U.S. flag

An official website of the United States government

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

National Clinical Guideline Centre (UK). Urinary Incontinence in Neurological Disease: Management of Lower Urinary Tract Dysfunction in Neurological Disease. London: Royal College of Physicians (UK); 2012 Aug. (NICE Clinical Guidelines, No. 148.)

Cover of Urinary Incontinence in Neurological Disease

Urinary Incontinence in Neurological Disease: Management of Lower Urinary Tract Dysfunction in Neurological Disease.

Show details

15Potential complications: providing information and initial management

The management of the neuropathic lower urinary tract has, in general, had to rely heavily on expert opinion because definitive, high quality research has yet to answer many important questions about the optimal approach to maintaining continence. In addition, the dramatic improvement in survival for patients with complex disability due to long-term neurological conditions over the last century has been achieved, in part, by the adoption of a somewhat dogmatic approach to urinary tract management and patient care, notably in spinal cord injury units. However, it is now clear that there are many circumstances where the patients and their carers will be able to choose between different, clinically appropriate management regimes depending on their underlying neurological condition and individual circumstances.

There are a limited number of basic LUT management systems that can be used (see table 123). These can be considered as the means by which the patient drains or collects most of their urine output. They are not mutually exclusive so that some patients will use a combination of different systems. For example, a patient with multiple sclerosis might void with voluntary control as their main way of emptying the bladder but might also drain residual urine using intermittent catheterisation before going to bed in order to reduce nocturia. They might also choose to use a pad to contain incontinence when away from home.

Table 123. Urinary tract management systems for draining or collecting urine output.

Table 123

Urinary tract management systems for draining or collecting urine output.

It must also be appreciated that medical or surgical interventions are often needed in order to enable the use of a management system or optimise its use. For example, a patient with spina bifida with severe incontinence might wish to manage their LUT with intermittent catheterisation and to be reliably continent between catheterisations. This could require surgical treatment to overcome both impaired bladder storage of urine and incontinence due to an incompetent urethral sphincter mechanism.

Given that patients, carers and clinicians can have fundamental choices to make between different treatment options and bladder management systems, it is important that there is information available to them about the effect of the different approaches on both quality of life and the accompanying risks. These judgements can be particularly difficult where a patient regards a particular approach as best suiting their circumstances even though there may be significantly greater risks attached to that management option. This can occur where major reconstructive surgical procedures are being considered, such as in a patient contemplating undergoing an augmentation cystoplasty in order to be continent while using intermittent self catheterisation. Conversely, there are occasions when a patient will choose the relative convenience of an indwelling catheter, despite the added risk of complications such as urinary tract stone formation and infection.

15.1. Intermittent Catheterisation, Indwelling Catheters and Penile Sheath Urine Collection

15.1.1. What are the long term risks associated with the long term use of intermittent catheterisation, indwelling catheters and penile sheaths?

Clinical Methodological Introduction
Population:Patients with incontinence due to neurogenic lower urinary tract dysfunction (NLUTD)
Intervention:What are the long term risks (renal impairment, hydronephrosis, urinary tract stones, urinary tract infection, malignancy (bladder cancer) associated with the long-term use of intermittent catheterisation, indwelling catheters (supra pubic and urethral) and penile sheath collection/pads?
Comparison:Not applicable
Outcomes:
  • What is the quality of life associated with the above
  • Long term risks as specified in question
  • Include kidney, bladder and renal stones (urolithiasis, cystolithiasis renal lithiasis and nephrolithiasis)

15.1.1.1. Clinical evidence

We searched for observational studies reporting on the long term risks associated with long-term use of intermittent catheterisation, indwelling catheters (supra pubic and urethral) and penile sheath collection/pads. In addition, we searched for observational studies reporting on the quality of life associated with these methods of urine collection.

Long term Risks

For the long term risk associated with catheters 17 studies were identified, with a minimum follow-up of 12 months233 234 235 236 237 238 239 240 241 242 243 244 245 246 247,248 249.

Quality of Life studies

For quality of life, 3 papers were identified 250 251 252. The search included observational studies. All of the studies were on adults with spinal cord injury, except for one on patients with myelomeningocele 250. The results are reported by outcome.

Quality of studies

The majority of studies were retrospective reviews of medical records. The non-randomised comparisons between various catheterisation methods were prone to confounding from unstandardised management strategies being used for different population groups with different baseline risk profiles. In some studies statistical adjustments were made for such confounding, although in the majority of studies this did not occur. Studies were therefore categorised as very low quality.

