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Intermittent self-catheterisation

Alison Bardsley
MSc RGN DiPDN
Continence Adviser
Oxfordshire Community NHS Trust
Chair
RCN Continence Care Forum
E:Alison.Bardsley@swoxon-pct.nhs.uk

Intermittent self-catheterisation (ISC), or clinically clean intermittent catheterisation (CCIC), is a long-accepted method of periodically draining a poorly emptying bladder. The patient or carer passes a catheter into the bladder to drain residual urine, helping to reduce infection and prevent the bladder from becoming overdistended.(1) ISC can also be used to prevent urethral strictures and administer intravesical medication.(1)
This article provides an understanding of the principles of ISC and how it can be successfully implemented.

Bladder function
The production and excretion of urine is essential for normal healthy living.(2) The bladder is a hollow, muscular sac sited in the pelvis that stores urine ready for excretion and contains around 350-500ml when full (see Figure 1). 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.

[[NIP21_fig1_30]]

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 that 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 250ml, the stretch receptors within the bladder wall are stimulated, exciting sensory 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.(4,5) 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 10ml of urine should remain in the bladder.(4,5)
Regular bladder drainage is important to prevent infection and dilatation of the upper urinary tract.(6)

Bladder dysfunction
There are many reasons for bladder dysfunction and a patient to need to perform ISC. Some patients may have a combination of bladder problems: for example, a patient may have bladder instability with a postvoid residual and require ISC.

Bladder dysfunction in neurological patients
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, constipation, congenital abnormality, and surgery or injury. Continence problems also 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 can cause disorders of both storage and emptying. 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.

Voiding dysfunction
Voiding dysfunction can lead to the development of large residual urine volumes and can be caused by bladder outflow obstruction or detrusor hypoactivity (underactivity). Patients' symptoms include poor voiding flow, postvoiding dribble, urgency, frequency and nocturia.
Bladder outflow obstruction is more commonly seen in males due to prostatic enlargement or urethral stricture; however, tumours and chronic constipation can also cause anatomical obstruction. When retention is due to an enlarged prostate it is not advisable to use ISC as this may damage the bladder neck.(7) Urethral stricture (narrowing of the urethra) results from scar tissue that can result from infection or instrumentation (such as catheterisation) and is more common in males.
Bladder neck dyssynergia (lack of coordination: for example, the sphincter may contract instead of relaxing when the bladder contracts to empty) can lead to functional retention of urine as the sphincters either fail to relax or contract when urine is voided. The cause of dyssynergia is often unknown.
Detrusor hypoactivity (or underactivity) occurs when the bladder muscle is unable to sustain or provide adequate contraction to empty the bladder completely. The sensation of bladder filling is often reduced or absent, and it results in a large bladder volume. This condition usually results from nerve damage, commonly due to diabetes and pelvic floor injury,(8) and occasionally after prostate surgery.
Some patients may experience incomplete emptying following surgery such as colposuspension or tension- free vaginal tapes (TVTs). Those particularly at risk may be taught the procedure before surgery.

Teaching ISC technique
Teaching ISC is an extremely intimate technique and requires awareness of both verbal and nonverbal communication. The nurse teaching ISC needs to be empathetic, supportive and skilled as patients face changes to their lifestyle and body image.
Residual urine can be measured at assessment using an ultrasound scanner or by passing a catheter. Frequency of performing ISC depends on individual needs. In order to determine frequency for ISC, patients should be asked to measure voided volumes and residual urine at each catheterisation. Urinary volumes plus residual urine should not exceed 400-500ml.(9) If the patient does not void at all, bladder volumes should not exceed 500ml between catheterisations. When the residual urine remaining in the bladder following voiding falls below 100-200ml, frequency of catheterisation is reduced.(10)

Patient selection
ISC requires a high level of patient commitment, and some patients may abandon it, particularly if under stress. ISC is safe for both children and adults, although children can often find it difficult as they do not "fit in" with their peers. However, nurses need to be aware of issues around consent and protection from abuse when teaching children. 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.(11) Although it may take more time and support, disabilities such as blindness, tremor or mental disability should not preclude patients from performing ISC. 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.
The advantages of ISC include:(10)

  • 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 encrustation.
  • The upper urinary tract is protected from reflux.
  • There is a reduced need for equipment and ­appliances.
  • There is a greater freedom for expression of ­sexuality and positive body image.

For patients who experience symptoms of frequency, urgency and nocturia, a combination of anticholinergic medication plus ISC may be helpful.

