A detailed history as part of the initial evaluation is imperative. Presenting complaints associated with urinary retention usually are attributed to dysfunctional bladder emptying. Thus, most patients complain of voiding problems (hesitancy; straining; poor, prolonged and intermittent flow; terminal dribble) and post-micturition symptoms (sensation of incomplete emptying, post-micturition dribble), terms for which have been developed and defined by the International Continence Society (ICS) .

The interview should elicit information regarding initiation of micturition (reflex, strain, Credé) and investigate whether performed by individuals themselves or with caretakers. Patients may also present with complete lack of voiding (usually accompanied by abdominal pain) or incontinence (due to overflow). In patients already catheterized, the duration of each catheter use before change and performed catheterization technique should be recorded. Reassessment of bladder-emptying technique is also important. Patients should be asked about other urological complaints, in particular storage problems (urgency, frequency, nocturia), as both NDU and DSD may sometimes present with mixed storage and voiding symptoms [21]. Clinician should also evaluate the presence of bladder sensation. The onset of complaints should be carefully investigated and classified as acute or chronic. In patients with chronic retention, symptom onset may be gradual and it can go unnoticed by caregivers or by patients with limited bladder sensation or who are severely cognitively impaired and cannot report symptoms [22]. Previous history of urinary retention or episodes of catheterization should be elicited. Possible progression of the voiding dysfunction should be clarified (stable or changing complaints), as it has been shown that DSD tends to worsen over time, and there is a correlation between neurological status and clinical findings [7]. Similarly, the prevalence of detrusor underactivity may increase with age, and studies report that it is more common in men. Up to 48% of elderly non-neurogenic patients may show underactive detrusor [5]. Potential myogenic causes of detrusor underactivity should also be excluded [4]. This include impaired bladder perfusion (chronic ischemia is commonly seen in patients with atherosclerosis and microvascular diseases), bladder fibrosis, and age-related degradation [21]. Special attention should be given to diabetic patients, as reported symptoms usually result from integrative mechanism, i.e., both myogenic and neurogenic damage [23]. In elderly male patients, reported voiding symptoms may be associated with bladder outflow obstruction (BOO) mainly due to benign prostatic hyperplasia. However, it is not possible to differentiate NDU, DSD, and BOO without urodynamic study [21]. Studies have shown that there is a poor correlation between symptoms and urodynamic diagnosis in this specific group of patients [24, 25]. Accurate assessment of symptoms indicating possible complications or other causes of retention (hematuria, dysuria, fever) should be conducted to rule out comorbid pathology such as malignancy, urolithiasis, or urinary tract infection. Neurological symptoms related to underlying neurological pathology should also be documented with onset, severity, evolution, and any treatment.

It is important to analyze how reported complaints affect the patient’s quality of life. Patients should be asked about the degree of hardship the symptoms cause and whether they influence their daily activities, social life, and work productivity.

As patients with neurourological complaints may also suffer from neurogenic bowel and sexual dysfunction, bowel and sexual histories are important [26, 27]. Bowel history should elicit information regarding pattern and frequency of defecation; rectal sensation; desire to defecate; and possible episodes of fecal incontinence, constipation or defecation initiation (digitation, suppository use) [28]. Sexual history should investigate symptoms of genital or sexual dysfunction; presence of sensation in genital area; lack of desire (loss of libido); difficulty in achieving orgasm; dyspareunia in women; and erectile dysfunction or ejaculation problems (premature, delayed, retrograde, anejaculation) in men.

