**4. Microbiology—urine culture**

Urinary tract colonization often follows colonization of the urogenital tract, perineum or urethra with enteropathogenic microorganisms [66, 67]. In a study of 15 adult men with SCI and other neurogenic urinary dysfunctions, the normal flora of the perineum, penis and urethra regions was compared with the flora of 10 control men without neurogenic urinary disorders [68]. The predominant microorganisms with respect to the control group were Grampositive granules and diphtheroids. In the individuals with the neurogenic urinary disorder, the microorganisms isolated from the skin flora include species such as Enterobacteriaceae, Pseudomonas, Acinetobacter, and Enterococcus [68]. In addition, other studies of individuals with SCI as compared to non-injured patients, the presence of *E.coli* microorganisms and Klebsiella spp. are less, and have a higher frequency of infections than Pseudomonas, Proteus, and Serratia. Esclarin De Ruz et al. [20] reported that *E. coli*, 36% enterobacteria, 15% *Pseudomonas aeruginosa*, 15% *Acinetobacter* spp., 12% Enterococcus, 6% other microorganisms, and 26% multiple strains were isolated in 45%. In another study in 43 of 50 individuals with SCI, the same types of microorganisms as those from various areas of the skin, including perineal, peripubic, and perinatal regions, were isolated in urine [69]. In 50% of the cases, the same microorganism was isolated from the anterior urethra and from the bladder [70]. Also, the catheter insertion mode is also considered to be significant, which appears to cause an increase of approximately 10 times the number of bladder colonies [70]. The above results demonstrate the important role of bacterial colonization of the skin and urethra as a source of vaccination, through the catheters, of the bladder with microorganisms.

When a UTI is suspected, it is important that the urine specimen is obtained in an appropriate manner in order to prevent contamination and a potential false-positive result. For patients with indwelling catheters (either the urethral catheter or suprapubic), the indwelling catheter should be changed to a new catheter, and the specimen should be obtained from the new catheter after capping the catheter for a few minutes to allow a small amount of urine to collect in the bladder. The urine specimen should then be collected by uncapping the catheter. For patients with external catheters or those who perform IC, the specimen should be collected by catheterization with a new sterile catheter.
