Bladder Irrigation

1 Along with bladder irrigation or forced polyuria intravesical or intravenous cidofovir has been used for the treatment of BK virus hemorrhagic cystitis.

From: Hematology (Seventh Edition) , 2018

Health Care–Associated Urinary Tract Infections

John E. Bennett MD , in Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases , 2020

Bladder Irrigation With Antimicrobial Therapy or Saline

Bladder irrigation with antimicrobial agents such as povidone-iodine, chlorhexidine, neomycin, or polymyxin B sulfate has shown little overall benefit in the era of closed urinary drainage. 14 , 20 In one demonstrative study, 187 adult patients who required short-term urinary catheterization were randomized to closed drainage with a triple-lumen, neomycin-polymyxin irrigated system, or with a double-lumen nonirrigated catheter system. 143 There was no significant difference in the rates of catheter-associated bacteriuria between the two groups, but uropathogens isolated from irrigated patients were significantly more resistant to the irrigating antimicrobial than those in the nonirrigated group. Bladder irrigation with saline or acidic solutions also does not have any clear benefit in reducing the risk of catheter blockage resulting from encrustation or in reducing symptomatic UTIs. 174 In summary, bladder irrigation does not appear to be effective in preventing or eradicating catheter-associated bacteriuria in the majority of patients with short-term or long-term indwelling catheterization, is time consuming, may damage the bladder mucosa, and may select for antimicrobial-resistant organisms. Catheter irrigation may have a role in reducing blood clots after urologic surgery, but this topic is outside the scope of this chapter.

Urine and Bladder Washings

Andrew A. Renshaw , in Cytology (Fourth Edition), 2014

Bladder Washings

Bladder washings have the advantage over urine samples in improved cellularity and cell preservation. The sensitivity of a positive bladder washing cytology is slightly higher than that of urine cytology, ranging from 66% to 77% when all grades and stages of bladder tumor are included (Table 3.2). The superiority of bladder washings over voided urine cytology has been well documented. 52-54 This is not to say that voided urine from patients undergoing cystoscopy can be neglected. From 7% to 13% of bladder tumors not detected by bladder washings are discovered in urine samples obtained before cystoscopic examination. 53,55

Bladder washing cytology is not without its drawbacks. Most significantly, catheterization is required to obtain the specimen. Bladder washings sample the bladder epithelium only, whereas urine contains cells exfoliated from the ureters and kidneys.

Washings of the ureter and pelvis have similar sensitivity (70% to 80% for high-grade lesions) but are particularly prone to false-positive results 29 because of the marked cellularity of these specimens.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9781455744626000039

Urologic Procedures

James R. Roberts MD, FACEP, FAAEM, FACMT , in Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care , 2019

Bladder Irrigation

After prostate surgery (transurethral resection) or in other clinical scenarios, blood clots may form in the bladder and cause acute urinary retention. Blood loss can be significant. This condition is usually easily relieved by the use of a large three-way irrigation catheter. A 22F to 26F Foley three-way catheter is preferred. Infuse saline irrigation fluid continuously into the bladder, while allowing the egress of fluid and blood clots. Continue the procedure until the bladder remains decompressed or bleeding stops (seeFig. 55.21,steps 8-10). Gravity alone usually provides adequate ingress-egress of fluid, but gentle syringe irrigation with 60-mL aliquots of saline may be used. Irrigation can be brisk, 1 to 2 L/hr or more, as long as the volume of drained saline is equal to the volume infused. Infuse saline (supplied in 2- or 4-L bags) by gravity. As stated previously, syringe irrigation of a Foley catheter with 60-mL aliquots is an acceptable alternative. The goal is to obtain clear urine.

Nongynecologic Fluid and Brushing Cytology

A. Goyal , T.M. Elsheikh , in Pathobiology of Human Disease, 2014

Bladder washings and brushings

Bladder washings and brushings are performed in patients at high risk for a new or recurrent urothelial cancer or when cystoscopy is performed for other reasons. Washings can be performed through a catheter: multiple pulses of sterile normal saline solution are instilled into the bladder and then recovered. Because these specimens are of much higher cellularity and better cellular preservation than voided urine, they are the preferred sample types for ancillary tests, including FISH and flow cytometry (FCM) ( Figure 5 ). Disadvantages include a risk of infection and instrumentation artifact that may compromise the cytological interpretation.

Figure 5. Instrumented urine (bladder washing). Urothelial cells are abraded by the instrument (catheter or cystoscope) and exfoliate in cohesive groups. Note the orderly arrangement of the group, capped by umbrella cells (Papanicolaou stain, ThinPrep™, 400   ×).

