Clean intermittent catheterisation from the acute period in spinal cord injury patients. Long term evaluation of urethral and genital tolerance

Factors associated with symptomatic urinary tract infection in persons with spinal cord lesions who perform clean intermittent catheterization with single-use catheters

OBJECTIVES

To investigate factors associated with symptomatic urinary tract infection (sUTI) in persons with chronic spinal cord lesion (SCL) who were using single-use catheters for intermittent self-catheterization (ISC).

METHODS

Among respondents to an internet survey on the burden of illness on persons with SCL who were considered to be able to perform ISC, 111 persons using single-use catheters were included to examine factors associated with self-reported sUTI by univariate as well as multivariable analysis.

RESULTS

The incidence of sUTI was significantly higher in males than in females (56.9% vs. 31.6%, p = .011), persons with stocks of antibiotics than those without it (82.9% vs. 28.6%, p < .011), and persons with more frequent bleeding during catheterization than those with less frequent bleeding (100% vs. 46.5%, p = .036). The incidence did not significantly differ between respective groups when various variables were evaluated by other characteristics of the participants, adherence to ISC procedures, and complications. On multivariable analysis, male gender and stocks of antibiotics were significant independent factors for sUTI.

CONCLUSIONS

Male gender and stocks of antibiotics were associated with sUTI in persons with SCL who were performing ISC with single-use catheters.

Evolution of Quality of Life and Treatment Adherence after One Year of Intermittent Bladder Catheterisation in Functional Urology Unit Patients

OBJECTIVE

To determine patient difficulties and concerns when performing IBC (Intermittent Bladder Catheterisation), as well as the evolution of adherence, quality of life, and emotional state of patients one year after starting IBC.

METHOD

A prospective, observational, multicentre study conducted in 20 Spanish hospitals with a one-year follow-up. Data sources were patient records and the King's Health Questionnaire on quality of life, the Mini-Mental State Examination (MMSE), and the Hospital Anxiety and Depression Scale (HADS). Perceived adherence was measured using the ICAS (Intermittent Catheterization Adherence Scale) and perceived difficulties with IBC were assessed using the ICDQ (Intermittent Catheterization Difficulty Questionnaire). For data analysis, descriptive and bivariate statistics were performed for paired data at three points in time (T1: one month, T2: three months, T3: one year).

RESULTS

A total of 134 subjects initially participated in the study (T0), becoming 104 subjects at T1, 91 at T2, and 88 at T3, with a mean age of 39 years (standard deviation = 22.16 years). Actual IBC adherence ranged from 84.8% at T1 to 84.1% at T3. After one year of follow-up, a statistically significant improvement in quality of life (p ≤ 0.05) was observed in all dimensions with the exception of personal relationships. However, there were no changes in the levels of anxiety (p = 0.190) or depression (p = 0.682) at T3 compared to T0.

CONCLUSIONS

Patients requiring IBC exhibit good treatment adherence, with a significant proportion of them performing self-catheterisation. After one year of IBC, a significant improvement in quality of life was noted, albeit with a significant impact on their daily lives and their personal and social relationships. Patient support programmes could be implemented to improve their ability to cope with difficulties and thus enhance both their quality of life and the maintenance of their adherence.

Quality of Life and Autonomy in Patients with Intermittent Bladder Catheterization Trained by Specialized Nurses