Retention and other voiding problems may be aggravated by different comorbidities. Apart from underlying neurological disorder, other causes of urinary retention can be categorized as obstructive, infectious/inflammatory, or pharmacologic [11]. The most common obstructive pathology in men is benign prostatic hyperplasia [29, 30]. Furthermore, end-stage BOO may also lead to significant detrusor underactivity. Other obstructive causes include prostate cancer, phimosis, paraphimosis, and external-constricting devices applied to the penis. In women, obstructive retention often involves pelvic organ prolapse such as cystocele, rectocele, or uterine prolapse. In both sexes, urethral strictures, stones, and foreign bodies, as well as bladder tumors with blood clots can directly block the flow of urine [31]. Benign or malignant pelvic masses as well as fecal impaction and gastrointestinal or retroperitoneal masses may lead to external compression of the bladder neck. Infectious/inflammatory causes of urinary retention include sex-specific and general pathologies. In males, acute prostatitis and prostatic abscess may cause urine retention. In females, painful vulvovaginal lesions and vulvovaginitis can vitally impair voiding. Urethritis (from a urinary tract infection or sexually transmitted infection) as well as genital herpes (with local inflammation and painful urination) may lead to urine retention in both sexes. Numerous pharmacologic agents have direct or indirect effects on the lower urinary tract and can decrease detrusor contractility [3, 30, 32]. Both prescribed and over-the-counter drugs may worsen voiding symptoms and lead to retention. Drugs with antimuscarinic properties, such as tricyclic antidepressants, may compete with acetylcholine at muscarinic receptors, resulting in bladder relaxation. Nonsteroidal anti-inflammatory drugs have shown to doubly increase the risk of urinary retention [33]. Calcium channel antagonists may also occasionally precipitate retention in individuals who have presumably been rendered more vulnerable as a result of predisposing risk factors [3]. It has been shown that polypharmacy significantly increases the risk of urinary retention [34]. Table 8.1 lists medications associated with voiding difficulties [3, 30, 32]. Other causes may include any prior urinary tract trauma or surgery, post-partum complications (e.g., obstetric anal sphincter injury, peri-urethral lacerations, wound breakdown), as well as de novo post-partum urinary symptoms.

A well-conducted medical history should be completed with an assessment of the patient’s social situation. Accessibility to care, toileting, catheters, and other supplies may be limited by financial constraints or other social factors. Family or caregiver support should be queried and the patient’s independence should be evaluated.

A proper history should not only aim to diagnose the cause and nature of bladder dysfunction but also to identify associated complications of neurogenic lower urinary tract dysfunction. The consequences of urinary retention depend on the chronicity of the problem and the degree of urine retention. In patients with acute complete obstruction, metabolic disturbances, including acidosis, azotemia, and hyperkalemia, can be life-threatening. Increased intravesical and intraureteral pressures can dramatically reduce the glomerular filtration rate and renal blood flow. Rupture of the urinary tract is also possible. In patients with chronic retention, hydronephrosis, renal failure, recurrent urinary tract infections, or urolithiasis may be observed during initial consultation (see Chaps. 10–15).

In addition to medical history , a comprehensive physical examination should be performed. It consists of examining the abdomen, back, and loins, as well as pelvic and genital organs. Abdominal examination should include percussion and palpation of the bladder [11]. A bladder may be percussible if it contains at least 150 mL of urine and it should be palpable with more than 200 mL [30, 35]. Bladder tone and pain should be assessed. Further exam may also reveal abdominal or flank masses or fullness, suggesting malignancy or fecal impaction. Clinicians should evaluate sensation within sacral dermatomes (special consideration for S2–S4 dermatomes) and perianal area (see Chap. 4, “Medical History and Physical Examination,” Fig. 4.​1), spinal cord-mediated reflexes (see Chap. 4, Table 4.​3), as well as anal sphincter tone and voluntary contractions. The urethra should be examined for the presence of obstructing masses, diverticula, cysts, or breakdowns. The external genitalia are evaluated for evidence of injury, pathological masses, or local irritation contributing to painful urination or urine retention. In men, prostate size should be assessed. In women, a pelvic exam should analyze pelvic organ prolapse that can cause bladder outflow obstruction. A bimanual exam may help to evaluate uterine size, position, and support, as well as rule out any palpable pathological masses. Inspection of the vagina and surrounding perineal skin may reveal atrophy, lesions, or scars associated with prior surgery, as well as urine-related skin breakdown. Tenderness of the levator muscles may suggest pelvic floor hypertonicity associated with dysfunctional voiding. Urethral hypermobility and the presence of stress urinary incontinence (spontaneous or induced by Valsalva or cough) should be assessed.

The clinician should carefully examine hand function, in particular functional ability of the thumb and index or middle finger, as patients with retention usually require intermittent catheterization.

Clinicians should also assess the patient’s mental status, cognition, mode of ambulation, mobility, gait, balance, coordination, weakness, and spasticity.

