Method Of Bladder Drainage Research Articles

Bladder drainage methods for acute urinary retention due to benign prostatic hyperplasia: patient-preference analysis

Introduction. Currently, the classical management of acute urinary retention creates a certain discomfort for the patient and leads to explore alternative method of management, such as intermittent catheterization, including focusing on the patient opinions.Objective. To assess the preference of high-risk patients for acute urinary retention relative to bladder drainage in the occurrence of acute urinary retention.Materials & methods. A survey was conducted among 200 ambulatory male patients. All the participants were tested to assess their mental status and ability to perform self-intermittent catheterization before filling out the questionnaire. The questionnaire included questions about the preferred method of bladder drainage for acute urinary retention, as well as factors influencing the patient's choice of self-intermittent catheterization in case of non-recovery. After completing the questionnaire, all the patients were shown a video on self-catheterization and asked to re-take the questionnaire after watching it. This allowed evaluating the impact of the training video on patients' preferences and their confidence in performing self-catheterization.Results. Among the 200 patients, 151 (75.5 %) preferred intermittent catheterization, while 40 (25.5 %) chose an indwelling urinary catheter. Additionally, 152 (76 %) patients opted for intermittent catheterization until the planned surgery, and 48 (24 %) selected a suprapubic catheter. The main factors influencing the patient choice of intermittent catheterization were: the desire to restore bladder function faster (on the first or second day) in 96 (63.2 %) patients; unwillingness to stay in the hospital in 56 (36.8 %); the desire to return to work in 22 (14.5 %); avoiding the use of a suprapubic catheter in 51 (33.5 %). After watching the video, there was a statistically significant change in patients' assessments of their ability to perform self-intermittent catheterization (p < 0.001).Conclusion. The patient's choice of the intermittent catheterization is significantly influenced by the patient self-confidence in the ability to practice self-intermittent catheterization and the demonstration of the video tutorial. Due to the high efficiency and safety of intermittent catheterization, this method should be introduced into clinical practice based on the proposed algorithm.

Сравнение оперативных методов лечения при разрыве мочевого пузыря

Introduction. Еven though open bladder suturing is a traditional method of surgical treatment of intraperitoneal rupture of the bladder, laparoscopic bladder suturing is a prospective method for treating such injuries. Materials and methods. In N.V. Sklifosovsky Research Institute of Emergency Care during the period from January 2016 to April 2020, 22 patients with bladder injury were treated. 15 of them had an intraperitoneal rupture, 5 had an extraperitoneal rupture, and 2 had a bladder rupture. Among the affected men there were 15 (68%), women - 7 (32%), the average age of patients was 42 ± 18 years. The clinical picture was dominated by gross hematuria and pain in the lower abdomen. All patients underwent ultrasound examination (US) according to the FAST protocol, and cystography was performed in some patients. Results. 20 (91%) patients were operated and 2 (9%), with extraperitoneal rupture of the bladder, were drained by urethral catheters. Patients were divided by the method of surgical treatment into 2 groups. In the 1st group, 2 (10%) patients underwent laparoscopic suturing of the bladder with drainage of the bladder with a urethral catheter. 18 (90%) patients of the 2nd group underwent laparotomy with suturing of the bladder. Depending on the method of bladder drainage, patients were divided into the cystostomy group (group A) and the urethral catheter group (group B). Group A - 16 (73%) patients who underwent laparotomy, suturing a rupture or ruptures of the bladder, epicystostomy, drainage of the abdominal cavity and lower pelvis. Group B-4 (18%) patients after laparotomy, laparoscopy, as well as patients who underwent conservative therapy with the installation of an urethral catheter – 2 (9%). Discussion. In the world literature, there are few scientific articles on the laparoscopic method of treating bladder injury, and the presented works are based on a small sample of patients. But, despite this, the method seems to be a promising and effective method for treatment and can be used in patients with intraperitoneal rupture of the bladder with stable hemodynamics, without life-threatening concomitant injuries. Conclusion. Тhe use of open or laparoscopic suturing of the bladder without epicycostomy significantly reduces the hospital stay and allows to restore natural urination on average 7 days after surgery. Laparoscopic suturing of the bladder is an effective and alternative treatment for bladder rupture.

