At a first glance, assisted urine voiding through catheterization may seem like an unnatural thing. If, however, the evidence surrounding intermittent catheterization (a more technical name for it) is studied, it becomes clear that this is indeed something useful. New research reveals that intermittent catheterization is a central part of many treatment regimens. In this month’s Science Alert we look into some of them.
Three newly published studies highlight the use of intermittent catheterization in children. The therapy is identified as a central treatment option for urological management of children with spina bifida, but it is also recognized as a suitable and central option in resource-poor settings. In another, more resource-strong setting, evidence in favor of hydrophilic-coated catheters for intermittent use has been found. The evidence suggests that hydrophilic-coated catheters decrease the risk of urinary tract infection (UTI), as compared to non-coated catheters, when used for intermittent catheterization in children with neurogenic bladder.
The idea that intermittent catheterization in general, and hydrophilic-coated catheters in particular, can reduce UTI risk is not new. On the contrary, there are studies published continually to support this notion. This month, another study concludes that hydrophilic-coated catheters are cost-effective for intermittent use because they reduce incidence of UTI at a reasonable additional cost for the healthcare system. In addition, a randomized controlled trial has found that intermittent catheterization should be considered instead of placing an indwelling catheter in women with postpartum urinary retention, as it reduces the total time spent with a catheter. The idea behind this recommendation is to reduce the rate of catheter-associated UTI. A parallel can be drawn to another study showing lower rates of catheter-associated UTI after patients switched from indwelling to intermittent catheter use in a hospital trauma unit.
Quality of life aspects are also frequently studied when it comes to intermittent catheter use. Two new studies from Brazil dig deeper into the relationship between quality of life and use of intermittent catheterization among people with neurogenic bladder. Other research concludes that the relationship between bladder management and quality of life is uncertain and likely very patient-specific. As a contrast, a conference abstract, presented at the International Continence Society’s annual meeting, suggests that health-related quality of life can be influenced by catheter choice for people practicing intermittent catheterization.
Furthermore, research tells us that many people living with multiple sclerosis (MS) are in need of intermittent catheterization and that treating bladder symptoms in people with MS may provide benefits beyond direct effects on the bladder. For example, people with MS who have urinary urgency and incontinence are likely to be at greater risk of falls.
Another aspect of the use of intermittent catheterization is that it has been found to work for both overactive and underactive bladder. For example, a need for intermittent catheterization may arise after Botox injections for people with overactive bladder. Recent studies, however, claim that the rate of intermittent catheterization use associated with Botox injections is quite low in clinical practice. This may be a result of strict eligibility criteria for initiating catheter use, and reflect that the need for intermittent catheterization after Botox may be age-related.
Finally, speaking about intermittent catheterization, it is worth highlighting that the Cochrane review that studies long-term use https://www.ncbi.nlm.nih.gov/pubmed/28796279 has been withdrawn due to possible methodological issues. These are being investigated and the review will be re-published following updating, revision and peer review.
Summary of Publications
Evaluation and Lifetime Management of the Urinary Tract in Patients with Myelomeningocele.
https://www.ncbi.nlm.nih.gov/pubmed/28716320
Author and Origin
Cardona-Grau D, Chiang G. US
Summary
Review summarizing urological management in children with spina bifida.
Conclusions
Findings suggest that lifelong urological management focuses on renal preservation, achieving continence, and optimizing quality of life. Needs may become more challenging as patients become older.
Comments
Study summarizing considerations for urological management of children with spina bifida. Intermittent catheterization is recognized as a central treatment option.
The management of paediatric neurogenic bladder: an approach in a resource-poor setting.
https://www.ncbi.nlm.nih.gov/pubmed/28714784
Author and Origin
Maison POM, Lazarus J. South Africa
Summary
Review of management options for children with neurogenic bladder living in resource-poor settings.
Conclusions
Children with neurogenic bladder in resource-poor settings should have early bladder management to preserve renal function and provide social continence. Intermittent catheterization is the most suitable treatment.
Comments
Study highlighting the use of intermittent catheterization in management of children with neurogenic bladder in resource-poor settings.
Results of a prospective randomized control trial comparing hydrophilic to uncoated catheters in children with neurogenic bladder.
https://www.ncbi.nlm.nih.gov/pubmed/28713004
Author and Origin
DeFoor W, Reddy P, Reed M, VanderBrink B, Jackson E, Zhang B, Denlinger J, Noh P, Minevich E, Sheldon C. US
Summary
Randomized controlled trial comparing use of hydrophilic and uncoated catheters for one year in 78 children practicing intermittent catheterization.
Conclusions
The study concludes that hydrophilic-coated catheters reduce the risk of urinary tract infection (UTI) compared to non-coated catheters. Fewer events were reported during the one-year follow-up (2 vs. 17 events, p = 0.003).
Comments
Study showing evidence in favor of hydrophilic-coated catheters when used for intermittent catheterization in children with neurogenic bladder.
This publication is described further in the highlight section.
