Annals of Physical and Rehabilitation Medicine 59 (2016) 125–129

Available online at

ScienceDirect
www.sciencedirect.com

Update article

Intermittent catheterization in neurologic patients:

Update on genitourinary tract infection and urethral trauma
X. Biardeau a,b, J. Corcos a,*
a
Service d’Urologie, Hôpital Général Juif, Université McGill, 3755, chemin de la Côte-Sainte-Catherine, Montréal, QC, H3T 1E2 Canada
b
Service d’Urologie, Hôpital Claude-Huriez, Université Lille-Nord-de-France, Lille, France

A R T I C L E I N F O A B S T R A C T

Article history: Intermittent catheterization is considered the standard of care in most neurologic patients with lower
Received 26 November 2015 urinary tract disorders. However, in this context, genitourinary tract infection and urethral trauma
Accepted 28 February 2016 represent specific challenges. Such conditions have been found to significantly deteriorate quality of life
and complicate subsequent treatments. Only optimal prevention associated with appropriate treatment
Keywords: allows for the long-term continuation of such bladder management. Here, we discuss the diagnosis and
Self-catheterization therapeutic and preventive approaches associated with genitourinary tract infection and urethral
Complications
trauma in this specific population. This ‘‘state-of-the-art’’ article results from a literature review
Prevention
Treatment
(MEDLINE articles and scientific society guidelines) and the authors’ experience. It was structured in a
Genitourinary tract infection didactic way to facilitate comprehension and promote the implementation of advice and
Urethral trauma recommendations in daily practice. Genitourinary tract infection and urethral trauma associated with
intermittent catheterization in neurologic patients should be managed with a global approach, including
patient and caregiver education, optimal catheterization with hydrophilic-coated or pre-lubricated
catheters and adequate use of antibiotic therapy.
ß 2016 Elsevier Masson SAS. All rights reserved.

1. Introduction infection and urethral trauma associated with self-intermittent

catheterization in neurologic patients. An extensive search of
Intermittent catheterization, especially self-intermittent cath- MEDLINE via PubMed and the authors’ experience constituted the
eterization, introduced in the second part of the 20th century [1,2], basis of the present recommendations.
is now considered the standard of care for most neurologic patients
with lower urinary tract disorders [3]. As compared with 2. Genitourinary tract infections: diagnosis, treatment and
indwelling catheterization, supra-pubic tube insertion, the Crede prevention
manoeuver or reflex micturition, intermittent catheterization has
repeatedly been reported to improve quality of life and decrease
2.1. Epidemiology–genitourinary tract infection
mid- and long-term urinary tract complications [4–6]. Such
bladder management aims to protect the upper urinary tract,
When talking about genitourinary tract infection, one must
improve urinary incontinence and decrease urinary tract infection.
clearly distinguish between urinary tract colonization and infection
However, in neurologic patients, the bacteriuria rate is high and
[10]. Urinary tract colonization is defined by the presence of one (or
repeated urethral manipulations has been associated with urethral
more) microorganism(s) in the urinary tract, without any clinical
trauma and strictures [7]. In this specific population, genitourinary
manifestation. The much-abused term ‘‘asymptomatic bacteriruria’’
tract infection and urethral trauma constitute challenges because
refers to the same entity but is not related to any threshold value. For
they can affect quality of life [8] and significantly complicate
patients undergoing intermittent catheterization, urinary tract
subsequent treatments [9].
colonization corresponds to asymptomatic bacteriuria  102 colo-
This ‘‘state-of-the-art’’ article provides updates regarding the
ny-forming units/ml [11]. Urinary tract infection refers to the
diagnosis, treatment and prevention of genitourinary tract
infestation of a tissue by one (or more) microorganism(s) generating
an inflammatory response with different types of symptoms varying
* Corresponding author. Tel.: +(1) 514 340 8222; fax: +(1) 514 340 7559. in type and severity. Therefore, the infection is defined in the general
E-mail address: jcorcosmd@yahoo.com (J. Corcos). population by the presence of a positive urine culture associated

http://dx.doi.org/10.1016/j.rehab.2016.02.006
1877-0657/ß 2016 Elsevier Masson SAS. All rights reserved.
126 X. Biardeau, J. Corcos / Annals of Physical and Rehabilitation Medicine 59 (2016) 125–129
with at least one of the following symptoms: fever (> 38 8C),
urgency, frequency, supra-pubic or lumbar pain.
