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
18, Vasantha Avenue, M.R.C. Nagar, South Beach Road, Chennai - 600 028
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.
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Narayanaswamy A. Clean intermittent self-catheterisation - principles and practice.Indian J Urol 2000;17:1-5
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Narayanaswamy A. Clean intermittent self-catheterisation - principles and practice. Indian J Urol [serial online] 2000 [cited 2021 Apr 17 ];17:1-5
Available from: https://www.indianjurol.com/text.asp?2000/17/1/1/41003
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.
Guttman and Frankel (1967)  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).  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 
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.Reduces Symptomatic Urinary Infection: As residual urine is eliminated, urinary stasis leading to urinary infection and calculi is reduced.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.
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. 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.Motivation: Motivation is absolutely essential for the success of this program.
Neuropathic Bladder (Spinal Dysraphism, Multiple Sclerosis, Spinal Cord Tumour and Injury, Disc Prolapse, Diabetic Neuropathy, Transverse Myelitis, Unknown).Acontractile Bladder.Post Operative Retention.Following Bladder Reconstruction (Augmentation Cystoplasty, Continent Reservoir).
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.
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.  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.  The use of stainles steel catheters  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. 
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  (Sodium hypochlorite, Povidone iodine, etc.) Some have advocated boiling  or microwave sterilisation of the catheter. But even with the most casual catheter use, symptomatic UTI are not more than what is commonly reported.  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,  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 
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  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  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  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.
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.  A device (Devin Hunt device)  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.
Acceptance of the Technique
Overall the patients were satisfied. According to Diokno,  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.  The dropout rate reported by most of the authors is low, ranging between 0% and 9%. ,, However Sutton  reported a rate of 19% and Hellstorm  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.  About 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. , The rates of bacteriuria range from 42% to 88.6% (average 72%) and that of clinical infection from 5% to 42% (average 23%). ,,,,,,,,,,, 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. 
A study by Bakke  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 is achieved in the majority. The continence rates reported ranged between 80% and 95%. ,,, 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%). ,,,,,, 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  also reported improvement of initially dilated upper tracts in 74%, but settling of reflux in only 33%. In Lindehall's  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.
Apart from infective complications, urethral complications such as bleeding, stricture, and false passage are important. Lapides  reported a 11% complication rate in patients followed up for 5 years and Wyndale  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.  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, , squamous cell carcinoma, and xanthogranulomatous pseudotumour.  The risk of urethral complications is greater in male patients and in patients with decreased sensation.
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.
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