Selection of the urine derivation method in patients with acute urinary retention before surgical treatment of benign prostatic hyperplasia

Actuality. Nowadays it is necessary to recognize that the problem of acute urinary retention associated with benign prostatic hyperplasia is one of the most frequent causes of hospitalization into the urology hospital. A number of standard urine derivation techniques are used as a part of preoperative treatment.
 The aim of the study is to optimize the choice of the preoperative bladder drainage.
 Material and methods. The data of 280 patients hospitalized in the Urology Department of Samara City Clinical Hospital No. 8 over the period of 20122015 were studied to evaluate the results of acute urinary retention.
 Results and conclusions. Retrospective pseudo-factor analysis allows to evaluate the effect of the bladder drainage method on the results of treatment of acute urinary retention in benign prostatic hyperplasia. The results can be used as the basis for a mathematical model which allows to predict the outcome of the treatment of acute urinary retention during surgical treatment of benign prostatic hyperplasia. Obtained data were used to develop recommendations on the methods of bladder drainage as a part of preoperative treatment in patients with benign prostatic hyperplasia.

The impact of catheter-based bladder drainage method on urinary tract infection risk in spinal cord injury and neurogenic bladder: A systematic review.

To systematically compare the impact of catheter-based bladder drainage methods on the rate of urinary tract infections (UTIs) amongst patients with neurogenic bladder. A search of Cochrane Library, Embase, Medline, and Grey literature to February 2019 was performed using methods prepublished on PROSPERO. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Eligible studies were published in English and compared UTI incidence between neurogenic bladder patients utilizing bladder drainage methods of the indwelling urethral catheter (IUC), suprapubic catheter (SPC) or intermittent self-catheterization (ISC). The odds ratio of UTI was the sole outcome of interest. Eight nonrandomized observational cohort studies were identified, totaling 2321 patients who utilized either IUC, SPC, or ISC. Studies enrolled patients with neurogenic bladder due to spinal cord injury (seven studies) or from any cause (one study). UTI rates were compared between patients utilizing IUC vs SPC (four studies), IUC vs ISC (six studies), and SPC vs ISC (four studies). Compared with IUC, five of six studies suggested ISC use was associated with lower rates of UTI. Studies comparing IUC vs SPC and SPC vs ISC gave mixed results. Meta-analysis was not appropriate due to study methodology heterogeneity. Low-level evidence suggests amongst patients with neurogenic bladder requiring catheter-based drainage, the use of ISC is associated with lower rates of UTI than IUC. Comparisons of IUC vs SPC and SPC vs ISC gave mixed results. Future randomized trials are required to confirm these findings.

Redefining Healthy Urine: A Cross-Sectional Exploratory Metagenomic Study of People With and Without Bladder Dysfunction

We used the PathoScope platform to perform species level analyses ofpublicly available, 16S rRNA pyrosequenced, asymptomatic urine data to determine relationships between microbiomes, and clinical and functional phenotypes. We reanalyzed previously reported, cross-sectionally acquired urine samples from 47 asymptomatic subjects, including 23 controls and 24 subjects with neuropathic bladder. Urine was originally collected by the usual method of bladder drainage and analyzed by urinalysis, culture and pyrosequencing. Urinalysis and culture values were stratified as leukocyte esterase (0, or 1 or greater), nitrite (positive or negative), pyuria (fewer than 5, or 5 or greater white blood cells per high power field), cloudy urine (positive ornegative) and urine culture bacterial growth (less than 50,000, or 50,000 or greater cfu/ml). PathoScope was used for next generation sequencing alignment, bacterial classification and microbial diversity characterization. Subjects with neuropathic bladder were significantly more likely to havepositive leukocyte esterase and pyuria, cloudy urine and bacterial growth. Of 47 samples 23 showed bacterial growth on culture and in all samples bacteria were identified by pyrosequencing. Nonneuropathic bladder urine microbiomes included greater proportions of Lactobacillus crispatus in females and Staphylococcus haemolyticus in males. The Lactobacillus community differed significantly among females depending on bladder function. Irrespective of gender the subjects with neuropathic bladder had greater proportions of Enterococcus faecalis, Proteus mirabilis and Klebsiella pneumonia. In 4 subjects with neuropathic bladder Actinobaculum sp. was detected by sequencing and by PathoScope but not by cultivation and in all cases it was associated with pyuria. Using PathoScope plus 16S pyrosequencing we were able to identify unique, phenotype dependent, species level microbes. Novel findings included absent L. crispatus in the urine of females with neuropathic bladder and the presence of Actinobaculum only in subjects with neuropathic bladder.

