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REVIEW ARTICLE
Year : 2000  |  Volume : 17  |  Issue : 1  |  Page : 1-5
 

Clean intermittent self-catheterisation - principles and practice


Department of Urology, Sri Ramachandra Medical College and Research Institute, Chennai, India

Correspondence Address:
Arun Narayanaswamy
18, Vasantha Avenue, M.R.C. Nagar, South Beach Road, Chennai - 600 028
India
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   Abstract 

This review of the literature on the principles and prac­tice of clean intermittent self-catheterisation includes the role of antiseptics/antibiotics, and outcome. It covers ac­ceptance of the technique, urinary tract infection, conti­nence, and preservation of upper urinary tract.


Keywords: Urethral Catheterisation; Clean Intermittent Self-catheterisation; Antiseptics; Antibiotics; Urinary Tract Infection; Continence; Upper Urinary Tract


How to cite this article:
Narayanaswamy A. Clean intermittent self-catheterisation - principles and practice. Indian J Urol 2000;17:1-5

How to cite this URL:
Narayanaswamy A. Clean intermittent self-catheterisation - principles and practice. Indian J Urol [serial online] 2000 [cited 2019 May 22];17:1-5. Available from: http://www.indianjurol.com/text.asp?2000/17/1/1/41003



   Introduction Top


The major concern in the care of patients with urinary retention or incontinence due to acontractile or neuropathic bladder is adequate bladder emptying, prevention of uri­nary tract infection and preservation of upper urinary tract function. Clean intermittent catheterisation has been clearly established as the best way of achieving good bladder emptying and has transformed the lives of people rendered housebound by bladder problems. Once the initial appre­hension is overcome, most people find intermittent cathe­terisation easy. Age and disability does not preclude a trial of intermittent catheterisation, and even patients with se­vere spinal deformity, absent perineal sensation, intention tremor, poor eyesight, etc., have been taught to catheter­ise themselves. Follow-up has shown that clean intermit­tent catheterisation gives good long-term results.


   History Top


Guttman and Frankel (1967) [1] pioneered the use of in­termittent catheterisation in spinal units. They advocated the use of sterile catheters and strict asepsis and stressed that the procedure should be performed by medical per­sonnel, in order to prevent infection. A different view of the origin of urinary infection in intermittently catheter­ised patients was expressed by Lapides (1972). [2] He pro­posed that a decreased blood flow to the renal tissue, ureter, bladder, and urethra due to over distension of the bladder and high intravesical pressure was the most frequent mechanism of the genesis of infection. It was postulated that the tissues became vulnerable to infection by inva­ding gram negative organisms from the patient's own gut via haematogenous and lymphogenous routes and that the bacterial flora of the urethra and vagina were of little im­portance. Any bacteria introduced into the bladder by the catheter would be neutralised by the resistance of the host, provided that an adequate blood supply was maintained to the tissues. On the basis of this hypothesis, Lapides devised a nonsterile "Clean" intermittent-self-catheteri­sation technique and proved it to be safe and effective. Intermittent catheterisation was thus made simple and could be incorporated into a daily routine.


   Effects of Intermittent Catheterisation Top
[3]

  1. Bladder Empties Completely and Under the Pa­tient's Control (Continence): A bladder that contains a large volume of residual urine soon reaches capacity, caus­ing frequency, urgency or incontinence. By eliminating residual urine, intermittent catheterisation enables the blad­der to function more effectively as a reservoir.
  2. Reduces Symptomatic Urinary Infection: As re­sidual urine is eliminated, urinary stasis leading to uri­nary infection and calculi is reduced.
  3. Prevention or Improvement of Upper Urinary Tract Dilatation: Sphincter overactivity leading to outlet obstruction, detrusor sphincter dyssynergia, and high in­travesical pressures is responsible for upper tract dilation by impeding drainage of urine from the kidneys and/or causing vesicoureteric reflux. Infection increases the risk of upper tract damage. Intermittent catheterisation pre­serves the upper tract by eliminating residual urine, de­creasing intravesical pressure and reducing urinary infection.



