Urinary Tract Infections

The SCIRE Community Team | Bonnie Nybo, RN | Last updated: Nov 9, 2018

Urinary tract infections (UTIs) are a common problem that can happen after spinal cord injury (SCI). This page discusses what urinary tract infections are and how they are treated following SCI.

Key Points

  • A urinary tract infection is an infection of the bladder, kidneys or their connecting tubes.
  • Urinary tract infections are common after SCI because of changes to how the bladder works, side effects of bladder treatments (such as use of urinary catheters), and other factors.
  • Common symptoms of urinary tract infections include cloudy, dark or bad-smelling urine and fever, chills, or fatigue. Symptoms may also involve increased muscle spasms which can cause leaking or autonomic dysreflexia. If you have sensation you may experience discomfort over the abdomen and back or when urinating.
  • Urinary tract infections should be treated with antibiotics only if symptomatic, not just for the presence of bacteria in the urine. There are several things that can be done to prevent urinary tract infections, such as maintaining an effective bladder routine, adequate water intake, seeking treatment for bladder problems, and staying healthy.
  • Urinary tract infections can be very serious and even become life-threatening. If you suspect you might have a urinary tract infection, see your doctor as soon as possible.

Image showing the urinary system. Bottom right image shows a person's abdomen with two bean-shaped kidneys connecting by tubes labelled 'ureters' to the bladder (just above the pubic bone). Enlargement top left shows the bladder surrounded by a smooth muscle labelled 'bladder wall muscle'. Urine is contained in the bladder. The bladder connect downward to a tube labelled 'urethra'. The exit of the bladder to the urethra has muscles surrounding it labelled 'bladder sphincter muscles'.

Urinary tract infections can happen in the kidneys, bladder, or their connecting tubes.1

urinary tract infection (commonly called a ‘UTI’) is an infection of part of the urinary tract. This may be the kidneys, the bladder, or the urinary tract’s connecting tubes (the ureters or urethra). Kidney infections are called pyelonephritis and bladder infections are called cystitis.

Urinary tract infections are common after SCI, affecting around 1 in 5 people early after injury, and as many as 7 in 10 people living with SCI long-term.

In severe cases, UTIs can progress to a life-threatening infection called sepsis. In the early days of SCI care, complications of UTIs were the most common cause of death after SCI.

Today, treatment and prevention of UTIs is much more effective and infections can be treated effectively in most cases. However, it is very important to take steps to prevent infections and to seek out treatment for new infections as soon as they are detected.

The symptoms of UTIs usually consist of whole body symptoms of infection (like fever), changes to urination (such as appearance or odour), or signs that indicate something is wrong below the injury (such as increased muscle spasms or autonomic dysreflexia).

However, UTIs are not always easy to recognize, especially if you don’t have sensation in the area. If you suspect you might have a UTI, contact a health provider as soon as possible.

Signs and symptoms of UTIs may include:

  • Cloudy urine (from pus), dark-coloured or red urine (from blood), or bad-smelling urine
  • Fever, chills, tiredness, or a feeling of unease
  • More frequent or severe muscle spasms
  • Autonomic dysreflexia (in people with injuries above T6)
  • Leaking of urine or leakage around the catheter
  • Reduced appetite

If you have sensation in the area, you may also experience:

  • An urge to urinate often
  • Pain or discomfort while emptying the bladder
  • Pain in the abdomen or back

Watch for changes to your bladder function

As a part of your regular bladder care, keep an eye out for changes that could indicate a UTI. For example, monitoring changes in the colour or volume of urine emptied may help you detect infections earlier.

Urinary tract infections happen when bacteria or other microorganisms enter the urinary tract and start to multiply and grow. Most UTIs are caused by bacteria like E. coli. However, fungi, viruses, and parasites can also cause infections.

What is E.coli?

Low-temperature electron micrograph of a cluster of E. coli bacteria, magnified 10,000 times.

Low-temperature electron micrograph of a cluster of E. coli bacteria, magnified 10,000 times.2

Escherichia coli (E. coli) is a species of bacteria which is commonly found in the lower intestine of mammals. There are many types of E.coli and most are harmless to us, or even beneficial, as they are part of the normal gut flora and can produce beneficial compounds that we absorb and by preventing pathogenic bacteria from moving in. However, while E. coli normally resides in the gut it does not normally reside in the bladder and is responsible for most UTIs.

Although anyone can experience a UTI, people with SCI have a greater risk of developing one because of changes to how the bladder works, catheterization which may be used to manage the bladder, and a number of other factors:

Changes to how the bladder works

Incomplete emptying

If a person cannot fully empty the bladder, any bacteria that have entered into the urinary tract cannot be flushed out fully during emptying. The leftover urine in the bladder can create an environment that promotes growth of bacteria that can cause infection.

Bladder overfilling

Overstretching of the bladder due to overfilling can damage the bladder walls, which increases the risk of infection. Overfilling can also cause reflux which causes the urine to back up to the kidneys (see below).

