Spinal Cord Injury and
Urinary Tract Infections
Glen W. White, Ph.D.
Meghan Zavodny, Mindy Von Wolf, & Sam Ho
Research and Training Center on Independent Living
at the University of Kansas
This training
sponsored through a
grant from the
Christopher and Dana
Reeve Foundation
Special thanks to…
• The Christopher and Dana Reeve Foundation
• Centers for Disease Control
• Ann Sullivan Center of Perú
• Dra. Liliana Mayo and Staff members
• Scott Richards, Ph.D. – Spain Rehabilitation
Center, University of Alabama at Birmingham
• Suzanne Groah, M.D., M.S.P.H. – National
Rehabilitation Hospital, Rehabilitation
Research & Training Center on Secondary
Conditions in the Rehabilitation of Individuals
with Spinal Cord Injury
Special thanks to…
• Sam Ho
• Jaime Huerta
• Monica Ochoa
• And special
thanks to Julio
Chojeda for
translation of
materials from
English to
Spanish…
Acknowledgement of sources used for this
presentation:

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Yes You Can! (Paralyzed Veterans of America)
SCI: A Manual for Healthy Living (TIRR)
Urinary Tract Infections (RTC/IL & PVA)
Bladder Management: What You Should Know (by the
Consortium for Spinal Cord Medicine)
Presentation Review
• Define urinary tract infections (UTI)
• Identify who is at risk?
• Causes of Urinary Tract Infections
• Signs and Symptoms of UTI
• Testing and diagnosing UTIs
• Methods to empty your bladder
• UTI prevention techniques and treatment
Urinary Tract Infections A Major Problem
• What are Urinary Tract Infections?
– Urinary Tract Infections or UTIs are caused
when bacteria is introduced into the urinary tract
system. This may be caused by contamination of
catheter equipment, and may be more likely to
occur when the individual has poor hygiene, low
fluid intake, or infrequent urination.
Urinary Tract Infections (UTI)
• Significance of the problem
– Most common complication with spinal
cord injury
– Biggest threat to health and survival
– Most common hospital acquired
infection
• Often due to indwelling catheters
How the Urinary System Works…
• Normal urinary system
– Sterile, little or no bacteria
– Kidney filters waste and
excess water from blood,
becomes urine
– Urine carried by ureters
(narrow tubes) to the
bladder
– The bladder then holds the
urine
How the Urinary System Works…
• Bladder signals
brain when full
• Brain signals via the
spinal cord system
to the bladder to
contract and open
• Urine is retained by
sphincters that relax
to empty
What Is a UTI?
• After a spinal cord injury:
– Signals from the brain are
unable to communicate
with the bladder
– The bladder may overflow or
void involuntarily
– Or, it may not empty
completely
– Individuals may have more
frequent urination
Who Is at Risk for UTIs?
• People with:
– Spinal cord injuries
– Urinary catheters
– Diabetes
– Enlarged prostate
– Who are older
– Who have had frequent previous UTIs
• People who have difficulty urinating
• Affects more women than men
– 1 out of 5 women
(http://kidney.niddk.nih.Gov/kudiseases/pubs/utiadult/index.htm)
What are Causes of UTI
• High bacteria counts
• Colonies of bacteria multiply
rapidly
• Microorganisms cling to the
urethra (urine pathway
between bladder and outside
of body)
• Can be caused from
contamination with feces
coming in contact with the
catheter
http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult/index.htm
Causes of UTI
• Intermittent catheterization
– Catheter inserted in
urethra may pick up
outside bacteria
– Bacteria pushed into
bladder
– Bacteria quickly
multiplies if bladder is not
emptied of urine within
4-6 hours
Types of intermittent catheters
Causes of UTI
• Indwelling catheter
– Catheter gives bacteria
direct path to bladder
– Bacteria can develop into
UTI if:
• Catheter blocked
• Decreased resistance to infection
• Concentrated urine, not enough fluids
• If the urine in the bladder is not kept
acidic enough (many drink cranberry
juice to keep the bladder acidic).