Can hydrophilic coated catheters be beneficial for the public healthcare system in Brazil? - A cost-effectiveness analysis in patients with spinal cord injuries.
https://www.ncbi.nlm.nih.gov/pubmed/28792195
Author and Origin
Truzzi JC, Teich V, Pepe C. Brazil
Summary
Health-economic evaluation that uses modeling to compare hydrophilic-coated to non-coated catheters for intermittent catheterization. The model is adjusted to the Brazilian public healthcare system.
Conclusions
Use of hydrophilic-coated instead of non-coated catheters reduces the lifetime number of urinary tract infections (UTIs) with an additional 6 % cost. Despite the cost, the study concludes that hydrophilic-coated catheters are a cost-effective treatment.
Comments
Study concluding that using hydrophilic-coated catheters for intermittent catheterization is cost-effective because they reduce UTIs at a reasonable additional cost.
This publication is described further in the highlight section.
Comparison of clean intermittent and transurethral indwelling catheterization for the treatment of overt urinary retention after vaginal delivery: a multicentre randomized controlled clinical trial.
https://www.ncbi.nlm.nih.gov/pubmed/28856403
https://www.ics.org/2017/abstract/237
Author and Origin
Mulder FEM, Hakvoort RA, de Bruin JP, van der Post JAM, Roovers JWR. The Netherlands
Summary
Randomized controlled trial comparing intermittent to indwelling catheter use in 68 women with postpartum urinary retention.
Conclusions
Catheter use was significantly reduced in the group practicing intermittent catheterization. A 35 % required only one catheterization before complete bladder emptying occurred.
Comments
Study showing evidence in favor of intermittent catheter use in women with postpartum urinary retention when compared to indwelling catheter use.
Effect of Implementation of Intermittent Straight Catheter Protocol on Rate of Urinary Tract Infections in a Trauma Population.
https://www.ncbi.nlm.nih.gov/pubmed/28738946
Author and Origin
Kelley K, Johnson T, Burgess J, Novosel TJ, Weireter L, Collins JN. US
Summary
Observational retrospective study investigating the impact of a catheter-associated urinary tract infection (CAUTI) prevention protocol, with intermittent catheterization, in a trauma unit.
Conclusions
Early removal of indwelling catheters and replacement with intermittent catheters reduced the UTI rate from 1.9 % to 1.0 % (p = 0.035). The improvement was most prominent in women (3.3 % to 0.9 %, p = 0.007), as compared to men (1.2 % to 1.0 %, p = 0.837).
Comments
Study showing lower observed rates of catheter-associated UTI after switching from indwelling to intermittent catheter use in a hospital trauma unit.
Comparison of urinary tract infection rates associated with transurethral catheterization, suprapubic tube and clean intermittent catheterization in the postoperative setting: a network meta-analysis.
https://www.ncbi.nlm.nih.gov/pubmed/28736320
Author and Origin
Han CS, Kim S, Radadia KD, Zhao PT, Elsamra SE, Olweny EO, Weiss RE. US
Summary
Meta-analysis comparing post-operative risk of urinary tract infection (UTI) associated with different catheterization techniques in 1 391 patients.
Conclusions
The meta-analysis was not able to find any differences in UTI when comparing intermittent and indwelling catheter use. Results suggest that there is a lower risk of UTI for intermittent and suprapubic indwelling catheter use when catheterization exceeds 5 days.
Comments
Review article that suggests a lower risk of UTI for long-term post-operative intermittent and suprapubic catheter use as compared to traditional indwelling use.
Quality of life of patients using intermittent urinary catheterization.
https://www.ncbi.nlm.nih.gov/pubmed/28699993
Author and Origin
Fumincelli L, Mazzo A, Martins JCA, Henriques FMD, Orlandin L. Brazil
Summary
Observational study of quality of life among 170 Brazilian and 52 Portuguese neurogenic bladder patients using intermittent catheterization.
Conclusions
Spinal cord injury was overall the main cause of neurogenic bladder. Quality of life relates to improvement in urinary symptoms, independence, self-confidence, social relationships, and access to work activities.
Comments
Study mapping quality of life among neurogenic bladder patients using intermittent catheterization.
Open access.
Quality of Life of Intermittent Urinary Catheterization Users and Their Caregivers: A Scoping Review.
https://www.ncbi.nlm.nih.gov/pubmed/28742287
Author and Origin
Fumincelli L, Mazzo A, Martins JCA, Henriques FMD, Cardoso D, Rodrigues MA. Brazil
Summary
Review investigating patients’ and caregivers’ quality of life associated with neurogenic bladder and intermittent catheter use.
Conclusions
A total of 13 studies were selected and a general conclusion is that daily use of intermittent catheterization can cause changes in the living activities of patients, family members, and/or caregivers.
Comments
Review article that focuses on quality of life aspects of intermittent catheter use for management of a neurogenic bladder.
