Q.  Healthcare-related UTIs are common, particularly among patients who require endourethral procedures, such as catherization. Do you feel costs and morbidity could be lowered with more effective prevention?

A. Based on multiple surveys that have identified UTIs as the most common type of nosocomial infection, a large literature has emerged outlining strategies to reduce risk. As catheterizations are the most common source of healthcare-related UTIs, this has been the most common focus of efforts toward risk reduction. Not least important, many guidelines and review articles, including the 2009 practice recommendations from the Infectious Diseases Society of America (IDSA) suggest strict indications for urinary catheters in order to restrict use to those who cannot be managed with alternative approaches. In those who do require catheterization or any invasive endourethral procedure, steps to improve sterile technique and address risk factors for pathogen invasion should be considered critical to efforts to reduce the complications imposed by iatrogenic infection. Avoiding UTIs means avoiding the costs of managing a UTI, which can be particularly substantial if a UTI results in a hospital admission or extended length of stay.

Q.  For endourethral procedures, an antiseptic to eliminate potential pathogens makes sense, but is there potential value for urethral lubrication to reduce the inflammatory response induced by catheters, cystoscopes, or other devices inserted into the urethra?

A.  There is a relatively small pool of evidence that directly demonstrates a reduction in the risk of UTI when lubrication is employed to facilitate the introduction of a catheter or other device into the urethral canal, but lubrication can reduce discomfort. Certainly, lubrication can be recommended on the basis of a more favorable patient experience. It is reasonable to expect lubrication to reduce trauma from a device passing through the membranous tissue that lines the urethra even if it has not yet been shown specifically that a reduction in the pain response will avoid activation of inflammatory mediators. When lubrication is combined with an antiseptic, there is potential for both to reduce the risk that pathogens will adhere to urethral cells to initiate colonization.

Q.  What is the potential for anesthetic properties in a lubricating antimicrobial gel to encourage proper technique to lower UTIs?

A.  The likelihood of achieving a meaningful reduction in the risk of UTIs from endourethral procedures is likely to be dependent on developing a strict and multifaceted protocol. No step may be more important that ensuring a sterile technique. The perigenital region is rich in resident bacteria that are readily converted to pathogens when allowed access to the urinary tract. Introducing catheters and other endourethral devices into the urinary tract with a lubricating gel that combines an antiseptic and an anesthetic should be part of a regimented protocol that includes sterilization of the perigenital region as well as patient education regarding the goals of treatment and the risks of UTI. Patient comfort is not the least important part of a strategy that requires patient cooperation and adherence. Lowering the risk of UTIs associated with endourethral procedures has proven challenging. A comprehensive approach is likely to be instrumental to success.