WOCA, Botulinum Toxin Considered for Neurogenic Bladder


Expert Analysis from the Annual Meeting of the American Urological Association

WASHINGTON – How should one manage a 35-year-old woman with multiple sclerosis on self-clean intermittent catheterization who complains of pelvic pain and cloudy urine?

Such a patient with “neurogenic bladder” and possible urinary tract infection needs careful diagnosis, catheterization review, and possibly other management considerations, said Dr. Stephen R. Kraus during a panel discussion of recurrent UTIs at the meeting.

Patients with neurogenic bladder commonly have chronic bacteriuria and recurrent UTIs, and thus generally require a combination of bacteriuria and leukocyturia – as well as clinical symptoms or an increase in autonomic dysreflexia – for the initiation of empirical UTI therapy. Such criteria will help avoid unnecessary use of antibiotics.

“Original criteria were based on bacterial colonization counts but were criticized for being highly insensitive,” said Dr. Kraus, professor and vice chairman of the department of urology at the University of Texas, San Antonio.

Assuming the patient has already had a video urodynamic test, Dr. Kraus said, he would obtain a catheterized specimen for urinalysis, culture, and a sensitivity test; treat as needed; and then consider increasing her catheterization frequency. A trial of a hydrophilic catheter could also be considered in the context of recurrent UTIs, he said.

Various catheter modifications – from silver alloy catheters to antibiotic-impregnated catheters – have been used with some success in reducing the risk of UTIs, but “they carry their own problems such as cost, development of resistance, and even, as one study suggested, the possibility of silver toxicity,” Dr. Kraus said.

Two randomized, controlled trials have shown that hydrophilic catheters will reduce the risk of UTIs, compared with regular polyvinyl chloride catheters, he noted. Although the choice of single-use vs. reusable catheters is “always a point of contention,” several studies have “clearly” shown that clean intermittent catheterization (CIC) poses no greater risk of recurrent UTIs than do single-use catheters, he added.

Frequent changing of intermittent catheters can prevent biofilm development, and one study showed that UTI was five times less likely when CIC was performed six times per day rather than three times per day, he noted.

Routine chronic antibiotic prophylaxis should be avoided in patients with neurogenic bladder, he said, but a short course of antibiotics could be useful during the initial CIC period, and is certainly prudent before any invasive genitourinary procedures are performed.

Dr. Kraus said he is intrigued by the concept of a weekly oral cyclic antibiotic (WOCA) program that uses weekly alternating antibiotics as a prophylactic measure. In one 2-year trial of WOCA, investigators “saw dramatic reductions in UTIs (from 9.4 to 1.8 per patient year) … and most importantly, they did not see any change in the number of multidrug-resistant infections.”

As a final management option for the above-described patient, Dr. Kraus said he would consider injections of botulinum toxin (Botox). This approach “has exploded in the market for neurogenic bladder management, and it has been associated with a significant reduction in UTI at 6 months … presumably because the neurogenic bladder management is that much better.”

The term “neurogenic bladder,” Dr. Kraus noted, is one that's “not very precise.” For the purposes of his discussion, he defined it as a condition in which the bladder is affected by a neurologic process and has an impaired ability to store and empty urine.

Dr. Kraus disclosed that he is an investigator for the National Institute of Diabetes and Digestive and Kidney Diseases, a course director for Laborie (which manufactures catheters and other products for urinary and pelvic disorders), and a consultant/adviser for Pfizer.

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