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Journal of Wound, Ostomy & Continence Nursing:
doi: 10.1097/WON.0b013e3181e3e465
Continence

Continence Literature Review 2009

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Urinary Incontinence and Related Lower Urinary Tract Symptoms

C1 TITLE: Weight Loss to Treat Urinary Incontinence in Overweight and Obese Women

AUTHORS: Subak LL, Wing R, Smith West D, Franklin F, Vittinghoff E, Creasman JM, Richter HE, Myers D, Burgio KL, Gorin AA, Macer J, Kusek JW, Grady D; Pride Investigators

SOURCE: New England Journal of Medicine 2009;360:481–490

ARTICLE TYPE: Randomized Trial

DESCRIPTION/RESULTS:

* Obesity is an epidemic in North America and a known risk factor for urinary incontinence. To assess if an active weight-loss and education program was more effective than education alone, the authors randomized 338 women with BMI approximately 36 and at least 10 UI episodes a week to one of two groups.

* Over the 6 months of the study, weight loss was higher in the diet group than the education alone group and although relatively low (7.8 kg) did result in an improvement in stress urinary incontinence symptoms but no difference in urgency symptoms.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* The study supports other data that even a modest weight loss can improve urinary incontinence symptoms, in addition to other health-related benefits. CWOCN need to be sensitive to the issues of adherence to diet and assist obese individuals to find appropriate professional assistance rather than just instructing them to lose weight. Continence clinic managers may wish to ensure that nutritional advice and professional obesity management are incorporated into their holistic care model.

C2 TITLE: Practical Aspects of Lifestyle Modifications and Behavioral Interventions in the Treatment of Overactive Bladder and Urgency Urinary Incontinence

AUTHORS: Wyman JF, Burgio KL, Newman DK

SOURCE: International Journal of Clinical Practice 2009;63(8):1177–1191

ARTICLE TYPE: Review Article and Summary of Approaches to Managing Urgency and Urge Urinary Incontinence

DESCRIPTION/RESULTS:

* The authors provide a succinct but comprehensive overview on ways to improve the symptoms of overactive bladder: healthy bladder habits and lifestyle modifications, normal voiding intervals, elimination of bladder irritants from the diet, management of fluid intake, weight control, management of bowel regularity and smoking cessation.

* Behavioral interventions such as bladder training and pelvic floor muscle (PFM) training are included as well as an example of a bladder diary and directions for completion. The recommendations could easily be part of any primary care practice.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* This integrative review article provides an excellent overview of behavioral interventions appropriate for managing any patient overactive bladder, either with or without urgency urinary incontinence. Full scope CWOCN and CCCN should also implement these strategies for patients with mixed urinary incontinence.

C3 TITLE: De Novo Stress Incontinence and Pelvic Muscle Symptoms After Transvaginal Mesh Repair

AUTHORS: Aungst MJ, Friedman EB, Von Pechmann WS, Horbach NS, Welgoss JA

SOURCE: American Journal of Obstetrics & Gynecology 2009;201(1):73.E1–E7

ARTICLE TYPE: Review Of 335 Cases

DESCRIPTION/RESULTS:

* The authors conducted a chart review to assess postoperative outcomes in women who underwent transvaginal mesh repair for stress urinary incontinence. They reviewed the incidence of de novo (postoperative) incontinence, pelvic muscle symptoms, mesh exposure, bladder injury rate, and recurrent prolapse following repair. The follow-up period was approximately 8 months following surgery.

* Intraoperative injuries during the mesh, mesh exposure rate and recurrent failure rate were low (around 5%) but postoperative de novo stress incontinence rate was comparatively high at 24.3%. Other centers have also reported a high incidence of urgency or stress incontinence after vaginal mesh surgery.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* The findings of this study confirm previous research indicating that patients should be informed about the risk of incontinence. Findings also suggest that initiation of preventive interventions, such as lifestyle modification, pelvic floor training, or weight loss may be indicated. For certified nurses involved in research, these findings indicate the need for additional research, including a study that randomizes women to pelvic floor muscle training preoperatively vs standard care in order to enhance our knowledge of the efficacy of specific preventive interventions.

