INTERMITTENT CATHETERIZATION WITH A PRELUBRICATED CATHETER IN SPINAL CORD INJURED PATIENTS: A PROSPECTIVE RANDOMIZED CROSSOVER STUDY

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reference lists of relevant articles and conference proceedings, and we attempted to contact other investigators for unpublished data or for clarification.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.

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.

Prospective multicentre observational study assessing the tolerance and perception of patients using the Liquick Base catheter with an Ergothan tip

INTRODUCTION

Intermittent self-catheterisation has revolutionised the management of neurogenic bladder-sphincter dysfunctions. The Liquick Base catheter is characterised by a streamlined Ergothan tip. The purpose of this study is to assess the tolerance and perception of patients using this catheter.

MATERIALS AND METHODS

A French prospective multicentre observational study was conducted on patients with neurogenic bladder-sphincter dysfunctions. Upon inclusion in the study, the doctor completed a questionnaire on the patient's pathology. After 3 and 6 months, the doctor checked for neurogenic developments or observations and looked for any complications relating to intermittent self-catheterisation. The patient completed a questionnaire to assess his or her perception of using the catheter.

RESULTS

Out of 42 patients included in the study, two were excluded. Out of the 40 assessed patients (30 males, 10 females) with an average age of 50.1±14.9 years, there were no reported cases of false passage. Bleeding occurred at least once in 10 patients (25%) in the first three months and in three out of 20 patients (15%) between 3 and 6 months. Two (5%) patients sought medical attention in the first three months for complications related to the catheter and 4 patients sought medical attention (10%) between 3 and 6 months. After 3 months 90% of patients were still using the catheter and after 6 months 90% of patients were still using the catheter.

CONCLUSION

The Liquick Base catheter is well tolerated. Patient perception is positive for all parameters being examined, leading to the continued use of the catheter in 90% of cases.

LEVEL OF EVIDENCE

2.

In Their Own Words: Adults' Lived Experiences With Intermittent Catheterization

PURPOSE

The aim of this study was to identify themes related to barriers and facilitators to the integration of intermittent catheterization (IC) in the daily lives or persons using the form of bladder evacuation.

DESIGN

Descriptive, qualitative study.

SUBJECTS AND SETTING

A purposive sample of 25 adults from 5 countries (United States, United Kingdom, Germany, France, and the Netherlands) was assembled. All participants had used IC as their primary method of bladder emptying for at least 1 year and, in that time, had used as least 2 different IC products.

METHODS

Guided telephone interviews with each participant were conducted by professional staff fluent in each participant's local language as well as trained in qualitative data collection. Interviews were digitally recorded and subsequently transcribed verbatim into English for analysis. We used ATLAS.ti qualitative analysis software (version 7.5.11) to assist with data organization and identification of major themes. Descriptive statistics (eg, mean, standard deviation, or frequency) were used to characterize the sample in terms of sociodemographic and clinical characteristics as collected during the interview.

RESULTS

Analysis revealed 9 main themes around individuals' lived experiences of IC: initial fear, urinary tract infection, pain/discomfort, independence, choice, community, life quality, resilience, and acceptance.

DISCUSSION

Our results indicate that IC is perceived as a burden by some, but not all, users. The challenge, and opportunity, is to learn more about what has gone right for those who have adapted and to leverage the clinical, practical, psychological, and social factors that enable individuals to integrate IC into the rhythm of their daily lives.

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.

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.

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.

Outcome comparison of different approaches to self-intermittent catheterization in neurogenic patients: a systematic review

STUDY DESIGN

Systematic review (Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA); http://www.prisma-statement.org).

OBJECTIVES

Different types of catheters and techniques have been described in the past three decades to identify the best self-intermittent catheterization method. Our aim is to review systematically the literature on the most appropriate material and technique to perform self-intermittent catheterization in the adult neurogenic population.

METHODS

A systematic review search was performed through PubMed/Medline, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) databases to study all types of self-intermittent catheters, and analyzing their impact on urinary tract infections (UTIs), urethral trauma, cost-effectiveness, quality of life and patient's satisfaction. We used the following keywords: 'intermittent catheterization/catheterisation', 'neurogenic', 'urinary catheters for intermittent use' and 'urethral catheterization/catheterisation' published by November 2015.

