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.

Investigation of anxiety levels in caregivers who perform clean intermittent catheterization on their children and affecting factors

PURPOSE

The study aimed to determine the anxiety levels of caregivers who performed clean intermittent catheterization (CIC) on their children and the factors affecting them.

METHODS

This descriptive study was conducted between January 6, and May 29, 2023 with caregivers of 42 patients who were followed up by the pediatric nephrology outpatient clinic of a university for CIC. The study data were collected using the "Participant Information Form" and the "State and Trait Anxiety Scale."

RESULTS

According to the results, of the children included in the study, 73.8% were female, 64.3% were diagnosed with spina bifida (SB), and 76.2% received CIC applications 4-6 times a day. All the caregivers were mothers, and 76.2% received CIC training from a doctor. However, 78.6% of them found the training insufficient, leading them to rely on self-experimentation when applying CIC to their own children. None of the caregivers received information or training on the CIC application from nurses, and there were no home visits or telephone counseling provided after the hospital discharge. The mean score for the state anxiety scale among the caregivers was 45.90 ± 10.57, while the mean score for the trait anxiety scale was 46.92 ± 8.43. Significantly higher mean trait anxiety scores were observed among caregivers with chronic diseases who did not receive training on the CIC application (p < 0.05). Additionally, caregivers of children who experienced 3-4 urinary tract infections (UTIs) within the last 3 months also had significantly higher mean trait anxiety scores (p < 0.05). The mean trait anxiety level scores of caregivers of children who had 3-4 UTIs in the last 3 months were significantly higher (p < 0.05).

CONCLUSIONS

It was concluded that caregivers' lack of training on CIC implementation, having chronic disease, and having frequent UTIs in their children were effective on anxiety levels.

A consensus statement on when to start clean intermittent self-catheterization: An untapped resource?

BACKGROUND

Clean intermittent self-catheterisation (CISC or ISC) is used by patients/carers to empty the bladder if needed. Sometimes the urethral lumen leading out of the bladder is blocked; sometimes, the bladder (detrusor) muscle itself or the autonomic motor nerves innervating the bladder are damaged, resulting in a failure of the detrusor muscle to work, leading to a failure of the bladder being able to empty adequately. Prior consensus as to the indications and timing of CISC has yet to be provided. This article aims to provide a multidisciplinary consensus view on this subject.

CONCLUSION

It is evident that every patient needs to be considered individually, bearing in mind the symptoms and investigations to be considered. We emphasise the importance of considering the term Bladder Voiding Efficiency (BVE). One group of patients who might find CISC helpful are those with a neurological disorder; these include spinal injury patients, multiple sclerosis, Parkinson's, and a condition called cauda equina. Sometimes bladder problems are treated with anticholinergics, and others may be treated with Botox. These may cause the bladder not to empty at all, which is good for leaks but needs self-catheterisation to empty the bladder. In the past, hospitals used a permanent catheter called an 'indwelling' or a 'suprapubic' catheter. These can have side effects, including infections, stones, and pain. For CISC, disposable catheters are the best option for patients as they come in different sizes and styles to provide individualised care. In conclusion, we would like hospitals to consider each patient separately and not use a general 'one-size-fits-all' bladder function for these patients.

New micro-hole zone catheter reduces residual urine and mucosal microtrauma in a lower urinary tract model

Urinary tract infections (UTIs) are the main complication associated with clean intermittent catheterization (CIC) and are facilitated by post-void residual urine and trauma to the mucosa during voiding. The risk of UTI may be diminished by reducing the residual volumes and preventing microtrauma caused by mucosal suction through the eyelets of conventional eyelet catheters (CEC). A new micro-hole zone catheter (MHZC) was developed and tested in an ex vivo porcine lower urinary tract model and in vivo, in pigs, against a CEC. It was shown that, irrespective of the micro-hole diameter, the new catheter ensured increased flowrates and significantly lower residual volumes at the first flow-stop. Furthermore, with a micro-hole diameter of 0.4 mm, mucosal suction was virtually eliminated, regardless of the insertion depth or simulated intra-abdominal pressure mimicking sitting or standing humans. Pressure profile experiments and endoscopy studies indicated that the bladder gradually folds against the drainage tip of the new catheter, without blocking the flow, and, unlike with the CEC, sharp pressure variations and flow-stops did not occur during voiding. The MHZC outperformed the CEC in all tested scenarios and decreased residual volumes, thus potentially decreasing the risk of UTIs.