C4 TITLE: Do Women With Pure Stress Urinary Incontinence Need Urodynamics?

AUTHORS: G. Digesu A, Hendricken C, Fernando R, Khulla V

SOURCE: Urology 2009;74(2):278–281

ARTICLE TYPE: Review of Cases Undergoing Urodynamics

DESCRIPTION/RESULTS:

* The authors reviewed 3400 files of women who had undergone urodynamics at their center in response to statements by some funders that urodynamic testing is not routinely indicated for women undergoing surgery for stress urinary incontinence. Contrary to the funders' opinions, the authors found that even in women who described lower urinary tract symptoms consistent with stress incontinence, there was enough likelihood of lower urinary tract dysfunction to justify urodynamic testing and to assist with postoperative management (for example in women with poor contractility obstructive voiding postoperatively could be an issue).

* The authors recommend careful review of current guidelines for the management of pure stress urinary incontinence.

* They conclude that if women do not undergo urodynamics preoperatively, that good preoperative counselling is imperative as preoperative detrusor overactivity and postoperative voiding difficulties may not be excluded.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* These findings suggest that urodynamic testing is indicated in women who undergo surgical management of stress urinary incontinence.

C5 TITLE: The Effects of Pelvic Floor Muscle Training on Stress and Mixed Urinary Incontinence and Quality of Life

AUTHORS: Sari D, Khorshid L

SOURCE: Journal of Wound, Ostomy and Continence Nursing 2009;36(4):429–435

ARTICLE TYPE: Randomized Controlled Trial

DESCRIPTION/RESULTS:

* The researchers compared the effects of pelvic floor muscle training (PFMT) to a control group. PFMT comprised muscle training using digital palpation, written instructions and weekly telephone calls to encourage adherence. Women were taught quick flick contractions, sustained contractions and the KNACK maneuver. Control group subjects were not contacted during the 8-week study period.

* Instruments included the Incontinence Quality of Life tool, pelvic floor muscle strength measured via manometry, 3-day voiding diaries and 1-hour pad testing.

* PFMT subjects experienced greater improvements in pelvic floor muscle strength, I-QOL scores, and experienced fewer episodes of urinary incontinence than control group patients.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* Findings related to the effectiveness of PFMT are confirmatory of existing evidence. However, the results influence practice because they demonstrate that even a comparatively brief period of FPMT (8 weeks) using digital stimulation to tech muscle identification, reduces the frequency of incontinence episodes and improves quality of life.

C6 TITLE: Clinical Research in Diabetes and Urinary Incontinence: What We Know and Need to Know

AUTHORS: Phelan S, Grodstein F, Brown JS

SOURCE: Journal of Urology 2009;182(6 SUPPL):S14-S17

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

* The authors reviewed the published epidemiological and clinical trial literature examining diabetes mellitus and incontinence and found that there is substantial evidence to confirm that Type II diabetes is a significant risk factor for urinary incontinence in women.

* There is also growing evidence indicating a higher prevalence and incidence rate of UI in Type I diabetic women. Further research is required on the effect of rigorous glycemic control and weight loss on incontinence.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* It has been established that women with Type II diabetes are at risk for urinary incontinence but current evidence suggests that lower urinary tract symptoms including incontinence is not routinely assessed. Findings from this study provide additional evidence supporting routine assessment of lower urinary tract symptoms in all women living with diabetes mellitus.

C7 TITLE: Risk Factors for Urinary Incontinence Among Women With Type I Diabetes: Findings From the Epidemiology of Diabetes Interventions and Complications Study

AUTHORS: Sarma AV, Kanaya A, Nyberg LM, Kusek JW, Vittinghoff E, Rutledge B, Cleary PA, Gatcomb P, Brown JS; Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions And Complications Research Group

SOURCE: Urology 2009;73:1203–1209

ARTICLE TYPE: Non-Experimental Study, Cross- Sectional Survey

DESCRIPTION/RESULTS:

* Subjects for this cross-sectional descriptive study were recruited from the follow-up study of the Diabetes Control and Complications Trial. The original study was a randomized controlled trial that enrolled 1441 subjects; the follow-up study included 652 women. This study comprised 550 of that cohort of 652 women. Women completed a questionnaire consisting of validated instruments used to measure the frequency, severity and type of urinary incontinence.

