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Intermittent self-catheterisation

Alison Bardsley
RGN DN MSc
Continence Services Manager
Oxford
Clinical Editor Continence UK

Intermittent self-catheterisation (ISC) or clean intermittent self-catheterisation (CISC) is a long established technique that enables patients to self-manage bladder emptying problems that have resulted in urinary retention.  

First practised in the 1970s by Jack Lapides, a US urologist, CISC is the technique of clean intermittent self-catheterisation where the patient or carer passes a catheter into the bladder in order to drain residual urine.1 Lapides and his colleagues found that CISC did not increase the incidence of kidney damage or urinary tract infection compared with sterile catheterisation. Performing CISC prevents overdistension of the bladder which can lead to reflux to the kidneys and reduces the incidence of urinary tract infections that develop due to retained stagnant urine.2

Bladder function
The bladder is a hollow, muscular sac sited in the pelvis that stores urine ready for excretion, and contains around 350–500 ml when full. Urine production by the kidneys is continuous, and during filling the bladder volume increases with very little change in internal pressure.3 The bladder muscle (detrusor) is relaxed during filling and leakage is prevented by the contraction of the bladder neck and external sphincter. During voiding the strong muscles in the bladder walls (the detrusor muscles) compress the bladder, squeezing the contents down into the urethra.

Two rings of muscle, the external and internal sphincters, maintain closure of the bladder neck. The internal sphincter is made up of smooth muscle fibres and these fibres maintain contraction, and is therefore not under voluntary control. The external sphincter is under voluntary control and is formed of a circular band of skeletal muscle supplied by the pudendal nerve. These fibres remain contracted as a result of central nervous system stimulation, except on voiding.

As the volume of the bladder reaches approximately 250 ml the stretch receptors within the bladder wall are stimulated, exciting sensory parasympathetic fibres that relay information to the sacral area of the spine. Parasympathetic motor neurones act to contract the detrusor muscle so that the pressure increases and the internal sphincter relaxes. At the same time, the somatic motor neurones supplying the external sphincter are inhibited, allowing the sphincter to open and urine to flow. The brain can override the micturition reflex by inhibiting the parasympathetic motor nerve fibres to the bladder and reinforcing contraction of the external sphincter.4 Increasing bladder volume leads to an increase in stretch receptor and nerve activity making the sensation to void more acute. When convenient, the brain centres remove the inhibition and voiding occurs under voluntary control. Following voiding less than 10 ml should remain in the bladder.4

Regular drainage of the bladder is important to prevent infection and dilation of the upper urinary tract.

Bladder dysfunction
There are many reasons for bladder dysfunction that may lead a person to need to perform CISC. Chronic retention is usually painless and many patients will still be able to pass urine urethrally, in fact some may pass normal volumes of urine through the day.5 Although not an emergency chronic retention patients may still require a urological assessment to determine the cause and check renal function.6

Problems with bladder function are often part of neurological disease or injury. The bladder in healthy individuals is controlled by neural input from different levels of the nervous system. Damage to the nerves and muscles within the pelvic floor can be caused by obstetric trauma (obstetric tears and epidural anaesthesia), chronic straining from constipation, congenital abnormality, surgery and injury.

Bladder dysfunction problems affect patients with cerebral diseases such as stroke, brain injury and progressive neurodegenerative diseases including multiple sclerosis and Parkinson's disease. Disease or injury to the peripheral innervation of the bladder (for example with uncontrolled diabetes) can cause disorders of both storage and emptying the bladder. If the bladder is unable to empty correctly the residual urine remaining acts as a stimulus causing bladder contractions. Some patients do not experience any sensation of incomplete emptying and may present only with frequency or recurrent urinary tract infections.

Bladder neck dyssynergia (lack of coordination), for example, where the sphincter contracts instead of relaxes when the detrusor contracts to empty the bladder, can lead to functional retention and is seen mainly in neurogenic patients.
When the bladder is unable to sustain an adequate contraction this is described as a detrusor hypoactivity. This condition usually results from nerve damage and the sensation to void is often absent or reduced leading to large bladder volumes.
Bladder outflow obstruction is most commonly seen in males due to prostatic enlargement or urethral strictures.7 However, tumours and chronic constipation can also lead to anatomical obstruction. CISC is not advisable for men with prostatic enlargement as this may damage the bladder neck. Urethral strictures (narrowing of the urethral opening) result from scar tissue as a consequence of infection or instrumentation (such as catheterisation) and are most common in males.

Some people experience incomplete bladder emptying following surgery such as colposuspension or tension free vaginal tapes (TVTs) and those at risk should be taught CISC before surgery. Botox injections into the bladder lining used to calm or deaden the sensation of overactive/unstable detrusor muscle can also lead to voiding dysfunction.  

