Use Of Intermittent Catheterization Research Articles

Patterns of neurogenic lower urinary tract dysfunction management and associated factors among Chinese community-dwelling individuals with spinal cord injury

To identify different patterns of neurogenic lower urinary tract dysfunction management among Chinese community-dwelling individuals with spinal cord injury and explore the factors associated with latent classes. This was a cross-sectional study conducted in communities throughout China Mainland. Participants were recruited through the China Association of Persons with Physical Disability and a total of 2582 participants was included in the analysis. The data were collected by a questionnaire consisting of socio-demographic factors, disease-related factors, and a list of 8 bladder management methods. Latent class analysis was used to identify different latent classes of neurogenic lower urinary tract dysfunction management. Then the multinomial logistic regression was applied to analyze the relationship between neurogenic lower urinary tract dysfunction management patterns and socio-demographic and disease-related factors. Neurogenic lower urinary tract dysfunction management pattern among community-dwelling individuals with spinal cord injury was divided into four latent classes: “urinal collecting apparatus dominated pattern” (40.3%), “bladder compression dominated pattern” (30.7%), “intermittent catheterization dominated pattern” (19.3%) and “urethral indwelling catheterization dominated pattern” (9.6%). Multinomial logistic regression analysis found that the employment status, residential region, nursing need, payment method for catheterization products, hand function, time since spinal cord injury, urinary incontinence and concerns about social interaction affected by urination problems were significantly associated with latent classes. Only 19.3% of people used the intermittent catheterization as their main neurogenic lower urinary tract dysfunction management method. More attention needs to be paid to the promotion of the standardization process of intermittent catheterization in community-dwelling individuals with spinal cord injury. The associated factors of the four classes can be used for tailored and targeted interventions to increase the use of intermittent catheterization.

Interactions between fatigue and urinary quality of life in patients with Multiple Sclerosis

IntroductionNeurogenic bladder as well as fatigue related symptoms are common in patients with Multiple Sclerosis (MS) and have a significant impact on the patients’ Quality of Life (QoL). The aim of this study is to investigate the relationship between fatigue related symptomatology (FRS) and Urinary Quality of Life (UQoL). MethodsA total of 120 consecutive MS patients were recruited from the Outpatient Clinic of Demyelinating Diseases (Second Dept. of Neurology, Attikon University Hospital Greece). Participants were then asked to complete the Modified Fatigue Impact Scale (MFIS) and the Short Form Qualiveen questionnaire. Demographic and bladder function related characteristics (incontinence, urinary frequency, use of intermittent catheterization) were collected. ResultsThe physical and cognitive dimensions of MFIS had a moderate to high correlation with SF Qualiveen (r = 0.403, p <.000), (r = 0.329, p <.000).Multiple linear regression produced a fitted model (R2 = 0.150, F(3,111) = 5.554, p =.001) in IC use (β = 1.086, p =.036) and the physical dimension of MFIS (β = 0.66, p =.046) significantly predicted the SF Qualiveen score. ConclusionUQoL had a moderate correlation with both physical and cognitive dimensions of fatigue. Patients with MS who experience lower levels of physical fatigue and/or manage their neurogenic bladder symptomatology (mainly with the use of intermittent catheterization) appear to have higher levels of UQoL. Due to the versatile and subjective nature of both fatigue related and neurogenic bladder symptoms, more focused studies utilizing objective evaluation tools (e.g urodynamic urine bladder study) are necessary.

