Clinical Profiles and Symptom Burden Estimates to Support Decision-Making Using the Urinary Symptom Questionnaire for People with Neurogenic Bladder (USQNB) using Intermittent Catheters

Questionnaires for Neurogenic Lower Urinary Tract Dysfunction

The evaluation of people with neurogenic lower urinary tract dysfunction (NLUTD) often involves objective parameters, however quality of life (QOL) assessments are crucial for patient-centered care. This article discusses how to measure QOL and urinary symptoms in NLUTD and highlights various questionnaires such as the Qualiveen, Neurogenic Bladder Symptom Score (NBSS), and the Incontinence Quality of Life Questionnaire (I-QOL). These questionnaires focus on bladder-related QOL or symptoms and have been validated in multiple NLUTD populations. These tools are important for advancing research and the clinical care of NLUTD patients, and have the potential to impact decision-making and improve patient outcomes.

Intravesical Lactobacillus rhamnosus GG Alters Urobiome Composition and Diversity Among People With Neurogenic Lower Urinary Tract Dysfunction

Background

Neurogenic bladder is associated with bacterial colonization and frequent urinary tract infections.

Objectives

To explore the effects of one to two doses of intravesical Lactobacillus rhamnosus GG (LGG) on the urobiomes of adults with spinal cord injury/disease (SCI/D) who manage their bladders with intermittent catheterization (IC).

Methods

This was a pilot substudy within an 18-month phase 1 clinical trial of self-instilled intravesical LGG for urinary symptoms as directed by the Self-Management Protocol using Probiotics (SMP-Pro). Urine samples were collected monthly when participants were asymptomatic. When SMP-Pro "trigger" symptoms (cloudier and/or more foul-smelling urine) occurred, urine samples were collected immediately pre-LGG instillation and 24 to 48 hours after LGG instillation. Urine was collected via a new catheter, immediately placed on ice/freezer, and processed within 12 hours. Genomic DNA was isolated, and the V4 region of the 16S rRNA bacterial gene was amplified and high throughput sequenced. Amplicon sequence variants were inferred and bacterial composition, community structure, and variation across clinical phenotypes were determined.

Results

126 urine samples were collected from 26 participants (SCI/D = 23; multiple sclerosis = 2; spina bifida = 1) between 20 and 57 years of age. The urobiomes were characterized by four dominant phyla (>1%): Bacteroidetes, Firmicutes, Proteobacteria, and Actinobacteria, which were comprised of six dominant genera (>3%): Escherichia/Shigella (29.1%), Klebsiella (22.4%), Proteus (15.2%), Aerococcus (6.3%), Streptococcus (6.0%), and Pluralibacter (3.0%). Post-LGG samples were associated with a decline in Escherichia/Shigella predominance (p < .001) and altered bacterial diversity (p < .05).

Conclusion

Among people with SCI/D who use IC, intravesical LGG alters the bacterial composition and diversity of the urine ecosystem, potentially disrupting the uropathogenic urobiome.

Urinary Symptoms Among People With Neurogenic Lower Urinary Tract Dysfunction (NLUTD) Vary by Bladder Management

Objectives

To determine whether assessment and decision-making around urinary symptoms in people with neurogenic lower urinary tract dysfunction (NLUTD) should depend on bladder management.

Methods

Three surveys of urinary symptoms associated with NLUTD (USQNBs) were designed specific to bladder management method for those who manage their bladders with indwelling catheter (IDC), intermittent catheter (IC), or voiding (V). Each was deployed one time to a national sample. Subject matter experts qualitatively assessed the wording of validated items to identify potential duplicates. Clustering by unsupervised structural learning was used to analyze duplicates. Each item was classified into mutually exclusive and exhaustive categories: clinically actionable ("fever"), bladder-specific ("suprapubic pain"), urine quality ("cloudy urine"), or constitutional ("leg pain").

Results

A core of 10 "NLUTD urinary symptoms" contains three clinically actionable, bladder-specific, and urine quality items plus one constitutional item. There are 9 (IDC), 11 (IC), and 8 (V) items unique to these instruments. One decision-making protocol applies to all instruments.

Conclusion

Ten urinary symptoms in NLUTD are independent of bladder management, whereas a similar number depend on bladder management. We conclude that assessment of urinary symptoms for persons with NLUTD should be specific to bladder management method, like the USQNBs are.

Shared decision-making in multiple sclerosis physical symptomatic care: a systematic review

Background

Multiple sclerosis (MS) is a chronic autoimmune inflammatory, demyelinating, and neurodegenerative disease affecting young adults. People with MS are highly interested in engaging in physical symptom management and decision-making but are often not actively engaged in symptom management discussions. Research examining the benefit of shared decision-making in the management of physical MS symptoms is sparse.

Objectives

This study aimed to identify and synthesize the evidence on the use of shared decision-making in physical MS symptom management.

Design

This study is a systematic review of published evidence on the use of shared decision-making in physical MS symptom management.

