Other Issues Associated With Bladder Management and UTI Prevention
Table 25 summarizes studies that compare IC to other bladder management methods or use aids to augment the use of a particular bladder management method with a goal of preventing UTIs.
Discussion
In addition to intermittent catheterization, the effects of other bladder management methods have been investigated with respect to their impact in preventing UTIs. In particular, intermittent catheterization has been compared to indwelling catheterization. Joshi and Darouiche (1996) report that the response to an antibiotic, as indicated by reduced pyuria, is improved and can be assessed earlier in patients who utilize intermittent catheterization over those whose bladder drainage is reliant on suprapubic or indwelling foley catheters. All patients (n=29) experienced relief from appropriate antibiotic therapy after 3-4 days, but the level of residual pyuria was lowest at mid-therapy and after therapy completion in those patients using intermittent catheterization.
In another comparison study, Nwadiaro et al. (2007) conducted a retrospective comparison of indwelling urethral catheterization and suprapubic cystostomy on UTI prevalence in a predominately illiterate and impoverished population where intermittent catheterization is a less preferred option. Prevalence of UTI was significantly less in the group having a suprapubic versus indwelling urethral catheter (p<0.05). In addition, there was significantly less mortality with the SPC (p<0.05) at 1 year post admission with UTI-related septicaemia the number one cause of death in these patients. Sugimura et al. (2008) also examined the incidence of complications in patients using SPC, and reported a 29% incidence of UTI’s, though there was no comparison group in this study. However, in Ku et al. (2005) no bladder management technique was found to be superior in protecting against pyelonephritis (simple UTI was not tracked as an outcome); instead, the presence of vesicoureteral reflux led to a 2.8 fold higher risk of pylonephritis than those without reflux. Reflux is most often associatiated with high pressure urine storage due to low compliance or high pressure voiding due to sphincter spasticity and obstruction. Thus actual bladder pathophysiology may have the largest affect on clinically significant infections with the caveat that in this study, the group with urethral catheterization did experience more total upper tract deterioration than other bladder management groups.
Lloyd et al. (1986) conducted a case control investigation reviewing a group of 204 SCI patients grouped according to urological management techniques as follows: A) intermittent catheterization within 36h of injury, B) suprapubic trocar drainage within 36 h of injury, C) urethral catheter drainage for>36h prior to intermittent catheterization, D) indwelling urethral catheter drainage throughout and after discharge from hospital and E) intermittent catheterization placed in community hospital. Overall, these authors found that the method of initial bladder management does not affect the incidence of UTI, genitourinary complications or frequency of urological procedures at 1 year after injury. The only exception was group D who had a greater rate of UTIs as a result of the prolonged placement of indwelling urethral catheter drainage throughout and after discharge from hospitalization. It should be noted that individual variations in bladder management methods following the initial method and up to the one year follow-up were not accounted for in this investigation representing a potential major confound. As noted in several of these comparative investigations, complications occur most frequently in those with urethral catheterization. Despite this, many patients resort to using urethral catheterization for convenience or necessity, if hand dexterity is insufficient, or care givers unaffordable. Some investigators have suggested an approach to minimizing UTI when urethral catheterization is determined to be the most viable management approach. Darouiche et al. (2006) conducted a multicentre RCT of hospital inpatients (n=118) in which the effect of securing indwelling catheters with a device called the Statlock as compared to traditional means of catheter securement (i.e., tape, velcro strap, cath-secure, or nothing) was assessed. In addition to SCI, 10 subjects had multiple sclerosis. In this trial, there was a statistically non-significant trend for a lower rate of symptomatic UTI (p=0.16) and also a lower incidence of symptomatic UTI per 1000 device days (p=0.16) for those using this Statlock device versus the control group.
Condom catheters also can be a source of bacterial colonization, especially of the perineum, which has been suggested by Sanderson and Weissler (1990a) to be significantly correlated with bacteriuria in SCI individuals. By discontinuing night time use of an external condom drainage system in a prospective controlled trial involving SCI rehabilitation inpatients (n=119), Pseudomonas colonization of the urethra was found to be significantly reduced where Klebsiella colonization was not significantly affected (p<0.05; Gilmore et al. 1992). Further, a third group of patients did not use a condom drainage system at any time and colonization rates for both Pseudomonas and Klebsiella were significantly lower in this group at all sites tested (urethra, perineum and rectum) as compared to those using the external drainage system (p<0.05). However, the prevalence of bacteriuria caused by either gram-negative bacilli, was not reduced with either night-time or continuous disuse of an external condom drainage system.
Conclusion
There is level 2 evidence (from one prospective controlled trial, one case control study, and one case series study: Joshi & Darouiche 1996; Nwadiaro et al. 2007; Afsar et al. 2013) that intermittent catheterization may lead to a lower rate of UTI as compared to other bladder management techniques such as use of indwelling or suprapubic catheter.
There is level 3 evidence (from one case control study: Nwadiaro et al. 2007) that bladder management with a suprapubic as opposed to indwelling catheter may lead to a lower rate of UTI and reduced mortality in a poor, illiterate population where intermittent catheterization may not be viable as an approach to bladder management.
There is level 2 evidence (from one RCT: Darouiche et al. 2006) that use of a Statlocak device to secure indwelling and suprapubic catheters may lead to a lower rate of UTI.g
There is level 2 evidence (from one prospective controlled trial: Gilmore et al. 1992) that removal of external condom drainage collection systems at night or for 24 hours/day might reduce perineal, urethral or rectal bacterial levels but have no effect on bacteriuria.
There is level 4 evidence (from one case series: Ku et al. 2005) that no bladder management method is advantageous in preventing pyelonephritis (though indwelling urethral catheterization does have the highest incidence of upper tract deterioration). However, the presence of reflux results in a 2.8 fold higher incidence of pyelonephritis.
