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

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

BACKGROUND

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

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.

Microbial Transfer by Intermittent Catheters: An In Vitro Evaluation of Microbial Transfer in Catheter With Variable Protective Features

PURPOSE

The purpose of this study was to evaluate the effects of various protective features (eg, catheter cap, introducer tip, and catheter sleeve) of hydrophilic intermittent catheters against contamination with urinary tract infection-associated microorganisms using an in vitro model.

DESIGN

An in vitro study of microbial transfer.

MATERIALS AND METHODS

Gloves were contaminated with uropathogenic microorganisms and used to simulate intermittent catheterization of male anatomical models with and without the protective features present in 5 commercially available hydrophilic catheters. Using this contaminated touch transfer method, both the meatus of the sterile male anatomical models and sterile surgical gloves of an operator were inoculated with a high level of microorganisms (107 and 109 colony-forming units [CFU], respectively). The operator then performed catheterization of the anatomical model. The most relevant segments of the catheter were sampled, and the level of microbial transfer and catheter contamination was quantified. Results from experimental and sample replicates from the 3 microbial species and 5 catheters (sleeved and unsleeved) were analyzed by pair-wise t tests and analysis of variance.

RESULTS

Of the 5 commercially available sleeved intermittent catheters evaluated in this study, use of catheters with multiple protective components (ring cap, introducer tip, and catheter sleeve) resulted in significant improvement in protection against contamination with a 25- to 2500-fold lower level of microbial contamination (C1 segment) across all species as compared to catheters protected with only sleeves or un-sleeved catheters.

CONCLUSIONS

The combination of a ring cap, protective introducer tip, and protective sleeve provides additional protection when compared to sleeve alone from transferring microbial contamination from the meatus to the advancing catheter. Additional research is needed to determine whether these design features result in fewer urinary tract infections among intermittent catheter users.

New Intermittent Urinary Micro-Hole Zone Catheter Shows Enhanced Performance in Emptying the Bladder: A Randomised, Controlled Crossover Study

Urinary tract infections (UTIs) are common and troublesome complications of clean intermittent catheterisation (CIC) in individuals suffering from incomplete bladder emptying, which may exacerbate the underlying disease and lead to hospitalisation. Aside from the design of the intermittent catheter and its handling, a recent review highlighted residual urine as one of several UTI risk factors. A new urinary intermittent catheter with multiple micro-holes has been developed for improved bladder emptying. In a controlled crossover study, adult male CIC users were randomised for a health care professional-led catheterisation with the new micro-hole zone catheter (MHZC) and a conventional eyelet catheter (CEC) in two individual test visits to compare the number of flow-stops and the residual urine at the first flow-stop as co-primary endpoints. In 42 male CIC users, the MHZC resulted in significantly fewer flow-stop episodes compared to the CEC (mean 0.17, 95% CI [0.06, 0.45] vs. mean 1.09, 95% CI [0.75, 1.6], respectively; p < 0.001) and significantly less residual urine at the first flow-stop (mean 5.10 mL, SE [1.14] vs. mean 39.40 mL, SE [9.65], respectively; p < 0.001). No adverse events were observed in this study. The results confirm the enhanced performance of the MHZC compared to a CEC, ensuring an uninterrupted free urine flow with no need to reposition the catheter until the bladder is thoroughly empty.

Cost-effectiveness analysis of hydrophilic-coated catheters in long-term intermittent catheter users in the UK

OBJECTIVE

To estimate the cost-effectiveness of single-use hydrophilic-coated intermittent catheters (HCICs) versus single-use uncoated intermittent catheters (UICs) for urinary catheterization.

METHODS

The evaluation took a UK national health service (NHS) perspective. The population of interest were people using intermittent catheters, with either a spinal cord injury or multiple sclerosis. A Markov model was developed that estimated costs and clinical evidence over the lifetime of a hypothetical cohort and applied health-related quality-of-life estimates. Model inputs were sourced from published evidence, including a network meta-analysis to inform the treatment effect (reduction in catheter-associated urinary tract infections [CAUTIs]), and were supported by expert opinion. The model outputs included per-patient lifetime costs, quality-adjusted life years (QALYs), and the incremental cost effectiveness ratio (ICER). Event counts were also produced.

RESULTS

Using HCICs instead of UICs could prevent seven CAUTI events per patient over a lifetime horizon (1.8 requiring secondary care). Overall, lifetime use of HCICs is £3,183 more expensive than use of UICs per patient. However, for these additional costs, 0.55 QALYs are gained. The ICER is £5,755 per additional QALY gained. Key drivers of the model results were identified and subject to sensitivity analyses. The results were found to be robust to parameter uncertainty.

CONCLUSION

HCICs are likely to be a cost-effective alternative to UICs, a result driven by substantial reductions in the number of CAUTIs. Their adoption across clinical practice could avoid a substantial number of infections, freeing up resources in the NHS and reducing antibiotic use in urinary catheter users.

Hydrophilic versus non-hydrophilic catheters for clean intermittent catheterization: a meta-analysis to determine their capacity in reducing urinary tract infections

INTRODUCTION

Clean intermittent catheterization (CIC) is associated with an increased risk of urinary tract infections (UTI), urethral trauma, urethral stenosis, hematuria, and pain. The first catheters were developed of polyvinyl carbon (PVC). Several types of catheters have been developed to reduce these complications, such as those with hydrophilic coating.

OBJECTIVE

To conduct a systematic review and meta-analysis to evaluate the effectiveness of hydrophilic coated catheters compared to uncoated catheters on the rate of UTI in patients using CIC.

METHODOLOGY

A systematic literature search was performed in OVID, Embase, Scopus, Web of Science, PubMed, and CENTRAL databases. Randomized controlled trials (RCTs) or randomized crossover trials comparing UTI and hematuria rates in patients using hydrophilic vs. non-hydrophilic catheters for CIC were identified. The selected trials were evaluated for risk of bias using the "Revised Cochrane risk-of-bias tool for randomized trials (RoB 2)." The results were expressed as a risk ratio (RR) with a 95% confidence interval (CI), under a random-effects model. Data were analyzed using Review Manager 5.4 software.

RESULTS

Nine studies with a total of 525 patients in CIC were analyzed. Overall, the use of hydrophilic catheters had a lower risk of UTIs compared to uncoated catheters (RR = 0.78; 95% CI 0.62-0.97; I2 = 37%). Five of the studies include patients > 18 years, showing a reduction of UTIs with the use of hydrophilic catheters (RR = 0.83; 95% CI 0.74-0.93; I2 = 0%). There was no difference in UTI development when comparing single-use uncoated vs hydrophilic catheters. However, heterogeneity was high (RR = 0.77; 95% CI 0.59-1.00; I2 = 57%). Regarding hematuria risk reduction, we were unable to identify differences between the use of hydrophilic catheters compared to uncoated catheters (RR = 1.02; 95% CI 0.66-1.60).

