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clean technique self-catheterization

  • Complications - Intermittent Catheters

    Urethral Adverse Events  |  Scrotal Complications  |  Bladder-related Complications  |  Pain  | Urinary Tract Infections  |  Causes of IC-related UTIs  |  Video Lecture  |  References

    Intermittent catheterization (IC) is the preferred procedure for people with incomplete bladder emptying not satisfactorily managed by other methods. Complications and adverse events can arise in both men and women but are seen especially in male patients performing intermittent self-catheterization long-term.

    Urethral, Scrotal, Bladder-related Complications

    Urethral/scrotal events can include bleeding, urethritis, stricture, the creation of a false passage, and epididymitis. