​Avoiding Urinary Tract Infections-Part 1

Posted by Nurse Linda in Life After Paralysis on June 17, 2020 # Health

Recently, a reader asked what can be done to avoid urinary tract infections (UTIs)? This is a multiple level question as there are quite a few things that affect all areas of life, from what you take into your body to catheterization and catheterization technique to habits to break. There are so many ideas that this blog will be in two parts. Part 1 is about catheterization. Next week, Part 2 extends into ideas about daily life prevention.catheter

Technique

Perhaps the first review to reduce urinary infections is to reassess your technique. We all become complacent with activities overtime by going through well-rehearsed and familiar motions without really thinking about what we are doing. This is called being a human. It is not lack of interest. Simply put, it is doing something so routine that we don’t think through all the steps. Take a moment to review every step of your bladder care to notice if there is some slack in your technique. Don’t be surprised if there is. This happens to everyone. You can self-correct.

If your bladder management includes an indwelling catheter either through the urethra (typically a foley) or abdomen (suprapubic), review how often the catheter is changed and how it is changed. These catheters are replaced using sterile technique. Even though sterile gloves are used for insertion of the sterile catheter, hands should be washed with warm water, soap and use of friction by rubbing your hands on all sides vigorously together for at least 20 seconds before you begin the procedure.

Nighttime drainage bags should be positioned below the level of the bladder to avoid backflow of urine. A coil of the tubing should be on the bed to allow urine to flow into the bag by gravity. If the tube hangs off the bed, it can pull on the catheter at the insertion site. Urine cannot flow uphill if any part of the tube hangs lower than the bag. This will leave urine in the bladder for a longer time which lets bacteria grow.

The dressing around a suprapubic catheter should be clean and dry. It is a barrier to keep bacteria from entering the bladder. Leakage, drainage or other moisture will indicate an additional dressing change needs to be done. Moisture or other debris on the dressing is a signal to change it as bacteria will grow on the dressing which could enter the bladder.

Some male individuals use external catheters, occasionally called a condom catheter. An external catheter is a sheath that is placed around the outside of the penis. These are used for spontaneous but uncontrolled bladder emptying either alone or in conjunction with intermittent catheterization. The application of an external catheter is done using clean technique with strict handwashing.

For some males with spontaneous but uncontrolled urinating, a sphincterotomy or a small surgical cut has been made in the sphincter to allow urine to freely flow out. This creates an open sphincter that can let bacteria enter the bladder. Therefore, it is imperative to keep the urine flowing out, not allowing urine to re-enter back into the bladder. Good hydration is necessary. A night collection bag or leg bag should never be raised above the level of the bladder to avoid reflow of already expelled urine back into the bladder. Even though the system is closed, once urine has left the bladder it is exposed to light and heat which can make bacteria flourish.

Research demonstrates individuals who utilize intermittent catheterization have the least chance of infection. This is because the catheter is inserted, urine removed, and the catheter is removed. Since the catheter does not remain in the bladder and the sphincter is able to close when the catheter is removed, bacteria is not as able to easily re-enter the bladder. This technique also allows the bladder to expand as it fills with urine and to contract when urine is emptied which mimics the normal function of the bladder. Intermittent catheterization is done using clean technique with strict handwashing.

Mitrofanoff is a surgical procedure where a conduit to the bladder is surgically created from the abdomen generally through the umbilicus (belly button.) A straight catheter is inserted into the belly button opening, urine is drained, and the catheter is removed much like intermittent catheterization except the new opening is used as opposed to the urethra. Children and women most commonly use this technique due to anatomical needs, although sometimes men will opt for it. Clean catheterization technique is used with strict hand washing.

For a variety of reasons, some individuals will have a urostomy which is an opening in the abdomen directly into the bladder. This option is a later choice, not used unless there is a medical necessity. Sometimes, urine flows out through this small surgical opening and a collection bag is worn. At other times, a catheter is inserted for urine removal. Clean or sterile technique is used depending on your healthcare needs. Both involve hand hygiene and, in the case of sterile catheterization, sterile gloves.

When reviewing your technique, think about things such as if your supplies are where you can easily get them. You want to be able to access your catheter supplies with clean hands. All supplies for catheterization should be available at the time of use so you do not have to stop in the middle of the procedure to get something.

Disposing of your catheter supplies should occur right after catheterizing. Urine should be drained into the toilet. Be sure you have placed supplies in a garbage receptacle lined with a plastic bag, so you do not have to touch them later. Bacteria will grow in and on a collection bag. You do not want to contaminate yourself later when cleaning up. Clean any spills or splashes that could contaminate your catheterization later.

Timing

Pay close attention to timing with bladder management to reduce your risk of infection. Letting catheter changes slide a day or two can be serious for individuals with indwelling catheters. For those using intermittent catheterization, waiting too long or catheterizing too quickly has infection risk consequences both ways.

Indwelling catheters are generally changed every six weeks. Your catheter changing schedule may be more frequent. Crystals and minerals from urine can adhere to the inside of indwelling catheters which slows urine from flowing freely. Urine collecting in the bladder has the opportunity for bacteria to grow.

Leg bags and night drainage bags should be emptied. If the bag is full, urine cannot flow out of the bladder letting bacteria thrive. Stagnant urine in the bag can develop the growth of bacteria. The leg/drainage bag system works best when the system is not opened as when changing from a night bag to a leg bag. However, a night bag is needed for larger volumes of urine collection as you sleep. The leg bag is smaller but less conspicuous for day wear. When you open the system to change bags, use an alcohol pad to clean the adaptors before reconnection. Even if you have not touched the connectors, alcohol cleaning is still needed as there could be bacteria present. As always, clean hand hygiene is necessary for this activity.

The timing of intermittent catheterization is critical to success. Cathing too soon can lead to infection because you are introducing the catheter so closely after a previous catheterization thereby increasing risk. Waiting too long between catheterizations allows urine to sit stagnantly in your bladder which leads to overstretching. This gives bacteria time to multiply which can overload your immune system and its ability to control the infection. For most individuals, catheterization should be performed every 4-6 hours. Timing depends on your intake of fluids. Fluid management must be monitored to keep your bladder from overfilling or from you becoming dehydrated.

Overstretching your bladder can lead to infection. Each time the bladder becomes overstretched, it loses some of its elasticity or its ability to snap back to its normal size. The overstretching of the bladder muscle can create a lax muscle or little pockets where urine can hide, remaining stagnant and allowing bacteria to multiply.

If you have edema, you might find large volumes of urine when you get into bed. Your feet are even with your heart in bed. This helps edema resolve. Most people with edema find timing their catheterization at night to be more effective if they catheterize about an hour after getting into bed. This allows time for the edema to make its way to the bladder. The individual has a better night’s sleep because their bladder will be empty. Nurse Linda

Pediatric Consideration: These basic points are the same for children. The biggest difference is that young children will have someone perform catheterization for them. About the time for potty training is about the same time that you should begin to introduce the steps of catheterization to your child. Progressively give them steps to do on their own for catheterization. Start with learning to wash their hands. Then have them name or ready supplies. Eventually, the child should be able to catheterize on their own. You will need to monitor their abilities to avoid infections.

The older child or teen should be able to catheterize themselves. An adult must know the procedure in case of illness or emergency. Some teens might not want to catheterize at school or when with friends. Be sure there is a private place at school so they can cath as needed. Schedule catheterizations so a teen can go out without having to catheterize, if possible.

Your attitude is critical to your child’s willingness to catheterize. Treating the process as matter of fact is the best approach. Nurse Linda

Next week will be a continuation of ideas to avoid urinary tract infections.

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.