Intermittent self-catheterisation

Intermittent self-catheterisation (ISC) is a safe and effective way of managing patients with urinary retention or incontinence due to a neuropathic or hypotonic bladder. It has been shown to improve the quality of life of those rendered housebound by bladder problems and has preserved the kidneys of children with spina bifida, and of adults with spinal cord injury.^{1 2}

Indications³

• Neurological lower urinary tract dysfunction - there is usually chronic urinary retention from a neuropathic bladder condition: for example, multiple sclerosis, diabetic neuropathy, spina bifida, spinal cord injury or spinal tumour.^{4 5}

• Detrusor hyperactivity and functional obstruction: many have sphincter dysfunction and are at risk for pyelonephritis and upper urinary tract injury.

• Detrusor underactivity - may be associated with urge incontinence - for example, some patients with diabetes and with bladder neuropathy may have instability requiring bladder-relaxing drugs but also have intermittent weak detrusor function with poor emptying. The addition of bladder-relaxing drugs may worsen the baseline poor detrusor function, resulting in retention and overflow incontinence. In some cases, the solution may be to combine bladder-relaxing medical therapy with ISC.⁶

• Intermittent low-friction self-catheterisation is effective in preventing recurrences of urethral strictures.^{7 8}

Patient assessment

• Patients should be referred to a urologist for full assessment and to initiate the patient in using self-catheterisation.

• Physical examination should include testing for pinprick sensation in the saddle area.

• Sensory loss in the second to fourth sacral dermatomes implies diminished awareness of a full bladder.

• Sensory loss that extends to the third lumbar dermatome suggests that catheterisation will be painless.

Investigations

• Urinalysis.

• Blood U&Es, creatinine and glucose.

• Ultrasound of the urinary tract.

• Plain X-ray to show urinary calculi and spinal abnormalities.

• In children, urodynamic assessment should include a cystogram to detect vesicoureteric reflux.

Requirements

• Severe disability is not a contra-indication since patients in wheelchairs have mastered the technique despite paraplegia, an anaesthetic perineum, spinal deformity, intention tremor, learning disability, old age or severe sight impairment.

• Patients, and/or carer, must be highly motivated.

• Adequate and effective education and support.

• Catheterisation can be performed by the patient or carer, but must be gentle, especially if lacking sensation, and must be used at least four times a day.

• They should always keep their catheter with them and not wait for urge before using.

• The procedure is usually performed 4-6 times a day; doing so less frequently increases the risk of urinary tract infections (UTIs); frequency is determined by residual urine volume and generally speaking the larger the amount of urine left in the bladder the greater the frequency of catheterisation. Some people only perform ISC once daily but bladder volumes should not exceed 400 ml.

Hand function, the presence or absence of tremor and visual acuity have been rated as important (when considering patients for ISC) by their consultants.⁹

Intermittent catheters

Patient choice and ease of use are major considerations in the decision-making process regarding which catheter to prescribe, as are lifestyle and the underlying bladder problem. Silicone catheters are preferred over latex ones as they are associated with lower infection risk and also avoid potential allergies.⁵ Providing patients with a range of suitable intermittent catheters will allow them to make informed choices and reduce wastage.

• Nélaton's catheters: come in a range of sizes and lengths.

• Single-use catheters: are sterile and have either a hydrophilic coating, which requires immersion in water for 30 seconds to activate, or a gel coating, which does not require any preparation prior to use.

• Reusable catheters: are made out of polyvinyl chloride and are non-coated. They can be washed and reused for up to a week.

• Catheter kits: combine an intermittent catheter with a urine containment pouch. This system is useful for travelling or when access to a toilet would be difficult.

• Scott catheter: female length, more rigid catheter for women who find a Nélaton's catheter difficult to handle.

• Metal catheters: female length, stainless steel catheters that can be sterilised. Some girls and women find the rigid catheter easier to handle.

Hydrophilic-coated catheters are superior in decreasing risk of UTI and urethral trauma as well as improving the patient's satisfaction.¹⁰ Pre-lubricated catheters have been shown to be superior to conventional polyvinyl chloride catheters.

Sterile intermittent catheterisation (IC) significantly reduces the risk of UTI compared with clean technique. Sterile IC cannot be considered a routine procedure. Aseptic IC is an alternative to sterile IC.

Antibiotic prophylaxis against symptomatic recurrent urinary tract infection reduces the burden on patients using the clean IC technique.¹¹

Complications

• UTI. These are a frequent complication - affecting 12-88% of research cohorts.¹²

• Bladder calculi.

• Urethral bleeding.

• Urethritis.

• Urethral stricture.

• False passage.

• Epididymo-orchitis.