Intermittent catheterisation (IC) has been in practice for more than 40 years and is considered the gold standard for bladder drainage for chronic urine retention (National Institute for Health and Care Excellence (NICE), 2015). It is a simple, safe and effective method, in which the catheter is introduced through the meatus and then gradually pushed into the bladder. Urine emptying is ensured and then supplemented by manual pressure above the pubis to finish emptying the bladder. Once the bladder is emptied, the catheter is removed. This procedure can be repeated up to four to six times per day.
IC has many advantages over indwelling urethral or suprapubic catheterisation, including a reduced risk of infection, better bladder protection and improved quality of life (Woodward, 2014).
According to the literature, there are relatively few risks or complications associated with IC. Many risks have been reduced with the introduction of various different types of catheters on the market (Vahr et al, 2013). The risks are recognised as rare compared with the benefits derived from IC (Newman and Willson, 2011).
This review discusses some of the common complications that can occur with the use of IC, including urinary tract infections (UTIs) and urethral complications. It also highlights the role of nurses in the management of these complications.
Indications for intermittent catheterisation
According to the International Continence Society, IC is defined as the drainage of the bladder or a urinary reservoir with subsequent removal of the catheter, mostly at regular intervals (Gazewski et al, 2017).
IC can be used as treatment for voiding problems due to disturbances or injuries to the nervous system, non-neurogenic bladder dysfunction and intravesical obstruction with incomplete bladder emptying (Royal College of Nursing (RCN), 2019). Whenever possible, indwelling transurethral and suprapubic catheterisation should be avoided (Blok et al, 2017).
Before providing information and instructions for IC, it is necessary to assess the caregiver's general health, dexterity, motivation, understanding and availability to conduct IC (Vahr et al, 2013).
Teaching patients intermittent catheterisation
There are many things a patient or caregiver needs to know before they can perform the IC procedure confidently and safely. Patients need verbal explanation of IC, practical instruction in the procedure and written information (Vahr et al, 2013). They should also be taught how to deal with common complications associated with this procedure, including the signs and symptoms of a UTI, colonisation, bleeding, false passage, difficult insertion or removal, management of multi-drug resistant bacterial infection, and initiation of unscheduled care for urgent catheter-related needs (Blok et al, 2017; RCN, 2019).
IC is best taught by a competent and experienced specialist health professional with good communication skills (RCN, 2019). Patients should be encouraged to ask questions and to interact with their instructor. Learning sessions should be individualised, according to the needs of each patient, in a calm and uninterrupted environment. Optimal conditions need to be made available, for instance, a well-educated nurse, an adequate choice of catheters, comfortable place and hygienic toilet with adequate space (Vahr et al, 2013).
Types of catheter
Several types of catheters are available for the IC in the market. However, no single catheter can find universal application. When choosing which product to use, consideration must be given to patient preference, limitations or disabilities, cost benefits, cost effectiveness, ease of use and storage issues (Vahr et al, 2013). It is strongly recommended that the patient be included in the choice of catheters (Gamé et al, 2020).
Hydrophilic coated or pre-lubricated catheters should be offered to the patient first, as they appear to reduce the risk of UTI and result in less urethral trauma and are more convenient and easy to use compared with uncoated catheters (Campeau et al, 2020).
Complications of IC
It is necessary to have an in-depth understanding of the different short- and long-term risks of IC, the associated health implications and how to resolve or minimise these (RCN, 2019).
Urinary tract infection
The true incidence, prevalence and relative risk of UTIs in those practising IC are difficult to determine, because studies have varied significantly in their definition of UTIs and their means of reporting (Vahr et al, 2013). UTIs are considered the most common complication of IC (Engberg et al, 2020). The development of UTIs in the neurogenic bladder relays on a balance between bacterial virulence and local host factors (Kennelly et al, 2019). In UTIs, there are two conditions to be considered: asymptomatic bacteriuria (AB) and the infection itself (Bruyére et al, 2008):
- AB is defined by the presence of one (or more) microorganism(s) in the urinary tract, without any clinical manifestation
- UTI refers to an infestation of a tissue by one (or more) microorganism(s), leading to an inflammatory response with different symptoms varying in type and severity.
AB is a common problem in patients performing IC. Although AB does not increase the risk of incontinence or impaired kidney function (Zegers et al, 2017), it is considered a risk factor for UTI (Wyndaele et al, 2012).
AB in patients with neuro-urological disorders should not be treated (Groen et al, 2014). Special cases for which antibiotic treatment must be initiated are patients who are going to undergo invasive surgery, immunocompromised patients, pregnant individuals or cases requiring control of a nosocomial infection due to a virulent microorganism (e.g. Serratia marscens) (Tenke et al, 2008).
UTI is more common. The incidence of catheter-associated UTI as a consequence of IC is in the region of 2.5 per person per year (Woodbury et al, 2008).
During the initial rehabilitation phase after acute spinal cord injury, UTIs have been reported as a common medical complication, with an estimated prevalence of 19% (Girard et al, 2006).
Symptoms of UTI
The usual symptoms of UTI (dysuria, pollakiuria and urgency) are generally absent in patients performing IC. Patients with neurogenic bladder often have an absence of tenderness in the pelvic region. Recognising the potential symptoms of a UTI is often difficult (Hooton et al, 2010). The most common signs and symptoms in those with neuro-urological disorders are:
- Fever
- New-onset incontinence or increase in incontinence, including leaking around an indwelling catheter
- Increased spasticity
- Malaise
- Lethargy or sense of unease
- Cloudy urine with increased urine odour
- Discomfort or pain over the kidney or bladder
- Dysuria
- Autonomic dysreflexia (Blok et al, 2017).
Pyuria is evidence of inflammation in the genitourinary tract. The absence of pyuria in a symptomatic patient under catheterisation suggests a diagnosis other than a UTI (Hooton et al, 2010).
Laboratory diagnosis
The gold standard for diagnosis of UTIs is urine culture and urinalysis (Blok et al, 2017). To diagnose UTI in patients undergoing IC, it is recommended that the urine sample be obtained via the catheter (Wyndaele et al, 2012).
The international literature is extremely discordant on the clinical and bacteriological diagnostic criteria for UTIs in cases of neurological bladder. These criteria can vary extremely: the American Consensus Conference of the American Paraplegia Society recommends a bacteriuria count of >102 colony-forming units (CFU)/ml for patients under IC, while most other studies recommend >105 CFU/ml (Société Française de Médecine Physique et de Réadaptation, 2009).
The causative bacterial species should also be taken into consideration. Escherichia coli and gram-negative bacilli are more virulent and more likely to be the causative agent, even at low bacterial concentrations. Other bacteria, for example, coagulase-negative, staphylococci and some streptococci are unlikely to cause UTIs, even in high concentrations (Wyndaele et al, 2012).
Treatment of UTIs
In patients performing IC, only symptomatic UTIs should be treated (Vahr et al, 2013). It is recommended that diuresis be considered first and that a cytobacteriological urine test be requested before any initiation of antibiotic therapy.
When starting antibiotic therapy for patients with UTIs, the following should be considered: the severity of symptoms, risk of developing complications (which is higher in people with known or suspected structural or functional abnormality of the genitourinary tract, or immunosuppression), previous urine culture and susceptibility results and previous antibiotic use (NICE, 2018). UTIs in those with neuro-urological disorders are, by definition, complicated. Therefore, single-dose treatment is not advised (Blok et al, 2017).
The choice of the antibiotic therapy should be based on the results of microbiologic testing (Blok et al, 2017). Patients receiving intravenous (IV) antibiotics require a review of treatment within 48–72 hours in all care settings (RCN, 2019). The duration of treatment depends on the severity of the UTI and the involvement of the kidneys and the prostate. Generally, a 5–7-day course is advised, which can be extended up to 14 days.
It is recommended that patients with UTIs be referred to hospital if they have any symptoms or signs suggesting a more serious illness or condition (e.g. sepsis) (NICE, 2018). It is also recommended that specialist advice be sought for people with catheter-associated UTI if they are significantly dehydrated or unable to take oral fluids and medicines, are pregnant, have a higher risk of developing complications (e.g. people with known or suspected structural or functional abnormality of the genitourinary tract or underlying disease, such as diabetes or immunosuppression), have recurrent catheter-associated UTIs or have an infection caused by bacteria resistant to oral antibiotics (NICE, 2018).
Risk factors of UTI
Factors increasing the risk of infection of IC are low frequency of IC, bladder overdistension, female gender, poor fluid intake, use of a catheter without a hydrophilic coating, poor technique and poor patient/carer education (Vahr et al, 2013).
- Low frequency of IC: the frequency of catheterisation should be appropriate for each patient. The success of the IC will depend the appropriate balance being found. Urinary catheterisation should be performed often enough to limit bladder distension (>400 cm3) but not so often that this has a negative impact on patients' quality of life. Between four and six catheterisations per day are recommended (Stöhrer et al, 2009). The American Urologic Association recommends that patients try to maintain bladder volume below 500 ml in order to maintain kidney function and prevent UTI (American Urologic Association, 2016)
- Type of catheters: a Cochrane systematic review from 2014 was conducted to compare one type of catheter design and material versus another, aseptic catheterisation technique versus clean technique and single-use (sterile) catheters versus multiple-use (clean) catheters, in reduction of UTIs and other complications (Prieto et al, 2014). The authors found that there is still no convincing evidence that the incidence of UTI is affected by use of aseptic or clean technique, coated or uncoated catheters or single-(sterile) or multiple-use (clean) catheters (Prieto et al, 2014). Another meta-analysis comparing hydrophilic-coated catheters and standard polyvinyl chloride catheters found that the former were statistically significantly superior in reducing the incidence of UTI (Li et al, 2013).
