catheter-associated urinary tract infections: an online survey among caretakers involved

Background

The diagnosis of a clinically significant catheter-associated urinary tract infection (CAUTI) in patients performing clean intermittent catheterization (CIC) or with an indwelling catheter (IC) can be challenging.

Objective

To get an insight into the variation of the used definition, diagnosis and management of CAUTIs by relevant healthcare workers in the Netherlands.

Design

An online clinical scenario-based survey.

Methods

The survey was built in Limesurvey and distributed to healthcare workers from randomly selected urology departments, rehabilitation departments/centres and general practice offices between January and May 2022. Questions regarding their field of experience, management strategies, used guidelines and two hypothetical cases with clinical scenarios of a possible CAUTI were included.

Results

A total of 172 individuals participated, of which 112 completed the survey. In all, 32 individuals who completed the survey partially were also included. Participants consisted of 68 [44 urologists, 22 rehabilitation doctors (RDs) and 2 general practitioners (GPs)] doctors, 60 nurses (46 from the urology department and 14 from rehabilitation centres/departments) and 16 medical assistants (13 from urology department and 3 from GP offices). The majority consulted patients with an IC or on CIC on a daily/weekly or monthly basis. In all, 35 urologists (79.5%), 9 RDs (40.9%), 21 (45.7%) nurses in the urology department and 6 (42.9%) nurses from a rehabilitation department/centre indicated bladder irrigation as a treatment option for prevention/treatment of CAUTIs, treatment of symptoms or treatment of blockage of the catheter. In the clinical scenarios presented, treatment discrepancies were seen between subspecialties and healthcare workers. Various guidelines were named for the definition of CAUTIs.

Conclusion

A considerable variation in diagnoses and management of CAUTIs between the healthcare workers involved was seen. Uniformity in diagnosing and managing CAUTIs, to prevent overtreatment and possible resistance to antibiotics, is advised. Suitable multidisciplinary guidelines are preferred.

Clean intermittent catheterization in long-term management of neurogenic bladder in spinal cord injury: Patient perspective and experiences

OBJECTIVES

Bladder dysfunction due to spinal cord injury has a significant impact on the overall health and quality of life of an individual. Clean intermittent catheterization is the gold standard for bladder management and is recommended due to having the lowest complication rate. Transitions from intermittent catheterization to other less optimal strategies, such as indwelling catheter, are quite common. However, the research documenting patient perspectives, and epidemiological and demographic factors related to such transition is limited.

METHODS

Data from patients with spinal cord injury rehabilitated with clean intermittent catheterization were collected. Demographic and epidemiological details of the patients were documented from the inpatient records. Appropriate statistical tests were applied to the values.

RESULTS

Among the 45 participants, 68.89% continued clean intermittent catheterization. In those who discontinued clean intermittent catheterization, the median duration of practicing clean intermittent catheterization was 3.5 months. The commonest difficulty among compliant patients was carrying out clean intermittent catheterization in outdoor environments due to the unavailability of toilet facilities. Urinary tract infection was the most common (17.78%) complication noted. Dependence (20.00%) was a major procedural difficulty followed by pain. Adaptations to remain continent in special conditions were diapers and condom catheters. The duration of clean intermittent catheterization practiced influenced discontinuation of clean intermittent catheterization. With an increase in the duration of clean intermittent catheterization practiced after discharge, the risk of discontinuation of clean intermittent catheterization decreased with an adjusted odds ratio of 0.773 (95% confidence interval 0.609-0.982).

CONCLUSIONS

People with spinal cord injury have many challenging issues in the regulation of bladder function at their level inclusive of procedural difficulties, environmental barriers and medical complications, and understanding of which will help to establish a comprehensive and a holistic program to provide remote/community care.

Risk factors for recurrent urinary tract infection in children with neurogenic bladder following clean intermittent catheterization

OBJECTIVE

To investigate the risk factors for recurrent urinary tract infection (UTI) in children with a neurogenic bladder (NB) managed by clean intermittent catheterization (CIC).

METHODS

Over a 5-year period, we retrospectively assessed the risk factors for recurrent UTIs in children (age 9-151 months) who had CIC. All patients were followed up for more than 12 months and had at least two clinic visits during the study period. Demographic, clinical, and urodynamic parameters were assessed. All data were compared between the recurrent UTI (>1.0 UTI/study-year) and episodic UTI (≤1.0 UTI/study-year) groups.

RESULTS

Of 327 patients, 79 (24.2%) had recurrent UTIs and 248 (75.8%) had episodic UTIs. Univariate and multivariate analyses showed that older age, lumbar level lesions, long duration of NB, presence of vesicoureteral reflux (VUR), increased bladder wall thickness (BWT), and low bladder compliance were the significant factors for recurrent UTIs. Bladder trabeculation was associated with recurrent UTIs on univariate analysis, but not on multivariate analysis. During the follow-up period, chronic renal insufficiency was diagnosed in 31 (39.2%) and 29 patients (11.7%) in the recurrent and episodic UTI groups (p<0.05), respectively.

CONCLUSIONS

These results suggest that older age, high level of spinal cord lesions, long duration of NB, VUR, increased BWT, and low bladder compliance may be directly associated with recurrent UTIs in children with NB. Children with NB might have higher susceptibility to chronic renal insufficiency after recurrent UTIs.

Bladder instillation for urinary tract infection prevention in neurogenic bladder patients practicing clean intermittent catheterization: A systematic review

OBJECTIVE

To assess the efficacy and safety of different modalities of bladder instillation in patients with neurogenic bladder practicing intermittent catheterization.

METHODS

A systematic review of the literature were conducted using two databases: Medline via PubMed and Scopus. Articles evaluating bladder instillation in patients with neurogenic bladder, who are practicing intermittent catheterization, were collected and assessed for the efficacy and safety of the studied agent by two different reviewers.

RESULTS

Among the 1896 studies, eight involving 346 patients with neurogenic bladder, were included in this systematic review according to the PRISMA protocols. Gentamicin, Hyaluronic acid, and Lactobacillus rhamnosus was found to decrease the incidence of urinary tract infections, the former reduced multidrug-resistant organisms. Kanamycin-colistin, showed a drop in the mean incidence of bacteriuria in males only. Trisdine, the only studied antiseptic, significantly reduced bacteriuria. Neomycin, however, showed no efficacy in term of bacteriuria. Regarding safety, when evaluated, no major adverse events were reported with any of the studied modalities.

CONCLUSION

Bladder instillations of either antibiotics, antiseptics, hyaluronic acid, or Lactobacillus rhamnosus GG are efficient and safe in patients having neurogenic bladder, with recurrent urinary tract infections and practicing clean intermittent catheterization, with gentamicin being the most recommended product among the different studied agents.

Functional independence measure predicts the outcome of clean intermittent catheterization training in patients with multiple sclerosis

BACKGROUND

Clean intermittent catheterization (CIC) is the reference treatment of urinary retention in people with multiple sclerosis (pwMS). Predicting which patients could use this treatment, based on their motor and cognitive abilities, is crucial.

OBJECTIVES

To determine whether the Functional Independence Measure (FIM), used to assess degree of disability, can predict the outcome of CIC training in pwMS.

METHODS

All pwMS attending a tertiary neurourology department between 2011 and 2019 and eligible for CIC were included in this retrospective study. Level of disability was assessed with the FIM by an occupational therapist. Success for learning CIC, defined as the ability to perform at least 2 trials of the technique, was recorded at the end of the session by a continence nurse and a physiatrist. The association between the FIM and success for learning CIC was assessed by multivariable analysis.

RESULTS

We included 395 patients (mean [SD] age 49.8 [12.0] years; 70% women). More than half of patients had relapsing-remitting disease, and the Expanded Disability Status Scale score was ≥ 6. Mean FIM total, motor and cognitive scores were 108.0 (14.2), 75.9 (12.3) and 32.1 (3.7), respectively (maximal scores: 126, 91 and 35). At the end of the session, 87% of patients were successful in learning CIC. After adjustment of potential confounding variables including age, sex, obesity and EDSS score, FIM total, motor and cognitive subscores were significantly associated with success (odds ratio [95% confidence interval] 1.06 [1.03-1.08], 1.05 [1.03-1.08], 1.21 [1.12-1.32], respectively).

CONCLUSIONS

FIM was an independent predictor of successful CIC training in pwMS. A 1-point increase in FIM was associated with 6% increased odds of successfully mastering the CIC technique. A widespread use of the FIM could help determine the different cognitive and/or motor objectives that need to be improved before CIC teaching.

Benzalkonium chloride induced corrosive balanoposthitis in a man requiring clean intermittent catheterization

INTRODUCTION

Men who require intermittent catheterization may be susceptible to balanoposthitis. Benzalkonium chloride is commonly used to disinfect reusable catheters, but the concentration of this solution is critical.

CASE PRESENTATION

A 40-year-old man presented with fever, pus around the glans and foreskin, and difficult catheterization. On physical examination, his urethral meatus was too narrow to insert a catheter. Suprapubic catheterization and 2 weeks of intravenous and topical treatment cured the ulcer of the glans. However, after restarting catheterization, the ulcer of the glans relapsed, and the patient's urethral meatus was completely closed. Circumcision and incision of the meatus were performed, and antibiotics were administered. Unexpectedly, restarting catheterization caused recurrent balanoposthitis. Close inquiry revealed that the patient was using a 10% benzalkonium chloride soaking solution for a reusable catheter, which was a toxic concentration.

CONCLUSION

The disinfectant concentration should be confirmed when refractory balanoposthitis is encountered in patients who require catheterization.

Trends in the use and costs of intermittent urinary catheters in the Netherlands from 1997 to 2018: A population-based observational study

AIM

To obtain insight into the the use and costs of clean intermittent catheterization (CIC) in the Netherlands from 1997 to 2018.

METHODS

For this population-based study, data on the use and costs of disposable catheters were provided by the Drug Information Project database. This database contains information about the Dutch insured population, which increased from 9.9 to 17.1 million persons between 1997 and 2018 (64%-100% of the Dutch population). The following trends were evaluated: (1) CIC users, (2) distribution of users by gender and age-group, (3) distribution of users by neurogenic and non-neurogenic cause for CIC, (4) total costs, and (5) costs per user. Total users are adjusted for the Dutch population. Costs are corrected for inflation and expressed in euros.

RESULTS

Extramural use of CIC increased from 14,258 users in 1997 to 45,909 users in 2018. CIC users per 100,000 persons nearly tripled from 92 users to 267 users. Male CIC users almost quadrupled from 92 to 334 per 100,000 insured persons, whereas female users more than doubled from 91 to 201 per 100,000 insured persons. In 2018, 49% of the users had a non-neurogenic cause for CIC. Total costs increased from 16.4 million euros in 1997 to 74.6 million euros in 2018. Costs per user rose from 1151 to 1624 euros (41.1%).

CONCLUSIONS

The use and costs of disposable catheters in the Netherlands increased substantially over the past two decades. Non-neurogenic bladder patients represent 49% of the population on CIC, which has not been described before in the literature.

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.

Acute Urinary Retention from Knotted Urethral Catheter Treated with Holmium Laser Ablation

Background: Straight catheters are usually used for clean intermittent catheterization (CIC). Patients perform CIC without much difficulty. Spontaneous knotting of catheter is rare in large bore straight catheters and female patients. Case Presentation: A 50-year old lady, case of neurogenic bladder on CIC inserted a 14F straight catheter, drained some urine but was unable to remove the catheter. She presented in emergency with retention of urine. Her X-ray and ultrasound examination revealed a knotted catheter. Conservative measures to remove the catheter such as forceful injection of radio-opaque contrast and passage of hydrophilic guidewire did not work. She was taken in the operating room. The knot was ablated using holmium laser through transurethral passage of an 8F ureteroscope. Conclusions: Spontaneous knotting of urethral catheter is rare in adults. It should be suspected whenever a straight catheter cannot be removed. Inserting excessive length of catheter is an important risk factor. Holmium laser is an excellent tool to cut the catheter in a least invasive way when conservative measures have failed.