Reflux

Reflux occurs when urine flows backwards from the bladder to the kidneys and can increase the risk of infection in the kidneys and ureters. It can be caused by detrusor sphincter dyssynergia, where the coordinated action of two muscles (the detrusor of the bladder and the sphincter of the urethra) is disrupted. Instead of relaxing when urinating, the sphincter muscle contracts. This interrupts the outflow of urine causing pressure in the bladder to rise, which can result in reflux.

Use of urinary catheters

Urinary catheters (thin tubes that can be inserted into the bladder) are often used to drain the bladder after an SCI. However, catheters can also increase risk of infections because they provide a pathway for bacteria to enter the urinary tract. A catheter can pick up bacteria from contact with skin and surfaces and bring it into the bladder when it is inserted. This is a greater risk if catheters are reused or techniques are not done hygienically.

Indwelling catheters can sometimes get blocked, which prevents urine flow and can cause urine to remain in the urinary tract for too long. This can allow bacteria to grow and multiply. Proper care of catheters is important to reduce contamination and avoid blockages. The indwelling catheter is a foreign object in the bladder and this can increase the risk of bacteria or bladder stone formation as well.

Changes to bowel function

Most people also experience changes to bowel function after SCI which can cause bowel accidents and the need to perform regular bowel routines. This can lead to bacteria (often E. coli) from feces entering the urinary tract and causing infections.

Poor hygiene

Poor hygiene when performing a bladder routine, such as not washing the hands or genitals before inserting a catheter, not using sterile technique when inserting an indwelling catheter, or wearing condom catheters for longer than 24 hours without cleaning the genitals, especially, can allow bacteria to enter the urinary tract. In addition, wetness from a poorly managed bladder can increase the risk of infections spreading.

Other factors

  • Women are at greater risk for developing UTIs because female anatomy increases the risk of the natural bacteria from the vagina or anus to enter the urinary tract
  • Older age (especially over 65) increases the risk of developing a UTI because of incomplete bladder emptying
  • Obstruction of the urinary tract from something like a kidney or bladder stone, enlarged prostate, or narrowing of the urethra
  • Sexual intercourse, including the use of protective equipment such as diaphragms or spermicides
  • Other health conditions such as diabetes or conditions that reduce ability to fight infections such as HIV (human immuodeficiency virus)
  • Reduced sensation, as sensation is one of the ways that early infections of the urinary tract are detected. This is usually experienced as pain when urinating or over the abdomen or back
  • Other infections, such as infected wounds, can sometimes travel into the urinary tract
  • Reduced functional abilities may result in difficulty performing clean technique in bladder management
  • Reduced economic resources may result in reusing catheters or unclean environments or decreased care support
  • Pregnancy
  • Menopause
  • Depression

Medical examination

Your doctor will ask you about your medical history and symptoms and perform a visual and physical inspection. If they suspect that you might have a UTI, they will likely take a urine sample and do additional testing, such as a dipstick test and urine culture. Since most people with SCI will have a positive dipstick test or urine culture, the inspection of the urine, physical examination and history is very important to assist with directing treatment.

Urine sample

Taking a urine sample can help to confirm whether there is a UTI. The sample is then tested for signs of infection, bacteria and other features.

Taking a good urine sample

Urine for a urine sample needs to be collected in a careful way to ensure that it provides accurate information. To take a good urine sample, the genital area should be washed first. Urine is collected in a sterile container midstream during urination or catheterization. If the sample is collected from an indwelling catheter, the catheter should be changed first. Samples are never taken from a urine drainage bag. These steps can help to prevent the sample from being contaminated.


Picture of dipstick test strip beside black storage bottle with label for interpreting results

The dipstick or urine test strip is a basic diagnostic tool for identifying presence of substances or infection in urine.3

Dipstick Test

A dipstick test is a standard urine test strip that provides results in minutes. A positive result for leukocytes and nitrites indicates the need for a urine culture. Antibiotics would not be prescribed based on this test alone.

Urine culture

A urine culture may be done to determine the amount and type of bacteria causing the infection. This test is done using a urine sample that is left in conditions where bacteria can grow if they are present. It can later be tested to determine what type of bacteria are present, and a suitable antibiotic for treatment.

 

Bacteria in the urine alone does not require treatment

Although the bacteria in the urine can show a UTI, antibiotic treatment is not recommended unless it is also accompanied by other symptoms. People who use catheters often have some bacteria in the urinary tract, which does not indicate an infection. This is important because frequent use of antibiotics when they are not necessary can create antibiotic resistance (where antibiotics become less effective).

However, people who are more vulnerable when they have an infection (such as pregnant women or young children) may still be treated in this situation.