   Prerequisites Top
[3]

  1. Adequate Bladder Capacity: A large residual urine is a good indicator of bladder capacity. The greater the volume of residual urine, the better are the prospects of the patient remaining dry in between catheterisations. Pa­tients with hyper-reflexia require anticholinergic drugs to attain a storing capacity and if still not achieved, they may require augmentation.
  2. Sphincter Activity: Adequate sphincter activity is also indicated by the presence of residual urine. Drugs and/or surgery may be required in some to achieve this.
  3. Motivation: Motivation is absolutely essential for the success of this program.



   Indications Top


  1. Neuropathic Bladder (Spinal Dysraphism, Multiple Sclerosis, Spinal Cord Tumour and Injury, Disc Prolapse, Diabetic Neuropathy, Transverse Myelitis, Unknown).
  2. Acontractile Bladder.
  3. Post Operative Retention.
  4. Following Bladder Reconstruction (Augmentation Cystoplasty, Continent Reservoir).



   Procedure Top


Assessment

Physical examination should include assessment of spi­nal deformities, hand movements, eyesight, and sensation in the saddle area. Relevant investigations should be car­ried out to establish a diagnosis as well as to serve as a baseline for future comparison.

Teaching Catheterisation

Intermittent catheterisation is best taught with the pa­tient admitted to the hospital as this gives an opportunity to closely observe the patient during the learning process. It may also be wise to cover the initial few days with anti­biotics till the technique is perfected. A doctor, continence adviser or a specially trained nurse takes charge of the education, and must explain the rationale and benefits, reassuring the patient that intermittent catheterisation is neither painful, difficult nor dangerous. Clear diagrams help the patient in understanding the anatomy. The sup­port of a fellow user of intermittent catheterisation is in­valuable. A booklet or a list of "do's and don'ts" can be a very useful aid.

The lesson starts with emphasis on thorough cleaning of the hands and perineal area / penis with soap and water. The catheter is then washed with water. After washing the hands and catheter, the patient must be instructed not to touch any contaminated area. The female subject sits on the examination table with feet on the table, lower limbs flexed and knees held apart. In the sitting position the pa­tient is able to visualise the perineum in a mirror at the foot of the table. The labia are separated and the subject is instructed to insert the catheter through the urethral meatus into the bladder holding the catheter 2 cm from the tip. With practice the patient learns to locate the meatus with­out the mirror by just feeling for the meatus. Male pa­tients may learn the technique in the sitting or standing position and are advised to use a water-soluble lubricant for easy catheterisation. Once urine starts to flow out the patient is instructed to pass the catheter in for 2 cm more. Once urine has stopped flowing the catheter should be rotated and suprapubic pressure given. Then the catheter is withdrawn slowly. If urine starts to drain during with­drawal, the patient is instructed to wait with the catheter at that level till the urine stops flowing. These simple mea­sures ensure that the bladder is completely emptied. The patient is warned never to forego catheterisation even when soap and water are not available but to catheterise at the prescribed time with the best available measures.

How Often to Catheterise

Catheterisation must be frequent enough to prevent the bladder becoming overdistended and to keep the patient dry. [3] Patients should normally catheterise at least four times a day, more frequently in children, in patients with a high fluid intake, and in patients with a small capacity bladder. The volume obtained on catheterisation gives an estimate of bladder capacity and suggests how much can be drunk between catheterisation if the patient is to remain dry. This volume should ideally be kept around 300 ml. Patients soon learn to balance fluid intake with frequency of cath­eterisation in order to remain dry. To ensure timely cath­eterisation the technique is kept simple. No bedtime drink is to be taken, unless the patient catheterises during the night. A daily intake of 2 L is sufficient.

