Sherman J. Silber

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.