An unresolved relationship: the relationship between lesion severity and neurogenic bladder in patients with spinal cord injury

Objectives: We aimed to investigate the relationship between the severity of the spinal lesion and urodynamic findings, bladder drainage method at discharge, and incidence of renal calculi in patients with spinal cord injury (SCI).Studydesign: Retrospective.Setting: In-patient rehabilitation unit of a tertiary research hospital.Methods: A total of 131 patients who were admitted to our clinic with a diagnosis of SCI and placed into a rehabilitation program were included in the study. The severity of the lesion was determined according to the American Spinal Injury Association Impairment Scale (AIS). We evaluated the relationship between the severity of the lesion and the detrusor hyperactivity and compliance as determined by urodynamic investigation, the bladder drainage method used at discharge, and the renal calculi rate as determined by ultrasonography.Results: While no difference was found between the patients with complete and incomplete injuries in terms of age, sex, disease duration, detrusor hyperactivity and compliance, the bladder drainage method was found to show a significant change according to the severity of the lesion. None of the patients were found to have hydronephrosis and the rate of renal calculi showed no statistically significant difference according to the severity of the lesion.Conclusions: We concluded that urodynamic examination is required in each patient with SCI as the severity of the lesion is not sufficient to determine the bladder type, and patients with complete and incomplete injuries should be monitored with the same sensitivity in terms of complications.

Morbidity associated with operative management of bladder stones in spinal cord-injured patients.

Retrospective cohort study of spinal cord-injured (SCI) patients undergoing bladder stone removal operations between 1999 and 2013. To determine the morbidity associated with different operative management of bladder stones in SCI patients. National Spinal Injuries Unit, Stoke Mandeville Hospital, UK. Data on age, sex, level and Frankel classification of spinal cord injury, method of bladder drainage, method of bladder stone removal, complications and length of stay were collected from patient records. Complication was defined as bladder perforation, sepsis or persistent haematuria. Predictors of complications and length of stay were determined using univariate and multivariate regression analyses. Overall, 112 consecutive bladder stone removal operations were performed, one open cystolithotomy and 111 transurethral procedures utilising simple washout, stone punch or electrohydraulic lithotripsy (EHL). Of these procedures, 17% (19/112) had complications; 0/11 (0%) following washout, 5/44 (11%) after stone punch, 3/12 (25%) following EHL and 10/26 (38%) after combined procedures using stone punch and EHL. In a multivariate model, patients with a cervical-level injury and those undergoing a combined procedure were significantly more likely to have a complication (P=0.032 and P=0.046). Length of stay was longer following a complication, the mean was 4.18 days compared with 1.37 days without a complication (P<0.001). Controlling complications and age, use of a combined procedure was associated with significantly longer stay than use of stone punch alone. This study provides important outcome data that should guide operative procedure choice and inform patients about possible risks during consent. It sets a benchmark that other centres can evaluate their outcomes against.

Retrospective Analysis of Nosocomial Urinary Tract Infections with Spinal Cord Injury Patients in a Rehabilitation Setting

Objective: To define the distribution and antibiotic susceptibility of nosocomial urinary tract infections (NAUTIs) in patients with spinal cord injury (SCI). Material and Methods: Records of the spinal cord injured patients were reviewed for NAUTIs between 2008 and 2010. Antibiotic resistance rates and factors that might affect urinary tract infection susceptibility were investigated retrospectively. Results: The data of 276 patients were included, of whom 159 were acute SCI patients and 117 were chronic SCI patients; 166 (61%) infections were asymptomatic bacteriuria (ASB), and 110 (39%) infections were symptomatic urinary tract infections (SUTIs). In patients with acute SCI, E. coli was the most frequently isolated pathogen of SUTIs, followed by Pseudomonas. In patients with chronic SCI, E. coli was the most frequently isolated pathogen in SUTIs and ASBs. There was no statistically significant difference in the rates of NAUTI (ASB and SUTI) between acute and chronic SCI patients in terms of bladder drainage method. The susceptibility ratios for E. coli were very low in both acute and chronic SCI patients using Foley catheters. Although the susceptibility ratios for E. coli were not that low in SCI patients using clean intermittent catheterization, the resistance ratios were higher than 50% for most of the uropathogens. Conclusion: These results reveal a blunt truth that the treatment of NAUTIs will be a great challenge in near future.