Impact of clean intermittent catheterization on quality of life of patients with neurogenic lower urinary tract dysfunction due to radical hysterectomy: A cross-sectional study

AIMS

We investigated the quality of life (QOL) of a homogenous group of ambulant patients with neurogenic lower urinary tract dysfunction without significant comorbidities to elucidate the impact of clean intermittent catheterization (CIC) on QOL.

METHODS

The subjects were 71 female patients who underwent radical hysterectomy (RH) without recurrent disease. QOL was cross-sectionally measured with the Short-Form 36-Item Health Survey (SF-36) and King's Health Questionnaire (KHQ). We divided urinary management into spontaneous voiding (SV) and CIC as well as postoperative elapsed time into the entire period, less than 24 months (<24 months) and 24 months or more (≥24 months).

RESULTS

Patients with CIC showed significantly poorer QOL than patients with SV in some subscale/domain scores on SF-36 and KHQ for the entire period as well as <24 months after RH. In contrast, significant differences were not revealed between scores on both measures of patients with CIC and SV ≥24 months after RH. Moreover, in patients with CIC ≥24 months, some subscale/domain scores on both measures were significantly better than in those with <24 months. Norm-based scoring of SF-36 revealed that all subscales of patients with CIC <24 months were below the average score of healthy Japanese people, while only four subscales of those ≥24 months remained below the average.

CONCLUSIONS

QOL in patients with CIC was worse than in patients with SV in the short term, but similar in the long term, which suggests that QOL probably might improve with time in patients with CIC.

A case of female adrenoleukodystrophy carrier with insidious neurogenic bladder

A 65-year-old woman with mutation of the ABCD1 gene for adrenoleukodystrophy (ALD) was admitted to our hospital with a urinary tract infection. Abdominal computed tomography showed dilation of the urinary tract. Although she had noticed pollakisuria since her forties, she had not been followed up by any medical institutions until we diagnosed her as a female carrier with ALD. ALD is an X-linked pattern of inheritance that typically affects males, but many female carriers actually present slowly progressive myelopathy and neuropathy. Therefore, it is important to identify female carriers with ALD and treat them at the earliest stage possible.

Feasibility, complication and long-term follow-up of the newly nelaton based urethral dilation method, retrospective study

Introduction: Current methods for Urethral dilatation include filiforms and followers, metal sounds, balloon dilators, catheters of increasing size, introduction of a Council catheter over a guidewire, and coaxial dilators of increasing size. These methods however are effective but expensive and use of them is limited in many third world countries. In this retrospective study, we report the feasibility, complication and long-term follow-up of the newly Nelaton based urethral dilation method following by self calibration plan as a single referral center experience. Method: We reviewed the records of 333 men with urethral stricture longer than 1 cm over a 16-year period between March 2001 to December 2018. In this method the straight flexi-tip guide-wire is introduced through the urethra and advanced under cystoscopic vision. This wire then was used to guide the dilatation after withdrawal of the cystoscope. The tip of well-lubricated Nelaton urethral catheters incised and then advanced gently over the guide-wire serially from the smallest to the largest appropriate sizes. The patients were followed up regularly after the dilatation 1, 3, 6, 12 months and then annually postoperatively with taking history, PVR and uroflowmetry and all underwent retrograde urethrography at the 6^th and 12^th months of follow-up. Result: The mean age of patients was 39.19±16.9 years old (10 to 86 years). The mean period of the follow-up was 3.6±1.1 years (range, 3 to 4.3 years). Success rate after first attempted was 58.5% and after two attempted was 77.7% in two years follow up. After one year 51 (15.3%), two years 23 (6.9%) and after three years 11 (3.3%) cases required continued self dilatation once a month. Conclusion: Guide wire-assisted urethral dilatation is shown to be acceptable, cost-effective, simple, safe and feasible techniques for urethral dilation. Our technique may be the choice manner in selected patients with short memberanous urethral stricture, because of decrease the risk of incontinency.

Underactive bladder: A review of the current treatment concepts

According to the International Continence Society standardization reports, underactive bladder (UAB) is a decrease in detrusor contraction and/or shortening of the contraction time, resulting in an incomplete and/or prolongation of the bladder emptying within the normal time frame. It has been indicated that idiopathic, neurogenic, myogenic, and iatrogenic factors play a role in the etiology. To make a diagnosis, it is absolutely necessary to perform a pressure-flow study. Treatment alternatives are generally based on the evacuation of the lower urinary tract, independent of the etiology. UAB treatments are listed under the headings of conservative methods and clean intermittent catheterization, pharmacotherapy (alpha-blockers, cholinesterase inhibitors, muscarinic agonists, prostaglandin E2, and acotiamide), surgical treatments (sacral nerve stimulation-electrical stimulation, injections into the external sphincter, surgeries to be performed for bladder outlet obstruction, reduction cystoplasty, and latissimus dorsi detrusor myoplasty), and stem cell and gene therapies. It is still controversial whether satisfactory success is achieved in the treatment of patients with UAB. Owing to the better understanding of the pathophysiology, future developments in the pharmaceutical industry, gene therapy, and biomedical applications are expected to close the gap in the treatment.

Implications of Bacteriuria in Myelomeningocele Patients at Time of Urodynamic Testing

Objective: To identify those myelomeningocele (MMC) patients at risk for post-urodynamic study (UDS) complications. We hypothesized that patients who manage their bladder with clean intermittent catheterization (CIC) would have a greater risk of post-instrumentation complications due to higher rates of bacteriuria compared to those who freely void (FV). Design/Methods: Urine was collected from patients with MMC without augmentation cystoplasty undergoing routine renal ultrasound or urodynamic study (UDS). Samples were divided into those with bacteriuria (urine culture ≥10,000 colony-forming units) and those without. Post-UDS complications were evaluated and compared between CIC and FV patients. Results: A total of 91 urine samples from 82 total MMC patients were included for evaluation. Significantly more patients on CIC than those who FV had bacteriuria (67% vs 33%, p = .0457). From these urine samples, 54 were obtained at time of UDS of which 45 were from patients on CIC and 9 from FV patients. More patients on CIC had bacteriuria at the time of UDS than those who FV (60% vs 33%, respectively), but this did not reach significance (p = .1416). No patient with bacteriuria on CIC had a complication after UDS while one FV patient with bacteriuria developed post-UDS pyelonephritis. Conclusion: MMC patients with bacteriuria on CIC did not have post-UDS complications. Patients with bacteriuria who FV may be at particular risk for post-instrumentation UTI, providing guidance as to which MMC patients should undergo urine testing prior to UDS in order to prevent post-instrumentation pyelonephritis.

A new bladder-emptying method in females with neurogenic bladder: A randomized, phase II trial

AIM

To evaluate the performance of the new device compared with clean intermittent catheterization (CIC).

METHODS

From March 2015 to March 2018, patients who were admitted to the urologic outpatient clinic. A new intraurethral self-retaining device (ISRD) was made of medical grade silicone and it was inspired by similar catheters that use sliding disks to adjust or fix tubes used to drain the bladder. Patients were randomized into two groups (experimental group [GI]-ISRD vs control group [GII]-CIC). The evaluation was performed at the time of enrollment and 6 months after treatment. Intervention was initiated from the antisepsis of the perineal region and subsequent introduction of the device through the external urethral meatus. The primary outcome was quality of life (QOL). Urinary tract infections (UTIs) episodes, data on urodynamic parameters, adverse effects and number of diapers per day.

RESULTS

A total of 177 subjects were analyzed. We found a significant improvement on QOL analysis in the ISRD group (P < .01). ISRD group presented an important reduction (two episodes after ISRD use) on number of UTIs (P < .01) and diaper use, and significant improvement on bladder capacity (80 mL of the average improvement) (P < .01) and compliance (P = .01). Among all registered serious adverse effects, ISRD presented with lower proportion.

CONCLUSIONS

The new device has shown to be a safe and promising alternative for adequate emptying of the neurogenic bladder in female patients. Our study has a limitation that is related to a limited period of observation.

Effect of continuous care intervention on the quality of life in patients with neurogenic bladder dysfunction

Objective

This study aimed to evaluate the effect of continuous care intervention on the quality of life (QoL) of patients with neurogenic bladder.

Methods

Eighty-two patients with neurogenic bladder dysfunction caused by spinal cord injury were included into the study. All of the patients had continuous care intervention (for 3 months), including clean intermittent self-catheterization, drinking guidance, and bladder training guidance. A health record was established for each patient before discharge and was used to record changes in the patients when followed up. Scores of QoL, which were based on the World Health Organization Quality of Life-BREF, occurrence of complications, and compliance of all patients were recorded.

Results

After 3-month care intervention, there were significantly fewer complications than before the intervention. Patients’ compliance and QoL were significantly higher after 3 months of care intervention than before the intervention.

Conclusion

Continuous care intervention can improve patients’ compliance and reduce urinary complications.

Do appreciable changes in the upper extremity motor capability to perform clean intermittent catheterization come about with time after traumatic spinal cord injury?

INTRODUCTION

Bladder dysfunction after spinal cord injury (SCI) often requires clean intermittent catheterization (CIC) or other management strategies. A common dilemma in those desiring to perform CIC independently but lacking the appropriate upper extremity (UE) motor function is the timing of reconstructive surgery.

METHODS

We assessed the National Spinal Cord Injury Data Set for the years 2000-2016. Our cohort consisted of persons with cervical SCI, who underwent complete motor examination upon discharge from rehabilitation and at 1-year follow-up. Using a previously published algorithm, UE motor scores were transformed to predict a patient's ability to independently perform CIC. Improvements in the predicted ability to self-catheterize were evaluated.

RESULTS

Of the 1428 individuals meeting the inclusion criteria, improvements in the predicted UE motor function necessary to independently self-catheterize were observed in 39%, 42%, and 38% of those deemed possibly able, only able with surgical assistance, or unable to self-catheterize at rehabilitation discharge, respectively. On multivariate analysis, only increasing Association Impairment Scale (AIS) classification and AIS classification improvement over the first year were associated with an increased odds of improving predicted CIC ability (odds ratio [OR] = 1.44 for AIS C and 1.97 for AIS D compared with AIS A, and OR = 1.90 for AIS classification improvement versus stable AIS classification, P < 0.05 for each).

CONCLUSION

Improvements in UE motor function to independently perform CIC occur in approximately 40% of persons with cervical SCI in the first year after rehabilitation discharge. Those with incomplete injuries are more likely to improve. These findings should enhance patient bladder management counseling and guide surgeons in determining an appropriate timeline for offering reconstruction.

The prevalence and outcome of children with failure to thrive after pediatric kidney transplantation

BACKGROUND

Prior to transplantation, effects of advanced CKD contribute to malnutrition and impaired growth. After transplant, children are expected to thrive, however, in a subset of transplant recipients this does not occur. Factors associated with post-transplant FTT are poorly understood.

OBJECTIVE

A retrospective cohort study was conducted to determine factors associated with FTT and association of FTT with infections and hospitalizations.

METHODS

Records of 119 children transplanted between 2005 and 2016 were reviewed. FTT was defined by ≥2 of the following post-transplant criteria: (a) low BMI or deceleration in BMI z-score, (b) poor growth velocity, and (c) chronic hypoalbuminemia at 1 or 3 years post-transplant. Association of FTT with deceased donor transplant, de novo DSA, intolerance to MMF, anemia, vitamin D deficiency, and CIC was investigated by logistic regression. Poisson regression was used to identify outcomes associated with FTT.

RESULTS

Low pre-transplant BMI and post-transplant CIC dependence were independently associated with FTT after transplant. Odds of FTT at 1 year post-transplant decreased by 0.5 for each 1 unit increase in pre-transplant BMI z-score. Requirement for CIC conferred 3.8 and 7.8 higher odds of FTT at 1 and 3 years. Patients with FTT had 2.7 and 2.6 times infections and hospitalizations during the first year, and 4.2 and 4.3 times infections and hospitalizations over 3 years post-transplant.

CONCLUSIONS

Children with low BMI prior to transplant and those requiring CIC after transplant are at increased risk for post-transplant FTT. FTT is associated with adverse outcomes, evidenced by increased infections and hospitalizations.

Age and factors associated with self-clean intermittent catheterization in patients with spina bifida

PURPOSE

The purpose of this study is twofold: 1) to determine the age when a child with spina bifida (SB) will most likely transition from caregiver clean intermittent catheterization (CIC) to self-CIC, and 2) to identify factors associated with self-CIC in children older than that age.

