Hello. I am an RN specializing in wound ostomy and continence care. I have worked with some community based spinal cord patients for the past two years. When I started working with SCI patients, I discovered an astounding knowledge deficit concerning spinal cord care in both myself and other clinicians in my area. I enjoy research and have tried familiarize myself with the liturature concerning best management practices in SCI - the PVA guides, Consortium for Spinal Cord Medicine guidelines for Healthcare providers, a few current spinal cord medicine books, and a number of meta analysis, research trials, and published case studies. I have also learned many things from the nurses and SCI folks discussing problems and solutions on these messageboards. The Care Cure community is has been a fantastic resource for me. I felt compelled to join because I am having a lot of trouble with a particular patient's bladder issues, and even moreso, his urologist. The patient is 38, 22 years post-injury, a c4 c5. Initially he was managed with a condom catheter. In 2004 this was deemed no longer effective for reasons unknown to me (though I imagine he was unable to maintain a low pressure system) and he switched to intermittant catheterization. Around this time his urologist surgically "nicked" his sphincter , the patient refers to it as a sphincterotomy, though I am unsure if it was this or bladder neck surgery because he remains fully continent of urine. He was also placed on 15mg daily of enablex along macrobid and bactrim on alternating months for antibacterial prophylaxis. His urologist also prescribed 30 mls of acetic acid 0.25% instilled into the bladder BID. Roughly 5 years ago, the patient started using a Foley at night, and instead of true intermittant cathing, removed the Foley in the morning, instilled the acetic acid, wait 5 or so hours without cathing until dysreflexic, then start a red rubber IC cath, attach to a leg bag, leave the cath in for most of the day, instill acetic acid again and remove for a few hours in the evening, transfer to bed and start a foley. He drinks about 4000 milliliters of water a day. No utis for several years this way. Last Christmas, around the time I met him, the patient developed a stage I pressure ulcer on his coccyx. He remain in bed (low air loss) for a short time, then resumed regular activities. Shortly thereafter, it reappeared. This time he remained in bed for two weeks, ordered a new chair and a new cushion and was evaluated for body positioning, seating, and pressure mapping, improved his diet and skin check regimen and started taking pressure brakes on a regular basis when up. The pressure ulcer has not returned. Shortly after this he contracted bacterial conjunctivitis that became a respiratory infection treated with antibiotics, did not turn into pneumonia, but he did not eat well during the two weeks it took to recover and developed what I consider pretty severe constipation where he did not have a bowel movement in 2 weeks. His physiatrist instructed him to take an enema for this. Which he did. But without a catheter in place or emptying his bladder beforehand, so he was unable to discern bowel movement dysreflexia from full bladder dysreflexia, and as a result became significantly dysreflexic with a blood pressure of over 200, had a seizure, and was taken to the ER via Life Flight helicopter. I imagine the culprit was the overly distended bladder, since once he was hospitalized they drained over a thousand milliliters out and his dysreflexia immediately subsided. The medical staff at the hospital found no correlation between his seizure, his blood pressure, and his bladder and bowel issues, but that is a story for another day. While hospitalized for this seizure, it was determined that he had a UTI with e coli and enterococcus faecalis, and that he had hypoalbuminia and non specified anemia, which he has attempted to correct though diet. They gave him IV antibiotics for 2 days, he went home and resumed the same foley/ic left in place routine, brought in a urine specimen to his urologist, was told he was still infected, and this is where the antibiotic saga begins. For the next 6 months, his urologist did not physically examine him other than a renal scan, but prescribed at least 10 different oral antibiotics. The pattern was this: two weeks of an antibiotic, bring in a bacteruric urine sample, culture it, grow a different organism ( typically a back and forth between Enterococcus faecalis and e.coli, once it was Klebsiella pneumonia) prescribe two weeks of a different antibiotic, culture it, grow out a new organism another antibiotic, etc. The patient became far sicker than he was previously. His urine