Care at home

Guide to Spinal Cord Injury
Paraplegia and Urology

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contents

Care at home

CONTENTS

3FOREWORD

Foreword

3

Fundamentals

4

Aims of urological treatment

6

Neurourological diagnosis
 Imaging procedures Functional diagnosis
 Kidney function tests
 Laboratory tests

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8
9
10
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Treatment of bladder dysfunction
 Reducing bladder pressure Emptying the bladder

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However, urological issues are life-long concerns for
those affected by them. After completion of the first
rehabilitation phase, problems with bladder function
are the most common reason for a paraplegic to visit
a doctor. An understanding of the principles of bladder
health and knowledge of the possibilities and limitationsof urological treatment are consequently of extreme
importance. This guide is intended to address themost common issues encountered during managementof bladder function disorders and to supply basic
information with the aim of achieving, in conjunction
with urologists, independent control of bladder healthwhile maintaining the best possible quality of life.

Urinary tract infections
 Clinical signs

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Prof. Dr. med. Jürgen Pannek, Head Physician
Neurourology Swiss Paraplegic Centre, Nottwil

Alternatives tointermittent catheterization

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Incontinence24

New trends in the treatmentof bladder dysfunction

25

Sexuality and paraplegia
 Fertility

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28

Urine measurement

29

Homecare urology products

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It is not uncommon for people living with spinal cord
injury to have bladder dysfunction. Depending on
severity, this can represent a serious threat to kidney
function and/or greatly restrict quality of life. For a longtime kidney function disorders were the most common
cause of death among paraplegics. In the last 30 years,
advances in neurological diagnosis and therapy havedrastically reduced the risk of kidney damage, so thattoday life expectancy for the majority of paraplegics
has vastly improved.

Information in this brochure is for your generalknowledge and is not intended to be a substitute forthe advice of a qualified medical professional. The
information should not be considered complete andshould not be used in place of a visit, call,consultation or advice of your physician or other
healthcare provider.
Teleflex does not practice medicine nor provide
medical services or medical advice.
You should seek prompt medical advice for any
specific health issues and consult a qualified medical
professional before purchasing any product(s).
You should not disregard professional medical
advice or delay in seeking it because of something
you have read in this brochure. Do not consult thisbrochure in the event of a medical emergency.

4fundamentals

Care at home

5

FUNDAMENTALS
Coordination disorders of the lower urinary tract are
particularly common and are extremely severe after
spinal cord damage.

Renal pelvis

UreterOur urinary tract is divided into an upper and lower
section. The upper urinary tract consists of the kidneys
and ureters. The lower urinary tract includes the bladder,sphincter, urethra and, in men, the prostate gland. The
kidneys produce urine that is transported by the ureters
into the bladder. The lower urinary tract has twofunctions: to store urine and to empty the bladder.
To do these jobs, not only must the individual organs be
intact but their interaction must be controlled andcoordinated. The nervous system fulfills these functions.
The nervous system receives impulses from the bladder(e.g., the sensation felt when the bladder needs to be
emptied) and conveys this information via the nerves in
the pelvis minor to the spinal cord, and then from there to
the brain stem. Here the various pieces of incoming
information are interconnected to be controlled andmanaged by centers in the cerebrum.
The instructions from brain to bladder take the opposite
path (brain stem – spinal cord – nerves of the minor
pelvis) back to the lower urinary tract and trigger theactions required. Thus, the centers for voluntary control(cerebrum) and for coordination of the incoming signals(brain stem) are located above the spinal cord.
Damage to the spine means that the connections between
the urinary tract and the control centers in the skull arecompletely or partially disconnected. There are two reflex
centers in the spinal cord that are capable of activating,but not of coordinating, the bladder impulses: an upperand lower center. If the reflex centers in the spinal cord
located below the injury take over control, bladder andsphincter activity becomes uncoordinated.

With an injury above the lower center, both organs are
fully disconnected from the nervous system and do not
function at all. If the injury occurs above the lower center,the relaxing impulses are assigned to the bladder muscle;
the reason why the spinal cord sends uncoordinatedstimulation impulses to the lower urinary tract.
The bladder becomes active even if it contains only a little
urine. Often, the sphincter muscle becomes
simultaneously tensed, i.e., the bladder goes into ‘spasm.’
The bladder tries to squeeze the urine out while thesphincter muscle bars the way. The high pressure towhich the urine is exposed causes secondary damage.
Kidney damage develops when the urine is prevented fromflowing out of the kidneys or is squeezed back into thekidneys. The permanently overactive state of the bladderleads to muscular damage.

BladderNeck of the bladder
UrethraUrethral opening

URINARY TRACT IN WOMEN

Prostate
External sphincter
Penis

URINARY TRACT IN MEN

A potential visible result is the involuntary loss of urine(incontinence) because at any given moment, which cannot
be predicted, the pressure in the bladder becomes so strongthat the urine is squeezed out against the resistance of thesphincter muscle.
Coordination disorders of the lower urinary tract are
particularly common and are extremely severe after
spinal cord damage (caused by injury or congenitalabnormalities, e.g., spina bifida or meningomyelocele).
In principle, however, all disorders of the nervous system(e.g., multiple sclerosis, diabetes, slipped disks, etc.) canlead to bladder dysfunction.

Path of healthy nerve
impulses in the spinal cord

Spinal cord damage

Urinary bladder

Healthy nervous system (left) and disconnected nervous system (right)

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aims of urological treatment | neurourological diagnosis

Care at home

AIMS OF UROLOGICAL TREATMENTNEUROUROLOGICAL DIAGNOSISAll urological therapy aims to protect kidney function andto maintain the highest possible quality of life.

Many factors influence the type of bladder dysfunction thatdevelops in a person with paraplegia.

Protecting kidney function includes voluntary emptyingof the bladder and continence (no involuntary loss ofurine). Quality of life concerns include sexual dysfunction
and fertility disorders and are addressed as part ofurological treatment.

The type of bladder dysfunction that develops in aperson with paraplegia depends on many factors:
complete or incomplete paralysis, the degree of injury,
the duration of the damage and/or other diseases (e.g.,diabetes, injuries to the pelvis minor, craniocerebral
trauma). Obviously, factors that we do not completely
understand also play a role, for it is impossible to predicton the basis of the factors listed above which form of
bladder dysfunction will develop. In addition, thedysfunctional bladder is subject to dynamic changes.
Over time the disorder can change.

Urology is actually a surgical specialty. The treatmentof neurogenic bladder dysfunction, however, does notprimarily involve surgery on a diseased organ. The
consequences of dysfunction are treated in organs thatare themselves healthy. This requires another qualification.
Urologists who have specialized in the treatment of
bladder dysfunction, sexual dysfunction and fertility
disorders caused by damage to the nervous system
are known as Neurourologists.

