Intermittent self-catheterisation (ISC) is recognised as the gold standard for the treatment of neurological bladders (Holroyd, 2018). ISC involves the introduction of a catheter by the patient into the bladder and its immediate removal when drainage stops.
Nowadays, therapeutic patient education (TPE) is a popular method for treatment and care of patients with chronic disease; it aims to improve the quality of life of patients and helps reduce the cost of healthcare (Le Breton et al, 2012). Introducing ISC to patients and teaching them to perform it is important. Patients should be provided with detailed and accessible information to support them (Robinson, 2006). The additional time initially spent teaching and monitoring the patient will have a positive impact in the long term. In this context, community nurses are ideally placed to support patients who are learning to self-catheterise (Woodward, 2014).
This review discusses the key elements to consider when teaching ISC to a patient.
Advantages of ISC
Guidance from the National Institute for Health and Care Excellence (NICE) (2012a; 2012b) recommends that, whenever possible, intermittent catheterisation should be considered for its benefits.
ISC has many advantages over indwelling urethral or suprapubic catheterisation, including reducing the risk of infection, protecting the bladder and improving quality of life (Woodward, 2014).
Indwelling urinary catheters increase the risk of urinary tract infections (UTIs). Around 20–30% of catheterised patients may go on to develop bacteriuria, and 2–6% of patients whose urine becomes colonised with bacteria will develop symptomatic UTIs (NICE, 2012a). Bacteria can enter the bladder in different ways:
- During catheter insertion, through the lumen of the catheter or along the catheter–urethra interface
- During insertion, bacteria colonise the surface of the catheter and the drainage equipment. This bacterial colonisation is known as a biofilm. It appears within 7–28 days after catheter insertion. The biofilm protects bacteria from antibiotics and makes infections difficult to treat (Trautner et al, 2005).
An advantage of ISC is that biofilms do not develop on these catheters (Wyndaele et al, 2012).
In a study of 316 adults with spinal cord injuries conducted with a follow-up period of 18 years, Weld et al (2000) identified 398 serious complications (bladder and renal lithiasis, urogenital infections, morphological alterations of the upper apparatus and renal failure). The rate of complications occurring in the indwelling catheter group was significantly higher comparing with that in the clean intermittent catheterisation group (57% vs. 27%). The authors concluded that clean intermittent catheterisation is the safest bladder management method for patients with spinal cord injuries in terms of urological complications (Weld et al, 2000).
Problems with incomplete emptying can lead to bladder distension. This damages the nerves supplying the bladder, increasing the risk of infection, and it causes urine to flow back to the kidneys, causing kidney damage and infection.
Indwelling catheters affect the quality of life of patients. They can be painful, uncomfortable and sometimes restrict physical activity. Patients with indwelling catheters also experience difficulties with their sex life (Chapple et al, 2014). ISC improves the quality of life of patients and preserves body image, which helps them enjoy a normal sex life. In addition to these medical benefits, the practice of ISC supports urinary continence, providing voiding autonomy.
Community nurses can support patients' progress by helping patients to gain independence and self-confidence and, therefore, improve their quality of life (Girotti et al, 2011).
Disadvantages of ISC
The aim of ISC is to allow patients to control urination. However, the patient must have sufficient bladder capacity to remain continent between episodes of ISC, and incontinence can occur if the person has an overactive bladder (Nazarko, 2010).
Further, the patient must be organised and willing to perform ISC, as it sometimes needs to be performed up to six times a day. They must also have the physical ability to perform the procedure (Robinson, 2006).
Patients with conditions such as multiple sclerosis may not always be eligible for ISC, given the recurrent nature of the disease. In such circumstances, the person may switch to indwelling catheterisation and return to ISC when their physical condition improves (Pomfret et al, 2007).
There are multiple alternatives to ISC, including:
- Intermittent hetero-catheterisation (catheterisation carried out by a relative or carer)
- Suprapubic catheter: a percutaneous suprapubic bladder drain connected to a collection pocket
- Indwelling catheter: permanent bladder drainage through a urethrovesical catheter connected to a collection bag.
However, due to the high rate of complications with these techniques, these methods are no longer in regular use, except transiently and in the event of contraindication to ISC.
