"Patient perception is an important aspect of developing an effective treatment plan, and we should be able to arm patients with accurate data to help them make an informed decision," write Whitney Renee Smith, MD, and Gopal H. Badlani, MD.
Dr. Smith is a fellow in female pelvic medicine and reconstructive surgery, and Dr. Badlani is vice chair and professor of urology, Wake Forest Baptist Health, Winston-Salem, NC.
From the time Lapides popularized the use of self-intermittent or clean intermittent catheterization (J Urol 1972; 107:458-61), it has improved the quality of life of patients with neurogenic bladder due to a variety of conditions. Reuse of catheters for intermittent catheterization was the norm and still is common practice; it is in fact, the standard of care in some health care systems. In many developing countries, patients have limited access to medical supplies necessitating reusable catheters. It was not too long ago in the United States that insurances covered only four catheters per month, but in 2008 Medicare/Medicaid allowed for patients to receive up to 200 catheters per month.
The authors of a study by Madero-Morales et al provide answers to what many urologic providers and patients need (see article here).
What was lacking in the literature was a head-to-head comparison of intermittent catheterization with single-use versus reusable catheters (cleansed with 0.5% benzalkonium chloride) with a primary endpoint of urinary tract infections (defined as having a positive urine culture and symptoms). In this study of 75 patients with an average age of 12.7 years, they found that the rate of urinary tract infection did not differ between the groups: 35.2% with single-use catheters vs. 36.8% with reusable catheters (OR: 0.877, 95% CI: 0.42, 2.76). Rates of asymptomatic bacteriuria also did not differ between the two groups.
Interestingly, being unable to walk and having vesicoureteral reflux grade 2 or higher were identified as risk factors for having a symptomatic UTI in both groups. In the reusable catheter group, male gender and presence of a bladder diverticulum were risk factors for developing a UTI.
One of the arguments against reusable catheters is the variability among cleansing methods and patient adherence to a sanitation regimen. In this study, the catheters were washed with plain soap and water, stored in a container with benzalkonium chloride, and used for 1 week. Although this regimen is simple enough, having protocols designed for patients who spend part of their day outside the home is needed.
A topic of interest and debate is the environmental impact of the waste that humans generate. It is estimated that the generated waste of single-use intermittent catheterization is between 26,500 and 235,400 pounds per day, with the vast majority of urinary catheters made from non-biodegradable materials (Neurourol Urodyn 2018; 37:2204-8). We should all be considering alternatives to help reduce waste going to our landfills. Perhaps with policies and protocols for reusable urinary catheters, we can help lower waste while maintaining patient safety. Reduce, reuse, and recycle!
Single-use catheters were introduced as a means to decrease the risk of developing UTIs, and many patients in the Western world cannot fathom the idea of a reusable catheter, especially when multiple health care providers are telling them this. However, the author of this study essentially calls this “fake news.” Patient perception is an important aspect of developing an effective treatment plan, and we should be able to arm patients with accurate data to help them make an informed decision.
If reusable catheters are going to be presented as an option, future research should be focused on determining the number of times a catheter may be reused, developing a protocol for sanitation, identifying additional risk factors that may contribute to UTIs, and calculating potential cost savings and affordability. With further insight into these factors, reusable catheters can again become a standard of care.
Also, while we are on the subject, use of antibiotics should be limited to symptomatic UTIs and not bacteriuria in patients performing self-intermittent or clean intermittent catheterization.
Send your comments to Drs. Smith and Dr. Badlani c/o Urology Times, at firstname.lastname@example.org