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Educational Interventions for Maintaining a Healthy Bladder and Preventing UTIs

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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.

Table 31 Individual Studies of Educational Interventions

Author Year

Country
Research Design
Score
Total Sample Size

MethodsOutcome
Cardenas et al. 2004 USA

RCT

PEDro=5

Ninitial=68; Nfinal=56

Population: Age range 20-77 yr; Gender: males=42, females=14; Level of injury: C1-S4/5; Severity of injury: AIS A-D; Bladder Management: IC=33, Condom catheter=11, Indwelling catheter=11, Spontaneous management=1; Time post-injury=5-48 yr.

Intervention: Specialized educational program for the prevention of urinary tract infections (UTIs) versus no program.

Outcome Measures: Episodes of symptomatic UTI, bacterial colony counts, number of antibiotic treatments for UTI, UTI related symptoms, health belief questionnaire, multidimensional health locus of control, self-efficacy.

1.   No significant difference between the groups for National Institute on Disability Rehabilitation Research (NIDRR) defined UTI.

2.     Significant changes in favour of treatment:

a.    Fewer Urinary Colony Counts (p=0.009).

b.    Fewer symptom reports (p=0.097).

c.    Fewer episodes treated with antibiotics (p=0.232).

3.   Increase in the perception of the severity of the UTI (p=0.042).

4.   Higher locus of control (p=0.066).

5.   Lower self-efficacy (p=0.033).

Hagglund et al. 2005

USA

Prospective Controlled

Trial

N=60

Population: Mean age: 39 yr; Gender: males=44, females=16; Receiving personal assistance=8 yr.

Intervention: Based on geographic residence subjects were assigned to either i) treatment group: 6hr training group workshop delivered by a SCI specialist physician addressing commonly occurring secondary conditions, prevention and treatment including an 8 min video specific to urinary tract infections (UTIs) followed by discussion or ii) control group with no education session.

Outcome Measures: Number of d/visits to hospital/ER and presence of UTIs via interview at baseline and 6 mo later.

1.   Within treatment group significant reduction in UTI (p≤0.03) between baseline and 6 mo.

2.   Significantly fewer UTIs at 6 mo (p≤0.02) in the treatment versus control group for both those reporting and not reporting a UTI at baseline.

3.   Those reporting a UTI at baseline were significantly more likely to report one at 6 mo (p=0.04).

Anderson et al. 1983 USA

Case Control

N=75

Population: SCI inindividuals.

Intervention: Urinary tract care education program (individual and staff training), 5 classes and one manual.

Outcome Measures: Functional Impairment Scale for Bacteriuria, urinary tract infections (UTIs), UTI symptoms, time lost due to UTI assessed 6 mo after discharge.

1.   Treatment versus Control following education:

·       No impairment: 71 versus 32%.

·       Symptomatic: 24 versus 57%

·       No time lost: 71 versus 50%

·       Time lost: 5 versus 23%

2.    Recognition of symptoms: no difference

Barber et al. 1999

USA

Pre-Post

N=17

Population: SCI outindividuals.

Intervention: Intensive counselling by clinic nurse with respect to proper clean intermittent catheterization (IC) technique, daily external catheter application and care, appropriate hygiene. If subjects continued to exceed 2 or more urinary tract infections (UTIs) in the following 6 mo they were started on either nitrofurantoin or methenamine mandelate with ascorbic acid or given more instruction on proper techniques.

Outcome Measures: Compliance with regime, number of UTIs collected over 1000 d prospectively.

1.   Compliance found to be a problem in individuals in both medication regimes after 1 yr of treatment.

2.   11/17 responders although 8 of these required multiple counselling sessions.

3.   4/17 were placed on prophylactic methenamine mandelate and ascorbic acid with various treatment periods; 2/4 developed 1 UTI

4.   3/17 were placed on prophylactic nitrofurantion for 1 to 2 3/4 yr; none developed UTIs

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 study; 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.

A variety of bladder management education programs are effective in reducing UTI risk in community-dwelling persons with SCI, although limited information exists as to which is the most effective approach.