Initial consultation and assessment
A consultation between the health professional and patient should be held before the start of the TPE programme, as it will help alleviate fears, anxieties and misconceptions, which can create barriers to patient learning. An anxious patient will be tense and find the procedure more difficult, and their ability to retain information will be hampered.
How patients are informed of the need to initiate ISC as a treatment is important. In the study by Cobussen-Boekhorst (2016), a patient said she felt she had to do something ‘terrible’ because the doctor was so nervous during the discussion of the need for ISC.
Both patients and nurses need to be clear about the clinical outcomes expected from the educational programme (Mangnall, 2006). Some patients may feel reluctant to undertake ISC. If this happens, the patient should not be put under pressure, as they may become more anxious or distressed. The health professional should try to calm the situation and then contact the patient again to see if their thoughts and ideas have changed. It may also be helpful to give examples of patients (while maintaining anonymity and confidentiality) who learned about ISC and how it benefited them.
Educating patients on ISC
Patient education regarding ISC should include theoretical and practical aspects. In terms of the theory, patients should have knowledge of basic human anatomy and physiology. This will allow a better understanding of essential points to remember (Leach, 2018).
The bladder is a smooth muscular organ under voluntary control. Normal bladder function involves an interaction of the somatic and vegetative nervous systems, and impairment of nerve control at any level can result in a neurological bladder. Three types of disorders are described according to the type of involvement: an acontractile bladder in the case of peripheral involvement, an overactive spastic bladder in the case of central involvement or a mixed bladder, which includes the elements of central and peripheral bladders.
Clinically, neurological bladders manifest two main symptom categories:
- Urinary incontinence: unintentional urine leaks are noted, linked either to an overactive bladder-also called irritable or uninhibited bladder-or to sphincteric insufficiency
- Chronic or acute retention of urine: the bladder is no longer able to empty, causing stagnation of urine in the bladder. It may result from paralysis of the bladder muscle, making urination slow and painful, or from poor opening of the sphincter during urination (where sphincters no longer play their role of bladder cock).
Urine retention can result in bacterial growth, which can lead to a UTI. This infection is likely to go back to the kidneys, which can have negative consequences on the patient's overall health.
In 2013, the European Association of Urology Nurses released evidence-based guidelines for urethral catheterisation in adults. These provide information on patient education, catheter selection and the frequency of catheterisation. However, these guidelines are quite general, and no detailed procedural steps are provided regarding a clean technique, and the method is not evidence-based (Beauchemin et al, 2018).
Among the three methods of ISC described in the literature (sterile, aseptic or clean), only two methods are suitable for TPE (Le Breton et al, 2012).
- Aseptic intermittent catheterisation: in this method, the use of a single-use catheter is recommended, preceded by disinfection of the perineum with an antiseptic solution and without direct manual contact with the catheter. It is also called the no-touch technique
- Clean intermittent catheterisation: in this method, the use of a disposable or dry, reusable catheter is recommended, preceded by cleaning of the hands and perineum with a non-antiseptic solution.
Each step of the catheterisation procedure will be shown to the patient and then re-evaluated with them, including hand and perineum hygiene without an antiseptic, installation, location of the meatus and handling of the equipment. The choice of equipment will be adapted to the functional, cognitive and psychological abilities of the patient.
Generally, catheter insertion and hygiene procedures should be performed according to a codified educational approach (Le Breton, 2012):
- The community nurse shows the patient the different steps of the procedure: installation of the equipment, positioning, the catheterisation itself and emptying the tank. The procedure is usually first explained verbally or in writing, often using audio-visual aids
- The patient then conducts the catheterisation with support from the nurse
- Lastly, the patient performs the process independently without the help of the nurse.
It is well recognised that hydrophilic-coated catheters are slippery and can be difficult to grasp, especially when the patient is first learning the process. It is important for nurses to demonstrate the best technique for handling the catheter, while helping the patient to maintain a non-touch technique to avoid contamination (Logan, 2012).
The procedure is easier for men than for women. In men, the penis can be moved up and down to straighten the urethra, with the catheter held in the other hand. Women should try different positions when inserting the catheter to find the most comfortable and suitable position. A good light source and a mirror are helpful for identifying the urethral orifice (Bennett, 2002). For women with disabilities, a variety of aids are available-for example, labial separators.
