Continence Coach: Bladder Health Vigilance

Coverage Savvy
  For the past 3 years, the Centers for Medicare and Medicaid Services (CMS) covered the monthly cost of up to 200 single-use, disposable catheters for any Medicare beneficiary who met the basic coverage criteria. This coverage includes Medicare beneficiaries with permanent urinary incontinence or urinary retention. Each can receive one sterile urological catheter and one packet of lubricant for each episode of covered catheterization for emptying one’s bladder. This represented a long-awaited deviation from past coverage policy that stipulated a fixed number of catheters (four) were allowed monthly, for which the cost would be covered regardless of the patient’s medical circumstances.   Today, as a result of this substantial change in policy, intermittent catheterization (IC) using a sterile intermittent catheter is covered when the Medicare beneficiary meets one of the following criteria:
    • Resides in a nursing facility;
    • Is immune-suppressed, such as a person diagnosed with AIDS or on chemotherapy for treatment of cancer;
    • Is pregnant with a spinal cord injury (SCI);
    • Has documented vesico-ureteral reflux, a concern and possible complication particularly for people living with SCI; or
    • Has experienced two or more documented urinary tract infections (UTIs) a year.

  Many Medicare beneficiaries qualifying for such coverage, as well as their providers, remain unaware of the progressive change in policy, and as such are vulnerable to recurrent and costly UTIs. For persons qualifying for sterile, disposable catheters, cleaning and reusing catheters is no longer necessary.

  The NAFC diligently continues to communicate this change in coverage policy. The Association also continues to seek policy updates by private payors, encouraging them to follow Medicare guidelines on this matter for their enrollees. OWM readers are urged to contact the NAFC to act as an ally in your local battle. In the meantime, patients whose health status remains compromised, such as those with a SCI, remain at risk of infections and complications and should be educated regarding how to be vigilant regarding their condition.

Bladder Infections
  Most UTIs are caused by bacteria that normally live in the colon and rectum and are present in bowel movements. The bacteria cling to the opening of the urethra, begin to multiply, and travel up to the bladder. UTIs that occur only in the bladder are called cystitis. If the infection is in the urethra, it is called urethritis. If it gets into the kidneys, it is called pyelonephritis. Because women have a shorter urethra, they are much more prone to develop UTIs than men. Plus, after menopause and especially with weakened sphincter tone, older women are likely to have residual urine retained at the bladder neck and trapped in the urethra, creating a haven for bacteria and increasing the potential for UTIs. Younger women with multiple sexual partners are also more likely to experience recurrent UTIs.

  People with a SCI also are more susceptible to UTIs because the bladder does not function as efficiently as it should. However, when a UTI is suspected, practitioners try to avoid administering antibiotics excessively or without due cause. Nearly 20 years ago, an expert panel organized by the National Institute on Disability and Rehabilitation Research (NIDDR) determined three criteria had to be met for confirming the presence of a UTI in persons with SCI:
    • Increased bacterial colony counts;
    • Increased urinary white blood cells; and
    • New onset of symptoms, including:
      o Discomfort or pain over the bladder or kidney areas;
      o Dysuria (ie, painful urination);
      o Increased frequency of incontinent episodes;
      o Fever;
      o Increased spasticity;
      o Autonomic dysreflexia (ie, a syndrome affecting individuals with SCI above the midthoracic level, characterized by excessive sweating, facial flushing, headache, and slowed pulse rate below 60 in response to distention of the bladder or rectum);
      o Cloudy urine with odor; and/or
      o Malaise, lethargy or a general flu-like feeling of unwellness.   Nurses responsible for patients with SCI should advise prompt testing for a possible bladder infection precipitated by a sudden onset of such symptoms signaling the presence of a UTI so treatment can be initiated.

Vesico-Ureteral Reflux
  Vesico-ureteral reflux describes a condition where urine from the bladder backs up into the kidneys. This is due to an abnormal position of the opening from the ureter, the tube that connects a kidney to the bladder. It also can be caused by excessive bladder pressures or a bladder that becomes too full of urine and has been become distended. This frequently happens in men with an enlarged prostate who go undiagnosed and unattended; eventually, their bladders become inelastic and overfill. It can easily happen to an individual living with SCI who lacks sensation of the bladder filling.

  In persons with normal bladder function, urine moving between the bladder and kidney is not likely a problem. However, neurogenic bladders are more likely to have bacteria that contaminate the urine that is pushed back into the kidney. This can be more of a problem if the individual has an overactive bladder that is contracting with significant force. If the bladder is constantly overstretched and has contractions, vesico-ureteral reflux can cause several problems, such as kidney infections and poor drainage from the kidneys. The latter can lead to renal pelvis distension due to prolonged and unrelieved obstruction (hydronephrosis), painful kidney stones, and eventually permanent, life-threatening kidney damage. No drugs or other therapies are known to reverse a distended bladder; therefore, an enlarged, but non-cancerous, prostate gland needs to be recognized, appropriately diagnosed, and treated in older men, including persons without a SCI or neurogenic bladder.

  Clinicians should not be alarmists. Rather, they should be mindful that the bladder and kidneys are vulnerable and subject to infection, complications, and injury.

The National Association For Continence is a national, private, non-profit organization dedicated to improving the quality of life of people with incontinence. The NAFC’s purpose is to be the leading source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence. This article was not subject to the Ostomy Wound Management peer-review process.