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1.  Hydrophilic Catheters 
Executive Summary
To review the evidence on the effectiveness of hydrophilic catheters for patients requiring intermittent catheterization.
Clinical Need
There are various reasons why a person would require catheterization, including surgery, urinary retention due to enlargement of the prostate, spinal cord injuries, or other physical disabilities. Urethral catheters are the most prevalent cause of nosocomial urinary tract infections, that is, those that start or occur in a hospital.
A urinary tract infection (UTI) occurs when bacteria adheres to the opening of the urethra. Most infections arise from Escherichia coli, from the colon. The bacteria spread into the bladder, resulting in the development of an infection.
The prevalence of UTIs varies with age and sex. There is a tenfold increase in incidence for females compared with males in childhood and throughout adult life until around 55 years, when the incidence of UTIs in men and women is equal, mostly as a consequence of prostatic problems in men. Investigators have reported that urethritis (inflammation of the urethra) is found in 2% to 19% of patients practising intermittent catheterization.
The Technology
Hydrophilic catheters have a polymer coating that binds o the surface of the catheter. When the polymer coating is submersed in water, it absorbs and binds the water to the catheter. The catheter surface becomes smooth and very slippery. This slippery surface remains intact upon insertion into the urethra and maintains lubrication through the length of the urethra. The hydrophilic coating is designed to reduce the friction, as the catheter is inserted with the intention of reducing the risk of urethral damage.
It has been suggested that because the hydrophilic catheters do not require manual lubrication they are more sterile and thus less likely to cause infection. Most hydrophilic catheters are prepackaged in sterile water, or there is a pouch of sterile water that is broken and released into the catheter package when the catheter is ready to use.
Review Strategy
The Medical Advisory Secretariat searched for reports of systematic reviews of randomized controlled trials (RCTs), meta-analyses of RCTs, and RCTs. The following databases were searched: Cochrane Library International Agency for Health Technology Assessment (fourth quarter 2005), Cochrane Database of Systematic Reviews (fourth quarter 2005), Cochrane Central Register of Controlled Trials (fourth quarter 2005), MEDLINE (1966 to the third week of November 2005), MEDLINE In-Process and Other Non-indexed Citations (1966 to November 2005), and EMBASE (1980 to week 49 in 2005). Search terms were urinary catheterization, hydrophilic, intermittent, and bladder catheter.
The Medical Advisory Secretariat also conducted Internet searches of Medscape ( for recent reports on trials that were unpublished but presented at international conferences. In addition, the Web site Current Controlled Trials ( was searched for ongoing trials on urinary catheterization.
Summary of Findings
Five RCTs were identified that compared hydrophilic catheters to standard catheters. There was substantial variation across the studies in terms of the reason for catheterization, inclusion criteria, and type of catheter used. Two studies used reusable catheters in the control arm, while the other 3 RCTs used single-use catheters in the control arm. All 5 RCTs focused mainly on males requiring intermittent catheterization. Age varied considerably across studies. One study consisted of young males (mean age 12 years), while another included older males (mean age 71 years).
The RCTs reported conflicting results regarding the effectiveness of the hydrophilic catheters compared with standard catheters in terms of rates of UTIs. All 5 RCTs had serious limitations. Two of the studies were small, and likely underpowered to detect significant differences between groups. One RCT reported 12-month follow-up data for all 123 patients even though more than one-half of the patients had dropped out of the study by 12 months. Another RCT had unequal groups at baseline: the patients in the hydrophilic group had twice the mean number of UTIs at baseline compared with the standard catheter group. The fifth RCT used catheters to treat patients with bladder cancer; therefore, the results of their study are not generalizable to the population requiring intermittent catheterization.
Two studies did not find significant differences between the hydrophilic and standard catheter groups for patient satisfaction. Another RCT reported conflicting results; however, the overall opinion of the catheters was not significantly different between the treatment groups. A fourth RCT found that the hydrophilic catheters were substantially more comfortable than standard catheters. The fifth RCT did not report results for quality of life or patient satisfaction. Similar to the results for effectiveness, it is not possible to clearly establish if there is a significant difference in patient satisfaction between the patients using hydrophilic catheters and those using standard catheters.
Patients requiring intermittent catheterization use, on average, 4 to 5 intermittent catheters per day. Patients admitted to hospitals using intermittent catheters typically do not reuse catheters, owing to the potential increased risk of infection in hospital. Patients self-catheterizing at home are more likely to reuse catheters. Standard catheters cost about $1.00 to $1.50/catheter. Hydrophilic catheters cost about $2.00 to $5.00/catheter, depending on the type and whether they have antibiotics inside. All hydrophilic catheters are single-use.
At this time there is insufficient evidence to indicate whether hydrophilic catheters are associated with a lower rate of UTIs and improved patient satisfaction among people requiring intermittent catheterization.
PMCID: PMC3386556  PMID: 23074500
2.  Portable Bladder Ultrasound 
Executive Summary
The aim of this review was to assess the clinical utility of portable bladder ultrasound.
Clinical Need: Target Population and Condition
Data from the National Population Health Survey indicate prevalence rates of urinary incontinence are 2.5% in women and 1.4 % in men in the general population. Prevalence of urinary incontinence is higher in women than men and prevalence increases with age.
Identified risk factors for urinary incontinence include female gender, increasing age, urinary tract infections (UTI), poor mobility, dementia, smoking, obesity, consuming alcohol and caffeine beverages, physical activity, pregnancy, childbirth, forceps and vacuum-assisted births, episiotomy, abdominal resection for colorectal cancer, and hormone replacement therapy.
For the purposes of this review, incontinence populations will be stratified into the following; the elderly, urology patients, postoperative patients, rehabilitation settings, and neurogenic bladder populations.
Urinary incontinence is defined as any involuntary leakage of urine. Incontinence can be classified into diagnostic clinical types that are useful in planning evaluation and treatment. The major types of incontinence are stress (physical exertion), urge (overactive bladder), mixed (combined urge and stress urinary incontinence), reflex (neurological impairment of the central nervous system), overflow (leakage due to full bladder), continuous (urinary tract abnormalities), congenital incontinence, and transient incontinence (temporary incontinence).
Postvoid residual (PVR) urine volume, which is the amount of urine in the bladder immediately after urination, represents an important component in continence assessment and bladder management to provide quantitative feedback to the patient and continence care team regarding the effectiveness of the voiding technique. Although there is no standardized definition of normal PVR urine volume, measurements greater than 100 mL to 150 mL are considered an indication for urinary retention, requiring intermittent catheterization, whereas a PVR urine volume of 100 mL to 150 mL or less is generally considered an acceptable result of bladder training.
Urinary retention has been associated with poor outcomes including UTI, bladder overdistension, and higher hospital mortality rates. The standard method of determining PVR urine volumes is intermittent catheterization, which is associated with increased risk of UTI, urethral trauma and discomfort.
The Technology Being Reviewed
Portable bladder ultrasound products are transportable ultrasound devices that use automated technology to register bladder volume digitally, including PVR volume, and provide three-dimensional images of the bladder. The main clinical use of portable bladder ultrasound is as a diagnostic aid. Health care professionals (primarily nurses) administer the device to measure PVR volume and prevent unnecessary catheterization. An adjunctive use of the bladder ultrasound device is to visualize the placement and removal of catheters. Also, portable bladder ultrasound products may improve the diagnosis and differentiation of urological problems and their management and treatment, including the establishment of voiding schedules, study of bladder biofeedback, fewer UTIs, and monitoring of potential urinary incontinence after surgery or trauma.
Review Strategy
To determine the effectiveness and clinical utility of portable bladder ultrasound as reported in the published literature, the Medical Advisory Secretariat used its standard search strategy to retrieve international health technology assessments and English-language journal articles from selected databases. Nonsystematic reviews, nonhuman studies, case reports, letters, editorials, and comments were excluded.
Summary of Findings
Of the 4 included studies that examined the clinical utility of portable bladder ultrasound in the elderly population, all found the device to be acceptable. One study reported that the device underestimated catheterized bladder volume
In patients with urology problems, 2 of the 3 studies concerning portable bladder ultrasound found the device acceptable to use. However, one study did not find the device as accurate for small PVR volume as for catheterization and another found that the device overestimated catheterized bladder volume. In the remaining study, the authors reported that when the device’s hand-held ultrasound transducers (scanheads) were aimed improperly, bladders were missed, or lateral borders of bladders were missed resulting in partial bladder volume measurements and underestimation of PVR measurements. They concluded that caution should be used in interpreting PVR volume measured by portable bladder ultrasound machines and that catheterization may be the preferred assessment modality if an accurate PVR measurement is necessary.