Since less than one-third of those affected are madeaware of a change by symptoms (e.g., incontinence,urinary tract infections, spasticity and problems emptying
the bladder), regular neurourological assessments
are necessary.
In the early phase after the injury, the initial
examination should take place after approximately
6 weeks with an assessment after 3 months. Further
appointments depend on findings and individual risk
profile. As a rule, an assessment should be carried out
every 1 to 2 years. If the patient’s condition is stable,
this interval can be extended.
EXAMINATIONS
A typical initial examination consists of a detailed
discussion (medical history), a physical examination,
urinalysis, an ultrasound scan of the kidneys andbladder and video urodynamic testing. Whether further
examinations are necessary will be decided by the
results of this “basic diagnosis.” In addition, kidney
function should be determined using blood and urine
tests or by kidney function testing (the renal clearance
test used in nuclear medicine).
What do these specialist terms actually mean?

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MEDICAL HISTORY
A discussion takes place between neurourologists andthe persons affected to ascertain exact details of thetechnique used to empty the bladder, how often the
bladder is emptied, whether and how those affected sensethat the bladder is full, whether problems with bladderfunction (e.g., incontinence, urinary tract infections,problems with catheterization) have occurred, which
medicines are taken and how happy the person is withthe current treatment.
The effects of bladder problems on quality of life canbe measured using questionnaires. The type of bowel
evacuation and sexual function, such as whether the
person concerned wishes to have children, should also
be discussed.
As many of the points discussed may change between
two assessments, it is extremely important that these
discussions take place regularly at every assessment.
Because there are generally several months or even years
between assessments it is useful to keep a record at homeabout the frequency of urinary tract infections and towrite down possible questions.

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neurourological diagnosis

Care at home

IMAGING PROCEDURES

FUNCTIONAL DIAGNOSISThe position and appearance of kidneys and bladder canbe assessed with ultrasound and contrast radiography.

Bladder examination may include video
urodynamic testing and cystoscopy.

ULTRASOUND (SONOGRAPHY)
An ultrasound machine sends out high-frequency soundwaves, which reflect off body structures. A computer
receives these reflected waves and uses them to create a
picture. Unlike with an x-ray or CT scan, there is no
ionizing radiation exposure with this test.
Ultrasound can be used to assess the position andappearance of kidneys and bladder without exposure toradiation. This technique can detect stones in the urinary
tract, bladder outflow obstruction (which prevents urine
drainage) and scar tissue on the kidney or renal tumors.
Stones or tumors can be found when the bladder is full.
In addition, sonography is a quick and easy way tomeasure the urine that remains after the bladder has been
emptied (residual urine). Special probes that are inserted
into the rectum can also be used if there are particular
problems and to determine the size and appearance of theprostate by ultrasound.

VIDEO URODYNAMIC TESTING(RADIOGRAPHIC OR CYSTOMANOMETRY)Video Urodynamic testing (measuring bladder pressure),
also called radiographic or cystomanometry, is used totest bladder function and at the same time to find out
whether urine is flowing back to the kidneys (reflux).
A pressure-measuring catheter is inserted via theurethra into the bladder and the bladder is slowly filledwith sterile contrast.
To prevent false pressure readings caused by pressure
variations in the abdomen, a soft catheter is usedsimultaneously to record the pressure in the colon.
Moreover, adhesive electrodes record muscle activity inthe sphincter muscle. Exposure to radiation is very low
with modern radiography equipment.

Ultrasound image of the bladder with residual urine

Images supplied by: SPC Nottwil

Ultrasound can assess the appearance but not the functionof the kidneys. This means that another way of measuring
kidney function besides ultrasound must be used.
CONTRAST RADIOGRAPHY OF THE URETHRA(URETHROGRAPHY)
By inserting contrast medium (a dye) into the maleurethra it is possible to see urethral narrowing,scars or injuries.
In women, this examination is necessary only in veryrare exceptional cases.

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Contrast radiography of the urethra

Continual measurement of pressure in the bladder during
filling and emptying, in combination with testing for reflux,
enables a precise classification of the bladder dysfunction
and a risk assessment of kidney function to be achieved ina single procedure.
Measurement of bladder pressure does not have to
be combined with radiography at every assessment.
An examination without radiography is known as
urodynamic testing or cystomanometry.
BLADDER EXAMINATION (CYSTOSCOPY)
Cystoscopy is used for direct inspection of the inside of
the urethra and urinary bladder. A thin optical device ispushed through the urethra into the bladder. This makes
the inner walls of the bladder and urethra visible. Scars,stones, tumors, foci of infection and other pathologicalchanges are identified directly. Changes that cannot be
identified by other imaging procedures can be diagnosed
early by means of this visual inspection.
Today’s technology offers flexible instruments, whichcause no further discomfort in bladder and urethra
than that caused by a thin catheter, even in patients
who retain sensation.

Analysis protocol for video urodynamic testing10

neurourological diagnosis

Care at home

KIDNEY FUNCTION TESTSLABORATORY TESTSAs the muscles are often affected to a very different degree
after paraplegia, the results are often inaccurate.

Bacteria are accurately classified in the laboratory
and the appropriate antibiotic is tested.

BLOOD TESTS
Blood tests to assess kidney function are very
unreliable in persons with paraplegia because kidney
function is calculated on the basis of the muscle massof a non-paralyzed person.
As the muscles are often affected to a very different
degree after paraplegia, the results are often inaccurate.
BLOOD TESTING COMBINED WITH URINALYSISThe accuracy of blood testing can be greatly improvedby combined testing of excretory products in bloodand urine. To perform this test, however, it isnecessary to collect all urine excreted over 12 hours,
which is often technically very difficult to carry out in
outpatient assessments.

RENAL SCINTIGRAPHY
This examination is the most accurate procedure used tomeasure kidney function. A radioactive agent is injected
into a vein and the distribution of the radioactivity in thekidneys is subsequently measured. The quantity ofradioactivity or radiation administered is extremely low.
Ideally blood tests, urinalysis and scintigraphy arecarried out in rotation so that an examination involving
radioactive substances is necessary every 2–5 years
at the most.

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URINALYSIS
Urinalysis can be performed using a test strip or underthe microscope. Test strips are more suited to preliminary
testing. A detailed examination requires white and red
blood cells to be counted under the microscope and a testof whether or not bacteria are present in the urine.
If bacteria are detected, a urine culture is set up.
Bacteria are accurately classified in the laboratory
and the appropriate antibiotic is tested.

Test strips for uRinalysis

12treatment of bladder dysfunction

Care at home

TREATment of BLADDER DYSFUNCTION

REDUCING BLADDER PRESSURE

Bladder dysfunctions are assessed through neurologicalexamination and divided into risk groups.

