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Intermittent catheterization

Some patients need a catheter long term to empty their bladder. This is often managed by teaching them clean intermittent self‐catheterization (CISC). This involves passing a catheter into their bladder to drain urine and then removing it immediately when the bladder is empty (Logan [132]).

Patients who may need to do this include those who are unable to empty their bladder effectively (with a residue of 150 mL or more). This could be due to a number of factors including urethral or meatal strictures or prostatic issues such as benign prostatic hypertrophy or prostate cancer (Logan [132]).

Intermittent self‐catheterization can also be used short term for the management of post‐operative voiding – for example, following surgery for stress incontinence or pelvic‐surgery‐related neuropathy (Rantell [203]).

Evidence‐based approaches

Rationale

Indications

This procedure may be required by patients who have undergone continent reconstruction surgery to manage post‐operative incontinence. Patients with a Mitrofanoff reconstruction will need to perform this procedure to facilitate bladder emptying through their abdominal tract, for life. Additionally, many patients with an orthotopic neobladder reconstruction will have to perform this procedure on a regular basis to either facilitate neobladder emptying or drain residual urine.

Patients suitable for intermittent self‐catheterization include those:

with a bladder capable of storing urine without leakage between catheterizations
who can comprehend the technique
with sufficient dexterity and mobility to position themselves for the procedure and manipulate the catheter
who are highly committed to carrying out the procedure (Nazarko [157]).

Contraindications

Contraindications for intermittent self‐catheterization include the following:

insuffient bladder control (bladder not capable of storing urine without leakage between catheterizations)
insufficient dexterity and/or mobility
patient resistance.

Related theory

CISC is not a new technique, although it has become noticeably more popular in recent years. The procedure involves the episodic introduction of a catheter into the bladder to remove urine. After this, the catheter is removed, leaving the patient catheter free between catheterizations. In hospital, this should be a sterile procedure because of the risk of hospital‐acquired infection. However, in the patient's home a clean technique may be used (Stafford [231]). Catheterization should be carried out as often as necessary to stop the bladder becoming over‐distended and to prevent incontinence (Naish [154]). How frequent this is will depend on the individual.

The advantages of intermittent catheterization over indwelling urethral catheterizations include improved quality of life, as patients are free from bulky pads or indwelling catheters, greater patient satisfaction and greater freedom to express sexuality. In addition, urinary tract complications are minimized and normal bladder function is maintained (Wilson [254]).

There are challenges to intermittent catheterization. Patients need to have an understanding of their anatomy, an understanding of what is causing their voiding problems and an understanding of how intermittent catheterization works (Logan [132], RCN [208]).

There can be physical and psychological barriers to intermittent catheterization:

Physical barriers include poor eyesight, reduced mobility and reduced dexterity.
Psychological barriers include anxiety about intermittent catheterization, fear of pain or discomfort, concern regarding sexual function, lack of understanding and cultural concerns (Wilson [254]).

Nurses can help allay some of these anxieties through teaching and encouragement. Continued nursing support can be offered in the community (Nazarko [157]).

Pre‐procedural considerations

Equipment

Nelaton catheters are generally used to carry out intermittent self‐catheterizations (see Figure 6.7). These catheters are available in standard, female and paediatric lengths and in charrière sizes 6–24; as they are not left in the bladder, they do not have a balloon. They are normally manufactured from plastic but there is also a non‐PVC, chlorine‐free catheter available. Many Nelaton catheters are coated with a water‐activated lubricant; others are packaged with a lubricant gel that coats the catheter as it slides out of the packaging (these catheters are for single use only). Some Nelaton catheters are also available with an integral drainage bag, which is useful when toilet facilities are unavailable or the environment is not conducive to performing a clean procedure safely or comfortably.

Procedure guideline 6.7

Urinary catheterization: intermittent self‐catheterization patient guidance: male

Procedure guideline 6.8

Urinary catheterization: intermittent self‐catheterization patient guidance: female

Table 6.4 Prevention and resolution (Procedure guidelines 6.4, 6.5, 6.6, 6.7 and 6.8)

Problem	Cause	Prevention	Action
Urethral mucosal trauma	Incorrect size of catheter, procedure not carried out correctly or skilfully, or movement of the catheter in the urethra	Select an appropriate size of catheter (smallest diameter for type of drainage required). Ensure adequate training is received before carrying out the procedure.	Reinsert the catheter using the correct size of catheter. Check the catheter support and apply or reapply as necessary.
	Inadequate lubrication of the catheter	Ensure adequate lubrication.	Add additional lubrication as required.
	Trauma to the urethral tissue due to rapid insertion of the catheter	Ensure the catheter is inserted slowly and gently.	It may be necessary to remove the catheter and wait for the urethral mucosa to heal.
Patient has a vasovagal attack	This is caused by the vagal nerve being stimulated so that the heart slows down, leading to syncope (fainting)	Difficult to predict or prevent; however, ensure the person performing the procedure is prepared and trained in the actions to take following a vasovagal attack.	Patient should lie down in the recovery position (see Figure 12.59) and their doctor should be informed.
Male
Paraphimosis	Failure to extend the foreskin after catheterization	Ensure adequate training is received before carrying out the procedure.	Refer to a relevant medical colleague to review and attempt to extend the foreskin. The foreskin must not be left in a retracted position.
Female
No drainage of urine	Incorrect identification of the external urinary meatus	Ensure there is sufficient light to observe the area. Review the female anatomy prior to the procedure.	Check that the catheter has been sited correctly. If the catheter has been wrongly inserted in the vagina, leave it in position to act as a guide, reidentify the urethra and perform the catheterization. Remove the inappropriately sited catheter.
Difficulty in visualizing the urethral orifice	Vaginal atrophy and retraction of the urethral orifice into anterior vaginal wall		The index finger of one hand (for nurses carrying out the procedure in hospital, this will be the ‘dirty’ hand) may be inserted in the vagina, and the urethral orifice can be palpated on the anterior wall of the vagina. The index finger is then positioned just behind the urethral orifice. This then acts as a guide so that the catheter can be correctly positioned (Robinson [212]).

Procedure guideline 6.9

Urinary catheter bag: emptying

Procedure guideline 6.10

Urinary catheter removal