Causes of UTI
• Without prompt treatment
bacteria can move from bladder
to ureters (small tubes) and infect
kidneys
• Can cause Pyelonephritis =
kidney infection
– Caused by backflow of urine
into ureters and kidneys
– Occurs less often than bladder
infections
– If kidneys are damaged because of
repeated infections, people may
require dialysis
– Can cause death in severe cases
Causes of UTI
• For women
– When toileting wipe front to back
• Should wipe: FRONT TO BACK
– Sexual intercourse
• Outside bacteria pushed into uterus
during intercourse
– Birth control methods
• Diaphragms or spermicide lubricates/condoms
can increase bacteria growth
http://kidney.niddk.nih.gov/kudiseases/pubs/uti_ez/index.htm
Signs and Symptoms of UTI
• Burning of urethra, penis or pubic area
when urinating
• Mild, low back pain or other aches
• Fever or chills
• Frequent urge to urinate
• Feeling the need to catheterize often or
immediately
www.sci-info-pages.com/uti.html
Signs and Symptoms of UTI
• Headache
• Fever
• Confusion
• Nausea
• Feeling lousy or tired
• Leakage
• Increased spasms of leg, abdomen, or bladder
• NOTE: UTI symptoms are often masked in
individuals with SCI.
Signs and Symptoms of UTI
• What to look for in urine
– Sediment
• Gritty material
– Mucus
– Cloudy Urine
– Concentrated appearance
– Blood
• Pink or red urine
– Foul smelling odor
Testing for UTI
• Urine culture
– Sample of urine
– Excess bacteria
or infection
– Sensitivity
testing
• Find correct
antibiotic
Testing for UTI
• Urinalysis
– Urine sample
– Chemical and
cell make-up
Diagnosing UTI Causes
• Urodynamics
– Series of observations
– Analyze urinary system
and how it empties
– May recommend bladder
management program
Diagnosing UTI Causes
• Cystourethrogram
– X-ray
• Inject dye into bladder
• Reveals size/shape of
bladder
– Reflux tested
• Pressure pushes urine
in kidneys to determine
resistance to reflux
Diagnosing UTI Causes
• Cystometrogram
– Fill bladder with carbon dioxide or water
• Simulates full bladder
• Measures amount of pressure and if bladder is
spastic or flaccid
• Determines whether the bladder can contain
small versus large amounts of urine
• determines the volume point at
which urine is likely to
“spill over”
Diagnosing UTI Causes
• Cystoscopy
– See urethra and
bladder
– Prism in cystoscope
reflects light
– Helps determine if
there are bladder
stones or calculi in the
bladder that can
cause recurrent
infections
Diagnosing UTI Causes
• Renal scan
– Radioactive material
injected in bloodstream
– Patient drinks several
glasses of water
– Measures
• Blood supply to
kidneys
• How each kidney is
functioning for the
production of urine
Diagnosing UTI Causes
• Ultrasound
– Uses sound waves
• Bounce off organs
– Creates a picture
of urinary organs
– Detects tumors,
cysts, and stones
Artificial Emptying
• Once the pathway between the brain and
bladder is interrupted, a person cannot
voluntarily empty or control his bladder.