Drug treatment with drugs known as anticholinergics, also
called antimuscarinics, can suppress this bladder activity.

A complete neurological examination is essential inassessing bladder dysfunction. Dysfunctions canfundamentally be differentiated into “flaccid” and “spastic”
bladder. In the case of flaccid bladder, bladder muscle andsphincter have lost their function; in the spastic form bothmuscles are overactive and work against each other in an
uncontrolled manner.

DRUG TREATMENT
When the bladder musculature is overactive, even if bladdervolume is low, involuntary uncontrollable contractions
occur, also known as bladder spasticity or spasm.
Drug treatment with drugs known as anticholinergics, also
called antimuscarinics, can suppress this bladder activity
by blocking the nerve endings directly at the bladdermusculature. Various medications are currently available.

The kidneys are always at risk when high internalpressure is present in the bladder even when the bladderis filling. “Spastic” bladder therefore presents a higher
risk for kidney function than “flaccid” paralysis. Further
risk factors for kidney function are as follows: backward
flow of urine to the kidneys (reflux), obstruction of theflow of urine to the bladder (when pressure in the bladderis higher than in the kidneys the urine cannot flow out andaccumulates in the kidneys) and loss of bladder elasticity.
High blood pressure and the headaches this causes(“autonomic dysregulation”) can also be a warning signal
from the urinary tract. In addition, an overactive bladder
can also cause incontinence.

These medications work according to the same principle,
but are differently constructed in chemical terms. Because
these medicines block nerve endings not only in the
bladder but also in other organs, they can cause adverse
effects (e.g., dry mouth, constipation). As people react
differently to medications, it is important to carefully selectthe product that is the safest and most effective for every
person affected.

The ideal way to prevent the complications mentioned
would be complete restoration of nervous system controlof the bladder. Unfortunately, this has proved impossible
to date. Therefore, urological treatment is limited toprotecting the kidneys by sufficiently reducing pressurein the bladder.

BladderSphincter muscle

Spastic
Flaccid/areflexic(absence of reflexes)

BOTULINUM TOXIN A
If the medications are not sufficiently effective or are notwell tolerated, there is the option of injecting botulinum
toxin A (e.g., Botox ®) into the muscle of the bladder.
This medicine is injected directly into the bladdermusculature using cystoscopy and acts almost exclusively
in the bladder.
Side effects are very rare. The drug is renowned to be very
effective over and above other medications. The treatment
is only effective for a certain period and so needs to berepeated every 6–9 months. As treatment is given via
cystoscopy, local numbing or anesthesia may be necessary.
In January of 2013, the FDA expanded the use of Botox to13

Injection of botulinum toxin
Image supplied by: SPC Nottwil

treat adults with overactive bladder who did not respondwell to anticholinergics. It was previously approved to treat
urinary incontinence in people with neurologic conditions
such as SCI and MS who have overactive bladder.
SURGICAL THERAPY
If the bladder muscles are already severely scarred or havelost their elasticity, it is no longer possible to achieve a
reduction in bladder pressure by means of the measures
named above. In these cases, the bladder has to beenlarged using parts of the small intestine. In thisprocedure, part of the damaged bladder is removed via an
incision in the abdomen and a piece of small intestine is
attached to the remaining part of the bladder. The small
intestine is very elastic so the result is the enlargement
and also improved elasticity of the bladder.

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treatment of bladder dysfunction

Care at home

EMPTYING THE BLADDERThis kind of treatment is unnecessary in patients who
had flaccid paralysis of the bladder from the outset.
If one of the procedures for reducing bladder pressure
has been successful in suppressing bladder activity, i.e.,making a “spastic” bladder into a “flaccid” bladder, thekidneys are protected.
This kind of treatment is unnecessary in patients who had
flaccid paralysis of the bladder from the outset. However,a flaccid bladder cannot empty by itself. Externalintervention is therefore required to empty the bladder.
INDWELLING CATHETER
At first, draining the bladder using an indwelling catheter
via the urethra seems to be a very practical idea because
it does not require any further measures. The use of aurethral indwelling catheter over a longer period is thevery last resort. Independently of the amount of liquid a
person has drunk and of how well that person looks after
the catheter, indwelling catheters result in colonizationof the urine with bacteria within a few weeks. The risk ofinfection of the bladder, kidneys, prostate and testicles isgreatly increased. Small crystals develop because of
the chronic irritation, which block the catheter or cause
bladder stones. When the catheter is used for a long
period, contracted bladder or even malignant bladdertumors may develop. An indwelling urethral catheter isuseful in exceptional cases only for a short period suchas after urological surgery or during a flight.

INTERMITTENT CATHETERIZATION (IC)“Intermittent” means “occurring occasionally or at
regular intervals.” During intermittent catheterization(IC), the bladder is emptied at certain times using asingle-use catheter. The frequency of voiding is roughly
equivalent to the frequency with which a non-paraplegic
person would empty their bladder, 4–5 times a day
depending on the amount the person has drunk. Patients
who sense the desire to urinate are guided by thesensation of urgency. People who do not experience thedesire to urinate are guided by the time that has passed
since the last bladder emptying.
IC is performed by the person himself or herself(intermittent self-catheterization: ISC) or by anotherperson, e.g., a relative, caregiver (intermittent
catheterization by another). The bladder can be emptied
without pressure and without leaving residual urine using
this procedure. This protects kidney function while also
reducing the frequency of inflammation of the bladder.
Many patients become continent by using IC. A further
benefit is that the procedure is not associated withirreversible changes. If the situation alters, the procedurecan be stopped at any time without causing damage.

CONDITIONSThe IC technique is not equally well suited to everyone.
Certain conditions in relation to both bladder function andthe situation of the affected person as a whole must be met.
Understanding and motivation to want to perform thetechnique are essential requirements. The person
concerned should be capable of understanding thefundamentals of the technique and the consequencesof performing IC irregularly.
Hand function must be preserved to the extent that theperson is able to access the urethra independently. If thisis not possible in a sitting position, then it needs to beascertained that the person is perfectly able to reposition
independently, into a position that permits thecatheterization to take place. To reiterate, hand functionneeds to be effective enough for ISC to be carried out
independently (with or without aids).

Indwelling catheter

Sufficient space must be available to lay out the materials
and to perform IC. Anatomical changes or injuries to theurethra can make IC impossible.
Bladder spasticity must be sufficiently well suppressed.
Bladder capacity should be 400 – 500 mL.

Suprapubic fistula catheter

SUPRAPUBIC FISTULA CATHETER (SC)This is an indwelling catheter that is inserted between the
pubic bone and the navel by means of a puncture throughthe abdominal wall. Compared to an indwelling catheter
inserted into the urethra, the SC, also known assuprapubic catheter, is less likely to cause complications.
Inflammation of the bladder, bladder stones and blockingof the catheter can also occur, however, with the SC.
If long-term use of an indwelling catheter cannot be
avoided the SC is the better option.

Intermittent catheterization
Image Labeling Text

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treatment of bladder dysfunction

Different types of catheter tips:

Care at home

17

Nelaton Tip

Tiemann Tip

CATHETER MATERIAL
Today, a variety of different catheter materials areavailable. The basic difference is between coated,lubricated (hydrophilic) catheters and catheters thatare inserted using a sterile lubrication gel. Today, almost
all manufacturers offer hydrophilic catheters because they
have better lubrication properties and thus appear to be
associated with less trauma to the urethra. In addition,
they are more convenient as no additional lubricating gel
is required. However, there are certain situations in which
the use of lubricating gel can have advantages.

Magnified catheter eye.
The example shown here isof an eye that is rounded off
internally and externally.

COMPLICATIONS
Potential complications include injuries to the urethra andurinary tract infections caused by introducing bacteria
during catheterization. However, these may be reduced byusing appropriate techniques.
It is extremely important to strictly follow certain basic
guidelines during catheterization:
 The hands and urethral opening are cleaned (washed)

and disinfected with a disinfection agent.
 A sterile catheter should be used for every

catheterization. When the catheter is introduced, thepart of the catheter that is inserted into the urethra andbladder should never be handled or come into contact
with the environment (the non-touch technique). Thiscan also be achieved by utilizing the catheter packaging
sleeve (with certain catheters). The catheter is left in thesleeve and held firmly while it is advanced. If in doubt,
it is better to discard a catheter and to repeat theprocess with a new catheter!

 I f possible, ISC should always be the preferredtechnique, as fewer injuries to the urethra and fewer
urinary tract infections occur with self-catheterization
than via alternative means of catheterization (e.g.,long-term indwelling catheter also called a Foley
catheter). In addition, indwelling catheter changes
invariably depend on other people to make the changes
and this often leads to further inconvenience.
 Normal bladder capacity (400 – 500 mL) should not be

exceeded. If catheterization is not frequent enough or the
bladder is overstretched the rate of infection increases.
 T he diameter of the catheter chosen should not be too

big, so as to avoid injury to the urethra. In addition, if
the catheter shaft diameter is too small, it will take toolong for the urine to flow out of the bladder. The
diameter of catheters is measured by French size (Fr.)
otherwise known as Charrière in Europe after theinventor. In adults, catheters of size 12 – 14 Fr.
(3 Fr. = 1 mm) have proved the best.

LEARNING THE TECHNIQUE
Clinical studies show that patients who have been trained
effectively are far less likely to cause any trauma to theurethra and have fewer infections than patients who are
not familiar with the technique. Careful training istherefore decisive for a low complication rate andlong-term satisfaction with the procedure.
Specialist health care professionals are qualified to teachthe ISC technique. Various aids are available, e.g., a leg
position holder in severe spasticity of the thigh,cystoscopy systems, aids to remove and put on trousers,
catheterization aids if hand function is restricted, etc.,
which can be introduced during detailed training. In somecases, they can make catheterization substantially easier.
During training, it is important to go into the individual
needs of those concerned. Besides conveying thetechnique, this also involves banishing fears anduncertainties. Some people only discover during practical
exercises that pain-free catheterization, even whenresidual sensitivity is maintained, is generally possible.
Specially packaged catheters can be carried discreetly,
even several at a time, in a handbag, trouser or jacket
pocket. Catheters with integrated collection bags areavailable to facilitate catheterization in the workplace
or on holiday, for example. The important thing is toremember to take enough catheters with you.

A further fundamental difference is catheter length. Shortcatheters are available for women and longer catheters formen. Various “ultrashort” catheters have been developed
recently for women that can be carried very discreetly
because of their short length. However, these products are
not suitable for all women. If movement of the legs is
restricted, this kind of catheter may be too short to empty
the bladder completely. If there is too much residual urine
left, it is simply not a suitable catheter.
Because of their substantially longer urethra, men need alonger catheter. There are straight catheter tips and bent
tips known as Tiemann or Coudé tips. The latter are moresuitable for men with prostate enlargement to overcome
the curvatures of the male urethra.
IC technique is used by those affected several times daily
for a long indefinite period. Because of this, the cathetersmust fulfill certain quality requirements to guarantee
safety even during long-term use.
Packaging should be ready to use and easy to open even incases where hand function is limited. The openings in thecatheter through which the urine drains, known ascatheter eyes, should be rounded off and smooth so as not
to cause injuries. The coating should not lose its
lubrication during use – it should be possible to remove
the catheter, even if voiding takes somewhat longer, as
easily as it was to insert it.
There is a huge variety of catheter types in the market place
today. This is very positive as such a situation offers choice.
One catheter is perfect for one but may be not so perfect foranother person. Every person should have the opportunity totest different types. This is the only way to determine
absolute suitability of the product for any given individual.
The main considerations are ease of access via packaging,long-term comfort, duration to drain and the coating.

18 urinary tract infections

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URINARY TRACT INFECTIONSWhen bacteria multiply in the urinary tract (bladder, urethra,kidney and prostate), this is described as colonization of germs.
When bacteria (or other microorganisms) multiply in theurinary tract (bladder, urethra, kidney and prostate), this is
described as colonization of germs. As these microorganisms
attack the mucosa they induce a defensive reaction by the
body. On account of this, white and possibly red blood cells
penetrate the urine. As soon as colonization by germs
causes clinical symptoms it is described as inflammationof the urinary tract. Inflammation of the renal pelvis isparticularly dangerous as inflammation of the kidneys
generates serious symptoms with chills and fever and canalso leave scarring on the kidney tissue.
Urinary tract infections are more likely to occur in people
with paraplegia. Residual urine, inadequately treatedspastic bladder and catheterization represent risk factors for
infections. The risk of infection with indwelling catheters ismuch higher than with IC.

CLINICAL SIGNS
Not every germ colonization of the bladder has to betreated. It is not necessary to test the urine regularly e.g.,with test strips if you do not have any symptoms.
Clinical signs of urinary tract infection can be fever without
other source, recently occurring involuntary loss of urine,
sudden reduction in bladder capacity, pain in the abdomen
and the urethra, increased spasticity, generally feelingunwell or loss of capacity. Fever indicates severe
inflammation, which can progress in extreme cases to blood
poisoning or kidney damage, and rapid advanced diagnosis
is a matter of urgency.
A change in the odor of the urine or cloudy urine can beinitial signs of urinary tract infection, but does not require
treatment when it is the only symptom as long as there isno particularly negative impact on the person concerned.

DIAGNOSTICS
If urinary tract infection is suspected, the urine should betested using test strips or better still by examination underthe microscope (urinary sediment). If bacteria and whiteblood cells (the body’s defense cells) are present a urine
culture is set up to determine the type of bacteria and theantibiotics to which these pathogens are sensitive.
Increased white blood cells in the urine show that the
body is fighting the bacteria. If there is evidence ofbacteria without white blood cells, “peaceful coexistence”
can be assumed.
ADVANCED DIAGNOSTICS
In the case of severe, febrile urinary tract infections or
repeatedly occurring (recurrent) infections a physicalexamination and ultrasound scan of the kidneys, bladderand the prostate in men if necessary should be carriedout to exclude organ involvement.
TREATMENT
Treatment of acute urinary tract infection depends on
how severe it is. Infections without fever and with only
a few symptoms can be treated by drinking more water(> 1.5 liters/day approximately 6 eight ounce glasses).
Cranberry juice or tablets are a therapy option.
Homeopathic medicines are also an alternative. In this case,
it is important to seek the advice of a highly trained
homeopath rather than to use self-medication.
The standard treatment is therapy with antibiotics. An
antibiotic is a medication that destroys the bacteria in the
body or so strongly inhibits their growth and multiplicationthat they can no longer spread. Not all bacteria are sensitive
to all antibiotics. Therefore, germ testing should be
performed before every treatment to find out which antibiotic
should be administered.

Treatment should be given for 5–7 days for non-febrileinfections and for 10-14 days for febrile infections. (Inurgent cases, treatment can be initiated before the resultsof antibiotic sensitivity testing have arrived. If it becomes
evident from the results that the bacteria are not destroyedby the antibiotic, the drug should be changed if necessary).
Antibiotics are not able to differentiate between pathogens
that have penetrated from outside and the body’s own
bacteria. This means that antibiotics can cause side effects
such as diarrhea (because the protective intestinal bacteria
die away) or fungal infestation of the vagina, penis, oralcavity or bowel (also because of the destruction of the local
flora). Bacteria can learn to protect themselves against
certain antibiotics. Moreover, it is possible to develop
allergies to antibiotics. As allergies can be threatening in
the worst case, if you have known allergies, it is advisable
to obtain an allergy alert card to show to the doctor
treating you.
There can be no doubt that antibiotics are extremely
important medications that enable human beings to survive
infectious diseases. Without them, many diseases would not
be treatable.
Overuse of these medications is dangerous, however.
Antibiotics administered unnecessarily provoke thedevelopment of non-sensitive (resistant) pathogens, which
are not only more difficult to treat but can also have side
effects. Antibiotics should therefore be used specificallyand sparingly.

REPEATEDLY OCCURRING/RECURRENTURINARY TRACT INFECTIONS
If you have four urinary tract infections or more per year,
this is called recurrent infection. As these infections areburdensome and distressing subjectively, prevention(prophylaxis) should be discussed when the infection rate
becomes this high.
PROPHYLAXISBefore prophylaxis is initiated, all sources that promotefrequent urinary tract infections should first be clarified:poorly controlled spastic bladder, stones or foreign bodies
in the urinary tract, chronic inflammation of the prostateand imperfect catheter technique. In patients who do notuse catheterization to empty the bladder, residual urine isa source of infection.
If these factors are excluded, the following meansof prophylaxis are available.
HERBAL MEDICINES
Cranberry products may reduce the frequency of urinary
tract infections, but they appear to act on certain species ofbacteria only (e.g., E. coli). The same applies to a sugar(D-mannose) that binds bacteria in the urine and inactivatesthem. The effects of certain teas known as “bladder andkidney teas” are not proven.

cautionConsult your doctor or health care professional
before you start, stop, or change any prescribedpart of your health care plan or treatment and to
determine what course of therapy is right for you.

20 urinary tract infections | alternatives to intermittent catheterization

Care at home

21

ALTERNATIVES TO INTERMITTENTCATHETERIZATIONThe effect of this acidification is restricted as many bacteria
are capable of life independently of the degree of acidityof the urine.
ACIDIFYING URINE
The acidity of the urine can be reduced by L-methionine.
The effect of this acidification is restricted as many
bacteria are capable of life independently of the degreeof acidity of the urine. A non-medicinal alternative toacidification is cider vinegar.
BLADDER RINSING
Regular rinsing of the bladder with disinfectant solutions
or water is not suitable for preventing infection if you
use IC to empty your bladder. In people with indwelling
catheters, rinsing can flush out deposits and small stones
and thus the frequency of symptomatic infections
can be limited.
VACCINATION
There exists an oral vaccination against E. coli bacteria,very common causative pathogens of urinary tract
infections, which can reduce the number of infections.

HOMEOPATHIC AGENTS
Self-medication (from a ”homeopathic medicine chest”)
is not advisable as prophylaxis of urinary tract infections.
In general, it is true that homeopathic medicines belong
in the hands of well-trained experts (homeopaths or
doctors who are trained in homeopathy) if they areintended to be used against a chronic disease (such as
preventing urinary tract infections). No one should simply
order an antibiotic from the internet without specialist
knowledge and the same applies to homeopathic medicines.
ANTIBIOTICS
After acute treatment, continuing to give a low dosage ofantibiotics (to treat the current bacterium) as a single dosein the evening, over 6 weeks to 3 months, is effective, butalso has side effects. One alternative is a type of switch
therapy in which two antibiotics are selected andadministered alternately once a week (e.g., medicine A
every Wednesday in week 1, 3 and 5 etc., medicine B every
Wednesday in week 2, 4 and 6).
Resistance may be effectively avoided with this treatment
and the burden caused by the medicines is lower thanwhen they are taken daily.

It is often necessary to reduce sphincter spasticity by making
small incisions in the internal sphincter (sphincterotomy) toensure pressure-free outflow of urine.
EMPTYING THE BLADDER THROUGH
REFLEX EMPTYING
Men tetraplegics, who cannot perform ISC because theirhands do not function, often develop a spastic bladder. If it
is possible to immobilize the sphincter to such a degree
that it can no longer close the bladder, then a small degreeof bladder activity is enough to evacuate the urine. One
advantage of this procedure is that even tetraplegics canempty the bladder independently. In this case, thepressure that is required to empty the bladder should be
so low that no kidney damage occurs even in the longterm. Evacuation of the bladder is caused by stimulating
the reflex zones, generally by percussion (“triggering”) of
the lower abdomen.
It is often necessary to reduce sphincter spasticity
by making small incisions in the internal sphincter(sphincterotomy) to ensure pressure-free outflow of urine.
During cystoscopy, an incision is made in the ring-shaped
sphincter muscle. As a result the muscle can no longer
contract effectively so that the urine can flow out withoutpressure. Most patients who use this method of emptying
the bladder need a urinary condom because the outflow ofurine cannot be controlled. For this reason, the procedure
is performed exclusively in men.

MANUAL BLADDER MANIPULATION
In cases of flaccid paralysis of bladder and sphincter,many people succeed by using their hands to manually
manipulate the bladder (Credé maneuver). This method
may damage the bladder because unnaturally highpressure is exerted on the bladder and sphincter,damaging the organs. In addition, urine may be squeezed
back into the kidneys. Consult your health care provider
before attempting this maneuver.
SURGICAL PROCEDURES ON THE SYSTEMREGULATING THE LOWER URINARY TRACT
All treatments touched upon so far are performed on the
bladder. As the source of the actual disorder is not the
bladder but the nerves, it is logical to turn to treatment of
the regulatory system. Devices known as “bladderpacemakers” have been developed for this.
This term is often used to describe two completely
different surgical procedures that are very different
from each other: sacral neuromodulation and sacral
deafferentation with implantation of an anteriorroot stimulator.
SACRAL NEUROMODULATION“Neuromodulation” is used to describe an effect on
intact nerves that do not function normally. A condition
for successful neuromodulation is the retention of
nerve function between bladder and brain. Therefore,
the technique cannot be used in people withcomplete paraplegia.

22alternatives to intermittent catheterization

Care at home

23

The goal of sacral neuromodulation is to influence theconnection between brain and bladder by exerting specificpermanent impulses on the nerve pathways.

Sacral neuromodulation functions similarly to a heart
pacemaker which regulates the heart rate. In spastic
bladder, the impulses that stimulate the bladder are
suppressed and the over-activity is reduced.
In flaccid bladder, the sphincter muscle is relaxed and the
bladder activated to make evacuation via the urethra
possible. In this minimally invasive procedure, electrodes
are applied at the sacral bone to the sacral nerves leading
to the bladder. These nerves are regulated by an emitterwith an integrated battery. Because this device works bypermanent stimulation, the battery has to be changed
after about 5 years on average. It can be changed easily
in a minor procedure.
DEAFFERENTATION AND ANTERIOR ROOTSTIMULATION (“BRINDLEY PACEMAKER,” SDAF/SARS)
After complete paraplegia in the chest or neck region,
reflex activity (spasticity) of the bladder develops whichcauses uncontrolled evacuations. In the operation, thesacral sensory nerves (which conduct sensations) and thereflex arc, which is responsible for the uncontrolled
bladder activity, are severed. This means that the bladdercenter in the spinal cord no longer retains any activating
impulses. As a result, bladder contractions no longer occur.
At the same time, the autonomic reflexes, such as
sweating, goose bumps, an increase in blood pressure andheadaches, are suppressed when the bladder is full.
Severance of the nerve fibers that cause spastic bladderis the most important step in this operation because thisis what calms the bladder down.
The sacral motor nerves (which cause activity) remain
intact and can be stimulated by electrodes. These areconnected with a small receiver that is implanted in the
subcutaneous tissue in the abdominal region. The bladdercan be activated and emptied by means of a transmitting
antenna that is attached above the receiver. Thus the‘calmed’ bladder can be emptied in a controlled fashion“at the touch of a button.” Therefore, the bladder retains

its original tone and can be emptied voluntarily again bystimulation when a suitable time and place are found.
To be able to separate the motor and sensory nerves safely
it is necessary to sever them within the spinal cord. This
procedure is performed exclusively in cases of complete
paraplegia. The procedure is unsuitable for cases ofincomplete and congenital paraplegia.
In contrast to neuromodulation, in which permanent
output of electricity has long-term effects on nerve
function, this procedure results in the nerves being
activated to voiding only by short-term electrical output.
The energy for this stimulation comes from the patient’s
controller; an implanted battery is not required for thisprocedure. The operation was developed in Great Britain
by Professor Giles Brindley.
The success rate with regard to bladder function isapproximately 90%. The technical life expectancy of theimplant is at least 25 years. If the implant fails, it can bechanged. By an appropriate change in stimulation of thevarious nerves, the rectum can generally be evacuated aswell. By implantation of an anterior root stimulator,
voluntary evacuation of bladder and bowel can beachieved and continence attained at the same time.
Moreover, the risk of kidney damage is substantiallydecreased and the frequency of urinary tract infections
markedly reduced, which prolongs the life expectancy
of people with paraplegia. For those with a high degreeof paralysis, implantation of the anterior root stimulatormeans independence from helpers and significant
improvement of quality of life.
As nerves are severed and thus permanently destroyed
during the operation, the procedure is irreversible.
If possible, the operation should be performed only if
non-surgical treatment options have been exhausted

Urinary sheath and urine collection bag

without success. The earliest time for surgery is one
year after the injury.
Male External Catheter
In some people affected, the sphincter muscle is weakafter paraplegia, which means that even in cases of mild
physical stress, e.g., coughing, changing position or restingin a wheelchair, urine flows out of the urethra. This can bea desired effect, e.g., after sphincterotomy, or may occur
as a result of paralysis of the sphincter muscle. In men,treatment with a device known as a Male External
Catheter (MEC) or Condom Catheter is possible in thiscase. After sphincterotomy, treatment with a urinary
sheath means that the bladder can be emptied by"triggers" without permanent pads or incontinencepads being necessary.

long-term use. When selecting a suitable MEC thefollowing points must be taken into account:

An MEC looks like a normal condom but has a hole andan attachment for a urine collection bag at the end.
The MEC is pulled on over the penis and attached. Bothself-adhesive models and MECs which are attached withadhesive or an adhesive strip can be used.

Problems with MECs can arise when there is no reflex
erection (problems with attaching the MEC), chronic skindamage, reflex pulling back of the penis (MEC is pulled off)or by a reduction in the adhesive area (“contracted penis“).

An MEC is generally a long-term treatment. It is extremely
important that it causes no skin damage even during T he MEC should not cause skin allergies(e.g., no latex-containing products).
 It should be attached easily, safely and in a skin-friendly

manner. It does not matter whether self-adhesive MEC
or with additional adhesive are used. It is important totest as many different variants as possible.
 MEC size should be carefully measured and adjusted.

One that is too large does not adhere well and one too
small may cause skin damage and circulatory disorders
and result in serious damage to the penis.

This procedure cannot be used for women for anatomicalreasons. To date, there are no alternatives for women thatmake a similarly safe form of incontinence treatment possible.

24 incontinence | new trends in the treatment of bladder dysfunction

Care at home

Urinary incontinence, an involuntary anduncontrollable loss of urine, is both a medical
and a social problem.
Urinary incontinence, an involuntary and uncontrollable
loss of urine, is both a medical and a social problem.
Incontinence can lead to skin changes (fungal infestation,
inflammation) and cause pressure sores. In addition, theodor nuisance, the need to use incontinence aids and theresulting lack of confidence have an extremely negative
effect on quality of life. Many of those affected withdraw
from social life because of urinary incontinence.
Incontinence may occur as the result of an overactive
bladder that squeezes the urine through an intact
sphincter. This type of incontinence is called urge
incontinence or reflex incontinence in people withparaplegia. It can be treated by calming the spastic
bladder.
Stress incontinence is another type. This is caused by
too weak a sphincter. Even when the bladder is completely
at rest, loss of urine may occur when coughing, sneezing,
moving or playing sports, because the flaccid sphincter
cannot control the additional strain. Stress incontinence
can often only be treated surgically, e.g., by inserting an
artificial sphincter or through inserting a tension-freetape under the urethra.
If an artificial sphincter is used, a plastic cuff is placedaround the exit to the bladder, which is connected to aballoon and a pump. All parts are inserted into the body.

NEW TRENDS IN THE TREATMENTOF BLADDER DYSFUNCTION
Research has focused on restoring bladder function.

The pump is placed in the scrotum or in the labia majora
so that they can be operated from outside. The cuff,
which is filled with liquid, ensures that no urine loss
occurs. When the bladder is voided the cuff is emptied
using the pump. After a few minutes, the cuff automaticallyrefills with liquid and the bladder is “tight” again.

In recent years, there have been many attempts toovercome paraplegia. Despite all efforts, neither stem
cell therapy nor nerve transplantation (e.g., from the nasal
mucosa) nor drug therapies (e.g., anti-NOGO A) have
proved so successful that they present an effective
clinical treatment.

The risks associated with the operation are the typicalcomplications connected with every procedure in which
foreign bodies are inserted: a material defect and/or
infection of the device implanted. Approximately 30%
of patients need to be operated on for a second timewithin 5 years.

Research has therefore focused on restoring bladderfunction. For a time, one procedure caused a sensation.
It involved suturing nerves from the chest onto the bladdernerves to “bypass” the damaged nerves. The very goodresults obtained by the person who invented thistechnique did not stand up to critical testing, which meantthat the technique was not translated into practice.

The tension-free tapes are inserted through a small skinincision around the lower part of the urethra and support
the function of the sphincter. The operation is much lessserious but the procedure is less likely to be successful
than the artificial sphincter. In addition, the procedure
has been in existence for only a short time. Very little
experience is available in paraplegics.

Reservoir

BladderSphincter cuff

Balloon pump

The Scott artificial urinary sphincter

Early electric stimulation by the implantation of electrodesin the sacral region as used in sacral neuromodulation
was able to prevent spastic bladder from occurring in avery small group of affected persons. To date, however,these results have not been confirmed by any otherresearch group.

Image supplied by: SPC Nottwil

INCONTINENce

As both types of incontinence may also occur together, anessential prerequisite of successful treatment is initial
testing to ascertain which type of incontinence is present.
The wrong therapy is not just frustrating; it also involves
medical risks that may include damage to kidney function.

Radiograph of an artificial sphincter25

26 sexuality and paraplegia

Care at home

27

SEXUALITY AND PARAPLEGIA
Sexual dysfunction includes sensory dysfunction,orgasmic incapacity and infertility.
The nerve supply to the genitals uses the same nerves as
the supply to the bladder. If paralysis of the bladder ispresent, sexual dysfunction will also have to be confronted.
Sexual dysfunction includes sensory dysfunction,orgasmic incapacity and infertility. In women, vaginal
moistening and in men erection and ejaculation may not
function normally.
ORGASMIC CAPACITY
In cases of incomplete paralysis in sensory terms, thesensation of orgasm may be equivalent to the earlier
sensation. People with paraplegia feel the physicalsensation in the genital and pelvic region but not as
intensely as they did before the paralysis occurred.
Orgasm is either experienced in a different way, througha feeling of well-being or warmth in the pelvis, notexperienced at all or experienced as unpleasant, forexample as spasticity in the legs or abdomen or as
autonomic dysreflexia (the abrupt onset of excessively
high blood pressure also referred to as hyperreflexia).
The rhythmic, involuntary muscle contractions that occur
during orgasm may last longer and be experienced as
unpleasant by the person concerned after the onset ofparaplegia. In the case of paraplegia above Th12, orgasm
is often preceded by spastic reactions in the legs. Moreover,it takes longer to reach orgasm than before paralysis.
Women talk in terms of an orgasm that they describe as”para-orgasm.” This means that the orgasm theyexperience differs from genital orgasm and has acompletely different quality. It can consist of a combinationof physical sensation, emotional reaction, memories,
fantasies and visual and/or auditive stimulation and thus
more closely resemble a holistic physical experience.
SENSATION
To date, no established procedure exists for restoring
the sensation of touch in the paralyzed region. Many of
those affected report that they have discovered, over time
and through mutual experimentation, areas in the
non-paralyzed part of their body that are experienced aserogenous zones. Courage and the willingness toexperiment are vital here.

MOISTENING OF THE VAGINA
In women with complete high paraplegia, the vagina canbe moistened by direct stimulation. This procedure is
known as reflex lubrication. Women with complete low
paraplegia have no reflex lubrication but can moisten
their vagina psychogenically to some extent.
If the vagina cannot be moistened, lubricants (oil orwater-based lubricants) can be used.
ERECTION
In principle, psychogenic erection can occur in men withparaplegia when the paraplegia is below T11 to L2, even
if the sacral roots or sacral spine is destroyed. How strong
the psychogenic components are and how strong a direct
stimulation is required differs from one individual toanother and depends on age. Reflex erection can occur
when the sacral roots and sacral spine are intact. In reflex
erection, stimulation of the sacral spine is produced bydirect genital stimulation. Reflex erection is possible only
in cases of paraplegia above T11. Because the signal fromthe brain is missing, stimulation must be constant tomaintain the erection. It is often inadequate in men anddoes not last long enough for sexual intercourse.
When erection is inadequate, most men choose drug
therapy as the preferred treatment because it is easier
to deal with.
Phosphodiesterase-5 inhibitors (PDE5 inhibitors) are
medications that help erection. They work in about twothirds of men affected. Although the medications comefrom the same class of drug, their effect is similar but not
the same. These medications should be tested before
another type of therapy is chosen. It is important thatthese medications should not be taken together withcertain blood-pressure lowering medications (nitrocontaining drugs), because a life-threatening decrease inblood supply to the heart may occur. Further potential side
effects of all medications are headaches, nausea andtransient changes in color vision. If these medications are
not sufficiently effective or are contraindicated, othermedicines can be injected directly into the penis usinga syringe (self-injection into the erectile tissue) or by

application in tablet form into the urethra. The first
method is generally much more successful.
As these medications are very reliable, a prosthetic penis
is usually not necessary. In addition, such prostheses havebeen associated with a risk of perforation in patients withparaplegia because of reduced sensory function. It is
important that all methods named affect only erection,
not sensation or the desire for sexual intercourse.
EJACULATION
After paraplegia, premature ejaculation may occur,
fail to occur or the semen may go backwards into thebladder. In the case of premature ejaculation,
improvement can be achieved by applying a mild
anesthetic cream to the glans or by using medications.

