Q. I’m a C5 complete quad and have been having recurring urinary tract infections. My doctor doesn’t want to treat them with antibiotics unless I have a fever of at least 101. By then I’m really sick. Is there a rule of thumb on when to treat a UTI with antibiotics?
— Jeff

A. Jeff, the answer to your question is one of the “Holy Grails” of the physical medicine and rehabilitation world. When and how often to treat a UTI with antibiotics in somebody with a neurogenic (affected by nerve damage) bladder is a balancing act. Treating every suspected UTI with antibiotics can cause antibiotic-resistant bacteria. But if a serious UTI isn’t treated soon enough, it can migrate up the urinary tract and cause permanent kidney damage.

Urine from a person with a “normal” bladder is sterile. However if you manage your bladder with a catheter, you will almost always have bacteria in your urine. According to the book, Spinal Cord Medicine: Principles and Practice (2002, Vernon W. Lin and Diana D. Cardenas) approximately 98 percent of people with indwelling catheters and 70 percent of people who use intermittent catheterization have chronic bacteria in their urine. For the most part this chronic bacteria doesn’t cause any symptoms. The book goes on to say that there is no universally accepted diagnosis of symptomatic UTI in people with spinal cord injuries.

Several PM&R physicians I spoke with said it is important to find a doctor that understands SCI and, even more importantly, listens to you and gets to know what your normal state of health is. They stressed that just seeing a urinalysis with a high white blood cell count (indicating an infection) or just looking for fever before treatment, isn’t enough. The key to when to treat UTIs with antibiotics in people with SCI is looking at the person’s whole “health picture” because everybody is different and will present different symptoms when a serious UTI is taking hold.

Some of the common symptoms of an oncoming UTI can be confused with other issues. Cloudy, smelly urine, for example, may signal a UTI, but it may also mean that you had asparagus for dinner, or that you are dehydrated. If this symptom does arise, the first thing you should do is drink plenty of water to make sure you are properly hydrated, which often helps clear things up. Plus, if bugs are trying to make a stronghold, extra hydration can help wash them out of your bladder. While staying hydrated is important, it is also very important to empty your bladder frequently enough. An adult bladder is full when it reaches 400cc-600cc — any more than that and you risk stretching and permanently damaging your bladder.

Other symptoms of an oncoming UTI may include an unexplained increase in spasticity, generalized joint and muscle aches — like an onset of the flu, a feeling of malaise, or unexplained fatigue. Like cloudy urine, these symptoms may signal an oncoming UTI or may have another cause — but combined with cloudy, or smelly urine, these symptoms help your doctor diagnose a UTI. If a person comes in with one or more of these symptoms, many physicians will combine this information with a urinalysis, and if there is a high white blood cell count they will start the patient on an antibiotic while waiting for the results of a culture (for the specific type of bug), before the patient presents a fever. One of the PM&R physicians reiterated the importance of knowing each patient’s baseline. For instance, if someone comes in twice a month with cloudy urine but no other symptoms, then they would wait until that person presents a fever before starting treatment with antibiotics.

Properly diagnosing a symptomatic UTI should be a team effort between you and your physician. A big part of the “when to treat” equation is knowing what “normal health” is to you. Another part of that equation is to make sure you communicate any and all symptoms to your physician

One of the PM&R physicians I spoke with offers a shortcut for his patients who are at higher risk of developing a UTI. He gives them several urine sample cups and a prescription to have a urine culture done. That way if they feel physical symptoms of a UTI coming on, they can drop off a urine sample at the lab and the doctor can assess the results to make an educated decision on whether to start his patient on antibiotics or not — without the wait for an office visit.

The other half of the equation is up to us — to do what we can to avoid getting UTIs in the first place. Much of this comes back to the basics that we learned in rehab and have covered in this column but are worth repeating. Staying hydrated enough to keep your urine in the clear to light-yellow range is very important for keeping the urinary system healthy and may help wash out unwanted bugs. Another area to remember is basic clean catheterization technique. Handi-wipes are a great way to clean hands when away from a bathroom.

It is also important to have a yearly check-up with a urologist. The check-up should include a renal/bladder ultrasound — a quick, painless and relatively inexpensive test that gives a good view of the kidneys and bladder and will point out kidney or bladder stones. Stones can form around bacteria. Since antibiotics can’t penetrate the stone, the bacteria in the stone can cause UTIs to pop up again and again until the stone is removed.

Another area you may want to look at if you have chronic UTIs is the type of catheter you are using. Many people find that closed system catheters — a sterile, pre-lubed catheter that comes in a clear collection bag, or sheath with an introducer tip on one end, help reduce their incidence of UTIs. In a closed system, the 5/8” introducer tip goes into the urethra. Then the catheter passes through the introducer tip to the main part of the urethra and into the bladder. Since most bacteria that cause UTIs are near the urethral entrance, the introducer tip prevents them from being carried to the bladder by the catheter. Closed systems are also touchless. If you use them used properly, your hands — and any bacteria on them — never come in contact with the catheter.

If you are using a Foley catheter, there are two types of Foleys on the market that make it harder for bacteria to make a stronghold. Bard Medical makes a Foley catheter called the Bardex I.C. with a silver alloy coating — and silver has natural antibacterial properties. For more on the Bard silver Foley see the August Bladder matters.

And Rochester Medical makes a nitrofurazone-impregnated Foley catheter called the StrataNF. The catheters are designed to elute a controlled release of nitrufurazone, an antibacterial agent, into the urethra and bladder. For more information see the December Bladder matters.

The easiest way to try out any of the catheters mentioned above is to contact the company that sends your monthly urological supplies. They should be more than happy to send you free samples. In addition, many manufacturers also provide free samples. Their web addresses are listed below.

Catheter Resources
• Bard, 800/526-4455; www.bardmedical.com
• Coloplast, 800/788-0293 ext. 7800; www.us.coloplast.com
• Rochester Medical, 800/243-3315; www.rocm.com 
• Rusch, 800/514-7234; www.rusch.com/urology.cfm