Instead he must use different techniques:
–
–
–
–
–
–
Intermittent catheterization
Indwelling catheter
Condom or external catheter
Suprapubic catheter
Urinary ileostomy or ileal conduit
Sphincterotomy
– Tapping
– Crede
Artificial Emptying
• Intermittent
catheterization
– Tube inserted into
bladder for
drainage
– Routine emptying
usually 3-4 times
daily
• Catheter volume should
be kept below 500 mL
Artificial Emptying
Intermittent catheterization (continued)
• Sterile technique
• May be better for older persons and those with
impaired immune systems
• Non-sterile “clean”
• Clean intermittent catheterization (CIC)
• Developed because hard to accomplish true
sterile catheters in normal environment
• Produces similar results to sterile technique
Artificial Emptying
• Indwelling catheter
or Foley catheter
– Inserted and left in
bladder
– Balloon deflated
and catheter is
changed every 2-4
weeks
– Collection device
required
• Leg bag
Artificial Emptying
• Condom or external
catheter
– Males only
– Condom for reflex
voiding
• Empty voluntarily
– External catheter
for spontaneous
emptying of urine
Artificial Emptying
• Condom or external catheter
(continued)
– Materials
• Latex rubber
• Polyvinyl
• Silicone
– Attached by
• Double-sided adhesive
• Latex inflatable cuff
• Foam strap
Artificial Emptying
• Suprapubic
– Opening created
in abdomen and
bladder
– Catheter placed
in bladder
through incision
Artificial Emptying
• Suprapubic (continued)
– Inserted in bladder surgically
by doctor
– Changed every 2-4 weeks
– More comfortable
– Less chance to fall out or leak
– Preferable and more
convenient than indwelling
catheter
– User are just as vulnerable to
UTIs
Artificial Emptying
• Surgery
– Urinary ileostomy or ileal conduit
• New urinary pathway formed using part of small
intestine
– Sphincterotomy
• Sphincter cut
• Outlet from bladder no longer has tight pressure
Other Voiding Methods
• Artificial stimulation
– “Tapping”
• Tap abdomen over bladder
• Usually best with spastic bladder
• Causes bladder muscles to contract and
void
– Crede’
• Push on abdomen to squeeze urine out
• Usually best with flaccid bladder
RISKS Associated
with Catheters
• Intermittent catheterization
– Swelling of urethra
– Strictures or narrowing of uretha from
scar tissue
– False passages
– Kidney damage
Risks Associated with Catheters
• Indwelling Catheter
– Strictures
• Narrowing of urethra from scar tissue
– Erosion of urethra, requiring larger
catheter
– Shrinkage of bladder
– Bladder walls more rigid
– Increased mortality and risk of
bladder cancer
Risks Associated with Catheters
• Indwelling catheter (continued)
– External collection bag
• Ideal place for bacteria growth or infection
• Bacteria or infection can spread up catheter to
bladder, kidneys, and blood stream
– Maintaining collection system as a closed
and sterile environment
• Outside of catheter can still breed bacteria and
infect bladder
Risks Associated with Catheters
• External or Condom Catheter
– Problems result from improper or
prolonged use
– Chance of infection
– Less than internal catheters
– Skin irritation
• Friction from catheter
• Prolonged moisture against skin
• Adhesives or pressure straps to hold
catheter in place
Risks Associated with Catheters
• External or condom catheter (continued)
– Older men
• Penis may have retracted
• Difficult to keep catheter secure on penis
– Careful attention to avoid:
• Skin rash
• Maceration of penis = softening of penis
tissue
• Ischemia (loss of blood flow in
the penis)
• Penile obstruction
Risks Associated With Catheters
• Suprapubic
– At time of insertion
• Swelling at insertion site
• Bleeding
• Bowel injury
– Management problems
• Uncontrolled urine leakage
• Skin erosion
• Catheter reinsertion problems
Common Catheter Problems
• Burning or spasms
– When urine passes through catheter
– Common and normal
– May cause leakage or indicate needed catheter
change
• Falling out or accidentally pulled out
– Accidentally pulled out or falls out from
excessive tension or bladder spasms
• Blockage or obstruction
– Formation of encrustations of calculi
Common Catheter Problems
• Catheter leakage
– Frequently occurs
– Results from
• Bladder spasms
• Infection
• Catheter or balloon excessive in size
• Irritated bladder
• Catheter infection
– Development of bacteria in urine
Causes of Pressure Build up
• Indwelling catheter
– Blocked or kinked
• Intermittent catheterization
– Wait too long for catheter insertion
• External catheter
– Sphincter doesn’t relax
– Autonomic Dysreflexia
– Kinked catheter or un-emptied leg bag
Selecting A Urinary
Management Program
• Should be based on individual need, injury
level, and lifestyle
• Should look at long term versus short term
• Primary goal
– Achieving low pressure filling and
complete emptying
When to Change Urinary
Program or See a Doctor
• Fever (temperature above 100o F.)