In the case of ejaculation into the bladder, an attempt at
drug treatment is also possible. If this is unsuccessful,sperm can be collected from the urine, e.g., for
fertilization.
If no sperm are ejaculated, electrostimulation can beapplied to obtain sperm. This can be achieved by a kindof vibrostimulation. If this is unsuccessful, electric
stimulation can be attempted using a probe inserted
into the colon.
Both procedures can only be conducted independentlyof sexual intercourse and are used to obtain sperm for
fertilization only. The last-named procedure in particular
can be associated with substantial side effects(hypertensive crisis, massive spasticity, pain) and should
be done under medical supervision only.

28 sexuality and paraplegia

Care at home

FERTILITYFERTILITY IN WOMEN
After spinal injury, menstrual bleeding may initially
fail to occur for several months to return at a later timeof its own accord. Pregnancy is still possible, just as with
non-paralyzed women. Because of this, contraception
must be used if the woman does not wish to have children.
The pill or contraceptive coil (“IUD”) can be considered ascontraceptives. The diaphragm (a cap placed over thecervix) is less reliable. Some medications used to suppress
spastic bladder are not approved for use by pregnant
women. Every pregnant woman with bladder dysfunction
which requires drug treatment should contact a urologist
as soon as possible.
Towards the end of pregnancy, labor pains can gounnoticed because of reduced sensitivity. Caesarian
section is no more frequently required than in non-paralyzed
women. In cases of high paralysis, extremely high bloodpressure increases can occur during birth.

URINE MEASUREMENTFERTILITY IN MEN
In men with paraplegia, sperm quality is somewhat
inhibited for reasons that have yet to be determined.
However, sperm quality seems to remain consistent for
many years, which means that there is no point infreezing sperm directly after paralysis.

NAME:

Time

DATE:

Amount drunk

Because no spontaneous ejaculation occurs in most men,
sperm are obtained by stimulation, or in extremely rarecases, taken directly from the testicles in a surgicalprocedure, it is not unusual for methods of assisted
fertilization to be used. Inserting the sperm obtained into
the uterus using a syringe, for example, is not usually
successful. In most cases, therefore, the techniques of
in-vitro fertilization (specific insertion of the sperm into
the egg cell in the laboratory) are used. The success rates
are approximately 25%.

TOTAL
Duplicate master copy as needed.

Amount of urine

Wet padDry padRemarks29

30 homecare urology products

Care at home

31

HOMECARE UROLOGY PRODUCTSYour Life, Your Health, Your Choiceflocath quick™
Hydrophilic Intermittent Catheter
The Rüsch FloCath Quick Hydrophilic Intermittent
Catheter is an “All-In-One” intermittent catheter providing
the ultimate convenience.

Rüsch® MMG H2O®
Hydrophilic Intermittent Catheter
Closed System
Balancing your personal and professional life can bechallenging. It’s time for a product that fits into your life,
without compromise. It’s time for the Rüsch MMG H 2O
Intermittent Catheter Closed System.
The Rüsch MMG H 2O Hydrophilic Intermittent Catheter
Closed System maximizes patient comfort and helps
reduce the risk of urethral trauma. The uniquehydrophilic coating, activated by the integrated sterile
0.9% saline pouch, allows the MMG H 2O Catheter to glide
easily through the urethra. The soft silicone introducer
protects the catheter from bacteria residing in the first few
centimeters of the urethra, helping to reduce the risk ofurinary tract infection.

Rüsch® MMG™
Intermittent Catheter Closed System
The Rüsch MMG Intermittent Catheter Closed Systemis the only clinically-proven closed system catheter toreduce the risk of urinary tract infections.1 For more than
two decades, this product has protected individuals fromrecurrent UTIs. Simply remove the protective cap, load
the pre-lubricated catheter into the Guardian Tip™
Introducer, insert introducer into the urethra and passcatheter into the bladder.

1. Bennett J, Carol, Young N, Mary, Razi S, Salman, Adkins, Rodney, Diaz, Frances and McCrary, Annie. The Effect Of Urethral Introducer Tip Catheters
On The Incidence Of Urinary Tract Infection Outcomes In Spinal Cord Injured Patients. Journal Of Urology. Vol. 158, No. 2, August 1997.

The integrated package contains a FloCath Hydrophilic
Catheter with our patented handling sheath and a packet ofsterile 0.9% saline. Before opening, break the sterile saline
pouch to hydrate the catheter. Sterile saline is much closer
to the body’s natural fluids than sterile water, giving thecatheter an extremely lubricious coating for a much more
comfortable insertion. The handling sheath provides aneasy grip, allowing for touchless insertion.

easycath™
Intermittent Catheter
The EasyCath Intermittent Catheter is uncoated andfeatures smooth, polished Soft-Eye Technology anda gently tapered tip for a more comfortable, safer
insertion. The EasyCath Catheter is not made withnatural rubber latex. A full line of Straight Tip, CoudéTip, and Female lengths are available. Also available inkits with insertion supplies.

Rüsch® belly bag ®
Collection Device
The Belly Bag Collection Device is a urine bag designed
to be worn at the waist. It is designed for either males or
females who have an indwelling catheter/Foley and not to
be used for Suprapubic drainage or with a male external
catheter. The bag fastens around the waist with a woven
belt and a quick release buckle. It has a 1,000 mL capacity
and is not manufactured from materials containing natural
rubber latex.

Botox is a registered trademark of Allergan, Inc.
Teleflex, Belly Bag, EasyCath, FloCath Quick, Guardian Tip, MMG, MMG H²O and Rusch are trademarks or registered trademarksof Teleflex Incorporated or its affiliates.

Teleflex is a global provider of medical products designed to enable healthcare providers to protect against infections
and improve patient and provider safety. The company specializes in products and services for vascular access,respiratory, general and regional anesthesia, cardiac care, urology and surgery. Teleflex also provides specialty
products for device manufacturers.
© 2014 Teleflex Incorporated. All rights reserved. 2013-1700

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Toll Free: 866.246.6990 Phone: +1.919.544.8000
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