- Catheterisation methods (self versus assisted catheterisation): there are few randomised clinical trials comparing UTI rates depending on the catheterisation method used. One study showed that both types of catheterisation (self and assisted) significantly decreased the rate of UTI in patients with spina bifida (Faleiros et al, 2018). Patients who underwent assisted catheterisation had low annual UTI episodes, but the reduction in frequency of UTI episodes was greater in those who performed self-catheterisation (Faleiros et al, 2018)
- Technique of IC: UTI is a complication often related to poor catheter insertion technique (Jones et al, 2019). Educating the patient and family on the most reliable IC technique remains the best way to prevent this complication (Lee et al, 2015). It is necessary to ensure that the health professional is proficient in both the skills and teaching of IC (Vahr et al, 2013). IC, when performed correctly, is a simple and inexpensive way to reduce the risk of UTI (Wyndaele et al, 2012). A study published in 2018 showed that the average frequency of UTI before IC was 2.8 episodes per year, compared with 1.1 episodes per year after IC (Faleiros et al, 2018). Another study evaluating 194 patients in the US reported a similar rate of UTI after IC; 75% of patients with IC-managed neurogenic bladder had few or no UTIs (Chaudhry et al, 2017)
- Lack of follow-up and adherence: appropriate support and products are crucial to long-term concordance with IC. Several sessions are required, over a period of time, to support learning and problem solving and to review experiential learning and related habits. The patient will then require follow-up and review, depending on their needs (RCN, 2019).
It is important to provide ongoing social support (by consultation/telephone) to improve quality of life and prevent complications (Vahr et al, 2013). Depending on service protocol, follow-up visits should be undertaken at regular intervals.
Couloures et al (2015) found that adherence to IC reduces symptomatic UTI episodes, preserves kidney function, prevents selection of resistant organisms and reduces the need for antimicrobial prophylaxis.
Urethral complications
Urethral complications, such as urethral strictures, haematuria and urethral false passage, do occur but are less prevalent than UTI (Engberg et al, 2020).
Bleeding/urethral trauma
Most of the time, minimal haematuria is observed in patients practising IC. This is normally related to mild trauma, especially during the learning period. A previous study has shown that the use of lubricated catheters reduces friction with the urethral mucosa, leading to less pain, better medication adherence and an improvement in patients' quality of life by approximately 30% (Chan et al, 2014).
Referral to urology is strongly recommended in the event of recurrent macroscopic haematuria in a patient under IC (Gamé et al, 2020).
The false passage
A false passage in the urethra is the formation of an epithelialised tract when the catheter is inserted against the urethral wall rather than guided through the urethral lumen and into the bladder vesicle (Håkansson et al, 2015). Most often, the false passage is prevented by advising against the forced passage of the catheter, especially in patients with dyssynergic spasm.
A false passage in a patient performing IC should be treated with antibiotic therapy, the choice and duration of which will be dictated by local policy, as well as an indwelling urethral catheter (Vahr et al, 2013).
Urethral stricture
Repetitive trauma from IC can lead to the formation of urethral stricture. Urethral strictures are either a single or multiple narrowings along the length of the urethra and are common in men than in women (Mangera and Chapple, 2011). The occurrence of strictures in those with IC has been estimated to be 4.2% (Cornejo-Dàvila et al, 2015). In the event of urethral stricture, it is recommended that the patient be referred to a urologist. The treatment will depend mainly on its location, extent and recurrence.
Cost of treating complications of intermittent catheterisation
Performing IC versus other bladder drainage techniques reduces the morbidity and costs generated by infectious and uro-nephrological complications. The direct and indirect costs of treating UTI are significant. Approximately 15% of all antibiotics prescribed in the US are for UTIs, and each episode of survey-related UTIs cost at least $600 in 2009 (Lamin and Newman, 2016). Survey-related bacteraemia was estimated to cost approximately $2800 per episode (Lamin and Newman, 2016).
The European Association of Urology (EAU) guidelines on neurogenic bladder dysfunction suggest that an aseptic technique would be the most appropriate compromise between UTI incidence, practicality and economic viability. Aseptic technique is defined as ‘catheters remain sterile, the genitals are disinfected and disinfecting lubricant is used’ (Vahr et al, 2013).
In addition to UTI and pyelonephritis, the second greatest cost related to IC comes from complications from urethral strictures (Håkansson et al, 2015).
Conclusion
IC is the most effective method for bladder drainage in patients with neurological bladder. It also limits urological complications and improves quality of life. However, complications have been described related to this drainage method, specifically UTIs. Therefore, teaching IC to patients is essential to ensure the success and sustainability of the technique. The success of the technique relies heavily on patient education and regular monitoring.
Nurses play a fundamental role in the education of patients performing IC. They provides theoretical and practical learning and ensure patient follow-up to detect and address complications early.
KEY POINTS
- Intermittent catheterisation is considered the gold standard for bladder drainage for chronic urine retention
- Frequent complications of intermittent catheterisation include urinary tract infections and urethral complications
- Community nurses play a key role in the detection of complications associated with intermittent catheterisation
CPD REFLECTIVE QUESTIONS
- What are the effective measures to take in order to prevent urinary tract infections (UTIs)?
- What should be done when a patient performing intermittent catheterisation develops a UTI?
- Should the health provider systematically introduce supplemental educative sessions about management of complications among patients undergoing intermittent catheterisation?