15.2.R3 Recommendation
Bladder scan for urinary tract infection
- Strength of recommendation:
- Strong for intervention
- Level of evidence:
- Very low
How the strength and level of evidence are graded
What the strength of a recommendation means
The strength of a recommendation reflects the extent to which a guideline panel is confident that desirable effects of an intervention outweigh undesirable effects, or vice versa, across the range of patients for whom the recommendation is intended.
Strong for (↑↑) or against (↓↓) intervention
For patients: Most individuals in this situation would want the recommended course of action and only a small proportion would not.
For clinicians: Most individuals should receive the recommended course of action.
Conditional for (↑) or against (↓) intervention
For patients: The majority of individuals in this situation would want the suggested course of action, but many would not.
For clinicians: Recognize that different choices will be appropriate for different patients, and that you must help each patient arrive at a management decision consistent with her or his values and preferences.
Neither intervention nor comparison (—)
The panel did not recommend for or against the intervention.
Source: GRADE Handbook, section 6.1, Table 6.1 (GRADE uses “weak” and “conditional” interchangeably).
For the rating of the strength of the recommendation, in addition to evidence from studies in FRDA, evidence from like conditions, clinical experience and expert consensus are taken into account when published evidence is not available.
The level of evidence is based on published evidence from studies in FRDA. If there is no published evidence in FRDA, evidence from other like conditions or clinical expertise may have been used to make the recommendation – this is graded as ‘very low’ or in some cases ‘low’ level evidence. See the table below for an explanation of the symbols used to grade recommendations.
| Strength of recommendation | Symbol | Level of evidence | Symbol |
| Strong for intervention | ↑↑ | High | ⨁⨁⨁⨁ |
| Conditional for intervention | ↑ | Moderate | ⨁⨁⨁◯ |
| Neither intervention nor comparison | — | Low | ⨁⨁◯◯ |
| Conditional against intervention | ↓ | Very low | ⨁◯◯◯ |
| Strong against intervention | ↓↓ |
The assessment of UTIs in the emergency department for individuals with Friedreich ataxia should not be fundamentally different from standard care in individuals without Friedreich ataxia. However, we recommend reviewing self-catheterization technique, if appropriate, and performing diagnostic evaluation to assess for elevated residual urine (including a bladder scan) and morphological causes (including an ultrasound of the kidneys, ureters and bladder (KUB) and outpatient cystoscopy).
Question
Should bladder scan versus standard assessment be used for people presenting with urinary tract infection (UTI) with Friedreich ataxia?
Justification
Individuals with Friedreich ataxia have risk factors for increased incidence of UTIs, including neurogenic bladder and diabetes mellitus. Individuals with Friedreich ataxia and lower urinary tract symptoms should therefore be screened for the presence of a UTI and have a bladder scan to assess for any associated urinary retention.
Diagnosis of UTI in individuals with Friedreich ataxia is challenging because they may have lower urinary tract symptoms with no laboratory evidence of infection, or they may have bacteriuria in the context of self-catheterization or using an indwelling catheter.
Subgroup consideration
This recommendation is for individuals with Friedreich ataxia with urinary tract infection. Bladder scans may be contraindicated if there is open skin or a wound in the suprapubic region. In addition, care needs to be taken with bladder scans in pregnant women to ensure the bladder, not the uterus, is visualized.
Evidence to recommendation table (PDF)
Part of 15.2 Other presentations to the emergency department with Friedreich ataxia
References (24)
1. Bourke T, Keane D. Friedreich's Ataxia: a review from a cardiology perspective. Ir J Med Sci. 2011;180(4):799-805.
2. Schadt KA, Friedman LS, Regner SR, Mark GE, Lynch DR, Lin KY. Cross-sectional analysis of electrocardiograms in a large heterogeneous cohort of Friedreich ataxia subjects. J Child Neurol. 2012;27(9):1187-92.
3. Friedman LS, Schadt KA, Regner SR, Mark GE, Lin KY, Sciascia T, et al. Elevation of serum cardiac troponin I in a cross-sectional cohort of asymptomatic subjects with Friedreich ataxia. Int J Cardiol. 2013;167(4):1622-4.
4. Legrand L, Maupain C, Monin ML, Ewenczyk C, Isnard R, Alkouri R, et al. Significance of NT-proBNP and high-sensitivity troponin in Friedreich ataxia. J Clin Med. 2020;9(6).
5. Schulz JB, Boesch S, Burk K, Durr A, Giunti P, Mariotti C, et al. Diagnosis and treatment of Friedreich ataxia: a European perspective. Nat Rev Neurol. 2009;5(4):222-34.
6. Akhlaghi H, Corben LA, Georgiou-Karistianis N, Bradshaw JL, Storey E, Delatycki MB, et al. Superior cerebellar peduncle atrophy in Friedreich’s ataxia correlates with disease symptoms. Cerebellum. 2011;10:81-7.
7. Maring JR, Croarkin E. Presentation and progression of Friedreich ataxia and implications for physical therapist examination. Phys Ther. 2007;87(12):1687-96.
8. Corben LA, Georgiou-Karistianis N, Bradshaw JL, Evans-Galea M.V, Churchyard AJ, Delatycki MB. Characterising the Neuropathology and Neurobehavioural Phenotype in Friedreich Ataxia In: Hannan A, editor. Tandem Repeat Polymorphisms: Genetic Plasticity, Neural Diversity and Diseas. Texas USA: Landes Bioscience and Springer Science and Business Media 2012.