Who decides? A qualitative study on the decisional roles of patients, their caregivers and doctors on the method of bladder drainage after spinal cord injury.

Qualitative study using individual in-depth interviews. To explore the roles of patients, their caregivers and doctors when making decisions on the method of bladder drainage after spinal cord injury (SCI). Five public hospitals in Malaysia. Semistructured (one-to-one) interviews with 17 male patients with SCI, 4 caregivers and 10 rehabilitation professionals. Eight themes describing the respective decisional roles of patients, their caregivers and doctors emerged from the analysis: patient's right and responsibilities, patient as an informed decision maker, forced to accept decision; surrogate decision maker, silent partner; doctor knows best, over-ride patient's decision, or reluctant decision maker. Both patients and doctors acknowledged the importance of patient autonomy but not all patients had the chance to practice it. Some felt that they were forced to accept the doctor's decision and even alleged that the doctor refused to accept their decision. Doctors considered the caregiver as the decision maker in cases that involved minors, elderly and those with tetraplegia. Some patients considered bladder problems an embarrassing subject to discuss with their caregivers and did not want their involvement. Doctors were described as knowledgeable and were trusted by patients and their caregivers to make the most appropriate option. Some doctors were happy to assume this role whereas some others saw themselves only as information providers. A paternalistic model is prevalent in this decision-making process and there is a discrepancy between patients' preferred and actual decisional roles.

MP38-20 THE EFFICACY OF BOTULINUM TOXIN A FOR CONTROL OF URINARY INCONTINENCE IN PATIENTS WITH A SUPRAPUBIC CATHETER

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence Therapy II1 Apr 2014MP38-20 THE EFFICACY OF BOTULINUM TOXIN A FOR CONTROL OF URINARY INCONTINENCE IN PATIENTS WITH A SUPRAPUBIC CATHETER Bashir Mukhtar, Shafiul Chowdhury, Mahreen Pakzad, Julian Shah, Jeremy Ockrim, Tamsin Greenwell, and Rizwan Hamid Bashir MukhtarBashir Mukhtar More articles by this author , Shafiul ChowdhuryShafiul Chowdhury More articles by this author , Mahreen PakzadMahreen Pakzad More articles by this author , Julian ShahJulian Shah More articles by this author , Jeremy OckrimJeremy Ockrim More articles by this author , Tamsin GreenwellTamsin Greenwell More articles by this author , and Rizwan HamidRizwan Hamid More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1277AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There are a variety of methods for bladder drainage in disease state including suprapubic catheterisation (SPC). A proportion of these patients continue to have urgency related urinary incontinence refractory to antimuscarinics. Intradetrusor Botulinum toxin A (BTX) is an accepted treatment for control of detrusor overactivity (DO). However, the efficacy of BTX in controlling incontinence in patients with SPC is not well documented. We present our experience with BTX in this setting. METHODS We compiled a retrospectively collated database of patients that between September 2012 and September 2013 had undergone intradetrusor injections of BTX into multiple sites of the bladder wall at our institution. 206 patients were identified, of which 16 had SPC as a method of bladder drainage. All but one had urodynamic proven DO with urinary incontinence. 12 had a pre-treatment diagnosis of neuropathic bladder dysfunction, with the majority of these being secondary to multiple sclerosis. 3 had idiopathic bladder dysfunction and 1 had a diagnosis of chronic pelvic pain syndrome. Data on urodynamics results, including evidence of DO, leakage, BTX dose and further treatment, was collected from the trust computer database. Associated complications, improvement in symptoms, duration of cessation of leakage and if subsequent BTX treatment was effective, was collected via clinic letters, repeat urodynamics and subjectively via a telephone interview. RESULTS The mean age of the cohort was 59 years (range; 34-77 years). Gender ratio was 12 females to 4 males (3:1). From our cohort of 16 patients, 10 reported significant improvement in symptoms with quality-of-life improving effects. 3 had no discernable improvement in symptoms. In 3 the result could not be established. 6/10 patients with improvements were cured of incontinence. Indeed, at the time of follow-up, only one had reported a relapse (at 7 months). The others were within 3,3,5,5 and 9 months of their treatment and still asymptomatic for leakage. In those that had repeat BTX within the study time, all (5/5) reported excellent efficacy. Only 1 patient experienced significant discomfort from the treatment, which resulted in cessation of the procedure. No others reported any peri-operative difficulties (15/16). CONCLUSIONS In patients with urodynamic diagnosed DO who have SPC as a means of bladder drainage, and who experience urinary incontinence that is refractory to antimuscuranics, BTX is an effective treatment option, with good tolerability and beneficial effects that appear to be sustained with repeated injections. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e410 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Bashir Mukhtar More articles by this author Shafiul Chowdhury More articles by this author Mahreen Pakzad More articles by this author Julian Shah More articles by this author Jeremy Ockrim More articles by this author Tamsin Greenwell More articles by this author Rizwan Hamid More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Factors influencing bladder management in male patients with spinal cord injury: a qualitative study