All 3 studies with post-operative populations found portable bladder ultrasound use to be reasonably acceptable. Two studies reported that the device overestimated catheter-derived bladder volumes, one by 7% and the other by 21 mL. The third study reported the opposite, that the device underestimated catheter bladder volume by 39 mL but that the results remained acceptable
In rehabilitation settings, 2 studies found portable bladder ultrasound to underestimate catheter-derived bladder volumes; yet, both authors concluded that the mean errors were within acceptable limits.
In patients with neurogenic bladder problems, 2 studies found portable bladder ultrasound to be an acceptable alternative to catheterization despite the fact that it was not as accurate as catheterization for obtaining bladder volumes.
Lastly, examinations concerning avoidance of negative health outcomes showed that, after use of the portable bladder ultrasound, unnecessary catheterizations and UTIs were decreased. Unnecessary catheterizations avoided ranged from 16% to 47% in the selected articles. Reductions in UTI ranged from 38% to 72%.
In sum, all but one study advocated the use of portable bladder ultrasound as an alternative to catheterization.
Economic Analysis
An economic analysis estimating the budget-impact of BladderScan in complex continuing care facilities was completed. The analysis results indicated a $192,499 (Cdn) cost-savings per year per facility and a cost-savings of $2,887,485 (Cdn) for all 15 CCC facilities. No economic analysis was completed for long-term care and acute care facilities due to lack of data.
Considerations for Policy Development
Rapid diffusion of portable bladder ultrasound technology is expected. Recently, the IC5 project on improving continence care in Ontario’s complex continuing care centres piloted portable bladder ultrasound at 12 sites. Preliminary results were promising.
Many physicians and health care facilities already have portable bladder ultrasound devices. However, portable bladder ultrasound devices for PVR measurement are not in use at most health care facilities in Ontario and Canada. The Verathon Corporation (Bothell, Wisconsin, United States), which patents BladderScan, is the sole licensed manufacturer of the portable bladder ultrasound in Canada. Field monopoly may influence the rising costs of portable bladder ultrasound, particularly when faced with rapid expansion of the technology.
Several thousand residents of Ontario would benefit from portable bladder ultrasound. The number of residents of Ontario that would benefit from the technology is difficult to quantify, because the incidence and prevalence of incontinence are grossly under-reported. However, long-term care and complex continuing care institutions would benefit greatly from portable bladder ultrasound, as would numerous rehabilitation units, postsurgical care units, and urology clinics.
The cost of the portable bladder ultrasound devices ranges from $17,698.90 to $19,565.95 (Cdn) (total purchase price per unit as quoted by the manufacturer). Additional training packages, batteries and battery chargers, software, gel pads, and yearly warranties are additional costs. Studies indicate that portable bladder ultrasound is a cost-effective technology, because it avoids costs associated with catheterization equipment, saves nursing time, and reduces catheter-related complications and UTIs.
The use of portable bladder ultrasound device will affect the patient directly in terms of health outcomes. Its use avoids the trauma related to the urinary tract that catheterization inflicts, and does not result in UTIs. In addition, patients prefer it, because it preserves dignity and reduces discomfort.
PMCID: PMC3379524  PMID: 23074481
3.  Current Trends in the Management of Difficult Urinary Catheterizations 
Routine urinary catheter placement may cause trauma and poses a risk of infection. Male catheterization, in particular, can be difficult, especially in patients with enlarged prostate glands or other potentially obstructive conditions in the lower urinary tract. Solutions to problematic urinary catheterization are not well known and when difficult catheterization occurs, the risk of failed catheterization and concomitant complications increase. Repeated and unsuccessful attempts at urinary catheterization induce stress and pain for the patient, injury to the urethra, potential urethral stricture requiring surgical reconstruction, and problematic subsequent catheterization. Improper insertion of catheters also can significantly increase healthcare costs due to added days of hospitalization, increased interventions, and increased complexity of follow-up evaluations. Improved techniques for catheter placement are essential for all healthcare personnel involved in the management of the patient with acute urinary retention, including attending emergency physicians who often are the first physicians to encounter such patients. Best practice methods for blind catheter placement are summarized in this review. In addition, for progressive clinical practice, an algorithm for the management of difficult urinary catheterizations that incorporates technology enabling direct visualization of the urethra during catheter insertion is presented. This algorithm will aid healthcare personnel in decision making and has the potential to improve quality of care of patients.
PMCID: PMC3555603  PMID: 23359117
4.  Urinary Catheterization in Medical Wards 
The study aims to determine the: 1. frequency of inappropriate catheterization in medical wards and the reasons for doing it. 2. various risk factors associated with inappropriate catheterization, catheter associated urinary tract infections (CAUTI) and bacterial colonization on Foley's catheters (BCFC).
Settings and Design:
Hospital-based prospective study.
Materials and Methods:
One hundred and twenty five patients admitted consecutively in the medical wards of a tertiary care hospital, who underwent catheterization with a Foley's catheter, at admission, have been included in the study. Patient profiles were evaluated using the following parameters: age, sex, diagnosis, functional status, mental status, indication, duration and place of catheterization, development of BCFC and CAUTI.
Statistical tests used:
Chi-square test.
Thirty-six out of 125 (28.8%) patients included were inappropriately catheterized. BCFC developed in 52.8% and 22.4% were diagnosed with a CAUTI. The most frequent indication for inappropriate catheterization was urinary incontinence without significant skin breakdown (27.8%). The risk factors for inappropriate catheterization were female sex (RR=1.29, 95% CI=0.99, 1.69, P<0.05) and catheterization in the emergency (RR=0.74, 95% CI=0.61, 0.90, P<0.05). The risk factors for developing a BCFC were age>60 years (RR=0.65, 95% CI=0.48, 0.89, P<0.05), non-ambulatory functional status (RR=0.57, 95% CI=0.39, 0.84, P<0.01), catheterization in the emergency (RR=2.01, 95% CI=1.17, 3.46, P<0.01) and duration of catheterization>3 days (RR=0.62, 95% CI=0.43, 0.89, P<0.01). The risk factors for acquiring a CAUTI were age>60 years (RR=0.47, 95% CI=0.25, 0.90, P<0.05), impaired mental status (RR=0.37, 95% CI=0.18, 0.77, P<0.01) and duration of catheterization>3 days (RR=0.24, 95% CI=0.10, 0.58, P<0.01).
Inappropriate catheterization is highly prevalent in medical wards, especially in patients with urinary incontinence. The patients catheterized in the medical emergency and female patients in particular are at high risk. Careful attention to these factors can reduce the frequency of inappropriate catheterization and unnecessary morbidity.
PMCID: PMC2889669  PMID: 20606958
Bacterial colonization on Foley's catheters; Catheter associated urinary tract infections; Inappropriate catheterization; Medical wards
5.  Multimodal Supervision Programme to Reduce Catheter Associated Urinary Tract Infections and Its Analysis to Enable Focus on Labour and Cost Effective Infection Control Measures in a Tertiary Care Hospital in India 
Catheter Associated Urinary Tract Infections (CAUTI) contribute 30%-40% of all the nosocomial infections and they are associated with substantially increased institutional death rates. A multimodal supervision program which incorporates training of the staff with respect to infection control measures can be effective in reducing the CAUTIs in hospitals.
To assess the impact of a multimodal UTI supervision program on the CAUTI rates over a year, from January 2009 to December 2009, in a tertiary care hospital in India.
A 215 bedded tertiary care private hospital.
Materials and Methods
The CAUTI rates were analyzed for the first 6 months (January 2009-June 2009). A UTI supervision program was instituted in the month of July 2009, which included training with respect to the standard protocols for the sample collection and diagnosis, the bundle components of the urinary catheter checklist and hand hygiene practices. The impact was assessed as per the CAUTI rates in the subsequent months.
