Current evidence on intermittent catheterization: sterile single-use catheters or clean reused catheters and the incidence of UTI.

PURPOSE: Intermittent catheterization is a commonly prescribed procedure for people with incomplete bladder emptying not managed by other methods. The most frequent complication of intermittent catheterization is urinary tract infection (UTI). It is unclear what strategies, including sterile vs clean catheters or coated vs uncoated PVC catheters, affect the incidence of UTIs. This systematic review summarizes current evidence on the relationship between sterile single-use catheters or clean reused catheters and the incidence of UTIs. SEARCH STRATEGY: The Cochrane Incontinence Group trials register, Medline, EMBASE, CINAHL, and ERIC were searched, plus the reference lists of relevant articles and conference proceedings. Randomized controlled trials comparing at least two different products or methods for intermittent catheterization were included. DATA COLLECTION AND ANALYSIS: Three reviewers assessed the methodological quality of trials and abstracted data. MAIN RESULTS: Of the 13 trials that met the inclusion criteria on intermittent catheterization protocols, there was considerable variation in length of follow-up, definitions of UTI, and numbers of subjects. Attrition was a problem for several studies, and all were underpowered. Several studies were more than 10 years old, and outcome measures were imprecise, making it difficult to draw conclusions on the benefit of one catheterization method over another. CONCLUSIONS: There are no definitive studies illustrating that incidence of UTIs is affected by sterile single-use or coated catheters compared to clean reused catheters. However the current research base is weak and design issues are significant. Based on the current data, it is not possible to state that one catheter method is better than another and further research on the topic is strongly recommended.     

Epididymitis in children and adolescents on clean intermittent catheterisation.

The records of 119 children and adolescents on clean intermittent catheterisation (CIC) were reviewed to assess the incidence and predisposing factors, if any, of epididymo-orchitis. CIC had been performed for a total of 448 patient years with a mean of 4.5 years (range 3 months to 19 years). Of the evaluable 99 patients, 10 suffered attacks of epididymo-orchitis after commencing CIC. There was an equal incidence on both sides. Three patients had recurrent attacks. Epididymitis occurred at the rate of 1 episode for 10 patient years. Those who had neuropathic bladders and more than 2 symptomatic urinary tract infections annually had a higher incidence. Prophylactic antibiotics did not reduce the incidence but long-term specific antibiotic therapy may prevent further attacks. Vasectomy and orchidectomy had to be done in 2 patients for recurrent attacks and intractable sepsis.     

The use of the Mitrofanoff principle in achieving clean intermittent catheterisation and urinary continence in children

The Mitrofanoff principle has been used to achieve clean intermittent catheterisation (CIC) and urinary continence in 28 children. The mean age at operation was 10.1 years (range, 1 to 19 years). A catheterisable conduit was created using the appendix (19), ureter (8), or vas deferens (1). CIC was commenced 10 to 28 days postoperatively (median, 15 days). After a mean follow-up of 13 months (range, 2 to 45 months), 24 children (86%) have achieved successful CIC and urinary continence. Use of the Mitrofanoff principle is a valuable adjunct to the treatment of urinary incontinence in children and may allow successful CIC in patients who are unable to catheterise urethrally.     

Effect of clean intermittent catheterisation on radiological appearance of the upper urinary tract in children with myelomeningocele

Of the 102 consecutive children with myelomeningocele who were treated by intermittent catheterisation between 1977 and 1985, 89 were investigated with regard to the development of the upper urinary tract. The median follow-up period was 6.7 years. Dilatation and vesicoureteric reflux were assessed by means of repeated urography and voiding cystourethrography. Of the 49 children with normal radiology at the start of catheterisation, all but 2 remained normal. In 27 with isolated dilatation of the upper urinary tract or reflux at the start, 17 subsequently became normal. Dilatation together with reflux was seen in 13 patients at the start; 3 became normal, 4 still had reflux and in 6 patients both dilatation and reflux persisted. Intermittent catheterisation thus had a positive effect on the upper urinary tract in the vast majority of cases. In children with both dilatation and reflux, however, there is a risk of deterioration and they should be followed up closely.     