[Intermittent catheterization: What are the environmental impacts and how can they be reduced?]

INTRODUCTION

If the use of intermittent catheterization has revolutionized the prognosis of neuro-urology patients, it seems necessary to question the ecological cost of single-use catheters, in a process of decarbonization of the health sector. The aim of this work is to identify the environmental impact of intermittent catheterization and potential solutions to reduce it.

METHODS

A review of the literature on the environmental impact of intermittent catheterizations was conducted. Potential solutions to reduce this impact and possible alternatives were then studied based on data from the literature.

RESULTS

Only two studies were identified. The first estimated the amount of waste generated by intermittent catheterization in the USA to be between 4400 and 38,964 tons per year. The second study showed a higher overall environmental impact of thermoplastic polyurethane (TPU) catheters than polyvinyl chloride (PVC) catheters and catheters made from polyolefin material. Reuse of catheters would reduce the amount of waste, but the paucity of data does not allow us to determine if the incidence of urinary tract infection would be affected. Alternative micturition methods, in addition to the complications they may cause, require the use of collection bags or pads, which also have an environmental impact. Other treatments for dysuria exist, but the evidence is limited and does not cover all patient populations.

CONCLUSION

With limited alternatives, it appears essential to develop more environmentally friendly catheters.

Evaluation of Quality of Life and Self-reported Complications in Patients With Clean Intermittent Catheterization: An Observational Study

PURPOSE

This study sought to determine health-related quality of life and self-reported complications associated with clean intermittent catheterization (CIC).

DESIGN

Observational, cross-sectional study.

SUBJECTS AND SETTING

The target population was patients cared for by the urology department at Hospital 12 de Octubre in Madrid, Spain, undergoing CIC for chronic urinary retention of any etiology (neurogenic bladder dysfunction, neobladder, and other). The sample comprised 50 respondents with a mean age of 49 years; a majority (66%, n = 33) were female. Participants performed an average of 4 CICs.

METHODS

All participants completed the ISC-Q (Intermittent Self-Catheterization Questionnaire) and a questionnaire about CIC-associated complications. Data were collected in February 2019.

RESULTS

A vast majority of respondents (98%, n = 49) indicated preparation for catheterization was simple, and 76% (n = 38) indicated the catheter was easy to insert. One in 5 (20%, n = 10) considered carrying catheters and supplies inconvenient, though 58% (n = 29) indicated it was easy to dispose of the catheters outside the home. Most respondents (98%, n = 49) indicated they felt self-conscious about their need to self-catheterize, and 16% (n = 8) felt that CIC created limitations when visiting friends and family. The most frequent complication was symptomatic urinary tract infections (UTIs); participants reported an average of 1.7 UTIs in the last year. Additional complications, such as epididymo-orchitis, urethral stenosis, and urethral bleeding, were reported by less than 5% (n = 2) of participants.

CONCLUSIONS

Participants managed by CIC for chronic urinary retention of any cause reported acceptable levels of satisfaction with the procedure. The reported incidence of complications was low, except for UTIs.

Risk factors associated with recurrent febrile urinary tract infection in children with neurogenic bladder who perform clean intermittent catheterization

OBJECTIVE

To identify the clinical and urodynamic risk factors associated with the development of recurrent febrile urinary tract infections (FUTIs) in children with neurogenic bladder (NB) who perform clean intermittent catheterization (CIC).

METHODS

Children with NB receiving CIC were prospectively enrolled from January to December 2019 and followed up prospectively for 2 years. All data were compared between occasional (0-1 FUTI) and recurrent FUTIs (≥2 FUTI) groups. In addition, the risk factors for recurrent FUTIs in children were evaluated.

RESULTS

Complete data from 321 children were analyzed. Occasional FUTIs occurred in 223 patients, and 98 patients experienced recurrent FUTIs. Univariate and multivariate analyses, showed late-initiation and low-frequency CIC, vesicoureteral reflux (VUR), small bladder capacity and low compliance, and detrusor overactivity were associated with an increased risk of recurrent FUTIs. Children with high-grade VUR (grades IV-V) had a higher risk of recurrent FUTIs than those with low-grade VUR (grades I-III) (odds ratio [OR]: 26.95 vs. OR: 4.78, p < 0.001).

CONCLUSIONS

Our study suggests that late-initiation and low-frequency CIC, VUR, small bladder capacity and low compliance, and detrusor overactivity were associated with recurrent FUTIs in patients with NB. In addition, high-grade VUR is a crucial risk factor for recurrent FUTIs.