The average CAUTI rate was reduced by 47.1% (from 10.6 to 5.6) after the introduction of the supervision program. This study presented the mean age of the patients with CAUTIs as 54.5 years and it showed an approximately equal contribution of both the sexes (52.94% in males and 47.05% in females). The impact analysis of the supervision program showed a reduction of 8.7% (from 23 days to 21 days) during the average duration of the catheterization. The adherence to the components of the urinary catheter check list was increased by 44.4% (p=0.069) and the hand hygiene compliance was increased by 56.4% (p=0.004) respectively after the interventions. Components like bladder irrigation and practising perineal cleaning were found to show no effect on the CAUTI rates.
The most common labour and cost effective infection control measures as revealed by the supervision programme were adherence to the urinary catheter checklist components (indication for catheter insertion and change, asepsis maintenance during and after the catheter insertion and avoiding urine reflux) and hand hygiene practices, whereas bladder irrigation and practising perineal cleaning thrice a day were unnecessary measures.
PMCID: PMC3471501  PMID: 23205350
Multimodal UTI supervision program; Risk stratification; CAUTI rates; Labour and cost effective interventions
6.  Long-term Urinary Catheter Users Self-Care Practices and Problems 
Journal of clinical nursing  2013;22(0):356-367.
The aims were to characterize a sample of 202 adult community-living long-term indwelling urinary catheter users, to describe self-care practices and catheter problems, and to explore relationships among demographics, catheter practices, and problems.
Long-term urinary catheter users have not been well studied, and persons using the device indefinitely for persistent urinary retention are likely to have different patterns of catheter practices and problems.
The study was a cross-sectional descriptive and exploratory analysis.
Home interviews were conducted with catheter users who provided information by self-reported recall over the previous two months. Data were analyzed by descriptive statistics and tests of association between demographics, catheter practices, and catheter problems.
The sample was widely diverse in age (19–96 years), race, and medical diagnosis. Urethral catheters were used slightly more often (56%) than suprapubic (44%), for a mean of 6 yrs. (SD 7 yrs.). Many persons were highly disabled, with 60% having difficulty in bathing, dressing, toileting, and getting out of the bed; 19% also required assistance in eating. A high percentage of catheter problems were reported with: 43% experiencing leakage (bypassing of urine), 31% having had a urinary tract infection, 24% blockage of the catheter, 23% catheter-associated pain, and 12% accidental dislodgment of the catheter. Treatments of catheter-related problems contributed to additional health care utilization including extra nurse or clinic visits, trips to the emergency department, or hospitalization. Symptoms of catheter associated urinary tract infections were most often related to changes in the color or character of urine or generalized symptoms.
Catheter related problems contribute to excess morbidity and health care utilization and costs.
Relevance to clinical practice
More research is needed in how to minimize catheter associated problems in long-term catheter users. Information from this study could help inform the development of interventions in this population.
PMCID: PMC3915411  PMID: 23301577
urinary catheterization; nursing; urinary tract infection; urinary retention; complications; self-care
7.  Non-inferiority of short-term urethral catheterization following fistula repair surgery: study protocol for a randomized controlled trial 
BMC Women's Health  2012;12:5.
A vaginal fistula is a devastating condition, affecting an estimated 2 million girls and women across Africa and Asia. There are numerous challenges associated with providing fistula repair services in developing countries, including limited availability of operating rooms, equipment, surgeons with specialized skills, and funding from local or international donors to support surgeries and subsequent post-operative care. Finding ways of providing services in a more efficient and cost-effective manner, without compromising surgical outcomes and the overall health of the patient, is paramount. Shortening the duration of urethral catheterization following fistula repair surgery would increase treatment capacity, lower costs of services, and potentially lower risk of healthcare-associated infections among fistula patients. There is a lack of empirical evidence supporting any particular length of time for urethral catheterization following fistula repair surgery. This study will examine whether short-term (7 day) urethral catheterization is not worse by more than a minimal relevant difference to longer-term (14 day) urethral catheterization in terms of incidence of fistula repair breakdown among women with simple fistula presenting at study sites for fistula repair service.
This study is a facility-based, multicenter, non-inferiority randomized controlled trial (RCT) comparing the new proposed short-term (7 day) urethral catheterization to longer-term (14 day) urethral catheterization in terms of predicting fistula repair breakdown. The primary outcome is fistula repair breakdown up to three months following fistula repair surgery as assessed by a urinary dye test. Secondary outcomes will include repair breakdown one week following catheter removal, intermittent catheterization due to urinary retention and the occurrence of septic or febrile episodes, prolonged hospitalization for medical reasons, catheter blockage, and self-reported residual incontinence. This trial will be conducted among 512 women with simple fistula presenting at 8 study sites for fistula repair surgery over the course of 24 months at each site.
If no major safety issues are identified, the data from this trial may facilitate adoption of short-term urethral catheterization following repair of simple fistula in sub-Saharan Africa and Asia.
Trial registration Identifier NCT01428830.
PMCID: PMC3353217  PMID: 22433581
Vaginal fistula; Catheter; Non-inferiority randomized controlled trial; Surgery
8.  Urinary tract infections in the critical care unit: A brief review 
The use of indwelling catheters in the Critical Care Units (CCUs) has a major role in determining the incidence and the morbidity as well as mortality from hospital-acquired urinary tract infections (UTIs). Instituting evidence-based protocols can significantly reduce both the prevalence of indwelling catheterization as well as the incidence of hospital-acquired UTIs. The prevalence of catheter-associated urinary tract infections (CAUTIs) in the CCUs is directly linked to the widespread use of indwelling catheters in these settings. CAUTIs result in significant cost escalation for individual hospitals as well as the healthcare system as a whole. A UTI is an inflammatory response to colonization of the urinary tract, most commonly by bacteria or fungi. A UTI should be differentiated from the mere detection of bacteria in the urinary tract. This condition, referred to as asymptomatic bacteriuria, is common and does not require treatment, especially in the patient with an indwelling urinary catheter. A CAUTI occurs when a patient with an indwelling urinary catheter develops 2 or more signs or symptoms of a UTI such as hematuria, fever, suprapubic or flank pain, change in urine character, and altered mental status. CAUTI is classified as a complicated UTI. The current review highlights the important management issues in critical care patients having CAUTI. We performed a MEDLINE search using combinations of keywords such as urinary tract infection, critical care unit and indwelling urinary catheter. We reviewed the relevant publications with regard to CAUTI in patients in CCU.
PMCID: PMC3902573  PMID: 24501490
Catheter-associated urinary tract infection; critical care unit; urinary tract infection
9.  Stop Orders to Reduce Inappropriate Urinary Catheterization in Hospitalized Patients: A Randomized Controlled Trial 
Hospitalized patients frequently have urinary catheters inserted for inappropriate reasons. This can lead to urinary tract infections and other complications.
To assess whether stop orders for indwelling urinary catheters reduces the duration of inappropriate urinary catheterization and the incidence of urinary tract infections.
A randomized controlled trial was conducted in three tertiary-care hospitals in Ontario, Canada. Patients with indwelling urinary catheters were randomized to prewritten orders for the removal of urinary catheters if specified criteria were not present or to usual care.
Six hundred ninety-two hospitalized patients admitted to hospital with indwelling urinary catheters inserted for ≤48 h.
The main outcomes included days of inappropriate indwelling catheter use, total days of catheter use, frequency of urinary tract infection, and catheter reinsertions.
There were fewer days of inappropriate and total urinary catheter use in the stop-order group than in the usual care group (difference −1.69 [95% CI −1.23 to −2.15], P < 0.001 and −1.34 days, [95% CI, −0.64 to −2.05 days], P < 0.001, respectively). Urinary tract infections occurred in 19.0% of the stop-order group and 20.2% of the usual care group, relative risk 0.94 (95% CI, 0.66 to 1.33), P = 0.71. Catheter reinsertion occurred in 8.6% of the stop-order group and 7.0% in the usual care group, relative risk 1.23 (95% CI, 0.72 to 2.11), P = 0.45.
Stop orders for urinary catheterization safely reduced duration of inappropriate urinary catheterization in hospitalized patients but did not reduce urinary tract infections.
PMCID: PMC2517898  PMID: 18421507
urinary tract infections; urinary catheters; randomized controlled trial; stop order
10.  Novel Antiseptic Urinary Catheters for Prevention of Urinary Tract Infections: Correlation of In Vivo and In Vitro Test Results▿  
Antimicrobial Agents and Chemotherapy  2009;53(12):5145-5149.
