Effective Neurogenic Bladder Management to Minimize Hospitalization and ED Visits
By Todd J. Doran, MS, PA-C
Earn 2.0 CEUs for this e-learning opportunity.
March 5, 2012
The purpose of this article is to familiarize ourselves with contemporary neurogenic bladder (NGB) management while minimizing the overtreatment of urinary tract infections (UTIs) in this colonized population. Treatment of this population is complex due to the complicated medical and social history typically involved (i.e., polypharmacy, multiple allergies to environmental/medications, injury/surgical history, psychiatric comorbidity, social support or lack thereof, and insurance coverage). This population rarely has case managers and the healthcare disparity that exists boils down to family/financial support and strength of their insurance coverage. This article will outline a simple approach to this population that will decrease office calls and minimize the overtreatment of UTIs, while discussing the appropriate referral to specialty care.
Case Study: An Initial Look
A 32-year-old male, T4 complete spinal cord injury (SCI) patient on Medicaid presents to the emergency department (ED) complaining of two-day history of dark urine, odor and debris. He performs clean intermittent catheterization (CIC) four times per day with difficulty, reuses catheters, and leaks between catheterizations despite maximal antimuscarinic therapy. He sees you in follow up as a new patient with a foley catheter on antibiotics and urine culture shows mixed gram positive organisms. What treatment principles can you employ to minimize hospitalization and ED visits?
Adequate Support and Evaluation
I would argue that the patient above shouldn’t even be seeking treatment -- yet. We see patients at the end of both spectrums: those seeking treatment at the earliest sign of a UTI and those seeking treatment late when they are inpatient and ill. All NGB/catheterizing patients should be engaged in a therapeutic clinic relationship, defined by being seen at least annually and should receive verbal and written instructions regarding suspected UTI. Suspected UTI complaint can be handled via a nurse clinic visit on a walk-in basis. Specialists should work with the patient’s local primary care physician (PCP) when appropriate to obtain the necessary studies. Odor, discolored urine, and debris drive the majority of suspected UTI complaints, but those complaints must also accompany other systemic signs/symptoms to warrant evaluation and treatment because diet, hydration, or variation in catheterization schedule can explain the typical above complaints. The additional signs or symptoms to assess are fever, nausea, vomiting, night sweats, dysuria, change in urgency/frequency/urinary incontinence, suprapubic pain, costovertebral angle/flank pain, lethargy/fatigue, elevated white blood count (WBC), pyuria (>10 WBC/hpf), increased spasticity, or dysreflexia.
The minimum evaluation includes a clean catch urinalysis with microscopy (UA) with a new catheter and possibly bladder barbotage to obtain a sample. All UAs must be sent for culture and requesting the lab report all organisms cultured with sensitivities can be helpful in guiding treatment decisions. Documenting urine culture results can be helpful to provide evidence when ordering a sterile closed catheter system or sterile catheter with insertion supplies, as well as determining if further anatomic evaluation is necessary. Additional lab evaluation may include a complete blood count and basic metabolic panel. Diagnostic imaging includes CT abdomen/pelvis without contrast, abdominal ultrasound, or a kidneys, ureter and bladder (KUB) X-ray. The goals in supporting this population are for patients to use single use sterile catheters, obtain them via mail order and to facilitate early outpatient evaluation and treatment for systemic signs/symptoms consistent with a UTI, while eliminating treatment of asymptomatic bacturia.
Back to our case. Solution to pollution is dilution. Encourage the patient above to drink enough fluid to produce two liters of urine a day and perform CIC four to six times per day with a single use catheter on an even time interval. Urine should be sent for culture and a decision to treat can be delayed until the urine culture is resulted 24-48 hours later. Often, the patient feels better and the urine culture result grows mixed organisms.
The first intervention in a patient that presents for evaluation with an indwelling catheter is to change the catheter and if possible convert to CIC or condom catheter. All urine samples are obtained via new catheter and not from drainage bags. Old urine culture results can be used to guide treatment while waiting for the present urine culture. Empiric antibiotic choices include fluoroquinolones, aminopenicillins with betalactamase inhibitors, cephalosporins (Group 2 or 3a) or an aminoglycoside and length of treatment of seven days should be sufficient. Follow up urine cultures for test of cure are not performed in this population, and prophylactic antibiotics are not successful and can lead to multidrug resistant strains.
The risks of chronic indwelling urinary catheters are bladder cancer, urinary stones, urethral stricture disease, acquired hypospadias, and bladder neck/sphincter erosion. All are troublesome, if not catastrophic and are preventable. If a chronic indwelling catheter is necessary due to poor hand function, difficult urethra/sphincter, or lack of social support, then conversion to a suprapubic tube essentially eliminates bladder neck/sphincter erosion, urethral stricture disease and acquired hypospadias.
When to Refer to a Specialist
Patients with NGB can expect to have one to two symptomatic UTIs per year with systemic symptoms listed previously. Important history to obtain is a change from patient’s baseline status prompting urologic referral. Important changes include worsening severity/frequency of UTI, new onset/worsening urinary incontinence, gross hematuria, or difficulty catheterizing. Evaluation of the upper urinary tracts with CT abdomen/pelvis without contrast, renal ultrasound or KUB X-ray are aimed at detecting calculi in the upper tracts, followed by video urodynamics and office cystoscopy. If gross hematuria is present with risk factors for bladder cancer then phased contrast CT (if no renal insufficiency) and urine cytology is performed along with the evaluation listed above.
Urologic evaluation is aimed at detecting urinary calculi, bladder cancer, urinary reflux, or poor bladder compliance (normal bladder compliance means that intraluminal bladder pressure should remain a constant with increasing volume), while assessing sphincter function and bladder capacity. Treatment aimed at correcting the above problems will typically resolve frequent UTIs and urinary incontinence, thereby reducing the risk of deteriorating renal function caused by poor bladder compliance and urinary reflux.
In the above case study, the office visit should concentrate on converting him to single-use catheters and setting him up with mail-order catheters and lube. Explaining the concept of asymptomatic bacturia due to colonization and the importance in avoiding unnecessary antibiotics lessens the risk of developing multidrug resistant organisms. Describing those systemic symptoms suggestive of UTI and when to seek treatment, while facilitating outpatient evaluation will minimize ED visits. Recognizing when to refer for urologic evaluation will ultimately lead to fewer hospitalizations and preservation of renal function and the lower urinary tract.
Hollister Inc.- Principal Investigator and Advisory Board
Allergan Inc.- Speaker’s Bureau
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Todd J. Doran, MS, PA-C, is an associate in urologic surgery in the Department of Urologic Surgery at Vanderbilt University. He received his B.S. in Sports Medicine from Willamette University in 1989 and his M.S. in Human Performance from Oregon State University in 1997. His early career was in Sports Medicine when he decided to attend physician assistant school and received his BCHS from University of Washington in 1997 on a Navy HSCP scholarship. He was active duty from 1995-2004 and stationed at BMC Parris Island, SC, BMC Kaneohe Bay, HI and NMC San Diego. His clinical assignments included family medicine, emergency medicine and urology. Mr. Doran was deployed with 1st Marines for the initial assault in Iraq in 2003 in Operation Enduring Freedom/Iraqi Freedom and was assigned to Charlie Surgical Company. He joined the Department of Urologic Surgery in 2004 and his clinical practice and research focus include complex voiding dysfunction, sexual dysfunction and reconstructive surgery. He’s also adjunct faculty in the Physician Assistant Program at Trevecca University teaching first and second year students and performs clinical precepting.