Commentary by Brenda Roe

This is an interesting article, and the authors are to be congratulated for their novel approach of investigating fluid intake, urinary output, catheter blockage and UTI in people with long-term urinary catheters using diary evidence and data from semistructured interviews at 2 time points. Few qualitative studies have been undertaken on the experience of living with an indwelling catheter. More work remains to be done in this area, but this research adds to the small body of evidence that exists and points to new directions for future study.

No significant associations were found between patient perceptions of increasing their fluid intake and UTI prevention. The data suggest that catheter manipulations (insertion or removal) and blockage are associated with self-reported frequency of UTI, and this is the first research to investigate this. Of note, in this group, sediment and catheter kinking were not associated with self-reported UTI. Sediment could be associated with increased frequency of catheter blocking, need for increased fluid intake, or frequent catheter change but was not the focus of the article. Rather, the researchers explored the patients' experiences living and coping with an indwelling catheter. Another study could explore patients' perceptions of catheter-associated infection and their decision making on when to seek treatment. This study reported on sensations of urine flow and measurements of fluid intake and urine output and as such it is a first; this has not been reported before.

Large catheter French size and immobility have also been associated with catheter-related pain, especially in males.1 Earlier research found an association between large balloon size and urinary leakage in people with long-term indwelling urethral catheters.2 The authors note that there were people in the present study with large French catheters and large balloons, which could have affected urine flow, leakage, pain, and discomfort. It is important for the reader to understand that this qualitative study was not about intervention but rather about the experience of having a long-term indwelling catheter in terms of awareness of urine flow related to catheter blockage and self-reported UTI. Quantifying UTI was difficult because the data collected were subjective only. Further research might explore the objective signs of UTI with the subjects' perceptions of an infection. How patient perceptions of UTI and bacteriuria differed would have been interesting to elucidate, and the relevance of these 2 aspects could be reviewed and discussed from the existing research literature in a future article. More may have been made from patients' experience of urine flow from the qualitative data, which was descriptive and experiential with specific focus made of saturation of data. By its nature, qualitative research uses small carefully chosen samples because of the type and amount of data analysis. Therefore, qualitative data are more difficult to generalize to other catheterized groups. Future research could involve stratified samples so accounts can be taken of duration of catheter use, type of catheter use (indwelling urethral or suprapubic), reason for catheterization, and underlying medical conditions. People with SCIs may actually perceive urine flow differently from more mobile patients, as would those with urethral vs suprapubic catheters. In the United Kingdom, where male-length and female-length catheters are available, a comparative evaluation could be conducted. If the products are favorably viewed in the United Kingdom, could they not be introduced in North America? Another product used in the United Kingdom is a catheter valve (clamp) that gives the patient freedom from tubing and bags and works well for individuals who are able to empty on a regular basis. The role of intermittent drainage with a catheter valve vs continuous drainage should also be investigated in relation to urine flow, pain, discomfort, symptomatic UTI, catheter blockage, and need for catheter change. Finally, more research is required for people with suprapubic and urethral catheters.

In this study, the authors note that males are overrepresented in their sample. They also point to their concern over the use of latex catheters in the sample and potential for latex allergy. The authors have conducted a thoughtful and interesting study that provides useful insights into areas of future inquiry and research. The investigators are to be congratulated and encouraged to continue to pursue these areas.

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