* Thirty-eight percent of women reported any urinary incontinence and 17% reported urinary leakage once weekly or more often. Factors associated with urinary incontinence were: (1) increasing body mass index, (2) advancing age, (3) recurring urinary tract infections.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* Urinary incontinence is prevalent among women with Type I diabetes mellitus. Findings from this study suggest that interventions designed to prevent weight gain and urinary tract infections may prevent urinary incontinence or ameliorate its severity.

C8 TITLE: Double-Blind Randomized Controlled Trial of Electromagnetic Stimulation of The Pelvic Floor vs Sham Therapy in The Treatment of Women With Stress Urinary Incontinence

AUTHORS: Gilling PJ, Wilson LC, Westenberg AM, Mcallister WJ, Kennett KM, Frampton CM, Bell DF, Wrigley PM, Fraundorfer MR

SOURCE: British Journal of Urology International 2009;103(10):1386–1390

ARTICLE TYPE: Randomized Controlled Trial

DESCRIPTION/RESULTS:

* This study compares extracorporeal electromagnetic (NeoTonus, Marietta, GA, USA) stimulation (ES) treatment of stress urinary incontinence (SUI) compared to a sham ES in 70 women who had SUI confirmed on urodynamics.

* Subjects underwent 3 treatment sessions per week for 6 weeks and comprehensive data were collected immediately proceeding, and at 2 and 6 months following therapy. Outcome measures included a pad testing with a pre-determined bladder volume (the primary outcome measure), a 3-day bladder diary, and 24 h pad-test. Pelvic floor muscle strength and two health related quality of life questionnaires were evaluated as secondary outcome measures.

* All subjects were instructed to also perform pelvic floor muscle training at home during the study period. Clinicians were blinded to treatment group.

* Overall there were significant improvements both groups at 8 weeks and significant improvements in primary and secondary outcome measures in the active treatment group when compared with baseline measures. However, these improvements were not statistically significant when compared with the sham-treatment group. Patients on active treatment who had a poor pelvic floor contraction at the initial assessment (defined by a circumvaginal muscle score and perineometry) experienced a significant reduction in urine loss when compared with the sham-treatment group.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* As with many conservative therapies for urinary incontinence, one therapy is not beneficial or necessary for all women. Many may have improved simply because they did the PFME at home. However, the subgroup of women with poor pelvic floor contraction strength improved significantly and suggests that ES may be an alternative to biofeedback or clinician directed instruction for pelvic floor muscle training. A comparison study of other methods would be a valuable addition to the knowledge base.

C9 TITLE: Association Between Urinary Incontinence and Depressive Symptoms in Overweight and Obese Women

AUTHORS: Sung VW, West DS, Hernandez AL, Wheeler TL II, Myers DL, Subak Ll

SOURCE: American Journal of Obstetrics and Gynecology 2009;200(5):557.E1-557.E5

ARTICLE TYPE: Research Study; Cross-Sectional

DESCRIPTION/RESULTS:

* The authors evaluated depression symptoms in 338 women participating in an incontinence, diet and exercise study.

* Depression was evaluated using the Beck Depression Inventory; a diagnosis of depression was based on a score ≥ 10. Lower urinary tract symptoms and health related quality of life were evaluated via a 7 day voiding dairy, and scores from the Urogenital Distress Inventory and Incontinence Impact Questionnaire.

* The authors report that women who had worse incontinence were more likely to report depression symptoms and lower QOL than those with fewer incontinent episodes. They conclude that incontinence severity, bother, and quality of life are factors in depression in women.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* Incontinence has been identified as a risk factor for depression in several studies, while other studies have identified depression as a risk factor for overactive bladder syndrome and urgency urinary incontinence. The findings of this study suggest that incontinence severity is associated with the likelihood of depression, suggesting that incontinence may increase the likelihood of subsequent depression. Regardless of which comes first, certified WOC nurses should remain sensitive to the possibility of depression in patients with urinary incontinence. Additional research is needed to clarify the relationship between urinary incontinence and depression and to determine whether treatment of depression may help resolve urinary incontinence, or whether treatment of incontinence may alleviate depression symptoms.