Qualitative study using individual in-depth interviews. The objective of this study was to explore the factors influencing the choice of bladder management for male patients with spinal cord injury (SCI). Public hospitals in Malaysia. Semistructured (one-on-one) interviews of 17 patients with SCI; 7 were in-patients with a recent injury and 10 lived in the community. All had a neurogenic bladder and were on various methods of bladder drainage. Interviews were audio-recorded, transcribed verbatim and analyzed using thematic analyses. The choice of bladder management was influenced by treatment attributes, patients' physical and psychological attributes, health practitioners' influences and social attributes. Participants were more likely to choose a treatment option that was perceived to be convenient to execute and helped maintain continence. The influence of potential treatment complications on decision making was more variable. Health professionals' and peers' opinions on treatment options had a significant influence on participants' decision. In addition, patients' choices depended on their physical ability to carry out the task, the level of family support received and the anticipated level of social activities. Psychological factors such as embarrassment with using urine bags, confidence in self-catheterization and satisfaction with the current method also influenced the choice of bladder management method. The choice of bladder management in people with SCI is influenced by a variety of factors and must be individualized. Health professionals should consider these factors when supporting patients in making decisions about their treatment options.

Suprapubic catheter insertion using an ultrasound‐guided technique and literature review

What's known on the subject? and What does the study add? The conventional 'blind' technique for suprapubic catheter (SPC) insertion relies on adequate filling of the bladder to displace bowel away from the site of needle puncture. However, in a small percentage of patients this fails to happen, which can occasionally lead to life-threatening bowel injury. Recently published British Association of Urological Surgeons (BAUS) guidelines have recommended that ultrasonography (US) may be helpful to identify bowel loops and recommends its usage whenever possible. This paper describes the technique of US-guided needle puncture and SPC insertion to reduce the likelihood of bowel injury. The paper addresses training, equipment and logistical issues associated with this advice. We have reviewed the available publications on the outcomes from this technique and also present our experience. Suprapubic catheter (SPC) insertion is a common method of bladder drainage in contemporary urological practice. The procedure involves insertion of a sharp trocar into the bladder percutaneously, usually by palpation, percussion or cystoscopy for guidance. Although generally considered a safe procedure, the risk of bowel injury is estimated at up to 2.4% with a mortality rate of 1.8%. Recently published British Association of Urological Surgeons (BAUS) guidelines have recommended that ultrasonography (US) may be helpful to identify bowel loops and recommends its usage whenever possible. The present paper describes the use of US for SPC insertion and discusses the implications of this advice. This paper is designed to support and supplement practical techniques learnt on a course and in clinical practice.

Urinary Tract Infections in Patients with Spinal Cord Injuries

Spinal cord injuries (SCI) result in different lower urinary tract dysfunctions. Because of both the disease and the bladder drainage method, urinary tract infections (UTIs) are one of the most frequent conditions seen in SCI patients. Diagnosis is not always easy due to lack of symptoms. Asymptomatic bacteriuria needs no treatment. If symptoms occur, antibiotherapy is indicated. Duration depends mainly on severity of illness and upper urinary tract or prostatic involvement. Choice of antibiotherapy should be based on local resistance profiles, but fluoroquinolones seems to be an adequate empirical treatment. Prevention of UTI is important, as lots of complications can be foreseen. Catheter care, permanent low bladder pressure and clean intermittent catheterization (CIC) with hydrophilic catheters are interventions that can prevent UTI. Probiotics might be useful, but data are limited.

