Self Catherization. An alternative to Turp, Greenlight, HoLEP...?
Posted , 82 users are following.
Since I posted a thread about self-catherization -- more formally called Clean Intermittent Catherization (CIC) -- there have been a few different discussions on the topic in various threads. I thought it might make sense to bring those discussions over to a dedicated thread. With that in mind, I will summarize and/or copy and paste some of what was said before into this thread for better continuity.
My story in a nutshell. 68 years old with BPH probably since my late 20’s. Watch n’Wait strategy with on-and-off trials of Tamsulosin (Flomax) with poor results. Symptoms were the normal retention issues resulting in frequent urination with incomplete emptying, urgency, and having to go to the bathroom at night in increasing frequencies. Near the end, two or three uti’s per year often accompanied by gross hematuria (bleeding).
Two years ago things got significantly worse and I couldn’t urinate on my own without physically pushing against my bladder (Crede Maneuver). That led to another trip to the urologist where ultrasound showed significant retention and hydronephrosis (water in the kidneys). I was told I needed an operation (this facility primarily did Turps) but first I had to rehabilitate my bladder because at the time it was too flaccid (stretched) for a good surgical outcome. I was given the choice of wearing a Foley Catheter for six weeks, or a program of self-catherization (CIC) in order to decompress the bladder. I chose CIC so I didn’t have to wear a Foley 24/7, and also because I felt it put me more in control.
Six weeks later my bladder was rehabilitated to the extent they could do a Turp, and the hydronephrosis was gone. After doing some research and a lot of thinking I decided to put off the Turp due to the potential of irreversible side effects, primarily retrograde ejaculation. Two years later, I am still doing CIC while waiting for newer procedures with better outcomes and fewer side effects.
I will detail my experiences with CIC in following posts -- but to summarize, once mastered, it’s a painless five minute procedure that allows you to empty your bladder completely any time you want. With CIC, I therefore have no retention issues, no urgency, and in most cases sleep 6-8 hours through the night without having to get up and go to the bathroom. No UTI’s in over 18 months. And because my bladder has been partially rehabilitated, I can urinate normally about 50% of the time without using the Crede maneuver. My IPSS Score (International Prostate Symptom Score) would be Zero (the best), albeit with a little mechanical assist. 
As of now, nothing that I have read about the various current procedures has tempted me to have an operation. That could, or could not change, in the future, but the nice thing about CIC is that you can stop it any time you want with no repercussions. The caveat is that CIC should be done under the supervision of a doctor who will monitor your BPH as required. Similar to seeing a doctor on a regular basis during a Watch n’ Wait BPH strategy.
I know many of you here have already had operations like Turp, and in most cases people seem pleased with the outcomes. CIC certainly isn’t’ for everyone, and I can understand why someone does not want to carry around a urinary “tool box” with them. On the other hand, with practice, it’s not the traumatic and scary procedure some think. I can honestly say right now that for me it’s about as traumatic as brushing my teeth.
I’m offering my experiences and thoughts on CIC for any of those who haven’t yet made up their mind on an operation. It even can make sense for those of you who don’t need an operation yet, but want to increase their IPSS quality of life score. In fact, wish I had done CIC earlier while on Watchful Waiting. Didn’t realize how much BPH had been affecting me for most of my adult life until I was able to empty my bladder completely.
CIC doesn’t have to be a permanent solution, it could just part of a waiting strategy like I’m on, until better surgical operations are developed with better outcomes and fewer permanent side effects.
For any number of reasons, the majority of urologists don’t seem to offer CIC as an alternative to surgery. My current urologist doesn’t as far as I know, but he’s OK with what I’m doing because it works for me. So, either you have to find a urologist you can convince to go along, or go to some of the major teaching hospitals where CIC is probably more in use and better understood. That is where I was taught, albeit not very well, but that is another story.
Jim
19 likes, 2092 replies
tim68354 jimjames
Posted
jimjames tim68354
Posted
Hi Tim,
If your PVR is hovering around 500-600ml, I suggest you increase your cath frequency and/or adjust fluid intake so your bladder isn't holding more than 400ml at any one time. The 400ml would be the sum of what you cath and any natural void just preceding it. If you consistently carry around more than 400ml, your bladder will remain stretched and it will compromise rehabilitation. Keeping void logs from time to time will help keep things honest. Feel free to post or private message me a 24 hour void log if you want.
As to how long it might take, first of all there are no guarantees your bladder will be rehabbed because we are all different and different pre-existing.
conditions. That said, I had significant improvements after the two year mark, so your urologist is not wrong.
For me, alcohol stings and irritates so I don't use it, but I would not worry about killing any "good" bacteria during the cath process. You want to get the head of the penis and meatus as clean as possible. Providone Iodine doesn't irritate me but like I mentioned it can be a little messy because of its red color. BZK wipe are another option but the ones I get are often on the dry side. In fact, I've been thinking of looking into just buying BZK solution and using my own wipes or swabs to apply it.
Jim
keith42667 jimjames
Posted
I made a Uro appointment, not because I'm having any problems but because I tried to get my supplier to increase my catheters to 5 a day. I thought they could do it; or arrange it but they said I had to talk to the doctor. So I called them & the nurse said they wanted to see me first. Thats ok, I have been thinking I should probably go in to have my kidneys checked just to be safe. I know some of you gentlemen have recommended supervision by a good urologist if they will do so. I'll see how this visit goes. I've turned down about everything they wanted to do. Been thinking I should have a cystoscopy and/or a urodynamics test even though I'm pretty sure my problem is BPH. I ran out of the catheters I've been using the other day; glad I had some samples left over. Not sure how that happened. I chalked it up to snafus getting adjusted to new supplier.
I don't think I'm using 5 a day but its often more than 4. I'm using two between like 12:30 A.M. & 8:30 A.M. Some days, like today, I don't feel an urge until @1:30 P.M. Sometimes I have to do it because its been 5 hours or more. Other times I get a strong urge in early afternoon and have to do it twice within 2 hours and get around 350 - 380 cc or more. It seems to be all over the place. Today I've only done it 3 times since 6:30 A.M. and its almost 11:00 P.M. now. But I got @400 each time; had a strong urge before doing it but could never NV more than about 40cc.
I guess my question is: Will this settle down at some point? I feel kind of nervous when leaving to go somewhere because I don't know how long its going to be before I have to cath. I do have a travel kit but I much prefer to do CIC before I leave home if possible. Just less of a hassle and probably a little safer. I think I'm not worried about leaking or wetting myself; just trying to stay under 400. I still know that if I get a certain feeling that I'm getting close to 400. So typical I guess; Jim James always mentions that threshold and it DOES hold true for me. But I can definitely retain over that and not feel it if I'm not vigilant and aware of my internals.
jimjames keith42667
Posted
What you describe is normal. Unfortunately, the kidneys do not look at the clock to unload urine into the bladder. They have their own rhyme, reason and rhythm which is difficult to predict, although looking at 24 urine logs may be helpful.
But rather than worry too much, I would just keep going with the intent to keep total bladder volumes under 400ml. Sometimes, it's just easier to throw in an extra cath or two when convenient, regardless of the urge, so that you might be able to delay a cath when it's not convenient. In a nutshell, better to cath more than you need to, as opposed to less than you need to. In fact, might even be better to cath more than you need to, period, since the more the bladder is decompressed, the more it can rehab. I have more on this in my "on/off" CIC thread.
It took me a couple of years before things started to even out and I could have long spaces between caths.
Are you on Medicare? They pay for up to 6 catheters a day, and I would get an rx for that. Don't have to use them all, but good to have them there if you need them. 6 also seems to be the magic number if you have no or very little natural voids. I cathed 6x/day for some time, and often even more when needed.
As to away from home, a little planning and organizing goes a long way. Weather or not, you pack single use kits (catheter, wipe, hand wash, etc in a baggie) or pack separately, find something that works for you. Unfortunately, the Speedicaths don't fold that well so I put them in a cardboard tube that then went into a back pack or briefcase. I see no reason you couldn't have special pockets made to accommodate them either under a jacket, or even in your pants.
Jim
tim68354 jimjames
Posted
mike588 tim68354
Posted
I was having trouble with UTIs when using a dry catheter and lubricating it with gel - I spoke to my Urologist about self cath, she said not to worry about pushing bacteria in because you are going to flush it right out again. My theory is the gel does not flush out so easily, so if somehow bacteria gets on catheter with gel UTIs more likely.
Since I switched to a lubricated catheter I haven't had problems recently, I just wash everything with soap and warm water, no need for iodine or anything on tip - I'm using Coloplast Hydrophylic and get from a wholesaler for just over a dollar each, no insurance involved. I grab the catheter at the top to get a good grip, the hand can touch part of the catheter at the top that doesn't go in.
Good luck
jimjames tim68354
Posted
Tim,
When you say, "constant utis", could you be more specific. How often do you get them? Are they symptomatic or just cloudy urine with bacteria per urinalysis and culture? How symptomatic? In general, you only treat symptomatic UTIs when you self cath. A little cloudiness, some bacteria, even a little blood is pretty normal.
But if you are getting truly symptomatic UTIs, then you might try changing your cath technique even more. In my case, I find urethral trauma precedes my UTIs, probably making the urethra more vulnerable to the bacteria already there. For that reason, I ask for prophylactic antibiotics prior to procedures like cystoscopy, and even take them if I haven't cathed for say a couple of months where my urethra might have lost its conditioning.
Lastly, you could try urethral irrigation. It adds maybe a couple of minutes to the procedure, but I found success with it at one point. What you will want is some sort of antiseptic like providone iodine or perhaps BZK fluid, one of the Microcyn type products, even sterile water. I would not use alcohol or anything that stings.
What I did was to get a small bottle of OTC Gly Oxide, dump the Gly Oxide (actually you could save it for your gums) and then fill the bottle of Gly Oxide with an antiseptic after rinsing it out. Then before self cathing, I'd clean the head of the Gly Oxide applicator, stick it just inside the urethra, and give a little squirt (holding the penis somewhat straight) until the liquid came back out. Hopefully it got all the way to the internal sphincter and then out, but the idea is to clean out the urethra.
If you want to go further, I've seen setups where instead of irrigating from the meatus in, you irrigate from the internal sphincter out. In this case, you would fashion a short catheter and attach a syringe barrel. You would then insert the catheter just short of the internal sphincter and irrigate at that point. Never tried it but the idea here is that you're not pushing anything toward the bladder but away.
I did this for about four months at one point and not only did I not have a UTI, I didn't even become colonized. And then I did. Today, I use a much simpler technique and trade speed and ease for colonization, but if I started to get too many UTIs, I might go back.
Jim
jimjames
Posted
Forgot to expand on the "urethral trauma" part. If this rings a bell, then experimenting with a different catheter, or different size catheter might be worthwhile.
Jim
jimjames mike588
Posted
@Mike: I was having trouble with UTIs when using a dry catheter and lubricating it with gel - I spoke to my Urologist about self cath, she said not to worry about pushing bacteria in because you are going to flush it right out again.
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I haven't seen a difference in UTIs with gel based CIC versus Hydrophillic. It's possible that your lack of UTIs with hydrophillics has more to do with less urethral trauma than the gel. At least for me, urethral (or prostatic) trauma always seems to precede a UTI as it leaves the vunerable tissue more suseptible to the bacteria already there.
As to "flushing it out", not sure I agree. Some studies suggest that the problematic bacteria lives in urethra the first two or three inches from the meatus, and this can get pushed inside with resulting UTIs. That's one reason it's always ideal to void just prior to CIC, but some of us can't always do that. Some catheters have insertion tips that address the issue by forming a tunnel for the catheter to pass through those first few inches. I tried them years ago but found the trauma of the insertion tip outweighed the benefits. Urethral irrigation is another possibility for someone with repeated UTIs, especially if they don't have natural voids. Some even propose bladder irrigation which I tried several times but decided I didn't have a bad enough UTI problem to experiment with something with unknown long term side effects, although I suppose irrigating with sterile saline wouldn't be much of an issue.
Jim
mike588 jimjames
Posted
Thanks Jim, amazing how much you know about this stuff!