became malodorous and cloudy, he experienced new onset edema under his eyes, around his face and hands, and when he was on minocycline I saw what I believe was bilirubin in his urine and yellowing of his eyes. Mild fever that came and went a few times, occational chills. Still on the macrobid and bactrim in between the other antibiotics. I grew concerned about kidney function in light of the edema and heavy antibiotic use so a creatinine clearance test was ordered. This serum creatinine was 0.4, and the urologists office never obtained lab results from the urine collected or did an actual clearance ratio, adjusted for SCI or otherwise, so it was a waste of time and I have still no idea about creatinine clearence. Of course, the patient continued to have non-sterile urine while using the foley so then along with continued culturing and antibiotics, the urologist added daily intravesical installation of potassium premagenate after removing the Foley each AM, rinsing the bladder with 60 cc's of saline after each cath, and installation of acetic acid after every cath. This did not help either. In September the patient finally met with his urologist and arranged a cystoscope. He requested urodynamic testing, but every time he went in for it they would say he was infected and it could not be done. However, I am fairly certain with good timing it could be done because during the course of antibiotics, his urine would clear up and he would appear uninfected for a few days, then the symptoms would return. He had the cystoscope done, the urologist said it was unremarkable apart from redness in the dome of the bladder which he attributed to the balloon of the Foley. He said go back to IC. He said the urine " looked terrible" and gave him 2 days of IV antibiotics in the hospital. He also stated that sterile urine was his treatment goal, and "there was no reason for him to be having UTIs with all the water he drinks and doing IC. Said he would culture the urine again in 2 weeks and a month. This experience was enough to get the patient to adopt the following methods for bladder management:
Continuing with 4000 milliliters of water a day, stopping at around 6 p.m.
Ensuring that all nurses that cath him use aseptic technique and standard hand washing.
Using single use hydrophilic catheters and aseptic technique to fully empty the bladder every 3 to 4 hours.
Aiming to empty his bladder before it fills over 500 mls, though realistically he takes out anywhere between 400 and 600 every time he caths.
Avoiding constipation and meticulously cleaning up after the bowel program. The patient now takes colace and benefiber and does bowel program three times a week vs two times a week, constipation is resolved.
Showering and washing the perineal area with chlorhexidine soap after the bowel program.
Using saline as a flush twice a day or when sediment appears excessive, though I feel that excessive sediment is pretty subjective and am not sure if it is entirely beneficial to flush the bladder when evidence seems to point otherwise. He does not produce a lot of sediment. His urologist also wanted him to put in acetic acid 3 times a day. When the patient started getting dysreflexia from each acetic acid installation, he finally stopped doing it. His urologist says the acetic acid will prevent stones and infection, yet the actual product information states that in order to acidify the urine to 5.0 and prevent pathogen colonization, it would require a continuous bladder irrigation of atleast 1000 milliliters per day. I think the acetic acid is an exercise in futility and possibly hurting the mucosa of the bladder.
The patient is concerned with antimicrobial resistance and aplastic anemia and renal deterioration, as am I, and he attempted to stop the prophylactic macrobid and bactrim when discharged from the hospital. However, a few days later he had the mild dysreflexia chills( but no elevation in BP), cold clammy sweats, and semi cloudy urine. He started to take macrobid and all of these things resolved. After 2 weeks the urine became somewhat cloudy with increased sediment. He then switched to the scheduled bactrim. Urine remained clear for a few days, then sediment reappeared, a few days later he experienced cold clammy sweats for two days which then resolved. He took in his urine sample and they cultured it, said he had ecoli, and prescribed ceftin again. Instead of taking the ceftin, he switched back to macrobid, and the urine again was crystal clear and all symptoms resolved for about a week. Then another cold clammy sweat day, small amounts of sediment.
Apart from this issue, he is a healthy individual who remains active, works, and is able to do what he needs to do.