Long-term follow-up study of outcomes of bladder management in spinal cord injury patients under the care of The Midlands Centre for Spinal Injuries in Oswestry

Retrospective longitudinal study of short- and long-term urinary complications in chronic spinal cord injury (SCI) patients managed at the Midlands Centre for Spinal Injuries (MCSI). MCSI, Oswestry, UK. A total of 185 SCI patients were admitted to the MCSI between 1984 and 1989. Only 119 patients who met the following criteria were included: traumatic SCI, Frankel grade A-D, admission within 6 weeks post injury, regular annual follow-up or alternate year at MCSI, follow-up longer than 8 years. Follow-up ranged between 8 and 21 years with a mean of 17.7 (s.d.=1.98). The method of bladder drainage varied from the time of injury. Drainage was by indwelling urethral catheterisation (IndUC) before admission to the MCSI. Within 24 h of admission, assisted clean intermittent catheterisation (ACIC) by the nursing staff was commenced. This was followed by clean intermittent self catheterisation (CISC) once the patient was mobilised in the wheel chair and trained in the procedure. When detrusor reflex activity develops, patients with good hand function were given a choice between CISC and reflex voiding (RV). Patients with poor hand function are given the choice between RV, suprapubic catheters or ACIC during hospitalisation and after discharge. Only a minority of these patients choose ACIC following discharge. RV was supplemented occasionally by sphincterotomy. There were 99 males and 20 females (5:1). The age at the time of injury was 16-63 years with a mean of 29 (s.d.=12). Instead of a single method, a pattern of bladder management was analysed in the context of three continuous phases: Phase1 preadmission to MCSI. Phase2 during first hospitalisation at MCSI. Phase3 post discharge. In each phase, the patients were divided into those with and without complications. The complications were analysed in relation to the management and other relevant factors. The total complication rate at all stages was 62%. Complications of the upper urinary tract accounted for 22.6%. These results compared favourably with published material. The sequential system of supervised bladder management commencing with brief IndUC followed by IntC and/or RV remains effective in keeping the complication rate relatively low in SCI patients, who undergo regular surveillance and timely intervention. The project was supported by SPIRIT, a charitable not for profit trust that supports teaching, training, clinical research and dissemination of knowledge about all aspects of spinal paralysis in the UK.

Is Transurethral Catheterisation the Ideal Method of Bladder Drainage? A Survey of Patient Satisfaction With Indwelling Transurethral Urinary Catheters

Bladder catheterisation is a routine part of major abdominal surgery. Transurethral catheterisation is the most common method of bladder drainage but is also notorious for its discomfort and increased risk of urinary tract infection. The present study aimed to establish patient satisfaction with transurethral catheterisation and to assess the incidence of clinically significant urinary tract infections after transurethral catheterisation through survey. All patients who underwent major open abdominal surgery between October 2006 and December 2008 and required standard transurethral bladder catheterisation, were asked to participate in the study. Fifty patients were recruited. Male patients were more dissatisfied than their female counterparts with transurethral catheterisation (satisfaction score: 4.18/10 vs. 2.75/10; p = 0.05). Male patients had more than double the score for pain at the urinary meatus with the catheter in situ (p =0.012) and during urine catheter removal (p = 0.013). Half the patients in the study also had symptoms of urinary tract infection after catheter removal. Our study emphasised the discomfort of transurethral urinary catheters, especially in male patients, and the high incidence of urinary tract infections in both sexes. Consideration should be given to the utilisation of alternative methods of bladder drainage, such as suprapubic catheterisation, which can be performed with ease during laparotomy.