New concept in urologic surgery: The total extended genital sparing radical cystectomy in women

The aim of the study was to evaluate genital sparing radical cystectomy surgery in female patients from the point of view of both oncologic and functional outcomes (with emphasis on urinary and sexual outcomes) in a single high-volume center for the treatment of muscular invasive bladder cancer. Between January 2014 and January 2018, 14 female patients underwent radical cystectomy with preservation of genital organs (the entire vagina, uterus, fallopian tubes, ovaries) and orthotopic urinary neobladder (Padua neobladder). Inclusion criteria were recurrent T1G3 tumors; refractory tumors after BCG therapy without associated carcinoma in situ (CIS); T2 or T3a tumors entirely resected at endoscopic transurethral resection of the bladder and not involving urethra/bladder trigone. Exclusion criteria were: T3b or higher bladder cancer, associated CIS and involvement of urethra or bladder trigone. Oncological and histopathological outcomes (Overall Survival - OS, Recurrence Free Survival - RFS), urinary outcomes (day and night incontinence, intermittent catheterization use, Sandvik Score) and sexual outcomes (Female Sexual Function Index 19 FSFI-19) were considered. The average follow-up time was 56 months. Considering oncological outcomes, histologic examination reported urothelial carcinoma in 13/14 patients; 8/13 patients (61.5%) had high grade T1 stage, 3/13 patients (23%) had high grade T2 stage and finally 2/13 patients (15.5%) had high-grade T3 stage. One patient presented with embryonal rhabdomyosarcoma completely excised after surgery (PT2aN0M0). No patient developed local or metastatic recurrence (RFS 100%); OS was 100%. Considering urinary continence outcomes, 12/14 patients retained daytime and nighttime continence (85.5%); 2/14 (14.5%) complained of low stress urinary incontinence daily and nighttime urinary leakage. The Sandvik Score showed complete continence in 7/14 patients (50%); mild degree incontinence in 6/14 patients without use of incontinence devices (43%); moderate degree of incontinence in one patient (7%). The FSFI administered at 1 year from the surgery showed sexual desire in all patients (100%); subjective arousal, achievement of orgasm and sexual satisfaction in 12/14 patients (85.5%); sufficient lubrication in 11/14 patients (78.5%). Only one patient (7%) complained about dyspareunia during sexual intercourse. Our study aims to demonstrate that genital-sparing radical cystectomy is a safe surgery in terms of oncologic outcomes and, most importantly, that it is beneficial in terms of urinary and sexual function. Indeed, patients' quality of life together with their psychological and emotional health should be put on the same level as oncological safety. However, it is a treatment reserved for selected patients who are strongly motivated to preserve fertility and sexual function and thoroughly informed about the benefits and complications of such a procedure.

Burden of illness among intermittent catheter users with non-neurogenic urinary retention in Denmark

ABSTRACT Background Urinary retention (UR) caused by non-neurogenic conditions is a frequent disorder often requiring the use of intermittent catheterization (IC). This study examines the burden of illness among subjects with an IC indication due to non-neurogenic UR. Methods Health-care utilization and costs were extracted from Danish registers (2002–2016) related to the first year after IC training and compared to matched controls. Results A total of 4,758 subjects with UR due to benign prostatic hyperplasia (BPH) and 3,618 subjects with UR due to other non-neurological conditions were identified. Total health-care utilization and costs per patient-year were significantly higher compared to matched controls (BPH: 12,406 EUR vs 4,363, p < 0.000; other non-neurogenic causes: 12,497 EUR vs 3,920, p < 0.000) and driven mainly by hospitalizations. Urinary tract infections (UTIs) were the most frequent bladder complications often requiring hospitalization. The inpatient costs per patient-year for UTIs were significantly higher for cases than controls (BPH: 479 EUR vs 31, p < 0.000; other non-neurogenic causes: 434 EUR vs 25, p < 0.000). Conclusions The burden of illness caused by non-neurogenic UR with need for IC was high and essentially driven by hospitalizations. Further research should clarify if additional treatment measures may reduce the burden of illness in subjects suffering from non-neurogenic UR using IC.