Session type
Theoretical skills can be learned in individual or group sessions, but practical skills should ideally be taught in individual sessions (Logan et al, 2008).
Session duration
Educational sessions take time and patience, since people learn at different rates and in different ways. It is important not to overload the patient with a lot of information. Several shorter sessions may be better than one long session.
Many patients/caregivers will not achieve the expected skills after a single session (Mangnall et al, 2015). Certain sections should be repeated, if necessary, in order to help the patient gain the confidence to undertake ISC.
To the authors' knowledge, no data have been published regarding the time required to learn the technique. Similarly, the time needed to teach a patient ISC is poorly understood and depends on several factors related to the patient, their condition and their environment. The time spent on integrating theoretical knowledge can vary considerably from one patient to another (Robinson, 2007). As a rule, the minimum duration of the initial session is 60 minutes. The number and frequency of sessions will depend on the patient's condition-that is, whether it is chronic or acute (Société Française de Médecine Physique et de Réadaptation, 2009). In a study of 60 patients learning ISC, 55 (92%) were found to be able to perform the no-touch technique after a single training session, and only 5 (8%) patients required more than two sessions to learn the technique (Girotti, 2011).
Hygiene
When teaching ISC to the patient, special attention should be paid to the patient's personal hygiene, particularly hand washing, cleaning of the external genitalia and preparation of the catheter for insertion (Robinson, 2006).
Hand washing might not always be possible. Advice on the use of alcohol-based hand sanitisers or wet wipes is needed. The genital area should be cleaned before each catheterisation (Doherty, 2000), although there is little scientific evidence that this is necessary (Benett, 2002). Washing the genitals once a day with mild soap and water is probably sufficient, as more frequent washing can eliminate bacterial flora.
Frequency of ISC
The success of ISC in preventing UTIs and upper urinary tract complications depends on the frequency of catheterisation: it is usually performed five to six times a day to ensure daily diuresis of 1.5 to 2 litres and so as not to exceed the 400 ml sample volume and obtain sufficient bacterial clearance.
The frequency of catheterisation is more important than sterility. The exact frequency of ISC is controlled by the patient. It depends on personal and circumstantial factors, such as fluid intake, bladder capacity and residual urine volume after voiding. Water intake must be distributed regularly throughout the day.
A voiding catalogue is a key element in monitoring intermittent catheterisation. It objectively specifies the number and times of catheterisation, the volume and the existence of any leaks. Completion of the voiding catalogue over three consecutive days is recommended.
Choice of urinary catheters and technique for ISC
The type of catheter, the method of cleaning and/or the optimal catheterisation technique remain controversial subjects in urology (Campeau et al, 2020). The selection of the type/technique of ISC requires a complex balance between the patient's motor functions, acceptance of the procedure, quality of life and economic implications. Hydrophilic-coated or pre-lubricated catheters should be offered to the patient as the first choice of treatment, as they appear to reduce the risk of UTIs, cause less urethral trauma and are more convenient and easy to use than conventional uncoated catheters (Campeau et al, 2020). Reuse of catheters can always be considered in specific clinical situations.
The material and/or catheterisation technique should be based on whether the risk of urinary tract deterioration can be avoided while minimising treatment-related morbidity. Further high-quality randomised controlled trials are warranted to identify the optimal catheter material and ISC technique.
Type of catheters
Several types of catheters are available for the ISC. They differ by the type of material used, shape, length, diameter, presence of lubricant and specific coating. A variety of catheters should be offered to the patient, and the advantages and disadvantages of each should be explained (Bermingham, 2013). The patient should try different types of catheters and choose from among them. In many cases, the nurse's choice may not be the same as the patient's (Doherty, 1999).
The selection of the catheter is a very personal decision and should take into consideration issues such as lifestyle, work environment, access to sanitation and travel. One type of catheter may not meet all patient needs. For instance, some patients may need two types of catheters: one for home use and one for work (Robinson, 2006).