Catheter-Related Urinary Tract Infection in Patients Suffering from Spinal Cord Injuries

Urinary tract infection is commoner in patients with spinal cord injuries because of incomplete bladder emptying and the use of catheters that can result in the introduction of bacteria into the bladder. 145 patients suffering from spinal cord injuries, admitted to the Institute for physical medicine and rehabilitation, Centre for paraplegia of the Clinical Centre of the University of Sarajevo, were included. The patients were divided in three groups according to the method of bladder drainage: Group A (n=61) consisted of patients on clean intermittent catheterization; Group B (n=54) consisted of patients with indwelling catheters; Group C (n=30) consisted of patients who had performed self-catheterization. From a total of 4539 urine samples, 3963 (87,3%) were positive and 576 (12,7%) were sterile. More than 90% of the infected patients were asymptomatic. The overall rate of urinary infection amounted to about 2,1 episodes, and bacteriuria to 8,1 episodes per patient. 77% of infections (113/145) were acquired within seven days from catheterization. Infection was usually polymicrobial; the greatest number of urine samples 1770/3943 (44,9%) included more than one bacterium. The vast majority of cases of urinary tract infection and bacteriuria are caused by Gram-negative bacilli and enterococci, commensal organisms of the bowel and perineum, representative of those from the hospital environment. Providencia stuarti (18,9%) being the most common, followed by Proteus mirabilis (16,3%), Escherichia coli (11,8%), Pseudomonas aeruginosa (10,2%), Klebsiella pneumoniae (8,1%), Morganella morgani (5,4%), Acinetobacter baumannii (4,6%), Providencia rettgeri (3,5%). 15,7% of isolates were Gram-positive with Enterococcus faecalis (8,6%) as the most common. 55,3% of isolates were multidrug-resistant, and the highest rates of resistance were found among Acinetobacter baumannii (87,8%), Providencia rettgeri (86,7%), Pseudomonas aeruginosa (85,4%), Providencia stuarti (84,3%) and Morganella morgani (81,0%). Lower rates of resistance were found in Group C, i.e. patients on intermittent self-catheterisation. Eradication of organisms was achieved in only 53 (10,05%) of patients; hence, antibiotic therapy had no or very low effect. Significant correlations were found between the method of catheterization and the frequency of bacteriuria and urinary tract infections. The analysis of Group C showed a rate of lower urinary tract infection and bacteriuria than the other two Groups of patients. The objective of this study is the update of etiology and antimicrobial susceptibility in urinary tract infections in this group of patients. In addition, possible correlations between UTI and the type of bladder management were examined.

Use of button in the bladder and bowel

Purpose To present our technique for the use of the MICKEY button in the bladder and bowel. Material and methods Our practice is to use the button extensively for bladder drainage in selected indications and also for the ACE for the last five years. We use the button exclusively for the ACE whilst leaving the appendix for the mitrofanoff conduit when indicated. Results Our video will demonstrate the techniques involved in these situations. We have large experience with the ACE button either inserted by colonoscope or by open technique. The cystostomy button has been very effective providing a socially and cosmetically acceptable method of bladder drainage as a temporary measure in selected indications. When we come to reconstructive surgery, we have the appendix available in majority of cases and the ACE is achieved with the help of a button. Conclusions The button is a useful device not just for the stomach for feeding but also a good alternative for bladder drainage and the ACE procedure. The appendix is put to better use in the bladder for reconstructive surgery.

A review of guidelines on benign prostatic hyperplasia and lower urinary tract symptoms: are all guidelines the same?

To compare overall and methodological quality with content in national and supra-national Clinical Practice Guidelines (CPGs) on benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS), as the purpose of CPGs is to reduce unwanted variation in practice and improve patient care by setting agreed standards based on the best available evidence. An electronic search was used to identify Internet-based national and supra-national CPGs on BPH and LUTS available in 2001. Two independent assessors analysed the content and appraised the methodological quality of the CPGs using an existing and validated instrument (St. George's Hospital Medical School Health Care Evaluation Unit Appraisal Instrument) comprising 37 items grouped into three broad areas, i.e. rigour of development, context and content, and clinical application. Eight CPGs were suitable for appraisal; there was much variation in overall and methodological quality. There was agreement that a patient history and physical examination (including a digital rectal examination) should be used in all symptomatic men. In addition, patients' symptoms should be assessed using a validated symptom score, e.g. the International Prostate Symptom Score. There was considerable variation in the number and type of diagnostic tests recommended for routine assessment. CPGs scoring low on the appraisal instrument (indicating poor overall and methodological quality) were more likely to recommend more diagnostic tests than those scoring high. There was general agreement between the guidelines on the treatment of BPH/LUTS and the importance of the patient's involvement in making management decisions. Guideline quality was independent of local health resources and publication year. The overall and methodological quality of CPGs on BPH/LUTS varies considerably. There appears to be an inverse relationship between guideline quality and the number of diagnostic tests recommended for routine assessment. Using CPGs of high quality may prevent men with BPH/LUTS being exposed to tests of doubtful utility. Although this may reduce both resource use and exposure to potential harm, moving to a more minimalist approach to diagnosis may itself be potentially harmful to patients.