Urinary catheters are widely used for hospitalized patients and are often associated with high rates of urinary tract infection. We evaluated in vitro the antiadherence activity of a novel antiseptic Gendine-coated urinary catheter against several multidrug-resistant bacteria. Gendine-coated urinary catheters were compared to silver hydrogel-coated Foley catheters and uncoated catheters. Bacterial biofilm formation was assessed by quantitative culture and scanning electron microscopy. These data were further correlated to an in vivo rabbit model. We challenged 31 rabbits daily for 4 days by inoculating the urethral meatus with 1.0 × 109 CFU streptomycin-resistant Escherichia coli per day. In vitro, Gendine-coated urinary catheters reduced the CFU of all organisms tested for biofilm adherence compared with uncoated and silver hydrogel-coated catheters (P < 0.004). Scanning electron microscopy analysis showed that a thick biofilm overlaid the control catheter and the silver hydrogel-coated catheters but not the Gendine-coated urinary catheter. Similar results were found with the rabbit model. Bacteriuria was present in 60% of rabbits with uncoated catheters and 71% of those with silver hydrogel-coated catheters (P < 0.01) but not in those with Gendine-coated urinary catheters. No rabbits with Gendine-coated urinary catheters had invasive bladder infections. Histopathologic assessment revealed no differences in toxicity or staining. Gendine-coated urinary catheters were more efficacious in preventing catheter-associated colonization and urinary tract infections than were silver hydrogel-coated Foley catheters and uncoated catheters.
PMCID: PMC2786341  PMID: 19805562
11.  Energy Delivery Systems for Treatment of Benign Prostatic Hyperplasia 
Executive Summary
The Ontario Health Technology Advisory Committee asked the Medical Advisory Secretariat (MAS) to conduct a health technology assessment on energy delivery systems for the treatment of benign prostatic hyperplasia (BPH).
Clinical Need: Target Population and Condition
BPH is a noncancerous enlargement of the prostate gland and the most common benign tumour in aging men. (1) It is the most common cause of lower urinary tract symptoms (LUTS) and bladder outlet obstruction (BOO) and is an important cause of diminished quality of life among aging men. (2) The primary goal in the management of BPH for most patients is a subjective improvement in urinary symptoms and quality of life.
Until the 1930s, open prostatectomy, though invasive, was the most effective form of surgical treatment for BPH. Today, the benchmark surgical treatment for BPH is transurethral resection of the prostate (TURP), which produces significant changes of all subjective and objective outcome parameters. Complications after TURP include hemorrhage during or after the procedure, which often necessitates blood transfusion; transurethral resection (TUR) syndrome; urinary incontinence; bladder neck stricture; and sexual dysfunction. A retrospective review of 4,031 TURP procedures performed by one surgeon between 1979 and 2003 showed that the incidence of complications was 2.4% for blood transfusion, 0.3% for TUR syndrome, 1.5% for hemostatic procedures, 2.8% for bladder neck contracture, and 1% for urinary stricture. However, the incidence of blood transfusion and TUR syndrome decreased as the surgeon’s skills improved.
During the 1990s, a variety of endoscopic techniques using a range of energy sources have been developed as alternative treatments for BPH. These techniques include the use of light amplification by stimulated emission of radiation (laser), radiofrequency, microwave, and ultrasound, to heat prostate tissue and cause coagulation or vaporization. In addition, new electrosurgical techniques that use higher amounts of energy to cut, coagulate, and vaporize prostatic tissue have entered the market as competitors to TURP. The driving force behind these new treatment modalities is the potential of producing good hemostasis, thereby reducing catheterization time and length of hospital stay. Some have the potential to be used in an office environment and performed under local anesthesia. Therefore, these new procedures have the potential to rival TURP if their effectiveness is proven over the long term.
The Technology Being Reviewed
The following energy-based techniques were considered for assessment:
transurethral electrovaporization of the prostate (TUVP)
transurethral electrovapor resection of the prostate (TUVRP)
transurethral electrovaporization of the prostate using bipolar energy (plasmakinetic vaporization of the prostate [PKVP])
visual laser ablation of the prostate (VLAP)
transurethral ultrasound guided laser incision prostatectomy (TULIP)
contact laser vaporization of the prostate (CLV)
interstitial laser coagulation (ILC)
holmium laser resection of the prostate (HoLRP)
holmium laser enucleation of the prostate (HoLEP)
holmium laser ablation of the prostate (HoLAP)
potassium titanyl phosphate (KTP) laser
transurethral microwave thermotherapy (TUMT)
transurethral needle ablation (TUNA)
Review Strategy
A search of electronic databases (OVID MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library, and the International Agency for Health Technology Assessment [INAHTA] database) was undertaken to identify evidence published from January 1, 2000 to June 21, 2006. The search was limited to English-language articles and human studies. The literature search identified 284 citations, of which 38 randomized controlled trials (RCTs) met the inclusion criteria.
Since the application of high-power (80 W) KTP laser (photoselective vaporization of the prostate [PVP]) has been supported in the United States and has resulted in a rapid diffusion of this technology in the absence of any RCTs, the MAS decided that any comparative studies on PVP should be identified and evaluated. Hence, the literature was searched and one prospective cohort study (3) was identified but evaluated separately.
Findings of Literature Review and Analysis
Meta-analysis of the results of RCTs shows that monopolar electrovaporization is as clinically effective as TURP for the relief of urinary symptoms caused by BPH (based on 5-year follow-up data).
Meta-analysis of the results of RCTs shows that bipolar electrovaporization (PKVP) is clinically as effective as TURP for the relief of urinary symptoms caused by BPH (based on 1-year follow-up data).
Two of the three RCTs on VLAP have shown that patients undergoing VLAP had a significantly lesser improvement in urinary symptom scores compared with patients undergoing TURP.
RCTs showed that the time to catheter removal was significantly longer in patients undergoing VLAP compared with patients undergoing TURP.
Meta-analysis of the rate of reoperation showed that patients undergoing VLAP had a significantly higher rate of reoperation compared with patients undergoing TURP.
Meta-analysis showed that patients undergoing CLV had a significantly lesser improvement in urinary symptom scores compared with TURP at 2 years and at 3 or more years of follow-up.
Two RCTs with 6-month and 2-year follow-up showed similar improvement in symptom scores for ILC and TURP.
Time to catheter removal was significantly longer in patients undergoing ILC compared with patients undergoing TURP.
The results of RCTs on HoLEP with 1-year follow-up showed excellent clinical outcomes with regard to the urinary symptom score and peak urinary flow.
Meta-analysis showed that at 1-year follow-up, patients undergoing HoLEP had a significantly greater improvement in urinary symptom scores and peak flow rate compared with patients undergoing TURP.
Procedural time is significantly longer in HoLEP compared with TURP.
The results of one RCT with 4-year follow-up showed that HoLRP and TURP provided equivalent improvement in urinary symptom scores.
The results of one RCT with 1-year follow-up showed that patients undergoing KTP had a lesser improvement in urinary symptom scores than did patients undergoing TURP. However, the results were not significant at longer-term follow-up periods.
Two RCTs that provided 3-year follow-up data reported that patients undergoing TUMT had a significantly lesser improvement in symptom score compared with patients undergoing TURP.
RCTs reported a longer duration of catheterization for TUMT compared with TURP (P values are not reported).
The results of a large RCT with 5-year follow-up showed a significantly lesser improvement in symptom scores in patients undergoing TUNA compared with patients undergoing TURP.
Meta-analysis of the rate of reoperation showed that patients undergoing TUNA had a significantly higher rate of reoperation compared with patients undergoing TURP.
Based on the results of RCTs, TURP is associated with a 0.5% risk of TUR syndrome, while no cases of TUR syndrome have been reported in patients undergoing monopolar or bipolar electrovaporization, laser-based procedures, TUMT, or TUNA.
Based on the results of RCTs, the rate of blood transfusion ranges from 0% to 8.3% in patients undergoing TURP. The rate is about 1.7% in monopolar electrovaporization, 1.4% in bipolar electrovaporization, and 0.4% in the VLAP procedure. No patients undergoing CLV, ILC, HoLEP, HoLRP, KTP, TUMT, and TUNA required blood transfusion.