Intermittent bladder catheterization (IBC) involves regular urine draining using a catheter, which is removed immediately after urinary elimination. It allows for the patient's urological health to be managed and their renal function to be preserved, and it promotes autonomy. Compliance with the prescribed number of daily catheterizations, which must be conducted by the patient, and infection prevention measures are crucial. To identify the patients requiring IBC, and to determine their adherence (whether they followed the prescribed guidelines and their difficulty in carrying out the procedure, as well as to assess how the IBC influences their quality of life and state of mind after receiving self-care training from a specialized nurse), we carried out a prospective, multicenter observational study in 24 Spanish hospitals with one month of monitoring and a sample of 99 patients. The sources of information were the patients' clinical records, the King's Health Questionnaire, the Mini-Mental State Examination (MMSE), and the hospital anxiety and depression scale (HADS). Descriptive and bivariate statistics were used to analyses the paired data. After recruitment (n = 99), 79 patients completed the questionnaire at a mean age of 35.2 years (SD = 20.5 years). In total, 53.5% (53) of the sample consisted of men and 32.3% (32) had neurological damage as the reason for prescription; 67% (67.7) performed self-catheterization and 86.7% adhered to the IBC. After one month of monitoring, a statistically significant improvement in quality of life was observed in all criteria, with the exception of personal relationships (p < 0.005), as well as an improvement in anxiety and depression levels (p < 0.001). Patients who require IBC show good adherence to the IBC with a significant percentage of self-catheterization. After one month of IBC, a significant improvement in the patients' quality of life and mood was observed. These results could be attributed to adequate patient training and adequate personalization of the IBC materials by the specialized nurses.

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.

Prevalence of self-reported complications associated with intermittent catheterization in wheelchair athletes with spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To identify the prevalence of complications associated with intermittent catheterization in wheelchair athletes with spinal cord injury (SCI).

SETTING

International and national sporting events.

METHODS

A total 130 competitive wheelchair athletes living with SCI completed a self-reported questionnaire during international or national sporting events. The questionnaire collected information regarding demographics, injury characteristics, method of bladder emptying, and complications related to intermittent catheterization.

RESULTS

Overall, 84% (109/130) of wheelchair athletes used intermittent catheterization. Within this group, 77% of athletes (84/109) experienced at least one complication associated with intermittent catheterization. Twenty-seven percent (29/109) sustained urethral injuries and 63% (69/109) had at least one episode of urinary tract infection during the last 12 months. Almost one-fourth of male athletes (22/95, 23%) had a history of inflammation / infection of genital organs associated with intermittent catheterization.

CONCLUSIONS

Here we report a high prevalence of self-reported complications associated with intermittent catheterization in wheelchair athletes with SCI. Considering their potential impact on lower urinary tract function, athletic performance, and health, further studies are needed to assess the role of preventative strategies to reduce complications related to intermittent catheterization in wheelchair athletes with SCI.

SPONSORSHIP

Coloplast Brazil and Instituto Lado a Lado pela Vida (a nongovernmental, nonprofit organization based in São Paulo) and Wellspect provided funding for this study.

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.

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.

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.

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.

[Objective and subjective requirement of aids and appliances in patients with neurogenic lower urinary tract dysfunction : Multicenter study to determinate the daily necessity of urological aids and appliances]

BACKGROUND

The provision of urological appliances for patients with neurogenic lower urinary tract dysfunction (NLUTD) is essential. Hitherto existing standard guidelines for the estimation of monthly material requirements are based solely on estimates.

OBJECTIVE

The goal of this work was to define the objective and subsequently subjective requirements for urological appliances on a scientifically validated basis.

MATERIALS AND METHODS

Data concerning bladder management and daily consumption of urological appliances for patients with NLUTD were collected through a standardized survey at six different centers in Germany during the period of October to December 2014 and statistically evaluated.

RESULTS

In all, 767 patient records were analyzed: 543 men and 221 woman (N/A = 3). The daily disposable catheter consumption of 577 patients who exclusively used intermittent catheterization was 5.13. Patients who used other means of bladder emptying (n = 31) in addition to catheterization consumed on average 3.17 catheters. The margin of deviation was larger for children. Of the 608 patients with intermittent catheterization, 94 (15.5 %) required additional paddings as absorbent aids (on average 2.29 paddings per day), 34 patients (5.6 %) additionally used pants (2.55 per day) and 46 patients (7.6 %) utilized condom catheters (3.81 per day) between catheterization. Among all surveyed patients, 126 (16.4 %) used paddings (5.03 per day) and 51 patients (6.6 %) pants (3.03 per day). Of all male respondents 82 (15.1 %) used condom catheters (2.80 urinary sheaths per day).