RESULTS

After screening 3768 articles, 31 were included in the final synthesis (level of evidence 1b to 2b). The 2188 trial participants were mainly spinal cord injury adults and women with multiple sclerosis. Hydrophilic-coated catheters tended to decrease the incidence of UTI as well as urethral trauma and improve patient's satisfaction when compared with non-hydrophilic-coated catheters. Similarly, prelubricated catheters were associated with better results in terms of patient satisfaction. Sterile technique seemed to decrease the incidence of recurrent UTI; however, these results are counter-balanced by significantly increasing cost compared with clean catheterization.

CONCLUSIONS

The present review demonstrated advantages of hydrophilic-coated catheters in decreasing risk of UTI and urethral trauma as well as improving patient's satisfaction. Prelubricated catheters has been shown to be superior to conventional polyvinyl chloride catheters. Randomized controlled trials comparing hydrophilic and prelubricated catheters must be conducted to assess possible superiority and cost-effectiveness.

[S2k guidelines of the German Society of Urology. Management and implementation of intermittent catheterization in neurogenic bladder dysfunction]

BACKGROUND

As a considerable heterogeneity in the procedure of intermittent catheterization (IC) was identified by a questionnaire survey conducted in hospitals and institutions for the treatment of patients with spinal cord injury in 2010, it became necessary to standardize the IC procedure (i.e. self-catheterization and assisted catheterization).

METHOD

These guidelines were developed within a structured consensus process (e.g. several consensus conferences and nominal group process) by members of the working group on neurourology (Arbeitskreis Neuro-Urologie) and the working group on nursing (Arbeitskreis Pflege) of the German-speaking Medical Society of Paraplegia (DMGP), a section of the German Society for Orthopedics and Traumatology (DGOU) and were published as S2k guidelines of the German Society of Urology (DGU). The guidelines developer group consisted of representatives from the following professional groups: neurourology, surgery, health and nursing, nursing science, urotherapy and hygiene.

RESULTS

Firstly, the indications for IC are presented and concepts such as sterile, aseptic and hygienic catheterization are defined. The materials necessary for the IC (e.g. quality of the customized single-use catheter and approved disinfectants for disinfection of the meatus) are presented in detail. The disinfection and catheterization techniques are described and a detailed explanation of the potential complications and their management is given. Finally, the legal aspects and issues of eligibility of catheter material and disinfectants are discussed.

CONCLUSIONS

The purpose of this consensus is to contribute to the standardization of IC. It should remove uncertainty and offer assistance to users (i.e. patients, staff and care providers). A particular focus is placed on practical instructions for carrying out the IC. The intention is to support the realization of IC in various settings (e.g. hospital, rehabilitation, long-term care institutions and home-based care). A wide implementation of the guidelines should lead to a reduction of the risks and complications of IC, which in most cases is a procedure that will be necessary throughout life.

A cost-effectiveness analysis of long-term intermittent catheterisation with hydrophilic and uncoated catheters

STUDY DESIGN

Cost-effectiveness analysisObjective:To establish a model to investigate the cost effectiveness for people with spinal cord injury (SCI), from a lifetime perspective, for the usage of two different single-use catheter designs: hydrophilic-coated (HC) and uncoated (UC). The model includes the long-term sequelae of impaired renal function and urinary tract infection (UTI).

SETTING

Analysis based on a UK perspective.

METHODS

A probabilistic Markov decision model was constructed, to compare lifetime costs and quality-adjusted life years, taking renal and UTI health states into consideration, as well as other catheter-related events. UTI event rates for the primary data set were based on data from hospital settings to ensure controlled and accurate reporting. A sensitivity analysis was applied to evaluate best- and worst-case scenarios.

RESULTS

The model predicts that a 36-year-old SCI patient with chronic urinary retention will live an additional 1.4 years if using HC catheters compared with UC catheters, at an incremental cost of £2100. Moreover, the lifetime number of UTI events will be reduced by 16%. All best- and worst-case estimates were within the UK threshold of being cost effective.

CONCLUSION

The use of HC catheters for intermittent catheterisation in SCI patients is highly cost effective. The outcome is consistent irrespective of whether UTI data are collected in hospital or community settings.

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.

A randomized controlled trial to assess the efficacy and cost-effectiveness of urinary catheters with silver alloy coating in spinal cord injured patients: trial protocol

BACKGROUND

Patients with non-acute spinal cord injury that carry indwelling urinary catheters have an increased risk of urinary tract infection (UTIs). Antiseptic Silver Alloy-Coated Silicone Urinary Catheters seems to be a promising intervention to reduce UTIs; however, actual evidence cannot be extrapolated to spinal cord injured patients. The aim of this trial is to make a comparison between the use of antiseptic silver alloy-coated silicone urinary catheters and the use of standard urinary catheters in spinal cord injured patients to prevent UTIs.

