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Your child’s primary physician can assess for a urinary tract or bladder infection. A urologist can assess bladder function and determine the need for urinary catheterization. A nephrologist can assess the impact on the kidneys. A pediatric pharmacist can screen for drug-drug interactions and anticipate the effect of medications for urine retention. Complex care and palliative care clinicians can help develop plans that decrease bladder infection frequency and adjust the care plan during decline.
Urinary Tract and Bladder Infections
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Children with SNI can be at risk for urinary tract (UTI) and bladder infections. This risk is increased when there is retention of urine in the bladder, and can be decreased with use of intermittent catheterization of the bladder. Catheterization empties the bladder of urine; however, catheterization can also introduce bacteria into the bladder which may lead to colonization (bacteria in the bladder causing no harm) or actual infections.
ESP Bladder Infection
Symptoms
Diagnosis
ESP Bladder Dysfunction
Bladder dysfunction can increase the risk for bladder infections. Urination flushes bacteria out of the bladder, but the bacteria can multiply when the urine stays in the bladder too long. Clean intermittent catheterization (CIC) can decrease the risk of a bladder infection. Use of CIC can also cause colonization of bacteria, meaning that bacteria are present in the bladder but are not causing an inflammatory reaction.
There are two ways to distinguish colonization from infection: the number of white blood cells in the urine analysis, and the presence of symptoms. Urine that is colonized with bacteria can appear cloudy, darker, and have an odor, so these features are not helpful for indicating infection versus colonization. Occasionally there will be another reason for recurrent symptoms (see link to Chronic Pain), with the bacteria in the urine due to colonization rather than the cause of recurrent symptoms. The medical team uses all of this information to balance the use of antibiotics to treat infections and limit use when possible. The goal is to not cause antibiotic resistance, which may limit what antibiotics can treat each infection.
Testing and Treatment
The medical team may use specialized testing called magnetic resonance urography (MRU), which is a type of MRI, to identify any issues that may be causing difficulty with your child’s urinary function. Some, but not all, of these issues require insertion of a catheter as part of the treatment. Catheterization may be temporary or ongoing (continued in the home setting), depending on your child’s condition.
If catheterization is determined to be in your child’s best interest, request a consultation with a child-life specialist who can help you and your child adjust to the procedure. The easier and calmer the initial experience, the easier it will be for you to continue catheterization in the home setting if it is determined to be needed.
If your child has recurrent bladder infections, the medical team might consider a lower dose of an antibiotic (continuous antibiotic prophylaxis) to decrease their frequency. Occasionally, after removing urine from the bladder the medical team may decide to use an antibiotic that can be placed in the bladder. The antibiotic is left in the bladder with the evening catheterization, and then is emptied during the morning catheterization. This is sometimes considered if the bacteria become resistant to the oral antibiotic options.
Some children have risk for vesicoureteral reflux (VUR), a condition in which urine flows backward from the bladder up the tubes (ureters) that connect the kidneys to the bladder and causes UTIs. Other children may have a blockage of the kidney, called hydronephrosis, that can lead to UTIs. Treatment of the UTI includes the use of an antibiotic either orally or through an IV. Sometimes surgery is needed to correct the VUR or hydronephrosis.
ESP Home catheterization adds new challenges. It naturally puts an additional burden on the care routine and will certainly present additional questions (for example, who will catheterize your child at school or daycare; will babysitters, aides or other family members be comfortable performing the procedure; or will your child now need nursing care?). You also may be wondering if you will feel further isolated if you have worries about having to catheterize when out in public.
While it is true that this intervention protects against the complications of an underactive bladder, and may provide your child with greater comfort by relieving bladder pressure and even assisting bowel functioning in the process, it is not always the only solution. You may find, as some parents do, that urinary catheterization is too daunting or emotionally challenging. It can also be uncomfortable at first in children who have intact sensation in their genitalia. It is important to discuss this with your care team so that they can help make you feel more comfortable with the task, or identify other solutions.