Long term risks outcomes
Renal impairment

Study: N=70233

Length of follow-up: years of bladder management ranged from 2 to 33 yrs, frequency of follow up not stated

Table 124Incidence of reflux and renal calculi

ComplicationIntermittent catheterisation (n=23)Padding (n=25)Urethral catheter (n=22)
Duration of follow-up2–10 yrs
(n=17)
2–10 yrs
(n=7)
11–23
(n=14)
2–10 yrs
(n=7)
11–23
(n=9)
24–33
(n=6)
Reflux1--244
Renal calculi--3-12

None of the 6 patients on intermittent catheterisation for 11 to 23 yrs or the 4 on padding for 24 to 33 yrs reported any complications.

Study: N=57237

Length of follow-up: 12 yrs, frequency of follow up yearly

Table 125Incidence of renal stones and pyelonephritis

ComplicationTotal (n=57)Catheterised group (n=32)Non-catheterised group (n=25)p-value (diff b/w catheterised and non catheterised group)
Renal stone14860.93
Pyelonephritis13850.66

Study: N=235239

Length of follow-up: Duration of bladder management 24.1 yrs (range 10 to 45 yrs), frequency of follow up 70% yearly or every other year

Table 126Incidence of renal calculi

Participants with renal calculi (%)Participants without renal calculi (%)
Initial discharge (n=46)Follow-up (n=47)Initial discharge (n=186)Follow-up (n=188)
Normal bladder emptying139128
Suprapubic tapping54285832
Abdominal pressure17191915
Crede manoeuvre223619
Intermittent catheterisation11401339
Urethral catheter719915

Study: N=140241

Length of follow-up: 17 yrs, frequency of follow up yearly

Table 127Incidence of renal stones

Spontaneous voiding (SV)Clean intermittent catheterisation (CIC)Suprapubic cystostomy (SC)Urethral catheter (UC)
Accumulated incidence (%)6 (13)3 (9)4 (11)8 (33)*
Episodes/100 person-years0.880.540.652.5
*

<0.05 in the SV versus the UC group, the CIC versus UC group, and the SPC versus the UC group by Fisher’s exact test

Table 128Results of multivariate analysis for renal stones

Bladder managementRenal stone OR adjusted (95%CI)p
Spontaneous voiding (SV)1.0
Clean intermittent catheterisation0.89 (0.17 to 4.6)0.89
Suprapubic cystostomy0.71 (0.16 to 3.2)0.66
Urethral catheter5.7 (1.3 to 25)0.021

Study: N=179240

Length of follow-up minimum 10 yrs, frequency of follow up yearly

Table 129Incidence of the complications of upper urinary tract

Urethral catheterIntermittent catheterisationSuprapubic cystostomyCrede manoeuvre or reflex voidingCondom catheter
Pyelonephritis12 (41.4%)20 (41.7%)13 (31.0%)10 (26.3%)6 (27.3%)
Renal calculi6 (20.7%)6 (12.5%)15 (35.7%)13 (34.2%)4 (18.2%)
Upper tract deterioration15 (51.7%)18 (37.5%)11 (26.2%)9 (23.7%)5 (22.7%)

Table 130Multivariate risk factors for complications of the upper urinary tract - adjusted odds ratio (95%CI)

PyelonephritisRenal calculiUpper tract deterioration
Urethral catheter1.01.01.0
Intermittent catheter0.930 (0.352–2.455)0.526 (0.147 to 1.888)0.330 (0.114 to 0.958)
Suprapubic catheter0.532 (0.186 to 1.519)1.827 (0.581 to 5.745)0.097 (0.026 to 0.359)
Crede manoeuvre or reflex voiding0.464 (0.158 to 1.366)1.856 (0.579 to 5.955)0.123 (0.035 to 0.428)
Penile sheath0.502 (0.148 to 1.704)0.746 (0.177 to 3.137)0.200 (0.051 to 0.780)

Study: N=8314235

Length of follow up: Mean 3 yrs (range 7 mths to 13 yrs), frequency of follow up yearly

Table 131Incidence of stones in the kidney or ureter

Bladder management at dischargeN%No. of stones 5-yr cumulative incidence%P
Catheter-free171020.6201.60.002
Urethral catheter102712.4496.9
Penile sheath5636.8255.1
Intermittent catheter440753.01795.0
Suprapubic catheter2963.682.7
Other2483.053.4
Unknown630.80

Table 132Risk factors for kidney stones occurring before and after the first year post injury – multivariate cox regression model