The mean length of hospital stay is between 2 and 5 days for patients undergoing TURP, about 3 days for electrovaporization, about 2 to 4 days for Nd:YAG laser procedures, and about 1 to 2 days for holmium laser procedures. TUMT and TUNA can each be performed as a day procedure in an outpatient setting (0.5 and 1 day respectively).
Based on a prospective cohort study, PVP is clinically as effective as TURP for the relief of urinary symptoms caused by BPH (based on 6-month follow-up data). Time to catheter removal was significantly shorter in patients undergoing PVP than in those undergoing TURP. Operating room time was significantly longer in PVP than in TURP. PVP has the potential to reduce health care expenses due to shorter hospital stays.
Economic Analysis
In the three most recent fiscal years (FY) reported, an average of approximately 5,000 TURP procedures per year were performed in Ontario. From FY 2002 to FY 2004, the total number of surgical interventions decreased by approximately 500 procedures. During this time, the increase in costs of drugs to the government was estimated at approximately $10 million (Cdn); however, there was a concurrent decrease in costs due to a decline in the total number of surgical procedures, estimated at approximately $1.9 million (Cdn). From FY 2002 to FY 2004, the increase in costs associated with the increase in utilization of drugs for the treatment of BPH translates into $353 (Cdn) per patient while the cost savings associated with a decrease in the total number of surgical procedures translates into a savings of $3,906 (Cdn) per patient.
The following table summarizes the change in the current budget, depending on various estimates of the total percentage of the 5,000 TURP procedures that might be replaced by other energy-based interventions for the treatment of BPH in the future.
Budget Impact With Various Estimates of the Percentage of TURP Procedures Captured by Energy-based Interventions for the Treatment of BPH
All costs are in Canadian currency. Parentheses indicative of cost reduction.
PMCID: PMC3379165  PMID: 23074487
12.  The burden of prolonged indwelling catheter after acute urinary retention in Ikeja – Lagos, Nigeria 
BMC Urology  2007;7:16.
Acute urinary retention (AUR) is a common urological problem. We have observed a growing list of patients on indwelling bladder catheter awaiting surgery after AUR. This study was aimed at identifying the health, financial and quality of life (QoL) implications of prolonged use of indwelling catheter in these patients
We review the side-effects, QoL and cost of changing an indwelling catheter among patients who were on the waiting list for definitive surgery after AUR. All the 62 patients who presented to weekly catheter clinic for change of the indwelling catheter were recruited over a 3 – week period into the study.
The mean age of the patients was 57.5 years and the mean catheter use time was 23 months. The aetiology of AUR was BPH in 40 (64%) and urethral trauma in 16 (28.4%) of the patients. The common side effects of prolonged catheterization included urethral/suprapubic pain, bleeding per urethram, loss of dignity, loss of job or being out of school, lack of sexual intercourse, pericatheter leakage of urine and recurrent urinary tract infection. The cost of change of the indwelling catheter to the patient each time ranged from 460.00 – 2500.00 Naira (averaged 789.67 Naira). The total annual cost for the change of indwelling catheter after AUR in our catheter clinic was estimated to be 7,350,000.00 Naira (58,800 US dollars) with 1,890,000.00 Naira (15,120 US dollars) being the cost borne by the patients per annum and the rest being government subsidy. Fifty-three (85.5%) patients described that they were unhappy. There was a significant correlation between QoL and the presence of pain (p = 0.015) and bleeding (p = 0.042) associated with the presence of an indwelling catheter.
The need to have an indwelling catheter for a prolonged period after AUR is a painful experience and associated with several side-effects. This has a significant negative effect on the patients' QoL and constitutes a significant financial burden to the patients and the government. We suggest that measures should be put in place to reduce the waiting time for surgery and therefore the catheterization time among the patients with AUR.
PMCID: PMC2222593  PMID: 17897467
13.  Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter: meta-analysis 
Objective To determine whether antibiotic prophylaxis at the time of removal of a urinary catheter reduces the risk of subsequent symptomatic urinary tract infection.
Design Systematic review and meta-analysis of studies published before November 2012 identified through PubMed, Embase, Scopus, and the Cochrane Library; conference abstracts for 2006-12 were also reviewed.
Inclusion criteria Studies were included if they examined antibiotic prophylaxis administered to prevent symptomatic urinary tract infection after removal of a short term (≤14 days) urinary catheter.
Results Seven controlled studies had symptomatic urinary tract infection after catheter removal as an endpoint; six were randomized controlled trials (five published; one in abstract form) and one was a non-randomized controlled intervention study. Five of these seven studies were in surgical patients. Studies were heterogeneous in the type and duration of antimicrobial prophylaxis and the period of observation. Overall, antibiotic prophylaxis was associated with benefit to the patient, with an absolute reduction in risk of urinary tract infection of 5.8% between intervention and control groups. The risk ratio was 0.45 (95% confidence interval 0.28 to 0.72). The number needed to treat to prevent one urinary tract infection was 17 (12 to 30).
Conclusions Patients admitted to hospital who undergo short term urinary catheterization might benefit from antimicrobial prophylaxis when the catheter is removed as they experience fewer subsequent urinary tract infections. Potential disadvantages of more widespread antimicrobial prophylaxis (side effects and cost of antibiotics, development of antimicrobial resistance) might be mitigated by the identification of which patients are most likely to benefit from this approach.
PMCID: PMC3678514  PMID: 23757735
14.  Epidemiology and impact of a multifaceted approach in controlling central venous catheter associated blood stream infections outside the intensive care unit 
BMC Infectious Diseases  2013;13:445.
Outside ICUs, CVC-ABSIs epidemiology and the results of strategies for their prevention are not well known. The aim of this study was to investigate the epidemiology and the impact of a multifaceted “bundle” approach in controlling CVC-ABSIs outside ICU.
From 1991 we performed prevalence studies of device and parenteral nutrition use, and prospective surveillance of all episodes of CVC-ABSIs in a 350-bed teaching hospital. CVC-ABSIs incidence/1,000 inpatient-days was calculated. An estimated CVC-ABSIs incidence/1,000 catheter-days was calculated based on the prevalence rates of catheter use and the total number of inpatient-days in each year. On november 2008, an education programme was instituted for care of catheter lines: reinforcing instructions in aseptic insertion technique, after care and hand-washing; in order to assess the adherence to these measures the quantity of alcohol-based hand-rub consumption/1,000 patient-days was quoted in litres. From January 2009, a checklist intervention for CVC insertion in ICU was started: hand hygiene, using full barrier precautions, cleaning the skin with alcoholic chlorhexidine, avoiding femoral access and removing unnecessary catheters. Compliance with the central line insertion checklist was measured by real-time audits and was achieved in 80% of cases.
Prevalence of use of CVC and parenteral nutrition was similar throughout the study. We followed-up 309 CVC-ABSIs cases. Estimated CVC-ABSIs rate progressively increased to 15.1/1,000 catheter-days in 2008 (0.36/1,000 inpatient-days). After the intervention, the alcohol-based hand-rub consumption increased slightly and estimated CVC-ABSIs rate fell to 10.1 /1,000 catheter-days in last three years (0.19/1,000 inpatient-days), showing a 32.9% decrease. The infection rates achieved were lower in Internal Medicine wards: decreased from 14.1/1,000 catheter-days (0.17/patient-days) in 2008 to 5.2/1,000 catheter-days (0.05/1,000 inpatient-days) in last three years, showing a 63.1% decrease. In 2009, the estimated CVC-ABSIs incidence rate was significantly lower in the Internal Medicine ward compared to the Surgery ward: rate ratio (RR) = 0.14, 95%CI: 0.03-0.60), and within the Internal Medicine ward, the estimated CVC-ABSIs incidence rate was significantly lower in 2009 compared to 2008 (RR = 0.20, 95%CI: 0.04-0.91).
The rate of CVC-ABSIs increased outside-ICU, and the implementation of multifaceted infection control programme decreased their clinical impact.
PMCID: PMC3849631  PMID: 24063563
Catheter; Bloodstreams; Infection control
15.  A randomized controlled trial to assess the efficacy and cost-effectiveness of urinary catheters with silver alloy coating in spinal cord injured patients: trial protocol 
BMC Urology  2013;13:38.