Hydrophilic-coated catheters for intermittent catheterisation reduce urethral micro trauma: a prospective, randomised, participant-blinded, crossover study of three different types of catheters

OBJECTIVE: To compare two hydrophilic-coated (SpeediCath and LoFric and one uncoated gel-lubricated catheter (InCare Advance Plus) concerning withdrawal friction force and urethral micro trauma. METHODS: 49 healthy male volunteers participated in this prospective, randomised, blinded, crossover study of three different bladder catheters. The withdrawal friction force was measured, and urine analysis of blood, nitrite and leucocytes, microbiological analysis of urine cultures and subjective evaluation of the catheters were performed. RESULTS: 40 participants completed the study and were included in the analysis. SpeediCath exerted a significantly lower mean withdrawal friction force and work than the gel-lubricated uncoated catheter, whereas LoFric exerted a significantly higher mean friction force than both of the other catheters. The hydrophilic catheters caused less microscopic haematuria and less pain than the gel-lubricated uncoated catheter. Furthermore, 93% of the participants preferred the hydrophilic catheters. CONCLUSION: Hydrophilic-coated catheters perform better than uncoated catheters with regard to haematuria and preference. SpeediCath, but not LoFric, exerts less withdrawal friction force than InCare Advance Plus.     

Self-sterilizing catheters with titanium dioxide photocatalyst thin films for clean intermittent catheterization: Basis and study of clinical use

OBJECTIVE: Clean intermittent catheterization (CIC) requires a large number of disposable catheters or a large amount of water and disinfectant. We made titanium dioxide (TiO(2))-coated catheters for CIC using technology we have developed previously, and examined the photocatalytic antibacterial effect of this catheter using only light energy and the safety of this type of catheter for practical clinical use. METHODS: TiO(2)-coated catheters were filled with bacterial cell suspensions and illuminated with a 15-W black-light lamp for testing antibacterial potency. Next, we soaked control toxic materials (zinc diethyldithiocarbamate) and the tips of TiO(2)-coated catheters in M05 medium, and evaluated cell toxicity from the numbers of V79 colonies in these dilutions. Then, bodyweight curves and histological tissue changes were observed over a period of time in mouse-transplanted TiO(2)-coated catheters and control catheters. Finally, we investigated the use of these TiO(2)-coated catheters in 18 patients by questionnaire and bacterial culture of TiO(2)-coated catheters and control catheters. RESULTS: The survival rate of Escherichia coli in the liquid inside the TiO(2) catheter decreased to a negligible level within 60 min under ultraviolet (UV)-A illumination. The survival rate of Staphylococcus aureus, Pseudomonas aeruginosa and Serratia marcescens also decreased to a negligible level within 60 min. V79 cells showed no cytotoxicity of this catheter, and there was no difference in bodyweight or foreign body reaction between mouse-transplanted TiO(2)-coated catheters and control catheters. In a preliminary clinical analysis of 18 patients who voluntarily used this catheter, the rate of positive bacterial culture of the tips of TiO(2)-coated catheters was 20% versus 60% for conventional catheters after 4 weeks of use. CONCLUSION: TiO(2)-coated silicone catheters were easily sterilized under certain light sources and were shown to be safe in an experiment using cultured cells and in animal experiments. Sterilizing catheters with TiO(2) photocatalyst thin films are expected to be used clinically for clean intermittent catheterization after proper modification based on this study.     

微波加热对脱钙骨基质诱导活性的影响

为了观察不同时间、温度微波加热后脱钙骨基质诱导活性的变化,作者以２４只成年纯种新西兰白兔为实验对象,随机分为２周（７只）、４周（７只）８周（５只）、１２周（５只）四个时间组。取兔左下肢胫骨用电锯锯成长度为０．８ｃｍ的移植骨６块,行微波加热。按不同时间、温度分为：３７℃、３０分钟组为１组;４５℃、３０分钟为Ⅱ且：６０℃、３０分钟为Ⅲ组;７５℃、３０分钟为Ⅳ组;７５℃、６０分钟为Ⅴ组;１００℃、３０分     

The systemic effects of intermittent claudication are reversed by angioplasty.

INTRODUCTION: exercise in patients with intermittent claudication causes systemic effects, the consequences of which are unknown. This study investigates whether successful PTA reverses the systemic effects. PATIENTS AND METHODS: ten patients with IC were recruited prior to PTA. Having emptied their bladders and rested for 1 h, pre-exercise blood and urine samples were collected. Patients underwent treadmill exercise to maximum walking time and blood samples were collected at 10, 20 and 30 min. A second urine sample was collected at 60 min. Total antioxidant capacity (TAC) and von Willebrands Factor (vWF) were measured in blood and albumin/creatinine ratio (ACR) and retinol binding protein/creatinine ratio (RBP/Cr) in urine. Patients were recalled 2 weeks after successful angioplasty and the protocol repeated. Following PTA patients walked for a maximum of 5 min. RESULTS: there was no significant change in vWF. Exercise in claudicants induced a significant increase in median ACR (pre/post exercise=0.85 p =0.03) and in median RBP/Cr (pre/post exercise=1.8 p =0.04). These changes were no longer evident after successful PTA. TAC was significantly different before and after angioplasty at all time intervals. CONCLUSION: successful PTA reverses glomerular effects of exercise in claudicants. Future work should investigate the use of PTA in conjunction with exercise in the treatment of peripheral vascular disease.     