CONCLUSION

Applying twice the standard deviation of the mean as a measure of assessing the objective requirement of urological appliances and aids for adult patients with NLUTD allows the following daily thresholds to be defined: 1-9 disposable catheters, 0-7 urinary sheaths, 1-9 paddings and 0-7 pants. These thresholds can serve as a basis for estimating the subjective need. They allow for a scientifically validated benchmark for an economically feasible and patient-tailored supply with urological aids and appliances. Individually required appliances and aids have to be recognized. Verifiable quality standards need to be developed.

Incidence of Urethral Stricture in Patients With Spinal Cord Injury Treated With Clean Intermittent Self-Catheterization

OBJECTIVE

To report the incidence of urethral stricture and its management in patients with spinal cord injury treated with clean intermittent self-catheterization (CIC).

MATERIALS AND METHODS

The clinical records of 333 patients with spinal cord injury treated with CIC since 2001 were identified, and those who developed a urethral stricture during their follow-up, including their treatment and results achieved, were analyzed.

RESULTS

The patients had a median age at the time of injury of 27 years, of which only 14 patients (4.2%) developed urethral stricture at a mean duration of self-catheterization of 9 years; 86% of them were treated with urethrotomy, without recurrence through a mean of 1-year follow-up. There are no previous reports of rates of urethral stricture in this type of patients in our institution; the rate found is considerably low, as is the recurrence after urethrotomy, which can be decreased by the continuous self-obturation achieved with catheterization.

CONCLUSION

Urethral stricture as a complication of CIC in patients with spinal cord injury has a low incidence and can be effectively treated in those who develop it.

Urethral strictures in men with neurogenic lower urinary tract dysfunction using intermittent catheterization for bladder evacuation

STUDY DESIGN

Retrospective investigation.

OBJECTIVES

To investigate the occurrence, characteristics and clinical consequences of urethral strictures in men with neurogenic lower urinary tract dysfunction (NLUTD) using intermittent catheterization (IC) for bladder evacuation.

SETTING

Spinal cord injury rehabilitation center.

METHODS

The patient database was screened for men with NLUTD who had presented for a routine video-urodynamic investigation between 2008 and 2012. Patient characteristics, bladder diary details, the occurrence of urethral strictures and performed urethrotomy procedures were collected from patient charts. Urethral strictures were classified using the Wiegand scoring system modified for men with NLUTD.

RESULTS

The occurrence rate of urethral strictures (that is, 25% confidence interval (CI) 21-30%) was significantly (P=0.0001) higher in men using IC (n=415) than in men using other bladder evacuation methods (that is, 14% CI 11-17%) (n=629). Urethral strictures had occurred after a median 5.9 years (range 0.5-48.9 years) of IC. There was no significant (P>0.08) effect of tetraplegia or catheter type on the stricture occurrence rate. Approximately one-third of the men suffering from urethral strictures underwent internal urethrotomies. The radiographic stricture severity score was not associated with the need for surgical correction of the stricture. The radiographic recurrence rate of urethral strictures in operated men was 100%, a median 14 years after the first urethrotomy.

CONCLUSIONS

The occurrence rate of urethral strictures is significantly higher in men using IC than in men using other bladder evacuation methods. Every fourth men using IC may be affected by urethral strictures. However, only every third stricture may require a surgical intervention.

Intermittent self-catheterisation in women: reducing the risk of UTIs

Intermittent self-catheterisation (ISC) is the insertion and removal of a catheter to drain the bladder and is a safe and effective way to preserve renal function. It can be used as a one-off intervention to drain urine post-operatively or to measure residual urine volumes if a bladder scanner is unavailable. ISC can also be used as a long-term option to manage bladder dysfunction, and for some provides an excellent option to maintain independence and improve quality of life. Urinary tract infections are a common complication for women undertaking ISC. This article explores the prevention of urinary tract infections in women undertaking long-term ISC for the management of bladder dysfunction.

Salmonella prostatitis in a man with spinal cord injury

CONTEXT

Prostatitis is a very unusual manifestation of Salmonella urinary tract infection and has not been reported in men with spinal cord injury (SCI).

