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Bladder Management

Intermittent Catheterization and Prevention of UTIs

Most SCI-related, UTI prevention research has focused on various techniques for intermittent catheterization and these types of studies are summarized in Table 23.

Author Year; Country
Score
Research Design
Total Sample Size
Methods Outcome

Li et al. 2013; China
Review of published articles between 1991-Aug 2011
N=5

Method: Comprehensive literature search of English and Chinese RCT, quasi-RCT (parallel-control, crossover-control, prospective cohort studies) of SCI individuals with bladder dysfunction and using hydrophilic and nonhydrophilic (standard) catheters.
Databases: PubMed, EMBASE, CNKI (China National Knowledge Infrastructure), Chinese Biomedical Literature Database, Cochrane Library
Level of evidence: 2 – RCT (Note: Research Design/ Description of the 5 included studies not fully defined)
Questions/measures/hypothesis: Compare the impact of hydrophilic and nonhydrophilic catheters on the occurrence/incidence of UTIs and hematuria.
  1. The use of hydrophilic catheters versus standard catheters reduced the odds of UTI by about 64% (OR=.36, CI=95% (24-54%), p<.00001; i.e., there was a significantly lower incidence of reported UTIs in those using hydrophilic catheters than in those using standard catheters).
  2. The more individuals that used hydrophilic catheters, the more significant the results.
  3. The use of hydrophilic catheters versus standard catheters reduced the odds of hematuria by about 43% (OR=.57, CI=95% (35-92%), p=.001). (i.e. there was a significantly lower incidence of reported hematuria in those using hydrophilic catheters than in those using standard catheters).
  4. The incidence of hematuria was 45.7% (95/208) in individuals using hydrophilic catheters versus 55% (115/209) in individuals using standard catheters.

Bonfill et al. 2017; Spain
RCT
PEDro=7
NInitial=489
NFinal=440

Population: Silver alloy coating catheter (SAC): Mean age=55.30yr; Gender: males=174, females=69; Etiology: Traumatic SCI=177; Medical SCI=61.Standard catheter (STC): Mean age=57.25yr; Gender: males=179, females=67; Etiology: Traumatic SCI=177; Medical SCI=65.
Intervention: Individuals were randomly assigned to either silver alloy coating catheter (experimental group) or standard catheter (control group) for at least 7 days. Outcome measures assessed before and after gentamicin instillations.
Outcome Measures: Occurrence of catheter-associated symptomatic UTI; symptomatic bacteraemia; adverse events related to catheterization procedure.
  1. There was no significant difference in the occurrence of catheter-associated UTI.
  2. Sixteen individuals had adverse events potentially related to catheterization: SAC=12 (4.9%), STC=4 (1.6%) (OR 0.03 [0.00-0.006]).
  3. Bacteremia confirmed in three individuals: SAC=1, STC=2.

Lavado et al. 2013; Brazil
RCT
PEDro=9
N=42

Population: Mean age: Control (C)=38.5±10.6 yr, Intervention (I)=34.1±11.1 yr. Gender: (C)=17 male, 4 female, (Int)=males=18, females=3; Level of injury: C5-L2; Motor level: C8-T12; Neurological level: ASIA A, B and C; Time since injury: (C)=4.05±1.6 yr, (|)=4.8±2.2 yr.
Intervention: Individuals were randomized into Control (C) or Intervention (I) groups All individuals performed a stress test and had a urine analysis and urine culture completed prior to exercise (i.e. pre-training) and at 16 weeks post-training. Physiotherapy sessions consisted of passive mobilizations, stretching and functional activity training. Control group instructed to maintain their current activities of daily life
Intervention training group (Int) had additional physiotherapy sessions consisting of a 16-week programme of aerobic physical training (i.e. cycloergometer of upper limbs, distance with a wheelchair, and general muscle exercise (progressive loading of residual muscle and muscle stretching))
Training activity=1 hour, 2 or 3x/week
Intensity determined by maximum heart rate (goal of 70-80%), or peak oxygen consumption. Stress tests were completed to verify a significant increase of oxygen consumption in order to demonstrate the effectiveness of a physical training programme
Outcome Measures: Estimated peak oxygen consumption (VO2peake), Chronic asymptomatic bacteriuria (CAB)
  1. The mean length of study participation was 17.9 ± 1.8 weeks.
  2. The rate of adherence to the exercise programme was 94.6%.
  3. Treatment with antibiotics was required for 2 participants (1 from each group resp.). These 2 cases were considered a negative outcome.
  4. No adverse effects related to the physical activity were recorded during the training period.
  5. VO2peake before versus after training for the Cont group was 896mL min-1 (range 677-1158) versus 834mL min-1 (range 711-1005), which was not statistically significant. (p=0.906)
  6. VO2peake before versus after training for the Int group was 939mL min-1 (range 714-1215) versus 1154mL min-1 (range 1005-1351), which was statistically significant. (p=0.009)
  7. The difference in VO2peake between the 2 groups was not statistically significant prior to training (p=0.529), however it was statistically significant after training. (p<0.001)
  8. The number of individuals testing negative for CAB before training in the Cont versus Int groups was 8 (38.1%) versus 10 (47.6%) resp, which was not statistically significant. (p=0.755).
  9. The number of individuals testing positive for CAB after training in the Cont versus Int groups was 15 (71.4%) versus 3 (14.2%) resp, which was statistically significant. (p<0.001).

Moore et al. 2006; CanadaRCT
PEDro=4
N=36

Population: SCI inindividuals undergoing rehabilitation and requiring intermittent catheterization due to neurogenic bladder; Mean age: 40 yr; Gender: males=28, females=8; Level of injury: cervical.
Intervention: Comparison of clean versus sterile intermittent catheterization (IC). Laboratory personnel were blinded to subject allocation.
Outcome Measures: Prevalence of urinary tract infection (UTI), time to onset of UTI, costs of intermittent catheterization, types of bacteria, adverse effects. Urine analysis was conducted weekly.
  1. No significant difference (p>0.05) between the groups was seen in:
    1. Prevalence of UTI.
    2. Time to onset of UTI.
    3. Cost for clean intermittent catheterization/d was half that of sterile ($7.56 CDN versus $16.62 CDN).
    4. The most common type of bacteria included Enterococcus and Klebsiella.
  2. No adverse effects were reported.

Prieto-Fingerhut et al. 1997; USA
RCT
PEDro=2
N=29

Population: SCI during inindividual rehabilitation: Gender: males=16, females=13; Severity of injury: AIS: A-D.
Intervention: Comparison of sterile versus non-sterile (clean) intermittent catheterization technique every 4 to 6 hr.
Outcome Measures: Number of urinary tract infections (UTIs) over a 3 mo period, cost analysis.
  1. There were less UTIs with the sterile versus the non-sterile cathetirization program (28.6% versus 42.4%) but this difference was not significant.
  2. Sterile catheterization program was 277% more costly.

Pearman et al. 1991; Australia
RCT
PEDro=5
N=43

Population: SCI individuals: Group A (n=20, males=19, female=1); Group B (n=23, males=17, females=6).
Intervention: Individuals were randomized to either Group A or Group B.
Group A: Individuals underwent intermittent catheterization by Nelaton catheter with the instillation of Trisdine into the bladder at the end of each catheterisation.
Group B: Individuals performed intermittent catheterization with the O’Neil catheter.
Outcome Measures: Incidence of significant bacteriuria, which was classified as a catheter specimen of>1000 colony forming units (cfu)/ml. 
  1. In group A, the mean incidence of significant bacteriuria in males and females was 0.58 and 0.48% per catheterization; while in group B the mean incidence of significant bacteriuria in males and females was 1.16 and 2.93% per catheterization.
  2. The instillation of Trisdine in group A resulted in a significantly lower incidence of bacteriuria compared to group B (p<0.001).

Bennett et al. 1997; USA
Prospective Controlled Trial
N=27

Population: Mean age: 26±7.5 yr (range 17-38); Level of injury: tetraplegic (n=11), paraplegic (n=16).
Intervention: Group 1: Individuals performd intermittent catheterization (IC) with an introducer tip catheter (no spontaneous void or external urinary catheter). Group 2: Same as group 1 except IC with nonintroducer tip catheter.  Group 3: Individuals performing IC with introducer tip catheter (voiding by reflex and wearing an external urinary catheter). Group 4: Same as group 3 except IC with nonintroducer tip catheter.
Outcome Measures: Urodynamic parameters.
  1. A significant difference was between individuals using an introducer tip catheter and those who were not, regardless if an external urinary catheter was worn in measured urodynamic parameters (p=0.0121).
  2. Furthermore, a significant difference was found between individuals using and not using the introducer tip catheter in the intermittent catheterization only group (p=0.0093).