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9780123864567065035

Evaluation and Management of Hematuria

Alan W. Partin MD, PhD , in Campbell-Walsh-Wein Urology , 2021

Management of Hemorrhagic Cystitis

The management of hemorrhagic cystitis may occasionally be guided by the particular cause for the condition (e.g., treatment of infection). However, in most cases no cause-directed therapy can be offered, and instead, a sequential approach, depending on the severity of the condition, should be undertaken (Fig. 16.2 ). Supportive management in the form of increasing urine output via hydration/diuresis, catheter placement with continuous bladder irrigation, and transfusion as needed represent the mainstay of first-line therapy and typically suffice for mild cases. If hematuria continues and/or clotting of the urine cannot be controlled with bladder irrigation, cystoscopy under anesthesia with clot evacuation and fulguration of discrete bleeding sites, as well as biopsy of any areas suspicious for malignancy, is then recommended.

For hematuria that persists despite such conservative measures, various agents have been investigated for bleeding control. Importantly, there is a lack of large, prospective trials reporting comparative treatment efficacy and safety. Nevertheless, an overview of these measures is warranted to facilitate a systematic approach to management. For one, alum (aluminum ammonium sulfate or aluminum potassium sulfate) may be dissolved in sterile water (50 g alum in a 5-L bag of sterile water [1% alum solution]) and then used to irrigate the bladder at a rate of 200 to 300 mL/h. Through its action as an astringent at sites of bleeding,alum may cause protein precipitation on the urothelial lining (Ostroff and Chenault, 1982)and thereby stimulate vasoconstriction and a decrease in capillary permeability (Choong et al., 2000). In small series, widely variable success rates (e.g., 45% to 100%), with limited durability of hematuria control, have been reported after alum instillation (Abt et al., 2013;Choong et al., 2000;Westerman et al., 2016). Although cell penetration and therefore overall toxicity of this agent are low (consisting mainly of suprapubic discomfort and bladder spasms),systemic absorption may nevertheless occur and may result in aluminum toxicity, with consequent mental status changes, particularly among patients with renal insufficiency. However, alum may be instilled without anesthesia and has overall relatively favorable efficacy and safety profiles. Thusthis agent may be considered for first-line intravesical therapy among patients with hemorrhagic cystitis failing initial supportive measures, particularly among those without renal insufficiency.

Although several alternatives exist for initial intravesical instillation therapy options, the collective data to support use are limited by small sample sizes, short-term follow-up, and varied definitions of treatment success. For example, prostaglandins (e.g., carboprost tromethamine [prostaglandin F2-α, PGF2-α]) (Abt et al., 2013) have been used intravesically for hemorrhagic cystitis, and although the precise mechanism of activity remains unclear, these agents are thought to cause vasoconstriction, platelet aggregation, and cytoprotection via mucous barrier regulation (Choong et al., 2000;Abt et al., 2013). Response rates of 50% to 60% have been noted (Choong et al., 2000;Abt et al., 2013), and in fact in a small (19 patients) prospective randomized study, no significant difference in efficacy was noted between PGF2 and alum (Praveen et al., 1992). Notably, however, difficulties with PGF2 access, storage, and high costs have limited generalized utility (Abt et al., 2013). As a defect in the bladder's glycosaminoglycan layer has been thought to contribute to the pathogenesis of hemorrhagic cystitis (Bassi et al., 2011;Payne et al., 2013), intravesical sodium hyaluronate has been used in this setting with noted symptomatic improvement (Payne et al., 2013;Shao et al., 2012). Alternatively, silver nitrate may be instilled into the bladder, resulting in chemical coagulation at bleeding sites. A 0.5% to 1% solution is instilled for 10 to 20 minutes (Rastinehad et al., 2007). The potential for precipitation and upper tract obstruction with this agent led to the recommendation for a cystogram to rule out reflux before administration (Rastinehad et al., 2007).

Nosocomial Urinary Tract Infections

Thomas M. Hooton , in Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases (Eighth Edition), 2015

Bladder Irrigation with Antimicrobial Therapy or Saline

Bladder irrigation with povidone-iodine or chlorhexidine has been effective in preventing CA-bacteriuria in some studies of orthopedic and urologic patients undergoing short-term catheterization. 177,178 Overall, however, bladder irrigation with agents such as povidone-iodine, chlorhexidine, neomycin, or polymyxin B sulfate has shown little overall benefit in the era of closed urinary drainage. 16,24 In one demonstrative study, 187 adult patients who required short-term urinary catheterization were randomized to closed drainage with a triple-lumen, neomycin-polymyxin irrigated system, or a double-lumen nonirrigated catheter system. 144 There was no significant difference in the rates of CA-bacteriuria between the two groups, but uropathogens isolated from irrigated patients were significantly more resistant to the irrigating antibiotic than those in the nonirrigated group. In summary, catheter irrigation does not appear to be effective in preventing or eradicating CA-bacteriuria in the majority of patients with short-term or long-term indwelling catheterization, is time consuming, and may select for antimicrobial-resistant organisms.

