Is intermittent urethral catheterization preferred over continuous indwelling catheters for short-term management of urinary retention in my hospitalized patient?

For continuous urethral catheterization (CUC), the estimated daily risk of acquisition of bacteriuria is 3% to 8%1-3.  For intermittent urethral catheterization (IUC), the incidence of bacteriuria is 1% to 3% per insertion4. The Infectious Diseases Society of America recommends that IUC should be considered as an alternative to short-term CUC to reduce catheter-associated bacteriuria or UTI based on “poor evidence”  (Category C) and, as relates to symptomatic UTIs, without properly designed randomized-controlled studies2.  

A Cochrane systematic review of CUC vs IUC in hospitalized patients failed to find any significant differences between the 2 interventions as relates to the rates of symptomatic UTI and asymptomatic bacteriuria in hospitalized patients requiring short-term catheterization5.   Of interest, nearly 3 times as many people developed acute urinary retention with IUC compared to CUC in this study (16% vs 45%, respectively, RR 0.45, 95% CI 0.22-0.91).  

In short, despite its theoretical advantage in reducing the risk of UTIs due to lack of a constant presence of a catheter, solid data to support preference of IUC over CUC in short-term management of urinary retention in hospitalized patients is still lacking.

Bonus pearl: Did you know that compared to indwelling urinary catheters, suprapubic catheters are associated with lower incidence of asymptomatic bacteriuria, but not necessarily symptomatic UTIs? 5

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References

  1. Lo, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:464-78. https://www.ncbi.nlm.nih.gov/pubmed/25376068
  2. Hooton TM, Bradley SF, Cardenas DD, 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;50:625-663. https://academic.oup.com/cid/article/50/5/625/324341
  3. Kunin CM, McCormack RC. Prevention of catheter-induced urinary-tract infections by sterile closed drainage. N Engl J Med 1966;274:1155-61. https://www.ncbi.nlm.nih.gov/pubmed/5934951
  4. Saint S, Lipsky BA. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Intern Med 1999;159:800-808. https://reference.medscape.com/medline/abstract/10219925
  5. Kidd EA, Stewart F, Kassis NC, et al. Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterization in hospitalized adults (review). Cochrane Database of Systematic Reviews 2015; Issue 12. Art No. :CD004203. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004203.pub3/full

 

 

 

 

Is intermittent urethral catheterization preferred over continuous indwelling catheters for short-term management of urinary retention in my hospitalized patient?

What is an abnormal post-void residual (PVR) volume?

Although measurement of PVR is a common everyday occurrence in hospitalized patients, the threshold of what constitutes an abnormal value is often poorly defined and not standardized. However, most urologists consider volumes of 50 ml to 100 ml to constitute the lower threshold of abnormal PVR (1).

Large PVRs are associated with urinary tract infections, especially in persons at risk (e.g. diabetes, spinal cord injury), while very large PVRs (>300 ml) may be associated with an increased risk of upper urinary tract dilatation and renal insufficiency.

Chronic urinary retention is often defined as a PVR > 300 ml (2).

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References

1. Kelly CE. Evaluation of voiding dysfunction and measurement of bladder volume. Rev Urol 2004;6 (suppl 1):S32-S37. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472847

 

2. Kaplan SA, Wein AJ, Staskin DR, Roehrborn CG, Steers WD. Urinary retention and post-void residual urine in men: separating truth from tradition. J Urology 2008;180:47–54. https://www.ncbi.nlm.nih.gov/pubmed/18485378

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

What is an abnormal post-void residual (PVR) volume?

How might constipation lead to urinary retention?

The association between constipation and urinary retention is well known (1,2).

Several mechanisms may explain this relationship,  including sharing of the innervations of the internal anal and urinary sphincters  via S2-S4 nerve roots, and the presence of impacted stool in the rectum leading to invaginations in the posterior wall of the bladder and urethral obstruction (1,2). 

Interestingly, in laboratory experiments involving rats, rectal distention with a balloon diminished bladder contractility (3).   So, along with many other factors, constipation should routinely be considered a potential cause of acute urinary retention.  

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References

1. Selius BA, Subedi R. Urinary retention in adults: diagnosis and initial management. Am Fam Physician 2008;77:643-650. https://www.aafp.org/afp/2008/0301/p643.html  

2. Ariza Traslavina, Del Ciampo LA, Ferraz IS. Acute urinary retention in a pre-school girl with constipation. Rev Paul Pediatr 2015;33:488-492.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4685571/

3. Miyazato M, Sugaya K, Nishijima S, et al. Rectal distention inhibits the spinal micturition reflex via glycinergic or GABAergic mechanisms in rats with spinal cord injury. Urol Int  2005;74:160-65. https://www.ncbi.nlm.nih.gov/pubmed/15756069

How might constipation lead to urinary retention?

When should I consider treating my hospitalized patients with asymptomatic bacteruria (ASB)?

The great majority of hospitalized patients with ASB do not need treatment with antibiotics.

In fact, there are only a couple of conditions for which treatment of ASB is indicated:  pregnant women (due to risk of pyelonephritis and low-birth infants/pre-term delivery) and before  GU instrumentation, such as transurethral resection of the prostate or other GU procedures for which mucosal bleeding is anticipated (1).  

So for the great majority of our hospitalized patients, including the elderly, diabetic women, institutionalized residents of long-term facilities, and spinal cord injury patients treatment of ASB is not indicated.  Even in the case of renal transplant patients, supportive evidence for the  use of prophylactic antibiotics in ASB is so far lacking (2).  

The estimated prevalence of ASB varies widely in the population,  with rates of 15-20% among community-dwelling women > 70 yrs of age, and 5-10% for men>65 yrs for community-dwelling men. In long-term care facility residents, 25-50% of women, 15-40% of men, and 100% of those with chronic indwelling catheters have ASB (3).  

So keep these rates in mind before attributing patient’s symptoms to ASB (ie, patient’s presentation may have nothing to do with urine findings).  It’s also worth emphasizing that pyuria accompanying ASB is not an indication for treatment.

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References

1. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54.  https://academic.oup.com/cid/article/40/5/643/363229

2. Coussement J, Abramowicz D. Should we treat asymptomatic bacteriuria after renal transplantation? Nephrol Dial Transplant 2013;0:1-3. https://academic.oup.com/ndt/article/29/2/260/1913512

3. Nicolle LE. Asymptomatic bacteriuria in older adults. Geriatrics & Aging 2003;6:24-28. https://www.healthplexus.net/files/content/2003/October/0609bacteriuria.pdf

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis or its affiliate healthcare centers, Mass General Hospital, Harvard Medical School or its affiliated institutions. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

When should I consider treating my hospitalized patients with asymptomatic bacteruria (ASB)?

My 70 year old male patient with recent hip fracture has developed fevers with sterile pyuria. How do I interpret the sterile pyuria in this patient?

Although historically sterile pyuria (SP) has been associated with genitourinary (GU) tuberculosis, there are many more common causes to consider in the hospitalized patient (1-3).    

Recent antibiotic exposure (within past 2 weeks) in the setting of UTI is one of the most frequent causes.  Prostatitis is also an often overlooked cause.  Sexually transmitted diseases such as gonorrhea and Chlamydia trachomatis should also be considered in at risk patients. Hospitalized patients with systemic infections outside of the GU tract (e.g. pneumonia, appendicitis, diverticulitis) may also have SP (1-3). High prevalence of SP (>70%) has been reported among patients with appendicitis or diverticulitis (2). 

Non-infectious causes include current or recent catheterization of bladder, urinary stones, stents, GU malignancy, papillary necrosis,  Kawasaki’s disease, autoimmune diseases (eg, SLE) and analgesic nephropathy. 

I would start with repeating the u/a as 50% of sterile pyuria may be transient (3). If repeat u/a still shows pyuria, a prostate exam in our elderly male is indicated to exclude prostatitis. 

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References:

  1. Wise GJ, Schlegel PN. Sterile pyuria. N Engl J Med 372;11:1048-54. https://www.nejm.org/doi/pdf/10.1056/NEJMra1410052
  2.  Goonewardene S, Persad R. Sterile pyuria: a forgotten entity. Ther Adv urol 2015; 7:295-298.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549703/ 
  3. Hooker JB, Mold JW, Kumar S. Sterile pyuria in patients admitted to the hospital with infections outside of the urinary tract. J Am Board Fam Med 2014;2&:97-103. https://www.jabfm.org/content/27/1/97.long#T1 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

My 70 year old male patient with recent hip fracture has developed fevers with sterile pyuria. How do I interpret the sterile pyuria in this patient?