Chapters Transcript Video Avoiding the Blame Game: UTI Management in Individuals with Neurogenic Bladder Today we have Doctor Hilary Kopp here with us. Doctor Kopp is the chief of pediatric urology at UCSF, where she has been a faculty member since 2009. She completed her medical degree at Pennsylvania State University College of Medicine, which was followed by urology residency at the University of Virginia, and a fellowship in pediatric urology at Stanford University. In addition to her clinical work in Oakland and San Francisco, she serves as the pediatric Urology Fellowship director at UCSF and as the director of neurologic care for children with spina bifida, as well as serving as the as the co-director of the UCSF Lifetime congenital urology program. She is passionate about educating patients and families about pediatric neurologic conditions, specifically improving the clinical and quality of life outcomes of children. With congenital urologic pathologies. Please join me in welcoming Doctor Kopp. Thank you so much, Kelly. Well, good morning, everybody. It's a pleasure uh to be on this webinar and uh talk to you a little bit about a passion of mine, um, and we'll just get right into it. I'm going to talk about urinary tract infection management and individuals with neurogenic bladder. This is my disclosure. So today we'll uh talk about the etiology, the prevention, the evaluation and treatment of individuals with neurogenic bladder, uh, and also some unique situations um that arise when we're thinking about this. To begin, um, we'll talk about what neurogenic bladder is, and, uh, essentially it's nerve damage that disrupts communication between the brain and the bladder, and this can be congenital or acquired, and this leads to changes in bladder control, which really can impact safety for the individual and their quality of life. This can happen through dis coordination between the bladder contraction and sphincter relaxation, which is the normal mechanism with voiding. Um, we can also see high pressure storage within the bladder. The bladder is supposed to be nice and elastic such that as it increases its volume, the pressure stays low, which would be a highly compliant bladder. We see that change over time, potentially with spina bifida neurogenic bladder. And then we also can see urinary incontinence from lack of control with the sphincter which uh can affect quality of life and also have medical issues with, you know, chronic irritation from uh urine leakage. The largest number of patients that we see and care for as a as a pediatric urologists and those in general who care for these patients with neurogenic bladder tend to come from individuals with spina bifida, and that is because the birth prevalence is about 3 per 10,000 children or 1600 children born each year in the US with spina bifida. The majority of individuals with spina bifida have a neurogenic bladder, and again, this is bladder dysfunction that's caused by this neurologic malformation um or damage. And neurogenic bladder is a major source of morbidity in individuals with spina bifida, again, causing incontinence, recurrent urinary tract infections, and chronic kidney disease. In fact, we, we understand that 90% of children with spina bifida have normal kidney function at birth, and if we do not perform any urologic intervention, 50% of those will have decline in kidney function from bladder hostility and recurrent urinary tract infections. So they, they care and attention by a pediatric urologist is extremely important for um long term, um, you know, health of the individual with spina bifida. Recurrent urinary tract infections are a major source of morbidity. The annual incidence of urinary tract infections in individuals with neurogenic bladder is 20%, and by 15 months of age, over half of children with spina bifida will experience a urinary tract infection. And by 15 years, almost half of patients will have up to 5 urinary tract infections or more. Um, this, this really is not only um detrimental to the health of the individual with, with spina bifida, but also really is a huge burden on the health system and, and is associated with increased healthcare utilization. We've spent time looking at this and recently uh have published some work on uh increased utilization both in the ED setting and also um in the inpatient setting. And uh recently some work by one of our chief residents and medical student going into urology, so Adrian Fernandez and Tanov looked at ED utilization between individuals with spina bifida and controls across the lifespan in the state of California um between 2005 and 2017. And we've seen higher median numbers of merchant department encounters and individuals with spina bifida versus controls with the median amount of encounters around 2 in controls and up to between around 5 median encounters for individuals with spina bifida. And after adjusting for other factors, we see an 8-fold increase in the risk for ED visits versus controls. Importantly, here, the, the one of the top reasons for seeing this utilization is urinary tract infection. And when we look at individuals with spina bifida versus controls, the spina bifida group um had greater than one urinary tract infection, uh, almost a quarter of the time versus uh uh controls having less than 5% of their ED visits being related to urinary tract infection. We also see increased healthcare utilization in the inpatient setting and um two medical students that are uh that have worked with our research group looked at length of stay and also hospital encounters, uh, time between 1st and 2nd encounter and other factors associated with increased uh uh. Encounters and uh Camille and Mohammed uh performed this, this work with us and we found that greater than um a four-fold increase in encounters and individuals with spina bifida um versus controls, longer length of stay, increased charges, less time between encounters and more total hospital days spent with again, a leading cause for these admissions being infection and sepsis, um. Also, we know that this, there's a higher mortality in individuals with spina bifida with sepsis. So this really the uh is a major area of um burden of disease for individuals with spina bifida. When we think about urinary tract infection, it's very important to consider the etiology and how we can prevent this and when to evaluate it. And so when we think about etiology, why do individuals with spina bifida uh have an increased risk for urinary