Year one RR (adjusted) (95%CI)Year 2 and later RR (adjusted) (95%CI)
Catheter-free1.01.0
Urethral catheter1.3 (0.6 to 2.7)2.5 (1.1 to 5.7)
Penile sheath1.3 (0.6 to 2.8)2.0 (0.9 to 4.6)
Intermittent catheter1.2 (0.6 to 2.1)2.4 (1.2 to 5.2)
Suprapubic catheter0.3 (0.1 to 1.3)2.6 (1.1 to 6.3)
Other0.6 (0.1 to 2.6)4.2 (1.7 to 10.6)

Study: N=149247

Length of follow-up: 68 months, range 3 to 179 months, frequency of follow up variable

Table 133Incidence of renal complications

ComplicationSuprapubic catheterisation
All renal complications20/149
Acute pyelonephritis8/149
Renal calculi12/149
Renal scarring9/149
All vesicoureteral reflux (VUR)
 VUR with renal stones
 VUR with renal scarring
 VUR with renal stones and scarring
21/149 (bilateral in 5)
3/149
1/149
1/149

Renal scarring and calculi were more prevalent in quadriplegic than paraplegic patients. Renal scarring was generally mild, and the risk of scarring was zero if the bladder was normal or areflexic

Study: N=204 (142 followed up)242

Length of follow up: 12 years, frequency of follow up not stated

Table 134Incidence of renal complications

Adverse eventUrethral catheterNon catheterisedp
Renal stones18/566/860.0001
Recurrent pyelonephritis7/562/860.015
Parenchymal thinning13/564/860.0009

Study: N=316249

Follow up mean 18.3 (12.4) yrs since injury, frequency of follow-up unclear

Table 135Incidence of renal complications

ComplicationsUrethral n=114CIC n=92Spontaneous n=74Suprapubic n=36p
pyelonephritis8%1%1.5%3%<0.001
Renal stone55%22%20%36%<0.001
VUR23%7%8%28%0.001
Abnormal upper tracts30%16%27%39%0.038
Hydronephrosis

Study: N=70233

Length of follow-up: range 2 to 33 yrs, frequency of follow-up not stated

Table 136Incidence of hydronephrosis

ComplicationIntermittent catheterisation (n=23)Padding (n=25)Urethral catheter (n=22)
Duration of follow-up2–10 yrs
(n=17)
2–10 yrs
(n=7)
11–23
(n=14)
2–10 yrs
(n=7)
11–23
(n=9)
24–33
(n=6)
Hydronephrosis-1-42-

None of the 6 patients on intermittent catheterisation for 11 to 23 yrs or the 4 on padding for 24 to 33 yrs reported any complications.

Study: N=65243

Length of follow-up: mean 3.7 yrs (range 1 to 7.5 yrs), frequency of follow up not stated

Findings:

0/28 of the patients had hydronephrosis

Urinary tract stones

Study: N=70233

Length of follow-up: range 2 to 33 yrs, frequency of follow up not stated

Table 137Incidence of bladder calculi

ComplicationIntermittent catheterisation (n=23)Padding (n=25)Urethral catheter (n=22)
Duration of follow- up2–10 yrs
(n=17)
2–10 yrs
(n=7)
11–23
(n=14)
2–10 yrs
(n=7)
11–23
(n=9)
24–33
(n=6)
Bladder calculi1--1312

None of the 6 patients on intermittent catheterisation for 11 to 23 yrs or the 4 on padding for 24 to 33 yrs reported any complications.

Study: N=140241

Length of follow-up: 17 yrs, frequency of follow up yearly

Table 138Incidence of bladder stones

Spontaneous voiding (SV)Clean intermittent catheterisation (CIC)Suprapubic cystostomy (SPC)Urethral catheter (UC)
Accumulated incidence (%)14 (30)5 (15)15 (42)*5 (21)
Episodes/100 person- years2.00.895.11.7
*

<0.05 in the CIC vs SPC group by chi-square test

Table 139Risk of bladder stone – results of multivariate analysis

Bladder managementBladder stone
OR adjusted (95%CI)
p
Spontaneous voiding (SV)1.0
Clean intermittent catheterisation0.53 (0.16 to 1.8)0.30
Suprapubic cystostomy1.5 (0.56 to 3.9)0.43
Urethral catheter0.89 (0.24 to 3.3)0.86

Study: N=57237

Length of follow up: 12 yrs, frequency of follow-up yearly

Table 140Incidence of bladder stones

ComplicationTotal (n=57)Catheterised group (n=32)Non- catheterised group (n=25)p-value
(diff b/w catheterised and non catheterised group)
Bladder stone181350.10