Because reported complaints need to be objectively established, specific or generic questionnaires should be employed (note the discussion of questionnaires for SCI patients in Chap. 4, and the discussion of generic questionnaires and those for patients with multiple sclerosis in Chap. 7, “Incontinence Due to Neurogenic Detrusor Overactivity”). A voiding diary can be helpful in clarifying the frequency and severity of patient’s symptoms (see the discussion of voiding diaries in Chap. 5, “Testing”). In patients suffering from retention, a catheterization diary, used in the same manner as the voiding diary, may be more valuable [36]. Recorded parameters include time and volume of urine obtained at catheterization, as well as the same values obtained for any voids between catheterizations. When sensation is preserved, episodes of urgency may also be noted. Obtained quantities may help in characterizing the patient’s compliance to bladder management regimes. When catheterization volumes exceed the volume at which filling pressures become unsafe for the upper urinary tract, appropriate management needs to be implemented. Moreover, careful record of catheterizations can show fluctuations in diuresis and could be used to determine the optimal catheterization frequency to adopt.

Infectious and inflammatory pathologies may cause or aggravate reported voiding problems in neurologically impaired individuals. Therefore, a urinalysis is recommended in patients suffering from retention [37, 38]. It may also reveal hematuria, proteinuria, or glycosuria, indicating possible complications of neurogenic bladder or important comorbidities that may lead to urine retention. As described in Chap. 5, a dipstick analysis may be more useful to exclude than to prove urinary tract infection, and if any evidence of infection is detected, urine culture with antibiotic sensitivity is required. Of note, asymptomatic bacteriuria should not be routinely treated (see Chap. 5—section “Urinalysis/Urine Culture”) [17]. In already catheterized patients, samples from leg bags should not be analyzed. Well-obtained urine specimens are samples taken from a freshly inserted intermittent sterile catheter and those taken from a catheter port [39].

In patients who still void, non-invasive uroflowmetry should be conducted to objectively document the voiding pattern and the initial ability of bladder empting. It also serves as an valuable method to monitor treatment results [17]. Obtained findings may include a low flow rate, decreased peak flow rate, prolonged and intermittent flow, hesitancy, low voided volume , and prolonged voiding time (Fig. 8.1) [40]. However, these findings are not specific, because they may also be seen in NDU, DSD, or structural abnormalities [41].

Clinicians emphasize that post-void residual (PVR) urine volume should be assessed in all patients suspected of urinary retention [22]. Elevated PVR predisposes to incontinence, urinary tract infections, bladder stones, and renal dysfunction [42]. An elevated PVR indicates dysfunctional voiding, but it cannot be used to discern whether this is caused by poor detrusor contractility (underactive detrusor) or by obstruction (DSD, structural abnormalities). However, measurement of PVR may reveal the necessity of immediate introduction of bladder catheterization (if not already implemented). The PVR volume at which the patient’s bladder-emptying technique should be changed is related to the overall bladder capacity and remains a matter of dispute [43]. It is currently recommended to introduce patients to catheterization techniques when a PVR volume consistently exceeds 100 mL and patients present with related symptoms [44, 45]. On the other hand, chronic urinary retention was traditionally defined as a PVR >300 mL [46]. Available data suggest that ultrasound measurement of PVR is preferable to catheterization, and portable scanners can be easily used in daily clinical practice as a convenient non-invasive tool [47–51].

In patients with significantly elevated post-void residual, history of previous retention, or with risk factors for chronic kidney disease, renal evaluation is recommended. Basic laboratory and imaging studies are necessary to monitor kidney function. Measuring serum creatinine, blood urea nitrogen, and electrolytes levels, as well as calculating the glomerular filtration rate, help to assess renal function. Creatinine clearance provides more precise data but requires a 24-h urine collection to assess creatinine excretion. Incomplete collection can result in underestimation of renal function. Renal scintigraphy with assessment of glomerular filtration rate is recommended when renal function is poor, muscle mass reduced, or if the function of each kidney has to be assessed separately in high-risk patients [43]. A renal ultrasound is a valuable tool for the general assessment of kidney structure and may reveal hydronephrosis, abnormal masses , scarring, stones, and other structural changes affecting the parenchyma (see Chap. 5, Figs. 5.​2, 5.​3, and 5.​4).

Bladder ultrasound helps to detect stones and any possible tumor, indicating other causes of urinary retention or already developed complications of neurogenic bladder.

Additional tests may help in proper diagnosis. Their utilization depends on clinical presentation. Evaluation of serum blood glucose and prostate-specific antigen can be considered based on the patient’s history, symptoms, and signs. Contrast cystourethrography may be helpful in outlining the bladder neck and urethra, as well as vesicoureteral reflux. Direct visualization of the urethra and bladder via urethrocystoscopy may be useful to detect strictures, tumors, stones, or inflammation, and should be especially considered in patients with recurrent urinary tract infections [17]. Advanced imaging techniques (computed tomography, magnetic resonance imaging) should be performed when pelvic, abdominal, or retroperitoneal mass, as well as other malignancy causing external bladder neck compression is suspected [11].

