Intermittent self-catheterisation (ISC) is a highly effective method in the management of urinary incontinence issues. It is considered a gold standard for urine drainage (National Institute for Health and Care Excellence (NICE), (2015).
ISC is mostly used when dealing with issues that result from disturbances or injury to the nervous system, non-neurogenic bladder dysfunction or intravesical obstruction with incomplete bladder emptying. In a hospital, intermittent catheterisation is often used for diagnostic evaluation, such as in order to obtain a urine sample or to facilitate urodynamics (NICE, 2015).
Before starting a patient on intermittent catheterisation, the following should be considered: their symptom severity profile; renal function; risk assessment; psychological and physical ability to perform intermittent catheterisation; and their residual urine status (NICE, 2015). The patient should not be initiated on intermittent catheterisation based solely on their residual urine status.
ISC is preferred to an indwelling urethral or suprapubic catheter in patients who have a bladder emptying dysfunction or a spinal cord injury. ISC provides the most preferable mode of voiding urine, as it helps prevent infection, while regularly voiding the bladder in a hygienic manner, without a device remaining inside.
Types of intermittent self-cathers
The Bladder and Bowel Community (2022) state that there are three main types of intermittent self-catheters: coated, non-coated, and pre-lubricated. Coated catheters come with a hydrophilic coating, which creates a lubricated surface when run under water prior to its use. This helps ease insertion. Non-coated catheters are traditional intermittent catheters and, apparently, the most preferred types by researchers studying the topic. They can be washed and reused, and are made of plastic (PVC), silicone, silver or stainless steel (the latter two being only suitable for women due to the urethral length) (Bladder and Bowel Community, 2022). The reusable catheters are less often used; this is because they have to be cleaned, as well as due to client preferences towards an easier option that does not require this. Pre-lubricated catheters are ready to use straight from the packet, requiring no additional preparation, and are already packed in a water soluble gel, making the device easier to use. This is often preferred by someone who lives independently, as it consumes far less time and is a better option in general, when clean water and facilities are not always available (Bladder and Bowel Community, 2022).
Coloplast have a Speedicath range of self-catheters, designed for both males and females; other brands providing ISC devices include Rusch Robinson and Nelaton, Hollister, Teleflex, and Wellspect.
Considering cognition, consent, motivation and compliance
ISC involves requiring the individual to learn various steps; and this information needs to be conveyed by a competent and experienced specialist healthcare professional, with the relevant communication skills (Royal College of Nursing (RCN), 2019). Exclusions to ISC include cognitive impairment and lack of consent. Therefore, the patient’s healthcare providers must be confident that the individual is able, can provide consent, and has the cognition to have possible success with using intermittent catheters. It is also important that the healthcare professional assesses the likely levels of motivation and compliance with intermittent catheterisation. It may be found that increased support and follow up may be required, especially in the early stages, in order to ensure long-term compliance. The RCN (2019) suggested that motivational factors for intermittent catheterisation include, for example, the notion of an improved quality of life, symptom improvement, and reduced risks.
Independence
A study has found that females who are not dependent on others for any degree of help with catheterisation are more likely to indicate a stronger feeling of independence and confidence, as opposed to females who depend on others for help with this process (Marckiewicz et al, 2020). This supports the researchers’ hypothesis that ISC, when not requiring others for assistance in its utilisation, can offer a sense of independence and confidence, particularly in females.
Risk of urinary tract infection and antibiotic prophylaxis
There is a heightened risk of urinary tract infection (UTI) in patients using ISC. Pickard et al (2018) noted there was a clear benefit to using antibiotic prophylaxis, in terms of reducing frequency of infection in those using clean intermittent self-catherisation. Furthermore, they found antibiotic prophylaxis appears safe in the first 12 months, although resistant pathogens may present a public health concern by creating a pattern of recurring infections in the longer term. Therefore, the researchers agreed that longer term studies of resistance and non-antibiotic strategies are required (Pickard et al, 2018).
Alternatives have been explored to antibiotic prophylaxis in recent years. Studies, such as the one by Harding et al (2022), tested and compared the efficacy of methenamine hippurate for the prevention of recurrent urinary tract infections, with the standard low-dose daily antibiotic prophylaxis. The team concluded that the use of methenamine hippurate as an alternative to an antibiotic may be suitable for women with a history of recurrent urinary tract infections. This can be better informed by patient preference and by what is deemed appropriate, with antibiotic stewardship influencing the choices available.
Challenges of use
Wellspect (2023) explain the common challenges people may come across when using the devices. They discuss insertion difficulties, especially among men who may be tense and, therefore, have tense sphincter muscles. Wellspect (2023) recommend relaxation techniques such as deep breathing and a slight cough on insertion of the catheter. Twisting the catheter can help with insertion or using a device with a tapered tip to simplify insertion of the device. Another issue is finding the right entering point; Wellspect (2023) discuss how women, in particular, may have issues with this; finding the urethra may be difficult but with the right training and assistance aids such as a mirror, handle or leg spread, the company states the problem should resolve in time and with practice.
Another common problem is the anxiety and uneasiness someone might feel when emptying their bladder while they are out, due to fear of others noticing. The best way to overcome this is to use a catheter that is a smaller discreet device. A plastic bag can be brought along to disponse of the catheter, rather than in a friend’s bathroom bin. This helps the individual feel more subtle when using the device.
People who have difficulties with grip and hand movement may have issues with dexterity and, therefore, in using the catheter device. Furthermore, the time taken to remove the catheter may cause it to dry out and lose lubrication. In this instance, Wellspect (2023) recommend the use of a hydrophilic-coated catheter—activated with water, thus, eliminating the need for an external lubricant. They also recommend coughing, rotating the catheter, as well as trying relaxation techniques such as deep breathing.
A review conducted by Shamout et al (2017) also found further advantages of using hydrophilic-coated catheters in lowering the risk of UTI and urethral trauma, resulting in improved patient satisfaction. Prelubricated catheters were found to be at an advantage and preferable to conventional polyvinyl chloride catheters. However, randomised controlled trials comparing hydrophilic and prelubricated catheters are required in order to assess the possible superiority and costeffectiveness (Wellspect, 2023).
Conclusion
Overall, ISC addresses what was once a much more disabling issue, as it allows full independence and autonomy to someone living with a continence problem. ISC can be a great tool, if appropriate guidance is provided by healthcare providers and brands that produce the catheters. Numerous devices are available, and the hydrophilic option is usually recommended. Infections can be common but this be avoided through clean technique and antibiotic prophylaxis. Simple obstructions to using intermittent catheters can be addressed. These usually relate to the person simply needing some practice, guidance, or assistance aid, as well as confidence and the ability to relax, which can all be achieved over time.