Yadav et al. 1993; India
Prospective Controlled Trial
N=48

Population: Group A (n=27): Gender: males=26, females=1; Time post-injury=12-96 hr; Group B: Level of injury: paraplegia=19, tetraplegia=2; Chronicity=chronic. Group B (n=21).
Intervention: Group A (short-term clean intermittent catheterization (IC) starting on day 1 of hospitalization). Group B (long term clean IC; 1-12 yr).
Outcome Measures: Number of UTIs collected over 10 d to 3 mo (A) or over 6 mo (B).
  1. Both short-term and long-term groups had relatively low rates of UTI.
  2. Group A: 5 subjects had symptomatic UTI between 10 d and 3 mo.
  3. Group B: 0.07 episodes per individual per mo symptomatic UTI (33%).

Wyndaele & De Taeye 1990; USA
Prospective Controlled Trial
N=73

Population: SCI Inindividuals (n=25); Age range 6-59 yr; Gender: males=22, females=3; Level of injury: paraplegia, tetraplegia. Non-SCI (n=48).
Intervention: Comparison of individual self-catheterization versus in-hospital catheter team for intermittent catheterization (IC).
Outcome Measures: Success in balancing bladder, urinary tract infection (UTI) rate, and urethral trauma collected over inindividual stay.
  1. No difference in UTI between groups.
  2. No difference in achieving a state of balanced bladder between groups (i.e., able to empty bladder by tapping or straining after a mean of 5 weeks.)
  3. No difference in urethral trauma between groups.

Charbonneau-Smith 1993; Canada
Cohort
N=110

Population: Traumatic SCI on inindividual rehabilitation; 2 groups were similar with respect to median age (30.5 yr versus 30 yr), gender, paraplegics versus tetraplegics, level of lesion and extent of lesion; length of stay (LOS): 4.8 wk versus 11 wk.
Intervention: Assessment of no-touch versus traditional straight intermittent catheterization (IC) method.
Outcome Measures: Urinary tract infections (UTIs), infection free days, duration of infection, cost of antibiotics, nurse satisfaction with method collected during rehabilitation hospital stay.
  1. “No-touch” experimental group had fewer UTIs (p=0.0001), and reduced duration of infections (p=0.0004).
  2. No difference on total cost (including antibiotics) and number of infection-free days (trends were in favour of “No-touch”, p=0.072, p=0.125).
  3. Similar number of catheters used despite>2x longer length of stay (LOS) for traditional method.
  4. Majority of nurses reported they preferred “No touch” catheter.

Jensen et al. 1995; Norway
Pre-Post
N=12

Population: SCI rehabilitation inindividuals: Age range 17-72 yr; Gender: males=11, females=1; Time post-injury=3-7 mo.
Intervention: Effect of residual urine volume following intermittent catheterization (IC) on urinary track infections (UTIs).
Outcome Measures: Residual urine volume as measured by utrasonography and occurrence of UTIs collected during hospital stay.
  1. Residual urine volumes were not associated with UTIs – Mean & Max residual volumes/UTI correlations: r=0.19 & 0.16 (p=0.52 & 0.63) respectively.
  2. Trend for greater maximal residual urine in hyperactive versus hypoactive bladder following IC (p=0.06).
  3. No differences in hyperactive versus hypoactive bladder for mean residual volumes (p=0.21) or UTIs (p=0.49).

Krebs et al. 2016; Switzerland
Case Series
N=1104

Population: NLTUD; Mean age; 48 yr; Gender: males=821, females=283; Level of injury: C1-C4=73, C5-C8=249, T1-S5=622, AIS D=87, not determinable=73; Mean duration of NLTUD: 20.3 yr.
Intervention: Individuals had previously undergone prophylactic treatment for urological procedures and/or onabotulinumtoxin injections for NDO.
Outcome Measures: Assessment of both risk factors (catheterization, type of catheterization) for UTIs as well as prophylactic antibiotic treatment to prevent UTIs.
  1. Bladder evacuation method, botulinum toxin injections into the detrusor and prophylactic treatment to prevent UTIs significantly predicted the contraction of symptomatic UTIs and recurrent UTIs (p=0.049).
  2. Probability of experiencing a UTI was 10x higher for individuals voiding via a transurethral indwelling catheter compared to those voiding spontaneously.
  3. Bladder voiding by TUC increased the probability 5x of recurrent symptomatic UTIs.
  4. OnabotulinumtoxinA injections only increased the odds of symptomatic UTIs by 1.7x.