Catheter irrigation also does not appear to be beneficial in reducing the risk of catheter blockage resulting from encrustation. 179 In a randomized crossover trial of 32 long-term catheterized and bacteriuric women in whom 10 weeks of once-daily normal saline irrigation was compared with 10 weeks of no irrigation, the incidence of catheter obstructions and febrile episodes, including those that appeared to be of urinary origin, were similar. 180

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9781455748013003040

Painful Bladder Syndromes

Raymond A. Bologna , Kristene E. Whitmore , in Urogynecology and Reconstructive Pelvic Surgery (Third Edition), 2007

Bladder Instillations

Bladder instillations are reserved for patients who are not responding to oral therapy and for those who are doing well on oral therapy and have a flare in their symptoms. A common instillation mixture includes 50 mL dimethyl sulfoxide (DMSO), 10,000 units heparin, 10 mg triamcinolone, and 44 mEq NaHCO3 instilled once a week for 6 weeks. The pharmacologic properties of DMSO include anti-inflammatory and analgesic effects, collagen dissolution, muscle relaxation, and mast cell histamine release. Heparin is a GAG that is thought to mimic the activity of the bladder's mucopolysaccharide lining. An improvement in symptoms for up to 6 months has been achieved using the DMSO cocktail in 78% of patients receiving six weekly treatments. Intravesical heparin (20,000 units in 10 mL of sterile water), self-administered daily for 4 to 12 months, has resulted in a 60% or better response rate. A combination of 0.5% bupivacaine, heparin, hydrocortisone, NaHCO3, and gentamicin (pH 6.5), given to patients with IC and a history of recurrent UTI, resulted in an improvement in 78% of patients that lasted up to 6 months.

Intravesical hyaluronic acid, a GAG, showed a 71% response rate that was sustained for up to 6 months. Two recent, randomized controlled trials, however, showed no clinical benefit. Bacillus Calmette-Guérin (BCG), an immunogenic agent used to treat superficial transitional cell carcinoma of the bladder, is under investigation as an alternative for instillation therapy. Preliminary studies in patients with IC showed a response rate of 60% (compared with a 27% placebo response rate) that lasted for at least 6 months. Resiniferatoxin (RTX), a vanilloid receptor agonist, recently showed no significant benefit over controls in a randomized controlled trial.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9780323029025500356

Surveillance for Non-Muscle-Invasive Bladder Cancer

Ji Sung Shim , Sung Gu Kang , in Bladder Cancer, 2018

Urine Cytology

The examination of voided urine or bladder-washing specimens for exfoliated cancer cells has high sensitivity for G3 tumors and CIS, with sensitivities exceeding 90%. However, it has low sensitivity for G1 tumors. The sensitivity of cytology for CIS detection is 28%–100% [23]. Positive voided urinary cytology indicates urothelial tumor anywhere in the urinary tract. A negative cytology, however, does not exclude the presence of a tumor. Cytologic interpretation is user dependent [24]. Even if an evaluation is hampered by low cellular yield, urinary tract infections, stones, or intravesical instillations, the specificity is known to exceed 90% in experienced hands [25].

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9780128099391000291

Open Prostatectomy

Michael J. Lipsky , ... Matthew P. Rutman , in A Comprehensive Guide to the Prostate, 2018

Postoperative Management

Postoperatively, patients are maintained on continuous bladder irrigation and IV hydration until their urine clears, typically in 2–3  days. If bleeding continues, the catheter can be placed on traction to tamponade the prostatic fossa and blood transfusion may be required. If bleeding remains uncontrolled, transurethral fulguration can be attempted. The drain is left in place until the output slows, and finally foley catheter is removed usually 3–5   days after drain removal. DVT prophylaxis is continued while the patient is hospitalized and antibiotics are continued until catheter is removed for trial of void.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9780128114643000143

Fungal infections of the genitourinary tract

Jack D. Sobel , in Clinical Mycology (Second Edition), 2009

Candida cystitis

Symptomatic cystitis requires treatment with either amphotericin B bladder instillation (50 μg/dl) or systemic therapy, once more using intravenous amphotericin B, flucytosine or azole agents. 73-82,84,85 In general, amphotericin B bladder irrigation is used less frequently as it is labor intensive and because of the availability of fluconazole. 86 Of the azole class, ketoconazole, itraconazole and voriconazole are poorly excreted in the urine, and there is limited, suboptimal clinical experience. 87 In contrast, fluconazole is water soluble, well absorbed orally, and >80% is excreted unchanged in the urine, achieving high urinary concentrations with documented clinical efficacy. 88, 89 Single-dose IV amphotericin B, 0.3 mg/kg, has also been shown to be highly efficacious in the treatment of lower UT candidiasis with therapeutic urine concentrations for a considerable time after the single dose of amphotericin B administration. 90 This regimen may be preferable for resistant fungal species. Most non-catheterized patients are conveniently managed with oral fluconazole but as this is a complicated infection, therapy should be continued for at least 7 days, dose 200–400 mg/day.

Read full chapter

URL:

https://www.sciencedirect.com/science/article/pii/B9781416056805000268