The effects of long-term medical treatment combined with clean intermittent catheterization in children with neurogenic detrusor overactivity

Objectives  

To assess whether conservative treatment of pediatric patients with neurogenic detrusor overactivity (NDO) results in lower bladder pressure and increased expected bladder volume (EBV), we investigated the clinical and urodynamic effects of long-term intravesical oxybutynin instillation compared with a standard treatment of oral anticholinergic medication in patients with clean intermittent catheterization (CIC).     

Feasibility and outcome of clean intermittent catheterization for children with sensate urethra

Objective:

Clean intermittent catheterization (CIC) is an important asset in managing children with noncompliant bladders. We review the feasibility and late outcomes of patients with normal urethral sensation who began CIC.

Materials and methods:

We reviewed all patients with posterior urethral valve (PUV) or non-neuropathic bladder sphincter dysfunction (NNBSD) who began on CIC, and had at least 2 years of follow-up. We considered their age, indication, acceptance and compliance with CIC. Additionally, we examined the late outcome of bladder function and the need for any surgical intervention at follow-up.

Results:

Between 1999 and 2006, 52 patients with PUV (38 patients) or NNBSD (14 patients) were started on CIC. Of these 52 patients, 48% were under the age of 4. A total of 44 patients (85%) accepted the recommendation for CIC, and 34 patients (65%) were compliant with the protocol after at least 2 years of follow-up. The age of the patients was the only significant factor related to the success of the protocol (4 years old or younger, p = 0.03). After at least 2 years of follow-up, 28 patients (54%) remained on CIC and have not required urinary diversion or bladder reconstruction.

Conclusion:

The current study showed that CIC is a feasible option for patients with sensate urethra, which necessitates the introduction of treatment as early as possible. Further, those patients who are compliant with the CIC demonstrated a better chance of avoiding subsequent surgical intervention for the management of a non-compliant bladder.     

The outcome of voiding dysfunction managed with clean intermittent catheterization in neurologically and anatomically normal children

OBJECTIVE: To describe the tolerability and efficacy of clean intermittent catheterization (CIC) in the management of dysfunctional voiding in patients who are neurologically and anatomically normal. PATIENTS AND METHODS: The medical records were reviewed in 23 patients (16 girls, mean age 9 years, range 6-14.5, and seven males, mean age 8 years, range 5-20.5) with urinary incontinence and/or urinary tract infection (UTI) who were offered CIC because they had a large postvoid residual urine volume (PVR). All had extensive instruction before starting CIC. All patients underwent urodynamic studies, and urinary and fecal elimination habits were recorded. Detrusor hyperactivity, when present, was treated with anticholinergic medication. The follow-up evaluation included tolerance of CIC, continence status and the incidence of UTI. Behavioural modification or biofeedback training was not used in any patient. RESULTS: Of the 23 patients, 13 presented with both UTI and urinary incontinence, five with incontinence only, four with UTI only, one with frequency and no incontinence, and one with haematuria. Associated symptoms included frequency/urgency, constipation or soiling, and straining to void or incomplete emptying (in nine each), and infrequent voiding in six. CIC was performed within 2 days by 15 patients, while four others required up to 2 weeks to master CIC. However, three of the four patients (all older girls) who needed 2 weeks to learn the technique did not tolerate CIC and discontinued it within 3 weeks. Four other adolescents (three girls and one boy) refused to learn CIC. Of the 16 patients remaining on CIC only three had cystitis; no patient had a febrile UTI. Once successfully instituted, all patients became continent while on CIC. Six boys (mean follow-up 4 months) had a marked decrease in their PVR. CIC was discontinued in three girls who voided normally to emptiness within 6 months of starting CIC; they remained dry and infection-free 16 months (two) and 6 years later. CONCLUSION: CIC is a viable therapeutic option for the treatment of dysfunctional voiding, associated with a large PVR, in the absence of any neurological abnormality. CIC is well tolerated in the sensate patient and provides a means for expeditiously achieving continence and improving bladder emptying cost-effectively.     