Mukai et al. 2016; Japan
Case Series
N=259

Population: Neurogenic bladder; Median age: 47 yr; Gender: males=220, females=39; Level of injury: cervical=86, thoracic=138, lumbar=34, sacral=1; Injury etiology: traumatic=207, non-traumatic=52; ASIA classification: A=166, B=32, C=30, D=26, E=5.
Intervention: Individuals who required clean intermittent catherization (CIC) for neurogenic bladder were reviewed determine potential risk factors for febrile urinary tract infections (UTI).
Outcome Measures: Gender, ASIA classification, pyuria, bacteriuria, number of CIC performance per day, anticholinergic use, β-3 agonist use.
  1. A total of 67 participants had febrile UTI during the follow-up period.
  2. There were no significant associations for pyuria or bacteriuria with febrile UTI.
  3. Anticholinergic use, β-3 agonist use, number of CIC per day were not significantly associated with febrile UTI occurrence.
  4. In the multivariable analysis, gender being males (p=0.0431) and ASIA classification being C or more severe (p=0.0266) were significantly associated with an increased risk for febrile UTI occurrence.

Summarized Level 5 Evidence Studies

Krassioukov et al (2015) reported a direct link between significantly increased UTI frequency and catheter reuse (p<0.001). Although UTIs have many associated negative consequences to all people with SCI, the impact of UTIs emerging at critical times may have much more devastating consequences for subgroups (e.g. during competition for elite athletes) which may warrant consideration for sterile techniques. Addressing lack of health education and available resources would be strategies to undertake to shift routines in favour of sterile catheter use. However, even if CIC is the method of choice, males (p=0.431) and those more severely injured (AIS C, B, A, p=0.0266) experience significantly higher rates of febrile UTI. Martins et al. (2013) reported 71% of individuals used clean intermittent catheterization, 18.4% (n=7) used condom catheters, 7.8% (n=3) used suprapubic drainage, and 2.6% (n=1) used tapping. 65.7%of individuals tested positive for asymptomatic bacteriuria where E.coli was the most prevalent (60%). Antibiotic resistance rates from bacteria were 73.3% to Ampicilin, 60% to Sulfamethoxazole-Trimethoprim, and 33.3% to Norfloxacin. The high prevelance of prophylactic and emergent antibiotic treatment of bladder management related infections has increased catheter-associated urinary tract infections (CAUTI) in spinal cord injury individuals (Dedeic-Ljubovic et al. 2009). Regular rectal swab surveillence, disposable aprons and glove use, and strictly monitored cleaning procedures (materials, instruments, infected individuals and environmental) are among the necessary activities to prevent multi-drug resistant P. aeruginosa (MDRP).

Discussion

During inindividual rehabilitation, IC is generally the preferred method of bladder management and several prospective studies have compared sterile techniques with traditional or clean techniques of IC (Charbonneau-Smith 1993; Prieto- Fingerhut et al.1997; Moore et al. 2006). Notably, Moore et al. (2006) and Prieto- Fingerhut et al. (1997) employed RCT designs and showed no statistically significant differences in the number of UTIs occurring in individuals using the sterile technique versus the clean technique. Conversely, Charbonneau-Smith (1993) conducted a prospective trial and did find significantly reduced UTI rates for a sterile “no-touch” technique as compared to historical controls undergoing a traditional sterile method. Given the nature of the historical comparison confounding variables may affect this result. Both authors noted the greater expense associated with the sterile approach, making it a less attractive option in the absence of evidence for improved positive outcomes. On the other hand, Krebs et al. (2016) found that the use of transurethral indwelling catheters (TIC) increased the odds of symptomatic UTIs and recurrent UTIs by more than 10- and 4-fold, respectively. As such, the authors recommended that TIC “should be avoided whenever possible”. Also significantly increased are UTIs resulting from IC use (p ≤0.014) and botulinum toxin injections into the detrusor (p=0.03).

Another strategy for decreasing the incidence of UTI is through the use of antiseptic- coated indwelling catheters. Bonfill et al (2017) conducted an RCT comparing catheters coated with silver alloy to standard catheters supplied by the trial site. No significant difference was found between incidence of symptomatic UTIs between the experimental and control groups (7.41% vs 7.72%, respectively). The generally low overall incidence of UTIs in the study was attributed to the pragmatic design whereby cultures were only performed in participants with a clinical suspicion of UTI.

A meta-analysis of five RCTs comparing the impact of hydrophilic catheters on UTIs in people with SCI found a reduction in the number of UTIs (reduced by 64%) when the hydrophilic catheters were used (compared to non-coated catheters: Li et al. 2013). The coating on the hydrophlic catheters also reduced urethral trauma (reduced odds of hematuria by ~43%). Despite the general positive effect of hydrophilic catheters versus uncoated catheters, no significant difference was found in single studies for episodes of bacteriuria (Sutherland et al. 1996), number of UTIs (Vapneck et al. 2003) and frequency of symptomatic UTIs (Cardenas & Hoffman 2009). However, the reduced number of UTIs requiring antibiotics, significantly reduced UTI frequency and episodes of hematuria across multiple studies would generally advocate for the use of hydrophilic catheters.