Disposable urinary catheters have a hydrophilic coating. They have been developed specifically to reduce urethral friction, thereby minimising the risk of trauma and sticking, and to reduce the incidence of symptomatic UTIs. There are two types of hydrophilic coated catheters:
- The first type requires rehydration with the addition of water to the catheter package to activate the coating and produce a smooth surface prior to insertion (cold tap water can be used at home or sterile water/saline solution can be used in hospital)
- The second type is pre-hydrated and ready for immediate use (LoFric Sense and Rochester HydroSil Discreet).
NICE guidance (2012a) states that patients should be offered a choice of either single-use hydrophilic or gel reservoir catheters.
Reusable nelaton catheters are described as ordinary cylindrical catheters. Sterile lubrication or anaesthetic gel should be added to the surface of the catheter and urethra before insertion, for example, Instillagel. Patients should learn how to manage insertion of gel into the urethra and how to cover the surface of the catheter before insertion. After use, the catheter should be washed and stored until further use. On average, five catheters can be used per month (Association for Continence Advice, 2003). The advantages of these catheters are their price and the possibility of reuse. However, they do have some disadvantages, specifically, that they require prior lubrication and carry the risk of uterine and genital lesions in men.
Single-use pre-lubricated catheters are nelaton catheters prepared in a pre-gelled sterile package ready to use. After the catheter is inserted, urine can be drained into the toilet, a pitcher or a drainage bag attached to the catheter. Some companies produce catheters with an attached drainage bag, such as SpeediCath (Colopalst). These catheters have a sliding plaster that does not require lubrication, are easy to insert and remove and generally do not cause urethral lesions, microscopic haematuria or inflammatory reactions. However, they are expensive and cannot be reused as they lose their self-lubricating properties after the first use.
Dry catheters are preferred for women because of the shortness of the urethra and natural lubrication from local secretions. In men, however, the use of a lubricant (petroleum jelly, paraffin, glycerin or xylocaine) is advised to facilitate the passage of the catheter.
Studies have shown that the hydrophilic-coated and pre-lubricated catheters significantly reduce the risk of UTIs compared with standard catheters (Le Breton et al, 2012). In addition, hydrophilic-coated catheters can delay the onset of the first episode of urinary incontinence (Cardenas et al, 2011). A meta-analysis comparing hydrophilic-coated catheters and standard polyvinyl chloride (PVC) catheters found statistically significant superiority of hydrophilic-coated catheters in decreasing the incidence of UTI (Li et al, 2013). A previous study has also shown that the use of lubricated catheters reduces attrition with the urethral mucosa, leading to less pain, better treatment adherence and an improvement in the patient's quality of life (Chan et al, 2014).
According to the literature, single-use catheters have not shown any benefits in reducing UTIs over multiple-use catheters. The former are also responsible for greater healthcare spending (Biardeau et al, 2016). A review by Hakansson et al (2014) on reusable versus single-use catheters highlighted the lack of consensus on how to clean catheters between uses and how many times an individual catheter can be reused. Kiddoo et al (2014) compared single-use hydrophilic catheter to multiple-use PVC catheter and found no statistically significant differences in the incidence of fever, antibiotic use and physician visits.
Catheter dimensions
The diameter of the catheter is an important factor to consider. The smallest catheter possible should be used to obtain adequate drainage and avoid trauma or pain. Catheters are measured on the French scale (Fr), also called the Charrière scale (Ch). The procedure usually begins with a low Charrière (Ch) size-for example, 12 Ch, going up to 14-16 Ch and sometimes higher. One of the main risks associated with ISC is urethral bleeding, and it increases with the catheter diameter (Robinson, 2007). Adults typically use 10–14 Fr standard length or female catheters, while children use 6–10 Fr paediatric catheters depending on age and size (Robinson, 2007). Female catheters are shorter than those designed for men.
Role of the community nurse in the selection of urinary catheters
Community nurses can play a vital role in assisting patients in choosing the right catheter that suits the patient's needs (Logan, 2012). The nurse should discuss catheter choice with the patient; this discussion will not only be based around the products available in local formularies but also around patient preference and ease of use (Woodward, 2014). The patient's social circumstances also play an important role in catheter choice. For example, for people with limited access to wheelchair-accessible sanitary facilities, single-use catheters may be more appropriate (Hill et al, 2013). NICE guidance (2012) states that patients should be offered a choice of either single-use hydrophilic or gel reservoir catheters.