Patients with non-acute spinal cord injury that carry indwelling urinary catheters have an increased risk of urinary tract infection (UTIs). Antiseptic Silver Alloy-Coated Silicone Urinary Catheters seems to be a promising intervention to reduce UTIs; however, actual evidence cannot be extrapolated to spinal cord injured patients. The aim of this trial is to make a comparison between the use of antiseptic silver alloy-coated silicone urinary catheters and the use of standard urinary catheters in spinal cord injured patients to prevent UTIs.
The study will consist in an open, randomized, multicentre, and parallel clinical trial with blinded assessment. The study will include 742 spinal cord injured patients who require at least seven days of urethral catheterization as a method of bladder voiding. Participants will be online centrally randomized and allocated to one of the two study arms (silver alloy-coated or standard catheters). Catheters will be used for a maximum period of 30 days or removed earlier if the clinician considers it necessary. The main outcome will be the incidence of UTIs by the time of catheter removal or at day 30 after catheterization, the event that occurs first. Intention-to-treat analysis will be performed, as well as a primary analysis of all patients.
The aim of this study is to assess whether silver alloy-coated silicone urinary catheters improve ITUs in spinal cord injured patients. ESCALE is intended to be the first study to evaluate the efficacy of the silver alloy-coated catheters in spinal cord injured patients.
Trial registration
PMCID: PMC3735409  PMID: 23895463
Spinal cord injuries; Urinary tract infection; Urinary catheters; Protocol; Randomized clinical trial
16.  Reducing Inappropriate Urinary Catheter Use: A Statewide Effort 
Archives of internal medicine  2012;172(3):255-260.
Indwelling urinary catheters may lead to both infectious and non-infectious complications and are often used in the hospital setting without an appropriate indication. The objective of this study was to evaluate the results of a statewide quality improvement effort to reduce inappropriate urinary catheter use.
Retrospective analysis of data collected between 2007 and 2010 as part of a statewide collaborative initiative before, during, and after an educational intervention-promoting adherence to appropriate urinary catheter indications. The data was collected from 163 inpatient units in 71 participating Michigan hospitals. The intervention consisted of engaging clinicians about the appropriate indications for urinary catheter use and promoting the daily assessment of urinary catheter necessity during daily nursing rounds. The main outcome measures were change in prevalence of urinary catheter use and adherence with appropriate indications. We used flexible generalized estimating equation (GEE) and multilevel methodology to estimate rates over time while accounting for the clustering of patients within hospital units.
The urinary catheter utilization rate decreased from 18.1% (95% CI: 16.8–19.6) at baseline to 13.8% (95% CI: 12.9–14.8) at end of year 2 (p <0.001). The proportion of catheterized patients with appropriate indications increased from 44.3% (95% CI: 40.3–48.4) to 57.6% (95% CI: 51.7–63.4) by the end of year 2 (p = 0.005).
A statewide effort to reduce inappropriate urinary catheter utilization was associated with a significant reduction in catheter use and improved compliance with appropriate use. The effect of the intervention was sustained for at least 2 years. Word count: 249
PMCID: PMC3718283  PMID: 22231611
urinary catheter; device utilization; healthcare-associated infection; patient safety
17.  Posttraumatic ventral urethral fistula: a case report 
Cases Journal  2009;2:8644.
We present the first case reported in the medical literature of a patient with a posttraumatic urethral fistula accompanied by retraction urethral catheter with balloon.
Case presentation
A 69-year-old man was admitted to our hospital with the recurrence urinary tract infection. The patient reports history of urethral trauma, which is retraction urethral catheter with balloon 2 years ago. Cystoscopy and fistulography were performed, and urethrocutaneous fistula was detected. Initial surgical treatment consisted of surgical debridement of fistula tissue, and a urethral catheterization was performed. After 4 weeks of the operation the urethral fistula resolved. In a follow-up period of 24 months no recurrence and no urinary tract infection were occurred.
Self retraction of the urethral catheter with balloon may result with clinically important urethral fistula. A wide range of possible options such as complete excision of the fistula tract and primary closure may be considered for individual cases.
PMCID: PMC2827111  PMID: 20181212
18.  Estimating Hospital Costs of Catheter-Associated Urinary Tract Infection 
Journal of Hospital Medicine  2013;8(9):519-522.
Healthcare-associated infections are common, costly, and potentially deadly. However, effective prevention strategies are underutilized, particularly for catheter-associated urinary tract infection (CAUTI), one of the most common healthcare-associated infections. Further, since 2008, the Centers for Medicare and Medicaid Services no longer reimburses hospitals for the additional costs of caring for patients who develop CAUTI during hospitalization. Given the resulting payment pressures on hospitals stemming from this decision, it is important to factor in cost implications when attempting to encourage decision makers to support infection prevention measures. To this end, we present a simple tool (with easy-to-use online implementation) that hospitals can use to estimate hospital costs due to CAUTI, both before and after an intervention, to reduce inappropriate urinary catheterization. Using previously published cost and risk estimates, we show that an intervention yielding clinically feasible reductions in catheter use can lead to an estimated 50% reduction in CAUTI-related costs. Our tool is meant to complement the Society of Hospital Medicine's Choosing Wisely campaign, which highlights avoiding placement or continued use of nonindicated urinary catheters as a key area for improving decision making and quality of care while decreasing costs. Journal of Hospital Medicine 2013;8:519–522. © 2013 Society of Hospital Medicine
PMCID: PMC3786530  PMID: 24038833
19.  Management of Lower Urinary Retention in a Limited Resource Setting 
There is a projected increase in lower urinary tract obstruction by 2018, especially in the developing economies of Asia and Africa. However in many of these countries, the problems encountered both by the patients and the clinicians are not well documented. Our aims are, to prospectively analyse the management of urinary retention, the associated difficulties, and complications in our setting, where access to investigative modalities such as Computerize Tomography and Magnetic Resonance Imaging are not available.
Patients and Methods
The study was approved by the University Of Calabar Teaching Hospital ethical committee. A validated Proforma was used to collect data from all patients who were clinically diagnosed with urinary retention based on history, and physical examination, from July 2009 to June 2010. Data collected from the 1st of July 2009 to the 30th of June 2010, include demographics, findings on physical examination, previous medical history and co-morbid conditions. The results of investigations done such as: urinalysis, full blood count, electrolytes, urea and creatinine, intravenous urography, trans- abdominal ultrasonography, chest X-ray and histology of trans-rectal biopsies of the prostate . The total number of new patients seen, including those with urinary retention during the study was documented. The retentions were also classified into acute and chronic. All the patients were followed up throughout the study. The data was analysed using Epi-Info statistical program version 3.4 of 2007 to analyse the data, estimating averages, mean, median and percentages. RESULTS: The total number of new patients seen, including those with urinary retention was Seventy thousand, one hundred and thirty nine (70,139).Of this number, hundred and fifty nine (0.23%), presented with urinary retention; 145 (91.2%) were acute, and14 (8.8%) were chronic. The male: female ratio was 39:1.The patients ages ranged from 4 to 94 years, with a mean of 53.7±11.2. Seventy seven [48.4%] of them were in the 6th and 7th decades of life. The common causes were; prostatic diseases [BPH and cancer of the prostate] 77.0%, infections 75.8%, trauma 12.1%, and congenital 12.1%. Urinary retention was relieved by: indwelling urethral catheterization [IUC] 120 patients (75.5%), supra- pubic cystostomy [SC] 34 (21.4%) and intermittent urethral catheterization [IC] 5 (3.1%). The most frequently encountered complications include pyuria (18.2%), pericatheter sepsis 17.5%, and haemorrhage during change of catheter 16.8% [figure 2].
Complication after one week bladder drainage
Lower urinary retention is common in our environment. The management is appropriate and standard. The man power and facilities are inadequate, and requires urgent improvement.
PMCID: PMC4248032  PMID: 25489197
Urinary retention; management; limited resources
20.  Medical interns' knowledge and training regarding urethral catheter insertion and insertion-related urethral injury in male patients 
BMC Medical Education  2011;11:73.
Improper catheterization can lead to urethral injury. Yet research from four continents suggests training of junior doctors in catheterization is insufficient. European research suggests a majority of catheterization related morbidities occur when the procedure is performed by interns.