Mostly he is asymptomatic. Gets the occasional cold clammy sweats, which are a new thing. Yet his urologist continues to stress the goal of sterile urine, but this does not seem it obtainable, as he is sterile when on antibiotics for a time, and then quickly shows signs of bacteruia once the antibiotics stop or he remains on the prophylactic for more than a week. Ri have read about the nature of these infecting organisms, and how they can treat biofilms and hide and hide in intracellular spaces. I think that when he is on macrobid, his bladder is colonized with entero coccus resistant to it and free of e.coli, and when he is on bactrim, his bladder is colonized with E coli. I think that no matter what he does there is something that causes it to flare up every time the antibiotics are stopped. My main concern is if this is clinically significant or not. He has had those cold sweats three times for a few hours at abtime, usually when he gets out of bed, since September and this is disconcerting, but he has no other symptoms. Id like to know what is causing them. His skin, his bowel program, his energy and overall genitourinary function seem to be improved snice the IV antibiotics in September and discontinuing the foley. I do not have a complete copy of his lab results on hand, but on the phone I was told that the last urine sample two weeks ago grew over 100000 CFU of e. Coli, and had 5-10 white blood cells per field. There is little or no hematuria. there was sediment in his urine which resolved with macrobid. Because he feels like his urine looks better on macrobid than bactrim, he has elected to stay on it. The patient finds it hard to accept bacterial colonization because his urine was sterile for so long. My main concerns are this:
Wit those lab results in this type of situation, is this asymptomatic bacteria or is this a UTI?
Should his bladder be reassessed to see if there is still redness in the dome, or even biopsief, in light of the fact he used a foley for a long time and used to smoke?
Would he benefit from urodynamic testing?
Should he undergo further evaluation for stones, as in the past he formed a small stone in his kidney that spontaneously passed without intervention, according to his urologist. The renal scan came back negative for stones, but I know that sometimes they are hard to find and can be obscured by things like constipation. I was told that a prostate infection or a stone would mean the patient would only have recurrent infection with the same microbe. But if the majority of spinal cord injury patients have polymicrobial UTI, would an infected prostate or a stone not be polymicrobial as well?
Is there anything else you can recommend? I believe that his current urologist will endlessly culture and prescribe antibiotics and do no further evaluation uness prompted by the patient. He would like to know what to ask for. I feel that he should get a referral because the urologist himself has been fairly incompetent with any feedback, follow up, or general communication. I am also unsure how familiar he is with current best practice guidelines for neurogenic bladder. The patient was injured on the job and has workers compensation and can request a referral if his physiatrist feels it's warranted. Do you think he would benefit from going to the University of Alabama in Birmingham for an assessment of his urological situation? Or even just a general SCI check up? He has not had blood work done in ages, never had a cardiac exam, assessment for gallstones or anything else for that matter except a renal scan and periodic urine cultures.
This year of health problems and clammy sweats is a new phenomenon and he is concerned. Don you have any recommendations for who to see about urological issues at UAB? I know they literally wrote the book on some aspects of spinal cord management. There is a lack of SCI doctors here.
I know this is a very long post, but he is very upset and this is the one thing I felt I hadn't done. Thank you for your time.
Continuing with 4000 milliliters of water a day, stopping at around 6 p.m.
Ensuring that all nurses that cath him use aseptic technique and standard hand washing.
Using single use hydrophilic catheters and aseptic technique to fully empty the bladder every 3 to 4 hours.
Aiming to empty his bladder before it fills over 500 mls, though realistically he takes out anywhere between 400 and 600 every time he caths.
Avoiding constipation and meticulously cleaning up after the bowel program. The patient now takes colace and benefiber and does bowel program three times a week vs two times a week, constipation is resolved.
Showering and washing the perineal area with chlorhexidine soap after the bowel program.
Using saline as a flush twice a day or when sediment appears excessive, though I feel that excessive sediment is pretty subjective and am not sure if it is entirely beneficial to flush the bladder when evidence seems to point otherwise. He does not produce a lot of sediment. His urologist also wanted him to put in acetic acid 3 times a day. When the patient started getting dysreflexia from each acetic acid installation, he finally stopped doing it. His urologist says the acetic acid will prevent stones and infection, yet the actual product information states that in order to acidify the urine to 5.0 and prevent pathogen colonization, it would require a continuous bladder irrigation of atleast 1000 milliliters per day. I think the acetic acid is an exercise in futility and possibly hurting the mucosa of the bladder.
The patient is concerned with antimicrobial resistance and aplastic anemia and renal deterioration, as am I, and he attempted to stop the prophylactic macrobid and bactrim when discharged from the hospital. However, a few days later he had the mild dysreflexia chills( but no elevation in BP), cold clammy sweats, and semi cloudy urine. He started to take macrobid and all of these things resolved. After 2 weeks the urine became somewhat cloudy with increased sediment. He then switched to the scheduled bactrim. Urine remained clear for a few days, then sediment reappeared, a few days later he experienced cold clammy sweats for two days which then resolved. He took in his urine sample and they cultured it, said he had ecoli, and prescribed ceftin again. Instead of taking the ceftin, he switched back to macrobid, and the urine again was crystal clear and all symptoms resolved for about a week. Then another cold clammy sweat day, small amounts of sediment.
Apart from this issue, he is a healthy individual who remains active, works, and is able to do what he needs to do.
Mostly he is asymptomatic. Gets the occasional cold clammy sweats, which are a new thing. Yet his urologist continues to stress the goal of sterile urine, but this does not seem it obtainable, as he is sterile when on antibiotics for a time, and then quickly shows signs of bacteruia once the antibiotics stop or he remains on the prophylactic for more than a week. Ri have read about the nature of these infecting organisms, and how they can treat biofilms and hide and hide in intracellular spaces. I think that when he is on macrobid, his bladder is colonized with entero coccus resistant to it and free of e.coli, and when he is on bactrim, his bladder is colonized with E coli. I think that no matter what he does there is something that causes it to flare up every time the antibiotics are stopped. My main concern is if this is clinically significant or not. He has had those cold sweats three times for a few hours at abtime, usually when he gets out of bed, since September and this is disconcerting, but he has no other symptoms. Id like to know what is causing them. His skin, his bowel program, his energy and overall genitourinary function seem to be improved snice the IV antibiotics in September and discontinuing the foley. I do not have a complete copy of his lab results on hand, but on the phone I was told that the last urine sample two weeks ago grew over 100000 CFU of e. Coli, and had 5-10 white blood cells per field. There is little or no hematuria. there was sediment in his urine which resolved with macrobid. Because he feels like his urine looks better on macrobid than bactrim, he has elected to stay on it. The patient finds it hard to accept bacterial colonization because his urine was sterile for so long. My main concerns are this:
Wit those lab results in this type of situation, is this asymptomatic bacteria or is this a UTI?
Should his bladder be reassessed to see if there is still redness in the dome, or even biopsief, in light of the fact he used a foley for a long time and used to smoke?
Would he benefit from urodynamic testing?
Should he undergo further evaluation for stones, as in the past he formed a small stone in his kidney that spontaneously passed without intervention, according to his urologist. The renal scan came back negative for stones, but I know that sometimes they are hard to find and can be obscured by things like constipation. I was told that a prostate infection or a stone would mean the patient would only have recurrent infection with the same microbe. But if the majority of spinal cord injury patients have polymicrobial UTI, would an infected prostate or a stone not be polymicrobial as well?
Is there anything else you can recommend? I believe that his current urologist will endlessly culture and prescribe antibiotics and do no further evaluation uness prompted by the patient. He would like to know what to ask for. I feel that he should get a referral because the urologist himself has been fairly incompetent with any feedback, follow up, or general communication. I am also unsure how familiar he is with current best practice guidelines for neurogenic bladder. The patient was injured on the job and has workers compensation and can request a referral if his physiatrist feels it's warranted. Do you think he would benefit from going to the University of Alabama in Birmingham for an assessment of his urological situation? Or even just a general SCI check up? He has not had blood work done in ages, never had a cardiac exam, assessment for gallstones or anything else for that matter except a renal scan and periodic urine cultures.
This year of health problems and clammy sweats is a new phenomenon and he is concerned. Don you have any recommendations for who to see about urological issues at UAB? I know they literally wrote the book on some aspects of spinal cord management. There is a lack of SCI doctors here.
I know this is a very long post, but he is very upset and this is the one thing I felt I hadn't done. Thank you for your time.
(KDL), help me navigate these urological issues
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