Imaging

Various imaging tools can be used to visualize the urinary tract and detect structural abnormalities. Some examples are ultrasound or magnetic resonance imaging (MRI). A cystoscopy is a more invasive way to view the urinary tract in greater detail. It involves inserting a long thin camera through the urethra and up into the bladder.

Urinary tract infections are treated with antibiotic medications (antibiotics). Antibiotics help kill bacteria that cause infections. Antibiotics are usually taken orally, but in severe cases, may be delivered directly into the veins through an intravenous (IV) line.

There are a wide range of antibiotics that may be used to treat urinary tract infections after SCI. The most common antibiotics used to treat urinary tract infections after SCI include:

  • Fluorquinolones (such as Ciprofloxacin and Ofloxacin)
  • Trimethoprim/sulfamethoxazole (TMP-SMX)
  • Amoxicillin
  • Nitrofurantoin
  • Ampicillin

Fluorquinolones are the most common choice because they are effective for treating a wide range of different types of bacteria. The selection of antibiotic is individualized and based on various factors such as type of bacteria causing the infection, recent antibiotic use, allergies, and risk of side effects.

Length of treatment can vary depending on the health status of the individual and the severity of the infection. For catheter-related UTIs, the typical duration is about 2 weeks. Signs and symptoms should start to improve within a few days after starting treatment, but that does not mean the antibiotics should be stopped. The full course of treatment should be finished to prevent recurrent infections.  

While there are many studies to support the effectiveness of antibiotics for UTI treatment in people with SCI, there is a lack of research on what the optimal dose and length of treatment is.

A number of different practices may be used to prevent UTIs. A proper bladder routine and good hygiene is the first step. Some options such as antibiotics and bacterial interference are not usually encountered as a typical part of prevention, thought there is research in these areas. Some of these are part of self-care and others involve working together with your healthcare team.

The Bladder Routine

A bladder routine is a regular schedule of bladder techniques and treatments done every day to maintain bladder function and health. To decrease the risk of a UTI, a bladder routine will take into account a number of items:

Catheterization Method

Various studies on UTI prevention in SCI have been done on different types of catheterization with most research focusing on intermittent catheterization, which is one of the most common and preferred bladder-emptying methods for the neurogenic bladder. For a review of the different types of catheterization methods available please refer to our page on the topic.

Example of an indwelling catheter. Uncoupling the line above the ‘leg bag’ is not recommended. An optional ‘night drainage bag’ that attaches to the ‘leg bag’ may be attached and detached as needed.

Example of an indwelling catheter. Uncoupling the line above the ‘leg bag’ is not recommended. An optional ‘night drainage bag’ that attaches to the ‘leg bag’ may be attached and detached as needed.4

There is moderate evidence that intermittent catheterization carries a lower risk of UTI than both urethral indwelling or suprapubic indwelling catheters. If an indwelling catheter is required, there is moderate evidence to show that a StatLock device to secure urethral and suprapubic catheters may lead to a lower rate of UTI.

Suprapubic catheters lead to a lower rate of UTIs than urethral catheters. There is weak evidence that where intermittent catheterization may not be viable as an approach to bladder management due to socioeconomic challenges, bladder management with a suprapubic as opposed to urethral catheter may lead to a lower rate of UTI.

Maintaining closed systems with indwelling catheters is recommended practice. This means not uncoupling links in the line where the catheter is connected to the urine collection bag as to do so creates an entry route for bacteria.

Specially coated catheters

There is strong evidence that using a pre-lubricated or hydrophilic catheter for intermittent catheterization is more effective in reducing the risk of UTI or need for antibiotic treatment compared to non-coated catheters.

Catheterization Hygiene

Washing your hands thoroughly with soap and hot water before catheterization is the first step regardless of whether you use the clean technique, the sterile technique, or something in between.

Clean Technique

More common and less expensive

Often performed in the community

Usually done for intermittent catheterization

Requires thoroughly washed hands

Intermittent catheterization is often done with a single-use sterile catheter

The genital area is cleaned with soap and water

 

 

 

Sterile Technique

Less common and more expensive

Often performed in the hospital/rehab centre

Usually done for indwelling catheterization

Requires thoroughly washed hands and sterile gloves to be worn.

Intermittent catheterization is done with a single-use sterile catheter

The genital area is cleaned with a disinfectant

Requires a sterile catheterization kit that will include gloves, draping, an underpad, lubricant, swabs, a syringe, and a urine collection receptacle

There is moderate evidence that intermittent catheterization using the clean technique or sterile technique is equally effective in reducing UTI risk during inpatient rehabilitation for SCI.

The use of single use catheters is recommended over multiple use catheters as there may be a lower incidence of UTI in people who use single use catheters. For those who still use multiple use catheters for intermittent catheterization, properly cleaning the catheter and allowing it to dry completely before reuse is important.

Do not apply a multiuse tube of lubricant directly to the catheter. To prevent contamination, dispense lubrication on to a sterile napkin included with the catheter, then apply it to the catheter. Alternatively, you can use a small one-time use tube of lubrication. If the catheter touches any unsterilized surfaces during the bladder routine, a new catheter must be used.

Catheterization schedule

Perform intermittent catheterization when necessary. Usually a person will catheterize four to six times a day and collect less than 500mL of urine each time. If there is more than 500mL collected, one should consider more frequent catheterizations or review their fluid intake. This reduces the risk of having an overfilled bladder which can damage the bladder and cause reflux of fluid up towards the kidneys. Both these factors increase the risk for UTI. The amount of urine left over after catheterization does not seem to play a role in UTI occurrence in individuals with SCI. However, emptying the bladder completely is desired as performing more catheterizations than required may increase UTI risk as each catheterization is an opportunity for bacteria to be introduced into the urinary tract.

Genital Hygiene

Keeping the genital and perineal area clean may reduce bacterial growth in that area that could contribute to a UTI.

This involves a bowel routine to minimize the occurrence of bowel accidents which can increase UTI risk as fecal matter may gain access to the urethra. When cleaning up after a bowel movement, wipe from front to back. Also, preventing bowel accidents and bladder leaks will keep the area dry and help keep the skin healthy.

Women should avoid using douches and similar feminine hygiene products.

Individuals who are able to urinate should empty their bladder after sexual activity. For those who catheterize, clean the genital and perineal area after sexual activity.

 

Fluid Intake and Diet

Water being poured into a clear glass.

Research in the general population suggests that adequate hydration may contribute to the prevention of UTIs. There is no SCI specific research investigating the relationship between water intake and UTI risk.

What is known is that dehydration can have numerous short and long-term negative effects on one’s physical and mental health Therefore, (unless directed by your physician) decreasing fluid intake for the convenience of less catheterizations is unwise if doing so dehydrates you.

 


How much water do you need to prevent UTIs?

While there is some evidence that adequate hydration prevents UTIs, there is no guideline for how much is adequate. Even research in the general population for what constitutes adequate hydration is an unsettled question.

Based on the best evidence so far, guidelines for the general population indicate that adequate intake of water is between 2.2 Litres for women to 2.9 Litres for men. This includes water from all beverages and food. We get between ½ to 1 litre of water from the food we eat.

How do these guidelines change for individuals with SCI? It has been suggested that individuals with neurogenic bowel dysfunction require additional fluid compared to other people. For those who use intermittent catheterization 2 Litres per day is recommended. For those who have indwelling catheters, 3 Litres per day is recommended.

One way to easily gauge your hydration is to look at your urine colour. While no precise relationship between urine color and hydration level exists, dehydration creates concentrated urine which is darker in colour while adequate hydration usually yields light coloured urine, so aim to consistently produce light coloured urine. Note that diet, vitamin supplements, and medications may affect the colour to your urine independent of your hydration.


What should you drink to prevent UTI?

There is no SCI specific information regarding the role of choice of fluids in UTI prevention. There is also very little research regarding the role of choice of fluids in UTI prevention in the general population. From an overall health perspective, the optimal amount of soda and alcohol is none. Juices and blended drinks (frappucchino, etc) are best avoided because of the high amount of sugar and/or calories. If you are drinking coffee and tea for its health benefits, consider omitting dairy products from the beverage as milk blocks the absorption of phytonutrients into the body. Caffeinated beverages like coffee and tea can have a diuretic effect in people not used to drinking them, and this will need to be accounted for in how it may affect one’s catheterization schedule. Also, alcohol has a diuretic effect and hard alcohol has an additional dehydrating effect which will increase water requirements.

Green tea in a teacup with dry tea leaves on the sideConsider that what you eat can also affect your hydration levels. Whole foods like fruits and vegetables have high water content and will increase your hydration level more than processed foods. For information on cranberries for prevention of UTIs in SCI, see the oral antiseptic section below.

Finally, while there is no SCI specific information on these topics, there is some evidence that compounds in green tea, which are protective against E. coli that causes UTIs, make their way to the bladder. Also, there is evidence in the general population that suggests poultry may be a source of pathogenic E. coli that populates the gut and serves as a reservoir to infect the urinary tract.

 

Physical exercise

Based on one study with moderate evidence, regular moderate physical activity may prevent UTI following SCI. This may be due to strengthening of the immune system, one of the benefits of regular exercise.

 

Antibiotics as prevention

Certain antibiotics have been investigated for their role in preventing UTIs in SCI. However, there is evidence that taking antibiotics as a preventive measure cause an increase in antimicrobial resistant bacteria. With increasing antibiotic resistance becoming a major public health issue over the past decade, non-antibiotic strategies are recommended before considering antibiotics as a UTI prevention tool.

There is moderate evidence that ciprofloxacin, but not trimethoprim/sulfamethoxazole, may be an appropriate antibiotic for UTI prevention. There is weak evidence from one study which found that customizing therapy to the SCI individual and alternating between two antibiotics on a weekly basis is helpful in UTI prevention.

Antiseptics

Antiseptics rid bacteria differently than antibiotics. Many factors play a role in determining the effectiveness of antiseptics for UTI prevention such as the specific antiseptic, whether they are used in combination, and the methods of delivery. Antiseptics may be used during body washing, bladder irrigation, or by mouth in tablet form as described in more detail below.

Oral antiseptics

Close up image of cranberriesCranberries contain a substance that reduces the ability of E. coli bacteria to initially stick to the wall of the bladder. There is conflicting evidence for the effectiveness of cranberry products in preventing UTI in patients with neurogenic bladder due to SCI. It is worth noting that cranberry is relatively high in oxalate, a chemical that may raise the risk of kidney stones in some people. Also, cranberry may increase the risk of bleeding for those on anticoagulant medication like Warfarin.

purple bottle on side with white tablets spilling outD-mannose is a naturally occurring sugar similar to glucose. Only small amounts of d-mannose are used by the body and the rest is sent to the bladder to be excreted. Once in the bladder, D-mannose is believed to dislodge bacteria from the bladder wall. One study of able-bodied women and another in individuals with multiple sclerosis showed that D-mannose supplementation reduced UTI incidence. However, no research is yet published regarding D-Mannose and UTI incidence in individuals with spinal cord injury.

Dietary supplementation with vitamin C (ascorbic acid) is thought to reduce UTIs by increasing urine acidity. However, no clinical studies indicate that vitamin C improves symptoms or UTI incidence.

There is moderate evidence from one study that an oral form of antiseptic known as methenamine was not found to be effective for UTI prevention when used alone or in combination with cranberry.

Body washing

Moderate evidence from one study suggests that daily body washing with the application of chlorhexidine cream to the penis after every catheterization is more effective in reducing bacteria in the urine than standard soap, which may be helpful for UTI prevention.

Bladder irrigation

Antiseptics can be used to flush out the bladder through a process called bladder irrigation. However, only certain antiseptics have been shown to be effective in preventing UTIs, based on moderate evidence:

  • 5% hemiacidrin solution combined with oral methenamine
  • Trisdine
  • Kanamycin-colistin

Other agents delivered via bladder irrigation that are not effective in UTI prevention, based on moderate evidence or weak evidence, include:

  • Neomycin/polymyxin
  • Acetic acid
  • Ascorbic acid
  • Phosphate supplementation

Bacterial interference

Bacterial interference involves introducing harmless bacteria (usually a safe strain of E. coli) into the bladder to compete with and replace infection-causing bacteria. This is done via intravescical installation where the bacteria are pumped into the bladder via catheter. Although effectiveness depends on the specific type of bacteria used, there is moderate evidence that this method is useful for preventing UTIs. There is no evidence for the use of oral probiotics for the prevention of UTI in SCI.

 

Botulinum toxin injections

There is weak evidence from one study that botulinum toxin injected into the detrusor results in fewer UTIs. It is thought that this is a result of decreased detrusor pressure.

 

Electrical Stimulation

There is weak evidence showing that sacral anterior root stimulation achieved via an implanted electrical device may be associated with reduced UTIs. In most cases this was accompanied with posterior sacral rhizotomy.

There is moderate evidence from one study which shows that sacral nerve stimulation within the first half-year after injury results in improvements in urinary tract issues. These improvements included prevention of detrusor overactivity and urinary incontinence, normal bladder capacity, and reduced UTI rate. In this less invasive intervention, there was no accompanying rhizotomy.

Urinary tract infections are a common complication after SCI that require individualized antibiotic treatment.

Proper hygiene and a proper bladder management routine are the primary parts of UTI prevention.

In terms of bladder management for UTI prevention, intermittent catheterization with pre-lubricated or hydrophilic catheters and clean technique are most supported by research evidence.

Additional preventive techniques that are part of self-care include proper hydration and physical exercise.

Additional preventive techniques that require consulting with your healthcare team include antibiotics, some forms of antiseptics, bacterial interference, botulinum toxin, and electrical stimulation.

Further SCI-specific research is needed to better understand which techniques are most effective.

It is best to discuss all treatment options with your health providers to find out which treatments are suitable for you.

For a list of included studies, please see the Reference List. For a review of what we mean by ‘strong’, ‘moderate’, and ‘weak’ evidence, please see SCIRE Community Evidence Ratings.

Parts of this page have been adapted from the SCIRE Project (Professional) “Bladder Management” Chapter:

Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, Wolfe D, Teasell R. (2014). Bladder Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-196.

Available from:https://scireproject.com/evidence/rehabilitation-evidence/bladder-management/.

How are urinary tract infections treated?

[1] Dow G, Rao P, Harding G, Brunka J, Kennedy J, Alfa M et al. A prospective, randomized trial of 3 or 14 days of ciprofloxacin treatment for acute urinary tract infection in patients with spinal cord injury. Clin Infect Dis 2004;39(5):658-664.