Data sources and methods

MEDLINE, CINAHL, EMBASE, and CENTRAL databases were searched in April 2021, June 2022, and April 2, 2023, for primary, peer-reviewed studies of shared decision-making in the management of MS physical symptoms. Citations were screened, data extracted, and study quality assessed according to Cochrane guidelines for systematic reviews, including risk of bias assessment. Statistical synthesis of the included study results was not appropriate; results were summarized in a nonstatistical manner using the vote-counting method to estimate beneficial versus harmful effects.

Results

Of 679 citations, 15 studies met the inclusion criteria. Six studies addressed shared decision-making in the management of pain, spasms, neurogenic bladder, fatigue, gait disorder, and/or balance issues, and nine studies addressed physical symptoms in general. One study was a randomized controlled trial; most studies were observational studies. All study results and study author conclusions indicated that shared decision-making is important to the effective management of physical MS symptoms. No study results suggested that shared decision-making was harmful or delayed the management of physical MS symptoms.

Conclusion

Reported results consistently indicate that shared decision-making is important in effective MS symptomatic care. Further rigorous randomized controlled trials are warranted to investigate the effectiveness of shared decision-making associated with MS physical symptomatic care.

Registration

PROSPERO: CRD42023396270.

Urinary Symptoms Are Unrelated to Leukocyte Esterase and Nitrite Among Indwelling Catheter Users

Objectives

To explore the association between dipstick results and urinary symptoms.

Method

This was a prospective 12-month observational study of real-time self-administered urine dipstick results and symptoms in a community setting that included 52 spinal cord injury/disease (SCI/D) participants with neurogenic lower urinary tract dysfunction (NLUTD) who use an indwelling catheter. Symptoms were collected using the Urinary Symptom Questionnaire for Neurogenic Bladder-Indwelling Catheter (USQNB-IDC). The USQNB-IDC includes actionable (A), bladder (B1), urine quality (B2), and other (C) symptoms; analyses focused on A, B1, and B2 symptoms. Dipstick results include nitrite (NIT +/-), and leukocyte esterase (LE; negative, trace, small, moderate, or large). Dipstick outcomes were defined as strong positive (LE = moderate/large and NIT+), inflammation positive (LE = moderate/large and NIT-), negative (LE = negative/trace and NIT-), and indeterminate (all others).

Results

Nitrite positive dipsticks and moderate or large LE positive dipsticks were each observed in over 50% of the sample in every week. Strong positive dipstick results were observed in 35% to 60% of participants in every week. A, B1, or B2 symptoms co-occurred less than 50% of the time with strong positive dipsticks, but they also co-occurred with negative dipsticks. Participants were asymptomatic with a strong positive dipstick an average of 30.2% of the weeks. On average, 73% of the time a person had a negative dipstick, they also had no key symptoms (95% CI, .597-.865).

Conclusion

No association was observed between A, B1, and B2 symptoms and positive dipstick. A negative dipstick with the absence of key symptoms may better support clinical decision-making.

Intravesical Lactobacillus rhamnosus GG versus Saline Bladder Wash: Protocol for a Randomized, Controlled, Comparative Effectiveness Clinical Trial

Background

Complicated urinary tract infection (cUTI) is pervasive and costly among people with spinal cord injury (SCI) and neurogenic lower urinary tract dysfunction (NLUTD).

Objectives

To describe the protocol for a comparative effectiveness randomized controlled trial of intravesical Lactobacillus rhamnosus GG (LGG) versus saline bladder wash (BW) for self-management of urinary symptoms.

Methods

Comparative effectiveness trial of self-administered LGG versus saline bladder wash among 120 participants with SCI+NLUTD at least 6 months post SCI. The study has both treatment and prophylaxis phases. After predictive enrichment at screening, randomized participants will enter the treatment phase (6 months) in which they instill either LGG or normal saline after trigger symptoms occur (more cloudy or more foul-smelling urine). In the prophylaxis phase (6 months), participants will instill their respective intervention every 3 days after the first occurrence of trigger symptoms.

Results

Study results will provide a comparison of effects on Urinary Symptom Questionnaire for Neurogenic Bladder (USQNB) bladder and urine symptoms and episodes of "presumed UTIs"; number of days antibiotics were used (both self-reported); days of work, school, rehabilitation, or other activity lost due to urinary symptoms; engagement with the health care system; number of instillations; satisfaction; and safety.

Conclusion

cUTI is a variable clinical entity. Unlike clinical trials that assume a single, simple entity (UTI) in inclusion or outcome criteria, this protocol targets the mechanisms underlying cUTI causes and phenotypes. Featuring reliable and valid outcome measures with analytic methods specifically appropriate for quantifying self-report, patient self-management, inclusion of both intervention and prophylactic phases, and predictive enrichment, these design elements may be adopted for future research.

Development and Assessment of SCI Model Systems Complicated UTI Consensus Guidelines: A Psychometrically Designed Mixed-Methods Protocol

Background

Complicated UTI (cUTI) is highly prevalent among people with spinal cord injury and disease (SCI/D), but neither consistent nor evidence-based guidelines exist.