Catheters and Catheter Care

Plastic (Polyvinyl chloride) catheters are commonly used. In India, plastic catheters such as "K90", "Safe-flo" are available. Foley catheters have been successfully used by patients, but some feel more comfortable with the stiffer plastic catheter. In the West hydrophilic (Polyvinyl pyrro­lidone) coated "low fric" catheters are available, but are expensive. [4] The use of stainles steel catheters [5] by females and also red rubber tubes has been reported. Adults use 10-14 F catheters while children use 6-10 F catheters. For small babies, a 4-6 F infant feeding tube is ideal. [3]

The care of catheters is varied. Some authors have ad­vocated a new catheter for each use. Some have advo­cated keeping the catheter in antiseptic solutions [3] (Sodium hypochlorite, Povidone iodine, etc.) Some have advocated boiling [6] or microwave sterilisation of the catheter. But even with the most casual catheter use, symptomatic UTI are not more than what is commonly reported. [8] Infections are more of a problem in patients who catheterise infrequently, in patients with faulty techniques, and in those with established renal damage. Keeping the catheter clean and dry is all that is required, [8] and has been compared to the care of the toothbrush. After use, the outer surface of the cath­eter may be washed with soap and water and the inside with clean water. Water inside the catheter is then tho­roughly wrung out and the catheter carried in a dry state in a clean container. The catheter may be re-used, and there is no fixed period of time for usage. A common sense approach is applied and the catheter is changed when it gets dirty or damaged.

Role of Antiseptics [8]

In many spinal units where chlohexidine was used to prepare the urethra it was found that the normal gram posi­tive flora was reduced and in its place gram negative ba­cilli were usually responsible for urinary infection. These agents are more active against the gram positive skin in­habitants which are known to exclude the pathogenic bac­teria by producing antibacterial factors. The use of these agents may be counter-productive. Povidone iodine has been recommended in view of its more uniform activity against both gram negative and gram positive bacteria, but there was no evidence to suggest that it was effective in excluding the gram negative bacteria which was the real threat. Also these agents may, after repeated use, cause inflammation of the glans. Similarly there was no advan­tage of antibacterial lubricants or bladder instillations. Saline washes are adequate if there is accumulation of debris in the bladder. Perineal hygiene was the most im­portant factor in preventing skin and lower urethral coloni­sation by gram negative bacteria. Washing with soap and water was found to be adequate.

Role of Antibiotics

Bacteriuria is found in most patients practising inter­mittent catherisation. But the real question is its signifi­cance, and should it be treated?

Maynard et al [9] divided 50 patients on intermittent cathe­terisation following spinal injury into groups: those re­ceiving or not receiving prophylactic antibiotics. Both groups were further divided into sub-groups in which labo­ratory infections (bacteriuria) were treated with definitive antibiotics or in which antibiotics were given only for clini­cal infections. Antibiotic prophylaxis greatly reduced the probability of bacteriuria but not that of clinical infections, though a trend was noted towards fewer clinical infec­tions. No significant reduction was noted in the probabil­ity of clinical infections in the sub-groups treated promptly for bacteriuria. In most patients who developed clinical infections, there was no prior warning in the culture. Also cultures were found to become sterile with no treatment. Hence it seems that host resistance is more important, and that prophylactic antibiotics do not decrease the incidence of clinical infections.

Bakke [10] showed that the bacterial flora shifts from en­terobacteria to a more pathogenic species in patients us­ing antibiotics. Though bacteriuria was less in these patients, clinical infections were more. Kass [11] studied 255 children on long-term intermittent catheterisation and found that bacteriuria or in association with low grade (I,IIA) reflux was harmless, febrile urinary infections oc­curring only in 3%. Whereas, bacteriuria in association with high grade reflux was associated with a 37% inci­dence of febrile urinary infections. They advocated the use of antibiotics in this group, and if the urine could still not be made sterile, then reimplantation was recommended.

In summary, antibiotics seem to have a very limited role. All clinical infections are treated with antibiotics. Bacte­riuria need not be treated except in patients with severe upper tract damage/high grade reflux and in the immuno­compromised (Renal Transplant). Antibiotic prophylaxis is also recommended in this group. Therapeutic antibiot­ics are to be used in infections with stone-forming organ­isms (e.g. Proteus) even if asymptomatic.


