Prevention, treatment, and management of urinary tract infections in neuropathic bladders

Urinary tract infection (UTI) continues to be a major cause of mortality in patients with neurogenic bladders. Even patients who void reflexly and have unobstructed voiding with external condom drainage have a high incidence of chronic recurrent bacteriuria. Our recent studies have described the difficulty of diagnosing and localizing UTI in patients with neurogenic bladders. Symptoms correlated poorly with significant bacteriuria (greater than or equal to 10(5) colonies/ml) and the use of the Fairley washout test gave less than optimal results in our studied population. Breakdown of endogenous host defenses, development of drug resistant organisms, and external contamination from urinary drainage appliances and fecal incontinence should be considered in diagnosis and management of these patients. Adequate bladder drainage is the most effective prophylactic measure against recurrent urinary tract infections. Our methods of bladder drainage include use of alpha blockers, transurethral sphincterotomy, and in selected paraplegics, long-term intermittent self-catheterization. We stress decreasing pathogenic bacterial skin colonization through daily perineal washing with soap and water, and cleaning drainage appliances at least once daily with 0.06% sodium hypochlorite. We treat the symptomatic patients and patients with positive urine cultures with potential stone forming organisms. Antibiotic therapy in asymptomatic patients should be guided by an inflammatory response with white blood cell count of greater than or equal to 10(4) colonies/ml in the urine and positive bacterial culture of greater than or equal to 10(5) colonies/ml.