To assess the knowledge and practices of medical interns relating to urethral catheterization and iatrogenic urethral injury secondary to traumatic catheter insertion, a questionnaire survey was conducted of all first year medical interns at a tertiary national university hospital in the Philippines. The questionnaire contained 17 items covering 4 areas: methods of training in catheterization and level of experience; perceived adequacy of training; theoretical knowledge of catheterization; the mechanisms of catheter-related urethral injury.
225/240 interns (94%) completed the survey (130 (57.8%) female). 125 (55.6%) responded that they had adequate theoretical training and 150 (66.7%) adequate practical training. All had performed more than 10 catheterizations and 204 (90%) were supervised when they first performed catheterization. Despite relatively high levels of experience and confidence, deficits were identified in detailed knowledge of correct catheterization procedures and of risks associated with urethral injury.
More thorough training of incoming medical interns in urinary catheterization may help to reduce the risk of complications and injury. Training should be universal and thought given to its timing within the curriculum. Training should include step by step instruction in the process, emphasis on history taking and awareness of factors associated with increased risk of urethral injury.
PMCID: PMC3189902  PMID: 21951692
urinary catheterization; education; medical; injuries; urethral
21.  Multicenter Cohort Study to Assess the Impact of a Silver-Alloy and Hydrogel-Coated Urinary Catheter on Symptomatic Catheter-Associated Urinary Tract Infections 
The purpose of this study was to determine the effect of a silver-alloy hydrogel catheter on symptomatic catheter-associated urinary tract infections (CAUTIs).
Multicenter before-after non-randomized cohort study.
Seven acute care hospitals ranging in size from 124 to 607 beds participated in this study. The study population included adult patients with a positive urine culture 2 or more days after admission, who underwent Foley catheterization.
Catheter-associated urinary tract infection surveillance was conducted at each hospital for at least 3 months during the use of a standard catheter and 3 months during the use of the silver-alloy hydrogel catheter. Both the National Healthcare Safety Network (NHSN) surveillance and a clinical definition of CAUTI were used for rate calculation.
A 47% relative reduction in the CAUTI rate was observed with the silver-alloy hydrogel catheter compared to the standard catheter when both infection definitions were used (0.945/1000 patient days vs 0.498/1000 patient days) (odds ratio = 0.53; P < .0001; 95% CI: 0.45–0.62). When only NHSN-defined CAUTIs were considered, a 58% relative reduction occurred in the silver-alloy hydrogel period (0.60/1000 patient days vs 0.25/1000 patient days) (odds ratio = 0.42; P < .0001; 95% CI: 0.34–0.53). Antimicrobial days for CAUTIs decreased from 1165 (standard catheter period) to 406 (silver-alloy hydrogel period).
Use of a silver-alloy hydrogel urinary catheter reduced symptomatic CAUTI occurrences as defined by both NHSN and clinical criteria.
PMCID: PMC4165476  PMID: 24922561
catheter-associated urinary tract infection; Foley catheter; silver alloy catheter; silver catheter; urinary tract infection
22.  Management of acute urinary retention: a worldwide survey of 6074 men with benign prostatic hyperplasia 
Bju International  2012;109(1):88-95.
To evaluate the management of acute urinary retention (AUR) associated with benign prostatic hyperplasia (BPH) in real-life practice.To identify predictors of successful trial without catheter (TWOC).
In all, 6074 men catheterized for painful AUR were enrolled in a prospective, cross-sectional survey conducted in public and private urology practices in France, Asia, Latin America, Algeria and the Middle East.Patient clinical characteristics, type of AUR and its management (type of catheterization, hospitalization, TWOC, use of α1-blockers, immediate or elective surgery) and adverse events observed during the catheterization period were recorded.Predictors of TWOC success were also analysed by multivariate regression analysis with stepwise procedure.
Of the 6074 men, 4289 (71%) had a spontaneous AUR and 1785 (29%) had a precipitated AUR, mainly as the result of loco-regional/general anaesthesia (28.5%) and excessive alcohol intake (18.2%).Presence of BPH was revealed by AUR in 44% of men. Hospitalization for AUR varied between countries, ranging from 1.7% in Algeria to 100% in France. A urethral catheter was inserted in most cases (89.8%) usually followed by a TWOC (78.0%) after a median of 5 days. Overall TWOC success rate was 61%.Most men (86%) received an α1-blocker (mainly alfuzosin) before catheter removal with consistently higher TWOC success rates, regardless of age and type of AUR. Multivariate regression analysis confirmed that α1-blocker before TWOC doubled the chances of success (odds ratio 1.92, 95% CI 1.52–2.42, P < 0.001).Age ≥70 years, prostate size ≥50 g, severe lower urinary tract symptoms, drained volume at catheterization ≥1000 mL and spontaneous AUR favoured TWOC failure. Catheterization >3 days did not influence TWOC success but was associated with increased morbidity and prolonged hospitalization for adverse events.In the case of TWOC failure, 49% of men were recatheterized and had BPH surgery and 43.5% tried another TWOC with a success rate of 29.5%. Elective surgery was preferred to immediate surgery.
TWOC has become a standard practice worldwide for men with BPH and AUR.In most cases, an α1-blocker is prescribed before TWOC and significantly increases the chance of success.Prolonged catheterization is associated with an increased morbidity.
PMCID: PMC3272343  PMID: 22117624
acute urinary retention; alfuzosin; α1-blocker; benign prostatic hyperplasia; trial without catheter
23.  Role of biofilm in catheter-associated urinary tract infection 
The predominant form of life for the majority of microorganisms in any hydrated biologic system is a cooperative community termed a “biofilm.” A biofilm on an indwelling urinary catheter consists of adherent microorganisms, their extracellular products, and host components deposited on the catheter. The biofilm mode of life conveys a survival advantage to the microorganisms associated with it and, thus, biofilm on urinary catheters results in persistent infections that are resistant to antimicrobial therapy. Because chronic catheterization leads almost inevitably to bacteriuria, routine treatment of asymptomatic bacteriuria in persons who are catheterized is not recommended. When symptoms of a urinary tract infection develop in a person who is catheterized, changing the catheter before collecting urine improves the accuracy of urine culture results. Changing the catheter may also improve the response to antibiotic therapy by removing the biofilm that probably contains the infecting organisms and that can serve as a nidus for reinfection. Currently, no proven effective strategies exist for prevention of catheter-associated urinary tract infection in persons who are chronically catheterized.
PMCID: PMC2963581  PMID: 15153930
24.  Evaluation of an intervention program to prevent hospital-acquired catheter-associated urinary tract infections in an ICU in a rural Egypt hospital 
Aim: Catheter associated urinary tract infections (CAUTI) are the most common hospital-acquired infection in ICUs. The aim of this study was to estimate the effectiveness of an intervention program by implementing urinary catheter bundle elements to reduce the CAUTI frequency in an ICU.
Methods: The intervention study was conducted over a period of 6 months. During a pre-intervention phase, the base line catheter associated CAUTI incidence rates were determined and compared with the incidence rates during the post-intervention phase. The compliance of health care staff with urinary catheter bundle elements was also measured. The implemented CAUTI prevention bundle consisted of hand hygiene, wearing personal protective equipment, use of disposable gloves, cleansing of urethral meatus prior to catheter insertion using sterile saline, assessment of catheter need, aseptic urine sampling technique, and correct draining bag positioning.
Results: During the study period, 55 out of 77 patients were diagnosed with a CAUTI. The mean CAUTI incidence rate for the pre-intervention period was 90.12/1,000 catheter days and for the post intervention phase 65.69/1,000 catheter days. The CAUTIs rate was inversely proportional to insertion bundle elements and maintenance bundle elements compliance rate. This negative relationship was statistically significant only with maintenance bundle elements (p=0.042) (rs=–0.828). The compliance rate of the ICU nurses to the bundle elements was raised to 100% during the last 2 months of the post intervention phase.
Conclusion: Increased compliance to recommended catheter associated urinary tract infections preventive practices reduced the incidence of CAUTI in an ICU unit. It is simple and effective and is recommended as a part of patient safety culture.