   Follow-Up Top


Patients should be seen frequently till they are confi­dent about the technique. Ultrasound residual urine meas­urement may be done to ensure that the bladder is being completely emptied. In the male sphincter spasm may pre­vent the catheter from entering the bladder. Waiting at this level with gentle pressure or the use of a stiffer, narrower, curved catheter may be effective. [12] A device (Devin Hunt device) [13] which holds the legs in abduction and incorpo­rates a mirror has been devised for use in patients with adductor spasm. Long-term follow-up with blood bioche­mistry/urine culture and upper-tract imaging is also es­sential.


   Results Top


Acceptance of the Technique

Overall the patients were satisfied. According to Dio­kno, [14] about two out of three patients who learn intermit­tent catheterisation continue to use it indefinitely. For them it becomes a way of life, taking no longer to catheterise than other people do to void. Successful outcome was re­ported in 158 out of 208 patients by Hunt' and in 156 out of 172 patients by Webb. [15] The dropout rate reported by most of the authors is low, ranging between 0% and 9%. [15],[16],[17] However Sutton [18] reported a rate of 19% and Hellstorm [19] reported a rate of 24%. Dropout is usually due to difficulty in catheterisation (spine deformity, adductor spasm, sensory loss, poor manipulation), continued incon­tinence, infections, distaste, false passage, and worsening of the disease. [15] About 10% [10] of patients (unusual body conformations, poor hand function, blindness, and chil­dren) require help to catheterise.

Urinary Tract Infection

Even though complications from the urinary tract are decreased considerably in patients on clean intermittent catheterisation, urinary tract infection is still a major chal­lenge confronting these patients. The simple presence of organisms is referred as bacteriuria. Patients were classi­fied as having clinical urinary tract infection if they had signs of infection such as general malaise, fever, urethral discharge, offensive odour, urgency, suprapubic discomfort, and need for more frequent catheterisation. [10],[16] The rates of bacteriuria range from 42% to 88.6% (average 72%) and that of clinical infection from 5% to 42% (average 23%). [6],[9],[10],[11],[15],[16],[19],[20],[21],[22],[23],[24] Bacteriuria is harmless and is not associated with tissue invasion whereas clinical in­fection is associated with tissue invasion. Patients with clinical infections respond well to antibiotics. Infections were more common in patients with abnormal upper tracts and were frequently caused by organisms other than  E.coli Scientific Name Search . [6]

A study by Bakke [10] on 302 patients on intermittent cath­eterisation focussed on the risk factors of urinary tract in­fection. Predictive value for clinical urinary tract infections in women were low age and high mean-catheterisation value. In men, low age, neurogenic bladder dysfunction especially with urinary leakage, and non-self-catheterisa­tion were predictors. Bacteriuria was a risk factor of fu­ture clinical infections and bacteriuria. Low frequency of catheterisation, high age, and non-self-catheterisation were the risk factors of bacteriuria.

Continence

Continence is achieved in the majority. The continence rates reported ranged between 80% and 95%. [15],[16],[21],[22] Initial poor control often improves with time. Even if com­plete dryness was not obtained, the patients appreciate the decrease in leakage.

Upper Tract Preservation

Intermittent catheterisation is excellent for upper tract preservation. Deterioration rates reported ranged between 0% and 14% (average 9%). [6],[16],[20],[21],[22],[25],[26] The majority of the patients who have an initial normal upper tract remain normal. While most authors reported no deterioration in their patients with normal upper tracts, Jean Jacques re­ported deterioration in 6% of his patients. This occurred due to neuropathic changes causing a decrease in compli­ance. Jean Jacques [22] also reported improvement of initially dilated upper tracts in 74%, but settling of reflux in only 33%. In Lindehall's [25] report out of 49 patients with nor­mal upper tracts 47 remained normal, out of 27 patients with isolated dilatation or reflux 17 became normal, and out of 13 patients with dilatation and reflux only 3 be­came normal.

In summary, dilatation due to high grade reflux is less likely to settle with intermittent catheterisation. This indi­cates more severe bladder damage. Deterioration of the upper tracts is more likely in patients with initial abnor­mal upper tracts. However, even patients with initial nor­mal upper tracts have a small risk of deterioration. Hence it is mandatory to follow up patients on intermittent cathe­terisation with upper tract imaging.