Acute urinary retention refers to a sudden inability to pass urine, although many patients will report a reduction in flow rate over previous months. Acute retention will often be unexpected and always painful,8 and is predominantly found in male patients due to prostatic enlargement. It should be treated as a medical emergency, where a catheter needs to be passed to relieve the pain of retention as soon as possible.5

The purpose of CISC is to prevent the build-up of residual urine in the bladder in order to protect the upper urinary tract, prevent infection and promote continence by enabling individuals to completely empty their bladder. Symptoms of incomplete bladder emptying include:

  • Urinary tract infection (UTI).
  • Poor urine flow rate/stream.
  • Postvoiding dribble.
  • Straining to pass urine – or start flow.
  • Urgency, frequency and nocturia.
  • Suprapubic pain.
  • Distension of the abdomen.

For people who experience detrusor instability (frequency, urgency and nocturia) a combination of CISC and anticholinergic medication may be required.
The benefits of ISC include:9

  • Greater opportunity for patients to be independent and self-caring.
  • The risk of some catheter-associated problems is reduced or removed, such as urethral trauma, urinary tract infection and encrustration.
  • Upper urinary tract is protected from reflux.
  • There is a reduced need for equipment and appliances.
  • There is greater freedom for expression of sexuality and positive body image.

Types of catheter
Catheters for ISC do not require a retention balloon, and comprise a plastic tube with a tip at one end and funnel at the other. There are a number of different catheters available, and males require a standard/male length catheter. There are a number of Nelaton ISC catheters available which can be reused up to six times during a 24-hour period. These catheters may require an additional lubricant for patient comfort. A number of manufacturers produce single-use ISC catheters that have a hydrophilic coating to aid insertion. These are either water activated or coated with a lubricant that does not require water. These have been shown to be safe and comfortable for patients to use and can reduce urethral trauma.10,11

Also available are catheter "kits" where a urine drainage bag is attached within a sterile pack. These are useful for patients who cannot easily access toilet facilities or are travelling. Patients should be allowed the choice of catheter to promote maximum independence and to fit in with their lifestyle. This support will be provided under a specialist nurse/urologist care programme.

Patient selection
CISC requires a high level of patient commitment, and some people may abandon it, particularly if under stress. Patients need to be well motivated and require an appropriate level of manual dexterity. Generally it can be assumed that if a patient can write and feed themselves they have the dexterity to catheterise.12 Although it may take more time and support, disabilities such as blindness, tremor or mental disability should not preclude people from performing CISC. Where a person is unable to perform CISC independently a partner or carer can be taught. Healthcare professionals need to be aware that for many people performing such an intimate procedure for their partner may change their relationship to one of carer and patient and may be a step too far.

Females can have difficulty locating the urethra especially if balance is an issue, but the use of a mirror and the appropriate position and support can help.   

There are many aids available to help patients achieve independence with CISC such as handles/grips to help clients who have problems with manual dexterity, or leg spreaders to help female patients who have leg spasm. Information regarding these aids can be accessed through the charity Promocon (see Resource section) or through catheter manufacturers.

Patient education
When first discussing ISC with a patient it is important to use an open and friendly approach. Many people do not understand technical or medical terms such as voiding or micturition so it is important to use language that they can understand.13 It can be very difficult for patients to take in so much information in one appointment. The use of support literature helps to back up the information you have supplied and provides a pictorial aid to help them understand. Each manufacturer issues guidelines related to their individual product.

Teaching and supporting a patient to perform ISC should include:

  • A discussion with the patient regarding their individual bladder dysfunction and reasons for self-catheterisation.
  • Discussion of anatomy and identification of urethral orifice.
  • ISC technique including appropriate positioning.
  • Hygiene needs including handwashing and cleansing of genitalia.
  • The use of catheters: including, storage, cleaning (where required) and disposal.
    - Single-use catheters should be disposed of after one use.
    - Reusable catheters can be cleaned and reused for up to seven days (follow the manufacturer's guidelines).
    - All catheters should be stored flat, and away from extremes of temperature.
  • Possible problems and solutions.
  • Sexual relationships.
  • Avoidance of constipation and dietary advice.
  • Travelling with catheters.
  • How to obtain supplies.
  • Follow-up visit arrangements.

Determining frequency of catheterisation
Residual urine can be measured using a portable ultrasound bladder scanner in the person's home or clinic (where a scanner is not available a catheter can be passed). Residual urine should not be less than 100 ml as catheterisation would be required too frequently.9 To determine frequency, patients should measure voided volumes and residual urine at each catheterisation.

