Association between clean intermittent catheterization and urinary tract infection in infants and toddlers with spina bifida

• Published in: Journal of pediatric urology Vol. 12; no. 5; pp. 284.e1 - 284.e6
• Main Authors: Kaye, I.Y, Payan, M, Vemulakonda, V.M
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.10.2016
• Subjects: Child, Preschool; Clean intermittent catheterization; Cohort Studies; Female; Humans; Infant; Intermittent Urethral Catheterization - adverse effects; Male; Myelodysplasia; Pediatrics; Retrospective Studies; Risk Assessment; Spina bifida; Spinal Dysraphism - complications; Urinary tract infection; Urinary Tract Infections - epidemiology; Urinary Tract Infections - etiology; Urology; Spina bifida; Urinary tract infection; Clean intermittent catheterization; Myelodysplasia
• ISSN: 1477-5131; 1873-4898
• DOI: 10.1016/j.jpurol.2016.02.010

Summary Introduction The primary goal of urologic management in children with spina bifida is to reduce the risk of urinary tract infection (UTI) and associated renal injury. While clean intermittent catheterization (CIC) has been the mainstay of treatment, recent studies have suggested that this approach is not without risk. The objective of this study was to examine the association between alternative bladder management strategies and UTI in infants and toddlers with spina bifida. Methods A retrospective cohort study was conducted on spina bifida patients, aged 0–3 years, seen in a multidisciplinary spinal defects clinic between 2008 and 2013. Inclusion criteria included: a primary diagnosis of meningocele, myelomeningocele, or lipomyelomeningocele. Patients were excluded if they had: <1 year of follow-up, urologic surgery prior to initial evaluation, or incomplete data for analysis. Bivariate analyses were performed using Chi-squared or Fisher's exact tests. Multivariate analyses were performed using logistic regression. Results A total of 107 patients meeting study criteria were identified. The majority of patients had lumbar lesions (74.8%) and ventriculoperitoneal (VP) shunts (72.9%). Initial bladder management was by CIC in 39.3% of patients and spontaneous voiding in 60.8% of patients. Median age at follow-up was 2.5 years. During the study period, 23.4% of patients switched from spontaneous voiding to CIC. Patients managed with CIC were more likely to have UTIs at final follow-up than those managed with voiding (35.7% vs. 18.5%; P  = 0.045). Patients with vesicoureteral reflux (VUR) were also more likely to have UTIs (54.5% vs. 17.9%; P  = 0.015). Patients who switched from spontaneous voiding to CIC over the study period were more likely to be evaluated with urodynamics (72.0% vs. 31.8%; P  < 0.0001) than those managed with voiding alone. Patients who switched to CIC were also more likely to have VUR (16% vs. 0%; P  = 0.09) and UTIs (24% vs. 15%; P  = 0.06) than those managed with voiding alone; however, these differences were not statistically significant. Conclusions In the present series, infants and toddlers with spina bifida who were initially managed with spontaneous voiding had a lower risk of UTI than those managed with CIC. Patients who switched to CIC after a period of initial observation with voiding did not have a significantly different risk of UTI compared with those managed with CIC alone. These findings suggest that early initiation of CIC may not be warranted in all infants with spina bifida. Further studies are needed to more clearly define optimal indications for initiation of CIC in these patients. Table Association of UTIs and bladder management. UTI No UTI P -value OR (95% CI) Initial bladder management CIC 35.7% 64.3% Voiding 18.5% 81.5% 0.045 2.45 (1.01–5.97) Final bladder management CIC 33.3% 66.7% Voiding 13.6% 86.4% 0.021 3.17 (1.16–8.68) Change in bladder management CIC (no change) 39.5% 60.5% Voiding (no change) 15.0% 85.0% 0.27 (0.09–0.80) Voiding→CIC 24.0% 76.0% 0.063 0.48 (0.16–1.49)