METHODS

This is a retrospective, single-institution cohort study of individuals with SB. Data were collected prospectively as part of the National Spina Bifida Patient Registry. For Aim 1, we identified all individuals who perform self-CIC and who had a documented transition from caregiver-CIC. We then determined the age of transition to self-CIC. For Aim 2, we compared individuals over age 10 years (age cutoff determined by Aim 1) who use self-CIC to those who use caregiver-CIC to determine what variables were associated with self-CIC.

RESULTS

From our SB population, 206 individuals used self-CIC. Of these, 64 patients had documented ages of transition from caregiver- to self-CIC. 46 (71.9%) and 56 (87.5%) patients had transitioned to self-CIC by 10 and 14 years, respectively. For Aim 2, we used age 10 as a cutoff, based on the findings from Aim 1, and found that 287/696 patients were ⩾ 10 years and using CIC. Factors independently associated with lower likelihood of self-CIC were thoracic spinal lesions (odds ratio (OR) 0.45) and Medicaid insurance (OR 0.24).

CONCLUSIONS

The ages at self-CIC transition vary, although most patients transition by age 10. Thoracic-level spinal lesions and Medicaid insurance are associated with lower odds of self-CIC.

Expectant use of CIC in newborns with spinal dysraphism: Report of clinical outcomes

PURPOSE

Report urologic outcomes among newborns with spinal dysraphism managed within an expectant clean intermittent catheterization (CIC) program.

METHODS

Newborns were followed clinically and with serial ultrasound (US). Urodynamics (UD) and dimercaptosuccinic acid (DMSA) renal scan were obtained at 3-6 months, 1 year, 3 years, then as needed. Patients with initial evaluation after 6 months were excluded.

RESULTS

Median follow-up was 3.2 years. 11/102 began catheterization for continence (median 4.0 years) and 47/102 did not start CIC. Of these, 2/58 developed a DMSA abnormality. 44/102 began CIC early, often for elevated storage pressures and febrile urinary tract infection (UTI). Of these, 20/44 developed a DMSA abnormality including 9 who had abnormality detected prior to starting CIC. Being on CIC or starting immediately upon recognition of new hydronephrosis, reflux, elevated filling pressures, or febrile UTI was associated with lower chance of DMSA abnormalities (4/17, 24%) compared to delaying CIC (16/27, 60%) (p= 0.03).

CONCLUSIONS

CIC can be deferred until continence in select infants with a low risk of significant DMSA abnormality. However, immediate initiation of CIC upon recognition of risk factors is recommended as this was associated with fewer DMSA abnormalities than delaying CIC. Recommendations for expectantly-managed patients include close follow-up, serial US and UD, and prompt initiation of CIC upon recognition of new hydronephrosis, reflux, elevated storage pressures, or febrile UTIs.

Frequency of Multidrug-Resistant Organisms Cultured From Urine of Children Undergoing Clean Intermittent Catheterization

BACKGROUND

Children undergoing CIC frequently have positive urine culture results and receive many antimicrobial agents. Subsequently, this population is at high risk for infections caused by antimicrobial-resistant bacteria. Resistant pathogens, such as vancomycin-resistant Enterococcus (VRE), carbapenem-resistant Enterobacteriaceae (CRE), and organisms that produce extended-spectrum β-lactamases (ESBLs), which are third-generation cephalosporin resistant (3GCR), are of particular concern.

METHODS

In this retrospective study, all urine culture results and antimicrobial-susceptibility testing results were obtained between January 2008 and December 2014 from the electronic health record of children ≤18 years of age who were undergoing CIC (n = 14 832). Isolates were identified as VRE, CRE, or 3GCR. Organisms of the same type that were obtained in the same year and with identical antibiotic susceptibilities from the same patient were excluded. Simple linear regression was used to determine the association between year and rates of resistance.

RESULTS

A total of 3997 positive culture results were included in this analysis. Of all Enterococcus isolates for which susceptibility results were available, 4.6% were VRE, 11.1% of all isolates that belonged to the Enterobacteriaceae family were 3GCR, and 0.4% of eligible isolates were CRE. There were significantly higher rates of resistance to third-generation cephalosporins and CRE in 2014 than in 2008 (P < .01). Simple linear regression revealed a significant association between year and rate for resistance to third-generation cephalosporins but not for CRE or VRE. The rate of increase in resistance to third-generation cephalosporins in patients who required CIC was higher than that in patients who did not need CIC.

CONCLUSIONS

The rate of resistance to third-generation cephalosporins has increased significantly in the past 7 years in children undergoing CIC, which indicates that careful monitoring is warranted for continued increases in antimicrobial-resistant organisms in this unique patient population.

Predictors of long-term bladder management in spinal cord injury patients-Upper extremity function may matter most

INTRODUCTION

Clean intermittent catheterization (CIC) is the gold standard for neurogenic bladder management in most patients with spinal cord injury (SCI). There is nonetheless a lack of long-term adherence to CIC, with up to 50% discontinuance at 5-year follow-up. We hypothesize that limitations in upper extremity (UE) motor function represent a strong predictor for long-term CIC adoption.

METHODS

We assessed Forms I and II data from the 2000-2013 National SCI Database. Bladder management was determined at initial discharge and 1-year follow-up. Upper extremity (UE) motor scores were transformed using a previously published algorithm to predict a patient's ability to independently self-catheterize. Uni- and multivariable logistic regression modeling was performed to assess risk factors affecting: a) a lack of CIC adoption at rehabilitation discharge, b) CIC discontinuance by 1-year follow-up (CIC "dropout"), and c) adherence to management with an indwelling catheter rather than conversion to CIC at 1-year follow-up.

RESULTS

For all three modeled scenarios, UE motor function represented the most significant predictor for lack of CIC adoption (OR range 2.1-6.3, P ≤ 0.003 for all). Other predictors included increasing age (OR 1.01-1.02, P ≤ 0.001 for all models) and female gender (OR 1.6-1.7, P < 0.001 for lack of CIC adoption at discharge).

CONCLUSIONS

Among physically limiting factors, impairment in UE motor function appears to be the most significant predictor of a lack of long-term CIC adoption at 1-year follow-up.