Urological Management of the Spinal Cord-Injured Patient: Suggestions for Improving Intermittent Catheterization and Reflex Voiding

Spinal cord injury can either be complete with no neural communication across the injury level or incomplete with limited communication. Similarly, motor neuron injuries above the sacral spinal cord are classified as upper motor neuron injuries, while those inside the sacral cord are classified as lower motor neuron injuries. Specifically, we provide recommendations regarding the urological management of complete upper motor neuron spinal cord injuries; however, we also make limited comments related to other injuries. The individual with a complete upper motor neuron injury may encounter five lower urinary tract conditions: first, neurogenic detrusor overactivity causing urinary incontinence; second, neurogenic detrusor underactivity resulting in high post-void residual volumes; third, detrusor sphincter dyssynergia, which is contraction of striated and/or smooth muscle urethral sphincters during detrusor contractions; fourth, urinary tract infection; and fifth, autonomic dysreflexia during detrusor contractions, which produces high blood pressure as well as smooth muscle detrusor sphincter dyssynergia. Intermittent catheterization is the recommended urinary management method because it addresses the five lower urinary tract conditions and has good long-term outcomes. This method uses periodic catheterizations to drain the bladder, but also needs bladder inhibitory interventions to prevent urinary incontinence between catheterizations. Primary limitations associated with this management method include difficulties with the multiple catheterizations, side effects of bladder inhibitory medications, and urinary tract infections. Three suggestions to address these concerns include the use of low-friction catheters, wireless, genital-nerve neuromodulation for bladder inhibition, and consideration of urine egress into the urethra as a risk factor for UTI as well as egress treatment. The second management method is reflex voiding. This program uses external condoms for urine collection in males and diapers for females. Suprapubic tapping is used to promote bladder contractions. This method is not recommended because it has high rates of medical complications. In particular, it is associated with high detrusor pressure, which can lead to ureteral reflux and kidney pathology. Botulinum toxin injection into the urethral striated sphincter can manage detrusor sphincter dyssynergia, reduce voiding pressures, and risks to the kidney. We suggest a modified method for botulinum toxin injections as well as five additional methods to improve reflex voiding outcomes. Finally, the use of intermittent catheterization and reflex voiding for individuals with incomplete spinal injuries, lower motor neuron injuries and multiple scleroses are briefly discussed.

A Cost Comparison of Holmium Laser Enucleation of the Prostate with and without Moses™.

Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for the treatment of benign prostatic hyperplasia. HoLEP has been shown to have excellent improvements in prostate symptom scores and maximum flow rates that have been durable for 2 decades. However, the steep learning curve associated with HoLEP has prevented its widespread adoption. New advancements in lasers, specifically the Moses™ pulse-modulation technology, have resulted in improvements in hemostasis and achieving same-day discharges and catheter removals. We aimed to perform a cost-comparison to analyze if Moses-augmented HoLEP (m-HoLEP) resulted in cost-savings. A retrospective review was performed of a single expert surgeon's experience from May 2018 to November 2020, comparing m-HoLEP with HoLEP. Perioperative and postoperative variables were abstracted from the medical record. Univariate and multivariate analyses were performed using SAS® 9.4. Two-sided significance was set at p <0.05. A total of 312 men underwent HoLEP during the study period (192 in m-HoLEP group and 120 in HoLEP group). The m-HoLEP group had more same-day discharges (p <0.001) and emergency department visits (6.3% vs 1.7%, p=0.0071). m-HoLEP resulted in hospital cost savings of $840 for the initial surgical episode (p=0.0297). When factoring in emergency department visits/readmissions, the cost savings decreased to $747 per case (p=0.0574). m-HoLEP was associated with same-day discharge and hospital cost savings of $840 for the initial surgical episode. Further study in other institutions with surgeons of varying experience levels will need to be performed to see if these findings can be replicated.

Intermittent catheterisation: the common complications.

Intermittent catheterisation (IC) has been in practice for more than 40 years and is considered the gold standard in the management of urinary retention in the neurological bladder. IC has many advantages over indwelling urethral or suprapubic catheterisation, including reducing the risk of infection, protecting the bladder and improving quality of life. However, complications can be caused by the practice of this technique, the most common of which is infection. This review discusses some of the common complications that can occur with the use of intermittent catheterisation, including urinary tract infection (UTIs) and urethral complications. It also highlights the role of the nurse in the management of its complications.