Study: N=457246

Length of follow-up: median 60 months, frequency of follow up yearly

Table 141Risk of bladder stones

Bladder management typeMean follow- up(years)No. of bladder stones/no. of pts% forming bladder stones (no./total no.)Total group follow-up (years)% absolute annual risk stone formation
Penile sheath + sphincterotomy8.400 (0/55)4630
Intermittent self catheterisation (ISC)6.751/11.5 (1/70)4800.2
Expression voiding with or without penile sheath6.37/73 (7/240)1,5150.5
Urethral catheter5.959/3523 (35/152)7894% (first stone), 16% (subsequent stones)

Results of Cox- regression analysis: Although age, sex, and injury level were not significantly explanatory variables, degree of injury was considered (p=0.02) in the model. After correcting for degree of injury, both suprapubic and urethral forms of indwelling catheter were found to have a high risk of bladder stone formation compared with ISC or condom drainage with or without sphincterotomy.

The hazard ratio was 10.5 (p<0.0005, 95% CI 4.0–27.5) for patients with supra pubic catheters and 12.8 (p<0.005, 95% 5.1–31.9) for those with urethral catheters. Bladder stones were no more likely to form in patients with supra pubic catheters than in those with urethral urethral catheters (hazard ratio 1.2, p=0.6).

Study: N=149247

Length of follow-up: 68 months, range 3 to 179 months, frequency of follow up variable

Table 142Incidence of bladder stones

ComplicationSuprapubic catheterisation
Bladder stones33/149

Higher incidence in quadriplegics (26/96 quadriplegics versus 7/68 paraplegics). There were frequent recurrences, leading to a total of 56 episodes.

Study: N=204 (142 followed up)242

Length of follow up: 12 years, frequency of follow up not stated

Table 143Incidence of bladder stones

Adverse eventUrethral catheterNon catheterisedp
Bladder stones34/5610/860.0001

Study: N=35249

Length of follow up: 6 years (range 2–12 years), frequency of follow up 6 monthly for two years then yearly

Table 144Incidence of recurrent bladder stones

Adverse eventUrethral catheterIntermittent catheterisationp
Recurrent bladder stones13/130/13Not stated

Study: N=316249

Follow up mean 18.3 (12.4) yrs since injury, frequency of follow up unclear

Table 145Incidence of bladder stones

ComplicationsUrethral
n=114
CIC n=92Spontaneous n=74Suprapubic
n=36
p
Bladder stone28%0%8%22%<0.001
Urinary tract infection

Study: N=129236

Length of follow-up: One yr

Table 146Incidence of upper tract infection (data extracted from graph)

Bladder managementUrinary tract infection % (95%CI)
Normal voiding6 (2 to 36%)
Controlled voiding20 (5 to 50%)
Clean intermittent catheterisation70 (43 to 90)
Mixed (using clean intermittent catheterisation plus other method)72 (58 to 90)
Suprapubic tapping48 (30 to 68)
Compression or straining31 (11 to 59)

Study: N=65243

Length of follow-up: mean 3.7 yrs (range 1 to 7.5 yrs), frequency of follow up not stated

Findings:

12/28 patients had received treatment for one or more urinary tract infection

Study: N=125245

Length of follow-up: One yr

Findings:

Table 147Episodes and timing of urinary infections post admission

Timing (weeks)Urethral catheterisation
(n=85)
Supra-pubic cystostomy
(n=40)
Total (n=125)
1,212 (20%)6 (14%)16 (13%)
2,410(16%)3 (21%)13 (10%)
4,633(52%)1 (7%)34 (27%)
6,84 (6%)2 (14%)6 (4%)
8,102 (3%)1 (7%)3 (2%)
10,122(3%)1 (7%)3 (2%)

Study: N=149247

Length of follow-up: 68 months, range 3 to 179 months, frequency of follow up variable

Table 148Incidence of urinary tract infection

ComplicationSuprapubic catheterisation
All symptomatic UTIs45/149
 Cystitis38/149
Epididymo-orchitis3/149

Some had more than one episode.

Study: N=204 (142 followed up)242

Length of follow up: 12 years, frequency of follow up not stated

Table 149Incidence of urinary tract infections

Adverse eventUrethral catheterNon catheterisedp
Symptomatic UTIs (1 episode)6/5635/860.0001
Symptomatic UTIs (> 1 episode)42/5611/860.0001
Urosepsis
 Leading to death
12/56
2/56
7/86
0/86
0.023

Study: N=64248

Length of follow up: 1 year, frequency of follow up monthly

Table 150Incidence of urinary tract infections

Adverse eventIntermittent catheterisationCondom and collection bagp
Urinary tract infection17.2 infections/person- year18.9 infections/person-yearNS

Study: N=35244

Length of follow up: 6 years (range 2–12 years), frequency of follow up 6 monthly for two years then yearly

Table 151Incidence of urinary tract infections

Adverse eventUrethral catheterIntermittent catheterisationp
Symptomatic (febrile) UTIs12/137/22Not stated

Study: N= 705234

Length of follow up: 1 year

Findings:

At discharge there was no significant difference in rate of bacteriuria with fever (BWF) between those with self intermittent catheterisation, those with intermittent catheterisation by someone else and those with a urethral catheter.

