Frequency of Patient-Reported UTIs Is Associated with Poor Quality of Life After Spinal Cord Injury: A Prospective Observational Study - Beyond the Abstract

Urinary tract infections are a major cause of morbidity after spinal cord injury (SCI). Approximately 30-45% of individuals with SCI are hospitalized annually with urinary tract infections (UTIs).1.3 Recurrent UTIs are reported by over 50% of individuals with SCI,4-6 resulting in a moderate to severe impact on their lives.5,6 One of the biggest challenges for providers, however, is the accurate diagnosis of UTIs in this population when the clinical situation often favors over-diagnosis.



The symptoms that people with SCI attribute to a UTI can be vague and non-specific due to altered bladder sensation. These may include abdominal pain, increased skeletal muscle spasticity, and lethargy. When combined with chronic bacteriuria, it becomes difficult to attribute these symptoms to anything other than a UTI, resulting in frequent over-diagnosis and unnecessary use of antibiotics. In fact, data suggests that in 40% of instances when individuals with SCI think they have a UTI, a workup will reveal a different problem;7 such as constipation, detrusor overactivity, or bladder stones. Thus, a number of patient-reported UTIs (PRUTIs) may not be true UTIs, but the importance of these health events cannot be ignored because patient-perception drives antibiotic use. If we do not seek to better understand these PRUTI events we will not be able to shift the pendulum away from antibiotic overuse and improve patient care and genitourinary quality of life (QOL). Therefore, in this study, we sought to understand and define the burden of disease people attribute to their urinary tract by evaluating the association between PRUTIs and quality of life (QOL).

We used the Neurogenic Bladder Research Group (NBRG) SCI registry which was developed to prospectively study neurogenic bladder-related QOL after SCI (ClinicalTrials.gov NTC02616081). This is an observational registry and all participants completed a robust enrollment interview with a trained study coordinator to collect demographic and clinical data. The frequency of PRUTIs was gathered by participant response to the question: “How many UTIs (bladder or kidney infections) have you had over the past 12 months?”; no chart review was conducted to link these episodes to positive urine cultures or specific signs and symptoms because our goal was to understand the effect of patient-reported UTIs on QOL. We then used four validated QOL questions from the Spinal Cord Injury – Quality of Life (SCI-QOL) questionnaire8 to determine the association between PRUTI rate and QOL.

The results were impressive. We found that an increasing rate of PRUTIs is inversely related to QOL. When controlling for important confounders such as level of injury, time since injury, bladder management strategy, baseline bladder dysfunction, amount of support at home, and several other variables, we found that increasing PRUTIs was independently associated with worse QOL across all four QOL items. Specifically, more PRUTIs resulted in more limitation of daily activities, increased skeletal muscle spasms, a stronger perception that a UTI would not go away, and more avoidance of going out. Also of importance, the detrimental effect of PRUTIs on QOL occurred in a dose-dependent fashion arguing that even small improvements in PRUTI rate can improve patient QOL.

Our findings suggest that symptoms attributed to a UTI in people with SCI should be thoroughly evaluated and treated. Even if a true UTI is ruled out, diagnosing and treating the underlying cause of the symptoms is still important as it is significantly associated with declining QOL. Only when we better understand true UTIs and patient-perceived UTIs will we be able to effectively address antibiotic-seeking behavior and work with this population to offer non-antibiotic treatment alternatives for their bothersome symptoms.

Written by: Katherine M. Theisen, MD, Department of Urology, and Sean P. Elliott, MD, MS, Professor, Vice Chairman, Director of Reconstructive Urology, University of Minnesota.

References:

  1. James, Spencer L., Alice Theadom, Richard G. Ellenbogen, Marlena S. Bannick, Wcliff Montjoy-Venning, Lydia R. Lucchesi, Nooshin Abbasi et al. "Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016." The Lancet Neurology 18, no. 1 (2019): 56-87.
  2. Cardenas, Diana D., Jeanne M. Hoffman, Steven Kirshblum, and William McKinley. "Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis." Archives of physical medicine and rehabilitation 85, no. 11 (2004): 1757-1763.
  3. Skelton, Felicia, Jeanne M. Hoffman, Maria Reyes, and Stephen P. Burns. "Examining health-care utilization in the first year following spinal cord injury." The journal of spinal cord medicine 38, no. 6 (2015): 690-695.
  4. Biering-Sørensen, Fin, Helle-Merethe Nielans, Torben Dørflinger, and Bent Sørensen. "Urological situation five years after spinal cord injury." Scandinavian journal of urology and nephrology 33, no. 3 (1999): 157-161.
  5. Brinkhof, Martin WG, Abdul Al-Khodairy, Inge Eriks-Hoogland, Christine Fekete, Timo Hinrichs, Margret Hund-Georgiadis, Sonja Meier, Anke Scheel-Sailer, Martin Schubert, and Jan D. Reinhardt. "Health conditions in people with spinal cord injury: contemporary evidence from a population-based community survey in Switzerland." Journal of rehabilitation medicine 48, no. 2 (2016): 197-209.
  6. Craven, Catharine, Sander L. Hitzig, and Nicole Mittmann. "Impact of impairment and secondary health conditions on health preference among Canadians with chronic spinal cord injury." The journal of spinal cord medicine 35, no. 5 (2012): 361-370.
  7. Linsenmeyer, Todd, and Anne Oakley. "Accuracy of individuals with spinal cord injury at predicting urinary tract infections based on their symptoms." The journal of spinal cord medicine 26, no. 4 (2003): 352-357.
  8. Tulsky, David S., Pamela A. Kisala, Denise G. Tate, Ann M. Spungen, and Steven C. Kirshblum. "Development and psychometric characteristics of the SCI-QOL Bladder Management Difficulties and Bowel Management Difficulties item banks and short forms and the SCI-QOL Bladder Complications scale." The journal of spinal cord medicine 38, no. 3 (2015): 288-302.
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