Changes in the Trend in Bladder Emptying Methods in Patients With Spinal Cord Injury: A 20-Year Single-Center Retrospective Study.

ObjectiveTo review trends in bladder emptying methods over a 20-year period in patients with spinal cord injury (SCI) by severity according to the American Spinal Injury Association impairment scale (AIS).MethodsMedical records of patients with SCI from 1994 to 1998 (group 1) and from 2012 to 2016 (group 2) were retrospectively reviewed. We classified bladder emptying methods according to the International Spinal Cord dataset. We grouped patients with normal voiding, bladder reflex triggering, and bladder expression as those using voiding without catheter.ResultsA total of 667 patients were included in the analysis. The proportion of patients using voiding without catheter and intermittent catheterization decreased from 67.0% to 30.0% and increased from 26.8% to 54.8%, respectively. In patients with AIS-A and AIS-B, the proportion of patients with intermittent catheterization increased from 32.8% to 73.3%. In patients with AIS-D, the proportion of patients using voiding without catheter and intermittent catheterization decreased from 88.5% to 68.9% and increased from 11.5% to 26.8%, respectively. In group 2, among 111 patients with AIS-D using voiding without catheter at admission, 8 (7.2%) switched to intermittent catheterization at discharge due to decreased bladder volume, increased post-voiding residual urine, or incontinence.ConclusionOver the past 20 years, trends in bladder emptying methods in patients with SCI changed from voiding without catheter to intermittent catheterization in Korea. This was especially prominent in patients with AIS-A, AIS-B, and AIS-C. Even in patients with AIS-D, the use of intermittent catheterization at hospital discharge increased.

Worsening disability status in multiple sclerosis predicts urologic complications.

Multiple sclerosis (MS) causes voiding dysfunction and might predispose to urologic complications. However, long-term complications and risk factors for complications are unknown. We aim to assess long-term changes in voiding function and to determine risk factors for urologic complications during MS follow-up. We analyzed the records of MS patients and recorded baseline and follow-up voiding symptoms, urodynamic (UDS) findings, Expanded Disability Status Scale (EDSS), serum blood studies, imaging, and complications. T test and Chi-square test were used to determine statistical significance using a two-tailed p value < 0.05. We assessed complication-free survival using Kaplan-Meier curves and performed multiple variable Cox proportional hazard models to estimate hazard ratios predicting complications for various independent variables. 126 women and 35 men with MS were followed for a median of 9.7years (IQR 4.3-13). Mean age at MS diagnosis was 36.7 with a mean EDSS of 3.2. During follow-up, EDSS progressed to a mean of 5.5. In addition, at least one complication occurred in 60.2% and major complications were present in 16.7%. After multivariable analysis, EDSS progression ≥ 2.0 (p = 0.003), follow-up EDSS ≥ 6.0 (p = 0.01), use of intermittent catheterization (p < 0.001) and urinary reconstruction with continent catheterizable stoma (p = 0.009) were significantly related to an increased hazard for any complications. Upper tract changes and other major complications were uncommon. Complications were related to MS progression, resultant increase in total disability, and the need for intervention to maintain functional continence. Lower tract infections occurred more frequently in patients with the need for catheterization.