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

INTRODUCTION

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

OBJECTIVE

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

METHODOLOGY

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

RESULTS

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

CONCLUSION

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

Factors associated with recurrent urinary tract infections in spinal cord injured patients who use intermittent catheterization

INTRODUCTION

Urinary Tract Infection (UTI) has been cited as the primary cause of morbidity in patients with history of spinal cord injury (SCI). Despite the significance of recurrent UTI (rUTI) in this population, the causative physiologic and patient characteristics are not well described. We sought to assess associations between demographic, clinical and urodynamic variables and rUTI.

MATERIALS AND METHODS

The records of 136 individuals with SCI who perform clean intermittent catheterization (CIC) were retrospectively reviewed. All had a video urodynamics study (VUDS) available for analysis. Individuals were divided into non-recurrent (< 3/year) or rUTI (≥ 3/year) groups. Differences between the cohorts were analyzed. Multivariable logistic regression was performed to determine associations between various demographic, clinical, and VUDS variables and rUTI.

RESULTS

Self-reported rUTI were noted in 58 of 136 individuals. Of 124 individuals with urinary culture results, African American race (43.3% vs. 22.3%) and 'Other' race (13.3% vs. 8.5%) made up larger proportions in the rUTI group. Female gender (OR 4.96, 95% CI [1.44-17.13]) and African American race (OR 5.16, 95% CI [1.80-14.79]) were increasingly associated with rUTI on multivariable logistic regression. Shorter interval since injury was also significantly associated with recurrent infections with each year since injury indicating diminished likelihood (OR 0.91, 95% CI [0.82-0.99]). There were no significant differences in VUDS variables between groups and none were significant on regression as potential determinants of rUTI.

CONCLUSIONS

Patient race, gender, and time since SCI appear to have significant associations with rUTI in individuals with SCI using CIC. However, VUDS variables were not found to be significantly associated with rUTI.

Barriers affecting patient adherence to intermittent self-catheterisation

Intermittent self-catheterisation (ISC) is now considered the standard of care for most patients with neurological conditions and associated lower urinary tract disorders. Numerous societies, led by the International Continence Society, are in agreement on the effectiveness of ISC. Use of intermittent catheters is reported to reduce the risk of catheter-associated urinary tract infection compared with indwelling urinary catheters while improving patient comfort and quality of life. However, previous studies have shown that, despite the benefits of ISC, it will not guarantee behavior change and the integration of this procedure into the daily life of patients. Patients may encounter internal (related to the patient themselves) and external (related to their environment) difficulties. Identifying these obstacles early will help promoting ISC success. This review aims to identify internal and external barriers related to ISC and to propose adequate solutions to avoid them.

Intermittent catheterization with single- or multiple-reuse catheters: clinical study on safety and impact on quality of life

PURPOSE

Intermittent catheterization (IC) is a proven effective long-term bladder management strategy for individuals who have lower urinary tract dysfunction. This study provides clinical evidence about multiple-reuse versus single-use catheterization techniques and if catheter choice can have an impact on health-related quality of life (HRQoL).

METHOD

A prospective, multi-center, clinical trial studied patients who currently practiced catheter reuse, and who agreed to prospectively evaluate single-use hydrophilic-coated (HC) (i.e. LoFric) catheters for 4 weeks. A validated Intermittent Self-Catheterization Questionnaire (ISC-Q) was used to obtain HRQoL. Reused catheters were collected and studied with regard to microbial and debris contamination.

RESULTS

The study included 39 patients who had practiced IC for a mean of 10 years, 6 times daily. At inclusion, all patients reused catheters for a mean of 21 days (SD = 48) per catheter. 36 patients completed the prospective test period and the mean ISC-Q score increased from 58.0 (SD = 22.6) to 67.2 (SD = 17.7) when patients switched to the single-use HC catheters (p = 0.0101). At the end of the study, 83% (95% CI [67-94%]) preferred to continue using single-use HC catheters. All collected reused catheters (100%) were contaminated by debris and 74% (95% CI [58-87%]) were contaminated by microorganisms, some with biofilm.

CONCLUSION

Single-use HC catheters improved HRQoL and were preferred over catheter reuse among people practicing IC. Catheter multiple-reuse may pose a potential safety concern due to colonization by microorganisms as well as having reduced acceptance compared to single use.

TRIAL REGISTRY NUMBER

ClinicalTrials.gov NCT02129738.