Quality of Life and the Neurogenic Bladder: Does Bladder Management Technique Matter?
https://doi.org/10.1007/s11884-017-0443-2
Author and Origin
Welk B. Canada
Summary
Review on bladder management-associated quality of life.
Conclusions
The pros and cons of different types of bladder management are well known but their impact on quality of life is uncertain and likely to be patient-specific.
Comments
Review exploring the quality of life impact associated with intermittent and indwelling catheter use among people with neurogenic bladder.
Single-use hydrophilic coated intermittent catheters improve quality of life: Report from a clinical trial on catheter reuse in the United States.
https://www.ics.org/2017/abstract/196
Author and Origin
Newman D, O’Connor R, Clark R, Aberg Hakansson M. US
Summary
Observational prospective study exploring real life data on safety and satisfaction with catheter reuse vs. single-use in 21 individuals practicing intermittent catheterization.
Conclusions
Bacterial contamination was observed in 90 % of the reused catheter samples collected, and 29 % had biofilms. After trying single-use catheters for 1 month, health-related quality of life increased by 20 %, and 89 % of patients preferred to continue using single-use catheters.
Comments
Conference abstract showing improvements in health-related quality of life associated with intermittent catheterization with single-use instead of reusable catheters.
Chronic Urinary Retention in Multiple Sclerosis Patients: Physiology, Systematic Review of Urodynamic Data, and Recommendations for Care.
https://www.ncbi.nlm.nih.gov/pubmed/28716323
Author and Origin
Stoffel JT. US
Summary
Review summarizing urological symptoms in multiple sclerosis (MS).
Conclusions
Findings suggest that 53 % of MS patients have detrusor overactivity, 43 % have detrusor sphincter dyssynergia, and 12 % have atonic bladder. Urinary retention is also common and 1 patient in 4 performs intermittent catheterization.
Comments
Study summarizing epidemiological data for urological conditions in MS, and suggesting that many MS patients are in need of intermittent catheterization.
Associations Between Bladder Dysfunction and Falls in People with Relapsing-Remitting Multiple Sclerosis.
https://www.ncbi.nlm.nih.gov/pubmed/28835742
Author and Origin
Zelaya JE, Murchison C, Cameron M. US
Summary
Observational survey in 51 multiple sclerosis (MS) patients investigating the relationship between urological symptoms and the risk of falls.
Conclusions
People with MS who have urinary urgency and incontinence are likely at greater risk for falls as a significant association was observed (odds ratio, 57.57; 95% CI, 3.43-966.05; P = .005)
Comments
Study indicating that treating bladder symptoms in people with MS may provide benefits beyond direct effects on the bladder.
Open access.
What is the true catheterization rate after intravesical onabotulinumtoxinA injection?
https://www.ncbi.nlm.nih.gov/pubmed/28808734
Author and Origin
Patel DN, Jamnagerwalla J, Houman J, Anger JT, Eilber KS. US
Summary
Observational retrospective study of intermittent catheter use in 99 women who had 187 Botox injections for overactive bladder.
Conclusions
Catheterization was initiated in women with post-void residual of 350 ml or more, in those with subjective voiding difficulty, and in those who had acute retention. The rate of post-procedure urinary retention requiring catheterization was 1.6 %.
Comments
Study retrospectively observing the use of intermittent catheterization in association with Botox injections in women treated for overactive bladder. Strict eligibility criteria for catheterization seems to reduce its use.
Low incidence of clean intermittent catheterisation with onabotulinumtoxina in diverse age groups of overactive bladder patients with corresponding improvements in urinary symptoms, treatment response, and quality of life.
https://www.ics.org/2017/abstract/313
Author and Origin
Nitti V, Drake M, Everaert K, Rovner E, Dmochowski R, Ginsberg D, Radomski S, Aboushwareb T, Chang C, Chapple C. US/UK
Summary
Add-on analysis of 3 randomized controlled trials of intermittent catheter use associated with Botox injections.
Conclusions
Rates of intermittent catheterization following Botox were generally low but seemed to increase with age. People aged < 40 years reported a rate of 1.1 %, with a mean duration of 3 days. People aged ≥ 70 years reported a rate of 7.2 %, with a mean duration of 86 days.
Comments
Conference abstract presenting data on age-related intermittent catheter use associated with Botox treatment for people with overactive bladder.
Treatment of underactive bladder with clean intermittent self-catheterization: report of 27 cases.
https://doi.org/10.21037/tau.2017.s033
Author and Origin
Jia X, Liang C, Xu K, Xu X, Wang X. China
Summary
Observational survey exploring intermittent catheter use in 27 individuals with underactive bladder.
Conclusions
Results showed a mean frequency of catheterization of 3.7 times/ day. Intermittent catheterization relieved symptoms of voiding difficulty and chronic urinary retention but about 11 % of patients experienced a urinary tract infection.
Comments
Conference abstract showing an example of intermittent catheter use for a group of people with underactive bladder.
This blog post is an extract of the Science Alert from Sep 2017 (76040-USX-1709)
