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Suggest Treatment For Urinary Incontinence Due To UTI

Posted on Sat, 22 Feb 2014

Question: My spouse had spinal cord injury around 5 years back and developed bladder control issues. She was on foley's catheter since then but now switched to CIC (intermittent Cather) since last 1 month (due to UTI). She is on Tolterodine now (based on the recommendation of an urologist) however there is continuous leakage forcing her to be on diapers 24 hours. The CIC is barely used once/twice in 24 hours ,due to continuous leakage. She consumes 250 ml of water every hour during the day with a total of 1.8 to 2 lt per day. All fluid consumption is stopped after dinner 8-9 PM. This schedule helped a little with the leakage but not much. Please suggest available treatment options. Also, would urodynamics study help ? I'm attaching the reports for your reference. Alternative download link for reports: WWW.WWWW.WW

Answered by Dr. V. Sasanka (1 hour later)

Brief Answer: Urodynamics almost certainly will be useful Detailed Answer: Hi, It looks like she has a significant urinary tract infection. I hope she has been started on antibiotics like Amoxycillin-Clavulanic Acid which appears to be useful, and once the course is completed, she can be switched over to a drug like Nitrofurantoin for prolonged control. In the meanwhile, better drugs than Tolterodine have come in like Trospium or Darifenacin or Solifenacin for once daily use without the annoying side-effects like dry mouth. Do not anticipate miracles straightaway, but we should observe some improvement with antibiotics and change of anti-cholinergics like Tolterodine. I would also prefer that she has an ultrasound scan of her kidneys and bladder region to ensure both kidneys are normal without any swelling, and also her Serum Creatinine should be normal. If she has been on CISC, she should have it at least 5-6 times a day. Diapers are useful initially but eventually patients find they can stay dry between intermittent self-catheterizations. I hope she is taking measures to counter constipation which can be a trigger for future urinary infections. Lactulose syrup at bedtime with oral Isapgol powder diluted with water and taken at bedtime could be quite useful. If you have not had a urodynamics done so far, I sincerely suggest you get this done as this will inform you of risk of damage to kidneys and the functional bladder capacity which will guide us in keeping her dru through the day. Restricting water intake is useful, and I suggest you continue it till we get some more information. Hope I have been of help. Regards. Please let me know if there is any further query

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. V. Sasanka (24 hours later)

Thanks. The doctor I consulted with only recommend 100 mg Nitrofurantoin. Although, at that time (1 month back) my spouse had multi-drug resistant klebsiella pneumoniae which was sensitive to only Tigecycline & Colistin. The doctors decided not to treat it as it was asymptomatic. Could you please recommend the dosage and course for Amoxycillin-Clavulanic Acid (Augmentin or Augmentin XR ?). This is a bit urgent. She has little fever (100) and complaining muscle sprain and chills since this morning. For fever, I've given paracetamol (dolo). But apart from that there's no other symptoms i.e. vomiting etc. I'm not sure if the fever is due to infection, as it seems to be reducing. She had symptomatic infection (pseudomonas) in August and was treated with magnex forte inj after getting admitted. I'm also sharing previous treatment report for your reference. WWW.WWWW.WW ps - just in case I want to visit you, do you have a clinic ?

Answered by Dr. V. Sasanka (19 minutes later)

Brief Answer: Augmentin standard dose ishould be adequate Detailed Answer: Hi, I would suggest you consult a Urologist or Nephrologist before you start her on antibiotics yourself, but I guess Augmentin 625mg thrice daily is what I would probably advise, though you are unlikely to get this without prescription. I am available at Star Hospitals in Road No.10, Banjara hills, usually from 9am to 5pm.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. V. Sasanka (23 hours later)

Thanks. I had to take her to Apollo emergency ward yesterday night due to severity of the symptoms. They put her on Zofar & Paracetamol (IV) for few hours. Now she is feeling better and on Oflox 200mg (twice) and Nitrofurantoin 100 mg (twice) oral for 7 days. Just to know, Do you think is Oflox + Nitrofurantoin is better option to treat the infection ?

Answered by Dr. V. Sasanka (1 hour later)

Brief Answer: Unusual combination Detailed Answer: This is an unusual combination, but if your wife is comfortable with it, go ahead and complete the course, and we can see the position after 7 days. I guess the bladder capacity is quite low, and she almost certainly will need to be on some form of anti-cholinergics on CISC to prevent buildup of pressure in the bladder which can damage upper tracts,i.e kidneys. Therefore please continue Toletrodine also.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. V. Sasanka (57 minutes later)

Thanks, I just called the doctor and confirmed if he recommended combination and he said that we can start with Nitrofurantoin for 2 days and then add Oflox if there's fever. I'm very confused now as the doctor seems to be uninterested in the treatment. He even denied treating the patient currently. Looks like this combination is recommend by the temp. doctor in the Apollo emergency ward. However, the urologist confirmed that this is a safe combination. I'm not sure which medication to continue now. Currently the only symptom is weakness. No fever,chills, aches etc. for now. What's your suggestion ? I think I've to visit you tomorrow as I can't rely on the current doctor. How is Star Hospitals emergency ward ? Can I rely on getting my spouse admitted there under your supervision in case of emergency ? From my experience I can say that Apollo Hyderabad sucks big time. I would avoid going there again. Do you have any recommendation ?

Follow up: Dr. V. Sasanka (9 minutes later)

Hey, sorry to bother you again. The patient is complaining severe weakness and chills. Do you have a number I can reach you at to quickly discuss available options ? ps - I'll only call you if I need emergency help.