C10 TITLE: Urinary Incontinence Is Associated With an Increase in Falls: A Systematic Review

AUTHORS: Chiarelli PE, Mackenzie LA, Osmotherly PG

SOURCE: Australian Journal of Physiotherapy 2009;55(2): 89-95

ARTICLE TYPE: Systematic Literature Review

DESCRIPTION/RESULTS:

* Pooled data from nine studies were identified via systematic review and analyzed to determine the association between falls and urinary incontinence. Meta-analysis was based on 15,679 community dwelling subjects.

* The odds ratio (OR) of falling among persons with any urinary incontinence was 1.45 (95% CI 1.36 to 1.54). The OR for patients with stress urinary incontinence was 1.11 (95% CI 1.00 to 1.23). The OR among patients with urge urinary incontinence was 1.54 (95% CI 1.41 to 1.69) and the OR for patients with mixed urinary incontinence was 1.92 (95% 1.69 to 2.18).

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* The results of this meta-analysis provide additional evidence that overactive bladder dysfunction, when associated with urge or mixed urinary incontinence, increases the risk falls. This systematic review and meta-analysis is somewhat unique because it calculates OR based on incidence of falls rather than hip fractures, supporting the argument that fall prevention programs should be encouraged for community dwelling elders with urge or mixed urinary incontinence.

C11 TITLE: The Efficacy of Acupuncture in Treating Urge and Mixed Incontinence in Women

AUTHORS: Engberg S, Cohen S, Sereika SM

SOURCE: Journal of Wound, Ostomy and Continence Nursing 2009;36(6):661–670.

ARTICLE TYPE: Randomized Controlled Trial, Pilot Study

DESCRIPTION/RESULTS:

* This pilot study evaluated the effect of acupuncture for treatment of urge and mixed urinary incontinence in women.

* Study subjects were randomly allocated to acupuncture or sham treatment; participants in both groups received 12 treatments over a period of 6 weeks.

* Findings did not demonstrate significant differences between sham and active treatment groups, but the pilot study was not powered (did not enroll a sufficient number of women) in either group to measure differences. Findings did demonstrate that use of a sham device is feasible, and that results from a larger study (currently ongoing) will determine whether acupuncture is effective for treatment of urge and mixed urinary incontinence.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* Behavioral interventions and antimuscarinic medications are typically used as first line treatment for overactive bladder with urge urinary incontinence, and for mixed urge and stress urinary incontinence. Existing evidence demonstrated that these interventions are effective for most patients. However, there is a paucity of evidence concerning effective second line or alternative treatments for these prevalent conditions. This study demonstrates the feasibility of conducting a randomized controlled trial comparing a placebo group (treated with a sham device) to a group treated with active acupuncture. The findings from the main study will provide valuable information concerning whether acupuncture is the second line treatment continence clinicians are seeking.

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Fecal Incontinence and Associated Bowel Elimination Symptoms

C12 TITLE: Methylnaltrexone: A Subcutaneous Treatment for Opioid-Induced Constipation in Palliative Care Patients

AUTHOR: Kyle G

SOURCE: International Journal of Palliative Nursing 2009;15(11):533–540

ARTICLE TYPE: Integrative Review of Evidence on Treatment of Opioid Induced Constipation

DESCRIPTION/RESULTS:

* Constipation is common among palliative care patients receiving opioids for pain control. Management with laxatives, enemas, disimpaction are unpleasant but the consequences of bowel obstruction from constipation can be life threatening.

* This integrative review article provides stepwise description for treatment of constipation and discusses evidence for a newer medication to supplement bowel routines: methylnaltrexone bromide. An illustrative case study is included in the article.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* This is a practice-based article and provides guidelines for treatment of constipation associated with use of opioid analgesics. It is of interest to all certified nurses who manage patients in a palliative care setting who require opioids for pain management.