CONCLUSION

We found a risk reduction of UTIs associated with using hydrophilic catheters in adults, with low heterogeneity. Regarding hematuria, significant differences were not proved. We do not find a significant difference in UTI risk reduction in the pediatric population. Urethral trauma presence could not be meta-analyzed due to a lack of information reported.

The outcomes of penile prosthesis in neurologic patients: a multicentric retrospective series

Introduction

Neurological disease is a known entity for causing erectile dysfunction (ED). Pharmacological therapies are not always effective these patients - penile prosthesis implant (PPI) is an established surgical treatment option. For a variety of reasons, neurological patients may experience differing outcomes of PPI compared to those whose ED arises from other causes. We investigated outcomes of PPI in neurological patients using the Italian multi-institutional national registry of penile prostheses [Italian Nationwide Systematic Inventarization of Surgical Treatment for ED (INSIST-ED)].

Methods

Patients undergoing PPI were investigated via the INSIST-ED registry, from 2014 to 2021. Data were prospectively recorded by 45 surgeons on a dedicated website (www.registro.andrologiaitaliana.it) and reviewed by a data manager. We subselected patients with neurological disease undergoing PPI for ED, and these patients were reviewed at 3, 6, and 12 months, and annually thereafter. Postoperative complications and functional outcomes were evaluated through validated questionnaires [International Index of Erectile Function-5 (IIEF-5), Sexual Encounter Profile 2-3, and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS)]. A nonvalidated questionnaire was administered to assess patient satisfaction.

Results

A total of 33 patients were included with a median age of 49 [interquartile range (IQR) 41-55]. Median follow-up was 83 months (IQR 67-99.5). A penoscrotal approach for PPI was performed in most cases (90.9%), while infrapubic was used in three cases (9.1%). Inflatable and malleable devices were implanted in 30 (90.9%) and 3 cases (9.1%), respectively. Intraoperative complications occurred in one case (3%). Early postoperative complications (<90 days) were observed in three cases (9.1%): two wound dehiscence (Clavien-Dindo G1 and G3a respectively) and one device infection requiring prosthesis explant (Clavien-Dindo G3a). Mechanical failures of inflatable devices were not observed during the follow-up period. Median IIEF-5 before surgery was 8 (IQR 7-9). At the latest follow-up, IIEF-5 was 22 (IQR 19-23.5), and median EDITS was 79 (IQR 64-88). A total of 28 patients (84.8%) self-reported to be fully satisfied with the PPI.

Conclusion

Although PPI in the neurological population has been historically considered to be at increased risk, in our study, PPI complications and infections rates in this cohort did not differ from general population.

A Multicenter, Open-Label, Observational Study Evaluating the Quality of Life After Using a Hydrophilic-Coated Catheter (SpeediCath) With Self-Intermittent Catheterization

PURPOSE

We evaluated the change in patient quality of life after the use of a hydrophilic-coated catheter (SpeediCath) in adults requiring intermittent catheterization (IC).

METHODS

This was a multicenter, open-label, observational study using the Patient Perception of Intermittent Catheterization (PPIC) questionnaire and the Intermittent Self-Catheterization questionnaire (ISC-Q) and safety at 12 and 24 weeks in adult patients who had already used other type of catheters prior to switching to SpeediCath or in patients undergoing self-IC for the first time for any reason.

RESULTS

Among a total of 360 subjects, 215 (59.7%) were women, and the mean age was 62.0±13.2 years. At 24 weeks, the satisfaction rate after using SpeediCath was 84.1%, and 80% of patients responded that they could easily perform IC. In total, 81.6% of patients were willing to continue using SpeediCath. The mean ISC-Q score was 54.90±18.65 at 24 weeks. Men found less interference in their daily life by performing IC than women and found it easier to handle the catheter before it was inserted into the urethra. At week 12, the mean change in ISC-Q was significantly greater in patients <65 years (20.24±23.55) than in those ≥65 years (7.57±27.70, P=0.049), but there was no difference at 24 weeks. The most common adverse events were urinary tract infection in 9.72%, gross hematuria in 2.78%, and urethral pain in 1.39%.

CONCLUSION

The use of a SpeediCath provided good quality of life for patients who needed self-IC regardless of age or sex.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

Background

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

Search methods

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

Results

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

Conclusions

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

Supplementary Information

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

Differences in the incidence of urinary tract infections between neurogenic and non-neurogenic bladder dysfunction individuals performing intermittent catheterization

PURPOSE

To measure the incidence and severity of urinary tract infections (UTI) in intermittent catheter (IC) users with neurogenic and non-neurogenic diagnoses.

MATERIALS AND METHODS

Administrative health insurance claims data from the IBM MarketScan® Database between January 1, 2015 and  December 31, 2019, were analyzed. New IC-users with neurogenic lower urinary tract dysfunction (NLUTD); IC-users without NLUTD (non-NLUTD); and age-and-sex-matched general population without IC use (GEN) were compared. Individuals were followed for one year after initial IC utilization or random index date for GEN. The primary outcome was a patient seeing a physician or attending a hospital for a UTI (measured with a primary or secondary diagnosis code related to a UTI). UTI incidence, hospitalizations, and length of hospital stay were compared.

RESULT

We identified 6944 NLUTD, 5102 non-NLUTD, and 120 426 GEN individuals. The annualized UTI incidence was higher in IC-users (54.9% NLUTD IC-users and 38.9% non-NLUTD IC-users) compared to GEN individuals (9.8%) (p < 0.001 between groups). Hospitalization for UTI was more common in NLUTD and non-LUTD (11.3% and 4.0%, respectively) compared with GEN individuals (1.0%) (p < 0.001 between groups). NLUTD individuals had a greater average length of hospital stay than non-NLUTD (2.2 ± 3.6 vs. 1.6 ± 2.1 days, p < 0.001).

CONCLUSION

IC users had a significantly higher incidence of UTIs than the general population. NLUTD IC-users had a higher incidence of UTIs that required hospitalization compared to non-NLUTD individuals. Strategies to decrease the patient and healthcare burden of UTIs in those that catheterize should be prioritized.

Urinary catheter management: what neurologists need to know

Patients with neurological disorders often have lower urinary tract dysfunction, manifesting as urinary retention or urinary incontinence, and so commonly use catheters. Neurologists should therefore be aware of the different types of catheters and appliances and their risks, benefits and complications. Clean intermittent self-catheterisation is preferable to an indwelling catheter; however, if this is not possible, then a suprapubic indwelling catheter is preferable to a urethral catheter for long-term management. We review the decision-making process when selecting catheters for neurological patients, the evidence base regarding the different options and how neurologists can recognise and address complications. We also discuss alternatives to catheterisation, such as non-invasive containment products and surgical treatments, and the indications for urological referral.