Risk of urinary retention after nerve-sparing surgery for deep infiltrating endometriosis: A systematic review and meta-analysis

AIMS

Recently, nerve-sparing (NS) techniques have been incorporated in surgeries for deep infiltrating endometriosis (DIE) to prevent urinary complications. Our aim was to perform a systematic review and meta-analysis to assess the risk of urinary retention after NS surgery for DIE compared with classical (non-NS) techniques.

METHODS

Following the MOOSE guidelines for systematic reviews of observational studies, data were collected from published research articles that compared NS techniques with non-NS techniques in DIE surgery, with regard to post-operative urinary complications.

INCLUSION CRITERIA

randomized clinical trials, intervention or observational (cohort and case-control) studies assessing women who underwent surgery for painful DIE.

EXCLUSION CRITERIA

cancer surgery and women submitted to bladder or ureteral resections. The respective relative risks (RR) and 95% confidence intervals (CI) were extracted and a forest plot was generated to show individual and combined estimates.

RESULTS

Preliminarily, 1,270 potentially relevant studies were identified from which four studies were selected. A meta-analysis was performed to assess the risk of urinary retention at discharge and 90 days after surgery. We found a common RR of 0.19 [95%CI: 0.03-1.17; (I² = 50.20%; P = 0.09)] for need of self-catheterization at discharge in the NS group in relation to the conventional technique. Based on two studies, common RR for persistent urinary retention (after 90 days) was 0.16 [95%CI: 0.03-0.84].

CONCLUSIONS

Our results suggest significant advantages of the NS technique when considering the RR of persistent urinary retention. Controlled studies evaluating the best approach to manage the urinary tract after complex surgery for DIE are needed. Neurourol. Urodynam. 36:57-61, 2017. © 2015 Wiley Periodicals, Inc.

Effects of electroacupuncture combined with clean intermittent catheterization on urinary retention after spinal cord injury: a single blind randomized controlled clinical trial

PURPOSE

This study aimed to evaluate the therapeutic effects of electroacupuncture (EA) combined with clean intermittent catheterization (CIC) on spinal cord injury (SCI) induced urinary retention.

METHODS

A total of 107 patients with SCI induced urinary retention were randomly divided into 3 groups, including group 1 (CIC treatment), group 2 (EA combined with CIC treatment), and group 3 (sham acupuncture combined with CIC treatment). After different treatments, the residual urine volume, voided volume (each time), number of bladder balance patients, and frequency of CIC were recorded and compared.

RESULTS

There were no significant differences between group 1 and 3 in number of bladder balance patients and voided volume (ml) at the 1(st) month. The rate of patients reaching bladder balance was significantly higher in group 2 than group 1 and 3 (P<0.05). The frequency of CIC was significantly less in group 2 than the other groups (P<0.001). The voided volume at the 1(st) and the 3(rd) month after surgery was significantly higher in group 2 than that in group 1 and 3 (P<0.001). Meanwhile, after 1 month and 3 months of treatment, residual urine volume was significantly reduced in group 2 compared with that in group 1 and 3 (P<0.001).

CONCLUSION

The therapeutic effects of EA were effective for SCI induced urinary retention by reducing residual urine volume and the frequency of CIC, increasing voided volume, and promoting the balance of vesical function.

Urinary tract infections in children with myelodysplasia in whom clean intermittent catheterization was administered

AIM

In this study, it was aimed to evaluate the frequency of significant bacteriuria and antibiotic resistance characteristics in children with myelodysplasia in whom clean intermittent catheterization was administered.

MATERIAL AND METHODS

The study group was composed of 71 patients with myelodysplasia who were found to have significant bacteriuria (age: 8.20±4.57 years; 39 girls) and the control groups was composed of 49 children who were diagnosed with community-acquired urinary tract infection (age: 7.94±4.17 years; 29 girls). The patient and control groups were evaluated in terms of the microorganisms grown in urinary cultures and antibiotic resistance characteristics. The study approved by the ethics committe (14/02/2012-19/E).

RESULTS

Growth of Escherichia coli (E. coli) was found with the highest rate in myelodysplasic patients. However, when compared with the control group in terms of microorganism types, an increase in the growth rates of the microorganisms excluding E. coli was observed in the patients with myelodysplasia which was close to the significance limit (p=0.055). When antibiotic resistance properties were examined, a significantly increased resistance against cotrimaxazole was found in the patient group compared to the control group (p=0.001). 84.5% of the patients were using prophylactic antibiotic including mainly co-trimoxazole. A significantly increased co-trimoxazole resistance was also found in the patients who were using prophylactic antibiotic compared to the patients who were not using prophylactic antibiotic (p=0.025). The rate of symptomatic UTI was found to be 21% in the patients with myelodysplasia and a significant increase was found in the complaints of abdominal/side pain and nausea/vomiting as well as fever in these patients compared to the patients with asymptomatic bacteriuria (p=0.029 and p=0.032, respectively).

CONCLUSION

Our results show that UTI is still a significant problem in patients with myelodysplasia. In addition, they show that use of prophylactic antibiotic may increase the frequency of development of resistance and co-trimoxazole used for this objective is not a good option..

Eosinophilic cystitis in the pediatric population: a case series and review of the literature

PURPOSE

Eosinophilic cystitis is a rarely seen condition in the pediatric population with indistinct symptomatology and non-standardized treatment protocols. We review our experience of treating patients with this condition.

MATERIALS AND METHODS

We retrospectively reviewed the records of four patients from a single institution who have been diagnosed and treated for eosinophilic cystitis. In addition, the literature was reviewed for cases of pediatric eosinophilic cystitis. Our patients were added and compared to this cohort.

RESULTS

Our patients included 3 females and 1 male who range in age from 5 days to 18 years (5 days, 1 month, 7 years, 18 years). Both of the infants presented with a suprapubic mass and bilateral hydroureteronephrosis. The two older patients both had dysuria while the 18 yo also complained of fatigue, flank pain, and hematuria. Only 2 of the 4 patients were found to have significant peripheral eosinophilia and only one patient had eosinophiluria. All of the patients were diagnosed via cystourethroscopy with biopsy. Treatment in each case consisted of a combination of steroids, antihistamines, and antibiotics.