Risk Factors Associated With Recurrent Urinary Tract Infection in Neurogenic Bladders Managed by Clean Intermittent Catheterization

OBJECTIVE

To identify risk factors for recurrent urinary tract infection (UTI) in patients who perform clean intermittent catheterization (CIC).

METHODS

A 6-year retrospective chart review of patients with spina bifida or tethered cord who perform clean intermittent catheterization (8 months to 58 years) was conducted. A strict case definition for UTI was applied, and per-subject UTI events, demographic, and clinical data were abstracted. Data were compared between groups defined by no or infrequent UTI (≤1.0 UTI/study year) and frequent UTI (>1.0 UTI/study year).

RESULTS

Of 194 total patients, 146 (75%) had no UTIs or infrequent UTIs, and 48 (25%) patients had frequent UTIs. On univariate analysis, only younger age and suprasacral cord lesions were associated with frequent UTIs (P = .002 and P = .007, respectively). Among the 128 patients with urodynamic studies, bladder capacity, compliance, detrusor overactivity, and detrusor leak point pressure were not associated with frequent UTI on univariate analysis. On multivariate analysis, increasing age was found to be associated with decreased odds of UTI by 7% per year (odds ratio 0.93, P = .016).

CONCLUSION

The risk of UTI among individuals with spina bifida or tethered cord declines with increasing age. Bladder function based on urodynamic parameters did not correlate with frequent UTIs.

Shifting to 4 × 1 intermittent catheterization without an early follow-up urodynamic study is possible in most patients with subacute spinal cord injury

OBJECTIVES

We retrospectively evaluated the frequency of changing to 4/day intermittent catheterization (IC) in patients with subacute spinal cord injury (SCI) who had been initiated on IC 6 times a day and started oral anticholinergic treatment following urodynamic investigation for decreased maximum cystometric capacity and undergone a follow-up urodynamic study within 45 days. The goal of the study was to see if the second urodynamic study was necessary.

METHODS

The frequency of shifting to 4/day IC was investigated retrospectively in 27 patients with subacute SCI who were prescribed 6/day IC.

RESULTS

In 25 of 27 patients a bladder capacity of 400 ml or more was reached in urodynamic study carried out in the following 45 days and the patients were shifted to 4/day IC. There was a significant difference between the anticholinergic pre-treatment (293 ± 39 ml) and post-treatment (531 ± 81 ml) capacities (P < 0.001). The mean increase in bladder capacity in all patients was 237.6 ± 79.5 ml (83.5 ± 32.1%).

CONCLUSION

Patients with subacute SCI who were prescribed 6/day IC and were given an oral anticholinergic drug can be shifted to 4/day IC after 45 days without performing an early control urodynamic study if the patients use the drug properly. However in the long-run, periodic follow-up urodynamic studies should be carried out at appropriate intervals, according to the patients' clinical findings.

Decreasing frequency pattern in patients with clean intermittent catheterization for bladder voiding dysfunction

OBJECTIVES

To evaluate usefulness and morbidity of clean intermittent catheterization (CIC) using a decreasing pattern in patients with bladder voiding dysfunction (BVD) of varied etiology.

METHODS

We performed a retrospective study of patients with BVD in whom CIC was indicated. We evaluated the clinical presentation, post-void residual urine (PVR), results of the urodynamic studies (UDS), and response to CIC in a decreasing pattern, complications espeand patient adherence. The primary endpoint was a favorable response to CIC in a decreasing frequency pattern. Secondary endpoints were complications and patient perception of it.

RESULTS

We evaluated a total of 27 patients with BVD. Of these, 15 (56%) were women and 12(44%) were men. Mean age was 54.33 years (32-82) and mean follow-up time was 23.5 months (2-66). The mean catheterized volume and the number of catheterizations decreased in all groups of patients. 40.7% of all patients did not need to perform catheterization after an average time of 7.38 months. The average time to reach a stable PVR or the lack of it was 9.76 months (0.75 to 63). The only complication recorded were urinary tract infection (UTI) presenting as mild cystitis in 7 patients and orchitis in 2 patients. 70.4% (19/27) responded to the telephone survey. 79% (15/19) said they have had no major difficulty in learning CIC, 52.7% (10/19) said to be continuing CIC, and the mean personal rating was 6/10.

CONCLUSION

CIC in a decreasing pattern allows almost half of the patients to be totally free from catheterization. The other half reduces significantly the number of catheterizations, with little interference in their daily lives. It is an effective technique, well accepted and well learned by most patients with BVD in a wide range of indications, beyond neurogenic dysfunction.