A Project to Increase Nurses’ Comfort in Offering Bedpans to Women Laboring With Epidural Analgesia

ObjectiveTo improve nurses’ comfort in helping laboring woman void on a bedpan after initiation of epidural analgesia, to increase the frequency of bedpan use in the labor and birth unit, and to decrease the use of continuous indwelling Foley catheters during the intrapartum period. DesignQuality improvement project. SettingA single large, midwestern U.S. hospital (>3,000 births annually), where bedpans are infrequently used after epidural placement. ParticipantsRegistered nurses on a labor and birth unit. Intervention/MeasurementsA 20-minute educational presentation that included current urinary catheter evidence-based practice, preferential use of bedpans, and methods to help women void successfully was taught to all registered nurses in the author’s labor unit. Nurses rated on a scale of 0 (not comfortable at all) to 10 (extremely comfortable) their comfort level at helping a woman with a bedpan. Primary data were collected through a convenience sample of anonymous surveys (n = 52) completed by registered nurses regarding their experience with bedpan and catheter use during labor and their comfort level helping women be successful with voiding. This was followed by a retrospective chart audit for women with term, singleton pregnancies who labored with epidural analgesia. ResultsNurses’ comfort levels increased from an average of 5.7 to 7.2 (p = .067). Postepidural bedpan use increased from 5.5% (n = 12) to 19% overall (n = 20; p < .001), with five women using bedpans exclusively. When assisted with bedpan use, 38% (n = 12) of women were able to void 34 of the 53 times it was offered (64%). Use of continuous indwelling Foley catheters decreased from 61.7% (n = 137) to 54.7% (n = 58), and use of intermittent catheterization increased from 30.6% (n = 68) to 37.7% (n = 40). ConclusionWhen assisted by nurses educated in and comfortable with different voiding techniques, women may be able to avoid medically unnecessary use of urinary catheters during labor.

Health-related quality of life in non-paraplegic (ambulatory) children with myelomeningocele.

Evaluation of the effects of ventriculoperitoenal shunt and incontinence presence on health-related quality of life of ambulatory myelomeningocele patients. The study group included 35 myelomeningocele patients, between 5 and 18years old (mean age=9.6), who were neonatally operated. All patients were ambulatory. The Child Edition of the Child Health and Illness Profile (CHIP-CE) used to evaluate the patient group. Seventeen patients were using clean intermittent catheterization and nine patients had ventriculoperitoneal shunt. The CHIP-CE has five domains, and in satisfaction, resilience and achievement domains, significant lower scores were obtained from our study group. In terms of clean intermittent catheterization use, we got significantly lower scores on satisfaction, resilience and achievement domains (p<0.05). According to the presence of ventriculoperitoneal shunt, we found lower scores in satisfaction, resilience, risk avoidance and achievement domains but the differences were not significant (p>0.05). No significant difference was spotted according to gender and age. Continence problems have important effects on life quality of myelomeningocele patients. Incontinency should always be considered as a major variable in health-related quality of life evaluations.

A Clinical Nurse Specialist-Directed Initiative to Reduce Postoperative Urinary Retention in Spinal Surgery Patients.

: Postoperative urinary retention (POUR) is the inability to void when the bladder is full after surgery. It is a common complication in postoperative patients, especially in patients undergoing spinal surgery. At our institution, patients who were discharged from the postanesthesia care unit (PACU) to the inpatient surgical unit typically had bladder distention and a bladder volume of more than 450 mL. In an effort to address this situation, an interprofessional group of advanced practice RNs and physicians formed a team, reviewed the existing literature, examined the PACU nursing practice guideline for evaluating and managing POUR, and devised a quality improvement (QI) project to raise the PACU nursing staff's awareness of the potential for POUR among postoperative patients and to develop an updated nursing practice algorithm for the evaluation and management of POUR in spinal surgery patients. A description of the QI process, including the revised algorithm and pre- and postintervention results, is reported here. In the preintervention group (n = 42), 19 indwelling urinary catheterizations were documented in patient records; no use of intermittent catheterization was documented. In the postintervention group (n = 43), seven indwelling urinary catheterizations were documented in patient records; the use of intermittent catheterization was documented in 11. As a result of our intervention, we decreased the number of indwelling urinary catheters inserted in the PACU, and supported the PACU nursing staff in more frequent and appropriate use of intermittent catheterization in patients undergoing spinal surgery.

Continuous use of intermittent bladder catheterization--can social support contribute?