CONCLUSIONS

The presentation of eosinophilic cystitis is varied and diagnosis requires a high index of suspicion. Cystourethroscopy with biopsy is essential to establish the diagnosis as there is no typical appearance of the lesions or presenting signs/symptoms. Most cases of eosinophilic cystitis are responsive to medical therapy although in some cases recurrence may be noted.

Effects of intravesical electrical stimulation therapy on urodynamic patterns for children with spina bifida: a 10-year experience

OBJECTIVE

Intravesical electrical stimulation (IVES) has been performed for various purposes in children with a neurogenic bladder. We evaluated the results of IVES on urodynamic study parameters in children with spina bifida.

METHODS

We retrospectively analyzed the cases of 88 children who received IVES between August 1999 and May 2010 and whose comparative urodynamic data were available before and after treatment. According to the pre-IVES urodynamic study, children were divided into 3 groups: detrusor overactivity, detrusor underactivity and acontractile detrusor. We investigated the changes in detrusor function, bladder capacity and detrusor-sphincter dyssynergia.

RESULTS

In the group showing detrusor overactivity, the bladder had a synergic pattern in 41.7%, and normal detrusor function was observed in 16.7% of them. Bladder capacity increased after IVES therapy, especially in those who started therapy before 18 months of age (p = 0.019). Detrusor-sphincter dyssynergia was resolved in 55.6%. In the acontractile detrusor group, detrusor contraction ability increased in 48%, but bladder capacity did not.

CONCLUSIONS

Appropriate candidates for this treatment need to be carefully selected.

Preventing kidney injury in children with neurogenic bladder dysfunction

The most common cause of neurogenic bladder dysfunction (NBD) in newborn infants is myelomeningocele. The pathophysiology almost always involves the bladder detrusor sphincter dyssynergy (DSD), which if untreated can cause severe and irreversible damage to the upper and lower urinary tracts. Early diagnosis and adequate management of NBD is critical to prevent both renal damage and bladder dysfunction and to reduce chances for the future surgeries. Initial investigation of the affected newborn infant includes a renal and bladder ultrasound, measurement of urine residual, determination of serum creatinine level, and urodynamics study. Voiding cystogram is indicated when either hydronephrosis or DSD is present. The main goal of treatment is prevention of urinary tract deterioration and achievement of continuance at an appropriate age. Clean intermittent catheterization (CIC) in combination with anticholinergic (oxybutynin) and antibiotics are instituted in those with high filling and voiding pressures, DSD and/or high grade reflux immediately after the myelomeningocele is repaired. Botulium toxin-A injection into detrusor is a safe alternative in patients with insufficient response or significant side effects to anticholinergic (oral or intravesical instillation) therapy. Surgery is an effective alternative in patients with persistent detrusor hyperactivity and/or dyssynergic detrusor sphincter despites of the CIC and maximum dosage of anticholinergic therapy. Children with NBD require care from a multidisciplinary team approach consisting of pediatricians, neurosurgeon, urologist, nephrologists, orthopedic surgeon, and other allied medical specialists.

Outcomes of incontinent ileovesicostomy in the pediatric patient

PURPOSE

Ileovesicostomy is a reconstructive option in complex urological cases but pediatric specific outcomes are lacking. We report our results with pediatric ileovesicostomy.

MATERIALS AND METHODS

We retrospectively evaluated patients younger than 18 years undergoing incontinent ileovesicostomy at Vanderbilt University. History, urinary tract management and operative course were reviewed in the electronic medical record. Particular attention was given to immediate and long-term postoperative complications.

RESULTS

Nine patients underwent incontinent ileovesicostomy between 2000 and 2013 at a mean age of 10.3 years (range 1.4 to 15.5). Surgical indication was sequelae of neurogenic or nonneurogenic neurogenic bladder (such as infection or worsening hydronephrosis) in 5 patients, reversal of vesicostomy in 3 and closure of cloacal exstrophy in 1. All 9 patients were thought incapable of reliable clean intermittent catheterization due to family unwillingness, poor social support or patient refusal. Median followup was 11.5 months (mean 48.2, range 1.3 to 144.8). Immediate postoperative complications included ileus requiring total parenteral nutrition and a wound infection in 1 patient. Long-term complications included urinary tract infection in 2 patients (febrile in 1 and positive culture for foul smelling urine in 1), stomal issues in 2 and temporary urethral leakage in 1. Constipation affected 3 children in long-term followup (all with neurogenic bowel preoperatively). Postoperative creatinine was stable or improved in all patients.

CONCLUSIONS

Ileovesicostomy is a viable approach in children left with few other options, particularly those who are noncompliant or physically/socially unable to handle catheterization. This operation can help keep such patients out of diapers.

Promising long-term outcome of bladder autoaugmentation in children with neurogenic bladder dysfunction

PURPOSE

We evaluated the long-term outcome of bladder autoaugmentation in children with neurogenic bladder dysfunction.

MATERIALS AND METHODS

Data were compiled from the records of 25 children with a median age of 9.3 years (range 0.9 to 14.2) who underwent detrusor myotomy between 1992 and 2008. All patients were diagnosed with small bladder capacity, low compliance and high end filling pressures, and were unresponsive to clean intermittent catheterization and anticholinergics.

RESULTS

Median followup was 6.8 years (range 0.1 to 15.6). Median postoperative bladder capacity was unchanged or decreased to 95 ml (range 25 to 274) during the first 3 months compared to a median preoperative capacity of 103 ml (14 to 250). At 5 months postoperatively median bladder capacity increased significantly to 176 ml (range 70 to 420, p<0.01). This increase remained significant during the rest of followup. Median bladder compliance doubled after 1 year to 10 ml/cm H2O (range 1 to 31, p<0.05) compared to the preoperative level, and further increased to 17 ml/cm H2O (5 to 55) at 5 years (p<0.05). Median maximal detrusor pressure was 43 cm H2O (range 8 to 140) preoperatively. This value decreased significantly postoperatively (p<0.01) and at final followup it was 26 cm H2O (range 6 to 97). Kidney function developed normally in all patients except 1 with persistent uremia. Reflux was alleviated in 7 of 9 cases. Of the patients 18 became continent on clean intermittent catheterization.

