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Clinical Consultation: How Do We Prevent UTI in People Who Perform Intermittent Catheterization?
Situation: An elderly male patient of ours has had T3 ASIA D paraplegia of 25 years’ duration. At his insistence, his bladder has been managed by spontaneous voiding alone, with overflow and urge incontinence. Postvoid residuals average 250cc–300cc. Recently, he had eight clinically significant UTIs for which antibiotics were prescribed. Our clinical team has researched intermittent catheterization as a possible solution, but we are unsure whether this technique is appropriate and whether it will really solve his UTI problem. What do you suggest?
Consultation: Laura Heard, MS RN CRRN-A, clinical nurse specialist, spinal cord injury, and Richard Buhrer, MN ARNP CRRN-A, nursing practitioner, spinal cord injury, both of the Seattle VA Puget Sound Health Care System in Seattle, WA, reply:
The technique/approach to intermittent catheterization has been debated in the literature for years. Of particular concern has been whether sterile or clean technique makes a substantial difference in clinical infection rates.
It is important to begin with definitions of terms. In the able-bodied, normally voiding population, urinary tract infection (UTI) is defined by the presence of bacteria in the urine in significant concentration—usually more than 100,000 colony-forming units (cfu) per ml of urine of a single organism. When bacteria reach this level, there is usually significant dysuria, and people present for treatment because of that symptom. Virtually all people with neurogenic bladder, on the other hand, will demonstrate measurable levels of bacteria in their urine, often of sufficient quantity to meet the standard for “infection.” Furthermore, these people rarely sense dysuria because of their neurological impairment. Consequently, the criterion used for diagnosing UTI in people with neurogenic bladder needs to be different than that used to diagnose it in able-bodied people.
Clinically, we make a distinction between colonization and infection. In colonization, there may be large quantities of bacteria in the bladder and possibly a significant number of white blood cells, but the bacteria have not invaded the bladder wall and triggered the immune system of the person. When this invasion does occur, systemic symptoms are evident. These symptoms may include fever, nausea, vomiting, malaise, increased spasticity, and increased neuropathic pain. Patients often become anxious and seek treatment when the odor or turbidity of their urine changes. Usually, it is better to defer antibiotic treatment until symptoms are present. In summary, colonization is the presence of bacteria in the urine. Infection is the presence of bacteria in the urine along with systemic symptoms associated with an immune response.
Clean intermittent self-catheterization
The bladder wall is constructed to allow capillaries to pierce the bladder between the smooth muscle fibers and at right angles to them. When the bladder becomes stretched, the capillaries become occluded, preventing the delivery of metabolic and immune substrates to the bladder wall. Consequently, the mucous secretion on the inner surface of the bladder wall is interrupted, and the bladder wall is exposed to the bladder contents without buffering.
In 1972, Lapides proposed that bladder distention was the main contribution to clinically significant UTI. He postulated that pushing bacteria into the bladder had much less to do with clinical infection than overfilling; therefore, clean catheterization technique ought to be just as satisfactory an approach as sterile technique (Lapides, Diokno, Silber, & Lowe, 2002).
Clean intermittent catheterization now is practiced widely. In the National Institute on Disability and Rehabilitation Research Consensus Statement (1992), clean, intermittent catheterization was acknowledged as the most sensible, practical approach. The report suggested that clean technique was as good as sterile technique if performed by the patient (Cardenas & Mayo, 1987). Proper cleaning of reusable catheters was considered important. In 1996, the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) clinical practice guideline on management of urinary incontinence supported the use of clean technique. In 1998, the American Association of Spinal Cord Injury Nurses published a clinical practice guideline on neurogenic bladder management, calling for the use of clean technique when intermittent catheterization was needed (Hixon, 1998).
Though sterile technique is not considered necessary, proper cleaning of reusable catheters is recognized as an important step in the process of intermittent catheterization to prevent unnecessary introduction of bacteria into the bladder. Recommended cleaning methods have included soap-and-water washing, boiling, microwave sterilization, peroxide application, and betadine application. Douglas, Burke, Kessler, Cicmanec, and Bracken (1990) demonstrated the ability to achieve sterile catheters after 12 minutes of microwave processing. Kurtz, VanZandt, and Burns (1995) showed that peroxide, bleach solution, and betadine all cleared bacteria from contaminated catheters. Lavellee’s (1995) group studied the effect of cleaning catheters using either soap and water, peroxide, or vinegar and found that rinsing and drying the used catheters before any method of cleaning produced the greatest reduction in bacteria. We suggest the use of dishwashing soap and water, because the materials are readily available and simple to use.
A number of factors that contribute to clinically significant UTI in patients who practice intermittent catheterization can be reduced. To accomplish this aim, the nurse must conduct a careful assessment of the strategies the patient is using and coach and educate the patient about alternative approaches.
Infrequent emptying. Inadequate frequency of emptying leads to excessive bladder volumes, with long periods of urine stagnation. The combination of bacteriuria and “incubation” increases the risk of clinical infection. If, however, the urine is “turned over” regularly, bacteria are not exposed to the bladder long enough to produce infection. Anderson (1980) found that catheterizing 6 times/day was more healthful than catheterizing 3 times/day. It is recommended that total emptying be done at least 4 times/day. Even a modest improvement in emptying or reduction in chronic distention can produce dramatic improvement in infection rate.
Inadequate fluid intake. Inadequate intake is a companion problem to inadequate frequency of emptying. When low urine volumes are produced (less than 1,200 cc of urine per day), patients are less inclined to empty at desired intervals, producing stagnation and distention.