The effect of intermittent local heating on fracture healing in the distal tibia of the rabbit

Summary Two series of controlled experiments were carried out to investigate the effect of intermittent local heating on fracture healing in the distal tibia of the rabbit. In the first series, the distal tibia was fractured in a reproducible manner and then treated by compression plate fixation. Nine animals received intermittent local heating around the fracture site for 6 weeks postoperatively in comparison with 5 control animals. The mechanical strength of the healed tibia was then measured in a standardized 3-point bend test. Intermittent local heating produced stronger bones than the untreated controls in 6 of the 9 cases, a result which was marginally significant (P=0.055). In the second series of experiments, a reproducible bone defect was created by drilling a 2 mm diameter hole through the distal tibia; compression plate stabilization was not required. Fourteen animals received intermittent local heating around the fracture site for 3 weeks postoperatively in comparison with 7 control animals. Intermittent local heating produced stronger bones than the untreated controls in 8 of the 14 cases, a result which was not significant (P>0.1). It is concluded that intermittent local heating of the type studied has too small an effect on accelerating the rate of fracture repair to be clinically useful.

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Résumé Deux séries d'expérimentations contrôlées ont été effectuées dans le but d'évaluer les effets de l'échauffement local intermittent sur la consolidation des fractures au niveau de l'extrémité distale du tibia du lapin. Dans la première série, le tibia était fracturé de façon reproductible et traité par mise en place d'une plaque à compression. Neuf animaux furent soumis à un échauffement intermittent a niveau du foyer de fracture pendant six semaines post-opératoires et comparés à cinq animaux de contrôle. La résistance mécanique du tibia consolidé fut alors mesurée grâce à un test de flexion standardisé. L'échauffement local intermittent détermina des os plus solides que ceux des animaux non traités dans six cas sur neuf. Ce résultat était légèrement significatif (P=0,055). Dans la deuxième série, on créa une perte de substance osseuse reproductible en forant un trou de 2 mm de diamètre au travers du tibia, à sa partie distale. On n'utilisa pas de plaque de fixation. Quatorze animaux bénéficièrent d'un échauffement intermittent du foyer de fracture pendant trois semaines postopératoires et furent comparés à sept animaux de contrôle. L'échauffement local intermittent produisit des os plus solides que ceux des témoins dans huit des quatorze cas, ce qui n'était pas significatif (P>0,1). On peut en conclure que l'échauffement local intermittent, selon les modalités étudiées, n'a qu'un trop faible effet sur l'accélération du temps de consolidation des fractures pour pouvoir être utilisé en clinique.

     

Long-term metabolic effects of urinary diversion: a comparison of myelomeningocele patients managed by clean intermittent catheterization and urinary diversion.

We previously reported that chronic urinary diversion through intestinal segments may have adverse effects on bone and mineral metabolism. This study examined the long-term health of patients managed by urinary diversion (94% by ileal conduit) for neuropathic bladders secondary to myelomeningocele defects and compared them to a control population of myelomeningocele patients managed by intermittent catheterization. Of the patients 93 were studied by personal interview, chart review, morphometric analysis, serum studies and dual-photon bone density determination. Average followup was 23 +/- 6 years in the urinary diversion group and 17 +/- 5 years in the intermittent catheterization group. Fractures occurred in 40% of the patients in both groups. Patients with a urinary diversion had an increased need for surgery to correct spinal curvature (57% versus 40%) and a significantly increased incidence of complications resulting from orthopedic procedures (17% versus 3%, p less than or equal to 0.05). There was also an adverse effect on renal function. The urinary diversion group had an increased incidence of radiographic renal deterioration (57% versus 8%, p less than 0.001), nephrolithiasis (43% versus 2%, p less than 0.001), pyelonephritis (60% versus 21%, p less than 0.001) and intermittent metabolic acidosis (20% versus 5%, p = 0.05). Surgery was required in 37% for stomal complications and in 17% for ureterointestinal stricture. Linear growth was adversely affected by urinary diversion. Patients with urinary diversion had decreased lengths for all morphometric parameters and a greater percentage of them were at or below the 10th percentile standards. Serum electrolytes, liver function studies, vitamin D3 and parahormone showed no differences in the 2 groups. No patient had a significant metabolic acidosis at the time of study. Bone densities were significantly diminished in both groups and not significantly different. This study strongly suggests that urinary diversion through intestinal segments is associated with adverse effects on bone health.