Because symptoms lack adequate precision, urodynamic study is of value in the final diagnosis. It allows distinguishing between NDU (impaired contractility with low pressure-low flow) and DSD (functional obstruction with high pressure-low flow). Only urodynamic study can offer more detailed information about the underlying mechanism of neurogenic lower urinary tract dysfunction. Urodynamic study should be performed according to widely adopted and reliable recommendations. These include Good Urodynamic Practices and Terms 2016: Urodynamics, uroflowmetry, cystometry, and pressure-flow study, developed by the ICS and Urodynamic studies in adults: AUA/SUFU guideline, developed by the American Urological Association and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction [52, 53].

Pdet @Qmax—detrusor pressure at maximum flow rate, Qmax—maximum flow rate.

As female bladders generate lower pressures during voiding, some studies consider female detrusor underactivity when detrusor pressure at Qmax is less than 10 cm H₂O [25]. To objectify bladder contractility, mathematical equations have been developed. These mainly include bladder contractility index (BCI) [56], the Watts factor [57], and the linearized passive urethral resistance relation (linPURR) [58]. Among them, BCI seems to be the most useful for daily clinical practice. It is simple, quick to calculate, and easily reproducible. BCI is based on detrusor pressure at maximum flow rate (Pdet @Qmax) and maximum flow rate (Qmax):

In men, BCI > 150 suggests strong contractility; BCI 100–150 suggests normal contractility; and BCI < 100 suggests weak contractility. Complete absence of detrusor contraction may be termed as acontractile bladder (Fig. 8.4) [55, 57]. Because the equation was primarily developed for men with bladder outflow obstruction, Tan modified the BCI calculation and proposed a new formula of contraction strength for women, known as the projected isovolumetric detrusor pressure (PIP) [59]:

With this modified formula, normal contractility in the female was defined as PIP = 30–75 [59]. In efforts to better clarify detrusor underactivity, further calculations have been proposed that can be helpful in assessing more complicated patients; these should be studied in the professional urodynamic literature [60, 61].

In healthy individuals, there is a slight gradual increase in sphincter electromyogram (EMG) activity during bladder filling [67]. The EMG signal should stay relatively quiet and consistent [68]. During voiding, the first recorded event of this phase is a sudden and complete relaxation of the striated sphincteric muscles, shown by complete electrical silence of the EMG [67]. This is followed almost immediately by a rise in detrusor pressure as the bladder and proximal urethra become isobaric. The EMG signal then resumes once the bladder is empty. The sphincter complex is also coordinated during sudden increases in abdominal pressure. Coughing or Valsalva maneuvers elicit reflex contraction of the sphincter manifested as an increase in EMG activity [67].

In patients with DSD, relaxation of the striated sphincteric muscles during voiding is absent and coexists with detrusor contraction (Fig. 8.6) [67]. Diagnosis of DSD by EMG requires elevated EMG activity during detrusor contraction, in the absence of Valsalva and Crede maneuvers [8, 69]. These maneuvers would be detected as a rise in abdominal pressure (Pabd). Additional fluoroscopy has proven invaluable in the diagnosis because a urodynamist can see a dilation of the urethra to the level of the striated sphincter (spinning top urethra), no passing contrast through the area of the striated sphincter, and/or intermittent contractions of the striated sphincter.

Two classifications of DSD have been proposed. Blaivas et al. suggested that DSD should be classified according to the pattern of external urethral sphincter electromyographic activity, whereas Yalla et al. proposed classification according to the bladder pressure and resulting flow [70–72]. In order to simplify this condition for daily clinical practice, DSD can also be characterized as intermittent (Fig. 8.7) [68] or continuous (Fig. 8.8) [68] according to the consistency of the sphincter contraction during the detrusor contraction [10]. The initial description of DSD and the chronology of events still remain a matter of dispute. Studies have shown that urethral sphincter may contract before, after, or at the same time as detrusor [7, 71, 73].

Readers should be aware that the diagnosis of DSD with EMG is poorly standardized with variance in the type of electrodes (needle, patch) and their placement [8, 69]. Patch electrodes are frequently used due to easier placement, better tolerance, and greater patient mobility [69].