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

BACKGROUND

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

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 12 April 2021), the reference lists of relevant articles and conference proceedings, and we attempted to contact other investigators for unpublished data or for clarification.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or randomised cross-over trials comparing at least two different catheterisation techniques, strategies or catheter designs.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

Catheter-associated urinary tract infection

This guideline contains updated recommendations on the management and prevention of CAUTIs by the Urological Association of Asia and the Asian Association of Urinary Tract Infection and Sexually Transmitted Infection.

Neurogenic bladder - concepts and treatment recommendations

Introduction:

Bladder and urinary sphincter malfunctioning that results from some change in the central and/or peripheral nervous system is defined as neurogenic bladder. The urinary tract symptoms that can be related to its filling, emptying, or both have a significant impact on the quality of life of individuals. The present review was based on the document prepared for the public health system in Brazil as a treatment guidelines proposal.

Material and Methods:

Survey questions were structured as per PICO (Population, Intervention, Control, and Outcome). Search strategies were defined and performed in the MEDLINE/Pubmed, Embase, Epistemonikos and Google Scholar databases. The selection of articles followed the evidence hierarchy concept; evidence body was identified, and the quantitative study data were extracted. The quality of evidence and grade of recommendation were qualitatively assessed according to GRADE (Grading of Recommendations, Assessment, Development and Evaluations).

Results:

A total of 2.707 articles were identified, with 49 of them being selected to compose the basis for this review. Neurogenic bladder treatments were classified according to their focus on filling or emptying symptoms and sub- classified in pharmacological and surgical treatments.

Conclusion:

Treatment guidelines are important tools for the public health system to promote the best practice when treating neurogenic bladder patients.

Catheters for intermittent catheterization: a systematic review and network meta-analysis

STUDY DESIGN

Systematic review and network meta-analysis.

OBJECTIVES

Intermittent catheterization (IC) is considered the standard treatment for neuro-urological patients who are unable to empty their bladders. The present study aimed to conduct a systematic evaluation and network meta-analysis of all available types of intermittent catheters, and determine which one is best suited for clinical use.

METHODS

We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify relevant studies. Only randomized clinical trials (RCTs) were included. Five types of catheters were identified based on the included studies. A Bayesian network meta-analysis was then performed. The surface under the cumulative ranking (SUCRA) curve was used to determine the best catheter for each outcome.

RESULTS

A total of 25 RCTs, involving 1233 participants, were included. The pooled odds ratios of symptomatic UTI were lower for two ready-to-use single-use catheters (gel-lubricated non-coated catheter, OR: 0.30, 95% CI 0.095-0.86; pre-activated hydrophilic-coated catheter, OR: 0.41, 95% CI 0.19-0.83) as compared to single-use non-coated catheter. In terms of patient satisfaction, the SUCRA results showed that the pre-activated hydrophilic-coated catheter may the preferred option (SUCRA = 82.8%). However, there were no significant differences in all outcome measures between traditional single-use non-coated catheters and clean non-coated catheters.

CONCLUSION

Ready-to-use single-use catheters are associated with lower rates of UTI compared to traditional catheters. Patients may be most satisfied with the pre-activated one. For traditional single-use non-coated catheters and clean non-coated catheters, there is still no convincing evidence as to which is better. Thus, more well-designed trials are needed.

Multicenter urethroplasty outcomes for urethral stricture disease for patients with neurogenic bladder or bladder dysfunction requiring clean intermittent catheterization

BACKGROUND

Our objective is to better comprehend treatment considerations for urethral stricture disease (USD) in patients requiring long-term clean intermittent catheterization (CIC). Patient characteristics, surgical outcomes and complications are unknown in this population.

METHODS

Six members of the Trauma and Urologic Reconstruction Network of Surgeons (TURNS) participated in a prospective (2009 to present) and retrospective (prior to 2009) database recording patient demographics, surgical approach and outcomes. We included all patients undergoing urethroplasty who perform CIC. Descriptive statistics were used to analyze results.

RESULTS

A total of 37 patients with 39 strictures were included. Bladder dysfunction was characterized as detrusor failure in 35% and neurogenic etiology in 65%. Median stricture length was 3 cm (IQR: 1.5-5.5) with 28% repaired with dorsal onlay buccal mucosal graft, 26% excision and primary anastomosis, 8% dorsal inlay, 8% ventral and dorsal, 8% flap based 8% non-transecting and 15% other. Functional success was 90%: 4 patients required DVIU or dilation due to recurrence, with 2 of those ultimately requiring repeat urethroplasty. 86% of patients returned to CIC; no patients reported new pad use for urinary leakage after urethroplasty. During a median follow-up period of 3.1 years (IQR: 1.0-5.3), no patients underwent urinary diversion.

CONCLUSIONS

Urethroplasty is suitable, safe and effective for patients dependent on CIC suffering from USD. The effect of continual CIC on long-term outcomes remains uncertain.

Cost‐effectiveness of hydrophilic‐coated urinary catheters for individuals with spinal cord injury: A systematic review

Objective

To identify and critically evaluate the economic evaluations examining the cost‐effectiveness of hydrophilic‐coated vs uncoated catheters for individuals with spinal cord injury.

Methods

We searched MEDLINE, the Excerpta Medica database (EMBASE), Cochrane Database of Systematic Reviews, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Emcare for studies in English and French. There were no restrictions to the year of publication. Our search strategy included the following key terms: “spinal cord injury,” “catheterization,” and “cost analysis.”

Results

The search identified 371 studies, of which eight studies met the inclusion criteria. Five studies observed hydrophilic‐coated catheters to be cost‐effective compared to uncoated catheters. Two studies found hydrophilic‐coated catheters to be not cost‐effective compared to uncoated catheters and one study estimated that hydrophilic‐coated catheters reduced the long‐term health‐care costs compared to uncoated catheters.

Conclusion

The cost‐effectiveness of hydrophilic‐coated catheters was dependent on the comparator used, the consideration of long‐term effects, and the unit cost of treatment. Further studies are needed to explore the short‐term and long‐term effects of hydrophilic‐coated catheter use on urinary tract infections and clarify the impact of hydrophilic‐coated catheter use on long‐term renal function. Overall, our critical evaluation of the literature suggests that the evidence is pointing toward hydrophilic‐coated catheters being cost‐effective, particularly when a societal perspective is applied.

Protocolized Urine Sampling is Associated with Reduced Catheter-associated Urinary Tract Infections: A Pre- and Postintervention Study

Background

Standard urine sampling and testing techniques do not mitigate against detection of colonization, resulting in false positive catheter-associated urinary tract infections (CAUTI). We aimed to evaluate whether a novel protocol for urine sampling and testing reduces rates of CAUTI.

