Educational Interventions for Maintaining a Healthy Bladder and Preventing UTIs
SCI patients with neurogenic bladder typically receive education while in initial rehabilitation to assist with bladder management and maintain a healthy bladder. This may continue as their bladder function changes following rehabilitation discharge.
Discussion
Health care providers have an excellent opportunity to provide proper bladder management education during inpatient rehabilitation to significantly affect the quality of bladder management after discharge with the goal of assisting clients in maintaining a healthy bladder and preventing UTIs. Anderson et al. (1983) reported on a case-control study where patients completed a special urinary tract care education program consisting of classes, reading material, written examinations, and demonstration of acquired skills. With this approach 71% of patients were asymptomatic of UTI at 6 month follow-up. Only 32% of patients had no symptoms when a group of patients, tested 4 years earlier in 1975, did not undergo the education program. Furthermore, as a result of the education program only 5% of the educated group lost time from their usual daily activities compared to 23% of the non-educated group losing time. However, both groups registered the same incidence of confirmed or suspected UTI (62-63%). Therefore, the benefit translated into early detection and definitive action resulting in less impairment and less lost time due to the UTI. This study was assessed as comprising Level 4 evidence due to inadequate control of potential confounds between the education and non-education group, among other limitations.
Once discharged, some SCI patients experience unacceptable recurrence of UTIs. Cardenas et al. (2004) examined the effectiveness of an educational program in an RCT of 56 community-dwelling SCI patients with a self-reported history of UTIs. The educational intervention included written material, a self-administered test, a review by nurse and physician, and a follow-up telephone call. The control group did not receive the intervention and final interventional data was compared to an equivalent baseline period. A significant decrease in urine bacterial colony count (but not in UTI incidence) and increased Multidimensional Health Locus of Control scale score reflected the beneficial effects of UTI educational intervention in improving bladder health and the patient’s perception of control over their own health behaviour. These results were amplified by Hagglund et al. (2005) and Barber et al. (1999), who each examined participants with longstanding SCI and conducted their investigations in conjunction with outpatient rehabilitation follow-up services. Positive benefits of reduced UTI occurrences were seen following a 6 hour physician-mediated educational workshop conducted as part of a prospective controlled trial with 6 month follow-up periods (n=60) (Hagglund et al. 2005). Of note, Hagglund et al. (2005) directed their educational intervention at the consumer-personal assistant dyad.
Barber et al. (1999) identified 17 high risk patients (i.e. ≥ 2 UTI/6months) over 1000 consecutive outpatient SCI clinic days. These authors found that 11 (65%) of these patients were able to reduce their number of UTIs to be reclassified as not high-risk with intensive counseling on proper bladder management technique and hygiene, although 8 required multiple counseling sessions to realize an effective reduction of number of UTIs. The remaining patients in this series required pharmaceutical prophylaxis for UTI prevention although there were some issues with compliance when treatment was extended over 1 year. The authors suggested that education intervention by a clinic nurse is a simple, cost-effective means of decreasing the risk of UTIs in at-risk SCI individuals, although the sample size was small and the study was neither randomized nor controlled.
The four aforementioned articles were assessed collectively in a systematic review by Mays et al. (2014). While the authors reported that there is limited positive evidence for educational programs directed towards reducing UTIs, they also note that “As there is no downside to this simple, inexpensive intervention, the data are still supportive of nurses providing education on urinary care and management with their patients” (p. 9).
Conclusion
There is level 2 evidence (from one RCT: Cardenas et al. 2004) that a single educational session conducted by SCI specialist health professionals with accompanying written materials and a single follow-up telephone call can result in reduced urine bacterial colony counts in community-dwelling individuals with prior history of SCI.
There is level 2 evidence (from one RCT and two pre-post studies: Hagglund et al. 2005; Barber et al. 1999; Anderson et al. 1983) that there are beneficial effects of education mediated by SCI specialist health professionals on reducing UTI risk in community-dwelling individuals with SCI using various approaches (e.g. one-on-one or group workshops, demonstrations, practice of techniques and written materials).
There is no evidence assessing the relative effectiveness of different educational approaches for reducing UTI risk.