Table 152Rates of BWF at hospital discharge and at 1 year follow up N (%)

At dischargeAt 1 year follow up
Self intermittent catheterisation77/155 (50)33/62 (53)
Intermittent catheterisation by other60/103 (58)20/24 (83)
Urethral catheter48/114 (42)25/57 (44)

Examining only those who were on the same system of drainage at discharge from the initial rehabilitation and at year 1 follow-up, the patients on intermittent catheterisation by someone else (ICO) were more likely to have experienced at lease one episode of BWF than the group on self intermittent catheterisation and patients with urethral catheter (p<0.025).

Bladder cancer

Study: N=3670238

Length of follow-up: mean 2 yrs

Findings:

Analyses of potential risk factors for bladder cancer revealed a significantly greater proportion of participants who used an indwelling urethral catheter (IDC) (46% of IDC group, 39% of multi group (using both dwelling and non dwelling)) developed bladder calculi compared with 10% in the non-urethral catheter (NIDC) group (×2 =537.64, p<0.001).

Age- adjusted analyses revealed that increasing exposure to IDC use was associated with bladder cancer in spinal cord injury. The IDC group had an age – adjusted rate of 77 per 100,000 person-years, compared with rates of 56.1 and 18.6 per 100,000 person-years in the multi and NIDC groups, respectively.

After age and gender adjustment, participants with spinal cord injury were 15.2 (95% CI, 9.2 –23.3) times likely to develop bladder cancer than the general population. Of those using IDC only as their method of bladder management, the observed 15 cases of bladder cancer were compared with an expected 0.6 cases, yielding a ratio of 25.4 (95%, 14.0 –41.9).

Calculations of attributable risk (AR), revealed that IDC was responsible for 34.1 cases of bladder cancer per 100,000 person-years of SCI. This yielded an AR percentage of 55.8% for IDC use, whereas male gender and bladder calculi were responsible for fewer cases of bladder cancer, at 32.9% and 10.7% respectively. In those using IDC only, IDC was responsible for 58.4 cases per 100,000 person-years, or 64.8% of all bladder cancer occurring in the IDC population.

At the completion of the study, 13 persons with bladder cancer had died, with the cause of death identified as bladder cancer in 12. Of the 12, 10 had solely used IDC, where as 2 used multiple techniques. There were no bladder cancer deaths in the NIDC group.

Study: N=149247

Length of follow-up: 68 months, range 3 to 179 months, frequency of follow up variable

Table 153Incidence of cancer

ComplicationSuprapubic catheterisation
Low grade superficial transitional cell carcinoma1/149
Quality of life outcome

Study: N=22250

Young patients with spina bifida (Myelomeningocele MMC) aged 13–26 who had been using clean intermittent catheterisation (CIC) independently for at least 5 years. This was a qualitative study, using semi-structured interviews, to elicit attitudes to their condition and CIC. The study was conducted in Sweden.

Telling peers of their use of CIC was deemed as difficult but important and satisfying. Peer reactions ranged from disgust (catheter insertion) to childish (use of diapers) to admiration. Those not in wheelchairs experienced less belief from others about their CIC use, and some of these wished they were in a wheelchair to increase acceptance of their CIC use. Lack of medical staff understanding of CIC was perceived as a major problem.

All disliked being catheterised by someone else, but in medical appointments most were reticent at stating this, and the clinician would do the catheterisation.

Most of the participants rated their incontinence as a mild disability, and rated non-MMC disabilities they didn’t have, such as blindness, as more severe.

Eight participants had no friends at all. Two others spoke of friends, but on later investigation these were really casual acquaintances. 12 had a best friend. 15 found it easy to make friends but harder to keep them. Barriers to friendship were perceived as an inability to run, the use of crutches or the need for diapers. 12 were currently involved with a partner. Finding a partner was strongly desired by 17, but they found it difficult to realise this wish. None knew of the effects of their condition on sexual function, and felt that a medical professional should give them more information on this. Some could not imagine a future without children of their own. 19 were preoccupied with thoughts of parenthood in the future, but 9 were unsure if they would be able to do this. Of the 3 female adults in a relationship, one had had a healthy baby. At the end of the interview the participants were invited to ask anything. Two males and two females asked: “How am I going to find someone to marry?”