Urinary tract colonization is a frequent problem in patients
undergoing intermittent catheterization. Classically, males and
females do not differ in prevalence [12]. Colonization should be
considered a risk factor for genitourinary tract infection [13],
among which we can distinguish afebrile infection (cystitis,
urethritis) and febrile infection (epididymo-orchitis, pyelonephri-
tis, prostatitis). The incidence of epididymo-orchitis has been
estimated at about 0.03/100 patient-days [14] and would be higher
with urethral stricture [15]. Of note, recurrent epididymo-orchitis
episodes could greatly affect male fertility by increasing the risk of
azoospermia [16]. Urinary tract infection is more frequent and the
incidence has been estimated as high as 0.41–1.46/100 patient-
days [17]. The most frequently isolated microorganisms are E. coli,
Proteus, Citrobacter, Pseudomonas, Klebsiella, Staphylococcus aureus
and Staphylococcus fecalis. Among patients undergoing long-term
intermittent catheterization, some specific microorganisms can
also be found: Acinetobacter and Streptococus fecalis [17]. However,
as compared with other bladder management, self-intermittent
catheterization in neurologic patients aims in particular to
decrease the urinary tract infection rate [18,19].
2.2. Diagnosis - genitourinary tract infection
2.2.1. Physical examination
In neurologic patients undergoing intermittent catheretization,
the diagnosis of urinary tract infection is challenging. Indeed, this
diagnosis is particularly difficult because of the quasi-constant
urinary tract colonization as well as the atypical clinical
presentation. Typical symptoms such as urgency, frequency and
dysuria are sometimes not present in this specific population–
especially those with spinal cord injury (SCI)–and urinary tract
infection should be suspected with the following clinical signs:
fever, discomfort or pain over the kidney or bladder or during
urination, onset of urinary incontinence, malaise, lethargy or sense
of unease, increased spasticity and/or autonomic dysreflexia in
patients with SCI (upper lesion > T6) and persistent urethral
bleeding with long-term intermittent catheterization [20–22]. The
presence of odorous or cloudy urine is not specific and should not
be used alone to diagnose urinary tract infection [20]. However,
epididymo-orchitis is easier to diagnose and should be suspected
at the onset of an inflammatory and/or painful scrotum.
2.2.2. Laboratory tests
A urine analysis associated with urine culture and antibiogram
should be systematically performed when a urinary tract infection is
suspected and a urine sample should be obtained by catheterization
before any antibiotic treatment [23]. This process will allow for
identifying the microorganism(s) and then adapting the antibiotic
therapy. Because leucocyturia mainly reflects inflammation at the
urinary tract level, it should not be taken into account to confirm
infection, especially in this neurologic population [24]. However,
when leucocyturia is not found on urine analysis, another diagnosis,
other than urinary tract infection, should be considered. Blood
culture should be systematically performed with fever  38.5 8C.
Although positive blood culture findings will not affect the length of
antibiotic therapy prescribed, they could provide evidence for a
urinary tract infection and guide antibiotic therapy–by identifying a
specific bacteria. White blood cell count and C-reactive protein
measurement will be of interest only to monitor infection.
Epididymo-orchitis should be considered here and treated as a
urinary tract infection, not as a sexually transmitted infection. Tetra-
or paraplegic patients with no sensory function below the
neurological level should undergo a urinary tract imaging to
eliminate obstructive pyelonephritis.
2.3. Treatment–genitourinary tract infection
2.3.1. Urinary tract colonization
With certain minor exceptions, urinary tract colonization should
never be treated in patients under intermittent catheterization
[25]. Indeed, even if the antibiotic therapy is considered effective
against the microorganism(s) present in urine, bacterial infection
will often not be eradicated or will return rapidly [26] and
antimicrobial therapy will contribute to the selection of resistant
microorganisms [27,28]. Particular cases for which an antibiotic
treatment should be initiated are patients undergoing urologic
surgery or implantation of prostheses, immunosuppressed patients,
pregnant women or for control of nosocomial infection due to a
virulent organism prevailing in a treatment unit or an organism
causing a high incidence of bacteriemia (e.g., Serratia marscens) [25].
2.3.2. Genitourinary tract infection
Genitourinary tract infection should be treated with an empirical
broad-spectrum antibiotic based on the patient’s history and local
susceptibility pattern and introduced just after urine and blood
sample collection. For patients with increased risk of antibiotic
resistance (history of multi-drug–resistant bacteria, recent hospi-
talization and/or recent antimicrobial therapy), an infectiologist
should be consulted. This empirical antibiotic therapy should be
secondarily adjusted to urine culture results and maintained for
14 to 21 days. To date, no clinical studies have clearly assessed the
optimal length of treatment in this specific population [25]. There-
fore, antibiotic therapy should be continued depending on the
suspected localization, microorganism(s), comorbidities and patient
response. In case of no localizing features, alternative diagnoses
must be considered. Furthermore, observation rather than immedi-
ate antimicrobial therapy should be considered when the patient is
clinically stable and the fever is low grade [25].