FINDINGS

A 57-year-old man with paraplegia and a history of recurrent symptomatic urinary tract infections presented with Salmonella typhimurium prostatitis. Clinical and sonographic examination of the urinary tract, as well as urinalysis including microbiologic examination, revealed no relevant abnormalities. The microbiologic analysis of the ejaculate revealed growth of monophasic Salmonella enterica ssp. enterica serotype 4,12:i:-. A 6-week course of antibiotic treatment was initiated. There were no recurrent symptomatic urinary tract infections during follow-up.

CONCLUSION

Salmonellosis is a reportable disease and carriers have to refrain from activities in the food sector. Therefore, Salmonella prostatitis should be considered and excluded in men with SCI and a history of recurrent urinary tract infection who use intermittent catheterization for bladder management.

A survey of short- and long-term pre-lubricated intermittent catheters

The prospect of having to undertake clean intermittent self-catheterisation (CISC) for a short time, or for the rest of a patient's life, can be very daunting. It has an impact on their social, sexual, work and family life. Despite the challenges of the practical performance of the procedure, CISC has many advantages and is a means of reducing the subsequent problems and cost implications associated with long-term indwelling catheter use. There are many different products available on prescription for patients performing CISC and it can be a challenge to choose the right one. This article discusses the impact CISC has on the individual and focuses on a regional survey conducted in a district in the UK of nearly 100 patients who agreed to complete a confidential questionnaire about their experiences using a pre-lubricated CISC catheter (Actreen®). It also discusses the challenges facing nurses with patients practising CISC and offers advice to help patients come to terms with this procedure and its effect on their daily life.

A scoping review of important urinary catheter induced complications

This study presents a scoping review of the literature on the morbidity and mortality associated with several common complications of urinary catheterization. Data gathered from the open literature were analyzed graphically to gain insights into the most important urinary catheter induced complications. The results reveal that the most significant catheter complications are severe mechanical trauma (perforation, partial urethral damage and urinary leakage), symptomatic bacterial infection, and anaphylaxis, catheter toxicity and hypersensitivity. The data analysis also revealed that the complications with the highest morbidity are all closely related to the mechanical interaction of the catheter with the urethra. This suggests that there is a strong need for urinary catheter design to be improved to minimize mechanical interaction, especially mechanical damage to the urinary tract, and to enhance patient comfort. Several urinary catheter design directions have been proposed based on tribological principles. Among the key recommendations is that catheter manufacturers develop catheter coatings which are both hydrophilic and antibacterial, and which maintain their antibacterial patency for at least 90 days.

Intermittent self catheterisation with hydrophilic, gel reservoir, and non-coated catheters: a systematic review and cost effectiveness analysis

OBJECTIVE

To determine the most effective and cost effective type of catheter for patients performing intermittent self catheterisation in the community.

DESIGN

Systematic review and meta-analysis. Results were incorporated into a probabilistic Markov model to compare lifetime costs and quality adjusted life years (QALYs).

DATA SOURCES

We searched Medline, Embase, and Cochrane and Cinahl databases from 2002 to 18 April 2011 to identify studies comparing hydrophilic, gel reservoir, and non-coated intermittent catheters. Earlier guidelines were used to identify papers published before 2002. To capture studies comparing clean and sterile non-coated intermittent self catheterisation, each database was searched from its date of inception to 18 April 2011.

MAIN OUTCOME MEASURES

Clinical outcomes included symptomatic urinary tract infection (UTI), bacteraemia, mortality, patient preference or comfort, and number of catheters used. The economic model included downstream complications of UTI and cost effectiveness was calculated as incremental cost per QALY gained.

RESULTS

Eight studies were included in the systematic review. Most were conducted in patients with spinal cord injuries, and most of the included patients were men. People using gel reservoir and hydrophilic catheters were significantly less likely to report one or more UTIs compared with sterile non-coated catheters (absolute effect for gel reservoir = 149 fewer per 1000 (95% confidence interval -7 to 198), P=0.04; absolute effect for hydrophilic = 153 fewer per 1000 (-8 to 268), P=0.04). However, there was no difference between hydrophilic and sterile non-coated catheters when outcomes were measured as mean monthly UTIs (mean difference = 0.01 (-0.11 to 0.09), P=0.84) or total UTIs at 1 year (mean difference = 0.18 (-0.50 to 0.86), P=0.60). There was little difference in the incidence of one or more UTIs for people using clean versus sterile non-coated catheters (absolute effect = 12 fewer per 1000 (-134 to 146), P=0.86). Although the most effective, gel reservoir catheters cost >£54,350 per QALY gained and are therefore not cost effective compared with clean non-coated self catheterisation.