Overall all participants were satisfied with CIC and would not want to return to their previous voiding technique. Most, after five years experience, did not find it a problem in daily life. Overall, CIC was regarded as positive and most of the children’s negative experiences were related to their overall disability, independent of CIC.

Study: N=41252

SCI patients, mean age 39.5 yrs. Mean time post SCI 4 years. The study was conducted in Germany. Patients divided into “treatment successes” and “treatment failures”. Success determined by a bladder capacity of >360 mL, absence of autonomic dysregulation and continence

Table 154Qualiveen scale scores in relation to bladder function after correction for depression

Bladder management mean (SD)
ScaleSuccess (n=14)Failure (n=27)P value
Limitations37.2 (22.10)48.6 (18.29).0544
Constraints39.2 (21.44)52.9 (25.68).0377
Fears20.0 (16.40)44.7 (19.65).0014
Feelings12.7 (15.22)39.8 (27.69).0182

Study: N=132251

Follow up: 24 months. SCI patients using clean intermittent catheterisation, compared to healthy controls.

Effect

Comparison of SF-36 scores of patients and controls (general population) with respect to gender.

Table 155Comparison of SF-36 scores of patient and controls (general population) with respect to sex

Male mean (SE)Female mean (SE)
DomainPatients
(n=81)
Controls
(n=90)
P valuePatients
(n=51)
Controls
(n=60)
P value
Physical functioning18.4 (3.2)85.3 (1.7)<0.00128.3 (4.4)72.0 (2.3)<0.001
Role-physical functioning26.2 (4.5)81.8 (2.9)<0.00130.9 (5.7)71.2 (3.6)<0.001
Role- emotional functioning29.2 (4.8)70.2 (3.4)<0.00138.6 (6.4)60.8 (3.9)0.002
Vitality43.6 (2.4)52.7 (2.0)0.00542.3 (3.0)48.8 (1.9)0.064
Mental health55.6 (2.4)67.2 (1.7)<0.00151.9 (3.1)64.6 (1.7)<0.001
Social functioning49.5 (2.9)85.2 (1.8)<0.00154.4 (4.0)81.7 (2.1)<0.001
Bodily pain62.4 (3.3)81.4 (1.8)<0.00160.5 (4.0)70.9 (2.1)0.025
General health46.9 (2.1)54.7 (1.5)0.00244.0 (2.3)51.7 (1.8)0.013

Table 156Comparison of SF-36 scores of patients and controls (general population) with respect to age

< 50 yr≥ 50 yr
DomainPatients
(n=90)
Controls
(n=100)
P valuePatients
(n=41)
Controls
(n=50)
P value
Physical functioning20.1 (3.0)83.5 (1.7)<0.00127.1 (5.1)74.9 (2.3)<0.001
Role-physical functioning28.3 (4.2)81.0 (2.9)<0.00127.4 (6.6)73.0 (3.6)<0.001
Role- emotional functioning32.6 (4.7)66.9 (3.4)<0.00133.3 (7.0)64.4 (4.0)<0.001
Vitality46.8 (2.1)51.0 (1.9)0.14634.9 (3.5)50.9 (2.1)<0.001
Mental health56.2 (2.2)63.7 (1.7)0.00549.7 (3.7)68.4 (1.8)<0.001
Social functioning54.0 (2.8)84.2 (1.7)<0.00145.7 (4.3)83.3 (2.2)<0.001
Bodily pain64.4 (2.9)80.0 (1.7)<0.00155.7 (5.2)72.7 (2.3)0.004
General health47.1 (1.8)54.4 (1.6)0.00342.9 (3.2)52.1 (1.6)0.006

The results of this study demonstrate that a treatment regimen leading to favourable urodynamic data and continence correlates with better quality of life.

15.1.1.2. Economic evidence

No relevant economic evaluations comparing the short and long-term use of intermittent catheterisation, indwelling catheters and penile sheath collection/pads were identified.

Unit costs

In the absence of recent UK cost-effectiveness analysis, relevant unit costs are provided below to aid consideration of cost-effectiveness.

Table 157Resource costs

ItemCost*Frequency Cost per year
Average cost of indwelling catheters:£5.318.7/year£245.00
Average costs of intermittent catheters£0.755/day£1,365.93
Average cost of pads£0.255/day£456.25
Average cost of sheaths£4.841/day£1,766.6

Source:

*

NHS Supply Chain Catalogue (2011)12

GDG opinion.