Excessive fluid intake. If the patient cannot or will not adjust fluid intake appropriately for the clean intermittent catheterization schedule, he or she risks periodic or regular overdistention, and possible overflow incontinence. Excessive intake would produce bladder volumes greater than 500 cc at one time and/or be evidenced by the need to catheterize more than 6 times a day. The patient should be encouraged to drink regularly—small volumes paced hourly between breakfast and the evening meal and reducing to sips thereafter. Large fluid intake in the evening should be discouraged so as to minimize excessive urine volumes produced during the hours of sleep.
Excessive nocturnal diuresis. Some patients—especially those with spinal cord injury and multiple sclerosis—may have nocturnal diuresis related to inadequate antidiuretic hormone elevation at night. Even when those patients avoid fluid intake in the evening, they still produce large volumes of urine during the night. For the person on intermittent catheterization, even waking several times during the night to catheterize may not be sufficient to maintain acceptable bladder volumes. A trial of nasal Desmopressin (an antidiuretic hormone analog) administration at bedtime may prevent the diuresis (Szollar, Dunn, Brandt, & Fincher, 1997).
Inadequate emptying at the time of catheterization. Residual volume can be left in the bladder after straight catheterization. The patient must ensure adequate emptying by employing Valsalva and gentle Crede at the conclusion of the catheterization, before the catheter is removed.
Traumatic catheterization. The patient should make every effort to insert gently a well-lubricated catheter. Bleeding and the development of strictures or false passages are associated with traumatic catheterization (Vapnek, Maynard, & Kim, 2003). Breaks in the urothelium increase the risk of infection. Difficulty passing the catheter may lead the patient to avoid performing catheterization. Direct observation to help correct faulty insertion technique may contribute to improved outcomes. An alternative catheter, such as a Coude tip, may ease passage. We recommend referral for urological evaluation in the event of persistent difficulty with catheter insertion.
High bladder pressures. People with neurogenic bladder can develop a problem called bladder-sphincter dyssynergia, in which the bladder and the external sphincter contract together. This action leads to very high pressures in the bladder, decreases the blood flow to the bladder wall, and increases the pressure in the upper tracts, damaging the kidney even in the absence of ureteral reflux. People with neurogenic bladder may need an anticholinergic medication, such as oxybutynin or tolterodine, to prevent dangerously high bladder pressures.
Although it should not be the only determinant of approach to intermittent catheterization, cost differences among treatment alternatives are significant. Even if one is convinced of the efficacy of single-use, sterile, catheter systems or single-use hydrophilic catheters, for example, total reliance on these tools is very expensive. According to one supplier, water soluble lubricant sells for $1.82 per tube; red rubber catheters cost $2.26 each; vinyl catheters cost $1.14 each; self-contained catheter kits cost $6.70; and single-use hydrophilic catheters cost $4.20 each.
Calculating the monthly costs for self-catheterization performed 6 times/day, reusing and cleaning red rubber or vinyl catheters and lubricant ranges from $8.66 to $17.38; using a new red rubber or vinyl catheter with each use costs $205.20 to $406.80 (not including the lubricant cost); and using self-contained kits costs $1,406. It may be that periodic use of more expensive catheter kits can be justified when convenience is of utmost importance (e.g. while traveling). Consideration might also be given to the use of hydrophilic catheters when difficult insertion, diverticula, and urethral irritation are issues. One would want to have tried all other available means to reduce the frequency of UTI in this population before resorting to such costly solutions.
Clean intermittent self-catheterization is the best technique available for the management of severe neurogenic bladder. Infections can be reduced through proper cleaning, fluid management, and catheterization technique. Costs probably should be considered in identifying products for use in this process.
Agency for Health Care Policy and Research. (1996). Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline 2. Washington, DC: Author.
Anderson, R.U. (1980). Prophylaxis of bacteriuria during intermittent catheterization of the acute neurogenic bladder. Journal of Urology, 123, 364–366
Cardenas, D., & Mayo, M. (1987). Bacteriuria with fever after spinal cord injury. Archives of Physical Medicine and Rehabilitation, 68, 291–293
Douglas, C., Burke, B., Kessler, D.L., Cicmanec, J.F., & Bracken, R.D. (1990). Microwave: Practical cost-effective method for sterilizing urinary catheters in the home. Urology, 35, 219–222
Hixon, A. K. (1998). Nursing clinical practice guideline: Eurogenic bladder management. SCI Nursing, 15(2), 21–56
Kurtz, M.J., VanZandt, K., & Burns, J.L. (1995). Comparison study of home catheter cleaning. Rehabilitation Nursing, 20, 212–214.
Lapides, J., Diokno, A.C., Silber, S.J., & Lowe, B.S. (2002, reprinted from 1972). Clean intermittent self-catheterization in the treatment of urinary tract disease. Journal of Urology, 167, 1584–1586
Lavellee, D.J., Lapierre, N.M., Henwood, P.K., Pivik, J.R., Best, M., Springthorpe, S.V., et al. (1995). Catheter cleaning for re-use in intermittent catheterization: New light on an old problem. SCI Nursing, 12, 10–12.
National Institute on Disability and Rehabilitation Research Consensus Statement. (1992). The prevention and management of urinary tract infections among people with spinal cord injuries. SCI Nursing, 10, 49–59.
Szollar, S.M., Dunn, K.L., Brandt, S., & Fincher J. (1997). Nocturnal polyuria and antidiuretic hormone levels in spinal cord injury. Archives of Physical Medicine and Rehabilitation, 78, 455–458.
Vapnek, J.M., Maynard, F.M., & Kim, J. (2003). A prospective randomized trial of the LoFric hydrophilic coated catheter versus conventional plastic catheter for clean intermittent catheterization. Journal of Urology, 169, 994–998.