Community nursing and intermittent self-catheterisation

Clean intermittent self-catheterisation (CISC) is a treatment option for people with urinary incontinence-particularly those with neurogenic bladder dysfunction. When used for appropriate patients it has been shown to promote continence, maintain safe bladder function and improve quality of life. There is a range of different products available on prescription for patients, and community nurses are ideally placed to advise them regarding products and to offer choice to those performing CISC. CISC can promote privacy and dignity for patients with urinary incontinence due to impaired bladder emptying, and community nurses should offer this intervention to patients for whom it is suitable and support them in learning the technique.

Clean intermittent self-catheterisation: improving quality of life

Clean intermittent self-catheterisation (CISC) is often a treatment option for women with urinary incontinence, particularly those with neurogenic bladder dysfunction. When used for appropriate patients it has been shown to promote continence and improve quality of life. There are a range of different products available on prescription for patients and many have been designed specifically with women in mind. Curan Lady is a new catheter that has recently been added to the UK NHS Drug Tariff. Patients suffering from limited/restricted mobility in their hands, found the Curan Lady easy to open and use. CISC can promote privacy and dignity for women with urinary incontinence and patient choice regarding product selection is important. Nurses need to keep up to date with new product availability for patients in order to offer choice to women performing CISC.

Clean intermittent self-catheterization in neuro-urology

Neurogenic lower urinary tract dysfunction (NLUTD) is commonly encountered in rehabilitation settings, and is caused by a variety of pathologies. The management of spinal cord injury (SCI) has been the model of reference for the management of other pathologies with NLUTD. The introduction of intermittent catheterization (IC) led to decline in renal related mortality in SCI patients and allowed an improvement of quality of life (QoL) in all neurogenic patients with NLUTD. IC could be sterile, aseptic or clean. Sterile intermittent catheterization (SIC) is the preferred method of bladder drainage in emergency medicine units and during spinal shock in SCI patients, but it is costly and time-consuming. Catheterizations performed in institutions, such as rehabilitation hospitals and nursing homes, are done aseptically. Clean intermittent catheterization (CIC), i.e. self-catheterization (CISC) or third party catheterization, represents the "gold standard" method for bladder emptying in all neuropathic patients with NLUTD: the technique is safe and effective and results in improved kidney and upper urinary tract status, lessening of vesico-ureteral reflux and amelioration of urinary continence. CISC is mandatory in patients with NLUTD secondary to detrusor areflexia/hypocontractility and in patients suffering from neurogenic detrusor overactivity with detrusor external sphincter dyssynergia and high post void residual of urine, often in combination with antimuscarinics/bladder relaxants. The review summarizes the most important aspects of IC and CISC. Attention was focused on the history of urethral catheterization, aims, materials, advantages, indications, and present-day techniques of CISC, emphasizing the importance of teaching in order to perform correctly the catheterization technique.

Review of intermittent catheterization and current best practices

Intermittent catheterization is the insertion and removal of a catheter several times a day to empty the bladder. This type of catheterization Is used to drain urine from a bladder that is not emptying adequately or from a surgically created channel that connects the bladder with the abdominal surface (such as Mitrofanoff continent urinary diversion). Intermittent catheterization is widely advocated as an effective bladder management strategy for patients with incomplete bladder emptying due to idiopathic or neurogenic bladder dysfunction. Urologic nurses are at the forefront of educating and teaching patients how to self-catheterize. Catheterizations performed in institutions, such as acute and rehabilitation hospitals and nursing homes, are done aseptically. Historically, however, intermittent catheterization has been performed by the patient in the home environment using a clean technique involving the re-use of catheters. New guidelines released in the past three years have recommended changes to the practice of re-using catheters. Currently, nurses use their clinical judgment to determine which technique and type of catheter to use, in conjunction with patient preference. Differential costs and insurance coverage of catheters/echniques may also influence decision making. The authors provide an overview of the indications, use, and complications associated with intermittent catheterization, present current guidelines on self-catheterization and treatment of catheter-associated complications, detail types of catheters, and review clinical practice of intermittent catheterization.

Urinary tract infection rates associated with re-use of catheters in clean intermittent catheterization of male veterans

Clean intermittent catheterization used to manage urinary retention can be complicated by urinary tract infection (UTI). This retrospective study describes the frequency of antibiotic-treated UTI in patients undergoing intermittent catheterization. Most patients did not have UTI; this supports findings in previous studies.