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, including standard/male length and a shorter version for females. Female patients may find that a standard-length catheter is more useful due to the length and reach into the toilet. Some manufacturers produce single-use ISC catheters that have a hydrophilic coating to aid insertion. These have been shown to be safe and comfortable for patients to use and can reduce urethral trauma.(12,13) Also available are catheter "kits" where a urine drainage bag is attached within a sterile pack. These are particularly useful for patients who cannot easily access toilet facilities or are travelling.
As with indwelling urinary catheters, the most common size for females is 10-12Ch and for males 12-14Ch. For male patients with strictures a larger catheter size may be required.(14)

Patient education
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.
  • A discussion of anatomy and identification of the ­urethral orifice.
  • Full description of the ISC technique, including appropriate positioning, to aid the patient's comfort.
  • A discussion of hygiene needs, including ­handwashing and ­cleansing of genitalia.
  • A discussion of the use of catheters, including ­storage, cleaning (where required with reusable catheters) and disposal:
    1. Single-use catheters should be disposed of after one use.
    2. Reusable catheters can be cleaned and reused for up to seven days (follow the ­manufacturer's guidelines).
    3. All catheters should be stored flat and away from extremes of temperature.
  • A discussion of possible problems and solutions.
  • A discussion of avoidance of constipation and dietary advice.
  • Details of how to obtain supplies.
  • A discussion of follow-up visit arrangements.

Common problems with ISC
Occasionally the catheter will not go in at the first attempt. Usually if left for a while the catheter can be inserted at the next attempt. If not, the patient needs to be advised to contact their GP, continence adviser or clinic.
Although bacteriuria prevalence is lower than in patients with indwelling catheters, prevention of crossinfection remains an important consideration.(15) Patients need to be aware of changes in their urine, for example blood, sediment and smell. Any changes may indicate a urinary tract infection, which requires treatment and a review of ISC technique.
If the catheter cannot be removed, patients should be advised to try 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 - these can be obtained from catheter manufacturers.

Conclusion
ISC has been shown to be beneficial to patients, particularly in respect to quality of life. Using ISC can reduce the rate of infection found with indwelling catheters and prevent reflux to the upper urinary tract. However, ISC does require skilled practitioners in order to provide for the complex needs of patients. Practitioners should be aware of catheterisation technique and have good communication skills in order to ensure safe and effective care and support of patients.

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References

  1. Barton R. Intermittent self-­catheterisation. Nurs Standard 2000;15(9):47-52.
  2. McLaren SM. Renal function. In: Hinchliff SM, Montague S, Watson R, editors. Physiology for nursing ­practice. London: Ballière Tindall; 1996. p. 20-5.
  3. Getcliffe K, Dolman M. Normal and abnormal bladder function. In: Getcliffe K, Dolman M, editors. Promoting ­continence: a clinical research resource. London: Ballière Tindall; 2003. p. 21-51.
  4. Martini FH, editor. Fundamentals of anatomy and physiology. Upper Saddle River (NJ): Prentice Hall; 2002.
  5. Richardson M . The physiology of micturition. Nurs Times 2003;99(29):46-50.
  6. Lapides J, et al. Follow-up on ­unsterile ­intermittent self-catheterisation. J Urol 1974;111:184-7.
  7. Winder A. Intermittent self catheterisation. Urology News 2002;6(3):16-8.
  8. Fowler CJ. Investigation of the neurogenic bladder. J Neurol Neurosurg Psychiatry 1996;60:6-13.
  9. Alderman C. DIY catheter freedom. Nurs Standard 1988;2:25-6.
  10. Getcliffe K. Catheters and ­catheterisation. In: Getcliffe K, Dolman M, editors. Promoting ­continence:a clinical research resource. London: Ballière Tindall; 2003. p. 259-301.
  11. Fowler CJ. Bladder problems. In: Multiple sclerosis ­information for nurses and health ­professionals. Letchworth: MS Research Trust; 1998.
  12. Medical Devices Agency. Equipped to care. London: MDA; 2000.
  13. Hellstrom P, et al. Efficiency and safety of clean intermittent self catheterisation in adults. Euro Urol 1991;20:117-21.
  14. Lawrence W, Macdonagh R. The treatment of urethra stricture disease by internal urethrotomy followed by intermittent low friction self catheterisation. J R Soc Med 1988;81:136-9.
  15. Winder A. Intermittent self-catheterisation. In: Roe BH, editor.
  16. The promotion and management of continence. Hemel Hempstead; Prentice Hall; 1994. p. 175-8.

Resources
Association for Continence Notes on Good Practice
E:info@aca.uk.com
T:020 8692 4680
The Continence Foundation
Information leaflets for patients and carers
W:www.continence-foundation.org.uk
T:0845 345 0165
Multiple Sclerosis Trust
E:info@mstrust.org.uk
Spinal Net
Information on spinal injuries for patient carers and professionals
W:www.spinalnet.co.uk

Further ­reading
Management of Continence and Urinary Catheter Care
Pope Cruickshank J, Woodward S, editors. BJN monograph. Wiltshire: Mark Allen Publishing; 2001
Promoting Continence: A Clinical Research Resource Getcliffe K, Dolman M, editors. London: Ballière Tindall; 2003 Urological Nursing 3rd ed. Fillingham, S, Douglas J, editors. London: Ballière Tindall; 2004