Intermittent self-catheterisation (ISC) is considered a highly effective way to manage urinary incontinence issues, and, as stated by the National Institute for Health and Care Excellence (NICE) (2015), it is considered the gold standard for urine drainage.
ISC is mostly used for voiding problems that result from disturbances or injury to the nervous system, non-neurogenic bladder dysfunction or intravesical obstruction with incomplete bladder emptying. In a hospital, ISC is often used for diagnostic evaluation, for example, in order to obtain a sample or to facilitate urodynamics (NICE, 2015). Before starting a patient on ISC, their symptom severity profile, renal function, risk assessment, psychological and physical ability to perform ISC and residual urine status should be considered (NICE, 2015). The patient should not be initiated on ISC based solely on the residual urine status. ISC is preferred to an indwelling urethral or suprapubic catheter for patients who have a bladder emptying dysfunction or spinal cord injury. It is a preferable way to facilitate the voiding of urine, as it helps to prevent infection. The patient can regularly void the bladder in a clean way without a device remaining indwelling, where the possibility of bladder infection increases.
Despite the benefits, it is important to consider the patient's psychological health and cognitive status, in order to know whether ISC would be an effective urine drainage strategy. It is also important to monitor the patient's mental status once they have the ISC inserted, and to examine the risk of possible mental health problems from using the device, where body image and sexuality are considered to be at risk of harm, for example. ISC requires the individual to learn various steps and for this information to be conveyed by a competent experienced and specialist health professional with the relevant communication skills (Royal College of Nursing (RCN), 2019). Exclusions to ISC include cognitive impairment and lack of consent. Therefore, there should be confidence among the patient's health providers, such as their GP, continence nurse, psychiatrist or neurologist, that the patient is able and willing to consent and has the faculty to have possible success with using ISC. It is also important for the health professional to assess the likely level of motivation and compliance with ISC. Increased support and follow-up may be required, especially in the early stages, in order to ensure long-term compliance. The RCN (2019) explained that motivational factors for ISC include the notion of an improved quality of life (QoL), symptom improvement and reduced risks.
Consent is essential, and the patient needs to have capacity to consent. Those with severe mental health conditions may lack insight and, thus, would not be able to consent; alongside this, they would probably not be able to manage the technique independently, as they would require supervision and prompting, which might not be possible at all times.
When gaining consent from a patient to perform ISC, various factors should be considered. There would need to be an appropriate rationale for requiring ISC, and the patient's lifestyle and disability should be considered, what with the fact that the patient may need to perform the procedure three times a day for the rest of their life. The benefits of ISC should also be considered, including increased independence; however, the risks and common complications need to be balanced against the benefits. There would be a need for continual follow-up and regular review, which is not always suitable for all patients. If someone has significant mental illness, such as psychotic illness or recurrent bouts of severe depression, they may go through periods of time when they are unable to use the catheter or lack motivation to perform ISC, leading to risks due to the inability of the bladder to void properly on its own. Therefore, compliance needs to be considered carefully.
ISC has benefits, such as helping to prevent urinary tract infections, but physiological and psychological risk factors are significant, and to what extent this is a health burden is unknown. The primary objective of a study by Marckiewicz et al (2020) was to explore the emotional effects, social connectivity and QoL associated with ISC. Their literature review examined adjustment to life after spinal cord injury impacted by emotional and behavioural changes; some included publications did suggest that ISC influences the emotional status of users. The researchers also carried out a cross-sectional survey investigating aspects of life, health and limitations associated with ISC. Some 393 adults were surveyed, all of whom performed ISC as the primary method of bladder voiding. The survey was administered online through a secure link. Attributes of depression, anxiety, feeling bad about oneself, empowerment, independence and confidence associated with ISC were investigated as part of exploring the emotional aspects of adults using ISC (Marckiewicz et al, 2020).
With regard to whether ISC caused the respondents to feel depressed, anxious or bad about themselves, men and women responded in a similar manner, with most indicating a positive response, in that they did not experience these feelings. To support this further, significant linear decreases in the scaled response indicated that, as the scale moved toward the more negative anchor, fewer people responded that the response applied to them. Thus, the more negative the emotional response, the less often it was indicated to be experienced by the respondents who used ISC, indicating a more positive reflection of their emotional wellbeing while using ISC (Marckiewicz et al, 2020).
Marckiewicz et al (2020) then researched more specific areas of their data. They examined whether their hypothesis was correct-that dependence on others for help with the catheterisation process may influence the attributes. They found that, for men, the issue of depression and anxiety did not appear to be associated with reliance on another for help with the catheterisation procedure, but this was not the case with ‘feeling bad about oneself’. Men dependent on others for catheterisation were less likely to provide a positive response (70.7% vs. 84.4%). For women, significant differences were noted across the negative issues, where those relying on others for help with the catheterisation process were more likely to provide a negative response.
Positive attributes: empowerment, independence and confidence
With regards to the positive emotional attributes, it was speculated that the ability for self-catheterisation could offer a sense of empowerment, independence and confidence. For the attributes of empowerment and feeling confident, the researchers found no significant linear trend in either a positive or negative direction, nor did they find a difference between men and women in the distribution of their responses. However, for the attribute of independence, the study found that more women provided a positive response than men, which suggested that the use of an intermittent catheter may promote a greater feeling of independence for women than for men.
Similarly to the negative attributes, the positive attributes were then examined to see whether they could be influenced by a reliance on others for help with the catheterisation process, which hypothetically removed some self-control. The data indicated that, for empowerment, this did not appear to be an influence in either gender. Despite this, for the issues of independence and confidence, women were found to appear to be influenced by reliance on others for the catheterisation procedure. Thus, women dependent on others for help with the procedure were more likely to respond negatively to these issues.
Marckiewicz et al (2020) found that women who are not dependent on others for any degree of help with catheterisation are more likely to report stronger feelings of independence and confidence than those who are. This supports the researchers' hypothesis in part-that the ability to independently perform ISC offers a sense of independence and confidence, although this is gender specific, as the study found that male responses tend to contradict this. Overall, this would require further research in the future to examine why this is the case.
Resilience: the key to adaptability to ISC?
According to Marckiewicz et al (2020), people with specific emotional distress are known to lack positive emotional attributes rather than having the ability to overcome negative attributes. They found that paths for recovery may not be linear, but may instead involve more complex interactions (Marckiewicz et al, 2020). Because positive effects have been shown to improve adaptation and outcomes in people using ISC, the majority of their sample indicated that emphasising positive attributes in the rehabilitation process may be the way forward in reaching important psychological healthcare outcomes. Generally, those who exhibited high resilience at the start of rehabilitation would continue down a resilient path, which was associated with positive physical and psychological health outcomes. From these findings, Marckiewicz et al (2020) concluded that positive attributes require further research.
Friendship: considering the patient's support network
Marckiewicz et al (2020) also discussed that a key component of their analysis was the determination of friendship status, and, conversely, social isolation. Social isolation is considered to be ‘living without companionship, social support or social connectedness. It is the absence of significant others someone interrelates with, trusts, and turns in time of crisis’ (Marckiewicz et al, 2020). Such a lack of social connectivity may be related to poor health-related QoL. In the analysis by Marckiewicz et al (2020), 66.3% of the study respondents were found to be socially connected or very socially connected, while 22.3% indicated they were very socially isolated or had low levels of social support. It is known that increases in social interactivity, seen as increased social functioning or connectivity, are linked to an increase in health status, independent of the level of the health burden. Therefore, social interactivity can be of protective value for health, and, because health is considered a capital asset for the community, this means that social interactivity can be of socioeconomic benefit to society as a whole. The study sample indicated positive responses to the six items in Hawthorne's friendship scale, which the researchers stated suggested that both men and women in the study were living to a great extent with companionship and social support, with people to interrelate with, trust and turn to in times of crisis. The 23% of participants who reported living a socially isolated life, however, indicates a significant proportion of people. The overall QoL differed depending on social connectedness-those who were very socially connected had an overall mean QoL rating of 83.4, whereas those who were very socially isolated had a mean QoL rating of 51.8 (Marckiewicz et al, 2021).
Marckiewicz et al (2020) suggested that clinicians responsible for the wellbeing of populations using ISC should reinforce positive attributes and the need for social connectivity as part of an overall patient education programme. Different people will naturally perceive ISC differently, in terms of the cultural and psychological health perspective. This is partly why the study was performed-to gauge the general trends in the positive or negative personality attributes that someone using ISC might possess, depending on different factors as seen in the study, for example, whether they were independent or required assistance with using the technique. However, this may be a sensitive subject to discuss for some, and the vulnerabilities someone may possess may not always be freely discussed. Therefore, the way the participants in the study discussed the use of this technique may have varied depending on their perceptions of how they should have been coping or behaving, rather than the true reality of their emotional wellbeing, which they may not be able to truly recognise unless, for example, aided by the psychotherapist.
Conclusion
Overall, there is an array of considerations when treating a patient who is using or is being considered for ISC. It is, of course, important that their cognition and insight are considered so that a reliable learning process can take place, and it needs to be determined whether they have any ongoing mental health problems or risk factors, such as previous trauma, which might influence how they cope while using ISC. It is also important to remember that some patients may not be that comfortable talking about the catheter or about their mental health. Therefore, sensitive questioning is pertinent when ensuring that the patient's psychological wellbeing can be monitored and maintained as well as possible while they are using ISC.
KEY POINTS
- Cognition and ability to consent are vital when considering intermittent self-catheterisation (ISC), as psychological factors may be so significant that the patient cannot reliably learn the technique
- Independence, confidence and empowerment are identified as positive mental health factors in using ISC, especially among women
- Social isolation negatively affects quality of life, which may impact how the person experiences ISC
- The ability to learn ISC impacts feelings of wellbeing associated with independence and other attributes
CPD REFLECTIVE QUESTIONS
- What are the main reasons to not recommend ISC?
- Write a reflection of the psychological factors that require careful consideration when a patient you are caring for is using ISC