Methods

A preintervention and postintervention study with a contemporaneous control group was conducted at 2 campuses (test and control) of the same academic medical center. The test campus implemented a protocol requiring urinary catheter removal prior to urine sampling from a new catheter or sterile straight catheterization, along with urine bacteria and pyuria screening prior to culture. Primary outcomes were test campus CAUTI rates, compared between each 9-month pre- and postintervention epoch. Secondary outcomes included the percent reductions in CAUTI rates, compared between the test campus and a propensity score–matched cohort at the control campus.

Results

A total of 7991 patients from the test campus were included in the primary analysis, and 4264 were included in the propensity score–matched secondary analysis. In the primary analysis, the number of CAUTI cases per 1000 patients was reduced by 77% (6.6 to 1.5), the number of CAUTI cases per 1000 catheter days was reduced by 63% (5.9 to 2.2), and the number of urinary catheter days per patient was reduced by 37% (1.1 to 0.69; all P values ≤ .001). In the propensity score–matched analysis, the number of CAUTI cases per 1000 patients was reduced by 82% at the test campus, versus 57% at the control campus; the number of CAUTI cases per 1000 catheter days declined by 68% versus 57%, respectively; and the number of urinary catheter days per patient decreased by 44% versus 1%, respectively (all P values &lt; .001).

Conclusions

Protocolized urine sampling and testing aimed at minimizing contamination by colonization was associated with significantly reduced CAUTI infection rates and urinary catheter days.

Effectiveness of silver alloy-coated silicone urinary catheters in patients with acute traumatic cervical spinal cord injury: Results of a quality improvement initiative

Patients with acute traumatic cervical spinal cord injury (ATCSCI) have an increased risk of catheter-associated urinary tract infection (CAUTI). The effectiveness of silver alloy-coated silicone urinary catheters (SACC) in preventing CAUTI in ATCSCI is unknown and was the objective of this study. We performed a quality improvement initiative in an attempt to reduce CAUTI in patients undergoing spine surgery at a single quaternary center. Prior to July 2015, all patients received a latex indwelling catheter (LIC). All patients with ATCSCI with limited hand function (AIS A,B, or C) received a SACC. Incidence of CAUTI, microbiology, duration of infection, antibiotic susceptibility, and catheter-associated adverse events were recorded prospectively. We studied 3081 consecutive patients over the three years, of whom 302 (9.8%) had ATCSCI; 63% of ATCSCI patients were ASIA Impairment Scale (AIS) A or B. The overall rate of CAUTI was 19% (585/3081), and was 38% (116/302) in patients with ATCSCI. Of 178 ATCSCI patients with LIC, 100 (56%) developed a CAUTI compared with 28 of 124 (23%) patients with SACC (p < 0.05). Poly-microbial and gram-positive infection was more common in LIC than in SACC (p < 0.05). Median duration of infection was 9 days in SACC group and 12 days in LIC group (p = 0.08). Resistance to trimethoprim (p < 0.001) and ciprofloxacin (p < 0.05) were more common in LIC group. There was no difference in catheter-associated adverse events or length of stay between the groups. This quality improvement initiative illustrates the effectiveness of antiseptic silver alloy-coated silicone urinary catheters in patients with ATCSCI. In our population, the use of SACC reduces the incidence and the complexity of CAUTI.

Barriers and facilitators to optimising inpatient bladder management after spinal cord injury

STUDY DESIGN

Qualitative survey.

OBJECTIVES

Examine clinicians' perspectives on adherence to published evidence-based guidelines and clinician-perceived barriers, and facilitators to optimising inpatient bladder management within one Spinal Cord Injury (SCI) service.

SETTING

Surgical Hospital (acute care) and SCI Unit (sub-acute, rehabilitation) in Western Australia (WA).

METHODS

Clinicians reviewed an 'Evidence Matrix' summarising published clinical practice guidelines and recommendations for SCI bladder management. Focus groups examined the extent to which current practice adhered to recommendations and identified perceived barriers and facilitators to optimal management. Data were analysed thematically using a deductive approach.

RESULTS

Current management closely mirrors published recommendations. Key facilitators included long-standing prioritisation of rapid progression from urethral indwelling (IDC) to a 6 hourly intermittent catheterisation (IC) protocol; regular competency audits of catheterisation technique; and a Spinal Urology Clinical Nurse Consultant (CNC) position. Barriers included limited resources/staffing; restricted access to Neuro-urology consultation; inter-disciplinary communication gaps; and delays in determining and implementing long-term bladder management.

CONCLUSIONS

Inpatient SCI bladder care in WA closely emulates published evidence, although adherence at other sites may reveal different practices. Bladder management was found to have been facilitated by a strong culture of practice led by Neuro-urologists, informed by evidence and embraced by Senior Clinicians. Further reduction in duration of initial IDC, provision of early and ongoing Neuro-urology consultations as part of standard care, increased interdisciplinary communication and dedicated SCI Urology theatre lists would further optimise management.

Intermittent catheterization: Clinical practice guidelines from Association Française d'Urologie (AFU), Groupe de Neuro-urologie de Langue Française (GENULF), Société Française de Médecine Physique et de Réadaptation (SOFMER) and Société Interdisciplinaire Francophone d'UroDynamique et de Pelvi-Périnéologie (SIFUD-PP)

INTRODUCTION

Our objective was to provide guidelines covering all aspects of intermittent catheterisation (intermittent self-catheterisation and third-party intermittent catheterisation).

MATERIALS AND METHODS

A systematic review of the literature based on Pubmed, Embase, Google scholar was initiated in December 2014 and updated in April 2019. Given the lack of robust data and the numerous unresolved controversial issues, guidelines were established based on the formal consensus of experts from steering, scoring and review panels.

RESULTS

This allowed the formulation of 78 guidelines, extending from guidelines on indications for intermittent catheterisation, modalities for training and implementation, choice of equipment, management of bacteriuria and urinary tract infections, to the implementation of intermittent catheterisation in paediatric, geriatric populations, benign prostatic hyperplasia patients and continent urinary diversion patients with a cutaneous reservoir as well as other complications. These guidelines are pertinent to both intermittent self-catheterisation and third-party intermittent catheterisation.

CONCLUSION

These are the first comprehensive guidelines specifically aimed at intermittent catheterisation and extend to all aspects of intermittent catheterisation. They assist in the clinical decision-making process, specifically in relation to indications and modalities of intermittent catheterisation options. These guidelines are intended for urologists, gynaecologists, geriatricians, paediatricians, neurologists, physical and rehabilitation physicians, general practitioners and other health professionals including nurses, carers….

