Infection hazards in patients with neuropathic bladder dysfunction

Abstract

Patients with neuropathic bladder dysfunction are prone to develop repeated bladder infections. In the past, ascending infection resulting in chronic pyelonephritis has frequently been the cause of chronic ill health leading to untimely death (Tribe and Silver, 1969). Fortunately, during the last 20 years much has been learnt about the management of this condition and now it is usually possible to prevent the cascade of pathological events, provided correct management is started early and maintained by regular follow-up in a urological clinic specializing in the care of such patients. Patients with acute spinal cord trauma need immediate transfer to a spinal injuries unit where a trained team will provide the specialized initial bladder management needed to prevent the rapid onset of urinary infection and other urological complications such as calculi. The avoidance of insertion of foreign material into any organ or tissue where infection is likely to occur is a fundamental biological principle because it is almost impossible to eradicate infection associated with a foreign body. It follows that the most important factor in preventing infective complications in the urinary tract following spinal cord injury is avoidance of an indwelling catheter in both acute and long-term management. An exception to this general principle appears to be the use of a finebore percutaneous suprapubic catheter in the acute stage, and good results have been reported from several centres (Cook and Smith, 1976; Grundy et al., 1983). However, when a percutaneous catheter becomes infected it will perpetuate infection until it is removed. The problems caused by an indwelling urethral catheter are not reduced by resiting it, i.e. the creation of a permanent suprapubic cystostomy for the catheter. This method of bladder drainage generally results in a more rapid deterioration of renal function than when an urethral catheter is used-a lesson which was learned in the First World War, relearned in the Second World War, and is now being relearned by a third generation of doctors in the 1980s (Hackler, 1982). Patients with neuropathic bladder dysfunction need more care than regular urine cultures and the treatment of urinary infections when they occur with appropriate antibiotics. The incidence of urinary tract infection in patients with neuropathic bladder dysfunction is reduced by meeting four requirements: