Bladder Management Strategies Research Articles

Urinary Tract Infections in Relation to Bladder Emptying in Patients with Spinal Cord Injury

Background/Objectives: Spinal cord injuries are debilitating conditions with significant impacts on physical function and patient quality of life. The high incidence of urinary tract infections in these patients can be attributed to neurogenic bladder—a major complication of spinal cord injuries. The aim of this study is to investigate the incidence of urinary tract infections in patients with spinal cord injuries and their relation to the method of bladder emptying. Methods: A retrospective analysis on 560 patients admitted for rehabilitation at the Clinic for Rehabilitation “Dr Miroslav Zotovic” from December 2009 to January 2023 was conducted. Patients over 18 years old who were inpatients for longer than 30 days without any symptoms of urinary tract infection on admission were included. Patient demographics, injury details, and bladder emptying methods were recorded. Results: In our study, 402 (71.8%) participants developed a urinary tract infection during their rehabilitation. Urinary tract infections were significantly more common in patients with traumatic spinal cord injuries, lower ASIA scores, and thoracic-level injuries. The highest incidence of urinary tract infections was observed in intermittent self-catheterization patients (62.7%), with Escherichia coli and Proteus mirabilis being the most frequently isolated pathogens. Conclusions: The method of bladder emptying significantly impacted the incidence of urinary tract infection in patients with spinal cord injuries. Despite guidelines favoring intermittent catheterization, this study found it to be associated with the highest infection rates. These findings suggest a need for personalized bladder management strategies to reduce the risk of urinary tract infections and improve outcomes for spinal cord injury patients.

Risk factors of video urodynamics and bladder management for long-term complications in patients with chronic spinal cord injury

This study explores 15-year urological complications in chronic spinal cord injury (SCI) patients and investigates the predictive factors from video-urodynamic study (VUDS) and bladder management. Analyzing 864 SCI patients with a mean 15.6-year follow-up, we assessed complications and utilized multivariate logistic regression for risk evaluation. VUDS factors such as autonomic dysreflexia, detrusor sphincter dyssynergia, vesicourethral reflux (VUR), contracted bladder, and high voiding detrusor pressure significantly increased the likelihood of recurrent urinary tract infections (rUTI). Low bladder compliance, VUR, and contracted bladder notably raised the risk of hydronephrosis, while contracted bladder and detrusor overactivity with detrusor underactivity heightened chronic kidney disease risk. Volitional voiding reduced rUTI and VUR risk, whereas Valsalva maneuver-assisted voiding increased hydronephrosis risk. In conclusion, a contracted bladder identified in VUDS is associated with long-term urological complications in SCI, we propose that patients already experiencing a contracted bladder should prioritize volitional voiding as their preferred bladder management strategy to minimize the risk of additional complications such as rUTI and VUR. These findings unveil previously unexplored aspects in research, emphasizing the need for proactive management strategies in this patient population.

Enhancing bladder management for intrapartum/postpartum women at a maternity hospital in Taiwan: a best practice implementation project.

Voiding dysfunction is a common perinatal condition. Appropriate bladder management and monitoring during labor and postpartum improves bladder function and reduces the incidence of infections and complications. This project aimed to promote evidence-based bladder-management strategies for perinatal women at a maternity hospital in Taiwan. The project was implemented using the JBI framework and the Practical Application of Clinical Evidence System. Implementation audits were conducted by examining nurses and intra- and postpartum women. Ten criteria were applied in the baseline audit, and two follow-up audits were conducted to assess actual compliance with best-practice recommendations. Through a Getting Research into Practice analysis, we identified three barriers to and facilitators of changing practice. A comparison of the audit outcomes revealed that all criteria had improved by the second follow-up audit cycle. Specifically, the compliance rate increased from 37% and 50% to 100% for criteria 1 and 2, respectively; from 0% to 100% for criteria 3, 5, and 10; and from 7%, 28%, 50%, and 17% to 100%, 100%, 97%, and 100% for criteria 4, 6, 8, and 9, respectively. Following implementation, the frequency of intrapartum intermittent catheterization (53.44-38.30%) and the postpartum incidence of urinary retention (9.09-8.51%) decreased. The time to first voiding after vaginal delivery and between the first and the second voiding decreased from 5.51 and 4.01 h to 2.32 and 2.29 h, respectively. This evidence-based implementation project achieved substantial improvements in bladder management. Relational leadership theory, which integrates empowerment, purposefulness, ethical behaviors, and process orientation, underpinned the project.

A cost-effectiveness analysis of bladder management strategies in neurogenic lower urinary tract dysfunction after spinal cord injury: A publicly funded health care perspective.

Economic evaluation study. To investigate the long-term cost-effectiveness of clean intermittent catheterization (CIC) compared with suprapubic catheters (SPC) and indwelling urethral catheters (UC) among individuals with neurogenic lower urinary tract dysfunction (NLUTD) related to spinal cord injury (SCI) from a public healthcare perspective. University affiliated hospital in Montreal, Canada. A Markov model with Monte Carlo simulation was developed with a cycle length of 1 year and lifetime horizon to estimate the incremental cost per quality-adjusted life years (QALYs). Participants were assigned to treatment with either CIC or SPC or UC. Transition probabilities, efficacy data, and utility values were derived from literature and expert opinion. Costs were obtained from provincial health system and hospital data in Canadian Dollars. The primary outcome was cost per QALY. Probabilistic and one-way deterministic sensitivity analyses were performed. CIC had a lifetime mean total cost of $ 29,161 for 20.91 QALYs. The model predicted that a 40-year-old person with SCI would gain an additional 1.77 QALYs and 1.72 discounted life-years gained if CIC were utilized instead of SPC at an incremental cost savings of $330. CIC confer 1.96 QALYs and 3 discounted life-years gained compared to UC with an incremental cost savings of $2496. A limitation of our analysis is the lack of direct long-term comparisons between different catheter modalities. CIC appears to be a dominant and more economically attractive bladder management strategy for NLUTD compared with SPC and/or UC from the public payer perspective over a lifetime horizon.

Bladder Management Strategies for Urological Complications in Patients with Chronic Spinal Cord Injury.

Neurogenic lower urinary tract dysfunction, common in patients with chronic spinal cord injury, inevitably results in urological complications. To address neurogenic lower urinary tract dysfunction after spinal cord injury, proper and adequate bladder management is important in spinal cord injury rehabilitation, with the goal and priorities of the protection of upper urinary tract function, maintaining continence, preserving lower urinary tract function, improvement of SCI patients' quality of life, achieving compatibility with patients' lifestyles, and decreasing urological complications. This concise review aims to help urologists address neurogenic lower urinary tract dysfunction by focusing on the risks of long-term urological complications and the effects of different bladder management strategies on these complications based on scientifically supported knowledge.

Satisfaction with Urinary Incontinence Treatments in Patients with Chronic Spinal Cord Injury.

Purpose: To investigate the long-term satisfaction and complications in chronic spinal cord injury (SCI) patients after various bladder management strategies and surgical procedures for the treatment of urinary incontinence. Methods: Patients at a single institution with chronic SCI who received bladder management treatment or surgical procedure to improve urinary continence were retrospectively assessed. Thorough urological examinations and videourodynamic studies were performed. Patients were treated either through conservative approaches including medical treatment, clean intermittent catheterization (CIC), cystostomy, and indwelling urethral catheter, or through surgical procedures including detrusor botulinum toxin (Botox) injections, augmentation, ileal conduit, Kock pouch diversion, continent cystostomy, suburethral sling, and artificial urethral sphincter (AUS) implantation. The patients’ satisfaction with urinary continence improvement, causes of dissatisfaction, long-term complications, and overall satisfaction with bladder and voiding condition were assessed. Results: A total of 700 consecutive patients were enrolled in this study. High satisfaction rates were noted after detrusor Botox injection (81.1%), augmentation enterocystoplasty (91.4%), autoaugmentation (80%), Kock pouch diversion, and continent cystostomy (all 100%). Fair satisfaction rates were noted after ileal conduit diversion (66.7%), suburethral sling (64.3%), and AUS implantation (66.7%). Patients who received conservative treatment with medicines, CIC, cystostomy, or an indwelling urethral catheter all had less-satisfactory outcomes (all < 40%). Conclusion: Overall satisfaction with surgical procedures aimed to improve urinary continence in chronic SCI patients was higher than with conservative bladder management (35.4%). Appropriate surgical procedures for chronic SCI patients with neurogenic lower urinary tract dysfunction (NLUTD) and urological complications yielded satisfaction with both urinary continence improvement and with overall bladder and voiding condition.

Association between age of starting clean intermittent catheterization and current urinary continence in individuals with myelomeningocele

Patients with myelomeningocele often use clean intermittent catheterization (CIC) for renal preservation and to promote urinary continence. While starting CIC at an early age is associated with better renal outcomes, the impact of age of CIC initiation on continence outcomes has not been examined. To examine whether earlier CIC initiation is associated with higher likelihood of current urinary continence for patients with myelomeningocele. Data of patients aged ≥5 years at last visit were obtained from 35 spina bifida clinics participating in the National Spina Bifida Patient Registry from 2013 to 2018. Sociodemographic characteristics, disease characteristics, and current bladder management strategies were collected. Via univariate and multiple logistic regression models, the latter conducted controlling for all variables associated with current continent status, associations between continence and sociodemographic factors, condition characteristics, and age CIC began (<3 years of age, 3-5 years, 6-11 years, ≥12 years) were analyzed. Data from 3510 individuals were included (mean age at last visit=17.0 years, range 5.0-88.7). The sample was evenly distributed by sex (52% female); most individuals were non-Hispanic White (62.6%). The majority of patients (55.2%) started CIC before age 3 years. Continence varied markedly across those who never started CIC (0.6% of patients were continent) and those who started at any age (range 35.3-38.5%). Among those who started CIC, the magnitude of the association was not proportional to age CIC was started. Compared with those who started CIC at age 12 or older, estimated adjusted odds ratio of being continent ranged from 1.04 (6-11 years, 95% CI, 0.72-1.52) to 1.25 (<3 years, 95% CI, 0.89-1.76). Although CIC may be positively associated with achieving urinary continence in individuals with myelomeningocele, we could not demonstrate that younger age at CIC initiation increased the likelihood of achieving this goal. Limitations include lack of data on reason for starting CIC, urodynamic data, and the observational nature of data collection. Further study is needed addressing limitations of the current investigation to determine if urinary continence outcomes are influenced by the age of starting CIC among patients with myelomeningocele.

Quality of life in neurogenic patients based on different bladder management methods: A review.

To determine the overall quality of life and patient satisfaction associated with different bladder management strategies in neuro-urological patients. The second objective was to identify other associated factors that may further influence the patient's quality of life. Systematic Review. Studies from Pubmed, Cochrane, and Google Scholar databases were extracted using terms relating to 'quality of life', 'satisfaction', in 'neurogenic bladder' combined with 'bladder management methods' that included 'continent and non-continent urine diversion', 'intermittent-catheterization', 'indwelling catheter' and 'condom-catheter'. Only studies with a minimal proportion of 80% of neurogenic bladder patients were included. Search was conducted, and article titles and abstracts were rated. 136 papers were screened and assessed for eligibility. 25 studies were included in the final analysis and consisted of ten retrospective, nine prospective, five cross-sectional and a single randomized controlled trial. In total, 3002 patients were included, with a majority of male (55%) and spinal cord injury (88%) patients. 167 patients had incontinent urinary diversions, 464 had continent urinary diversions (bladder augmentation with or without cutaneous catheterizable channel), 1698 used intermittent catheterization (self or by an attendant), 550 had an indwelling catheter (urethral or suprapubic), and 123 had condom catheters. Quality of life was assessed using a wide variety of validated and non-validated questionnaires. Overall, patients with continent and incontinent diversion tended to have better scores. Use of catheters tended to have more unsatisfactory scores, with indwelling and attendant-intermittent catheterization often scoring worse. On the other hand, patients using self-intermittent catheterization tended to fair well. Normal micturition followed by self-catheterization yielded an overall higher quality of life. Data were too divergent to rank the other bladder management methods. However, by improving continence, each method aims to enhance quality of life.

Optimising the management of children with concomitant bladder dysfunction and behavioural disorders

Bladder dysfunction and behavioural disorders in children are commonly concomitant; hence, it is difficult to treat each in isolation. Pharmacotherapy is common treatment for behavioural disorders, and these medications may have intended or unintended positive or negative bladder sequelae. This review identifies the literature regarding the effects of behavioural pharmacotherapy on bladder functioning and possible bladder management strategies in children with concomitant behaviour and bladder disorders to enable clinicians to better manage both conditions. A PROSPERO registered PRISMA-guided review of three major databases was performed. After an initial scoping study revealed significant heterogeneity, a narrative approach was undertaken to discuss the results of all relevant cases relating to children being treated with pharmacotherapy for behaviour disorders and outcomes related to bladder function. Studies were screened to identify those that described effects of commonly prescribed medications in children with behavioural disorders such as stimulants, alpha 2 agonists, tricyclic antidepressants (TCA), serotonin and noradrenergic reuptake inhibitors (SNRI), selective serotonin reuptake inhibitors (SSRI) and antipsychotics, and the findings and implications were summarised. The review identified 46 studies relevant to behavioural pharmacotherapy and bladder function (stimulants (n = 9), alpha 2 agonists (n = 2), TCAs (n = 7), SNRIs (n = 8), SSRIs (n = 8) and antipsychotics (n = 6). Six studies focused specifically on bladder management in children with behavioural disorders with concurrent behavioural pharmacotherapy. This review identifies useful factors that may assist clinicians with predicting unintended bladder effects following initiation of behavioural pharmacotherapy to facilitate the best approach to the treatment of bladder dysfunction in children with behavioural disorders. With this evidence, we have provided a useful decision-making algorithm to aide clinicians in the management of these dual pathologies.

Advances in Assistive Electronic Device Solutions for Urology.

Recent technology advances have led urology to become one of the leading specialities to utilise novel electronic systems to manage urological ailments. Contemporary bladder management strategies such as urinary catheters can provide a solution but leave the user mentally and physically debilitated. The unique properties of modern electronic devices, i.e., flexibility, stretchability, and biocompatibility, have allowed a plethora of new technologies to emerge. Many novel electronic device solutions in urology have been developed for treating impaired bladder disorders. These disorders include overactive bladder (OAB), underactive bladder (UAB) and other-urinary-affecting disorders (OUAD). This paper reviews common causes and conservative treatment strategies for OAB, UAB and OUAD, discussing the challenges and drawbacks of such treatments. Subsequently, this paper gives insight into clinically approved and research-based electronic advances in urology. Advances in this area cover bladder-stimulation and -monitoring devices, robot-assistive surgery, and bladder and sphincter prosthesis. This study aims to introduce the latest advances in electronic solutions for urology, comparing their advantages and disadvantages, and concluding with open problems for future urological device solutions.

The safety cutoff storage pressure for preventing upper urinary tract damage in neurogenic bladder from spinal cord pathology and risk factor analysis.

Low-compliance bladder or high bladder pressure undoubtedly leads to hydronephrosis and renal impairment. As four decades have elapsed since a previous study found a detrusor leak-point pressure (DLPP) >40 cm H2 O to result in hydronephrosis, we suspected the possibility of hydronephrosis or vesicoureteral reflux occurring at any point below the 40 cm H2 O DLPP reference. Therefore, this study aimed to determine the storage detrusor pressure value and risk factors related to upper urinary tract damage (UUTD). This study retrospectively reviewed the hospital records of 110 patients who visited the Neurogenic Bladder TU Service of Excellence Unit, Thammasat University Hospital, Pathum Thani, Thailand, and were diagnosed with neurogenic bladder between 2016 and 2020. The inclusion criteria were as follows: patients who were diagnosed with neurogenic bladder from spinal cord problems (spinal dysraphism, spinal cord disease [tumor, degenerative, arteriovenous malformation, etc.], or traumatic spinal cord injury) and underwent a complete examination, including urodynamic study and renal ultrasound. The exclusion criteria were as follows: patients who had previous pelvic irradiation, other concomitant neurological disease (stroke, Parkinson's disease, etc.), or other urological diseases (stone, tumor, etc.), and those who had an indwelling suprapubic or urethral catheter. We identified the cutoff point for storage pressure related to UUTD using receiver operating characteristic (ROC) curve analysis to identify the value that produced maximum sensitivity and specificity. To identify risk factors for developing UUTD, we included seven risk factors: intravesical pressure, poor compliance, detrusor overactivity (DO), detrusor sphincter dyssynergia (DSD), level of the spinal cord pathology, male sex, and spontaneous voiding in univariable and multivariable regression analyses. Of the 110 patients who met the inclusion criteria, 22 were excluded from the study. Fifty-nine patients had a normal upper urinary tract, and 29 had UUTD. The mean age, sex, voiding pattern, type of spinal cord pathology, and level of spinal cord lesions were not different between the two groups. After performing ROC curve analysis, a cutoff value for daily storage pressure≥15 cm H2 O provided 79.31% sensitivity and 67.80% specificity (area under the ROC curve: 0.73) for UUTD development. From univariable analysis, low compliance (cutoff values at <12.5and <20 ml/cm H2 O) and a storage pressure≥15 cm H2 O was related to UUTD with statistical significance (risk ratio [RR]: 3.16, 2.3, and 3.6, respectively[p < 0.05]). After performing multivariable analysis, a storage pressure≥15 cm H2 O and both cutoff values for low compliance were related to UUTD with statistical significance (RR: 3.9, 2.4, and 3.2, respectively[p < 0.05]). However, other factors, including male sex, spontaneous voiding, suprasacral lesion, DSD, and DO, were not related to UUTD. Our results demonstrated that low compliance and a storage pressure ≥15 cm H2 O were significantly associated with UUTD. Various bladder-management strategies have been developed to prevent UUTDs. However, the main concept continues to be the maintenance of a low storage pressure.

Association of stone surgery with patient-reported complications after spinal cord injury.

To determine if a history of urinary stone surgery in individuals with spinal cord injury (SCI) is associated with an increased incidence of SCI-related complications and lower quality of life (QOL). The Neurogenic Bladder Research Group (NBRG) registry is a multicenter, prospective, observational study which measures QOL after acquired SCI. Over 1.5 years, 1479 participants were enrolled and grouped according to history of stone surgery. We evaluated SCI-related complications, QOL, and associations between patient factors and prior stone surgery using multivariable regression. Participants were a median of 11 years post-SCI and 189 (12.8%) reported prior bladder or kidney stone surgery; 95.8% of these occurred after the SCI. Median time between SCI and first stone was 5.6 years (IQR: 1.8-12.8). Hospitalizations were higher for those with prior stone surgery, with common reasons including UTIs, blood clots, pressure ulcers, and pneumonia (p < 0.001). During the year of observation, the incidence of stone surgery was 17% in those with a prior history of stone surgery and 2% per year in those without prior stone surgery (p < 0.001). Controlling for covariates, bladder management strategy, age, BMI, and years since SCI were associated with history of stone surgery. People with SCI and a history of surgical stone disease are at high risk for episodes of recurrent stones and increased hospitalizations, particularly those with kidney stones and indwelling catheter use. Identification of high-risk patients may guide tailored surveillance for complications and stone prevention strategies.

Urinary continence disparities in patients with anorectal malformations

PurposeWhile fecal incontinence is a primary concern for many children with anorectal malformations (ARM), urinary incontinence is also prevalent in this population. Racial, ethnic, and socioeconomic disparities in urinary continence have been observed in other conditions, but have not been previously evaluated in ARM. We aimed to evaluate urinary continence and associated demographic and socioeconomic characteristics in individuals with ARM. MethodsWe performed a multicenter retrospective study of ARM patients evaluated at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). We included all patients with ARM 3 years and older. The primary outcome was urinary continence which was categorized as complete (no accidents), daytime (accidents at night), partial (rare or occasional accidents), and none (frequent accidents or no continence). We evaluated for associations between urinary continence and race, sex, age, insurance status, and adoption status, employing Kruskal-Wallis and trend tests. Secondary outcomes included bladder management strategies such as clean intermittent catheterization and continence surgery. P-value < 0.05 was considered significant. ResultsA total of 525 patients with ARM were included. Overall, 48% reported complete urinary continence, and continence was associated with greater age. For school-aged children (age ≥ 5 years), 58% reported complete continence, while 30% reported none. Public insurance and adoption status were associated with decreased likelihood of incontinence. ConclusionsWe observed a novel finding of disparities in urinary continence for children with ARM related to insurance and adoption status. Further investigation regarding the etiologies of these inequities is needed in order to affect clinical outcomes.

PD46-04 TIME-RELATED CHANGES IN PATIENT-REPORTED BLADDER SYMPTOMS AND SATISFACTION AFTER SPINAL CORD INJURY

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making IV (PD46)1 Sep 2021PD46-04 TIME-RELATED CHANGES IN PATIENT-REPORTED BLADDER SYMPTOMS AND SATISFACTION AFTER SPINAL CORD INJURY Odinachi Moghalu, John Stoffel, Sean Elliott, Blayne Welk, Sara Lenherr, Chong Zhang, Angela Presson, and Jeremy Myers Odinachi MoghaluOdinachi Moghalu More articles by this author , John StoffelJohn Stoffel More articles by this author , Sean ElliottSean Elliott More articles by this author , Blayne WelkBlayne Welk More articles by this author , Sara LenherrSara Lenherr More articles by this author , Chong ZhangChong Zhang More articles by this author , Angela PressonAngela Presson More articles by this author , and Jeremy MyersJeremy Myers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002060.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Neurogenic lower urinary tract dysfunction is a significant source of concern and morbidity to individuals with spinal cord injury (SCI). Increased time from initial SCI is associated with improvements in bladder symptoms and satisfaction, despite a migration to bladder management strategies with higher morbidity such as indwelling catheters (IDC). We sought to better characterize the relationship between time from injury, bladder symptoms and satisfaction. METHODS: This is a cross-sectional analysis of time-related changes in patient reported bladder symptoms and satisfaction using data from the Neurogenic Bladder Research Group Spinal Cord Injury Registry. Study outcomes included: Neurogenic Bladder Symptom Score (NBSS-total) and its overall quality of life (QoL) question (NBSS-Satisfaction). Multivariable regression was performed to assess associations between time from injury and outcomes, adjusting for: demographics, injury characteristics, bladder management, and psychosocial aspects of health related QoL. Time from injury was categorized as 1-5 (ref.), 6-10, 11-15, 16-20, and >20 yrs. RESULTS: Of 1420 participants, median age at injury was 25.9 yrs. (IQR 19.7–38.8) and median time from injury was 11.6 yrs. (IQR 5.7–22.9). Primary bladder management changed with time from injury. There was a decline in use of clean intermittent catheterization (CIC) (55% 1-5 yrs. vs. 45% >20 yrs., p<0.001), and voiding (21% 1-5 yrs. vs. 17% >20 yrs., p<0.001) with increasing time from injury. Meanwhile, management with IDC (16% 1-5 yrs. vs. 21% >20 yrs.) and surgery (8% 1-5 yrs. vs 18% >20 yrs.) increased as time from injury increased (Figure 1). On multivariable analysis, increased time from injury was associated with less bladder symptoms (lower scores) at >20 yrs. from injury (NBSS-total -3.33, p<0.001) and better satisfaction in participants >10 yrs. from injury (NBSS-satisfaction 11-15 yrs. -0.36, 16-20 yrs. -0.59, >20 yrs. -0.86, p<0.001). CONCLUSIONS: Even in a contemporary population of SCI patients, there is a migration away from CIC, and an increase in IDC usage with time from injury. Despite this, there is a significant decrease in urinary symptoms, and improved QoL, even after adjusting for demographics, injury characteristics, bladder management, and psychosocial aspects of health related QoL. Source of Funding: This work was partially supported through a Patient-Centered Outcomes Research Institute (PCORI) Award (CER14092138). This investigation was supported by the University of Utah Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 5UL1TR001067-05 (formerly 8UL1TR000105 and UL1RR025764) © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e749-e750 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Odinachi Moghalu More articles by this author John Stoffel More articles by this author Sean Elliott More articles by this author Blayne Welk More articles by this author Sara Lenherr More articles by this author Chong Zhang More articles by this author Angela Presson More articles by this author Jeremy Myers More articles by this author Expand All Advertisement Loading ...

15. Leveraging Data to Explore the Consequences of Urine Testing and Antibiotic Use During the Spinal Cord Injury Annual Evaluation

BackgroundThe Veterans’ Health Administration (VHA), currently mandates that every spinal cord injury and disorder (SCI/D) patient receives a screening urinalysis and urine culture (UC) during the annual evaluation (AE). Our pilot study at a single VHA center showed that 87% of the UCs obtained during the AE represented asymptomatic bacteriuria (ASB), and that 35% of those UC were treated with antibiotics unnecessarily. The objective of the current study is to determine the association between UC and antibiotic use using a national VHA sample of SCI/D patients.MethodsRetrospective cohort of Veterans who presented to a VHA SCI/D clinic for their AE in FY18 or FY19. Demographic and clinical characteristics as well as information on primary outcomes (receipt of urine culture and antibiotics) were extracted from the VHA Corporate Data Warehouse. Associations between covariates and outcomes were assessed using logistic regression. P values < 0.05 were considered significant.Results9447 veterans with SCI/D were included, of whom 5088 (54%) had a UC obtained. Of those with a UC, 2910 (57%) were classified as positive (Figure 1). 1054 (11%) veterans were prescribed antibiotics within 7 days of their AE. Of these, 515 had a positive UC, 202 had a negative UC, and 2878 did not have a UC obtained during the AE. Age, ethnicity, neurologic level of injury (NLI), comorbidity score, frequently identified organism on positive culture, and receipt of antibiotics within 7 days of AE were significantly associated with obtaining a UC during the AE. Race, NLI, bladder management strategy, comorbidity score, frequently identified organism on positive culture, and having a UC obtained during the AE were significantly associated with receipt of antibiotics within 7 days of AE.Flowchart of SCI/D Veterans who had a urine culture and/or received antibiotics during their FY18/19 AE ConclusionOver half of Veterans with SCI/D presenting for their AE receive a screening UC, contrary to other national guidelines recommending against this practice. Age and type or organism identified on UC drive antibiotic use, which was similar to our previous findings and reflect themes identified during our qualitative interviews with SCI/D providers. The knowledge gained from this national VA study will assist the development of interventions to reduce unnecessary urine testing and antibiotic use in the SCI/D population.Disclosures All Authors: No reported disclosures

Interventions Post Catheter Removal (iPCaRe) in the Acute Care Setting: An Evidence- and Consensus-Based Algorithm.

Despite advances in the prevention of catheter-acquired urinary tract infections achieved by programs that include removal of the indwelling urinary catheter at the earliest possible time, evidence guiding bladder and incontinence management strategies following discontinuation of a catheter is sparse. To address this gap and guide best practice, the WOCN Society appointed a Task Force to develop an evidence- and consensus-based algorithm guiding clinical decision-making for effective bladder and incontinence management strategies after indwelling urinary catheter removal. This article describes the design and development of the algorithm, consensus-based statements used to guide best practice in this area, and its content validation.

Self-Reported Urological Hospitalizations or Emergency Room Visits in a Contemporary Spinal Cord Injury Cohort.

Individuals with spinal cord injuries frequently use urgent and emergent medical care. We hypothesized that urological causes are a primary driver of hospitalizations/emergency room visits in a contemporary spinal cord injury cohort. The Neurogenic Bladder Research Group spinal cord injury registry is a prospective cohort study evaluating neurogenic bladder related quality of life after traumatic spinal cord injury. Questionnaires were administered to participants querying whether a hospitalization or emergency room visit occurred during the interval 1-year followup and reason for visit. Primary outcome was the rate of urological related hospitalizations/emergency room visits in 1 year. Multivariable logistic regression was used to identify risk factors for urology related hospitalization/emergency room visit. Of the 1,479 participants enrolled 1,260 had 1-year followup. In all, 16.7% (211/1,260) reported at least 1 urological hospitalization/emergency room visit, and urinary tract infections were the most common reason cited. Patients with an indwelling catheter had the greatest odds of having a hospitalization/emergency room episode for a urological indication (OR 3.35, CI 1.68-6.67, p=0.001), followed by clean intermittent catheterization (OR 2.56, CI 1.36-4.84, p=0.004) as compared to those who voided spontaneously. Other predictors included SF-12 physical scores (OR 0.98, CI 0.96-0.996, p=0.014), diminished hand function (OR 1.83, CI 1.05-3.19, p=0.033), and unemployment (OR 1.64, CI 1.13-2.37, p=0.009). There was a high incidence of hospitalizations/emergency room visits for patients with spinal cord injuries during a 1-year followup and urological complications were the most common reason for admission. Patient self-reported physical health as well as unemployment, and bladder management strategy, particularly indwelling catheter use, were associated with increased risk of urology related hospitalization/emergency room visits.

A prevalence survey of patients with indwelling urinary catheters on district nursing caseloads in the United Kingdom: The Community Urinary Catheter Management (CCaMa) Study.

