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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 transformed the lives of people rendered housebound by bladder problems and has preserved the kidneys of children with spina bifida, and of adults with spinal cord injury. ISC has been shown to significantly improve the quality of life of those using it.
- 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[2, 3].
- 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.
- Intermittent low-friction self-catheterisation may be effective in preventing recurrences of urethral strictures, but the increased benefit over active surveillance is yet to be established.
- 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.
- 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.
- 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.
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. 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. 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; however, it has not yet been established whether incidence of UTI, other complications, or user satisfaction are affected by sterile or clean technique, coated or uncoated catheters or by any other strategy. Sterile IC cannot be considered a routine procedure. Aseptic IC is an alternative to sterile IC.
These are infrequent, particularly in female patients.
Further reading and references
Intermittent Self Catheterisation; Bowel and Bladder Community support group
Fumincelli L, Mazzo A, Martins JCA, et al; Quality of life of patients using intermittent urinary catheterization. Rev Lat Am Enfermagem. 2017 Jul 1025:e2906. doi: 10.1590/1518-8345.1816.2906.
Taweel WA, Seyam R; Neurogenic bladder in spinal cord injury patients. Res Rep Urol. 2015 Jun 107:85-99. doi: 10.2147/RRU.S29644. eCollection 2015.
Neuro-urology; European Association of Urology (2017 - updated 2018)
Chang YH, Siu JJ, Hsiao PJ, et al; Review of underactive bladder. J Formos Med Assoc. 2018 Mar117(3):178-184. doi: 10.1016/j.jfma.2017.09.006. Epub 2017 Sep 30.
Tian Y, Wazir R, Wang J, et al; Prevention of stricture recurrence following urethral internal urethrotomy: routine repeated dilations or active surveillance? Urol J. 2016 Aug 2513(4):2794-6.
Weynants L, Herve F, Decalf V, et al; Clean Intermittent Self-Catheterization as a Treatment Modality for Urinary Retention: Perceptions of Urologists. Int Neurourol J. 2017 Sep21(3):189-196. doi: 10.5213/inj.1734824.412. Epub 2017 Sep 12.
Shamout S, Biardeau X, Corcos J, et al; Outcome comparison of different approaches to self-intermittent catheterization in neurogenic patients: a systematic review. Spinal Cord. 2017 Jul55(7):629-643. doi: 10.1038/sc.2016.192. Epub 2017 Jan 24.