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Sir,

The study performed by Hakvoort et al.1 is the first randomised controlled trial that reports on the differences in urinary tract infection and recatheterisation after prolonged (five days) or short (one day) catheterisation after vaginal prolapse surgery. Urinary tract infections were more frequent after prolonged catheterisation (OR 15, 95% CI 3.2–68.8). However, the need for recatheterisation due to increased residual volumes was 40% in those patients with short time catheterisation, whereas only 9% in those patients with prolonged catheterisation. The authors conclude that the disadvantages of prolonged catheterisation outweigh the advantages, and removal should be performed the first day after surgery.

The presence of a urinary tract infection was defined as a positive urinary culture of >105 CFU/mL. No information is available on the patients' urinary symptoms or fever that could be related to urinary tract infection. It seems that asymptomatic bacteriuria was equalised with urinary tract infection. In clinical practice, it is common to base the latter diagnosis on the presence of symptoms referrable to the urinary tract such as dysuria, frequency, urgency, suprapubic pain or fever in combination with a significant bacteriuria (>105 CFU/mL). A prospective randomised study, originally designed to test if the incidence of post-operative urinary tract infection could be reduced by reversing the sequence of vaginal cleansing and urethral catheterisation, revealed a significant association between positive urine culture on different following occasions.2 A positive urinary culture at removal after a mean of 1.3 days of catheterisation appeared to result in a urinary tract infection within two days in 19 out of 58 patients (33%), when defined as significant bacteriuria with urinary symptoms or fever. Even when there was a negative culture on catheter removal, 15 out of 109 patients (14%) developed a urinary tract infection within two days. When we extrapolate these percentages to the study by Hakvoort, this would lead to a relative risk of a urinary tract infection, two days after removal of the catheter, of 0.71 (95% CI 0.19–1.08). These results imply that there is no statistically significant difference in the rate of urinary tract infections between short and long term catheterisation.

Even though asymptomatic bacteriuria can be a harbinger of a symptomatic urinary tract infection, there seems to be no clinical screening strategy or convincing therapeutic complications for a positive urinary culture in most clinical circumstances.3 In daily practice, no routine screening occurs when urinary catheters are removed. The decision to obtain a urine culture in a patient without urinary symptoms or fever after catheterisation should be based upon either suspicion of infection (such as cloudy urine) or the concern that an untreated infection might cause undue morbidity. In all cases, the patient should be made aware of the clinical symptoms that suggest a urinary tract infection and that these symptoms are likely to appear a few days after catheter removal, if they appear at all.

In the short catheterisation group, recatheterisation was necessary in 40% of patients. It is unclear whether Hakvoort et al. collected another urinary sample for culture when patients, who underwent a recatheterisation, had their second urinary catheter removed. It would have been interesting to investigate the rate of sympomatic urinary tract infection compared with prolonged catheterisation. The risk of infection seems to be lower with intermittent sterile catheterisation than with indwelling catheterisation.4

Removal of the catheter one day after surgery resulted in a mean duration of catheterisation of 2.3 days. In order to achieve a balance between number of recatheterisations and incidence of urinary tract infections, it is tempting to suggest that the optimal duration time of catheterisation lies somewhere between one and five days instead of one day.

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