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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.

Table 25 Other Issues Associated with Bladder Management and UTI Prevention

Author Year

Country
Score
Research Design
Total Sample Size

MethodsOutcome
Darouiche et al. 2006

USA

RCT

PEDro=4

Ninitial=127

Nfinal=118

Population: Hospital inindividuals with neurogenic bladders requiring an indwelling or suprapubic bladder; Experimental group: Mean age: 55 yr; Gender: males=53, females=7; Level of injury: cervical=29, thoracolumbar=24, mutiple sclerosis=7

Control group: Mean age: 56 yr; Gender: males=51, females=7; Level of injury: cervical=29, thoracolumbar=26, mutiple sclerosis=3

Intervention: Experimental group: indwelling bladder catheters secured by the Statlock device; Control group: catheter secured by tape, velcro strap, cath-secure, or nothing.

Outcome Measures: Rate of symptomatic urinary tract infections (UTIs), catheter dislodgement, urethral meatal erosion.

1.   Trend for lower UTI incidence in the Statlock group versus the control group (13.3% versus 24.1%, p=0.16).

2.   Trend for lower incidence of symptomatic UTI per 1000 device days in the Statlock group versus the control group (p=0.16).

3.   No significant difference in the rates of catheter dislodgement and urethral meatal erosion between the two methods of securing catheter.

Joshi & Daroucihe 1996 USA

Prospective Controlled Trial

Ninitial=41

Nfinal=29

Population: SCI inindividuals with UTI: Mean age: 45 yr; Gender: males=29, females=0; Severity of injury: AIS: A.

Intervention: Comparison of intermittent catheterization (IC)=10, Suprapubic catheter=10, Indwelling foley catheter =9 during a 7-d course of an appropriate antibiotic.

Outcome Measures: Pyuria (white blood cells x107/L) sampled at initial, mid and endpoint of 7 d antibiotic treatment.

1.   IC group had lowest residual pyuria at mid and endpoint (p<0.05) versus other 2 bladder management methods.

2.   Pyuria was significantly reduced with antibiotic for all management groups (p<0.005).

3.   Multiple organisms isolated in 62% of urine cultures.

Gilmore et al. 1992

USA

Prospective Controlled Trial

N=119

Population: SCI admitted for SCI inindividual rehabilitation: Mean age: 28 yr; Gender: males=119, females=0; Level of injury: paraplegia=49, tetraplegia=70.

Intervention: External urinary collection system (EUCS): Group 1-continuous EUCS, Group 2-EUCS during day only, Group 3-no EUCS.

Outcome Measures: Number of Pseudomonas and Klebsiella in swab cultures of urethra, perineum, rectum; significant bacteriuria (10,000 bacteria/ml urine). Each collected every 2 wk during inindividual stay.

1.   EUCS being on or off did not influence rate of bacteriuria.

2.   Reduced Pseudomonas and Klebsiella in urethra, perineum or rectum only if no EUCS (p<0.05).

3.   Removal of the EUCS at night reduced urethral colonization with Pseudomonas only (p=0.03).

Nwadiaro et al. 2007

Nigeria

Case Control

N=125

 

Population: Traumatic SCI; Mean age: 30 yr; Gender: males=117, females=8; Level of injury: cervico-thoracic=53, thoraco-lumbar=72; Severity of injury: complete=125, incomplete=0.

Intervention: Retrospective comparison of indwelling urethral catheterization (UC) versus suprapubic cystostomy (SPC).

Outcome Measures: Prevalence of urinary tract infection (UTI), individual satisfaction with management and complications collected from hospital admission to 1 yr post-admission.

1.     Prevalence of UTI was significantly less in the SPC group versus the UC group (p<0.05).

2.   Individual satisfaction was significantly higher in the SPC group rather than the UC group (p<0.05).

3.   SPC resulted in significantly less mortality at 1 yr post admission than UC (p<0.05).

 

 

Lloyd et al. 1986

USA

Case Control

N=204/203

Population: SCI admitted to acute SCI care: Mean age: 29 yr; Time post-injury= within 36 hr.

Intervention: Comparison of initial bladder management A) Intermittent catheterization (IC) at acute centre=21, B) suprapubic catheter followed by IC=21, C) indwelling catheter followed by IC at mean of 36 d=106, D) suspected long-term use of indwelling catheter=23, E) IC at community hospital=33.

Outcome Measures: Urinary tract infections (UTIs), episodes of chills and fevers, excretor urogram (IVP) graded by 2 MDs for pyelocaliectasis, renal plasma flow assessed at 1 yr follow-up.

1.   No statistically significant differences between groups at 1 yr post injury for any of:

·       rate of UTIs

·       number of chills and fevers

·       upper tract changes

·       genitourinary complications

·       frequency of urological procedures

Afsar et al. 2013

Turkey

Case Series

N=164

Population: Mean age: 40.7 yr (range 23-65 yr); Gender: males=102, females=62; Level of injury: Tetraplegia=43, Paraplegia=87, Conus-Cauda Equina Syndrome=34; Time post-injury: 51.5 d (range 5-292).

Intervention: Retrospective review of bladder management and emptying methods.

Outcome Measures: Prevalence of urinary tract infection (UTI).

1.     The number of UTIs was highest in individuals using indwelling catheters.
Sugimura et al. 2008

New Zealand

Case Series

N=149

Population: Gender: males=124, females=25; Level of injury: tetraplegia=96, paraplegia=68

Intervention: SCI individuals managed with SPC were retrospectively reviewed for complications.

Outcome Measures: Urinary tract infections (UTIs), complications, renal scarring, urethral incontinence.

1.     73 individuals experienced no complications

2.     43 experienced UTIs.

3.     The most common lower tract complication was bladder stones (22%).

4.     Renal complication was seen in 20 out of 149 individuals.

5.     Only 9 of individuals experienced renal scarring.

6.     11 individuals experienced urethral incontinence

Ku et al. 2005

Case Series

N=179

Population: Mean age: 25.2 yr; Gender: males=179, females=0; Severity of injury: complete=41, incomplete=138.

Intervention: Comparison of various bladder management methods including: urethral catheter, intermittent catheterization, suprapubic cystostomy, Crede menuever or reflex voiding, condom catheter.

Outcome Measures: Adverse events.

1.     No significant difference was found in incidence of pylonephritis or renal stones across bladder management methods.

2.     Overall, 61 individuals presented with pylonephritis, 44 had renal stones, upper tract deterioration was seen in 58.

3.     Risk of pylonephritis was 2.8 times higher in individuals with vesicouriteral reflux.

4.     Upper tract deterioration (abnormal kidney appearance or function) was more common in individuals using indwelling (urethral or suprapubic) catheters.

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.

Intermittent catheterization is associated with a lower rate of UTI as compared to use of indwelling or suprapubic catheter.

The Statlock device to secure indwelling and suprapubic catheters may lead to a lower rate of UTI.

Removal of external condom drainage collection systems at night or for 24 hours/day may reduce perineal, urethral or rectal bacterial levels but has no effect on bacteriuria.

The presence of vesicoureteral reflux likely has a greater impact on development of significant infections than the choice of bladder management.