The initiation of ISC can be delicate subject matter and requires specific support. The patient may view the transition to ISC as a handicap. It is, therefore, important to clearly explain that the choice of therapy is guided by the aim to ensure patient autonomy as quickly as possible and better manage any urinary and renal complications (Société Française de Médecine Physique et de Réadaptation, 2009). Psychological factors vary depending on the patient and, according to a study conducted in 2015, the majority of patients with spina bifida and their caregivers did not experience any major emotional difficulty in adopting the practice of ISC (Faleiros et al, 2017). When patients were asked whether they had any negative feelings or ideas that could affect the performance of ISC, the majority (77.5%) reported not having these feelings. In contrast, 22.5% (n=45) described emotional difficulties, such as fear and shame. These emotional factors should be taken into consideration by health professionals teaching ISC to patients and their families (Faleiros et al, 2017).
Patient motivation is essential for successful ISC learning, and lack of motivation is the most common reason for failure. The nurse should assess the patient's motivation and willingness to perform the procedure before beginning teaching. Patients sometimes expect ISC to be quick, easy, safe and painless, so it is important to manage their expectations from the beginning (Davis and Rantell, 2018).
The desire to maintain independence is a motivating factor in ISC learning. Cobussen-Boekhorst (2016) found that patients who had indwelling catheterisation before ISC reported preferring the latter. They experienced more freedom and were less constrained. The benefit to the patient should always outweigh the risk, as this will affect motivation and adherence (Addison, 2001).
The success of ISC requires that the procedure be acceptable to the patient from the start. This, in turn, requires skilled training, support and long-term follow-up by the healthcare team (Newman, 2013). Without support, anxieties and problems can go unreported, and therefore unresolved. As a result, patients quickly abandon the practice.
Usually, patients find associating ISC with an active social life difficult. Health professionals, especially nurses, can offer patients solutions, paying particular attention to simplifying the stages of preparing and carrying out the catheterisation and to regular patient follow-up. Community nurses are ideally placed to support patients to master the technique, and patients who are well supported by nursing staff are most likely to continue to perform the procedure (Woodward, 2014).
In terms of the environment, catheterisation can be performed in any private space; the goal is to be able to conduct self-catheterisation in any situation. Ideally, the space should have a sink for washing with running water, a trash can or a disposal bag. Good lighting and a mirror are also useful (Robinson, 2007).
Community nursing staff are often responsible for teaching patients to self-catheterise. The nurse's role in teaching ISC is well recognised in urology/continence nursing. Staff providing this education must, at minimum, be well-trained (Wilde et al, 2016). Patients value the knowledge, kindness and patience of the nurse training them. Therefore, all caregivers involved in patient education must understand the cause of the bladder and sphincter dysfunction and the reason for the proposed treatment (Di Benedetto et al, 2011). Community nurses should also be aware of the latest scientific advancements in ISC. Additionally, they must demonstrate good communication skills, so that the patient feels comfortable and relaxed, as any tension will interfere with performance. Patients should be encouraged to ask questions, and each patient should ideally be trained and monitored by the same nurse.
Conclusion
ISC is an important treatment option for people with neurological bladders. The community nurse plays a key role in patient learning, follow-up and support. TPE requires nurses to have good communication skills and a suitable place for teaching that respects the privacy and integrity of the patient. Various types of urinary catheters are available in the market, and an in-depth discussion must take place between the patient and community nurse so the best option for the patient can be selected.
KEY POINTS
- Intermittent self-catheterisation is the method of choice for bladder drainage in patients with neurological bladder
- Several points should be taken into account when introducing and teaching intermittent self-catheterisation to the patient
- Community nurses play a key role in training and monitoring patients on intermittent self-catheterisation
- Various products are available in the market, and the choice of product must be suited to the individual needs of the patient
CPD REFLECTIVE QUESTIONS
- How can the functional and cognitive abilities of patients to perform intermittent self-catheterisation be assessed using specific tests and scales?
- Further studies are needed to assess patient satisfaction with the catheters used and the comparison of the different types between them. What type of urinary catheters do patients prefer in terms of comfort and ease of use?
- At the end of a training session, how can you ensure that the patient is satisfied with the quality of the training provided?