9. Burtner PA, Woollacott MH, Qualls C. Stance balance control with orthoses in a group of children with spastic cerebral palsy. Dev Med Child Neurol. 1999;41(11):748-57.
10. Pandolfo M. Friedreich Ataxia: the clinical picture. J Neurol. 2009;256:3-8.
11. Eigentler A, Nachbauer W, Donnemiller E, Poewe W, Gasser RW, Boesch S. Low bone mineral density in Friedreich ataxia. Cerebellum. 2014;13(5):549-57.
12. Tsirikos AI, Smith G. Scoliosis in Friedreich’s ataxia. The Journal of Bone and Joint Surgery. 2012;94(B):684-9.
13. Dittmer DK, Teasell R. Complications of immobilization and bed rest. Part 1: Musculoskeletal and cardiovascular complications. Can Fam Physician. 1993;39:1428-32, 35-7.
14. Thompson AJ, Jarrett L, Lockley L, Marsden J, Stevenson VL. Clinical management of spasticity. J Neurol Neurosurg Psychiatry. 2005;76(4):459-63.
15. van Gaalen J, Kerstens FG, Maas RP, Harmark L, van de Warrenburg BP. Drug-induced cerebellar ataxia: a systematic review. CNS Drugs. 2014;28(12):1139-53.
16. Delatycki MB, Paris DB, Gardner RJ, Nicholson GA, Nassif N, Storey E, et al. Clinical and genetic study of Friedreich ataxia in an Australian population. Am J Med Genet. 1999;87(2):168-74.
17. Groen J, Pannek J, Castro Diaz D, Del Popolo G, Gross T, Hamid R, et al. Summary of European Association of Urology (EAU) Guidelines on Neuro-Urology. Eur Urol. 2016;69(2):324-33.
18. Goetz LL, Cardenas DD, Kennelly M, Bonne Lee BS, Linsenmeyer T, Moser C, et al. International Spinal Cord Injury Urinary Tract Infection Basic Data Set. Spinal Cord. 2013;51(9):700-4.
19. Everaert K, Lumen N, Kerckhaert W, Willaert P, van Driel M. Urinary tract infections in spinal cord injury: prevention and treatment guidelines. Acta Clin Belg. 2009;64(4):335-40.
20. Pannek J, Pannek-Rademacher S, Cachin-Jus M. Organ-preserving treatment of an epididymal abscess in a patient with spinal cord injury. Spinal Cord. 2014;52 Suppl 1:S7-8.
21. Cnop M, Mulder H, Igoillo-Esteve M. Diabetes in Friedreich ataxia. J Neurochem. 2013;126 Suppl 1:94-102.
22. Chakraborty PP, Ray S, Bhattacharjee R, Ghosh S, Mukhopadhyay P, Mukhopadhyay S, et al. First Presentation of Diabetes as Diabetic Ketoacidosis in a Case of Friedreich's Ataxia. Clin Diabetes. 2015;33(2):84-6.
23. Finocchiaro G, Baio G, Micossi P, Pozza G, di Donato S. Glucose metabolism alterations in Friedreich's ataxia. Neurology. 1988;38(8):1292-6.
24. Cnop M, Igoillo-Esteve M, Rai M, Begu A, Serroukh Y, Depondt C, et al. Central role and mechanisms of beta-cell dysfunction and death in friedreich ataxia-associated diabetes. Ann Neurol. 2012;72(6):971-82.
Disclaimer, intended use and funding
Disclaimer
The Clinical Management Guidelines for Friedreich ataxia (‘Guidelines’) are protected by copyright owned by the authors who contributed to their development or said authors’ assignees.
These Guidelines are systematically developed evidence statements incorporating data from a comprehensive literature review of the most recent studies available (up to the Guidelines submission date) and reviewed according to the Grading of Recommendations, Assessment Development and Evaluations (GRADE) framework © The Grade Working Group.
Guidelines users must seek out the most recent information that might supersede the diagnostic and treatment recommendations contained within these Guidelines and consider local variations in clinical settings, funding and resources that may impact on the implementation of the recommendations set out in these Guidelines.
The authors of these Guidelines disclaim all liability for the accuracy or completeness of the Guidelines, and disclaim all warranties, express or implied to their incorrect use.
Intended Use
These Guidelines are made available as general information only and do not constitute medical advice. These Guidelines are intended to assist qualified healthcare professionals make informed treatment decisions about the care of individuals with Friedreich ataxia. They are not intended as a sole source of guidance in managing issues related to Friedreich ataxia. Rather, they are designed to assist clinicians by providing an evidence-based framework for decision-making.
These Guidelines are not intended to replace clinical judgment and other approaches to diagnosing and managing problems associated with Friedreich ataxia which may be appropriate in specific circumstances. Ultimately, healthcare professionals must make their own treatment decisions on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge and expertise.
Guidelines users must not edit or modify the Guidelines in any way – including removing any branding, acknowledgement, authorship or copyright notice.
Funding
The authors of this document gratefully acknowledge the support of the Friedreich Ataxia Research Alliance (FARA). The views and opinions expressed in the Guidelines are solely those of the authors and do not necessarily reflect the official policy or position of FARA.