   Complications Top


Apart from infective complications, urethral complica­tions such as bleeding, stricture, and false passage are important. Lapides [21] reported a 11% complication rate in patients followed up for 5 years and Wyndale [22] reported a rate of 20% in patients followed up for 12 years. False passages are more common in patients who have had pre­vious surgery. A posterior ledge at the bladder neck has been found to develop in some patients. [27] When this is more than 0.5 cm it causes difficulty in catheterisation and bleeding. Bladder calculi may develop. Rare compli­cations include perforation of the bladder, [28],[29] squamous cell carcinoma, and xanthogranulomatous pseudotumour. [30] The risk of urethral complications is greater in male pa­tients and in patients with decreased sensation.


   Conclusion Top


Careful introduction, continued suppport, and consis­tent encouragement are the key to a successful clean in­termittent catheterisation program. Socio-economic factors, literacy, and availability of a convenient surround­ing are important factors to be considered, especially in our setting. Psychological assistance is also important. Other methods of bladder drainage such as Crede's ma­noeuvre, straining, and reflex voiding are much less ef­fective. Continuous catheterisation has a higher rate of urethral and infective complications. Diversion also has its fair share of complications. In comparison, intermit­tent catheterisation is simple and effective. If it is not suc­cessful all other options remain available as no surgery has been performed. Intermittent catheterisation is thus an outstanding weapon.