An interesting RCT finding reported by Lavado et al. (2013) found a significant reduction of positive urinary cultures in individuals randomized to 16 weeks of moderate aerobic physical conditioning compared to controls who were asked to maintain their daily life activities (Lavado et al. 2013). Increased peak oxygen consumption in participants of the intervention group suggested a correlation with an increased immune response, a known beneficial effect of regular physical exercise.

As with all aspects of rehabilitation, a primary goal of bladder training while an inindividual is maximal individual independence and self-care. Wyndaele and De Taeye (1990) conducted a prospective control trial (n=73) in which the incidence of UTIs was examined following introduction of an initiative to promote self- catheterization among those with paraplegia on an SCI unit. Prior to this, catheterization was conducted by a specialized catheter health care team using a non-touch technique. Neither UTI rates nor the proportion of people achieving a state of bladder balance or those encountering complications of urethral trauma were significantly different between these two approaches. Interestingly, the introduction of individual self-catheterization also seemed to be a factor in the individuals being ready for home visits much sooner in their rehabilitation stay.

Less information exists on the continued use of IC for individuals as they move into the community and live with SCI for a prolonged period of time. A prospective controlled trial was conducted by Yadav et al. (1993) comparing UTI incidence rates between those using a clean IC technique during inindividual rehabilitation with another group of individuals continuing to use the same bladder management method and living in the community for 1-12 years. Similar rates of UTI (termed acceptably low by the authors) were found in both samples although there were differences in the types of bacteria causing UTIs between the individuals with SCI in the rehabilitation unit versus in the community.

Regardless of the approach to bladder management, and even if IC is used, the rate of UTI in the SCI population is still elevated relative to a population with neurologically normal functioning bladders. This is thought to be partly due to the residual volume of urine that may persist in the bladder following IC. Jensen et al. (1995) conducted a study in inindividual rehabilitation (n=12), correlating UTI incidence over the rehabilitation period with the average residual urine volume after IC. Correlations between UTIs and residual volumes were low and suggested little relationship or as the authors point out it may have been that residual volumes would have had to be reduced to negligible values to be responsible for a lower incidence of UTI compared to the mean values of 40±11 mL for hyperactive bladder or 19±7 mL for hypoactive bladder observed in this study.

Conclusion

There is level 1a evidence (from one meta-analysis of five RCTs: Li et al. 2013) that the use of hydrophilic catheters versus non-coated catheters is effective in reducing the incidence and occurrence of UTI and hematuria.

The RCT conducted by Bonfill et al (2017) provided level 1b evidence that indwelling silver alloy coated catheters did not reduce the incidence of UTI when compared to standard catheter use.

There is level 1b evidence (from one RCT: Lavado et al. 2013) that regular, moderate aerobic physical activity significantly increases peak oxygen consumption and also significantly reduces the number of individuals with positive urinary cultures.

There is level 2 evidence (from two RCTs: Moore et al. 2006; Peta-Fingerhut et al. 1997) that there is no difference frequency of UTI between sterile and clean approaches to intermittent catheterization during inindividual rehabilitation; however, using a sterile method is significantly more costly.

There is level 4 evidence (from one prospective controlled trial: Wyndaele & De Taeye 1990) that there is no difference in UTI rates between intermittent catheterization conducted by the individuals themselves or by a specialized team during inindividual rehabilitation.

There is level 4 evidence (from one prospective controlled trial: Yadav et al. 1993) that similar rates of UTI may be seen for those using clean intermittent catheterization during inindividual rehabilitation as compared to those using similar technique over a much longer time when living in the community.

There is level 4 evidence (from one pre-post study: Jensen et al. 1995) that differences in residual urine volume ranging from 0-153 ml were not associated with differences in UTI during inindividual rehabilitation.

There is level 4 evidence (from one retrospective case series: Mukai et al. 2016) that reports significantly higher rates of febrile UTIs in more severely injured males that use CIC.

Level 4 evidence (from one case series study: Krebs et al. 2016) suggests that transurethral indwelling cather use results in the highest rate of symptomatic UTIs compared to lower rates from using intermittent catheters and receiving botulinmum toxin injections into the detrusor.

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