It is important to note that some volitional behaviors such as recruitment of pelvic floor due to pain or discomfort, Valsalva/Crede maneuvers, or any other source of artifact (fluid on patch, etc.) may mimic DSD [67]. If an unexpected increase in EMG signal was noted without any identifiable artifact, video imaging should be employed. Fluoroscopy can significantly help in the diagnosis of DSD and in the determination of vesicoureteral reflux [8, 17]. Furthermore, it is more sensitive in leakage detection than direct observation. Diagnostic discrepancy between EMG and fluoroscopy ranges from 40 to 46% [8, 69]. Male patients are more often diagnosed by means of EMG, whereas female patients are more often referred to video imaging [8, 69]. It has been suggested that the diagnosis of DSD in males by video imaging may be impaired due to anatomical bladder outflow obstruction (prostate), whereas in females diagnosis by EMG may be impaired due to increased electrode artifact [9]. A combination of EMG and fluoroscopy seems to be the best option but with limited availability [8, 69]. Moreover, it has been suggested that the clinician should be present during the urodynamic study to increase the accuracy of the diagnosis [9, 69].

A rare finding in neurologically impaired patients is a discoordination between bladder neck relaxation and detrusor contraction. This abnormality is also referred to as bladder neck dyssynergia, detrusor-internal sphincter dyssynergia, smooth sphincter dyssynergia, and proximal sphincter dyssynergia [7]. Similarly to DSD, this primary bladder neck obstruction leads to high detrusor pressure with low urinary flow rate. Non-neurogenic causes of the reported discoordination include benign prostatic hyperplasia and urethral stricture in males, and obstruction from pelvic organ prolapse, urethral stricture, previous anti-incontinence surgery, or urethral diverticulum in females [67]. Pelvic floor dysfunction is another possible cause seen in both sexes. Such discoordination does not cause a significant increase in EMG activity during voiding, as seen in tracing of patients with DSD or dysfunctional voiding (the EMG only reflects changes in the external urethral sphincter). Bladder neck dyssynergia can be diagnosed only by simultaneous imaging of the bladder outlet during voiding. Fluoroscopy of the pressure-flow study will show a failure of bladder neck opening (closed bladder neck and no bladder neck funneling) with a relaxation of the striated sphincter. Just for the record, patients with DSD will present with opened bladder neck without concurrent relaxation of the external sphincter [7, 74].

Clinicians should remember that in the absence of a neurological abnormality, impaired coordination of detrusor contraction and sphincter relaxation is more appropriately referred to as dysfunctional voiding or pelvic floor hyperactivity (see Chap. 2). Dysfunctional voiding is defined as an intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the peri-urethral striated muscle during voiding in neurologically normal individuals [1].

As patients with DSD are at high risk for multiple complications, including renal failure, and the disorder often worsens over time, routine lifelong follow-up monitoring should be offered to this specific group [7, 17, 70, 75]. It has been shown that patients with complete sensory and/or motor deficit have worse prognosis of DSD than those with incomplete deficits [75].

IC can be done either by the patient (intermittent self-catheterization, or ISC) or by a caregiver. Neurological disorders , including poor manual dexterity (in particular insufficient hand skills), weakness, tremor, rigidity, spasticity, disturbed perineal sensation, impaired visual acuity, cognitive impairment, or paraplegia, can affect the ability of a patient to perform self-catheterization [43]. Elderly patients should not be disqualified from self-techniques, as studies have shown that they have abilities similar to the general population in learning IC [81]. Thus, they should be offered IC preferentially over indwelling catheterization whenever possible. Furthermore, ISC is associated with reduced depression and lower discontinuation rates compared with assisted IC [82, 83]. General contraindications for IC include [54, 76]:

Such limitations should be carefully assessed before starting IC.