CONCLUSIONS

Bladder autoaugmentation in children with neurogenic bladder dysfunction offers, after a transient decrease in bladder capacity, a long lasting increase in capacity and compliance, while the end filling pressure decreases.

Intermittent catheterization and recurrent urinary tract infection in spinal cord injury

PURPOSE

To study the association of recurrent symptomatic urinary tract infections (UTIs) with the long-term use of clean intermittent catheterization (CIC) for the management of neurogenic bladder in patients with spinal cord injury (SCI).

METHODS

Retrospective study of 61 SCI patients with neurogenic bladder managed by CIC. Subjects were selected from 210 SCI patients seen at the Yale Urology Medical Group between 2000 and 2010. Medical UTI prophylaxis (PRx) with oral antimicrobials or methenamine/ascorbic acid was used to identify patients with recurrent UTI. The number of positive cultures (≥10(3) cfu/mL) within a year prior to starting PRx was used to confirm the recurrence of UTI.

RESULTS

Fifty-one male and 10 female subjects were managed with CIC. Forty-one (67%) subjects were placed on medical PRx for symptomatic recurrent UTI. Seventeen (28%) subjects had at least 3 positive cultures within the year prior to starting PRx. Fifteen of 20 (75%) subjects not on PRx had no complaints of UTI symptoms in the final year of follow-up.

CONCLUSION

Recurrent symptomatic UTIs remain a major complication of long-term CIC in SCI patients. Although CIC is believed to have the fewest number of complications, many SCI patients managed with long-term CIC are started on medical PRx early in the course of management. Future studies are needed to determine the efficacy of routine UTI PRx in these patients as well as determine what factors influence why many patients on CIC experience frequent infections and others do not.

Bladder management methods and urological complications in spinal cord injury patients

BACKGROUND

The optimal bladder management method should preserve renal function and minimize the risk of urinary tract complications. The present study is conducted to assess the overall incidence of urinary tract infections (UTI) and other urological complications in spinal cord injury patients (SCI), and to compare the incidence of these complications with different bladder management subgroups.

MATERIALS AND METHODS

545 patients (386 males and 159 females) of traumatic spinal cord injury with the mean age of 35.4±16.2 years (range, 18 - 73 years) were included in the study. The data regarding demography, bladder type, method of bladder management, and urological complications, were recorded. Bladder management methods included indwelling catheterization in 224 cases, clean intermittent catheterization (CIC) in 180 cases, condom drainage in 45 cases, suprapubic cystostomy in 24 cases, reflex voiding in 32 cases, and normal voiding in 40 cases. We assessed the incidence of UTI and bacteriuria as the number of episodes per hundred person-days, and other urological complications as percentages.

RESULTS

The overall incidence of bacteriuria was 1.70 / hundred person-days. The overall incidenceof urinary tract infection was 0.64 / hundered person-days. The incidence of UTI per 100 person-days was 2.68 for indwelling catheterization, 0.34 for CIC, 0.34 for condom drainage, 0.56 for suprapubic cystostomy, 0.34 for reflex voiding, and 0.32 for normal voiding. Other urological complications recorded were urethral stricture (n=66, 12.1%), urethritis (n=78, 14.3%), periurethral abscess (n=45, 8.2%), epididymorchitis (n=44, 8.07%), urethral false passage (n=22, 4.03%), urethral fistula (n=11, 2%), lithiasis (n=23, 4.2%), hematuria (n=44, 8.07%), stress incontinence (n=60, 11%), and pyelonephritis (n=6, 1.1%). Clean intermittent catheterization was associated with lower incidence of urological complications, in comparison to indwelling catheterization.

CONCLUSIONS

Urinary tract complications largely appeared to be confined to the lower urinary tract. The incidence of UTI and other urological complications is lower in patients on CIC in comparison to the patients on indwelling catheterizations. Encouraging CIC; early recognition and treatment of the UTI and urological complications; and a regular follow up is necessary to reduce the medical morbidity.

Bladder management methods and urological complications in spinal cord injury patients

BACKGROUND

The optimal bladder management method should preserve renal function and minimize the risk of urinary tract complications. The present study is conducted to assess the overall incidence of urinary tract infections (UTI) and other urological complications in spinal cord injury patients (SCI), and to compare the incidence of these complications with different bladder management subgroups.

MATERIALS AND METHODS

545 patients (386 males and 159 females) of traumatic spinal cord injury with the mean age of 35.4±16.2 years (range, 18 - 73 years) were included in the study. The data regarding demography, bladder type, method of bladder management, and urological complications, were recorded. Bladder management methods included indwelling catheterization in 224 cases, clean intermittent catheterization (CIC) in 180 cases, condom drainage in 45 cases, suprapubic cystostomy in 24 cases, reflex voiding in 32 cases, and normal voiding in 40 cases. We assessed the incidence of UTI and bacteriuria as the number of episodes per hundred person-days, and other urological complications as percentages.

RESULTS

The overall incidence of bacteriuria was 1.70 / hundred person-days. The overall incidenceof urinary tract infection was 0.64 / hundered person-days. The incidence of UTI per 100 person-days was 2.68 for indwelling catheterization, 0.34 for CIC, 0.34 for condom drainage, 0.56 for suprapubic cystostomy, 0.34 for reflex voiding, and 0.32 for normal voiding. Other urological complications recorded were urethral stricture (n=66, 12.1%), urethritis (n=78, 14.3%), periurethral abscess (n=45, 8.2%), epididymorchitis (n=44, 8.07%), urethral false passage (n=22, 4.03%), urethral fistula (n=11, 2%), lithiasis (n=23, 4.2%), hematuria (n=44, 8.07%), stress incontinence (n=60, 11%), and pyelonephritis (n=6, 1.1%). Clean intermittent catheterization was associated with lower incidence of urological complications, in comparison to indwelling catheterization.

CONCLUSIONS

Urinary tract complications largely appeared to be confined to the lower urinary tract. The incidence of UTI and other urological complications is lower in patients on CIC in comparison to the patients on indwelling catheterizations. Encouraging CIC; early recognition and treatment of the UTI and urological complications; and a regular follow up is necessary to reduce the medical morbidity.