tract infection? And we'll review these three main areas for why this happens, suboptimal function of the native bladder. Uh, very often we incorporate intestinal segments into the urinary tract and we'll review that and then and then just bladder emptying overall. He, uh, these suboptimal function of the neurogenic bladder, um, we see incomplete emptying. Um, there's also something called vesicoureal ref reflux, which many of you are probably familiar with. The urine should flow antegrade from the kidneys down the ureters and into the bladder, reflux is when once it gets to the bladder, it goes back up to the kidneys again. We very, we see this often uh in individuals with spina bifida, um, due to high pressure bladders, um. We see detrusor sphincter dysinergia, which again is that lack of coordination between when the bladder contracts, the sphincter should be relaxing ahead of time, um, and then also decrease in the normal protective flora within the bladder, um, due to, um, uh, colonization. And these different, these different factors lead to bacterial pers persistence and accumulation of bacteria within the bladder. They can, um, uh, lead to urinary tract infection or an increased risk for that. We also see an increase in bacterial translocation from the ureter, the urine into the bladder tissue, and this can be again from elevated uh bladder pressures over distension of the bladder and also disruption of uh a layer that we all have within our bladder that's a natural barrier called the glycosaminoglycan layer. Um, a second main reason that we, uh, will see an increased risk for urinary tract infections is due to, um, the need to incorporate intestinal segments into the urinary tract. So very often, um, the, these patients will have high Pressure bladder bladders or lower capacity bladders, and we will use a segment of bowel to augment the bladder, or sometimes they have a bladder that it's not usable and we create what we call a urinary reservoir or used intestines to um create a reservoir to store urine for them. And so this introduces bacteria into the urinary tract because we then plug the ureters uh into the, into the reservoir or they're um incorporated into this diversion. So, um, this leads to colonization from the bowel, and also, um, the majority of the time these individuals are no longer able to empty their bladder on their own, so then they're doing clean intermittent catheterization, which also contributes to colonization. Importantly, with these reservoirs, since they're no longer able uh to empty with voiding, um, emptying is extremely important and with incorporation of uh intestinal segments into the urinary tract, um, there's a secretion of mucus, which is, uh, this can accumulate within the bladder and uh regular irrigation and evacuation of mucus is, is important to make sure that the bladder gets empty. When we talk about bladder emptying, uh, the method of, of bladder emptying, uh, is, is important, so it can be through voiding, uh, something we call clean intermittent catheterization, or, uh, sometimes we do see, uh, an indwelling tube, uh, that could be urethral catheter or suprapubic tube. We generally don't like to leave urethral catheters in because it can cause erosion to the urethra. Um, so for various reasons, there are sometimes where we leave a chronic indwelling tube called the suprapubic tube, um, uh, and this, this generally is better than a urethral catheter, um, but these, uh, clean intermittent catheterization and the persistence of a tube do lead to colonization as well. The other thing that's important is that when we catheterize through a channel or a suprapubic tube, um, as you see here in the picture, the catheter is entering in through um a non-dependent portion of the bladder. So if we're coming through the urethra, Um, with, you know, with gravity drainage, um, you very often are able to better empty the bladder, but when we're thinking about using a, a catheter, it's very important to make sure that the catheter is getting, uh, all the way in and um that you're getting complete drainage at the reservoir. So, etiology and prevention go hand in hand, and it's important to again understand the cause, optimize the environment, and, and know when to evaluate. So we'll now talk about optimizing the environment um to help with uh prevention, and we'll we'll review hydration, bladder emptying, bladder irrigation, and constipation prevention, which are key elements for optimizing the environment. There have been um some studies on hydration and uh systematic reviews specifically um uh looking at the uh at UTI prevention in adults with spina bifida. um, uh, in, in this specific population, there aren't, there aren't great studies that assess uh oral fluid intake for urinary tract uh prevention among individuals with neurogenic bladder. In the general population, um, we do know that increased daily water intake, um, helps prevent recurrent cystitis, so extrapolating some of that literature, uh, to the, uh, spina bifida population is um is is important. Um, we know in general a natural defense against urinary tract infection. Uh, is fluid in and fluid out. So helping, uh, to, uh, clear those organisms that end up in the bladder, um, by increased hydration is very important. We also know that it's helpful with constipation, which we'll later talk about being a driver for uh uh urinary tract infection. So it being hydrated uh helps uh prevent constipation. When we talk about uh Prevention as well. Um, bladder emptying is a key element of this, and so, uh, regularly and completely are the, are the two elements of bladder emptying. So It, it should, the patient, the individual should um be counseled about uh whether they're avoiding, whether they're voiding or doing clean intermittent catheterization, uh regular emptying, and that starts with first morning urination or catheterization. I always say when your feet hit the floor, they should take you to the bathroom, um, and, uh, that. First morning emptying should start and then that begins the clock for the rest of the day on a schedule, ideally every 3 hours, uh emptying the bladder, whether it's through um catheterization or with voiding. And again, that really helps with the fluid in, fluid out. The other part of that again is completely emptying the bladder and especially in, um, you know, uh, as, as we're taking care of the, the uh pediatric patients and thinking about them through their lifetime. Uh, general things that that