Urinary volumes plus residual urine should not exceed 400–500 ml.14 Several authors have indicated catheterisation intervals ranging from four to seven times per day.14,15 If the patient does not void at all, bladder volumes should not exceed 500 ml between catheterisation.  

Common problems with ISC

  • Although bacteriuria prevalence is lower than in patients with indwelling catheters, prevention of crossinfection remains important.16 Patients need to be aware of changes in their urine that may indicate a UTI which requires treatment and a review of ISC technique. Signs of UTI include:
    • Leaking between catheterisations.
    • Needing to empty bladder more frequently than usual.
    • High temperature, sweats and shivers (flu-like symptoms).
    • Urine is stronger smelling than usual or cloudy.
    • Pain or burning when passing water.
    • Lower back ache.
    • More than a few spots of blood.
  • If the catheter cannot be removed, patients should be advised to relax, cough and gently withdraw it.
  • Females can often insert the catheter into the vagina by mistake. In this instance the catheter should be disposed of and a new catheter used.

It is safe to use ISC during pregnancy although there are some areas to highlight:

  • Positions used for ISC may need to be adapted.
  • The urethra elongates in the later stages of pregnancy, and some patients may require a longer length catheter.
  • Pregnancy often causes an increase in frequency and urgency.

Patients should be given written follow-up information with pictures where possible, which can be obtained from catheter manufacturers.
     
Role of the specialist nurse
Specialist nurses, such as urology, urogynaecology and continence advisers, within acute and primary care are usually responsible for teaching and supporting patients who are undertaking ISC. Initial patient education may take place within the hospital setting with follow-up provided by continence advisers; however, most patients are taught at home. Specialist nurses are often able to provide more time to patients and hold a range of product samples so that patients can choose the most appropriate catheter for their individual needs.

[[Box 1 ISC]]

Conclusion
When teaching anyone to catheterise the most important factor is time. It can take several consultations for a person to feel confident to catheterise independently. Healthcare professionals need to ensure that any verbal information given is backed up by quality written information. Guidelines from manufacturers can be backed up by written information individual to the person. It is important that healthcare professionals read company literature before giving it to clients to ensure that it is accurate and meets their own employer's guidelines and policies for provision of information and clinical governance.

ISC has been shown to be beneficial to patients, particularly in respect to quality of life, and using ISC can reduce the rate of infection associated with indwelling catheters.

References
1. Lapides J, et al. Follow-up on unsterile intermittent self-catheterisation. J Urol 1974;111:184-7.
2. Moy T, Amsters D. Urinary tract infection in clients with spinal cord injury who use intermittent clean self-catheterisation. Austral J Adv Nurs 2004;21(4):35.
3. Getliffe K, Dolman M. Normal and abnormal bladder function. In: Promoting continence: a clinical research resource. London: Ballière Tindall; 2007.
4. Martini FH, editor. Fundamentals of anatomy and physiology. Upper Saddle River, NJ: Prentice Hall; 2002.
5. Macdonald V. How to deal with acute urinary retention. Continence Essentials 2008;1:66-9.
6. Choong S, Emberton M. Acute urinary retention. Br J Urol Int 2000;85:186-90.
7. Colpman D. Reconstructive surgery for the promotion of continence. In: Fillingham S, Douglas J, editors. Urological nursing. 2nd ed. London: Baillière Tindall; 1997.
8. Emberton M, Anson K. Acute urinary retention in men: an age old problem. BMJ 1999;318:921-5.
9. Getliffe K. Catheters and catheterisation. In: Promoting continence: a clinical research resource. 3rd ed. London: Ballière Tindall; 2007
10. MDA. Equipped to care. London: MDA; 2000.
11. Hellstrom P, et al. Efficiency and safety of clean intermittent self catheterisation in adults. Eur Urol 1991;20:117-21.
12. Fowler CJ. Bladder problems. In: Multiple sclerosis information for nurses and health professionals. Letchworth: MS Research Trust; 1998.
13. Bardsley A. Instructing male patients in the technique of ISC. Continence Essentials 2008;1:94-8.
14. Chua BC, et al. The neurological bladder in spinal cord injury: pattern and management. Annuals Acad Med Singapore 1996;25:553-7.
15. Perrouin-Verbe B, et al. Clean intermittent catheterisation from the acute period in spinal cord injury patients: long term evaluation of urethral and genital tolerance. Paraplegia 1995;33:619-24.
16. Winder A. Intermittent self-catheterisation. In: Roe BH, editor. The promotion and management of continence. Hemel Hempstead: Prentice Hall; 1994.