METHODS/DESIGN

The study will consist in an open, randomized, multicentre, and parallel clinical trial with blinded assessment. The study will include 742 spinal cord injured patients who require at least seven days of urethral catheterization as a method of bladder voiding. Participants will be online centrally randomized and allocated to one of the two study arms (silver alloy-coated or standard catheters). Catheters will be used for a maximum period of 30 days or removed earlier if the clinician considers it necessary. The main outcome will be the incidence of UTIs by the time of catheter removal or at day 30 after catheterization, the event that occurs first. Intention-to-treat analysis will be performed, as well as a primary analysis of all patients.

DISCUSSION

The aim of this study is to assess whether silver alloy-coated silicone urinary catheters improve ITUs in spinal cord injured patients. ESCALE is intended to be the first study to evaluate the efficacy of the silver alloy-coated catheters in spinal cord injured patients.

TRIAL REGISTRATION

NCT01803919.

Types of indwelling urinary catheters for long-term bladder drainage in adults

BACKGROUND

Prolonged urinary catheterization is common amongst people in long-term care settings and this carries a high risk of developing a catheter-related urinary tract infection and associated complications. A variety of different kinds of urethral catheters are available. Some have been developed specifically to lower the risk of catheter-associated infection, for example antiseptic or antibiotic impregnated catheters. Ease of use, comfort and handling for the caregivers and patients, and cost-effectiveness are also important factors influencing choice.

OBJECTIVES

The primary objective was to determine which type of indwelling urinary catheter is best to use for long-term bladder drainage in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (last searched 31 March 2011), which includes searches of CENTRAL, MEDLINE and handsearching of journals and conference proceedings, and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised trials comparing types of indwelling urinary catheters for long-term catheterization in adults. Long-term catheterization was defined as more than 30 days.

DATA COLLECTION AND ANALYSIS

Data extraction has been undertaken by two review authors working independently and simultaneously. Any disagreement has been resolved by a third review author. The included trial data were handled according to the methods of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Three trials were included, involving 102 adults in various settings. Two trials had a parallel group design and one was a randomised cross-over trial.Only two of the six targeted comparisons were assessed by these trials: antiseptic impregnated catheters versus standard catheters (one trial) and one type of standard catheter versus another standard catheter (two trials).The single small cross-over trial was inadequate to assess the value of silver alloy (antiseptic) impregnated catheters. In the two trials comparing different types of standard catheters, estimates of differences were all imprecise because the trials also had small sample sizes; confidence intervals (CI) were too wide to rule out clinically important differences. One trial did suggest, however, that the use of a hydrogel coated latex catheter rather than a silicone catheter may be better tolerated (risk ratio (RR) for need for early removal 0.41, 95% CI 0.22 to 0.77).

AUTHORS' CONCLUSIONS

The updated search could not reveal any additional evidence. Very few trials have compared different types of catheter for long-term bladder drainage. All trials were small and showed methodological weaknesses. Therefore, the evidence was not sufficient as a reliable basis for practical conclusions. Further, better quality trials are needed to address the current lack of evidence in this clinically important area.

Neurological patients need evidence-based urological care

AIMS

To report the conclusion of the Think Thank on Neurourology discussions during the first ICI-RS meeting in 2009.

METHODS

During a 3-day meeting a group of specialists discussed evidence-based medicine in neurourology and made suggestions for future research.

RESULTS

In the vast majority of patients with neurological disease bladder dysfunction occurs. The actual rules of diagnosis and treatment lack a study related evidence base. From a long list of possible research subjects, prevalence, detrusor pressure, imaging, catheterization and surgery have been first discussed.

CONCLUSION

In each of these subjects, research items are suggested which can help to improve the care in this patient group.

A multicenter, double-blind, randomized, parallel group study comparing polyvinyl chloride and polyvinyl chloride-free catheter materials

PURPOSE

In this study we compared a polyvinyl chloride catheter with a new polyvinyl chloride-free catheter with the same hydrophilic coating, and determined whether patient perception of ease and comfort of clean intermittent catheterization was independent of the catheter material.

MATERIALS AND METHODS

This investigation was designed as a randomized, double-blind, parallel group, multicenter study. Eligible patients were experienced users of clean intermittent catheterization with a polyvinyl chloride catheter for a minimum of 1 month before randomization. They were randomized to continue to use the polyvinyl chloride catheter or switch to a polyvinyl chloride-free catheter for 4 weeks. Both catheters had a similar appearance. Patient perception of ease and comfort of clean intermittent catheterization was scored with questionnaires, and adverse events were documented.