Economic considerations

The economic issues in this question are dependent on the degree of choice available in selection of intervention leading to two situations:

  1. The choice of intervention is limited by what the patient can manage or by the indication for their condition.
  2. The patient and clinician have a choice over the intervention on the basis of comfort, convenience and prevention of adverse events.

In the first situation the economic considerations are not particularly important as the choice has already been made on other grounds. In the second situation, the economic considerations are around the risks of adverse events. The incidence of adverse events is considerable, as reported in the clinical evidence. Since these adverse events would require some costly treatment, we believe that those interventions that produce the lowest rates of adverse events will result in the lowest overall cost.

15.1.1.3. Evidence Statements

Clinical evidence statements

9 studies of 9664 participants reported on the incidence of renal impairment (follow-up 3 mths to 33 yrs) (very low quality)

1 study of 135 participants reported on the incidence of hydronephrosis (follow-up 2 to 33 yrs) (very low quality)

8 studies of 1428 participants reported on the incidence of urinary tract stones (follow-up 3 mths to 33 yrs) (very low quality)

8 studies of 1476 participants reported on the incidence of urinary tract infections (follow-up 3 mths to 12 yrs) (very low quality)

2 studies of 3819 participants reported on the incidence of bladder cancer (follow-up 3 months to 179 months) (very low quality)

2 studies of 154 participants reported on quality of life (unclear) (very low quality)

Economic evidence statement

The choice of intervention should be based on the results of the clinical review as the incidence of adverse events associated with each intervention will be the main driver of cost-effectiveness. The intervention with the lowest rate of adverse events is likely to be the lowest cost.

15.1.2. Recommendations and links to evidence

Recommendations:RENAL IMPAIRMENT
63.

Discuss with the person and/or their family members and carers the increased risk of renal complications (such as kidney stones, hydronephrosis and scarring) in people with neurogenic urinary tract dysfunction (in particular those with spina bifida or spinal cord injury). Tell them the symptoms to look out for (such as loin pain, urinary tract infection and haematuria) and when to see a healthcare professional.

64.

When discussing treatment options, tell the person that indwelling urethral catheters may be associated with higher risks of renal complications (such as kidney stones and scarring) than other forms of bladder management (such as intermittent self catheterisation).

65.

Use renal imaging to investigate symptoms that suggest upper urinary tract disease.

BLADDER STONES
66.

Discuss with the person and/or their family members and carers the increased risk of bladder stones in people with neurogenic lower urinary tract dysfunction. Tell them the symptoms to look out for that mean they should see a healthcare professional (for example, recurrent infection, recurrent catheter blockages or haematuria).

67.

Discuss with the person and/or their family members and carers that indwelling catheters (urethral and suprapubic) are associated with a higher incidence of bladder stones compared with other forms of bladder management. Tell them the symptoms to look out for that mean they should see a healthcare professional (for example, recurrent infection, recurrent catheter blockages or haematuria).

68.

Refer people with symptoms that suggest the presence of bladder stones (for example, recurrent catheter blockages, recurrent urinary tract infection or haematuria) for cystoscopy.

BLADDER CANCER
69.

Discuss with the person and/or family members and carers that there may be an increased risk of bladder cancer in people with neurogenic lower urinary tract dysfunction, in particular those with a long history of neurogenic lower urinary tract dysfunction and complicating factors, such as recurrent urinary tract infections. Tell them the symptoms to look out for (especially haematuria) that mean they should see a healthcare professional.

70.

Arrange urgent (within 2 weeks) investigation with urinary tract imaging and cystoscopy for people with:

  • visible haematuria or
  • increased frequency of urinary tract infections or
  • other unexplained lower urinary tract symptoms.
Relative value placed on the outcomes consideredThe evidence review was designed to assess the long-term risks that are attached to the use of different LUT management systems. The GDG considered that the outcomes under consideration are of high importance.
Quality of evidenceThe majority of studies were retrospective reviews of medical records. The non- randomised comparisons between different catheterisation methods were prone to confounding from un-standardised management strategies being used for different population groups with different baseline risk profiles. Studies were therefore categorised as very low quality. Studies were mainly restricted to patients with spinal cord injury.
Overall, the evidence suggested an increased risk of stones, hydronephrosis and scarring associated with all bladder management systems compared to spontaneous voiding. Comparisons of the risks associated with different management systems were very limited, but there was some suggestion that urethral catheters were associated with a higher risk of complications compared to other bladder management systems.
Trade-off between clinical benefits and harmsThe information presented in the evidence review is of relevance to clinicians, patients and carers when choices between management systems are under consideration. However, an analysis of the balance between benefit and harm is necessary. This should include an assessment of the possible benefits of the different management systems in the individual patient’s circumstances. The review has not included an assessment of such benefits so that no statement can be made in relation to the benefit/harm relationship.
Although the evidence was confined largely to spinal cord injury patients the GDG view was that the risks were applicable to a wider population.
Economic considerationsNo health economic evaluations were found for this question. The clinical review showed that the incidence of adverse events is considerable. Since these adverse events would require some costly treatment, and might be quite serious, those interventions that produce the lowest rates of adverse events are more likely to be least costly. Some interventions might be contraindicated for some patients; in these cases economic considerations are not particularly important when deciding the intervention.
Other considerationsThe GDG agreed complications associated with long term use of catheterisation needs to be discussed with patients prior to making decisions on bladder management. Patient GDG members acknowledged that potential kidney complications was a worry to patients and that it was important clinicians provided clear information and ensured patients knew where to go to obtain help when needed.
The GDG were aware that the incidence of cancer of the bladder in patients with NLUTD remains uncertain and might not differ greatly from that in the general population but when cancer does occur in a neurological population it is more invasive and aggressive. The GDG noted that there has been a lot of debate on what the incidence is and that it is difficult to come to conclusions based on the evidence included. They noted that the studies that addressed this issue in the evidence revue were those that looked at rates of bladder cancer in relation to bladder management system. Studies looking at bladder cancer rates that did not include management system comparisons were not included. However, such studies were known to have produced a range of different estimates of the risk of bladder cancer, with most studies looking at spinal cord injury patients (Bladder cancer in patients with spinal cord injuries. K Subramonian, RA Cartwright, P Harnden and SCW Harrison. British Journal of Urology International. 2004, 93,739–743.)
The recommendations were made on the basis of the information that arose from the literature review and the clinical experience of the GDG members. It was recognised that current practice, both in the UK and internationally, is to offer upper urinary tract surveillance to patients with neurogenic lower urinary tract dysfunction who are in groups (such as spinal cord injury) which have both a significantly increased risk of renal complications and a good prognosis with respect to their underlying neurological condition. Although there is no evidence that directly validates this approach, the GDG concluded that there is sufficient evidence of increased risk to suggest that current practice should be continued although it is hoped that future studies will evaluate the costs and benefits associated with upper tract screening.
The GDG recommended referral for cystoscopy in patients with suspected bladder stones on the basis that cystoscopy is the most reliable investigation for detecting bladder calculi (which can be small and poorly calcified in some cases).
The benefits of detecting and treating complications that include renal and bladder stones, hydronephrosis and bladder cancer were felt to be self-evident. The value to the patient of detecting minor degrees of renal scarring is uncertain

15.1.3. Research recommendations

Intermittent Catheterisation, Indwelling Catheters and Penile Sheath Urine Collection
5.

What are the long-term risks and effects on quality of life of different bladder management strategies for lower urinary tract dysfunction in people with neurological disease?

  • Why this is important
    The range of bladder management strategies available to manage lower urinary tract dysfunction in neurological disease includes permanent urethral catheterisation and suprapubic catheterisation, intermittent self-catheterisation, penile sheath collection systems and pads. However, there is very sparse evidence about which strategies are most acceptable to patients and/or their family members and carers. The current research base relates mainly to the spinal injury population but may be relevant to people with other neurological diseases.
    Bladder management strategies are a long-term treatment with implications for maintaining health and quality of life. In order to make informed choices about the most appropriate method of bladder management, patients and/or their family members and carers require information about the risks and benefits of the available options. There is currently little evidence about which methods are most likely to produce long-term complications (renal impairment, urinary stones and infections, hydronephrosis, bladder malignancy). The effect on quality of life for patients and/or their family members and carers of different bladder management strategies is not known. There are methodological difficulties due to the heterogeneity of the population with neurological disease, the long time course of treatments and the presence of cognitive impairment in some sub-populations.
    Proposed studies could include prospective cohort studies of disease-specific populations examining the effect of each method on quality of life using both generic and disease-specific assessment methods. In addition, prospective screening for complications including renal impairment, stone formation and infection should be carried out and comparisons made for each bladder management method. Particular emphasis should be placed on quality-of-life outcomes for family members and carers, especially for those looking after people with cognitive impairment.
Copyright © 2012, National Clinical Guideline Centre.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

The rights of National Clinical Guideline Centre to be identified as Author of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988.

Bookshelf ID: NBK132838

Views

  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (3.7M)
  • Disable Glossary Links

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...