CONCLUSION

The type of catheter used for intermittent self catheterisation seems to make little difference to the risk of symptomatic UTI. Given large differences in resource use, clean non-coated catheters are most cost effective. However, because of limitations and gaps in the evidence base and the designation of non-coated catheters as single use devices, we recommend a precautionary principle should be adopted and that patients should be offered a choice between hydrophilic and gel reservoir catheters.

[The relevance of catheterization in neurourology]

Together with comprehension and therapy of neurogenic failure of the storage function of the urinary bladder, intermittent catheterization as a pressure-free voiding method without residual urine, represents a major principle of therapy in lower urinary tract dysfunction. Aseptic intermittent catheterization is recommended in Germany and Europe and seems to be acceptable even in long-term application with low complication rates. It is a precondition that patients are seen for clinical and urodynamic reevaluation at risk-adapted time intervals. The major focus is on early recognition and avoidance of threatening complications. The most important preventive measures are the motivation and compliance of the well-educated patient and the use of careful catheterization techniques with individually optimized catheters.Although aseptic intermittent catheterization has been used effectively for many years there is still a lack of randomized controlled studies for some important questions of details and an optimal catheter has still to be defined. Furthermore, valid conclusions based on well-conducted studies on the self-estimated quality of life of patients with intermittent catheterization, especially those with catheterization by attendant, are urgently needed. Intermittent catheterization is never a ready-made solution but always an individually tailored treatment for patients with lower urinary tract dysfunction.

Therapeutic education and intermittent self-catheterization: recommendations for an educational program and a literature review

PURPOSE

To review the literature and to clarify the recommendations for therapeutic education programs for intermittent self-catheterization.

MATERIALS AND METHODS

The literature on Medline, Pubmed, and Cochrane Library, with specific keywords, as well as the recommendations based on expert consensus.

RESULTS

Clean intermittent self-catheterization (CICS) is the gold standard for managing chronic urinary retention, which allows the patients to improve their quality of life and to reduce the complications of upper urinary tract infections. Patient education needs to have a structured procedure in order to evaluate the ability to understand, accept and perform CISC.

CONCLUSION

Teaching self-catheterization is now well known; nevertheless, the effectiveness of CISC educational therapeutic programs remains to be demonstrated.

The neurogenic bladder: an update with management strategies for primary care physicians

Patients with lesions of the central nervous system often have neurogenic bladder dysfunction. Lifelong bladder monitoring and management in these patients is necessary to prevent severe complications, including renal damage. The urodynamic test, performed by neurourologists or other specially trained providers, is the definitive test for diagnosis and management of neurogenic bladder dysfunction. This article describes the indications and technique of urodynamic testing and the interpretation of the results of such testing. The management of patients with neurogenic bladder dysfunction is also discussed.

Intermittent catheterization with hydrophilic catheters as a treatment of chronic neurogenic urinary retention

AIMS

Neurogenic bladder can be effectively managed with intermittent catheterization (IC) to improve or restore continence, but there is no consensus on which type of catheter is preferred. Hydrophilic catheters were developed to reduce urethral friction, thereby minimizing trauma and sticking, and making them more acceptable to the patient, and easier and safer to use. The objective of this article was to review the literature on the benefits of hydrophilic catheters in patients with neurogenic bladder.

METHODS

A large body of experimental and observational evidence, including randomized controlled trials, was identified using PubMed.

RESULTS

Compared with plastic catheters that have been manually lubricated with gel, hydrophilic catheters reduce urinary tract infection and microhematuria. Hydrophilic catheters are also associated with high levels of patient satisfaction because they are comfortable to use.