2.3.3. Recurrent genitourinary tract infection
Recurrent genitourinary tract infection has been arbitrarily
defined by the occurrence of 3 episodes/year or 2 episodes/
6 months or 1 episode in the previous 3 months [10]. With
recurrent infection, the catheterization technique should be
systematically revised and a persistent underlying cause should
be sought by a bladder diary and a urodynamic study (to search for
detrusor overactivity or impaired bladder compliance) and urinary
tract imaging (to search for urinary lithiasis and urinary tract
abnormalities). These approaches may involve a physician as well
as a dedicated stoma nurse, and a multichannel urodynamic study
should be considered. Furthermore, with recurrent epididymo-
orchitis, urethrocystoscopy or micturating cysto-urethrography
should be performed to search for an urethral stricture [15].
2.4. Prevention–genitourinary tract infection
2.4.1. Technique: frequency
High micturition volumes have been repeatedly reported as risk
factors for urinary tract infection [29,30]. Therefore, catheterization
frequency will play a major role in the occurrence of urinary tract
complications and should be customized and adapted to each
patient. Success will undoubtedly lie in the determination of the most
appropriate balance. Catheterization should be performed often
enough to limit bladder distension (> 400 cm3) and infrequently
enough to limit the negative impact on social life and quality of life.
Between 4 and 6 catheterizations per day are advocated [22,31].
2.4.2. Technique: clean intermittent catheterization
It is currently recommended to use a ‘‘clean’’ technique,
consisting of introducing the catheter with an atraumatic and non-
infecting manner. This technique implies hand washing and
 X. Biardeau, J. Corcos / Annals of Physical and Rehabilitation Medicine 59 (2016) 125–129
disinfection of the urinary meatus before introducing a clean
catheter (single-use catheter or cleaned multiple-use catheter).
The ‘‘sterile’’ technique requires a sterile catheter handled with
sterile gloves. The technique can only be performed during a
limited duration, generally during the acute phase following SCI
and in a hospitalization unit with a sufficient number of qualified
staff. The ‘‘sterile’’ technique has shown superiority only in
asymptomatic bacteriuria [32] or urinary tract infection [32–34]
when performed by trained and dedicated nurses and generates an
increase in cost as compared with the ‘‘clean’’ technique [32,33].
2.4.3. Material: single-use catheter
To date, single-use catheters have not demonstrated any
advantages in decreasing urinary tract infection as compared with
multiple-use catheters [23,35]. Furthermore, they are responsible
for increased health expenditure. However, some authors insist on
the binding character associated with multiple-use catheters and
the lack of consensus about the cleaning technique [23]. In
practice, multiple-use catheters are considered only when finan-
cial resources are limited, mainly in developing countries.
2.4.4. Material: hydrophilic-coated and pre-lubricated catheters
Hydrophylic-coated and pre-lubricated catheters have been
found to significantly decrease the risk of urinary tract infection as
compared with standard catheters [36–40]. However, they do not
seem to have a significant impact on urinary tract colonization. A
recent meta-analysis comparing hydrophilic-coated and standard
polyvinylchloride catheters concluded a statistical superiority of
hydrophilic-coated catheters, decreasing by 3 the incidence of
genitourinary tract infection [40]. Furthermore, hydrophilic-
coated catheters can delay the onset of first urinary tract infection
[39]. If standard polyvinylchloride catheters are used, a lubricant
should be added before their introduction. A single-use container
with lubricant should then be used to avoid contamination.
2.4.5. Material: urethral introducer
Bacteriuria has occurred after inoculation of peri-urethral
bacteria into the urine during intermittent catheterization
[41,42]. For a few authors, the systematic use of a urethral introducer,
bypassing the distal part of the urethra, would decrease bacteria
inoculum and prevent the associated urinary tract infection [43].
2.4.6. Add-on therapies: oral prophylactic antibiotic therapy
Although prophylactic antibiotic therapy has been reported to
provide a significant but transient decrease in bacteriuria in this
specific population, it should be avoided at all costs [27,28,44]. In-
deed, such treatment was responsible for the selection and change in
urinary bacteriuria leading to the emergence of multi-drug-resistant
bacteria and increased incidence of urinary tract infection
[44,45]. However, a novel approach, the Weekly Oral Prophylactic
Antibiotic (WOPA), has recently been considered. The approach aims
to alternate different types of antibiotics, each administered weekly
in a single dose during several consecutive months, all during a
prolonged period. These antibiotics should be effective for urinary
bacteria, well tolerated and present a low selective pressure profile.
Salomon et al. [46] reported a significant decrease in incidence of
genitourinary tract infection, hospitalization rate and antimicrobial
consumption among 38 included patients. Moreover, the authors
did not report new cases of colonization with multi-drug-resistant
bacteria during a median follow-up of 29 months.
2.4.7. Add-on therapies: intra-vesical prophylactic antibiotic therapy
The intra-vesical instillation of antibiotic substances and the
use of antibiotic-coated catheters are controversial. Some authors
have reported some encouraging results for bacteriuria (Neomy-
xin, Polymixin, Kanamycin-colistin, Gentamicin) [47–50] and
127
reducing urinary tract infection (Neomyxin, Polymixin, Gentami-
cin) [47,49,50]. However, the therapy could expose patients
to severe adverse events and promote the development of
multi-drug-resistant bacteria.
2.4.8. Add-on therapies: oral and intra-vesical antiseptic substances
The interest of antiseptic substances (oral methenamin, intra-
vesical instillation of povidone-iodine, intra-vesical instillation of
chlorexidine) has never been demonstrated in preventing genito-
urinary tract infection among patients under intermittent cathe-
terization [25].
2.4.9. Add-on therapies: cranberry products
A recent Cochrane review (2007) including 10 articles
(1049 patients) did not report any advantage of cranberry products
in preventing genitourinary tract infection among patients under
intermittent catheterization [51].
2.4.10. Add-on therapies: bacterial interference strategy
A novel approach, known as the bacterial interference strategy,
was recently proposed. It aims to promote the colonization of the
urinary tract with one or more non-pathogenic microorganisms to
inhibit the growth of pathogenic microorganisms and decrease the
risk of urinary tract infection. This innovative technique is part of
the theories recently developed around the concept of microbiota
[52]. The use of E. coli 83972-coated catheters could significantly
decrease the incidence of genitourinary tract infection [53]. Further
studies should be conducted to address the efficacy and safety of
this technique.
3. Urethral complications: diagnosis, treatment and
prevention
3.1. Urethral complications: epidemiology
Among urethral complications, we classically distinguish ure-
thral bleeding, false passage and urethral strictures. Urethral
bleeding episodes are frequent, affecting as many as one-third of
patients under long-term intermittent catheterization, mainly
males [7]. False passages are also considered classical complications
and often occur in case of urethral stricture, bladder-sphincter
dyssinergia and enlarged prostate. However, their incidence has
tended to decrease for several years because of improved nursing
care and the development of new catheters [22]. Urethral strictures
constitute a real challenge in this specific population, because the
continuation of intermittent catheterization is difficult, which can
therefore significantly affect bladder management [9]. Such stric-
tures can be located at the distal part (urinary meatus, membranous
urethra) or the proximal part (bulbous urethra, prostatic urethra) of
the urethra and would result from repeated urethral trauma. Several
risk factors noted include long-term intermittent catheterization
[27,54,55], high catheterization frequency [55], forceful urethral
manipulations and frequent urethral bleeding episodes [56].
3.2. Urethral complications: diagnosis
3.2.1. Physical examination
Urethral stenosis should be systematically considered with any
new onset of difficulty in performing intermittent catheterization
and the emergence of recurrent genitourinary tract infection,
especially epididymo-orchitis.
3.2.2. Complementary examination
If urethral stricture is suspected, it should be confirmed by
urethro-cystoscopy or micturating cysto-urethrography. The
128 X. Biardeau, J. Corcos / Annals of Physical and Rehabilitation Medicine 59 (2016) 125–129
choice between these two techniques will mainly depend on the
urologist, the clinical history and accessibility.
3.3. Urethral complications: treatment
3.3.1. False passage
A false passage should lead to transiently stop intermittent
catheterizations and introduce an indwelling catheter for 3 to
6 consecutive weeks, associated with a 5-day antibiotic therapy [57].
3.3.2. Urethral stricture
The treatment for urethral stricture will mainly depend on its
localization, extension and recurrence. Different techniques are
available, including, from the least to most invasive, urethral
dilation, meatotomy, urethrotomy and urethroplasty [56].
3.4. Urethral complications: prevention
3.4.1. Patient education
The prevention of urethral complications should rely on patient
education, especially teaching an optimal catheterization tech-
nique. Bladder management education programs explaining
anatomy and the bladder-sphincter system, using a variety of
formats (written, pictures, videos), have been effective in reducing
urethral complications [22]. Furthermore, establishing an accessi-
ble and complete standardized information could help decrease
complications. The information delivered should systematically
include teaching an optimal catheterization technique, an expla-
nation about signs and symptoms that should lead to consulting a
doctor, and details about the types of available catheters. The
catheterization technique should be instructed in a setting that
offers complete privacy. A long-term follow-up would allow for
regularly re-evaluating the catheterization technique and the
patient’s ability and motivation to continue intermittent catheter-
ization [22,58].
3.4.2. Nurses’ education
A knowledgeable and experienced nurse was found important
for successful self-intermittent catheterization. Therefore, all
caregivers implicated in patient education should understand
the cause of bladder and sphincter dysfunction and the reason for
proposed treatment [22].
3.4.3. Catheterization technique
The catheter should be introduced gently to avoid any urethral
trauma. The patient must have full understanding of anatomy
beforehand and be able to easily manipulate the catheter. Several
tests and questionnaires are now available to evaluate the patient’s
dexterity before beginning self-intermittent catheterization
[59,60]. With a hypertonic urethral striated sphincter, the catheter
should be inserted up to the sphincter and kept it in position for 1–
2 minutes before pushing it into the bladder [22]. In this particular
situation, some authors have reported the advantage of botulinum
toxin A injections into the urethral striated sphincter, so that the
patient can continue with self-intermittent catheterization
[61]. However, this technique is counterbalanced by an increased
risk of incontinence [62] and is therefore not recommended by
current guidelines; further research should be conducted.
3.4.4. Material
Several types of catheters are available for intermittent
catheterization, differing by the material used, shape, length,
diameter or presence of lubricant and specific coating. However,
none can be universally used. Therefore, a variety of catheters
should be proposed to the patient, explaining the pros and cons
associated with each [63]. Furthermore, the patient should be
given the opportunity to try different catheters and choose among
them. However, pre-lubricated catheters have been found to
prevent urethral complications, with a significant decrease in
urethral bleeding episodes as compared with standard catheters
[36]. Similarly, hydrophilic-coated catheters have been reported to
significantly decrease urethral complications as compared with
standard catheters. Regardless, pre-lubricated and hydrophilic-
coated catheters have never been compared head-to-head.
4. Conclusion
Several important points should be kept in mind when
considering genitourinary tract infections and urethral complica-
tions in neurologic patients under intermittent catheterization.
Urinary tract colonization should never be treated (except in
particular situations), and prophylactic antibiotic therapy should
never be prescribed (except for WOPA, under evaluation). Urinary
tract infection and urethral complications should be prevented by
ensuring an optimal catheterization technique through patient and
caregiver education and by using hydrophilic-coated or pre-
lubricated catheters. Furthermore, the use of a urethral introducer
and bacterial interference strategy could help prevent genitouri-
nary tract infection.
Disclosure of interest
The authors declare that they have no competing interest.
References
[1] Guttmann L, Frankel H. The value of intermittent catheterisation in the early
management of traumatic paraplegia and tetraplegia. Paraplegia 1966;4:63–
84. http://dx.doi.org/10.1038/sc.1966.7.
[2] Lapides J, Diokno AC, Silber SJ, Lowe BS. Clean, intermittent self-catheteriza-
tion in the treatment of urinary tract disease. J Urol 1972;107:458–61.
[3] Groen J, Pannek J, Castro Diaz D, Del Popolo G, Gross T, Hamid R, et al. Summary
of European Association of Urology (EAU) Guidelines on Neuro-Urology. Eur
Urol 2015;69:324–33.
[4] Maynard FM, Diokno AC. Clean intermittent catheterization for spinal cord
injury patients. J Urol 1982;128:477–80.
[5] Diokno AC, Sonda LP, Hollander JB, Lapides J. Fate of patients started on clean
intermittent self-catheterization therapy 10 years ago. J Urol 1983;129:
1120–2.
[6] Sutton G, Shah S, Hill V. Clean intermittent self-catheterisation for quadriple-
gic patients–a five year follow-up. Paraplegia 1991;29:542–9. http://
dx.doi.org/10.1038/sc.1991.78.
[7] Webb RJ, Lawson AL, Neal DE. Clean intermittent self-catheterisation in
172 adults. Br J Urol 1990;65:20–3.
[8] Pinder B, Lloyd AJ, Nafees B, Elkin EP, Marley J. Patient preferences and
willingness to pay for innovations in intermittent self-catheters. Patient Prefer
Adherence 2015;9:381–8. http://dx.doi.org/10.2147/PPA.S73487.
[9] Afsar SI, Yemisci OU, Cosar SNS, Cetin N. Compliance with clean intermittent
catheterization in spinal cord injury patients: a long-term follow-up study.
Spinal Cord 2013;51:645–9. http://dx.doi.org/10.1038/sc.2013.46.
[10] Bruyère F, Cariou G, Boiteux J-P, Hoznek A, Mignard J-P, Escaravage L, et al.
Diagnostic et traitement des infections bactériennes urinaires de l’adulte :
généralités. Prog Urol 2008;18:4–8. http://dx.doi.org/10.1016/S1166-
7087(08)70505-0.
[11] The prevention and management of urinary tract infections among people
with spinal cord injuries. National Institute on Disability and Rehabilitation
Research consensus statement. January 27-29, 1992. SCI Nurs 1993;10:49–61.
[12] Bakke A, Digranes A. Bacteriuria in patients treated with clean intermittent
catheterization. Scand J Infect Dis 1991;23:577–82.
[13] Wyndaele J-J, Brauner A, Geerlings SE, Bela K, Peter T, Bjerklund-Johanson TE.
Clean intermittent catheterization and urinary tract infection: review and
guide for future research. BJU Int 2012;110:E910–7. http://dx.doi.org/
10.1111/j.1464-410X.2012.11549.x.
[14] Thirumavalavan VS, Ransley PG. Epididymitis in children and adolescents on
clean intermittent catheterisation. Eur Urol 1992;22:53–6.
[15] Ku JH, Jung TY, Lee JK, Park WH, Shim HB. Influence of bladder management on
epididymo-orchitis in patients with spinal cord injury: clean intermittent
catheterization is a risk factor for epididymo-orchitis. Spinal Cord
2006;44:165–9. http://dx.doi.org/10.1038/sj.sc.3101825.
[16] Allas T, Colleu D, Le Lannou D. Genital function in paraplegic men. Immuno-
logic aspects. Presse Med 1986;15:2119.
[17] Nicolle LE. Urinary catheter-associated infections. Infect Dis Clin North Am
2012;26:13–27. http://dx.doi.org/10.1016/j.idc.2011.09.009.
 X. Biardeau, J. Corcos / Annals of Physical and Rehabilitation Medicine 59 (2016) 125–129
[18] Weld KJ, Dmochowski RR. Effect of bladder management on urological compli-
cations in spinal cord injured patients. J Urol 2000;163:768–72.
[19] Escları́n De Ruz A, Garcı́a Leoni E, Herruzo Cabrera R. Epidemiology and risk
factors for urinary tract infection in patients with spinal cord injury. J Urol
2000;164:1285–9.
[20] Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, et al.
Diagnosis, prevention, and treatment of catheter-associated urinary tract
infection in adults: 2009 International Clinical Practice Guidelines from the
Infectious Diseases Society of America. Clin Infect Dis 2010;50:625–63.
[21] Loeb M, Bentley DW, Bradley S, Crossley K, Garibaldi R, Gantz N, et al.
Development of minimum criteria for the initiation of antibiotics in residents
of long-term-care facilities: results of a consensus conference. Infect Control
Hosp Epidemiol 2001;22:120–4. http://dx.doi.org/10.1086/501875.
[22] Di Benedetto P. Clean intermittent self-catheterization in neuro-urology. Eur J
Phys Rehabil Med 2011;47:651–9.
[23] Barnes DG, Timoney AG, Moulas G, Shaw PJ, Sanderson PJ. Correlation of
bacteriological flora of the urethra, glans and perineum with organisms
causing urinary tract infection in the spinal injured male patient. Paraplegia
1992;30:851–4. http://dx.doi.org/10.1038/sc.1992.161.
[24] Cardenas DD, Hooton TM. Urinary tract infection in persons with spinal cord
injury. Arch Phys Med Rehabil 1995;76:272–80.
[25] Tenke P, Kovacs B, Bjerklund Johansen TE, Matsumoto T, Tambyah PA, Naber
KG. European and Asian guidelines on management and prevention of cathe-
ter-associated urinary tract infections. Int J Antimicrob Agents 2008;31:S68–
78. http://dx.doi.org/10.1016/j.ijantimicag.2007.07.033.
[26] Schlager TA, Dilks S, Trudell J, Whittam TS, Hendley JO. Bacteriuria in children
with neurogenic bladder treated with intermittent catheterization: natural
history. J Pediatr 1995;126:490–6.
[27] Wyndaele JJ. Complications of intermittent catheterization: their prevention
and treatment. Spinal Cord 2002;40:536–41. http://dx.doi.org/10.1038/
sj.sc.3101348.
[28] Roghmann M-C, Wallin MT, Gorman PH, Johnson JA. Prevalence and natural
history of colonization with fluoroquinolone-resistant gram-negative bacilli in
community-dwelling people with spinal cord dysfunction. Arch Phys Med
Rehabil 2006;87:1305–9. http://dx.doi.org/10.1016/j.apmr.2006.07.260.
[29] Lapides J, Diokno AC, Gould FR, Lowe BS. Further observations on self-cathe-
terization. J Urol 1976;116:169–71.