[2] Reid G, Potter P, Delaney G, Hsieh J, Nicosia S, Hayes K. Ofloxacin for the treatment of urinary tract infections and biofilms in spinal cord injury. Int J Antimicrob Agents 2000;13(4):305-307.

[3] Waites KB, Canupp KC, DeVivo MJ. Efficacy and tolerance of norfloxacin in treatment of complicated urinary tract infection in outpatients with neurogenic bladder secondary to spinal cord injury. Urology 1991;38(6):589-596.

[4] Linsenmeyer TA, Jain A, Thompson BW. Effectiveness of neomycin/polymyxin bladder irrigation to treat resistant urinary pathogens in those with spinal cord injury. J Spinal Cord Med 1999;22(4):252-257.

What can be done to prevent urinary tract infections?

Evidence for ‘The Bladder Routine’ is based on the following studies:

[1] Moore KN, Burt J, Voaklander DC. Intermittent catheterization in the rehabilitation setting: A comparison of clean and sterile technique. Clin Rehabil 2006;20(6):461-468.

[2] Prieto-Fingerhut T, Banovac K, Lynne CM. A study comparing sterile and nonsterile urethral catheterization in patients with spinal cord injury. Rehabil Nurs 1997;22(6):299-302.

[3] Li L, Ye W, Ruan H, Yang B, Zhang S, Li L. Impact of hydrophilic catheters on urinary tract infections in people with spinal cord injury: Systematic review and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil 2013;94(4):782-787.

[4] Giannantoni A, Di Stasi SM, Scivoletto G, Virgili G, Dolci S, Porena M. Intermittent catheterization with a prelubricated catheter in spinal cord injured patients: A prospective randomized crossover study. J Urol 2001;166(1):130-133.

[5] De Ridder DJ, Everaert K, Fernandez LG, Valero JV, Duran AB, Abrisqueta ML et al. Intermittent catheterisation with hydrophilic-coated catheters (SpeediCath) reduces the risk of clinical urinary tract infection in spinal cord injured patients: A prospective randomised parallel comparative trial. Eur Urol 2005;48(6):991-995.

[6] Cardenas DD, Hoffman JM. Hydrophilic catheters versus noncoated catheters for reducing the incidence of urinary tract infections: A randomized controlled trial. Arch Phys Med Rehabil 2009;90:1668-1671.

[7] Cardenas DD, Moore KN, Dannels-McClure A, Scelza WM, Graves DE, Brooks M et al. Intermittent catheterization with a hydrophilic-coated catheter delays urinary tract infections in acute spinal cord injury: A prospective, randomized, multicenter trial. PM R 2011;3:408-417.

[8] Jensen AE, Hjeltnes N, Berstad J, Stanghelle JK. Residual urine following intermittent catheterisation in patients with spinal cord injuries. Paraplegia 1995;33(12):693-696.

[9] Krebs J1, Bartel P, Pannek J. Residual urine volumes after intermittent catheterization in men with spinal cord injury. Spinal Cord. 2013 Oct;51(10):776-9.

[10] Joshi A, Darouiche RO. Regression of pyuria during the treatment of symptomatic urinary tract infection in patients with spinal cord injury. Spinal Cord 1996;34(12):742-744.

[11] Nwadiaro HC, Nnamonu MI, Ramyil VM, Igun GO. Comparative analysis of urethral catheterization versus suprapubic cystostomy in management of neurogenic bladder in spinal injured patients. Niger J Med 2007;16(4):318-321.

[12] Darouiche RO, Goetz L, Kaldis T, Cerra-Stewart C, AlSharif A, Priebe M. Impact of StatLock securing device on symptomatic catheter-related urinary tract infection: A prospective, randomized, multicenter clinical trial. Am J Infect Control 2006;34(9):555-560.

[13] Gilmore DS, Schick DG, Young MN, Montgomerie JZ. Effect of external urinary collection system on colonization and urinary tract infections with Pseudomonas and Klebsiella in men with spinal cord injury. J Am Paraplegia Soc 1992;15(3):155-157.

[14] Christison K, Walter M, Wyndaele JJM, et al. Intermittent Catheterization: The Devil Is in the Details. J Neurotrauma. 2018;35(7):985–989.

Evidence for ‘Fluid Intake and Diet’ is based on the following studies:

[1] “4 Water.” Institute of Medicine. 2005. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: The National Academies Press. doi: 10.17226/10925.

Evidence for ‘Physical Exercise’ is based on the following studies:

[1] Lavado EL, Cardoso JR, Silva LG, ela Bela LF, Atallah AN. Effectiveness of aerobic physical training for treatment of chronic asymptomatic bacteriuria in subjects with spinal cord injury: A randomized controlled trial. Clin Rehabil 2013;27(2):142-149.