 
   References Top

1.Bloom DA, McGuire EJ, Lapides J. A brief history of urethral cath­eterisation. J Urol 1994; 151: 317-325.  Back to cited text no. 1  [PUBMED]  
2.Lapides J, Diokno AC, Silber SJ, Lowe BS. Clean Intermittent Self­Catheterisation in the treatment of urinary tract disease. J Urol 1972; 107: 458-461.  Back to cited text no. 2  [PUBMED]  
3.Hunt GM, Oakeshott P, Whitaker RH. Intermittent catheterisation: simple, safe, and effective but underused. B. M. J (London) 1996; 312:103-107.  Back to cited text no. 3    
4.Sutherland RS, Kogan BA, Baskin LS, Mevorach RA. Clean Inter­mittent Cathterisation in boys using the Lofric catheter. J Urol 1996; 156: 2041-2043.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Bruschini H, Denes FT, Mitre AI, Arap S. New method for aseptic intermittent self-catheterisation in females. Urology 1987; 30: 386­-387.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Taylor CED, Hunt GM, Matthews G. Bacterial study of clean inter­mittent catheterisation in children. Br J Urol 1986; 58: 64-69.  Back to cited text no. 6    
7.Silbar EC, Cicmanec JF, Burke BM, Bracken RB. Microwave ste­rilization - A method for home sterilization of urinary catheters. J Urol 1989; 141: 88-90.  Back to cited text no. 7  [PUBMED]  
8.Chawla JC, Clayton CL, Stickler DJ. Antiseptics in the long-term urological management of patients by intermittent catheterisation. Br J Urol 1988; 62: 289-294.  Back to cited text no. 8  [PUBMED]  
9.Maynard FM, Diokno AC. Urinary infection and complications during clean intermittent catheterisation following spinal cord injury. J Urol 1984; 132: 943-946.  Back to cited text no. 9  [PUBMED]  
10.Bakke A, Vollset SE. Risk factors for bacteriuria and clinical uri­nary tract infection in patients treated with clean intermittent cathe­terisation. J Urol 1993; 149: 527-531.  Back to cited text no. 10  [PUBMED]  
11.Kass EJ, Koff SA. Diokno AC, Lapides J. The significance of ba­cilluria in children on long-term intermittent catheterisations. J Urol 1981; 126: 223-225.  Back to cited text no. 11    
12.Hill VB, Davies WE. A swing to intermittent clean self-catheteri­sation as a preferred mode of management of the neuropathic blad­der for the dextrous spinal cord patient. Paraplegia 1988; 26: 405-412.  Back to cited text no. 12  [PUBMED]  
13.Hunt GM, Whitaker RH. A new device for self-catheterisation in wheelchair-bound women. Br J Urol 1990; 66: 162-163.  Back to cited text no. 13  [PUBMED]  
14.Diokno AC, Sonda P, Hollander JB, Lapides J. Fate of patients started on clean intermittent catheterisation therapy 10 years ago. J Urol 1983; 129: 1120-1121.  Back to cited text no. 14    
15.Webb RJ, Lawson AL, Neal DE. Clean intermittent self-catheterisation in 172 adults. Br J Urol 1990; 65: 20-23.  Back to cited text no. 15  [PUBMED]  
16.de la Hunt MN, Deegan S, Scott JE. Intermittent catheterisation for neurogenic urinary incontinence. Arch Dis Child 1989; 64: 821­-824.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]
17.Lindehall B, Moller A, Hjalmas K, Jodal U. Long-term intermittent catheterisation. The experience of teenagers and young adults with myelomeningocele. J Urol 1994; 152: 187-189.  Back to cited text no. 17    
18.Sutton G, Shah S, Hill V. Clean intermittent self-catheterisation for quadriplegic patients - a five year follow-up. Paraplegia 1991; 29: 542-549.  Back to cited text no. 18  [PUBMED]  
19.Hellstrom P, Tammela T, Lukkarinen O, Kontturi M. Efficacy and safety of clean intermittent catheterisation in adults. Eur Urol 1991; 20: 117-121.  Back to cited text no. 19    
20.Joseph DB, Bauer SB. Colodny AH, Mandell J, Retik AB. Clean intermittent catheterisation of infants with neurogenic bladder. Pae­diatrics 1989: 84: 78-82.  Back to cited text no. 20    
21.Lapides J, Diokno AC, Gould FR, Lowe BS. Further observations on self-catheterisation. J Urol 1976; 116: 169-171.  Back to cited text no. 21  [PUBMED]  
22.Wyndaele JJ, Maes D. Clean intermittent self-catheterisation: A 12-year follow-up. J Urol 1990; 143: 906-908.  Back to cited text no. 22  [PUBMED]  
23.Lin-Dyken DC, Wolraich ML, Hawtrey CE, Doja MS. Follow-up of clean intermittent catheterisation for children with neurogenic bladders. Urology 1992; 40: 525-529.  Back to cited text no. 23  [PUBMED]  
24.Kuhn W, Rist M, Zaech GA. Intermittent urethral self-catheterisa­tion - long-term results. Paraplegia 1991; 29: 222-232.  Back to cited text no. 24  [PUBMED]  
25.Lindehall B, Claesson I, Hjalmas K, Jodal U. Effect of clean inter­mittent catheterisation on radiological appearance of the upper uri­nary tract in children with myelomeningocele. Br J Urol 1991; 67: 415-419.  Back to cited text no. 25    
26.Bren AS, Martin D, Callaghan J, Maynard J. Long-term renal risk factors in children with meningomyelocele. J Pediatr 1987; 110: 51-55.  Back to cited text no. 26    
27.Perkash I, Friedland GW. Posterior ledge at bladder neck: Crucial diagnostic role for ultrasound. Urol Radiol 1986; 8: 175-183.  Back to cited text no. 27  [PUBMED]  
28.Elder JS, Synder HM, Hulbert WC, Duckett JW. Perforation of the augmented bladder in patients undergoing clean intermittent catheterisation. J Urol 1988; 140: 1159-1162.  Back to cited text no. 28    
29.Reisman EM, Preminger GM. Bladder perforation secondary to clean intermittent catheterisation. J Urol 1989; 142: 1316-1317.  Back to cited text no. 29  [PUBMED]  
30.Bellville WB, Park JM, Kelly JL, Vaccoro JA. Perineal xanthogra­nulomatous pseudo tumour due to intermittent catheterisation: a leiomyosarcoma mimic. Paraplegia 1994; 32: 624-626.  Back to cited text no. 30    




 

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    Abstract
    Introduction
    History
    Effects of Inter...
    Prerequisites
    Indications
    Procedure
    Follow-Up
    Results
    Complications
    Conclusion
    References

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