C13 TITLE: Comparison of Polyethylene Glycol (PEG) With and Without Electrolytes in the Treatment of Constipation In Elderly Institutionalized Patients: A Randomized, Double-Blind, Parallel-Group Study

AUTHORS: Seinelä L, Sairanen U, Laine T, Kurl S, Pettersson T, Happonen P

SOURCE: DRUGS & AGING 2009;26(8):703–713

ARTICLE TYPE: Randomized Controlled Trial

DESCRIPTION/RESULTS:

* Polyethylene glycol (PEG) osmotic laxative is being used more commonly in individuals with chronic constipation not responsive to other conservative measures. There are two formulations of PEG: one contains electrolytes and can be mixed with water, while the other contains no electrolytes and it can be mixed with juice or hot drinks which may render it easier to drink. In this study the authors randomized older people in long-term care with constipation to one of two groups: PEG 4000 without electrolytes (hypotonic PEG) and PEG 4000 with electrolytes (isotonic PEG). This randomized controlled trial compared the effectiveness, palatability, and side effects of the two formulations.

* Sixty-two patients (mean age 86 years; range 66-99 years) were randomized to PEG groups, 12 g once or twice daily or once every other day, for 4 weeks. Defecation frequency, stool consistency, straining and bowel elimination symptoms were recorded. No differences in stool frequencies, straining or GI symptoms were detected.

* Plasma sodium level was statistically significantly lower in the hypotonic PEG group at the end of the study (137.7 vs 138.9 mmol/L) but the clinical significance of this is not clear. Most patients preferred the taste of the hypotonic PEG. The authors concluded that both solutions of PEG were effective and safe in the treatment of constipation in elderly institutionalized patients.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* Chronic constipation impairs, compromises nutrition, and creates bothersome side effects such as abdominal bloating and discomfort. It is associated with an increased risk of fecal soiling, urinary tract infection and urinary incontinence. This study provides evidence of the benefit of PEG and supports other studies which have similar findings. Nurses reviewing bowel protocols at their center may wish to incorporate PEG in the algorithm of care.

C14 TITLE: The Impact of Flatal Incontinence on Quality of Life

AUTHORS: Steinberg AC, Collins SA, O'sullivan DM

SOURCE: American Journal of Obstetrics and Gynecology 2009;201:E1-E3

ARTICLE TYPE: Retrospective Study

DESCRIPTION/RESULTS:

* The negative impact of fecal incontinence on health related quality of life in women is well documented, but less is known about the influence of inability to control flatus. This study examined the influence of incontinence of gas alone on quality of life.

* Results of 160 out of a group of 678 women entered into a urogynecologic database were analyzed. Women with incontinence of flatus were older than other urogynecologic patients, had more pregnancies and vaginal deliveries, and were more likely to have constipation than women without incontinence of flatus. They did not differ based on number of caesarean deliveries, BMI or degree of pelvic organ prolapse. Four validated instruments were used to assess the relationship between inability to control flatus and quality of life: (1) Urinary Distress Inventory, (2) Colorectal-Anal Distress Inventory, (3) Pelvic Organ Prolapse Distress Inventory, and (4) Pelvic Floor Dysfunction Inventory.

* Women with incontinence of flatus had lower health quality of life when compared to those without incontinence.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* Definitions of fecal incontinence vary, with some researchers including women who experience incontinence of flatus alone while others exclude this cohort of patients. This variability influences estimates of both the prevalence and incidence of fecal incontinence, and our knowledge of its impact in quality of life. The results of this study affect practice because they reinforce traditional beliefs that incontinence of flatus is a clinically relevant finding that impairs quality of life and should be incorporated in the assessment and treatment of fecal incontinence.

C15 TITLE: Randomized Controlled Trial Shows Biofeedback to Be Superior to Pelvic Floor Exercises For Fecal Incontinence

AUTHORS: Heyman S, Scarlett Y, Jones K, Ringel Y, Drossman D, Whitehead We

SOURCE: Diseases Of The Colon And Rectum 2009;52(10): 1730-1737

ARTICLE TYPE: Randomized Controlled Trial

DESCRIPTION/RESULTS:

* The researchers compared pelvic floor muscle training using manometric driven biofeedback with pelvic floor muscle training using a videotape and verbal instruction. Muscle training occurred under clinician direction in both groups. The exposure time to the directing clinician was equal for each group.

* Patients who underwent pelvic floor muscle training augmented by manometric biofeedback had greater reductions in Fecal Incontinence Severity Index Scores, anal canal squeeze pressures, and less abdominal muscle tension than subjects who received training without instrument driven biofeedback. More patients receiving biofeedback reported adequate symptom relief when compared to pelvic floor muscle training without biofeedback at 3 and 12 months following treatment. Patients receiving biofeedback enhanced pelvic floor muscle training also reported significantly reduced Fecal Incontinence Index Severity scores 12 months.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* The value of biofeedback as a component of a pelvic floor muscle training program has long been debated. The findings of this study provide solid evidence that manometric biofeedback sessions enhance the efficacy of pelvic floor muscle training for patients with fecal incontinence.

C16 TITLE: Practical Strategies for Treating Postsurgery Bowel Dysfunction

AUTHORS: Sloots K, Bartlett L

SOURCE: Journal of Wound, Ostomy And Continence Nursing 2009;36(6):651–658

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

* The authors describe a comprehensive treatment program for patients with bothersome bowel elimination symptoms following complex surgical procedures such as ileoanal anastomosis, restorative proctocolectomy, and low anterior anastomosis.

* A comprehensive assessment is used to tailor an individualized treatment program that includes education and counseling, fluid and dietary advice, selective use of medications or nutritional supplements to modify stool consistency, teaching about physical activity, and emotional support.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* The authors focus on nursing interventions that provide a sound basis for treating persons with bowel dysfunction following reconstructive procedures. These techniques can also be applied to others with bothersome bowel elimination symptoms associated with a variety of disorders.

C17 TITLE: Treatment of Postsurgery Bowel Dysfunction: Biofeedback Therapy

AUTHORS: Sloots K, Bartlett L, Ho Y-H

SOURCE: Journal of Wound, Ostomy and Continence Nursing 2009;36(6):651–658

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

* The authors extend their previous article describing the effects of biofeedback on postsurgery bowel dysfunction.

* Multiple interventions for muscle retraining are advocated including pelvic floor muscle training using biofeedback to enhance muscle identification and isolation, slow diaphragmatic breathing techniques, and positioning techniques to maximize the mechanical efficiency of bowel elimination.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* The authors describe several useful techniques for enhancing bowel elimination in patients with postoperative dysfunction. Knowledge of these techniques is especially valuable because they can be readily adapted to the management of children or adults with chronic constipation.

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Indwelling Urinary Catheters

C18 TITLE: Do Catheter Washouts Extend Patency Time in Long-Term Indwelling Urethral Catheters? A Randomized Controlled Trial of Acidic Washout Solution, Normal Saline Washout, Or Standard Care

AUTHORS: Moore KN, Hunter KF, Mcginnis R, Bacsu C, Fader M, Gray M, Getliffe K, Chobanuk J, Puttagunta L, Voaklander DC

SOURCE: Journal of Wound, Ostomy and Continence Nursing 2009;36(10):82–90

ARTICLE TYPE: Randomized Controlled Trial

DESCRIPTION/RESULTS:

* Blockage is common in patients managed by long-term catheterization. Seventy-three community dwelling patients with long-term indwelling catheters that required frequent changes (every 3 weeks or more often) were randomly allocated to one of three groups: (1) usual care with no catheter washouts, (2) catheter washouts with 50 mL of sterile saline, and (3) catheter washouts with 50 mL of sterile Contisol, a mildly acidic solution.

* Results revealed no statistically significant differences between patients receiving washouts with saline or the mildly acidic solution when compared to patients receiving no washouts. Findings also revealed that, prior to evidence from in vitro studies, catheter blockage was associated with biofilm formation rather than encrustation.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* The results of this study provide evidence that irrigation of the catheter with sterile saline or a mildly acidic solution cannot be routinely recommended for preventing or alleviating recurring blockage in patients managed by long-term indwelling catheters.

C19 TITLE: Nursing Interventions to Reduce the Risk of Catheter-Associated Urinary Tract Infections. Part 1: Catheter Selection

AUTHORS: Parker D, Callan L, Harwood J, Thompson Dl, Wilde M, Gray M

SOURCE: Journal of Wound, Ostomy and Continence Nursing 2009;36(1):23–33

ARTICLE TYPE: Systematic Literature Review

DESCRIPTION/RESULTS:

* Insertion of a silver-alloy catheter reduces catheter-associated urinary tract infection risk for up to 2 weeks in adults managed by short-term catheterization. Insertion of an antibiotic catheter reduced the risk of infection for up to 7 days. Insufficient evidence was found to determine whether insertion of an antimicrobial catheter (silver alloy or antibiotic coated) reduces urinary tract infection risk in patients managed with long-term indwelling catheters.

* Insufficient evidence was found to determine whether insertion of a latex, hydrogel coated latex, or silicone catheter influenced urinary tract infection risk. Evidence was lacking concerning the influence of catheter size on urinary tract infection risk although expert opinion suggests that small catheters may reduce risk.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* Existing evidence supports insertion of a catheter with antimicrobial properties. Nevertheless, clinical practice guidelines may not advocate their routine use based on economic considerations. Therefore, it is important to work with an interdisciplinary team to determine the best policies for catheter-associated urinary tract infection prevention in your local facility.

C20 TITLE: Nursing Interventions to Reduce the Risk of Catheter-Associated Urinary Tract Infection. Part 2: Staff Education, Monitoring, And Care Techniques

AUTHORS: Willson M, Wilde M, Webb ML, Thompson D, Parker D, Harwood J, Callan L, Gray M

SOURCE: JOURNAL OF WOUND, OSTOMY AND CONTINENCE NURSING 2009;36(2):137–154

ARTICLE TYPE: Systematic Literature Review

DESCRIPTION/RESULTS:

* Limited evidence was identified supporting the following preventive interventions: (1) staff education about catheter management, (2) implementation of a facility-wide prevention program based on input from an interdisciplinary team, (3) daily cleansing of the urethral meatus using a perineal cleanser or soap and water, and (4) maintenance of a closed urinary drainage system for short-term indwelling catheters.

* Evidence failed to support multiple interventions supported by tradition and in some clinical practice guidelines. They included: (1) use of strict sterile technique for catheter insertion, (2) use of antimicrobial ointments or solutions with meatal care, (3) irrigation of the bladder, frequent changes of the urinary drainage bag, and (7) placement of an antiseptic solution in the urinary drainage bag.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* The risk of catheter-associated urinary tract infection is proportional to the time the catheter remains in the lower urinary tract and existing evidence strongly suggests that reduction of the time a catheter is left indwelling is an essential element of a prevention program. The evidence in this systematic review, when combined with the findings of Part 1, provides the basis for a facility wide, evidence based program for prevention of catheter-associated urinary tract infection.

C21 TITLE: Periurethral Cleaning Prior to Urinary Catheterization in Children: Sterile Water Versus 10% Povidone-Iodine

AUTHORS: AL-Farsi S, Oliva M, Davidson R, Richardson SE, Ratnapalan S.

SOURCE: Clinical Pediatrics 2009;48(6):656–660

ARTICLE TYPE: Randomized Controlled Trial

DESCRIPTION/RESULTS:

* One hundred eighty-six children were randomly allocated to periurethral cleaning with sterile water or a 10% povidone-iodine solution prior to catheterization in an emergency department setting.

* Positive urine cultures occurred in 18% of children undergoing cleansing with sterile water versus 16% of those cleansed by the povidone-iodine group. This difference was not statistically significant.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

* Sterile technique during insertion of an indwelling urinary catheter is advocated as one technique for preventing catheter-associated urinary tract infection. However, a systematic review published in the Journal of Wound, Ostomy and Continence Nursing and reviewed in this supplement found insufficient evidence to conclude that use of strict sterile technique is superior to a modified clean technique that includes use of sterile gloves and catheter. This article provides additional evidence that strict sterile technique does not reduce the risk of catheter-associated urinary tract infection when compared to modified clean technique. Additional research is needed to determine precisely how to operationally define clean technique for catheter insertion.

Copyright © 2010 by the Wound, Ostomy and Continence Nurses Society

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