The ‘no-touch’ method of intermittent urinary catheter insertion: can it reduce the risk of bacteria entering the bladder?

Understanding the properties of intermittent catheters to inform future development

Despite the extensive use of intermittent catheters (ICs) in healthcare, various issues persist for long-term IC users, such as pain, discomfort, infection, and tissue damage, including strictures, scarring and micro-abrasions. A lubricous IC surface is considered necessary to reduce patient pain and trauma, and therefore is a primary focus of IC development to improve patient comfort. While an important consideration, other factors should be routinely investigated to inform future IC development. An array of in vitro tests should be employed to assess IC's lubricity, biocompatibility and the risk of urinary tract infection development associated with their use. Herein, we highlight the importance of current in vitro characterisation techniques, the demand for optimisation and an unmet need to develop a universal 'toolkit' to assess IC properties.

Urinary Catheters: Materials, Coatings, and Recommendations for Selection

Urinary catheters have been used for more than 3000 years, although materials have changed from wood to silver to rubber. Research continues to try and find the optimal catheter materials, which improve safety and quality of life. Advantages when comparing newer catheter materials are not always obvious but catheters coated with a hydrophilic layer may reduce urethral trauma and the incidence of urinary tract infections. However, extrapolation of the data is limited by lack of end-point standardization and heterogenous populations.

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.

Pathogen displacement during intermittent catheter insertion: a novel in vitro urethra model

AIM

To develop a novel in vitro urethra model and use it to determine if insertion of an intermittent urinary catheter (IC) displaces pathogenic bacteria from the urethral meatus along the urethra.

METHODS

Displacement of microbial growth after catheter insertion was assessed using a novel in vitro urethra model. The in vitro urethra model utilized chromogenic agar and was inoculated with bacteria at one side of the artificial urethra channel, to act as a contaminated urethral meatus, before an IC was inserted into the channel. Three ICs types were used to validate the in vitro urethra model and methodology.

RESULTS

When compared to the bacterial growth control, a significant difference in bacterial growth was found after insertion of the uncoated (P ≤ 0·001) and hydrophilic coated (P ≤ 0·009) catheters; no significant difference when a prototype catheter was inserted into the in vitro urethra model with either bacterial species tested (P ≥ 0·423).

CONCLUSION

The results presented support the hypothesis that a single catheter insertion can initiate a catheter-associated urinary tract infection.

SIGNIFICANCE AND IMPACT OF THE STUDY

The in vitro urethra model and associated methodology were found to be reliable and reproducible (P ≥ 0·265) providing new research tool for the development and validation of emerging technologies in urological healthcare.

Urinary catheterization 2: technique and managing failure

Urinary catheterization is an important procedure that is regularly performed in hospital. All clinicians should have a good working knowledge of urinary catheters and the competence to manage them effectively. This topic is discussed over two articles: the first article focused on indications, and this second discusses techniques and managing failure. Good technique is essential to prevent complications and if problems do occur, these must be managed efficiently to prevent long-term consequences. In some situations, this may require referral to the urology team for more specialized intervention. This article discusses this in more detail to help guide clinicians involved in urethral catheterization.

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

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

WITHDRAWN: Intermittent catheterisation for long-term bladder management

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Intermittent self-catheterisation for urolgical problems caused by FGM

This is the fourth and final article in a series on female genital mutilation (FGM). It describes the complications of FGM, with a focus on the urinary ones. FGM refers to all procedures that involve partial or total removal of the external female genitalia and/or damage to other female genital organs for non-medical reasons. The World Health Organization (WHO) has classified FGM into four types (1-4). Women who have type 3 commonly experience long-term complications of their urological tract. The first-line treatment for type 3 FGM involves surgical defibulation, but this is not always successful and women can be left with neurogenic bladder dysfunction and urethral stricture disease. Intermittent self-catheterisation (ISC) enables these women to have control of their bladder function.

Varna tehnika dolgotrajne intermitentne samokatetrizacije

Uvod: Intermitentna samokatetrizacija je prednostna metoda praznjenja sečnega mehurja pri pacientih z zastojem urina. Medicinska sestra običajno pacienta nauči čiste ali aseptične tehnike samokatetrizacije. Namen prispevka je s pregledom literature ugotoviti, ali obstaja optimalna tehnika intermitentne samokatetrizacije, ki bi jo medicinske sestre priporočale pacientom. Metode: Uporabljen je bil sistematični pregled literature v bazah podatkov: CINAHL, Medline, ProQuest, COBIB.SI in Cochrane Library. Vključena je bila literatura od prve omembe samokatetrizacije leta 1972 do leta 2016. S selekcijo prvotnih 350 virov smo glede na njihovo skladnost z namenom raziskave izbrali 67 enot literature. Rezultati: Osemnajst referenc, izbranih z orodjem CASP, je bilo objavljenih med letoma 1992 in 2015: šest randomiziranih kliničnih in pet kohortnih raziskav ter šest sistematičnih pregledov literature in ena kritika. Ključne spremenljivke analize zbranih podatkov so bile sterilnost katetra, vrsta vlažilnega gela in higiena periuretralnega področja. Diskusija in zaključek: Nobena tehnika intermitentne samokatetrizacije se ne izkaže kot optimalna. Ob upoštevanju značilnosti in sposobnosti pacienta je za slovenske razmere najboljša uporaba sterilnega materiala za enkratno uporabo (katetra in vlažilnega gela), higiena periuretralnega področja s sterilno solucijo in tamponi ter tehnika nedotikanja.

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.