[30] Shekelle PG, Morton SC, Clark KA, Pathak M, Vickrey BG. Systematic review of
risk factors for urinary tract infection in adults with spinal cord dysfunction. J
Spinal Cord Med 1999;22:258–72.
[31] Stöhrer M, Blok B, Castro-Diaz D, Chartier-Kastler E, Del Popolo G, Kramer G,
et al. EAU guidelines on neurogenic lower urinary tract dysfunction. Eur Urol
2009;56:81–8. http://dx.doi.org/10.1016/j.eururo.2009.04.028.
[32] Prieto-Fingerhut T, Banovac K, Lynne CM. A study comparing sterile and
nonsterile urethral catheterization in patients with spinal cord injury. Rehabil
Nurs 1997;22:299–302.
[33] Duffy LM, Cleary J, Ahern S, Kuskowski MA, West M, Wheeler L, et al. Clean
intermittent catheterization: safe, cost-effective bladder management for
male residents of VA nursing homes. J Am Geriatr Soc 1995;43:865–70.
[34] Getliffe K, Fader M, Allen C, Pinar K, Moore KN. Current evidence on intermit-
tent catheterization: sterile single-use catheters or clean reused catheters and
the incidence of UTI. J Wound Ostomy Continence Nurs 2007;34:289–96.
http://dx.doi.org/10.1097/01.WON.0000270824.37436.f6.
[35] Schlager TA, Clark M, Anderson S. Effect of a single-use sterile catheter for each
void on the frequency of bacteriuria in children with neurogenic bladder on
intermittent catheterization for bladder emptying. Pediatrics 2001;108:E71.
[36] Giannantoni A, Di Stasi SM, Scivoletto G, Virgili G, Dolci S, Porena M. Inter-
mittent catheterization with a prelubricated catheter in spinal cord injured
patients: a prospective randomized crossover study. J Urol 2001;166:
130–3.
[37] Vapnek JM, Maynard FM, Kim J. A prospective randomized trial of the LoFric
hydrophilic coated catheter versus conventional plastic catheter for clean
intermittent catheterization. J Urol 2003;169:994–8. http://dx.doi.org/10.
1097/01.ju.0000051160.72187.e9.
[38] De Ridder DJMK, Everaert K, Fernández LG, Valero JVF, Durán AB, Abrisqueta
MLJ, et al. Intermittent catheterisation with hydrophilic-coated catheters
(SpeediCath) reduces the risk of clinical urinary tract infection in spinal cord
injured patients: a prospective randomised parallel comparative trial. Eur Urol
2005;48:991–5. http://dx.doi.org/10.1016/j.eururo.2005.07.018.
[39] Cardenas DD, Moore KN, Dannels-McClure A, Scelza WM, Graves DE, Brooks M,
et al. Intermittent catheterization with a hydrophilic-coated catheter delays
urinary tract infections in acute spinal cord injury: a prospective, randomized,
multicenter trial. PM R 2011;3:408–17. http://dx.doi.org/10.1016/j.pmrj.
2011.01.001.
[40] Li L, Ye W, Ruan H, Yang B, Zhang S, Li L. Impact of hydrophilic catheters on
urinary tract infections in people with spinal cord injury: systematic review
129
and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil
2013;94:782–7. http://dx.doi.org/10.1016/j.apmr.2012.11.010.
[41] Schlager TA, Hendley JO, Wilson RA, Simon V, Whittam TS. Correlation of
periurethral bacterial flora with bacteriuria and urinary tract infection in
children with neurogenic bladder receiving intermittent catheterization. Clin
Infect Dis 1999;28:346–50. http://dx.doi.org/10.1086/515134.
[42] Levendoglu F, Ugurlu H, Ozerbil OM, Tuncer I, Ural O. Urethral cultures in
patients with spinal cord injury. Spinal Cord 2004;42:106–9. http://dx.doi.org/
10.1038/sj.sc.3101554.
[43] Bennett CJ, Young MN, Razi SS, Adkins R, Diaz F, McCrary A. The effect of
urethral introducer tip catheters on the incidence of urinary tract infection
outcomes in spinal cord injured patients. J Urol 1997;158:519–21.
[44] Clarke SA, Samuel M, Boddy S-A. Are prophylactic antibiotics necessary with
clean intermittent catheterization?. A randomized controlled trial. J Pediatr
Surg 2005;40:568–71. http://dx.doi.org/10.1016/j.jpedsurg.2004.11.027.
[45] Bakke A, Vollset SE. Risk factors for bacteriuria and clinical urinary tract
infection in patients treated with clean intermittent catheterization. J Urol
1993;149:527–31.