Pathogenesis of bacteriuria and infection in the spinal cord injured patient

Spinal cord injury (SCI) produces profound alterations in lower urinary tract function. Incontinence, elevated intravesical pressure, reflux, stones, and neurological obstruction, commonly found in the spinal cord-injured population, increase the risk of urinary infection. The overall rate of urinary infection in SCI patient is about 2.5 episodes per patient per year. Despite improved methods of treatment, urinary tract morbidity still ranks as the second leading cause of death in the SCI patient. SCI removes the ability of the pontine micturition center and higher centers in the brain to inhibit, control, or coordinate the activity of the vesicourethral unit. As a result, a patient with complete quadriplegia is typically unaware of bladder activity. Bladder contraction is accompanied by vesicosphincter dyssynergia instead of sphincter relaxation. It is widely accepted that intermittent catheterization, when compared with indwelling catheters, reduces the risk of urinary tract infection (UTI) in SCI patients and is the preferred method of bladder drainage in this patient population. Attempts at eliminating bacteriuria associated with indwelling or intermittent catheters have generally been unsuccessful. There is now appreciation of the fact that a creeping adherent biofilm of bacteria frequently ascends through the luminal and external surfaces of an indwelling catheter, often within 8 to 24 hours, leading to bacterial adherence to the bladder surface and correlating with symptomatic infection. The use of antimicrobial agents to clear or prevent bacteriuria in patients on indwelling or intermittent catheterization has had mixed success. Treatment for asymptomatic bacteriuria in SCI patients remains controversial. SCI patients with symptomatic urinary infections should be treated with the most specific, narrowest spectrum antibiotics available for the shortest possible time. Guidelines for selecting antimicrobial agents in SCI patients are similar to guidelines for the treatment of complicated urinary infections in the general population. Characteristics of the quinolones make them well suited to treating UTI in the SCI patient.

The method of bladder drainage in spinal cord injury patients may influence the histological changes in the mucosa of neuropathic bladder – a hypothesis

BackgroundIn spinal cord injury (SCI) patients, no correlation was found between the number of bladder infections per year, the period since injury, the neurologic level of the spinal cord lesion and the histopathology of the urinary bladder mucosa. The use of chronic indwelling urethral and/or suprapubic catheters in SCI patients is often associated with inflammatory and proliferative pathological conditions in neuropathic bladder.Presentation of the hypothesisWe propose a hypothesis that the type of bladder drainage in SCI patients influences the histological changes in the mucosa of neuropathic bladder. This hypothesis implies that SCI patients with long-term indwelling urinary catheters develop certain histological changes in bladder mucosa, which are seen less frequently in SCI patients, who do not use long-term indwelling catheters. The latter group includes patients, who perform regular intermittent catheterisation and those, who wear a penile sheath and empty their bladders satisfactorily by reflex voiding.We hypothesise that the following histological lesions are seen more frequently in the neuropathic bladder of SCI patients with long-term indwelling catheters.(1) Papillary or polypoid cystitis; (2) widespread cystitis glandularis; (3) moderate to severe, acute and chronic inflammatory changes in bladder mucosa; (4) follicular cystitis; (5) squamous metaplasia; and (6) urothelial dysplasiaAs per this hypothesis, it is postulated that the above pathological conditions are seen less often in SCI patients, who achieve complete, low-pressure emptying of the neuropathic bladder by regular intermittent catheterisation, and SCI patients with penile sheath drainage, who empty their bladders satisfactorily by reflex voiding.Testing the hypothesisA large prospective study of bladder biopsies in SCI patients practising different methods of bladder drainage is required to validate this hypothesis that the histological changes in bladder mucosa are related to the method of bladder drainage in SCI patients.Implications of the hypothesisWe propose a hypothesis that the method of bladder drainage in SCI patients influences histological changes in the bladder mucosa. If this hypothesis is validated, methods of bladder drainage such as intermittent catheterisation, which do not require the use of chronic indwelling catheters, should be recommended, in order to minimise adverse histological changes in the mucosa of neuropathic bladder of spinal cord injury patients.