come up are, you know, very often kids exert their independence through their bladders and um the links that they go through, uh, to avoid emptying their, their bladder, um, uh, are, are harder than just emptying in the first place. So often, um, we'll see kids go into the bathroom and Uh, spend time in the bathroom to make us think that they're, you know, you know, emptying their bladder or catheterizing and they're just sitting in the bathroom and when we actually break it down, uh, we learned that, um, you know, that that's not what we actually think is happening when they go into the bathroom is not. So kind of going back to the basics and making sure that each step of the way, um, that that that's that that's happening. Also, um, to go back to emptying the bladder, as you, as you drain the, as you put a catheter into the bladder, um, again, it's important that, uh, as the bladder starts to drain, the catheters um pulled back slowly so that it comes back below the, the meniscus line and empties the bladder completely. On the, um, so when we talk about irrigation, um, this is an important aspect of individuals that have a bladder augmentation or a reservoir because that segment of bowel, um, that's incorporated into the urinary tract will make mucus. Um, and this is what mucus looks like in in the urine here. Um, it really looks like snot in the urine and um. If we, if this is not emptied or irrigated out, um, it, it makes it difficult for the catheters to work effectively and to drain and can be anitis for infection and also anitis for storm stem formation. So when we talk about irrigation, um, we, we'll review the fluid type and the quantity and to what extent. Um, Doug Housman, um, did a, a, a study back in 2016 with 75 patients with spina bifida and bladder augmentation. In randomized um individuals to daily saline irrigations at different volumes to understand uh what kind of volume needed to be done uh to irrigate and generally, uh, the individuals who use higher volumes, so over 240 mL um of irrigation had fewer total urinary tract infections over the 1010 year period for which they were followed. So, um, recommended to do high volume irrigations, um. There's not enough evidence for uh bladder irrigation recommendations for UTI prevention in, in individuals that just have chronic indwelling catheters without bladder augmentation. Um, but sometimes in individuals with recurrent urinary tract infections, we will try bladder irrigation, uh, as an, um adjunct to help prevent uh urinary tract infections. As far as data on types of irrigan, um, there really aren't comparisons between tap water and irrigation, but, um, really in, in my opinion, you know, um, opinion and and experience, the most important aspect of irrigation is doing it, and there's no reason to think that if you can drink water that you can't put it in your bla. And it really, as we learn in taking care of these patients, the biggest barrier is doing it. So making it easier is the most important thing. So all of my patients are on tap water irrigations, not saline irrigations where you're dependent on supply orders and, and then also the waste with the plastic bottles in which they come, etc. And then finally, bowel management. Um, there really are a few studies in this population that uh looking at constipation management for UTI prevention among individuals with neurogenic bladder, but we absolutely know how much of a difference, uh, constipation management makes in general for urinary tract infection. There's a whole body. literature in uh kids with uh vesicoureteral reflux and without, um, and just generally that constipation is a huge driver of urinary tract infection and um generally kids with neurogenic bladder will have neurogenic bowel and so actively managing. Uh, neurogenic bowel and preventing constipation, um, is important, uh, for UTI prevention. And there, there has been a study in 2018 that showed that it did decrease uh the frequency of urinary tract infections. So again, very important to optimize the environment uh to prevent urinary tract infections and doing this through hydration, regular and complete bladder empty, daily high volume irrigations to remove that mucus, uh, in patients who have um uh urinary diversions or bladder augmentations and then constipation prevention. So now we're gonna step into knowing uh when to evaluate and how to evaluate. So, How do you diagnose the urinary tract infection? What are, you know, what are the symptoms and what's the significance of the typical signs we see with urinary tract infection and thinking about spina bifida and neurogenic bladder, can the usual definition of positive culture with adequate colony forming units and white blood cells still be applicable? Well, the things to be thinking about within this population is that when we evaluate them is that, you know, um, we see differences in symptoms in individuals that don't have spina bifida as they present with urinary tract infection, but, uh, thinking about spina bifida and how this affects. The sensation that these patients have, it really can change how they interpret uh what a urinary tract infection is. Some present with abdominal pain, some present with back pain or just fever alone. Some have autonomic dysreflexia or get headaches. And so these are important, um. Things to work through with um with uh patients and, and really thinking about um uh what else this could be and how that they're interpreting the, the, the symptom. Accurate diagnosis of urinary tract infection in spina bifi can be difficult as well because bacterial colonization of the bladder, uh, and pyuria are common. So, uh, neurogenic bladder patients, uh, can have no symptoms and still have abnormal urines. And, in fact, this has been shown, um, Back in the mid 90s, where 81% of patients without symptoms had abnormal urine, uh, in the setting of spina bifida. 51% of those had bacteria and pyaria, so bacteria in the urine and white blood cells. Um, over a quarter had bacteriaia alone, and, uh, 5% had just pyuria alone. So, more recently, um, we've seen a study looking at individual urinalysis uh findings um among individuals with spina bifida, and, uh, you know, there's moderate sensitivity for leukocyte esterase and pyuria and moderate specificity for nitrites, but overall pretty poor diagnostic accuracy for symptomatic urinary tract infection. So the issue that we have with this is this tension that develops between diagnosis and treatment of urinary tract infection and, and spina bifida, and we um find ourselves in this conundrum and, and, and, and there's a spectrum of what happens or we can see that, that, you know, the, the, the perverbial pendulum swinging. Um, from not even considering a urinary tract infection, not even evaluating and undertreating UTIs because, uh, uh, you're not thinking about it versus always presuming because they're colonized, uh, and so not even evaluating and just treating, um, and seeing that this, you know, uh, leading overall to overall um overtreatment. And in fact, in a systematic review that was done, um, most studies evaluating UTI in spite of if it don't actually state how urinary tract infection is defined. And from this systematic review, uh, these authors proposed a consensus definition for urinary tract infection. Um, which is very, is, is similar to how we think about um UTI in the general population, but adds, uh, additional, uh, the importance of systemic symptoms or symptoms in general and greater than 2 symptoms. So fever greater than 38, abdominal pain, um, new back pain, new or worse incontinence, pain with catheterization or urination, or malodorous, uh, and cloud urine. And importantly, greater than 100,000 colony forming units of a single organism, and greater than, uh, you know, 10 white blood cells on urine microscopy. I think importantly, just having a general framework for how you think about urinary tract infections is key, and that changes in urine characteristics alone do not equate to urinary tract infection and very often you'll see cloudy or mallodorous urine and and that's again because there's, you know, colonization of the urine and so you have Um, different, different bacteria competing uh for space in the bladder and sometimes the, the bacteria type that wins is one that makes something that stinks, and then other times it's something that makes it cloudy and it doesn't necessarily mean That it's a urinary tract infection and if there are no other systemic symptoms, the first thing that we think about as urologists is looking at optimizing the environment. So increasing the hydration and increasing the caffeine more so that fluid in and fluid out and also thinking about prevention uh or constipation management, and so we jump on those things right away. If those symptoms persist or there's also other symptoms, so we uh that's an important uh indicator that we should move forward. So again, simultaneously assessing for systemic symptoms. And then remembering that urine testing really is, it's not performed uh to determine whether or not we want to initiate therapy, um, because we know that um that urine testing can, uh, from a urinalysis perspective, um it can be uh misleading. And that we're always gonna get a positive culture because they're colonized. So really we think about urine testing as using it to help us in uh tailor the empiric therapy that we've decided is important to start. And why is this important? It's important because we know that antibiotic use is linked to antibiotic resistance, and this is a great study that illustrates this, um, where we look at just in the general population, immuno uh so on the, the left x-axis, we have immunopenicillin prescriptions. The right x-axis, we have E. coli. Uh, resistance, so that's in red. So we follow the amino penicillin prescriptions and we see that it's, uh, about a month later, uh, we are seeing the, um, the rise in resistance. And so it's this um direct relationship between use of antibiotics and, and resistance. And we know that spina bifida patients receive antibiotics frequently. We don't have a great idea of what their cumulative exposure is, and this is um been something that we've been looking at recently, and Thao, a medical student that's going into urology, um. Has been working with uh uh with our research group to look at this, and we've, we have done some studies using market scan data, and this is uh some of our recent work we're looking from 2013 to 200 through 2021. Comparing spina bifida and controls, we see cumulative dosing um uh over the, the average cumulative dosing over time of um between spina bifida and controls significantly higher in the spina bifida population. And when we break it down and by age group, we see persistent, persistently higher antibiotic exposure for spina bifida individuals compared with controls across age groups. And then again, looking at cumulative antibiotic duration, so the cumulative days of antibiotics that individuals of spina bifida versus non-spina bifida individuals receive. And then looking at day supply, so, um, you know, uh, these longer duration, 11 to 30 days or 31 to 100, so you see much higher longer duration prescriptions for individuals with spina bifida compared with individuals without spina bifida. If we break this down further, we also see that genitourinary infections are responsible for a lot of these prescriptions. So, um, within the non-spina bifida population, we see that there's a higher um use of antibiotics and upper respiratory infections, but still substantial in spina bifida patients is, um, also, where we see big differences is again in urinary tract infection or genital urinary infection uh treatment in the yellow. And this is really where we see dramatic differences in the cumulative days of antibiotics um uh by population, by uh infection type. So fairly similar for upper respiratory and oitis media, much higher um uh for urinary tract infection treatment in spina bifida individuals versus non-spina bifida individuals. We see that when we look at the type of antibiotics prescribed, so high pres uh an antibiotics we frequently use for the urinary tracts, sulfonamides, and urinary anti-infectives, much higher in individuals with sin versus uh not, and then, you know, we see much higher use of penicillins and in individuals without spina bifida likely being used for the um otitis media, etc. All right. Well, when we think about uh treatment, does an individual with neurogenic bladder always require longer duration treatment? Um, it is considered a complicated urinary tract infection. There's not really any standard recommendations uh regarding duration of treatment for UTI and neurogenic bladder patients. We do know though that often we use longer courses and sometimes even dual therapy because it is classified as a complicated urinary tract infection. We also know there's a higher risk of antibiotic side effects with longer duration therapy. And we have evidence that prompt resolution of symptoms with the initiation of treatment um could be amenable to shorter duration uh therapy. There was actually a very good study done in 2016 uh by Denning colleagues looking at the management of febrile urinary tract infection among individuals with spinal cord injury, and um they assessed 112 individuals with neurogenic bladder and febrile urinary tract infections, and they compared three treatment groups, so less than 10 days, 10 to 15 days, and greater than 15 days of antibiotics. Uh, and they found no difference in Curate by treatment duration, or with mono or dual therapy. So, really, a single agent short course therapy of less than 210 days is likely, uh, sufficient as long as there's a response to the therapy and As you're monitoring the patient. So from there I was uh wanting to talk about three unique situations or that we often um see come up in our practice or questions that we get, um, and those include, um, you know, so is catheter reuse among individuals who perform clean intermittent catheterization OK? Do antibiotic installations help prevent urinary tract infection, so installations into the bladder. And does an indwelling catheter uh need exchange when treating urinary tract infection? Well, unfortunately, the debate continues as far as catheter reuse and urinary tract infection risks. So in 2009, there were some recommendations by the Infectious Diseases Society in North America. Uh, and through that review, multi-use catheters, um, were, were thought to be OK, um, and that a single sterile use catheter was not necessary and didn't really decrease the risk of catheter associated bacteria or catheter-associated urinary tract infection. Uh, subsequently, a Cochrane review supported this, um, and supported catheter reuse, not showing any difference in urinary tract infection rate. But then a group in 2018 did an independent data review of uh of, of the same uh Cochrane review and showed some discrepancies with the original analysis and saw a trend toward favoring single use of multi-use. So in a lot of ways this debate still continues. I will tell you that practically speaking, Catheterization, um, and reusing catheters is, is much preferred and better than not catheterizing at all because they, you know, they, they are having trouble getting their catheters uh delivered or issues with their prescriptions. And generally, um, patients, uh, you know, we have no problem with them using um their, their reusing their catheters. If they do have recurrent urinary tract infection, that would be something that we would, would, uh, work with them on. And continue and try to do single use catheterization. And then thinking if you are going to be reusing catheters, you know, cleaning recommendations for reuse, uh, really, uh, you know, what patients will often ask, well, how do I do it? What, what, what, what uh is the best method for cleaning catheters? Do you, do you boil them? Do you use a sterilizing fluid? Do you just use soap and water. And really, uh, the easiest way to get it done so that there's adherence to clean, cleaning the catheters, um, and, uh, and, and again, catheterizing on a regular schedule is what is most important with this. And so often I'll just recommend soap and water, letting them dry on the counter and then reusing them. All right, so antibiotic bladder installations, um, this is a concept of putting antibiotics directly into the bladder, um, and, uh, it, it's not putting them in and irrigating back and forth, but a gentle instruction of the solution and letting and, and, uh, and so this mechanical washing. There are limited observational studies providing evidence um that uh intravesicle gentamicin, which is a common antibiotic that is used for this, may be effective for urinary tract infection prevention. Um, in 2017, there was a study of 22 patients with neurogenic bladder evaluating these patients. Um, uh, 6 months before initiating gentamicin installation and then 6 months after, so having, uh, and, you know, each patient an internal control. And with this, there were fewer symptomatic urinary tract infections, 4 versus 1, and fewer oral antibiotic treatment courses, about 4 or 3.5 versus 1 after installation versus the period before installation began. And so we think about using uh antibiotic installations if we have trouble managing recurrent urinary tract infections in individuals. Um, but I can tell you that in my practice, I have very few individuals on um antibiotic installations and often the ones that are on them are coming from their practices, um, and, you know, being referred in and already started on that. In my experience, most importantly, again, it's optimizing the environment and that there's very often either um incomplete emptying of the bladder, and improvement in hydration that it could occur um or there's some constipation. So working on all of those things very um most probably would solve the problem versus bladder installations, but is an option. It's something to have in the toolkit. All right. How about catheter exchange with urinary tract infection treatment? Um, uh, you know, I, we, we, in my training, we used to think that this really probably wasn't, since we know that they get colonized within a week or two after having them in. Is it really valuable to change the catheter? Um. There have been some studies and there was actually a prospective uh randomized controlled trial done um actually quite a while ago, but looking at um nursing home residents with indwelling catheters and urinary tract infections. And those that were randomized to catheter replacement prior to treatment had a shorter time to reaching a febrile status and a lower rate of symptomatic clinical relapse. Um, and review of the literature, uh, and then the Infectious Diseases Society of North America guidelines, um, does recommend now that, um, or continues to recommend that if there has been an indwelling catheter in for granted in 2 weeks that, um, It would be good to replace the catheter to help um resolution of symptoms more quickly uh and reduce the um catheter associated bacteria and UTI rate. It's an important concept to understand though that really after uh an indwelling tube has been in place for a week and that includes something that's not even um Connected to the outside environment. So when we leave stents inside the urinary tract that, um, you know, after different surgeries, we recognize that they will become colonized, uh, you know, after about a week. Um, however, again, that said, we do exchange catheters with urinary tract infection if they've been in place greater than 2 weeks, um, to help, uh, quicken the resolution and um the UTI rate, uh, subsequent UTI rate. OK, so in conclusion, um, really when we think about um UTI management and neurogenic bladder, importantly, it's about optimizing um the, the environment with hydration, bladder empty, irrigation and constipation management to prevent infection. Um, it's important to perform selective symptom-driven urine testing, um, and when possible, utilize shorter duration single agent treatment, uh, that we then tailor by the urine culture results. And every time we think about treating an infection, we should be circling back uh to readdress the underlying risk factors, um, as we initiate antibiotic therapy. And in this manner, uh we can consider and evaluate uh urinary tract infection, um, uh, management, um, and really work towards optimal treatment and evaluate, you know, optimal evaluation and treatment, um, so that we can appropriately uh treat these patients and kind of get away from the undertreatment and overtreatment. Um, and, and in the end, um, hopefully, uh, make an impact on the overuse of antibiotics in this population. Thank you very much and um would love to take questions and, and use this time really um as a springboard to anything that comes up in management of urinary tract infection or in these patients in general, um. For the next few minutes. Thank you so much, Doctor Cupp. That was a great overview for a population and issue we often see in both the inpatient and clinic settings. Um, we have a bunch of questions in our Q and A, so I'll go ahead and um read them out for everyone. Um, first question, so I think you mentioned this in your lecture earlier that um, Any drinking water is appropriate to use with cats, um, any water that you take in by mouth is OK in the bladder. So in areas with questionable water, do you recommend that they boil and filter the tap water before using for irrigation? I think that that's reasonable. I will tell you that that honestly doesn't come up very often, but if you, if you're not drinking the water, then, uh, yeah, we, I think that that would be a fine recommendation to have them to have them boil it and then cool it and then use it as the Uh, irrigan, um, within the bladder, that's fine. Again, most, most importantly, it's about, I mean, we want, we want it to be safe water, but you're not, you know, the bladder has natural, uh, you know, natural barriers, um, so we don't, uh, it's more of agitating what's inside the bladder and uh getting it out, um, so. I think that after boiling it, it would be fine in areas where you can't drink the water. No studies for that. That is a completely an uh experience answer. Um, next question, um, so there's good data that ultrasound-based vesicoure urethrograms are equivalent to VCUGs. Why do we continue to irradiate the gonads in our kids in our hospital instead of transitioning to VUS? Yeah, uh, so we actually, um, there's different reasons. I think that's, um, an important question. We certainly use the, uh, as low as possible, um, dosing for um radiation, that's the Alara um concept we use, so what we're referring to there is is Cbus, um. And there's different information that we can get from um these, these studies and so uh we have moved toward doing CIS in the standard patient for diagnosing reflux. There's, there's some uh information with the fluoroscopic uh cystogram, um, and understanding, um. Uh, like, for example, a lot of times when we're looking at, we're talking about kind of different populations, but the non-spina bifida population with reflux and voiding, there's things that you can see, uh, at the bladder neck, um, and, uh, with voiding that you're not able to capture necessarily with uh Cbus, um. Using ultrasounds. So there's sometimes that fluoroscopic imaging, um, is advantageous. You'll also see us use something called video urodynamics in the spina bifida population, so we do get um Uh, bladder pressure studies. So a urodynamic study helps us to understand um capacity and compliance. It requires a pressure sensor catheter that goes in the bladder and then a, a, uh, uh, pressure sensor catheter in the rectum and helps us measure the true pressures within the bladder as it fills so that we get capacity and pressure readings of the um of the bladder. When we are first investigating, there's um important information with fluoroscopic imaging uh that we get looking for reflux, looking for what happens as the patient is uh filling and whether or not they're leaking and being able to capture that, uh, with fluoroscopic imaging where you're not able to do that with a CBS, uh, study. Um, so in the spina bifi population in particular, um, we, we do gain information from using the, the fluoroscopic study, and then once it's just measuring kind of bladder pressures and we do convert over to doing urodynamics in our clinic, uh, without the, without the X-rays. Interesting, thank you. Um, next question, um, what about other spinal cord injured patients who lack sensation of abdominal or back pain and pain with catheterizations? I think this was in reference to, um, How you diagnose these patients or decide to treat or not. So what other symptoms are we looking for? Was that the question? What signs? Um. You lack the sensation of abdominal pain or back pain and pain with catheterization. So I guess like how you even decide to test for UTI or when you decide to treat. Yeah, I, I think, um, you know, if, if a patient presents, so first of all, you know, going back to the basics, if it's just a change in urine and no other symptoms, and they're clinically doing well without fever, no change in vital signs, and it's malodorous urine or cloudy urine, I'm, I'm not going to treat because I think that's one of the things that leads to overtreatment, um. And they're clinically doing well. So I would go back to the basics. I would have them hydrated. I would have them catheterize more frequently. I would assess, you know, how are they managing their bowel if they have a bladder augment, are they irrigating and are they emptying their bladder completely, um, and whatever, you know, whatever the method they are for using for emptying their bladder. So I um In that sense, I would not be, I probably would not even be sending at that point, um, a urinalysis and culture um because that potentially uh triggers a treatment because it's going to come back positive, they are colonized. Unless, you know, we have very Good communication with this family and we're managing the care and we've communicated ahead of time that we anticipate a positive culture um coming back. And the only reason we would act on that culture is if your symptoms progress, um, um, such that you develop systemic symptoms, um, that become more concerning like fever especially, but also if you develop back pain or other systemic like poor appetite, um, Uh, other things that um are associated with the urinary tract infection. Some of these patients, again, get to know the symptoms they have associated with urinary tract infection. And so we try to help prevent those from developing and avoiding treatment to begin with. Great. Yeah, it's so tricky and some of those, um, some specific patients. Next question, um, how often are indwelling catheters changed generally regardless of UTI? Yeah, um, there's different thoughts about that, but I would say generally. Um, we change catheters that are indwelling on a monthly basis. Uh, it depends on, there are certainly patients that we have a hard time, so there, you know, first of all, why would you, why would you manage a patient with an indwelling catheter? Why would we do that? Well, um, there are some patients who um have trouble, uh, that they that are sensate and don't empty their bladder well and we can't get to catheterize. And so, uh, And they're, let's say 5 years old and so you can't really do a simple operation, for example, like a vesicostomy, um, because they're bigger, a vasiccostomy is when you bring the bladder directly to the skin, and that means they would need to be in diapers, um, but they won't catheterize and so how do you manage that patient? Well, sometimes to temporize them and keep them Uh, help mitigate their risk for urinary tract tract infection because one of the big issues is that they're not emptying their bladder, is doing the suprapubic tube. Um, and we also, uh, I, I didn't bring this up earlier, but we can use a mickey button like a G tube and use that in place of like a, a catheter, um, where we put that directly into their bladder and they open up the trap door, attach the device and empty their bladder and that way, uh, take the um You know, after they drained the bladder, then they close the, the trap door on the mickey button, and so they're not having to wear diapers. They can be on a schedule for emptying their bladder every 3 hours, um, and that, uh, prevents, uh, it helps really prevent urinary tract infection and manage them in a way that's much better for their quality of life, um, and less traumatic for them because they're not, they have not done well with clean intermittent catheterization and just not been able to do it. For those patients, I'll tell you, very often they start doing so well, but sometimes we have a hard time getting them to come back and so they're um a natural experiment as far as how often you need to change, change their um suprapubic tube and I will definitely tell you that the handful of patients that I managed like that are not getting their, their Um, Mickey button changed every month, and often it goes 3, you know, 3 months and they're doing fine. Some even up to 6 months, which is not ideal, but, um, so the textbook answer would be, we change it every month, but what happens in reality is, is definitely different than that. And most of the time, um, patients will do well. And often sometimes we'll end up learning how to change that at home, and then we get on a better schedule when the barriers to coming to clinic and having it done in the clinic setting, it's much easier to do at home once they can have that, once they can do that, we can order those supplies for them. Nice. Um, next question, what is your go to constipation management plan or regimen? Yeah, good question. And, and the eyes of a pediatric urologist, every patient is constipated until proven otherwise. Um, so anytime, and that's true of, um, individuals with with neurogenic bladder and bowel and and and those without. So, you know, we treat a lot of um Uh, kids without without spina bifida, neurogenic bladder and bowel, um, that have constipation, and that's a huge driver of urinary tract infections in the reflux world and then in just the infection world in general, and they're all constipated. So my go to first of all is hydration, again, cornerstone of really helping with uh uh with constipation, but as you all are aware, it's really hard to get um kids to eat and drink. In ways that would help constipation. So my go to. Is, um, is actually MiraLax, um, and, uh, very, it's, it's easy to use and it's easy to titrate, and, um, there's not really, we, you know, there are no studies that really show, uh, ill effects of um using long-term MiraLax, um, uh, and we do know that not treating constipation can have long-term effects. So, Uh, for kids less than 45 pounds, I'll use a half cap full uh daily and about 6 to 8 ounces of fluid, which whatever kind of fluid they want and make it easy. You can do it at dinner time, you know, with meals where that's part of their routine. Some kids don't like how it changes the texture and so putting it in something other than water helps, um. If they're over 45 pounds, it's a cap full daily, uh, in 6 to 8 ounces. That's kind of where I start. And then you can titrate up and down and there's some kids who need 1.5 or 2 cats a day, uh, but, uh, I generally use that as the starting point. And if kids are really constipated and, uh, and, you know, sometimes we'll use, we, we'll use a KUB to help look at the level of stool burden, and if they have stool throughout the colon. Um, then we'll do a clean out and I affectionately call that the pourama, um, and we'll do, uh, you know, if they're under 45 pounds, we do, um, uh, 7 capfuls of MiraLax and 32 ounces over a 4 to 6 hour period in one day, and then after doing that, they should have about 5 to 6 bowel movements, uh, and then they start on the daily routine thereafter. If they're over 45 pounds, they do 14 cats and 64 ounces in one day. Usually over 44 to 6 hours. Usually on a weekend, because, you know, they'll have some um looser stools the following day or so. Thank God for MiraLax. And there are some families who don't like Miralax. They've been on blogs, etc. and there's one of the, the, the probably the the biggest thing we see is families who say that they, they see, you know, issues with behavioral, uh, if you, if you look at if people on the blogs talk about behavioral disorders and using MiraLax and that it may be a cause of that. And, and honestly, it's probably that a lot of kids with behavioral disorders, you know, have issues with constipation, so it's not that the MiraLAX is causing it, but it's just Associated with it. Right. Um, sort of related to your constipation regimen go to. What's your, um, empiric antibiotic of choice? Great question. I love nitrofurannone, um, and that's because it has poor tissue penetration. So we're thinking about prophylaxis, we really want it to be concentrated in the urine and not necessarily absorbed systemically or, you know, um, so, uh, it's, first of all, important thing to say is don't use nitrofurantone for an infection with a fever and for treatment. Uh, for treatment of a systemic infection, um, it really should be reserved in general for prophylaxis in the pediatric population cause they're often, uh, we're treating them based on systemic symptoms, um. And so my go to uh empiric treatment actually is cephalosporins. So you see a lot of use of like uh septra, Bactrim, TMPSMX, um, you know, and actually our usage of that should be based on um Local antibiograms and looking at what the community resistance is to that organism and, and generally, um it's uh it's high at baseline and so, but if you look at cephalosporins, there's um Uh, low community resistance and so that's a very good empiric treatment option, especially since in the general population, 80% of urinary tract infections are typically caused by E. coli, and typically E. coli is um sensitive if uh to, to first generation cephalosporins. Now that does change with individuals with spina bifida and recurrent urinary tract infection. And again, that's why doing cultures is important so that we can tailor therapy um appropriately. And if you have started on, if it's somebody who has been on a prophylaxis or been on multiple treatments and you're starting with a broad spectrum antibiotic, follow up on those cultures and tailor down to a, um, you know, narrow spectrum antibiotic when possible. To go back and nitroranton and, you know, we, we, you have to be over 2 months of age for me, you know, we don't use it in very young kids because of uh liver immaturity. Um, you have to have a creatinine clearance um that allows it to concentrate, you know, to concentrate in the urine, so kids with renal failure, you don't use nitrofuranone. um, and then just in general, we're not, uh, we're not using it to treat infections. You'll see in the adult population that people use nitrofuranone, but again, Uh, adults communicate symptoms better and they're being treated for lower urinary tract infections without, you know, systemic, um, uh, symptoms such, you know, we're not thinking about pyelonephritis. So very often for kids it's febrile UTI, which is, is, is a pyelonephritis, and so you want antibiotics that have good tissue penetration to get into the kidney and treat the infection and that is not nitrofurantoin. Um, we are, we have a lot of questions left, very little time. Um, I guess next one, are there any specific devices or techniques besides clean intermittent cathing, as well as constipation management and hydration that you recommend for these patients or families at home? Well, that's a great thing, the simplicity of it though, right? So, um, just, uh, it, it, you know. That's a, uh, I guess I, I appreciate the question because we often get that from parents, but in, in my mind, the fact that it is hydration and uh emptying the bladder, I mean, our worst, we have a natural defense mechanism to prevent infection, and that fluid in fluid out is, is critical. I mean, we, we didn't used to have antibiotics and, you know, we didn't, we don't die from infections. And even now, you know, not being very, you know, you can get very sick and, and die from an infection. But a lot of times, um, our natural defenses are able really to fight, uh, infection quite well. And so, helping your body do what it, um, has been designed to do is, is, um, very powerful. So, um, not underestimating those critical elements, um, And how much of a profound effect they can have is, is important. So, um, I would, I would really say those, those are, those are the key elements. Um, maybe, last question, um, we'll see, um, any specific or different recommendations for menstruating adolescence? Should they avoid tampons or pad usage if they have recurrent UTIs, thoughts about menstrual cups? Um, so this is sort of a question. Beyond spina bifida in general, but I mean it can relate, but uh no specific use with tampons. I think generally, uh there's there's, yeah, it's um. I think that if you have somebody that is menstruating and having infections, uh, that it is not related to necessarily tampon use, um, more I've not, I can honestly tell you I've never had a referral for that sort of that question. So that's an interesting question. I think that probably, again, it's uh hydration. Regular emptying, um, you know, regular exchange of tampons, um. And I would, if that really was uh a big big issue, I would actually get the gynecologist, uh, the OBGYN involved in helping to think about that, um, and how it could play a role. I didn't talk anything about, you know, probiotics and cranberry extract and things like that. So actually to that last, that prior question, um, uh, that may be what the person was getting at, and we do do that. Um, so, uh, I would, I would, I don't use, I try not to use prophylactic antibiotics to prevent infections. So these kids are very, uh, with spina bifida and caffeine knowing that colonization is an issue, we really try not to have kids on uh prophylactic antibiotics, um. We will use things like we will use uh cranberry extract uh and probiotics. I don't have, I often get a question about which ones do I recommend um for probiotic, and I don't, I don't have a specific recommendation and advise them to go to the pharmacy and, and um talk to the pharmacist about uh what they would recommend, um, but generally any probiotic or even just uh yogurt with live active cultures, things like that. Great. OK. I think that's about it, um, time wise. Thank you so much for your presentation and um answering all these questions, Doctor Kopp. This is a great overview. Absolutely, yes. Um, and thank you for inviting me today, and it's been a great experience. I appreciate your engagement. Have a good day. Thanks. Take care. Created by