Answered by Dr. V. Sasanka (2 hours later)

Brief Answer: Welcome Detailed Answer: You are welcome to come to my place any time you please. Let the ER people know that you have been on medication and need to see me and take along all the reports. Once in a while the ER at Star Hospitals is very busy, but more often than not, some good physician will be able to attend to you immediately, and if required, they will call me from the Emergency room (ER) if they think you need to be admitted and be under supervision. As of now, I would probably be willing to look at better antibiotics than Nitrofurantoin considering that your wife has chills again. Weakness should go away after the infection comes under control and antibiotics dosage is reduced.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. V. Sasanka (37 minutes later)

So should I continue with oflox or augmentin tonight ? oflox was started in the morning. Do I need to combine it with Nitrofurantoin ? Regarding ER room physicians, I already had bad experience in Apollo. I do not a physician to write medication for my spouse. Do not get me wrong, but I can't take risk. She has already suffered a lot. I'm only preferring star hospitals for now as you are there and I'm expecting that you would treat the patient.

Answered by Dr. V. Sasanka (33 minutes later)

Brief Answer: Continue Oflox Detailed Answer: Hi again, Now that you have started Oflox, please continue it for the duration prescribed. The idea is, if the bacteria were sensitive to Oflox, if you start the treatment with Oflox and discontinue immediately, they develop resistance to Oflox and other drugs also, and you would need expensive IV antibiotics to manage what otherwise would have been a simple infection to treat. I do wish that two antibiotics were not prescribed together, but we cannot correct it now. I will be more than happy to examine and treat her as and when you bring her over.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. V. Sasanka (14 hours later)

Thanks a lot Dr.Sasanka . You've been a great help to me. Just to let you know an observation, the chills with weakness are there once she is on oflox. However, she has almost no complaints when on only Nitrofurantoin since last 15 hours.Hey I'm planning to visit you today. I called the hospital and they said you're in the OT and leave hospital by 4:30 PM. Can I meet you tomorrow ? If yes what time would be good.

Answered by Dr. V. Sasanka (48 hours later)

Brief Answer: Welcome before 4.30PM Detailed Answer: Hi, Hope your wife is better now. If she has no chills and fever on treatment with Nitrofurantoin, by all means, please continue the same, and Nitrofurantoin is also a good option for another reason - it can be used in smaller dose of 50 mg at bedtime for months together, and this has been found to be preventing recurrent urinary infections without adding to risk or cost to the patient. You are welcome any time. Let the hospital know you are coming, and if I am not in the operation theatre, I will be able to see you fairly soon. I usually am in the hospital from morning 9.30 am to 4.30 in afternoon.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. V. Sasanka (2 days later)

Thanks. Currently she has no complaints. However, she's back on foley's catheter because of the excessive leakage issue with CISC. We were advised earlier that during symptomatic infection we should avoid CISC. Tonight 5 days of Nitrofurantoin course would be over. I'll get the urine culture done tomorrow and get back to you with the results in 2-3 days. Based on the results you can advise further. Once the infection is cleared I'll get the other tests done i.e. urodynamics, ultrasound kidney etc. and get back to you for further treatment plan. Please let me know if we're on the right track or if you would like to recommend anything. Thanks for your time. You've been very helpful.

Answered by Dr. V. Sasanka (4 hours later)

Brief Answer: Catheter is right Detailed Answer: Hi, You have been advised correctly in that we prefer patients do not catheterize when there is active infection, and an indwelling catheter is preferable. However, it will be unlikely that there will ever be a time when there will be no infection. The question is how symptomatic is the infection, and if she does not have an actively symptomatic infection, there is no reason to not get the other tests done. I would advise you to hold urodynamics for the present till we have some basic knowledge, for example, at least a serum creatinine, an ultrasound of KUB with an estimate of post-void residue. Glad to know your wife is doing well now.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. V. Sasanka (5 hours later)

Sure, I'll get the serum creatinine and ultrasound of KUB done too. Will get back to you with the reports asap. Thanks again.

Answered by Dr. V. Sasanka (3 days later)

Brief Answer: I would be pleased to assist you in future. Detailed Answer: You are welcome. I look forward to assist you in future. Regards

Above answer was peer-reviewed by : Dr. Prasad

Follow up: Dr. V. Sasanka (29 hours later)

Thanks, Please find the reports in the link below (urine culture & serum creatinine ). WWW.WWWW.WW Looks like the multi-drug resistant Klebsiella Pneumoniae is back again. Same thing happened when she was back from hospital in October 2013. However, there are no symptoms. Last time doctor decided not to treat as it was asymptomatic. Should I continue Nitrofurantoin ? The culture guy said that culture should not be done while patient is on anti-biotics. Could you please confirm ? Should I repeat the culture ? Also, is it safe to get the other tests done (ultrasound of KUB with an estimate of post-void residue.) in the current condition? Please suggest the next plan of action.

Answered by Dr. V. Sasanka (6 hours later)

Brief Answer: You can get the ultrasound exam done Detailed Answer: Hi, You can get the ultrasound exam even when there is infection. This should be done with the catheter having been removed, and she should be voiding as normally as possible. The antibiotics is always going to be a problem. Almost certainly, the infection will be at least more virulent than usual in the case of your wife. I suggest you avoid higher and expensive antibiotics unless she is very symptomatic with chills and rigors.b Till that time, you can probably continue Nitrofurantoin, with the hope that while it may not eradicate the infection, it can prevent a bad infection coming up. There is a role for culture even in the situation of continuing antibiotic usage, if the patient has continued fever. If the patient has no fever, you can keep her off antibiotics for a few days and repeat complete urine examination, and a urine culture and sensitivity. All the best.

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Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar