Urinary Tract Infections (UTI's) are important clinical events that can harm the kidneys. Adult and Pediatric Urologists spend a great deal of effort in avoiding serious consequences of UTI in their patients. UTI's are common in people who cannot empty their bladders because stagnation of urine allows the bacteria to grow. Some patients who cannot void need to use a catheter to drain the bladder 3 to 5 times a day. By draining the bladder, stagnation of urine does not occur and the patient's condition is improved. However, there are some important facts to understand about urinary tract infections when you are catheterizing daily. No matter how careful the patient, bacteria are always pushed into the bladder with the catheter. While these bacteria do multiply and grow in the bladder, few problems result because most of the bacteria are drained out each time the catheter empties the bladder. Having bacteria present but not causing symptoms is common in medicine. Doctors call this condition "colonization."

For example every person has germs in the throat at all times; the throat is colonized with bacteria. Occasionally a bad germ (strep for example) starts growing in the back of your throat and this infection can cause symptoms like fever, sore throat, and swollen glands, which most definitely need treatment.

It is important to understand that the child catheterizing the bladder for drainage of urine will always have bacteria present. However this colonization without symptoms does not pose a threat to the kidneys.

But what about that cloudy and stinky urine because of the bacteria colonizing the bladder? No one likes that! There are things that can help reduce these symptoms while avoiding the use of oral antibiotics. The first thing of benefit is increased fluid intake. The increased fluids can dilute the germs, but of course patients will need to catheterize more often than normal so as to not experience urinary leakage. Bladder irrigations can also be of benefit in washing out the bladder. This bladder irrigation may be thought of as a "gargling" for the bladder. It is an effective way to minimize the odor and cloudiness of the urine without resorting to antibiotics. Irrigations are done usually in the morning when the urine is most cloudy. (See directions of bladder irrigation.)

Always having bacteria in the urine does complicate things for patients on intermittent catheterization. For example, to diagnose a UTI, medical professionals use two tests; a urinalysis and a urine culture and sensitivity (u/a and c/s). The u/a involves a dipstick test and a microscopic exam to detect infection. The u/a can be done in about 10 minutes, but it is sometimes inaccurate. The c/s takes 48 hours to be read but is much more accurate when diagnosing a urine infection. It provides information about the kinds of germs growing, the number of germs present, and the antibiotics that are effective against the bacteria that are present. For the reasons noted above, patients using a catheter to drain the bladder generally will show infection both on the u/a and the c/s. It is our practice to ignore these tests in patients that catheterize daily unless the patient is having significant symptoms that could be from a UTI. Most clinically important infections are associated with a fever greater than 102°F. Bladder pain, blood in the urine, and increased problems with urinary leakage can be signs of infection and warrant getting a urinalysis and culture done. It takes a while for families to get used to the cloudy and smelly urine that is often present in children that catheterize. These symptoms are often harmless and need not be treated.

There are some important medical issues that relate to treating patients with bladders that are colonized but not infected with bacteria. It is a well-known fact that doctors prescribe too many antibiotics. Because of this the bacteria are getting "immune" or resistant to many different commonly used antibiotics. It is possible to kill all of the germs in the bladder with antibiotics for a short period of time. After a while, the bacteria will become immune to the antibiotic and stronger antibiotics are necessary for treatment. It is better to ignore the bacteria colonizing the bladder and treat with antibiotics only when there are worrisome symptoms. By avoiding frequent antibiotics patients who catheterize will be colonized with germs that are not immune. A UTI with fever will be much easier to treat, as the germs will be sensitive to most of the antibiotics that are available.

Another aspect that should be mentioned is that a patient can be sick for some other reason and not be sick from the bacteria in the bladder. For example a patient who catheterizes may develop appendicitis. In the emergency room it is easy to predict that the urine will show "infection" as bacteria are always present because of the catheterization process. It would be a terrible mistake for the doctors to diagnose a "urine infection" and miss something else that is accounting for the symptoms, like appendicitis. In other words, the urine will always show infection in children who catheterize. Parents should make sure that, when their children are ill, all other sources of infection are ruled out.

Supplies

• Normal Saline ( or home-made solution of 1 qt water, 1 tablespoon of white vinegar, and 1 teaspoon of salt)
• Cath-tip syringe
• Straight catheter (if indwelling catheter is not in place)
• Lubricant

1. Catheterize patient (if no indwelling catheter is present)
   • Let urine drain out of bladder
   • Tape catheter to leg (if patient has a stoma attach catheter to abdomen)
2. Fill cath-tip syringe with normal saline
3. Insert into rubber end of catheter
4. Instill saline into bladder by pushing the plunger of the syringe and allowing the saline to flow through the catheter into the bladder.
5. Pinch off catheter
6. Unattach syringe
7. Keeping catheter pinched off with one hand, draw up 60 cc more of normal saline with the cath-tip syringe with the other hand.
8. Reattach syringe to catheter and release catheter with other hand (so it is no longer pinched off)
9. Instill saline into the bladder again
10. Draw back and forth on the plunger of the syringe several times
11. Draw back with plunger, drawing up instilled saline.
12. Pinch off catheter
13. Detach syringe and dispose of saline in syringe into a clean receptacle or sink.
14. Again attach syringe to catheter and release hold on the catheter
15. Repeat steps 11-13 until bladder is empty
16. Repeat this whole process until drainge is clear

With this description of UTI's in patients who cath, we should note that occasionally a male patient that catheterizes can get an infection in the testicle. This infection may or may not be associated with pain and fever. With the symptom of scrotal pain/swelling it is important to get evaluated immediately with a scrotal ultrasound in order to rule out the possibility of torsion, which requires prompt surgical treatment, verses epididymitis that can be treated with a course of antibiotic.