Multifunctional, Low Friction, Antimicrobial Approach for Biomaterial Surface Enhancement

Poly(vinyl chloride) (PVC) biomaterials perform a host of life-saving and life-enhancing roles when employed as medical devices within the body. High frictional forces between the device surface and interfacing tissue can, however, lead to a host of complications including tissue damage, inflammation, pain, and infection. We herein describe a versatile surface modification method using multifunctional hydrogel formulations to increase lubricity and prevent common device-related complications. In a clinically relevant model of the urinary tract, simulating the mechanical and biological environments encountered in vivo, coated candidate catheter surfaces demonstrated significantly lower frictional resistance than uncoated PVC, with reductions in coefficient of friction values of more than 300-fold due to hydration of the surface-localized polymer network. Furthermore, this significant lubrication capacity was retained following hydration periods of up to 28 days in artificial urine at pH 6 and pH 9, representing the pH of physiologically normal and infected urine, respectively, and during 200 repeated cycles of applied frictional force. Importantly, the modified surfaces also displayed excellent antibacterial activity, which could be facilely tuned to achieve reductions of 99.8% in adherence of common hospital-acquired pathogens, Staphylococcus aureus and Proteus mirabilis, relative to their uncoated counterparts through incorporation of chlorhexidine in the coating matrix as a model antiseptic. The remarkable, and pH-independent, tribological performance of these lubricious, antibacterial, and highly durable surfaces offers exciting promise for use of this PVC functionalization approach in facilitating smooth and atraumatic insertion and removal of a wide range of medical implants, ultimately maintaining user health and dignity.

Outcome of Different Approaches to Reduce Urinary Tract Infection in Patients With Spinal Cord Lesions: A Systematic Review

Neurogenic bladder disorders are common among patients with spinal cord lesions, which often result in upper and lower urinary tract complications. Urinary tract infection has remained the most frequent type of infection in this population. Our aim is to review systematically the literature on the outcome of different intervention methods to reduce urinary tract infection incidence. A literature search was conducted in the database of Medline, PubMed, Embase, and Scopus. After screening 1559 articles, 42 were included in this review. The intervention methods can be categorized into the four following groups: (1) indwelling catheterization and intermittent catheterization, (2) medications, (3) surgery, and (4) others. Intermittent catheterization is still the most recommended treatment for persons with spinal cord lesions. Hydrophilic catheters are more suitable for adults than children because of complex handling. Bladder management with spontaneous voiding is initially considered for infants and toddlers with spina bifida. Antibiotics treatment should be based on the results of urine cultures. Shortening the course of antibiotics treatment can reduce its adverse effects but may increase urinary tract infection recurrence. Because botulinum toxin injections and bladder surgery can improve urodynamic function, both are conducive toward lowering urinary tract infection incidence.

Bladder management practices in spinal cord injury patients: A single center experience from a developing country

Context/Objective: Inadequate bladder management in spinal cord injury (SCI) patients results in significant morbidity and even mortality. Clean intermittent catheterization (CIC) is the recommended option for SCI patients. The objective of the study was to document the bladder management practices of SCI patients in a developing country.Design: Questionnaire based cross sectional surveySetting: Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, PakistanParticipants: All patients with SCI (irrespective of duration, level and etiology)Interventions: Data documentation included demographics, level, severity and time since injury, bladder management techniques used, details of CIC, results of Urodynamic studies (if available), complications resulting from bladder management technique and patient awareness of the yearly follow up. SPSS V 20 was used for analysis.Outcome Measures: Not applicableResults: Thirty four consenting patients were enrolled. All were males. Mean age was 31.24 ± 10.9. Most (17) of the patients were thoracic level paraplegics, while 12 patients had sustained a cervical SCI. Majority (23) had complete injury (ASIA A). Fifteen patients used CIC for bladder management followed by in dwelling Foley catheters in thirteen patients. Those using CIC performed the procedure every four hours and used disposable catheters. The same 'disposable' catheter was used for 5-7 days by half of these patients. Only Six patients independently performed CIC. Three patients on CIC reported urinary tract infection.Conclusions: In the largest spinal rehabilitation unit of a developing country; Pakistan CIC was the preferred method of bladder management followed by indwelling catheter. Re-use of disposable catheters is a common practice due to cost issues. The rate of UTI was significantly lower in patients on CIC.

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

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

Early urinary tract infection after spinal cord injury: a retrospective inpatient cohort study

STUDY DESIGN

Retrospective audit.

OBJECTIVES

Examine factors associated with urinary tract infection (UTI), UTI incidence and impact on hospital length of stay (LOS) in new, inpatient adult traumatic spinal cord injury (SCI).

SETTING

Western Australian Hospitals managing SCI patients.

METHODS

Data on UTIs, bladder management and LOS were obtained from hospital databases and medical records over 26 months. Adherence to staff-administered intermittent catheterisation (staff-IC) was determined from fluid balance charts.

RESULTS

Across the cohort (n = 70) UTI rate was 1.1 starts/100 days; UTI by multi-resistant organisms 0.1/100 days. Having ≥1 UTIs compared with none and longer duration of initial urethral indwelling catheterisation (IDC) were associated with longer LOS (p-values < 0.001). For patients with ≥1 UTIs (n = 43/70), longer duration of initial IDC was associated with shorter time to first UTI (1 standard deviation longer [SD, 45.0 days], hazard ratio (HR): 0.7, 95% confidence interval [CI] 0.5-1.0, p-value 0.044). In turn, shorter time to first UTI was associated with higher UTI rate (1 SD shorter [30.7 days], rate ratio (RR): 1.32, 95%CI 1.0-1.7, p-value 0.039). During staff-IC periods (n = 38/70), protocols were followed (85.7% ≤ 6 h apart, 96.1% < 8 h), but 26% of IC volumes exceeded 500 mL; occasional volumes > 800 mL and interruptions requiring temporary IDC were associated with higher UTI rates the following week (odds ratios (ORs): 1.6, 95%CI 1.1-2.3, p-value 0.009; and 3.9, 95%CI 2.6-5.9, p-value < 0.001 respectively).

CONCLUSIONS

Reducing initial IDC duration and limiting staff-IC volumes could be investigated to possibly reduce inpatient UTIs and LOS.

SPONSORSHIP

None.

The relationship of seasonality and the increase in urinary tract infections among hospitalized patients with spinal cord injury

BACKGROUND

Urinary tract infection (UTI) is the most frequent complication in patients who have spinal cord injury (SCI). The occurrence rate of UTI in this type of hospitalized patients was correlated to seasonality, age, and gender.

METHODS

Patients hospitalized during the 4-year study period with underlying SCI were identified from Taiwan's National Health Insurance Research Database. Patients with a discharge diagnosis of UTI were identified as those with SCI and UTI; they were divided into the following four age groups: <18 years, 18 to 44 years, 45 to 64 years, and ≥65 years. The gender, monthly number of cases, major complication rate, seasonal differences, and odds ratios (ORs) of associated factors were analyzed.