• Symptoms interfering with life
• Acute urinary infection
– 2 episodes in 6 months
Personal Assistant Precautions
• Wash hands thoroughly before and after
catheterization and emptying drainage
bag
• Wear rubber or latex gloves for
procedure
• Disconnecting indwelling catheters
dangerous (keep system closed and sterile
as possible)
Preventing Odor
• Good hygiene
– Use plenty of warm water and soap to wash your
skin
– Wash clothing and wheelchair cushion after spills
• Protective waterproof pads
• Cold water for rubber catheter or drainage
bag
• Avoid carbonated beverages
Prevention Techniques
• Drink plenty of fluids
– Helps flush bacteria out
– Water is best choice (6-8 glasses per day)
• Urinate frequently
– If urine is in bladder too long, bacteria
quickly grow and multiply
Prevention Techniques
• Wear loose fitting clothes and cotton
underwear
– Helps keep area dry and free of moisture
• Always wipe front to back
Prevention Techniques
• For women
– Cleanse genitals before sexual intercourse
– Urinate after sexual intercourse
• Can help flush out any bacteria that entered the
urethra
– Using lubricated condoms without spermicide
or a spermicidal lubricant
– Showers not baths
– Avoid scented hygiene douche or sprays
– take a probiotic supplement to maintain proper
vaginal flora
http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult/index.htm
Prevention Techniques
• Follow management program
• Practice doctor recommendations
• Sterile catheterization
• Regular washing or frequent replacement of
catheters
Prevention Techniques
• Intermittent catheterization
– If notice UTI warning signs
• Catheterize self more often to reduce
bacteria
• Increase fluid intake
• Wash hands thoroughly with soap and
warm water before handling the catheter
and other equipment
Prevention Techniques
• Indwelling catheters
– Drink plenty of fluids, most important
• Urine clear and almost colorless
– Change catheter once a week up to one
month
• More if there is increased
build-up on the catheter
Prevention Techniques
• Indwelling catheters (continued)
– Alternative methods for catheterization
recommended
• Can cause bladder infections, damage to
urethra, increased risk for bladder cancer,
and increased mortality
• Intermittent catheterization or other forms of
catheterization recommended
http://www.tis-group.org/no_cath.html
Prevention Techniques
• Condom or external catheters
– Changed daily
– Use soap and warm
water to clean perineal
area
– Air dry penile area
• Suprapubic
– Keep ostomy area shaved and clean
Treatment
• Antibiotics
– Depends on patient history and results of
the bacteria culture
– Take pills 7 to 10 days as prescribed by
health professional to ensure infection is
gone
– For repeat infections, therapy may be
longer and may include intravenous
medications
– Treatment for men may be longer
• Bacteria can hide in the prostate tissue
http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult/index.htm
Treatment
• Relieving pain of a UTI
– Pain medication
– Heating pads may aid in discomfort
• Drink plenty of water
– Flush out bacteria
• Avoid coffee, spicy foods, and caffeine
• Quit smoking
– Major known cause of bladder cancer
Fungal UTIs
• Some UTIs are caused
by fungi of the genus
Candida
• Treatment is antifungal
drugs such as fuconazole
• Prevention includes
treatment of vaginal
yeast infections
Review of Today’s Session
Today we:
• Defined urinary tract infections
• Identified who is at risk for UTIs
• Listed causes of urinary tract infections
• Outlined signs and symptoms of UTIs
• Discussed testing and diagnosing UTIs
• Reviewed methods to empty your bladder
• Discussed UTI prevention and treatment