Objective to investigate the factors affecting the adequate continuous use of intermittent catheterization and its relation with social support. Method sectional, descriptive and correlational study involving 49 patients with neuropathic bladder caused by spinal cord injury. Results almost all (92%) participants continued the intermittent catheterization, but 46.9% made some changes in the technique. The complications (28.6% of the sample) were mainly infection and vesicolithiasis. There were high scores for social support in relation to people that were part of the patient's social support. Conclusion All of them noticed great support from the family, but not from the society in general. The difficulties were related to the lack of equipment and inadequate infrastructure, leading to changes that increased urologic complications.

Efficacy of infliximab in neuro-Behçet’s disease presenting with isolated longitudinally extensive transverse myelitis

Efficacy of infliximab in neuro-Behçet’s disease presenting with isolated longitudinally extensive transverse myelitis

Management of the bladder in traumatic injuries of the spinal cord during the First World War and its implications for the current practice of urology

What's known on the subject? and What does the study add? Prior to the First World War, traumatic injuries to the spinal cord rapidly led to death from severe infections of the bladder. During the Second World War, Ludwig Guttmann resurrected the use of intermittent catheterisation at Stoke Mandeville Hospital, by meticulous attention to detail and was so successful, that this method was introduced into general urological practice. Historical review of the management of the bladder in patients with spinal injuries. Spinal injury patients--literature review--personal experience at Stoke Mandeville Hospital. Review of the different methods of catheterisation from the 19th century to today. Methods learned from the management of the bladder of spinal injuries patients were adopted into mainstream urology.

Continent urinary diversion in the epispadias-exstrophy complex

Despite improvements in modern surgical reconstructive techniques, many patients with epispadias-exstrophy continue to experience urinary incontinence. Continent diversion is commonly performed to achieve urinary continence and improve quality of life. In this work we describe the population that can be considered for continent urinary diversion, consider the benefits and implications of concurrent augmentation and bladder neck closure, and review recent literature regarding continence outcomes and common complications. Even in this complex patient population, urinary continence can be reliably achieved by bladder augmentation and the use of intermittent catheterization via a catheterizable cutaneous stoma with or without closure of the bladder neck.

RCT of urethral versus suprapubic catheterization

To compare the use of intermittent urethral catheterization with indwelling suprapubic catheterization in women undergoing surgery for urodynamic stress incontinence or uterovaginal prolapse. Randomized controlled trial. Tertiary referral urogynaecology unit. Women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence. Women were randomized into one of two groups. Group 1 had bladder drainage using a suprapubic catheter inserted in theatre. The catheter was left on free drainage for 48 hours post-operatively before clamping. Group 2 was catheterized intermittently post-operatively. Length of post-operative hospital stay: time to resume normal voiding (defined as voided volumes greater than 200 mls and residual urine volumes less than 100 mls on three occasions); number of urinary tract infections (UTIs); catheterization costs; patient experience (determined from questionnaire); and a pain score. 75 women were randomized; 38 to suprapubic catheterization; 37 to intermittent catheterization. Three were withdrawn from study, leaving 36 women in each group. Groups were closely matched for age and type of surgery undertaken. Length of hospital stay and total duration of catheterization were both significantly shorter for the intermittent catheterization group; although there was no difference in the rate of UTI between the two groups. There was no clear patient preference for a specific catheterization method. The use of intermittent catheterization following urogynaecological surgery is associated with a more rapid return to normal micturition and a shorter hospital stay, although the clinical significance of the difference is perhaps limited.