RESULTS

Data of 30 149 hospitalized patients diagnosed with SCI were retrieved. SCI and UTI were diagnosed in 3405 (11.3%) patients, of them 2296 were males (67.4%) and 1109 were females (32.6%). The UTI occurrence rate in hospitalized SCI patients was higher in males (11.8%) than in females (10.4%) (OR: 1.24; 95% CI: 1.15-1.34); it was highest in the ≥65-year-old age group (12.8%) and lowest in the <18-year-old age group (5.8%) (OR: 2.51; 95% CI: 1.83-3.44). The UTI occurrence rate varied from 7% to 18%, and it was highest in the summer (13.0% ± 2.6%) and lowest in the winter (10.2% ± 1.9%) (OR: 1.27; 95% CI: 1.15-1.40). Acute pyelonephritis was the most common complication in SCI and UTI cases.

CONCLUSION

The mean occurrence rate of UTI in hospitalized SCI patients was 11.3%; it was higher in males, in patients aged ≥65 years, and in the summer. Therefore, physicians should pay attention to the occurrence of UTI in aged male patients with SCI, especially in the summer.

Adult Neurogenic Lower Urinary Tract Dysfunction and Intermittent Catheterisation in a Community Setting: Risk Factors Model for Urinary Tract Infections

A risk factor model for urinary tract infections in patients with adult neurogenic lower urinary tract dysfunction performing clean intermittent catheterisation was developed; it consists of four domains, namely, (1) general (systemic) conditions in the patient, (2) individual urinary tract conditions in the patient, (3) routine aspects related to the patient, and (4) factors related to intermittent catheters per se. The conceptual model primarily concerns patients with spinal cord injury, spina bifida, multiple sclerosis, or cauda equina where intermittent catheterisation is a normal part of the bladder management. On basis of several literature searches and author consensus in case of lacking evidence, the model intends to provide an overview of the risk factors involved in urinary tract infections, with specific emphasis to describe those that in daily practice can be handled and modified by the clinician and so come to the benefit of the individual catheter user in terms of fewer urinary tract infections.

Medical Management of Neurogenic Bladder for Children and Adults: A Review

Neurogenic bladder is a chronic condition affecting patients of all ages with significant medical and quality of life implications. Goals of treatment consist of protection of the upper urinary tract and promotion of reliable urinary continence. Successful management involves medications and most often bladder drainage via clean intermittent catheterization. This article reviews current literature on medical management to achieve goals of treatment.

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

AIMS

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

DESIGN

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

METHODS

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

RESULTS

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

Hydrogen peroxide stimulates uropathogenic Escherichia coli strains to cellulose production

Reactive oxygen intermediates, such as hydrogen peroxide, are toxic molecules produced by immune cells in response to bacterial invasion into the host. Bacteria try to protect themselves against the immune system through specific properties such as biofilm formation. This phenomenon occurs also during urinary tract infections. Cellulose is an important factor of Escherichia coli biofilm and contributes to building a protective shield around bacterial cells upon the host immune response. In this study, we aimed to analyze the effect of hydrogen peroxide on the production of this biofilm component. To achieve this goal, 25 clinical E. coli strains isolated from patients with urinary tract infections were used. These bacterial strains were characterized based on their growth characteristics, their ability to form biofilm and their capacity to produce cellulose upon exposure to sub-lethal concentrations of hydrogen peroxide growth, and the biofilm formation of these strains was analyzed. Our results revealed that the analyzed uropathogenic E. coli strains slightly, but significantly, reduced growth and biofilm production upon hydrogen peroxide treatment. However, when separating these strains regarding their ability to produce cellulose, we found that general biofilm production was reduced but cellulose expression was induced upon peroxide treatment. This finding contributes to a better understanding of how bacterial biofilm formation is triggered and provides interesting insights into how uropathogenic E. coli protect themselves in an inhospitable environment.

Review of Catheter-Associated Urinary Tract Infections and In Vitro Urinary Tract Models

Catheter-associated urinary tract infections (CAUTIs) are one of the most common nosocomial infections and can lead to numerous medical complications from the mild catheter encrustation and bladder stones to the severe septicaemia, endotoxic shock, and pyelonephritis. Catheters are one of the most commonly used medical devices in the world and can be characterised as either indwelling (ID) or intermittent catheters (IC). The primary challenges in the use of IDs are biofilm formation and encrustation. ICs are increasingly seen as a solution to the complications caused by IDs as ICs pose no risk of biofilm formation due to their short time in the body and a lower risk of bladder stone formation. Research on IDs has focused on the use of antimicrobial and antibiofilm compounds, while research on ICs has focused on preventing bacteria entering the urinary tract or coming into contact with the catheter. There is an urgent need for in vitro urinary tract models to facilitate faster research and development for CAUTI prevention. There are currently three urinary tract models that test IDs; however, there is only a single very limited model for testing ICs. There is currently no standardised urinary tract model to test the efficacies of ICs.

Non-surgical urologic management of neurogenic bladder after spinal cord injury

PURPOSE

To review the available data on non-surgical management for neurogenic bladder in patients with spinal cord injury (SCI). Before the introduction of urinary catheters and antibiotics, neurogenic bladder was one of the main culprits for death in those patients with SCI. Currently, the management of neurogenic bladder is focused in improving quality of life and preserving renal function.

METHODS

A literature review was performed and therapeutic management for neurogenic bladder was divided in six sections: (1) intermittent bladder catheterization; (2) indwelling catheters; (3) condom catheter drainage; (4) reflex voiding and bladder expression with Valsalva or Credé; (5) oral drug therapy of the spinal cord injured bladder; and (6) botulinum neurotoxin (BoNT).

RESULTS

Intermittent catheterization is recommended as the preferable method for management of neurogenic bladder in patients with SCI based on limited high-quality data. However, this may not be feasible or available to all and other alternative options include condom catheter drainage or indwelling catheters such as urethral catheters or suprapubic tube, reflex voiding, and bladder expression with Valsalva or Credé. Non-invasive medical therapies are the key to improve incontinence, urodynamic parameters, and quality of life in this population. Botulinum neurotoxin has revolutionized the management of neurogenic bladder in the last two decades decreasing the need for reconstruction or diversion.

CONCLUSION

The Joint SIU-ICUD (Société Internationale d'Urologie) (International Consultation on Urological Diseases) International Consultation reviewed the available presented data and provided specific conclusions and recommendations for each non-surgical urologic method to address neurogenic bladder after SCI.