No-touch intermittent catheterization: caregiver point of view on sterility errors, duration, comfort and costs

AIMS

To determine which method of intermittent urinary catheterization, sterile with a catheterization-set or the no-touch method, offers the most advantages for caregivers in a hospital setting

BACKGROUND

The no-touch catheter is assumed to decrease the risk for infection and increase the comfort for caregivers due to its construction, however, evidence is lacking

DESIGN

A cross-over experimental study was carried out from October until December 2009, 100 nurses and 71 nursing students participated.

METHOD

Every participant had to catheterize as well according to the no-touch method as to the standard intermittent catheterization method. A randomization programme determined whether the subjects had to catheterize a male or female simulation model.

FINDINGS

Multiple regression analysis shows that nurses and nursing students appear to make on average two more errors with the sterile intermittent catheterization method with set than with the no-touch method. The duration of the no-touch method is 92 seconds less than the classical catheterization method. On a scale with 10 points for comfort, the classical sterile method with set scored on average two points lower than the no-touch method, as well for the nurses as for the students.

CONCLUSIONS

Compared with the classical method, both students and nurses spend less time on performing the no-touch method, less sterility errors are made and a higher score is assigned to the no-touch method. Also classical catheterization of men implies higher costs compared with the no-touch method. No-touch intermittent catheterization is thus expected to be preferred above the gold standard catheterization method.

Intermittent self-catheterization habits and opinion on aseptic VaPro catheter in French neurogenic bladder population

STUDY DESIGN

Interventional, multi-center, open-label, randomized and crossover study.

OBJECTIVES

The study objectives were to describe the current catheterization habits of the French neurogenic bladder patients using intermittent catheterization (IC), and to evaluate the ease of use, reliability and patients' comfort and patients' acceptance of the new 'no-touch', presumably easy-to-use VaPro catheter.

SETTING

Patients were recruited from 11 centers in France.

METHODS

In total, 106 men and women (age 18-65 years) with neurogenic bladder using IC at least four times a day were randomized into two groups. All subjects were trained to use the approved 'no-touch' method. A questionnaire evaluating patients' experiences was distributed before the start of the trial and after each 15-day period of catheter use, that is, VaPro vs conventional catheter.

RESULTS

The majority of patients in this French IC user panel had very strong catheterization habits: 2/3 of them had been using IC for >2 years with high ease of use and comfort. Nevertheless, >50% of patients would recommend the VaPro catheter to other people who need IC. More than three out of four patients felt confident and more secure with the new catheter. Men and spinal cord injury (SCI) patients were significantly more positive about the VaPro catheter than women and patients without SCI, respectively.

CONCLUSION

The VaPro catheter is an acceptable and reliable alternative to the existing hydrophilic-coated 'no-touch' catheter.

SPONSORSHIP

This study was sponsored by Hollister France Inc.

[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.

Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America

Guidelines for the diagnosis, prevention, and management of persons with catheter-associated urinary tract infection (CA-UTI), both symptomatic and asymptomatic, were prepared by an Expert Panel of the Infectious Diseases Society of America. The evidence-based guidelines encompass diagnostic criteria, strategies to reduce the risk of CA-UTIs, strategies that have not been found to reduce the incidence of urinary infections, and management strategies for patients with catheter-associated asymptomatic bacteriuria or symptomatic urinary tract infection. These guidelines are intended for use by physicians in all medical specialties who perform direct patient care, with an emphasis on the care of patients in hospitals and long-term care facilities.

EAU guidelines on neurogenic lower urinary tract dysfunction

CONTEXT

Most patients with neurogenic lower urinary tract dysfunction (NLUTD) require life-long care to maintain their quality of life (QoL) and to maximise life expectancy.

OBJECTIVE

To provide a summary of the 2008 version of the European Association of Urology (EAU) guidelines on NLUTD and to assess the effectiveness of currently available diagnostic tools, particularly ultrasound imaging and urodynamics.

EVIDENCE ACQUISITION

The recommendations provided in the 2008 EAU guidelines on NLUTD are based on a review of the literature, using online searches of Medline and other source documents published between 2004 and 2007. A level of evidence and/or a grade of recommendation have been assigned to the guidelines where possible.

EVIDENCE SYNTHESIS

NLUTD encompasses a wide spectrum of pathologies, and patients often require life-long, intensive medical care to maximise their life-expectancy and to maintain their QoL. Treatment must be tailored to the needs of the individual patient and, in many cases, involves a multidisciplinary team of experts. Timely diagnosis and treatment are essential if irreversible deterioration of both the upper and lower urinary tracts are to be avoided. Therapeutic decisions are made on the basis of a comprehensive medical assessment, including urodynamics to identify the type of dysfunction. Advances in investigative technologies have facilitated the noninvasive and conservative management of patients who have NLUTD.

CONCLUSIONS

The diagnosis and treatment of NLUTD, which is a highly specialised and complex field involving both urology and medicine, requires up-to-date expert advice to be readily available. The current guidelines are designed to fulfil this need.

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.

Urologischer Erkrankungen bei Patienten mit Meningomyelozele

Since the 1980s the management of children and adolescents with meningomyelocele has undergone major changes. The introduction of pharmacotherapy with antimuscarinic agents, clean intermittent catheterization (CIC) and antibacterial prophylaxis has revolutionized the management of children with neurogenic bladder. The co-operation between neonatologists, neurosurgeons, paediatric neurologists, paediatricians, paediatric urologists, paediatric nephrologists, paediatric orthopaedists and paediatric surgeons is necessary to achieve an optimized therapy in each individual patient. In this interdisciplinary consensus paper we provide definitions and classifications as well as a timetable for the appropriate investigations. The conservative and surgical options are explained in detail. A short review is given concerning orthopaedic management, incidence of latex allergy, options for bowel management, diagnosis and treatment of urinary tract infections, problems with sexuality and fertility as well as the long-term compliance of these patients and their relatives.

[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.