Prevention of urinary tract infection in six spinal cord-injured pregnant women who gave birth to seven children under a weekly oral cyclic antibiotic program

Pregnancies in spinal cord-injured (SCI) patients present unique clinical challenges. Because of the neurogenic bladder and the use of intermittent catheterization, chronic bacteriuria and recurrent urinary tract infection (UTI) is common. During pregnancy the prevalence of UTI increases dramatically. Recurrent UTI requires multiple courses of antibiotics and increases the risks of abortion, prematurity, and low birth weight. A weekly oral cyclic antibiotic (WOCA) program was recently described for the prevention of UTI in SCI patients. To test the impact of WOCA in six SCI pregnant women (four paraplegic, two tetraplegic). This was a prospective observational study. WOCA consists of the alternate administration of one of two antibiotics once per week. We observed a significant reduction of UTI (6 UTI/patient/year before pregnancy to 0.4 during pregnancy and under WOCA; p<0.001) and no obstetric complications. Infant outcomes were good. The WOCA regimen could be useful for UTI prophylaxis in SCI pregnant women.

Prevalence and Natural History of Colonization With Fluoroquinolone-Resistant Gram-Negative Bacilli in Community-Dwelling People With Spinal Cord Dysfunction

Roghmann M-C, Wallin MT, Gorman PH, Johnson JA. Prevalence and natural history of colonization with fluoroquinolone-resistant gram-negative bacilli in community-dwelling people with spinal cord dysfunction. Objectives To estimate the prevalence of colonization with fluoroquinolone-resistant gram-negative bacilli (GNB) and to assess risk factors for and define the natural history of colonization. Design Cross-sectional study with follow-up of up to 1 year. Setting Multiple outpatient sites. Participants Eighty-four community-dwelling adults with spinal cord dysfunction. Interventions Not applicable. Main Outcome Measure Colonization of perineum with fluoroquinolone-resistant GNB. Results Overall, 24% of this community-dwelling cohort was colonized with fluoroquinolone-resistant GNB with resistance to both levofloxacin and gatifloxacin. The use of any antibiotic in the last 90 days was most strongly associated with an increased risk of colonization with fluoroquinolone-resistant GNB (relative risk, 2.3; 95% confidence interval, 1.1−4.8; P=.05). Incontinence was significantly more common among those with fluoroquinolone-resistant GNB colonization. Among the participants with incontinence (n=42), the use of intermittent catheterization (vs suprapubic, urethral, or condom catheters or overflow incontinence) was significantly protective. Colonization was not associated with an increase in urinary tract infection and was often transient. Conclusions Fluoroquinolone resistance among GNB colonizing community-dwelling people with spinal cord dysfunction is common. Colonization is more common among those receiving antibiotics and less common among those continent of urine. Among those with incontinence, those using intermittent catheterization have less colonization.

Bladder exstrophy repair: Complete primary repair of exstrophy

t t lthough the history of treatment of patients with exstrophy goes back several centuries, urinary iversion with ureterosigmoidostomy remained the reatment standard until the late 1950s. However, in he early 1960s, efforts at complete repair of bladder xstrophy, including both closure of the bladder and enital reconstruction, were reported. Lattimer et al.1 nd others2–4 discussed the results with 70 cases in 966. However, the initially encouraging results inluded significant problems with urinary infection nd upper tract dilation (90%).5 Perhaps these results eflect that, unfortunately, these efforts preceded the ommon use of intermittent catheterization for blader outflow obstruction. The reaction to these results as either to continue to treat young exstrophy paients with cystectomy and diversion or to use a taged approach in which the bladder is closed withut an initial attempt at repair of the bladder neck or rethra or epispadias.6–8 This staged approach was hampioned by Jeffs8 who was primarily responsible, long with Tate Chisholm and Julian Ansell, for howing that exstrophy could be repaired surgically ithout urinary diversion.9–11 These pioneers proved hat it was possible to achieve volitional urinary coninence and good health in the patient with exstrohy. However, the staged approach requires a numer of procedures and results have varied widely hroughout the world. We believe that a newer understanding of the athophysiology and anatomy of exstrophy faciliates neonatal complete primary repair of exstrohy (CPRE), and that this approach results in good otential for primary urinary volitional continence “potty training”) without the need for intermitent catheterization or bladder diversion or augentation. We also believe that CPRE facilitates he normalization of bladder development, which