Cost-effectiveness of hydrophilic-coated intermittent catheters compared with uncoated catheters in Canada: a public payer perspective

STUDY DESIGN

A Markov model was used to analyze cost-effectiveness over a lifetime horizon.

OBJECTIVE

To investigate the cost-effectiveness of hydrophilic-coated intermittent catheters (HCICs) compared with uncoated catheters (UCs) among individuals with neurogenic bladder dysfunction (NB) due to spinal cord injury (SCI).

SETTING

A Canadian public payer perspective based on data from Ontario; including a scenario analysis from the societal perspective.

METHODS

A previously published Markov decision model was modified to compare the lifetime costs and quality-adjusted life years (QALYs) for the two interventions. Three renal function and three urinary tract infection (UTI) health states as well as other catheter-related events were included. Scenario analyses, including utility gain from compact catheter and phthalate free catheter use, were performed. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of the model.

RESULTS

The model predicted that a 50-year-old patient with SCI would gain an additional 0.72 QALYs if HCICs were used instead of UCs at an incremental cost of $48,016, leading to an incremental cost-effectiveness ratio (ICER) of $66,634/QALY. Moreover, using HCICs could reduce the lifetime number of UTI events by 11%. From the societal perspective, HCICs cost less than UCs, while providing superior outcomes in terms of QALYs, life years gained (LYG), and UTIs. The cost per QALY further decreased when health-related quality-of-life (HRQoL) gains associated with compact HCICs or catheters not containing phthalates were included.

CONCLUSION

In general, ICERs in the range of CAD$50-100,000 could be considered cost-effective. The ICERs for the base case and sensitivity analyses suggest that HCICs could be cost-effective. From the societal perspective, HCICs were associated with potential cost savings in our model. The results suggest that reimbursement of HCICs should be considered in these settings.

Systematic review and practice policy statements on urinary tract infection prevention in adults with spina bifida

Urinary tract infection (UTI) is a source of morbidity and healthcare costs in adults with spina bifida (ASB). UTI prevention strategies are often recommended, but the evidence of various approaches remains unclear. We performed a systematic review to inform a best practice policy statement for UTI prevention in ASB. On behalf of the Neurogenic Bladder Research Group (NBRG.org), we developed an a priori protocol and searched the published English literature for 30 outcomes questions addressing UTI prevention in ASB. The questions spanned the categories of antibiotics, oral supplements, bladder management factors and social support. Where there was little literature in ASB, we included literature from similar populations with neurogenic bladder (NB). Data was abstracted and then reviewed with recommendations made by consensus of all authors. Level of Evidence (LoE) and Grade of Recommendation (GoR) were according to the Oxford grading system. Of 6,433 articles identified by our search, we included 99 publications. There was sufficient evidence to support use of the following: saline bladder irrigation (LoE 1, GoR B), gentamicin bladder instillation (LoE 3, GoR C), single-use intermittent catheterization (IC) (LoE 2, GoR B), hydrophilic catheters for IC (LoE 2, GoR C), intradetrusor onabotulinumtoxinA injection (LoE 3, GoR C), hyaluronic acid (HA) instillation (LoE 1, GoR B), and care coordination (LoE 3, GoR C). There was sufficient evidence to recommend against use of the following: sterile IC (LoE 1, GoR B), oral antibiotic prophylaxis (LoE 2, GoR B), treatment of asymptomatic bacteriuria (LoE 2, GoR B), cranberry (LoE 2, GoR B), methenamine salts (LoE 1, GoR B), and ascorbic acid (LoE1, GoR B). There was insufficient evidence to make a recommendation for other outcomes. Overall, there are few studies in UTI prevention in the specific population of ASB. Research in populations similar to ASB helps to guide recommendations for UTI prevention in the challenging patient group of ASB. Future studies in UTI prevention specific to ASB are needed and should focus on areas shown to be of benefit in similar populations.

Can hydrophilic coated catheters be beneficial for the public healthcare system in Brazil? - A cost-effectiveness analysis in patients with spinal cord injuries

INTRODUCTION

Detrusor sphincter dyssynergia affects 70% to 80% of all spinal cord injury patients, resulting in increased risk of urinary tract infections (UTIs) and potential exposure to antimicrobial resistance. In Brazil, local guidelines recommend intermittent catheterization as the best method for bladder emptying, and two catheter types are available: the conventional uncoated PVC and the hydrophilic coated catheters.

OBJECTIVE

To evaluate the cost-effectiveness of two types of catheters for intermittent catheterization from the perspective of the Brazilian public healthcare system.

MATERIALS AND METHODS

A Markov model was used to evaluate cost-effectiveness in those with spinal cord injuries. A primary analysis was conducted on all possible adverse events, and a secondary analysis was performed with urinary tract infections as the only relevant parameter. The results were presented as cost per life years gained (LYG), per quality-adjusted life years (QALY) and per number of urinary tract infections (UTIs) avoided.

RESULTS

The base scenario of all adverse events shows a cost-effective result of hydrophilic coated catheters compared to uncoated PVC catheters at 57,432 BRL (Brazilian Reais) per LYG and 122,330 BRL per QALY. The secondary scenario showed that the use of hydrophilic coated catheters reduces the total number of UTIs, indicating that an additional cost of hydrophilic coated catheters of 31,240 BRL over a lifetime will reduce lifetime UTIs by 6%.

CONCLUSIONS

Despite the higher unit value, the use of hydrophilic coated catheters is a cost-effective treatment from the perspective of the Brazilian public healthcare system.

Enhancing quality practice for prevention and diagnosis of urinary tract infection during inpatient spinal cord rehabilitation

OBJECTIVES

To reduce the incidence of Urinary Tract Infection (UTI) in subacute SCI individuals admitted for tertiary inpatient rehabilitation.

DESIGN

A quality improvement team was assembled to improve UTI prevention/diagnosis. To plan data collection, UTI-related factors were mapped in an Ishikawa (fishbone) driver diagram. Data including patient demographics, presence and frequency of signs and/or symptoms of UTI and antibiotic initiation from August to December 2015 were recorded. Sensitivity, Specificity, Positive and Negative Predictive Values (PPV, NPV), and Likelihood Ratios (LR) were calculated for each sign and symptom.

SETTING

Tertiary SCI Rehabilitation Results: Among 55 inpatients with subacute SCI who had signs/symptoms prompting urine culture and sensitivity (C&S), 32 (58.18%) were diagnosed with a UTI. The most frequent symptoms were foul smelling urine (41%), change in urine color (31%), and incontinence (25%), and the most common sign was fever (34%). Most UTIs (81%) occurred among individuals using Clean Intermittent Catheterization (CIC), with 46% of catheterizations performed by nurses. Foul smelling urine had the highest sensitivity (0.50, 95% CI: 0.31-0.69), and new incontinence had the highest specificity (0.88, 95% CI: 0.69-0.97) for UTI diagnosis. The highest PPV belonged to the cloudy urine (0.71, 95% CI: 0.42-0.92). The combination of cloudy and foul smelling urine increased the PPV to 78% (95% CI: (0.40-0.97).