PMCID: PMC4141633  PMID: 25152860
catheter-associated urinary tract infection; infection control; bundle; hand hygiene; compliance
25.  Sacral Nerve Stimulation For Urinary Urge Incontinence, Urgency-Frequency, Urinary Retention, and Fecal Incontinence 
Executive Summary
The aim of this review was to assess the effectiveness, safety, and cost of sacral nerve stimulation (SNS) to treat urinary urge incontinence, urgency-frequency, urinary retention, and fecal incontinence.
Background: Condition and Target Population
Urinary urge incontinence, urgency-frequency, urinary retention, and fecal incontinence are prevalent, yet rarely discussed, conditions. They are rarely discussed because patients may be uncomfortable disclosing their symptoms to a health professional or may be unaware that there are treatment options for these conditions. Briefly, urge incontinence is an involuntary loss of urine upon a sudden urge. Urgency-frequency is an uncontrollable urge to void, which results in frequent, small-volume voids. People with urgency-frequency may or may not also experience chronic pelvic pain. Urinary retention refers to the inability to void despite having the urge to void. It can be caused by a hypocontractile detrusor (weak or no bladder muscle contraction) or obstruction due to urethral overactivity. Fecal incontinence is a loss of voluntary bowel control.
The prevalence of urge incontinence, urgency-frequency, and urinary retention in the general population is 3.3% to 8.2%, and the prevalence of fecal incontinence is 1.4% to 1.9%. About three-quarters of these people will be successfully treated by behaviour and/or drug therapy. For those who do not respond to these therapies, the options for treatment are management with diapers or pads, or surgery. The surgical procedures are generally quite invasive, permanent, and are associated with complications. Pads and/or diapers are used throughout the course of treatment as different therapies are tried. Patients who respond successfully to treatment may still require pads or diapers, but to a lesser extent.
The Technology Being Reviewed: Sacral Nerve Stimulation
Sacral nerve stimulation is a procedure where a small device attached to an electrode is implanted in the abdomen or buttock to stimulate the sacral nerves in an attempt to manage urinary urge incontinence, urgency-frequency, urinary retention, and fecal incontinence. The device was originally developed to manage urinary urge incontinence; however, it has also been used in patients with urgency-frequency, urinary retention, and fecal incontinence. SNS is intended for patients who are refractory to behaviour, drug, and/or interventional therapy.
There are 2 phases in the SNS process: first, patients must undergo a test stimulation phase to determine if they respond to sacral nerve stimulation. If there is a 50% or greater improvement in voiding function, then the patient is considered a candidate for the next phase, implantation.
Review Strategy
The standard Medical Advisory Secretariat search strategy was used to locate international health technology assessments and English-language journal articles published from 2000 to November 2004. The Medical Advisory Secretariat also conducted Internet searches of Medscape (1) and the manufacturer’s website (2) to identify product information and recent reports on trials that were unpublished but that were presented at international conferences. In addition, the Web site Current Controlled Trials (3) was searched for ongoing randomized controlled trials (RCTs) investigating the role of sacral nerve stimulation in the management of voiding conditions.
Summary of Findings
Four health technology assessments were found that reviewed SNS in patients with urge incontinence, urgency-frequency, and/or urinary retention. One assessment was found that reviewed SNS in patients with fecal incontinence. The assessments consistently reported that SNS was an effective technology in managing these voiding conditions in patients who did not respond to drug or behaviour therapy. They also reported that there was a substantial complication profile associated with SNS. Complication rates ranged from 33% to 50%. However, none of the assessments reported that they found any incidences of permanent injury or death associated with the device.
The health technology assessments for urge incontinence, urgency-frequency, and urinary retention included (RCTs (level 2) as their primary source of evidence for their conclusions. The assessment of fecal incontinence based its conclusions on evidence from case series (level 4). Because there was level 2 data available for the use of SNS in patients with urinary conditions, the Medical Advisory Secretariat chose to review thoroughly the RCTs included in the assessments and search for publications since the assessments were released. However, for the health technology assessment for fecal incontinence, which contained only level 4 evidence, the Medical Advisory Secretariat searched for studies on SNS and fecal incontinence that were published since that assessment was released.
Urge Incontinence
Two RCTs were identified that compared SNS to no treatment in patients with refractory urge incontinence. Both RCTs reported significant improvements (> 50% improvement in voiding function) in the SNS group for number of incontinence episodes per day, number of pads used per day, and severity of incontinence episodes.
Urgency-Frequency (With or Without Chronic Pelvic Pain)
One RCT was identified that compared SNS to no treatment in patients with refractory urgency-frequency. The RCT reported significant improvements in urgency-frequency symptoms in the SNS group (average volume per void, detrusor pressure). In addition to the RCT, 1 retrospective review and 2 prospective case series were identified that measured pelvic pain associated with urgency-frequency in patients who underwent SNS. All 3 studies reported a significant decrease in pain at median follow-up.
Urinary Retention
One RCT was identified that compared SNS to no treatment in patients with refractory urinary retention. The RCT reported significant improvements in urinary retention in the SNS group compared to the control group for number of catheterizations required and number of voids per day. In addition to this RCT, 1 case series was also identified investigating SNS in women with urinary retention. This study also found that there were significant improvements in urinary retention after the women had received the SNS implants.
Fecal Incontinence
Three case series were identified that investigated the role of SNS in patients with fecal incontinence. All 3 reported significant improvements in fecal incontinence symptoms (number of incontinent episodes per week) after the patients received the SNS implants.
Long-Term Follow-up
None of the studies identified followed patients until the point of battery failure. Of the 6 studies identified describing the long-term follow-up of patients with SNS, follow-up periods ranged from 1.5 years to over 5 years. None of the long-term follow-up studies included patients with fecal incontinence. All of the studies reported that most of the patients who had SNS had at least a 50% improvement in voiding function (range 58%–77%). These studies also reported the number of patients who had their device explanted in the follow-up period. The rates of explantation ranged from 12% to 21%.
Safety, Complications, and Quality of Life
A 33% surgical revision rate was reported in an analysis of the safety of 3 RCTs comparing SNS to no treatment in patients with urge incontinence, urgency-frequency, or urinary retention. The most commonly reported adverse effects were pain at the implant site and lead migration. Despite the high rate of surgical revision, there were no reports of permanent injury or death in any of the studies or health technology assessments identified. Additionally, patients consistently said that they would recommend the procedure to a friend or family member.
Economic Analysis
One health technology assessment and 1 abstract were found that investigated the costing factors pertinent to SNS. The authors of this assessment did their own “indicative analysis” and found that SNS was not more cost-effective than using incontinence supplies. However, the assessment did not account for quality of life. Conversely, the authors of the abstract found that SNS was more cost-effective than incontinence supplies alone; however, they noted that in the first year after SNS, it is much more expensive than only incontinence supplies. This is owing to the cost of the procedure, and the adjustments required to make the device most effective. They also noted the positive effects that SNS had on quality of life.
Conclusions and Implications
In summary, there is level 2 evidence to support the effectiveness of SNS to treat people with urge incontinence, urgency-frequency, or urinary retention. There is level 4 evidence to support the effectiveness of SNS to treat people with fecal incontinence.
To qualify for SNS, people must meet the following criteria:
Be refractory to behaviour and/or drug therapy
Have had a successful test stimulation before implantation; successful test stimulation is defined by a 50% or greater improvement in voiding function based on the results of a voiding diary. Test stimulation periods range from 3 to 7 days for patients with urinary dysfunctions, and from 2 to 3 weeks for patients with fecal incontinence.
Be able to record voiding diary data, so that clinical results of the implantation can be evaluated.
Patients with stress incontinence, urinary retention due to obstruction and neurogenic conditions (such as diabetes with peripheral nerve involvement) are ineligible for sacral nerve stimulation.
Physicians will need to learn how to use the InterStim System for Urinary Control. Requirements for training include these:
Physicians must be experienced in the diagnosis and treatment of lower urinary tract disorders and should be trained in the implantation and use of the InterStim System for Urinary Control.
Training should include the following:
Participation in a seminar or workshop that includes instructional and laboratory training on SNS. This seminar should include a review of the evidence on SNS with emphasis on techniques to prevent adverse events.
Completion of proctoring by a physician experienced in SNS for the first 2 test stimulations and the first 2 implants
PMCID: PMC3382408  PMID: 23074472

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