CONCLUSIONS

There is a wealth of evidence, including randomized controlled trials, to support the benefits of hydrophilic catheters in terms of safety and quality of life, especially in men with spinal cord injury. More data are required for spina bifida, multiple sclerosis, and in women. Further research is warranted, especially large-scale and long-term robust comparisons of different types of catheter, and in well-defined and stratified populations.

Managing the urinary tract in spinal cord injury

This review sets out to provide an overview of the author's approach to the management of the urinary tract in the patient who has suffered from an injury to their spinal cord. Emphasis is given to the need to understand the fundamental pathophysiological patterns that are seen with injuries that involve the sacral segments of the cord (the conus) and those that spare the conus but interrupt communication between the sacral parasympathetic and somatic centers and the brain (supraconal lesions). The importance of patient participation in management decisions is highlighted by considering the different ways in which the urinary tract can be managed and how the clinician needs to try to meet patient expectations and requirements while establishing safe urological management. Finally, consideration is given to the importance of establishing an appropriate follow up regime and managing urinary tract complications effectively.

Self-catheterization during adolescence

OBJECTIVE

It has been suggested that clean intermittent catheterization (CIC) during the teenage years is associated with poor motivation to comply with the treatment, recurrent urinary tract infections and epididymitis. The aim of this study was to identify the main problems and complications associated with self-CIC in a group of adolescents with no overt neurological problems.

MATERIAL AND METHODS

The medical records of 24 boys and girls aged >/=12 years on self-CIC with severe bladder dysfunction and intact perineal sensibility and motor function in the lower limbs were reviewed. The median age of the patients was 16.5 years (range 12-24 years) and they had been on CIC for a median of 11 years (range 2-16 years).

RESULTS

No urethral damage was reported. Of the 11 patients (46%) who had good CIC routines, two had cystitis and none had epididymitis. Thirteen patients (54%) reported a poor CIC regimen at a median age of 11.5 years (range 9-16 years). In this group, 10 had recurrent cystitis, five had pyelonephritis, four had increasing creatinine levels and three of nine boys had epididymitis.

CONCLUSIONS

One of the main problems associated with CIC during adolescence is poor compliance with the treatment. Epididymitis and recurrent urinary tract infections were seen more frequently in connection with poor CIC routines.

Acquired nonobstructive urinary bladder diverticulum: a case report

Introduction

Urinary bladder diverticula are frequently resulting from obstructions. Our literature review did not reveal any cases of acquired urinary bladder diverticulum caused by long-term transurethral catheterization.

Case Presentation

We report a rare case of a nonobstructive big urinary bladder diverticulum developed after a long-term urethral catheterization in a 62-year old male diabetic patient with normal subvesical urinary tract. The diverticulum was demonstrated by ultrasonography. Its formation was associated with the decubital changes of the bladder wall when the Foley catheter stayed for a longer period.

Conclusion

Ultrasonographic examination of the urinary bladder is necessary to exclude such complication after a long-lasting catheterization as well as to maximally restrict the catheter's stay in the urinary bladder.

Urodynamic responses to anal stretch in patients with detrusor sphincter dyssynergia

OBJECTIVE

To evaluate the urodynamic responses to anal stretch in patients with detrusor sphincter dyssynergia (DSD).

DESIGN

Descriptive study.

SETTING

Rehabilitation hospital affiliated with a medical university.

PARTICIPANTS

Patients (N=36) with suprasacral spinal cord injury who had DSD confirmed on cystometrography.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Detrusor pressure, urethral pressure, and summated electromyogram of external urethral sphincter on cystometrography.

RESULTS

The urodynamic responses to anal stretch were evaluated in the first half (time 1, 1-15s) and the second half (time 2, 16-30s) of the evaluation time period. The activity of external urethral sphincter was reduced significantly in both times 1 and 2 (P<0.5). The medians of reduction percentages were 33% and 35% for times 1 and 2, respectively. The change of detrusor pressure was not significant in either time 1 or time 2.

CONCLUSIONS

Anal stretch can reduce the activity of external urethral sphincter without significant change in detrusor pressure.