Catheter-associated urinary tract infection (CAUTI) is common in both hospitals and the community. To investigate the prevalence of indwelling urinary catheters on district nursing caseloads in the UK. Participants were recruited through the Infection Prevention Society (IPS). An electronic survey was undertaken on a single day between November 2017 and January 2018. Data were analysed using descriptive statistics. A total of 49,575 patients were included in the survey, of whom 5352 had an indwelling urinary catheter. This gave a point prevalence of 10.8% (95% confidence interval [CI] = 10.53-11.07), which varied between organisations, ranging from 2.36% (95% CI = 2.05-2.73) to 22.02% (95% CI = 20.12-24.05). Of catheters, 5% were newly placed (within four weeks). Of these, most (77%) had a documented indication for insertion. Only half of patients with a newly placed catheter had a plan for its removal. This varied between organisations in the range of 20%-96%. Only 13% of patients had a patient-held management plan or 'catheter passport' but these patients were significantly more likely to also have an active removal plan (28/36 [78%] vs. 106/231 [46%]; P < 0.0001). Alternative bladder management strategies had been considered for 70/267 (26%) patients. The management of patients with an indwelling urinary catheter represents a significant component of district nursing caseloads. Given the high proportion of newly catheterised patients without an active management plan for removal of the catheter, the establishment of an optimal management pathway should be the focus of future prevention efforts.

Patient Reported Bladder Related Symptoms and Quality of Life after Spinal Cord Injury with Different Bladder Management Strategies.

Neurogenic bladder significantly impacts individuals after spinal cord injury. We hypothesized that there would be differences in bladder related symptoms and quality of life for 4 common bladder management methods. In this prospective observational study we measured neurogenic bladder related quality of life after spinal cord injury. Study eligibility included age 18 years or greater and acquired spinal cord injury. Bladder management was grouped as 1) clean intermittent catheterization, 2) an indwelling catheter, 3) surgery (bladder augmentation, a catheterizable channel or urinary diversion) and 4) voiding (a condom catheter, involuntary leaking or volitional voiding). The primary outcomes were the NBSS (Neurogenic Bladder Symptom Score) and the SCI-QoL Difficulties (Spinal Cord Injury Quality of Life Measurement System Bladder Management Difficulties). Secondary outcomes were the NBSS subdomains and satisfaction with urinary function. Multivariable regression was done to establish differences between the groups, separated by level. Of the 1,479 participants enrolled in the study 843 (57%) had paraplegia and 894 (60%) were men. Median age was 44.9 years (IQR 34.4-54.1) and median time from injury was 11 years (IQR 5.1-22.4). Bladder management was clean intermittent catheterization in 754 cases (51%), an indwelling catheter in 271 (18%), surgery in 195 (13%) and voiding in 259 (18%). In regard to primary outcomes, in cases of paraplegia and tetraplegia an indwelling catheter and surgery were associated with fewer urinary symptoms on the NBSS compared to clean intermittent catheterization while voiding was associated with more symptoms. In paraplegia and tetraplegia cases surgery was associated with fewer bladder management difficulties according to the SCI-QoL Difficulties. In regard to secondary outcomes, surgery was associated with improved satisfaction in individuals with paraplegia or tetraplegia. In individuals with spinal cord injury fewer bladder symptoms were associated with an indwelling catheter and surgery, and worse bladder symptoms were noted in voiding individuals compared to those on clean intermittent catheterization. Satisfaction with the urinary system was improved after surgery compared to clean intermittent catheterization.

MP27-19 SUPRAPUBIC CATHETER PLACEMENT DURING INFLATABLE PENILE PROSTHESIS PLACEMENT ASSOCIATES WITH IMPROVED OUTCOMES IN SPINAL CORD INJURED PATIENTS WITH NEUROGENIC BLADDER

INTRODUCTION AND OBJECTIVES:Inflatable penile prosthesis (IPP) placement is an effective treatment strategy for spinal cord injured patients with erectile dysfunction. These patients have poor mobility, and often suffer from urinary incontinence and/or retention. They often require prolonged catheterization after surgery and the optimal postoperative bladder management strategy is unknown. We compared suprapubic catheter to urethral Foley catheter placement at the time of surgery.METHODS:From 2008-2017, 15 patients with spinal cord injury and documented neurogenic bladder underwent IPP placement for the management of erectile dysfunction. Baseline patient characteristics, level and extent of spinal cord injury, as well as bladder management before and after IPP were recorded. Categorical variables were analyzed with Fisher’s exact test and continuous variables with Wilcoxon rank sum testRESULTS:Six patients had suprapubic catheter placement at the time of IPP. Nine patients had urethral Foley catheter pla...