Evidence for ‘Antibiotics as Prevention’ is based on the following studies:

[1] Morton SC, Shekelle PG, Adams JL, Bennett C, Dobkin BH, Montgomerie J, Vickrey BG. Antimicrobial prophylaxis for urinary tract infection in persons with spinal cord dysfunction. Arch Phys Med Rehabil. 2002 Jan;83(1):129-38.

[2] Bonkat G, Pickard R, Bartoletti R, et al. Urological infections. 2018. http://uroweb.org/guideline/urological­infections/

[3] Biering-Sorensen F, Hoiby N, Nordenbo A, Ravnborg M, Bruun B, Rahm V. Ciprofloxacin as prophylaxis for urinary tract infection: Prospective, randomized, cross-over, placebo controlled study in patients with spinal cord lesion. J Urol 1994;151(1):105-108.

[4] Sandock DS, Gothe BG, Bodner DR. Trimethoprim-sulfamethoxazole prophylaxis against urinary tract infection in the chronic spinal cord injury patient. Paraplegia 1995;33(3):156-160.

[5] Reid G, Sharma S, Advikolanu K, Tieszer C, Martin RA, Bruce AW. Effects of ciprofloxacin, norfloxacin, and ofloxacin on in vitro adhesion and survival of Pseudomonas aeruginosa AK1 on urinary catheters. Antimicrob Agents Chemother 1994;38(7):1490-1495.

[6] Salomon J, Denys P, Merle C, Chartier-Kastler E, Perronne C, Gaillard JL et al. Prevention of urinary tract infection in spinal cord-injured patients: Safety and efficacy of a weekly oral cyclic antibiotic (WOCA) programme with a 2 year follow-up–an observational prospective study. J Antimicrob Chemother 2006;57(4):784-788.

[7] Lee BB, Haran MJ, Hunt LM, Simpson JM, Marial O, Rutkowski SB et al. Spinal-injured neuropathic bladder antisepsis (SINBA) trial. Spinal Cord 2007;45(8):542-550.

[8] Sanderson PJ, Weissler S. The relation of colonization of the perineum to bacteriuria and environmental contamination in spinally injured patients. J Hosp Infect 1990a;15(3):229-234.

[9] Krebs M, Halvorsen RB, Fishman IJ, Santos-Mendoza N. Prevention of urinary tract infection during intermittent catheterization. Journal d’urologie 1984;131(1):82-85.

Evidence for ‘Antiseptics’ is based on the following studies:

[1] Hess MJ, Hess PE, Sullivan MR, Nee M, Yalla SV. Evaluation of cranberry tablets for the

prevention of urinary tract infections in spinal cord injured patients with neurogenic bladder.

Spinal Cord 2008;46:622-626.

[2] Lee BB, Haran MJ, Hunt LM, Simpson JM, Marial O, Rutkowski SB et al. Spinal-injured neuropathic bladder antisepsis (SINBA) trial. Spinal Cord 2007;45(8):542-550.

[3] Linsenmeyer TA, Harrison B, Oakley A, Kirshblum S, Stock JA, Millis SR. Evaluation of cranberry supplement for reduction of urinary tract infections in individuals with neurogenic bladders secondary to spinal cord injury. A prospective, double-blinded, placebo-controlled, crossover study. J Spinal Cord Med 2004;27(1):29-34.

[4] Waites KB, Canupp KC, Armstrong S, DeVivo MJ. Effect of cranberry extract on bacteriuria and pyuria in persons with neurogenic bladder secondary to spinal cord injury. J Spinal Cord Med 2004;27(1):35-40.

[5] Pearman JW, Bailey M, Harper WE. Comparison of the efficacy of “Trisdine” and kanamycin-colistin bladder instillations in reducing bacteriuria during intermittent catheterisation of patients with acute spinal cord trauma. Br J Urol 1988;62(2):140-144.

[6] Waites KB, Canupp KC, Roper JF, Camp SM, Chen Y. Evaluation of 3 methods of bladder irrigation to treat bacteriuria in persons with neurogenic bladder. J Spinal Cord Med 2006;29(3):217-226.

[7] Castello T, Girona L, Gomez MR, Mena MA, Garcia L. The possible value of ascorbic acid as a prophylactic agent for urinary tract infection. Spinal Cord 1996;34(10):592-593.

[8] Schlager TA, Ashe K, Hendley JO. Effect of a phosphate supplement on urine pH in patients with neurogenic bladder receiving intermittent catheterization. Spinal Cord 2005;43(3):187-189.

Evidence for ‘Bacterial Interference’ is based on the following studies:

[1] Darouiche RO, Thornby JI, Cerra-Stewart C, Donovan WH, Hull RA. Bacterial interference for prevention of urinary tract infection: A prospective, randomized, placebo-controlled, double-blind pilot trial. Clin Infect Dis 2005;41(10):1531-1534.