CONCLUSIONS

The concurrent presence of cloudy and foul smelling urine is predicted of UTI diagnosis inpatients tertiary setting. SCI inpatients are susceptible to UTI when learning CIC technique from nurses.

Efficacy and safety of urinary catheters with silver alloy coating in patients with spinal cord injury: a multicentric pragmatic randomized controlled trial. The ESCALE trial

BACKGROUND

Patients with spinal cord injury (SCI) who carry indwelling urinary catheters have an increased risk of urinary tract infection (UTI). Antiseptic silver alloy-coated (SAC) silicone urinary catheters prove to be a promising intervention to reduce UTIs; however, current evidence cannot be extrapolated to patients with SCI.

PURPOSE

This study aimed to assess the efficacy of SAC urinary catheters for preventing catheter-associated urinary tract infections.

DESIGN/SETTING

This is an open-label, multicenter (developed in Spain, Portugal, Chile, Turkey, and Italy), randomized clinical trial conducted in 14 hospitals from November 2012 to December 2015.

PATIENT SAMPLE

Eligible patients were men or women with traumatic or medical SCI, aged ≥18 years, requiring an indwelling urinary catheter for at least 7 days.

OUTCOME MEASURES

The primary outcome was the incidence of symptomatic UTIs. The secondary outcome included bacteremia in the urinary tract and adverse events.

MATERIALS AND METHODS

Patients were randomized to receive a SAC urinary catheter (experimental group) or a standard catheter (control group) for at least 7 days. Data were compared using chi-squared test and also calculating the absolute risk difference with a 95% confidence interval. An adjusted analysis including different risk factors of UTI was performed. This study was mainly funded by La Marató de TV3 Foundation (grant number # 112210) and the European Clinical Research Infrastructures Network organization. The funders had no role in the interpretation or reporting of results.

RESULTS

A total of 489 patients were included in the study, aged 55 years in the experimental group and aged 57 in the control group (p=.870); 72% were men; 43% were hospitalized patients, and 57% were outpatients (p=1.0). The most frequent cause of SCI was traumatic (73.75%), and the localization was mainly the cervical spine (42.74%). Most of the patients had an A score (complete spinal injury and no motor and sensory is preserved) on the ASIA scale (62.37%). The median time of urethral catheterization was 27 days in the experimental group and 28 days in the control group (p=.202). Eighteen patients (7.41%) in the experimental group and 19 in the control (7.72%) group had a symptomatic UTI (odds ratio [OR] 0.96 [0.49-1.87]). The adjusted analysis revealed no change in the results. Only three patients in the experimental group had bacteremia within the urinary tract. The experimental group presented more adverse events related to the use of a catheter than the control group (OR 0.03 [0.00-0.06]).

CONCLUSIONS

The results of this study do not support the routine use of indwelling antiseptic SAC silicone urinary catheters in patients with SCI. However, UTIs associated to long-term urinary catheter use remain a challenge and further investigations are still needed.

Cost-Effectiveness Analysis of Long-Term Intermittent Self-Catheterization with Hydrophilic-Coated and Uncoated Catheters in Patients with Spinal Cord Injury in Japan

OBJECTIVES

To evaluate the cost effectiveness of disposable, hydrophilic-coated catheters in Japan.

METHODS

A Markov decision model previously applied in a European study was used to evaluate the cost effectiveness of intermittent self-catheterization (ISC) with hydrophilic-coated catheters in Japanese spinal cord injury (SCI) patients suffering from chronic urinary retention from a lifetime perspective. To adjust the model to a Japanese setting, relevant Japanese data regarding the baseline risk of urinary tract infection (UTI), the average age at onset of SCI, costs, and general mortality were extracted from published literature, national statistics, or the opinions of Japanese experts. The direct medical costs, quality-adjusted life years (QALYs) and life years gained (LYG) were calculated from the payers' perspective. An annual discount rate of 2% was applied to both the costs and the effects.

RESULTS

The incremental cost of hydrophilic-coated catheters was 1 279 886 yen (US$ 10 578 at an exchange rate of US$ 1 = 121 yen) per SCI patient, but they yielded an additional 0.334 QALYs and 0.781 LYG compared with uncoated catheters. The incremental cost-effectiveness ratio (ICER) of hydrophilic-coated catheters vs. uncoated catheters was 3 826 351 yen/QALY (US$ 31 623/QALY) gained and 1 639 562 yen/LYG (US$ 13 550/LYG).

CONCLUSIONS

The ICER of 3.8 million yen (US$ 31 405) falls well within the Japanese societal willingness to pay per QALY gained; therefore, hydrophilic-coated catheters can be considered highly cost-effective in Japan compared with uncoated catheters. However, because of the lack of relevant studies, a number of key parameters could not be based on Japanese data, and further research among people with SCI in Japan is recommended.

WITHDRAWN: Intermittent catheterisation for long-term bladder management

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, and handsearching of journals and conference proceedings (searched 30 September 2013), the reference lists of relevant articles and conference proceedings, and we attempted to contact other investigators for unpublished data or for clarification.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or randomised cross-over trials comparing at least two different catheter designs, catheterisation techniques or strategies.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Thirty-one trials met the inclusion criteria, including 13 RCTs and 18 cross-over trials. Most were small (less than 60 participants completed), although five trials had more than 100 participants. There was considerable variation in length of follow-up and definitions of UTI. Participant dropout was a problem for several trials, particularly where there was long-term follow-up to measure incidence of UTI. Fifteen trials were more than 10 years old and focused mainly on comparing different catheterisation techniques (e.g. single versus multiple-use) on clinical outcomes whereas, several more recent trials have focused on comparing different types of catheter designs or materials, especially coatings, and user preference. It was not possible to combine data from some trials owing to variations in the catheters tested and in particular the catheter coatings. Where there were data, confidence intervals around estimates were wide and hence clinically important differences in UTI and other outcomes could neither be identified nor reliably ruled out. No study assessed cost-effectiveness.

AUTHORS' CONCLUSIONS

Despite a total of 31 trials, there is still no convincing evidence that the incidence of UTI is affected by use of aseptic or clean technique, coated or uncoated catheters, single (sterile) or multiple-use (clean) catheters, self-catheterisation or catheterisation by others, or by any other strategy. Results from user-reported outcomes varied. The current research evidence is weak and design issues are significant. More well-designed trials are strongly recommended. Such trials should include analysis of cost-effectiveness because there are likely to be substantial differences associated with the use of different catheter designs, catheterisation techniques and strategies.