It would be interesting to ask an expert who has studied bacterial infections - according to my Uroligist's PA the same logic applies to what you are saying, the first 2 or 3 inches might have bacteria, but it would get flushed right out during CIC - are you saying the bacteria would somehow cling to the side of the bladder?
jimjames mike588
Posted
Unfortunately, the "experts" can only theorize on these things as studies are scant and conflicting plus the experts generally don't self cath themselves! I can't answer the question whether the bacteria clings to the side of the bladder or not, but even if it doesn't, keep in mind that even with the best CIC technique, a little urine still remains in the bladder after CIC, so there's that. What we can be sure of is that you need bacteria for UTIs although the presence of bacteria doesn't always mean you will get a UTI. There have also been studies suggesting that these "introducer tips" (correct name) are helpful with UTIs but we all know that studies can be wrong. FYI the introducer tips seem only available on closed system catheters where a sheath covers the whole catheter and a bag is attached. I can't say too much about those systems because I found it next to impossible to navigate a Coude tip through the sheath and keep it oriented properly so ended up with more trauma than anything else. I suppose a closed system -- with sheath and bag -- would be a viable option for someone who has constant UTIs and uses a straight catheter instead of a Coude.
Jim
dennis47445 jimjames
Posted
Jim, I notice that my urine is a little cloudy. Clear, but cloudy. I think I'll try a natural void first, before using the catheter. Perhaps, this way, I may be able to flush some bacteria out before using the catheter. I can see how by using a catheter that bacteria, could be pushed up into the bladder, which I believe is supposed to be sterile.
jimjames dennis47445
Posted
Hi Dennis,
Are you symptomatic or just cloudy urine? Cloudy urine suggests white blood cells in the urine, and is pretty normal if you CIC. If you put a dip stick in the urine (I use Siemens 10SG) you will no doubt see that your leucocytes are positive. In fact, you may also notice positive nitrites, or even traces of blood, invisible to the eye. Again, all pretty normal if you CIC.
Voiding before CIC can be helpful in cleaning the urethra, but a large percent of us who CIC will become colonized. "Colonized" is another way of saying that you have asymptomatic bacteria in your urine. I am currently colonized and usually am when CIC unless I take extreme precautions or am lucky. Once colonized, I pretty much remain colonized unless I treat with antibiotics, for say a symptomatic UTI.
So, not to worry, as long as you are asymptomatic, and the rule of thumb is not to treat with antibiotics unless you are symptomatic.
As you suggest, urine is normally sterile, but not when you self cath.
Jim
dennis47445 jimjames
Posted
I went to my urologist, and he did a test. I have a staph infection, but I couldn't feel any pain, or discomfort. If it weren't for the test, I wouldn't even know that I had an infection. He gave me 10 days of antibiotics. I don't like taking antibiotics, because i read somewhere that it kills off the good as well as the bad bacteria in our bodies. Got any suggestions?
jimjames dennis47445
Posted
Hi Dennis,
In general, if you're self cathing, and asymptomatic, no reason to treat a staph UTI. It's what is called asymptomatic bacteriuria, or "colonization". Most people who self cath will be colonized within a month or so. I'm colonized at the moment, and probably would test positive for some sort of bacteria, staph or otherwise, but because I'm asymptomatic, I won't even bother to get it cultured.
That said, I'm not a doctor, and this is just general advice. There could be something special about your medical condition and/or this particular strain of staph that warrants treatment, but I doubt it.
My unprofessional suggestion? Don't take the antibiotics or stop them if you already have, and then get a second opinion from another urologist, preferably one who has self cath patients.
The problem isn't just killing off the good bacteria, it's also building up resistance to antibiotics. Save them for when you really need them!
Curious, which particular staph did the culture show and what antibiotics did they recommend?
Jim
dennis47445 jimjames
Posted
Jim, no pain, so I guess i"m asymptomatic. Lucky for me. Don't want to go the antibiotic route if at all possible. I read somewhere that antibiotics will wipe out the good and the bad bacteria in our bodies. Then we have to start all over again. Mahalo, for your input and knowledge that you share so unselfishly!
jimjames dennis47445
Posted
There is some truth to that, Dennis, and that's why always a good idea to eat some yogurt and/or other probiotic when taking antibiotics. But I think the bigger issue is resistance because when you really need it, you want it to work and quickly.
Jim