IC can be carried out with sterile or clean technique . The sterile (non-touch) variant involves using a sterile single-use catheter along with sterile gloves, gown, and mask; disinfectant wipes or swaps; and sterile drainage tray or closed collection bag. Healthcare professionals in hospital settings mainly use this technique. Clean technique uses either a sterile single-use catheter or a clean reused catheter and a clean container with clean gloves or hands washed with soap and water. Patient population using single-use hydrophilic catheters have an estimated incidence of urinary tract infection between 40 and 60%, compared with the observed prevalence of urinary tract infection for multiple use of 70–80% [84–87]. Clean technique has been widely adopted in community settings, as it is less time consuming and easier to perform, as well as decreases the cost of IC [88]. Nevertheless, the overall clinical evidence remains insufficient for powerful decision-making and it is not possible to state that one catheter method is better than another [77, 78, 89]. An updated systematic Cochrane review on strategies for catheter use emphasized that the evidence base is weak [90]. Currently, clean IC is most commonly used, and experts suggest that the sterile technique cannot be considered as a routine procedure [28, 91]. Sterile IC may be used in patients with recurrent urinary tract infections occurring with clean IC, and aseptic IC is an alternative to sterile IC [54, 76, 89, 92]. In addition, readers should be aware that decreased frequency of urinary tract infections with sterile technique is counterbalanced by significantly increasing cost compared with clean catheterization [89].

Suitable catheter material is an important factor for successful outcomes. Several types of catheter are currently available including [79]:

There are multiple products available with different features designed to make IC easier, depending on various circumstances (Fig. 8.9) [93]. A recently published systematic review with meta-analysis demonstrated advantages of hydrophilic-coated catheters in decreasing risk of urinary tract infection and urethral trauma, as well as improving patient’s satisfaction. Prelubricated catheters has been shown to be superior to conventional polyvinyl chloride catheters [89]. Moreover, it is noteworthy that catheter type may be important for patient compliance with treatment. Patient satisfaction is crucial, as it influences adherence to the IC regimen. Studies have shown greater degree of satisfaction with hydrophilic and prelubricated catheters , given their advantages of convenience, comfort, and ease of insertion when compared to conventional polyvinyl chloride [89, 94–98]. Therefore, acceptance might be maximized by starting all new patients on hydrophilic catheters [84].

In order to improve outcomes and prevent complications, proper education and support are required, both during initial teaching and future follow-up. A well-trained and experienced clinician, usually a specialized nurse, has a vital role in teaching proper self-catheterization technique, exploring possible barriers, and maintaining compliance with long-term management [99]. Well-structured training programs for patients have been shown to improve outcomes [81] and acceptance of treatment [100–102]. Patient education has been further described in Chap. 17, Proper Education of Patients Suffering from Neurogenic Bladder.

The frequency of catheterization depends on specific clinical presentation, including bladder volume, fluid intake, and PVR volume, as well as urodynamic parameters (compliance, detrusor pressure) [43]. Adequate frequency ranges from occasional IC to complete dependency on IC for bladder emptying [54]. Experts recommend that complete urinary retention should be managed with four to six catheterizations per 24 h [43]. Some individuals may need to awake from sleep at night to catheterize. If bladder volumes at catheterization consistently exceed 500 mL, it has been proposed to increase frequency of IC and adjust fluid intake, as well as to consider alternative method of bladder management [54, 76]. On the other hand, clinicians should be aware that more than six catheterizations per day is usually considered excessive and may have negative impact on patient compliance with treatment [42]. The catheter size most often used is between 12–16 Fr [28]. Patients who leak urine between catheterization require special attention. Possible causes of this situation include urinary tract infections, progression of neurological disease, emerging new problems of bladder or sphincter, as well as inadequate fluid intake. Those who are able to void but empty their bladder incompletely will need to use the catheter one to three times per 24 h after voiding [43].

Complications of IC include bacteriuria and urinary tract infection, urethritis, epididymoorchitis, epididymitis, prostatitis, urethral trauma/hematuria, urethral false passages, urethral stricture, autonomic dysreflexia (in those with injuries at T6 and above), and bladder stones [76]. Complications may increase in the long term [78]. However, it has to be emphasized that it is sometimes difficult to attribute causality because developing complications can potentially be caused by the underlying bladder dysfunction [79]. Complication rates are reduced with self-catheterization technique compared with assisted IC [86, 103, 104]. In individuals with recurrent urinary tract infections who perform IC, clinicians should reassess catheterization technique as well as consider change of catheter type, or start antibiotic prophylaxis [105]. Asymptomatic bacteriuria is a common finding in patients performing IC. It has been estimated that the incidence of bacteriuria is 1–3% per catheterization, and 1–4 episodes of bacteriuria occur for 100 days of clean IC [106]. After 30 days, almost all patients will develop this condition [107, 108]. Just for the record, asymptomatic bacteriuria should not be routinely treated except in pregnant women and individuals before surgical procedures within the urinary tract (see Chap. 10, “Urinary Tract Infection”).