Urethral reconstruction in patients with neurogenic bladder dysfunction

PURPOSE

There is limited literature examining urethral reconstruction in patients with neurogenic bladder dysfunction. We describe our experience of urethral reconstruction in men with concurrent neurogenic bladder.

MATERIALS AND METHODS

A prospectively maintained database of all urethral reconstruction procedures performed by 1 surgeon was analyzed for patients with neurogenic bladder dysfunction. Patient characteristics including the etiology of neurogenic bladder, urethral pathology, urethral reconstructive technique, complications and recurrences were evaluated.

RESULTS

A total of 23 patients were included in the analysis. Urethral pathology included erosions (10), strictures (7), diverticula (3), urethrocutaneous fistulas (2), and a combination of diverticular and stricture disease (1). Median length of the urethral pathology was 5.0 cm (range 2.0 to 10.0). Overall urethral reconstruction was successful in 16 of 23 patients (69.6%) at a mean followup of 24.7 months (range 2 to 79). Success rates differed among the types of pathology with 60% for urethral erosions, 85.7% for urethral strictures, and 66.6% for urethral diverticula and fistulas. Of those cases of recurrence 4 of 7 (57%) were after urethral erosion repair. There was 1 (4.3%) postoperative complication and no patient underwent urinary diversion after recurrence.

CONCLUSIONS

When identified at an early stage, urethral reconstruction in patients with neurogenic bladder dysfunction offers acceptable outcomes with limited morbidity. Men undergoing reconstruction for urethral erosion had inferior outcomes compared to those with other urethral pathology.

Catheterization: possible complications and their prevention and treatment

Intermittent catheterization (IC) is a more preferable method for bladder drainage than indwelling urethral or suprapubic catheterization. Several complications with IC have been described, however, including urinary tract infection, genital infection, urethral bleeding, urethritis, urethral stricture, and bladder stones. To prevent these complications, patients should be well instructed on the technique and the risks of IC. Indwelling catheterization should be used only exceptionally, under close control and the catheter should be changed with adequate frequency.

[Specific features of urethral diseases in spinal cord injury patients]

This article discusses all of the urethral diseases observed in patients with neurogenic bladder. The frequency of these disorders has decreased considerably with progress in intermittent catheterization and bladder retraining. However, urologists may occasionally be required to manage an urethral diverticulum, or an ulcer of the urethra over an indwelling catheter and must be familiar with the specific features in this setting.

[Urinary tract infection and neurogenic bladder]

One of the main complications of spinal cord injury is neurogenic bladder when the bladder fails to empty spontaneously. Urinary tract infection is the leading cause of morbidity and the second cause of mortality in these subjects. Patient education and personalized medical follow-up must ensure adapted management depending on the risk factors and the voiding mode. The risk of urinary tract infection can be decreased by perfect neurological control of detrusor activity combined with a method of drainage: intermittent self-catheterization. Despite these measures, many patients experience recurrent symptomatic urinary tract infections. Repeated antibiotic therapy increases the risk of selection of multiresistant bacteria without reducing either the incidence or the severity of symptomatic urinary tract infections. Asymptomatic bacteriuria is very frequent in patients treated by intermittent catheterization and does not justify antibiotic therapy, as antiseptics and urinary alkalinizers or acidifiers have been shown to be effective. "Antibiocycle" strategies could have a beneficial role by significantly decreasing the number of infections and hospitalizations with no major ecological risks, by using molecules that are well tolerated orally with a low selection pressure. All febrile urinary tract infections require rapid investigation and an urgent urological and infectious diseases opinion (abscess, severe sepsis, resistance). The SPILF-AFU 2002 consensus conference provided answers to major questions concerning the definition, treatment and prevention of nosocomial urinary tract infection, especially in a context of neurogenic bladder.

[Continent cutaneous urinary diversion in neurourology]

The management of some neurological patients can require urinary diversion. Continent cystostomy is one of the treatment options proposed in young patients, usually for cosmetic reasons. In this article, the authors describe the main techniques used in this particular indication and then review the literature to define the results of the various techniques used, as well as the modalities of follow-up in these patients in view of the potential complications.

[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.