[46] Salomon J, Denys P, Merle C, Chartier-Kastler E, Perronne C, Gaillard J-L, et al.
Prevention of urinary tract infection in spinal cord-injured patients: safety and
efficacy of a weekly oral cyclic antibiotic (WOCA) programme with a 2 year
follow-up–an observational prospective study. J Antimicrob Chemother
2006;57:784–8. http://dx.doi.org/10.1093/jac/dkl010.
[47] Haldorson AM, Keys TF, Maker MD, Opitz JL. Nonvalue of neomycin instillation
after intermittent urinary catheterization. Antimicrob Agents Chemother
1978;14:368–70.
[48] Pearman JW. The value of kanamycin-colistin bladder instillations in reducing
bacteriuria during intermittent catheterisation of patients with acute spinal
cord injury. Br J Urol 1979;51:367–74.
[49] Van Nieuwkoop C, Den Exter PL, Elzevier HW, Den Hartigh J, Van Dissel JT.
Intravesical gentamicin for recurrent urinary tract infection in patients with
intermittent bladder catheterisation. Int J Antimicrob Agents 2010;36:485–
90. http://dx.doi.org/10.1016/j.ijantimicag.2010.05.005.
[50] Liotta RF, Tarantino ML. Clean vesical intermittent catheterization: lubrication
of vesical catheter through lidocaine or gentamicine? Urologia 2012;79:49–
53. http://dx.doi.org/10.5301/RU.2012.9002.
[51] Jepson RG, Craig JC. Cranberries for preventing urinary tract infections.
Cochrane Database Syst Rev 2008;CD210013. http://dx.doi.org/10.1002/
14651858.CD001321.pub4.
[52] Wolfe AJ, Brubaker L. ‘‘Sterile Urine’’ and the presence of bacteria. Eur Urol
2015;68:173–4. http://dx.doi.org/10.1016/j.eururo.2015.02.041.
[53] Prasad A, Cevallos ME, Riosa S, Darouiche RO, Trautner BW. A bacterial
interference strategy for prevention of UTI in persons practicing intermittent
catheterization. Spinal Cord 2009;47:565–9. http://dx.doi.org/10.1038/
sc.2008.166.
[54] Wyndaele JJ, Maes D. Clean intermittent self-catheterization: a 12-year fol-
low-up. J Urol 1990;143:906–8.
[55] Perrouin-Verbe B, Labat JJ, Richard I, Mauduyt de la Greve I, Buzelin JM, Mathe
JF. Clean intermittent catheterisation from the acute period in spinal cord
injury patients. Long-term evaluation of urethral and genital tolerance. Para-
plegia 1995;33:619–24. http://dx.doi.org/10.1038/sc.1995.131.
[56] Mandal AK, Vaidyanathan S. Management of urethral stricture in patients
practising clean intermittent catheterization. Int Urol Nephrol 1993;25:
395–9.
[57] Michielsen DP, Wyndaele JJ. Management of false passages in patients prac-
tising clean intermittent self catheterisation. Spinal Cord 1999;37:201–3.
[58] Wyndaele JJ. Self-intermittent catheterization in multiple sclerosis. Ann Phys
Rehabil Med 2014;57:315–20. http://dx.doi.org/10.1016/j.rehab.2014.05.007.
[59] Amarenco G, Guinet A, Jousse M, Verollet D, Ismael SS. Pencil and paper test: a
new tool to predict the ability of neurological patients to practice clean
intermittent self-catheterization. J Urol 2011;185:578–82. http://dx.doi.org/
10.1016/j.juro.2010.09.106.
[60] Guinet-Lacoste A, Jousse M, Tan E, Caillebot M, Le Breton F, Amarenco G.
Intermittent catheterization difficulty questionnaire (ICDQ): A new tool for
the evaluation of patient difficulties with clean intermittent self-catheteriza-
tion. Neurourol Urodyn 2016;35:85–9.
[61] Schurch B, Hauri D, Rodic B, Curt A, Meyer M, Rossier AB. Botulinum-A toxin as
a treatment of detrusor-sphincter dyssynergia: a prospective study in 24 spinal
cord injury patients. J Urol 1996;155:1023–9.
[62] Kuo H-C. Satisfaction with urethral injection of botulinum toxin A for detrusor
sphincter dyssynergia in patients with spinal cord lesion. Neurourol Urodyn
2008;27:793–6. http://dx.doi.org/10.1002/nau.20606.
[63] Bermingham SL, Hodgkinson S, Wright S, Hayter E, Spinks J, Pellowe C.
Intermittent self catheterisation with hydrophilic, gel reservoir, and non-
coated catheters: a systematic review and cost effectiveness analysis. BMJ
2013;346:e8639.