Jack Lapides

Clean, Intermittent Self-Catheterization in the Treatment of Urinary Tract Disease

Based upon a series of studies involving urinary infection we postulated that most cases of urinary tract infection are due to some underlying structural or functional abnormality of the urogenital tract which leads to decreased resistance of tissue and to bacterial invasion. The urothelium or renal parenchyma can be affected through damage to its structural integrity by neoplasm, calculi, foreign bodies such as inlying catheters, traumatic instrumentation and so forth. However, the most common cause for increased susceptibility to bacterial invasion is decreased blood flow to the tissue. Blood flow to the bladder can be reduced by increased intravesical pressures and/or by overdistention of the organ. The resulting ischemic bladder tissue is then prey to invading gram-negative organisms from the patient’s own gut via the hematogenous or lymphogenous route. Transient bacteremia is believed to be a common phenomenon in healthy individuals. In the female patient poor voiding patterns, such as infrequent voiding, is the primary cause of cystitis whereas obstruction is the leading cause in the male patient.3–5 Thus, it can be inferred from our theory that maintenance of a good blood supply to the renal pelvis, ureter, bladder and urethra by avoiding high intraluminal pressures and over distension is the key to prevention of urinary tract infection. Residual urine in itself and organisms supposedly ascending through the urethra are of doubtful importance in the genesis of urinary infection. These ideas have led us to treat urinary tract infections in most girls and women with a regimen of frequent day and night voiding and appropriate antibacteria medication when indicated. We rarely have found it necessary to dilate the urethra or perform an operative procedure upon the lower or upper urinary tract, and this includes ureteral reimplantation for reflux. The concept under discussion provides an explanation for the tolerance of prolonged catheter drainage by many patients without becoming septic (for example cystostomy, ureterostomy and nephrostomy) and the excellent response of individuals following cutaneous vesicostomy, despite the fact that all of these people have continual bacteriuria. It will be observed readily, that the hypothesis serves also to account for the complications of catheter usage. As observed by Campbell “retention rather than catheterization is the thing to be feared.”7 A catheter which drains freely can provoke sepsis within minutes if it becomes obstructed and allows the bladder to overdistend or intravesical pressure to increase markedly. Under these circumstances the bacteria in the urine will be disseminated readily into the systemic circulation. Similarly intermittent catheterization becomes dangerous if the patient is catheterized and then the bladder is allowed to overdistend before catheterization is again performed. To recapitulate, intermittent catheterization of the bladder should be an innocuous procedure provided the bladder is not permitted to overdistend and it is performed in an atraumatic fashion. Furthermore, a clean and not an aseptic technique should suffice since any bacteria introduced by the catheter will be neutralized by the resistance of the host.

Further Observations on Self-catheterization

A non-sterile technique of intermittent self-catheterization was used for 218 patients with an inability to void in a normal fashion because of obstructive uropathy, decompensated detrusor or neurogenic bladder. Marked improvement was noted in urinary continence, urinary infection, renal function, bladder emptying and, perhaps most important, the mental and emotional status of the patient and/or parents. The extremely low incidence of complications and its therapeutic efficacy clearly make clean, intermittent self-catheterization an outstanding weapon in the urological armamentarium and a most persuasive reminder that host resistance is still the primary factor in the occurrence of infection.

Association of urinary tract infection and reflux with uninhibited bladder contractions and voluntary sphincteric obstruction.

We studied 53 neurologically normal children with recurrent urinary tract infection who were found to have bladder-sphincter incoordination characterized by voluntary sphincteric constriction during involuntary uninhibited bladder contraction. Increased intravesical pressure was documented during these events and was associated with vesicoureteral reflux in nearly 50 per cent of the children and with abnormalities of the ureteral orifice in 30 per cent of those without reflux. We hypothesize that increased intravesical pressure causes urinary infection in these children and produces a spectrum of intravesical anatomic distortion that predisposes to vesicoureteral reflux. In a prospective uncontrolled study treatment of the uninhibited bladder contractions allowed 58 per cent of the patients to maintain sterile urine without subsequent antimicrobial therapy after cure of the initial infection.

Effects of adrenalectomy and aldosterone on proximal and distal tubular sodium reabsorption.

Summary The technic of stop-flow analysis has been used to localize the site of renal sodium reabsorption which is affected by adrenalectomy and aldosterone. Following adrenalectomy, the distal tubule was not able to reduce sodium concentration to the low value achieved during stop-flow in normal dogs. Following aldosterone administration this distal reabsorptive capacity was restored. No conclusion could as yet be made regarding the effects of aldosterone on the proximal tubule.

Fate of Patients Started on Clean Intermittent Self-Catheterization Therapy 10 Years Ago

We evaluated 60 patients placed on a clean intermittent catheterization program more than 10 years ago to determine their outcome. To date 27 patients still are performing self-catheterization, 18 have discontinued the procedure and 15 have been lost to followup. No patient has had deterioration in renal function. Prior incontinence was alleviated completely in 10 of the 27 patients still on the program and 10 of the 18 patients no longer on catheterization have returned to normal voiding. Clean intermittent catheterization is an effective treatment modality in properly selected patients, with few complications and excellent long-term results.

The Significance of Bacilluria in Children on Long-Term Intermittent Catheterization

We reviewed the records of 255 children who have been managed by clean intermittent catheterization during the last 10 years to determine the incidence of bacilluria and upper tract changes. Bacteriuria was documented in 56 per cent of the children but febrile urinary tract infections occurred in only 11 per cent and fresh renal damage in 2.6 per cent. In the absence of vesicoureteral reflux bacilluria proved to be innocuous, since vesicoureteral reflux, progressive hydronephrosis or increasing parenchymal scarring did not develop. Bacteriuria in association with low grade reflux was rarely harmful and the reflux actually disappeared in up to 50 per cent of cases. However, bacteriuria in patients with high grade reflux was not an innocent phenomenon, since not only did the reflux tend to persist but pyelonephritis occurred in more than 60 per cent of the patients. In this latter group of patients reimplantation is an important therapeutic consideration if sterile urine cannot be achieved.

Mechanisms of urinary tract infection

Most urinary tract infections begin as a cystitis secondary to decreased host resistance brought on by disruption of tissue integrity or a decrease in blood supply to the bladder. In the female, infrequent voiding and the uninhibited bladder are the most common causes of urinary tract infection and are best treated by healthy voiding regimens; while in the male, structural and functional obstructive uropathy are most often associated with urinary tract infection and are alleviated by lowering the high intravesical pressures via surgical or medical measures. The concept that host resistance is the determinant of infection rather than the organism has permitted the use of clean, intermittent self-catheterization; clean intermittent self-dilatation; and transurethral diverticulectomy in the therapy of a host of urologic disease syndromes.

Transurethral treatment of urethral diverticula in women.

Six women with urethral diverticulitis and a history of having had previous operations for diverticula were subjected to transurethral diverticulotomy with a knife electrode. Each patient had multiple diverticula, some compartmented, located in the mid or most proximal segments of the urethra. All patients have been releived of the symptoms and infection during the postoperative period, varying from 1 1/2 to 7 years.

Urinary tract complications of anorectal surgery.

Abstract Intraoperative injury to ureters (eight), bladder (three), and urethra (one) occurred in 7 per cent of the patients undergoing coloproctectomy for carcinoma. Prompt recognition and proper management prevented prolonged morbidity or mortality. Thirty per cent experienced postoperative vesical dysfunction. Complete preoperative urologic evaluation, as outlined, will permit anticipation if not avoidance of many of these complications.

Action of oral and parenteral bethanechol on decompensated bladder

A double blind balanced Latin-square study was conducted on 20 adult patients with decompensated bladders to determine the relative effectiveness of oral and parenteral bethanechol chloride (Urecholine) on the stretch response of bladder muscle. Detrusor reaction was measured by modified cystometry. Five mg. of subcutaneous bethanechol chloride produced a significant increase in intravesical pressure which was more rapid in onset, of larger magnitude, and of shorter duration than oral doses of 100 and 200 mg.