[2] Darouiche RO, Green BG, Donovan WH, Chen D, Schwartz M, Merritt J, et al. Multiceter randomized controlled trial of bacterial interference for prevention of urinary tract infection in patients with neurogenic bladder. Urology 2011;78(2):341-346.

[3] Hull R, Rudy D, Donovan W, Svanborg C, Wieser I, Stewart C, Darouiche R. Urinary tract infection prophylaxis using Escherichia coli 83972 in spinal cord injured patients. J Urol 2000;163(3):872-877.

[4] Prasad A, Cevallos ME, Riosa S, Darouiche RO, Trautner BW. A bacterial interference strategy for prevention of UTI in persons practicing intermittent catheterization. Spinal Cord 2009, 47, 565-569.

[5] Trautner BW, Hull RA, Thornby JL, Darouiche RO. Coating urinary catheters with an avirulent strain of Escherichia coli as a means to establish asymptomatic colonization. Infect Control hosp Epidemiol 2007;28(1):92-94.

Evidence for ‘Botulinum Toxin Injections’ is based on the following studies:

[1] Jia C, Liao LM, Chen G, Sui Y. Detrusor botulinum toxin A injection significantly decreased urinary tract infection in patients with traumatic spinal cord injury. Spinal Cord. 2013 Jun;51(6):487-90.

Evidence for ‘Electrical Stimulation’ is based on the following studies:

[1] Van Kerrebroeck PE1, Koldewijn EL, Rosier PF, Wijkstra H, Debruyne FM. Results of the treatment of neurogenic bladder dysfunction in spinal cord injury by sacral posterior root rhizotomy and anterior sacral root stimulation. J Urol. 1996 Apr;155(4):1378-81.

[2] Vastenholt JM, Snoek GJ, Buschman HP, van der Aa HE, Alleman ER, Ijzerman MJ. A 7-year follow-up of sacral anterior root stimulation for bladder control in patients with a spinal cord injury: quality of life and users’ experiences. Spinal Cord. 2003 Jul;41(7):397-402.

[3] Creasey GH, Grill JH, Korsten M, U HS, Betz R, Anderson R, Walter J; Implanted Neuroprosthesis Research Group. An implantable neuroprosthesis for restoring bladder and bowel control to patients with spinal cord injuries: a multicenter trial. Arch Phys Med Rehabil. 2001 Nov;82(11):1512-9.

[4] Kutzenberger J. Surgical therapy of neurogenic detrusor overactivity (hyperreflexia) in paraplegic patients by sacral deafferentation and implant driven micturition by sacral anterior root stimulation: methods, indications, results, complications, and future prospects. Acta Neurochir Suppl. 2007;97(Pt 1):333-9.

[5] Martens FM, den Hollander PP, Snoek GJ, Koldewijn EL, van Kerrebroeck PE, Heesakkers JP. Quality of life in complete spinal cord injury patients with a Brindley bladder stimulator compared to a matched control group. Neurourol Urodyn. 2011 Apr;30(4):551-5.

[6] Sievert KD, Amend B, Gakis G, Toomey P, Badke A, Kaps HP, Stenzl A. Early sacral neuromodulation prevents urinary incontinence after complete spinal cord injury. Ann Neurol. 2010 Jan;67(1):74-84.

Other references:

Biering-Sorensen F. Urinary tract infection in individuals with spinal cord lesion. Curr Opin Urol 2002;12(1):45-49.

Foxman B. Epidemiology of urinary tract infections: Incidence, morbidity, and economic costs. Dis Mon 2003; 49(2):53-70.

National Institute on Disability and Rehabilitation. The prevention and management of urinary tract infections among people with spinal cord injuries. National Institute on Disability and Rehabilitation Research Consensus Statement. January 27-29, 1992. J Am Paraplegia Soc 1992; 15(3): 194-204.

Harrington RD, Hooton TM. Urinary tract infection risk factors and gender. J Gend Specif Med 2000;3(8):27-34.

Garcia-Arguello LY, O’Horo JC, Farrell A, Blakney R, Sohail MR, Evans CT, Safdar N. Infections in the spinal cord-injured population: a systematic review. Spinal Cord. 2017 Jun;55(6):526-534.

Image credits:

  1. Bladder: Adapted from BruceBlaus (Own work) [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons
  2. E. Coli: Photo by Eric Erbe, digital colorization by Christopher Pooley, both of USDA, ARS, EMU. – This image was released by the Agricultural Research Service, the research agency of the United States Department of Agriculture, with the ID K11077-1
  3. Dip stick: Photo by SCIRE Community
  4. Leg bag: Photo by SCIRE Community
  5. Water: Image from Pixabay released under Creative Commons CC0
  6. Drinks: Photo by SCIRE Community
  7. Green tea: Creative Commons CC0
  8. Cranberry: Image from Pixabay released under Creative Commons CC0
  9. Pills: Image from Pixabay released under CC0 Creative Commons

 

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