Twenty-seven years of complication-free life with clean intermittent self-catheterization in a patient with spinal cord injury: A case report

Currently, clean intermittent self-catheterization (CISC) is the most prevalent method of bladder management in patients with spinal cord injury (SCI) at discharge from rehabilitation centers. However, half of the patients discontinue using CISC and change to other methods of bladder management several months postdischarge despite the fact that it the best way to prevent urinary tract complications. Few studies, however, report the long-term consequences of CISC. In this case, we present a woman in her early fifties who had sustained thoracic SCI and had continued using CISC for 27 years without developing any complications. The possible reasons for her success were absence of incontinence because of underactive and normal capacity bladder; normal upper-extremity functions and absence of marked spasticity of lower extremities that facilitated CISC technique; and absence of sociovocational problems, enabling her to keep proper intervals between catheterizations each day. This case indicates that CISC is useful for long-term bladder management in patients with SCI, even for 25 years or more. Long-term outcomes of CISC and factors leading to success need to be delineated in future studies with larger samples.

COMPLICATIONS OF CLEAN INTERMITTENT CATHETERIZATION IN BOYS AND YOUNG MALES WITH NEUROGENIC BLADDER DYSFUNCTION

PURPOSE

We evaluate the risk for urethral lesions and epididymitis in boys with neurogenic bladder dysfunction treated by clean intermittent catheterization (CIC) for a minimum of 10 years.

MATERIALS AND METHODS

The medical records of 28 males with neurogenic bladder dysfunction followed from the start of CIC until the age of 15 to 20 years were reviewed.

RESULTS

CIC had been performed for a median of 16 years (range 10 to 21). Overall CIC was used for 438 years (265 before and 173 after puberty). During 76% of the years a noncoated polyvinyl chloride catheter with lubrication was used and in 24% of years a hydrophilic coated polyvinyl chloride catheter was used. The catheter size was 12C or greater in 43% of the cases. Independence from self-catheterization occurred during 37% of the CIC years. Of the patients 19 experienced at least 1 episode of difficulty inserting the catheter and/or had macroscopic hematuria on a total of 42 occasions. Major urethral lesions were seen on cystoscopy in 7 patients on 9 occasions (5 false passages, 1 superficial recess, 2 meatal stenoses, 1 urethral stricture). Major urethral lesions were not associated with puberty and did not occur during self-catheterization or with use of catheters 12C or greater. Epididymitis was seen in only a 12 year-old boy.

CONCLUSIONS

The overall rate of complications was low. The incidence of major urethral lesions did not increase during puberty. Self-catheterization and 12C catheter or greater seemed to be protective against major lesions.

COMPLICATIONS ASSOCIATED WITH CLEAN INTERMITTENT CATHETERIZATION IN CHILDREN WITH SPINA BIFIDA

PURPOSE

Clean intermittent catheterization (CIC) is commonly used in the management of voiding dysfunction associated with neurospinal dysraphism. We determined the incidence of genitourinary complications associated with this technique in a population of children with spina bifida.

MATERIALS AND METHODS

The charts of all children younger than 13 years attending a multi-disciplinary spina bifida clinic between 1987 and 2002 were reviewed. Children in whom CIC had been performed for a minimum of 5 years were identified. Catheterization was performed with a polyvinyl chloride catheter and a water-based lubricant. All genitourinary complications that had occurred in this group were recorded. The caregiver of each patient was then contacted by telephone to confirm the accuracy of our data.

RESULTS

There were 32 females and 27 males identified in whom CIC had been performed for a minimum of 5 years. Mean duration of CIC was 10.5 years (range 5 to 15). Of the patients 45 (76%) learned to perform CIC independently at a mean age of 8 years (range 4.7 to 15.3). Two complications were gross hematuria and a false passage in the bulbar urethra. Both complications occurred in males early in the course of CIC, and while being performed by a caregiver. Neither complication was associated with long-term sequelae.

CONCLUSIONS

The incidence of genitourinary complications associated with CIC in children with spina bifida is low. We identified 2 complications during a period of 570 patient-years for an incidence of 3.5 complications/1000 patient-years (95% confidence interval -1.3, 8.3) of observation.