Patients with spinal cord injury are at increased risk of developing symptomatic urinary tract infections (UTI).  Little is known about the true incidence of UTI in wheelchair athletes and the effect on training and performance. The incidence of UTI during Paralympic games in London in 2012 was reported as 8%, the fourth most common complaint after respiratory, skin and GI problems.(1)
The International Paralympic Committee acknowledges there are currently no guidelines on infection prevention or management targeted towards elite spinal cord injured athletes. (2)
We collected questionnaires with self reported UTI rates, catheter related complications and overall satisfaction with bladder management from members of the Wheelblacks New Zealand National wheelchair rugby team during a recent training camp. 
The aim is to evaluate incidence of UTI and catheter blockages, hospital admissions for UTI and disease specific absence from training. Further objectives are to understand the limitations to adequate infection prevention in these athletes and to highlight any inequities in access to healthcare specific to patients with disabilities

A questionnaire was developed and handed out during a Wheelblacks training camp. Questions focus on type and level of SCI, current type of bladder management, number of UTI or other catheter related complications and incontinence episodes.
Furthermore athletes were asked about their satisfaction with their bladder management, the impact on their life and training and how often they visit a urologist.
Hospital files were accessed to correlate urodynamic findings and urine culture results as well as attended follow up appointments and acute presentations with UTI.
An outline of patient demographics can be found in table 1.

The response rate to this audit was 74%. Out of the patients who replied the majority is being managed with suprapubic catheters (63%), two perform intermittent catheterization and one voids by volition.
All athletes report urinary tract infections, with the average being 2.6 infections in a 12 months period. One patient reports more than 5 infections.
Recurrent catheter blockages, for most of these patients associated with autonomic dysreflexia is reported by three of five patients (60%).
Four patients (50%) admit to urinary leakage per urethra, increased during training or competitions. 
This applies to patients with and without proven DOI or SUI on standard video urodynamics and is not related to catheter blockage.
Whilst only two patients have had emergency presentation with catheter related complications requiring hospital admission in the past year, half of them (50%) have missed at least one training session due to UTI. One patient has missed two training camps while another has missed an international competition due to infection.
The average urine output per 24 hour period as per urine collection is 3.07 litres  (2.68-4.16 litres) suggesting adequate fluid intake for infection and stone prevention.
Athletes attended on average one urology appointment per year, with two or more appointments attended in the private as opposed to the public sector.
One patient admits to disengaging from health care services completely after a traumatic experience attempted CIC. Another patient stopped attending follow-up as he has been well. Following our interview he agreed to come forward for an ultrasound of his renal tract and was found to have multiple bladder stones.
Only two out of the eight participating athletes are satisfied with their bladder management, one of them is performing intermittent catheterisation, the other one is voiding.
Urinary leakage during athletic performance and recurrent urinary tract infections remain the most common complaint

There is no standardized management or follow-up for high performance wheelchair athletes. Even with comparable injury level bladder management and related complications vary greatly. Whilst fluid intake and personal hygiene certainly play a role in infection prevention, other correlating factors specific to high performance athletes may be poorly understood. 
For patients with suprapubic catheters maintaining bladder capacity and alternative options of bladder drainage are a priority that may not have been explored. The number of infections with indwelling versus intermittent catheterisation is higher, 2.6 versus 2 infections per year respectively.
All questioned athletes admit to downplaying their bladder symptoms and self medicating for suspected infections for the sake of not missing out on training time. Only one of them has contacted a urologist for advice, with the remainder relying on the hospital system for follow-up or not engaging at all.
Urinary leakage during athletic performance and recurrent urinary tract infections remain the most common complaint. 
Especially lower level injury patients with suprapubic catheters expressed regrets over not being offered alternate measures of bladder emptying at the time of initial assessment

Little remains known about the specific requirements of professional wheelchair athletes with regards to urinary tract health.
The overall paucity of interaction with the healthcare system and lack of appointment availability leads to frustration for both patients and health care providers and a lot of work is needed to address this situation better. Regular surveillance is paramount for maintaining a healthy urinary tract and overall well-being to allow performance at this level of sport.
We must work at establishing a bladder management protocol specific to high performance wheelchair athletes taking into consideration position in training chairs, impaired catheter drainage and relative dehydration.
Disability sport lacks funding and support compared to able bodied team sports and this inequity extends into the healthcare sector.

Derman W, Schwellnus M, Jordaan E, et al Illness and injury in athletes during the competition period at the London 2012 Paralympic Games: development and implementation of a web-based surveillance system (WEB-IISS) for team medical staff British Journal of Sports Medicine 2013;47:420-425.
Compton, Stacey et al. “Australian Institute of Sport and the Australian Paralympic Committee position statement: urinary tract infection in spinal cord injured athletes.” British Journal of Sports Medicine 49 (2015): 1236 - 1240.

Continence 7S1 (2023) 100914
DOI: 10.1016/j.cont.2023.100914