RESULTS

A total of 195 patients were recruited from 6 countries and 13 centers for the intent to treat analysis, and 179 were used for the per protocol analysis. Before randomization 94% to 98% of the patients rated the polyvinyl chloride catheter as easy or manageable to handle during different phases of clean intermittent catheterization and overall 92% of patients were satisfied. Of the eligible patients satisfaction was reported by 89% randomized to continue using the polyvinyl chloride catheter and by 78% randomized to switch to the polyvinyl chloride-free catheter (not significant). The rate of adverse events was low and comparable between the 2 groups.

CONCLUSIONS

The study confirms that clean intermittent catheterization is easy and safe. Conversion from a polyvinyl chloride to a polyvinyl chloride-free core catheter material does not alter patient perception of catheterization.

Urinary tract infections in spinal cord injury: prevention and treatment guidelines

OBJECTIVES AND METHODS

The literature on prevention and therapy of urinary tract infection (UTI) in patients with spinal cord injury (SCI) was reviewed using 3 levels of evidence.

RESULTS

Antibiotic therapy is only indicated in symptomatic bacteriuria or in symptomatic exacerbations of chronic UTI. During the acute phase of a SCI, UTI's are more prevalent and bacteria are different and more resistant to antibiotics compared with the chronic phase of SCI. In SCI in general, routine screening urine cultures are not valuable as a high species turn over is seen. Intermittent catheterisation, tapping or Crédé manoeuvre coincide significantly with lower frequency of UTI compared to permanent catheter drainage. No measures are proven efficient in the long term in prevention of bacteriuria or UTI. Methenamine salts are perhaps useful in the prevention of UTI but not in patients with a permanent catheter (level III). Antibiotic prophylaxis was found useful in reducing asymptomatic bacteriuria but not in the prevention of symptomatic infections (level I). However, during prophylaxis a doubling of antibiotic resistance was found. In patients with augmented bladder antibiotic prophylaxis is useless (level II). In chronic SCI the first choice antibiotics are nitrofurantoin or trimethoprim, the second choice are fluoroquinolones (level III) whereas in acute SCI a higher resistance profile to antibiotics is frequent and therefore fluoroquinolones or cefuroxime are suggested (level III). There is no consensus in the literature but we suggest 5 days of antibiotic treatment in UTI during chronic SCI without fever, 7 days in acute SCI without fever and a minimum of 14 days in patients with UTI and fever (level III).

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Types of indwelling urinary catheters for long-term bladder drainage in adults

BACKGROUND

Prolonged urinary catheterisation is common amongst people in long-term care settings and this carries a high risk of developing a catheter-related urinary tract infection and associated complications. A variety of different kinds of urethral catheters are available. Some have been developed specifically to lower the risk of catheter-associated infection, for example antiseptic or antibiotic impregnated catheters. Ease of use, comfort and handling for the caregivers and patients, and cost-effectiveness are also important factors influencing choice.

OBJECTIVES

The primary objective was to determine which type of in-dwelling urinary catheter is best to use for long-term bladder drainage in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 15 December 2004), MEDLINE (January 1950 to February 2005) and CINAHL (January 1982 to February 2005). We also handsearched 28 relevant journals and conference proceedings. We examined the bibliographies of relevant articles and contacted catheter manufacturers, scientific societies and experts for trials.

SELECTION CRITERIA

All randomised trials comparing types of indwelling urinary catheters for long-term catheterisation in adults. Long-term catheterisation was defined as more than 30 days.

DATA COLLECTION AND ANALYSIS

Data extraction has been undertaken by two review authors independently and simultaneously. Any disagreement has been resolved by a third review author. The included trial data were handled according to the description of the Cochrane Collaboration Reviewers' Handbook.

MAIN RESULTS

Three trials were included involving 102 adults in various settings. Two trials had a parallel group design and one was a randomised cross-over trial. Only two of the six targeted comparisons were assessed by these trials: antiseptic impregnated catheters versus standard catheters (one trial) and one type of standard catheter versus another standard catheter (two trials). The single small cross-over trial was inadequate to assess the value of silver alloy (antiseptic) impregnated catheters. In the two trials comparing different types of standard catheters, estimates of differences were all imprecise because the trials also had small sample sizes: confidence intervals were too wide to rule out clinically important differences. One trial did suggest, however, that the use of a hydrogel coated latex catheter rather than a silicone catheter may be better tolerated (RR for need for early removal 0.41, 95% CI 0.22 to 0.77).

AUTHORS' CONCLUSIONS

Very few trials have compared types of catheter for long-term bladder drainage. All were small and showed methodically weaknesses. Therefore, the evidence was not sufficient as a reliable basis for practical conclusions. Further, better quality trials are needed to address the current lack of evidence in this clinically important area.

Current Evidence on Intermittent Catheterization

PURPOSE

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

SEARCH STRATEGY

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

CONCLUSIONS

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

[Single-use intermittent catheterisation]

In patients with bladder dysfunctions, intermittent catheterisation is a bladder evacuation technique with a low complication rate. Therefore, it is regarded as the method of choice in the treatment of chronic residual urine, mostly due to a hypo- or acontractile detrusor. Regarding the incidence of urinary tract infections and urethral strictures, aseptic catheterisation seems to be superior to the clean technique. There are, however, no independent, prospective, controlled, randomised, double-blinded studies comparing the different catheter types. Thus, the question of which catheter is the ideal one cannot be answered yet. Predominantly in patients who have to perform intermittent catheterisation for good, the prevention of long-term complications, especially of the upper urinary tract, is of the utmost importance. In the long run, using an inadequate technique and catheters not optimally designed will clearly lead to a higher complication rate. Despite the lower prices of certain catheters, treatment of these complications will lead to higher instead of lower costs. The data available today clearly demonstrate that aseptic intermittent catheterisation is the technique of choice today. Important details of this treatment modality, however, have to be elucidated by prospective studies in the future.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Managing Incontinence Using Technology, Devices, and Products

BACKGROUND

Millions of Americans with incontinence use some type of device or product to manage or collect urine or feces. However, research on their clinical uses, problems requiring nursing care, and patient satisfaction is lacking.

OBJECTIVES

To review the various products and devices used for incontinence, identify directions for research and development on technology, and outline the ways nurses can influence and participate in those investigations.

METHODS

Existing literature on incontinence technology, devices, and products was analyzed to generate a plan for future research.

RESULTS

Gaps in knowledge exist about the uses, best practices, quality of life factors, and problems associated with catheters, absorbent products, other internal and external devices, and skin care products.

CONCLUSIONS

Collaboration among public and private sectors would result in greater likelihood of high quality clinical research that has sufficient power and integrity, more efficient use of resources special to each setting, and expedited application of technologies for patient use.

Reused silicone catheter for clean intermittent catheterization (CIC): is it safe for spinal cord-injured (SCI) men?

STUDY DESIGN

Study of reusable catheter.

OBJECTIVE

To investigate whether a silicone cathether reused over years for clean intermittent catheterization (CIC) was safe for spinal cord injured (SCI) men.

SETTING

Maharaj Hospital, Chiang Mai, Thailand.

METHOD

A cross-sectional study was obtained from SCI men who had used CIC with a reusable silicone catheter for more than a year. Demographic data, urological management and urinary tract complications focusing on the radiologic status of the urethra were reviewed and analyzed. In addition, two reused and one new catheters were studied under electron microscope for catheter morphology (surface and lumen) and stiffness.

RESULTS

There were 28 SCI men included in this study. The average duration of CIC use was 4.8 years and the average time of usage for each catheter was 3 years (range 1-7 years). In all, 26 men previously used indwelling catheterization (ID) during the acute phase. In all, 23 men performed self-catheterization. Regarding urinary complications, three reported urethral bleeding, five had episodes of pus per urethra, five had epididymitis, four had passing stones, 18 had occasional foul smelly urine, 10 developed fever and cloudy urine during the past year. Of 17 patients who had ultrasonography done, four had pathologic findings in kidney and one had bladder calculi. Demographic data, urinary management and complications did not have significant relation to the abnormality of the urethrogram or urinary tract infection. However, where the frequency of CIC was higher, the abnormality of the urethra was lower (P<0.05). All had serum Cr level < or =1.3 mg/dl. Electron microscopic findings of reused catheters for 2 years revealed encrustation but no obstruction in the lumens and 20% increase in stiffness.

CONCLUSION

The clinical outcome, especially with regard to urethral abnormalities with this reusable silicone catheter is as good as with a disposable one. However, to reuse urinary catheters, one should consider the increasing risk of infection. For SCI patients in developing countries, CIC with a reusable silicone catheter may be a suitable and safe choice if one cleans and applies it properly to reduce infection. In order to answer the question how long a person in a developing country should use the same silicone catheter, further research should be conducted.