Objectives

We propose a two-phase, mixed-methods study to develop consensus around diagnostic and decision-making criteria for cUTI among people with SCI/D and the clinicians who treat them.

Methods

In phase 1 (qualitative), we will engage Spinal Cord Injury Model Systems (SCIMS) clinicians in focus groups to refine existing cUTI-related decision making using three reliable and validated Urinary Symptom Questionnaires for Neurogenic Bladder (USQNBs; intermittent catheterization, indwelling catheterization, and voiding) as points of departure, and then we will conduct a Delphi survey to explore and achieve consensus on cUTI diagnostic criteria among a nationally representative sample of clinicians from physical medicine and rehabilitation, infectious disease, urology, primary care, and emergency medicine. We will develop training materials based on these new guidelines and will deploy the training to both clinicians and consumers nationally. In phase 2 (quantitative), we will assess clinicians' uptake and use of the guidelines, and the impact of the guidelines training on consumers' self-management habits, engagement with the health care system, and antibiotic use over the 12 months after training.

Results

The output of this study will be diagnostic guidelines for cUTI among people with neurogenic lower urinary tract dysfunction (NLUTD) due to SCI/D, with data on uptake (clinicians) and impact (patients).

Conclusion

This mixed-methods protocol integrates formal psychometric methods with large-scale evidence gathering to derive consensus around diagnostic guidelines for cUTI among people with NLUTD due to SCI/D and provides information on uptake (clinicians) and impact (patients).

Independence of Urinary Symptoms and Urinary Dipstick Results in Voiders With Neurogenic Bladder

Background

Urinary symptoms and urinary tract infection (UTI) are frequent and burdensome problems associated with neurogenic lower urinary tract dysfunction.

Objectives

To determine whether an association exists between urinary symptoms and urine dipstick results among individuals with spinal cord injury (SCI) or multiple sclerosis (MS).

Methods

Prospective 12-month cohort study of 76 participants with SCI or MS who manage their bladders by voiding. Eligibility criteria included adults ≥18 years old, at least three UTIs since diagnosis, and residence in the United States. Participants completed the Urinary Symptoms Questionnaire for Neurogenic Bladder-Voider version (USQNB-V) biweekly (26 assessments) and tested their urine by dipstick at the same time. Symptom burden was estimated based on endorsements of USQNB-V symptoms classified as clinically actionable (9), bladder function (8), and urine quality (4). Urine dipstick results assessed were leukocyte esterase (LE) and nitrite (NIT).

Results

Participants were stratified into four groups based on etiology of neurologic dysfunction and whether they ever experienced any urinary symptoms (USx): SCI+USx (n = 14), SCI+NoUSx (n = 5), MS+USx (n = 32), and MS+NoUSx (n = 25). In descending order, symptom burden was greatest for the MS+USx group, followed by both SCI groups; it was lowest for MS+NoUSx. We assessed multiple definitions of "positive" dipstick and found evidence of independence of USQNB-V symptoms and urinary dipstick results with each definition. In each group, the median (and majority) of strong positive dipsticks did not coincide with any symptoms.

Conclusion

Among people with SCI or MS who void, self-administered urine dipstick results and urinary symptom reporting contribute independent information for clinical decision making.

Validity of the Urinary Symptom Questionnaires for people with neurogenic bladder (USQNB) who void or use indwelling catheters

STUDY DESIGN

Descriptive Psychometrics Study OBJECTIVES: Neurogenic lower urinary tract dysfunction (NLUTD), or "neurogenic bladder" is a common and disruptive condition for individuals with spinal cord injury (SCI) and disease (including multiple sclerosis, MS). Our team has developed patient-centered instruments of urinary symptoms specific to patients with NLUTD, across bladder management methods. Validity evidence is needed to support the use of two new instruments, Urinary Symptom Questionnaires for people with Neurogenic Bladder (USQNB) for those who manage their bladder with indwelling catheters (IDC), or who void (V).

SETTING

Online surveys completed by individuals in the United States with NLUTD due to either SCI or MS who manage their bladder with indwelling catheters (SCI, n = 306; MS, n = 8), or by voiding (SCI, n = 103; MS, n = 383). A total of n = 381 USQNB-IDC respondents (five control groups), and 351 USQNB-V respondents (four control groups), contributed to our convergent and divergent validity evidence.

METHODS

Data were collected online to estimate key aspects of psychometric validity (content, reflection of the construct to be measured; face, recognizability of the contents as representing the construct to be measured; structural, the extent to which the instrument captures recognizable dimensions of the construct to be measured). Divergent and convergent validity evidence was derived from multiple control groups, while evidence of criterion validity was derived from attribution of each item to their experience "with a UTI".

RESULTS

Evidence of face, content, criterion, convergent, and divergent validity was compiled for each instrument.

CONCLUSIONS

The instruments demonstrate adequate, multi-dimensional, validity evidence to recommend their use for decision-making by patients, clinicians, and researchers.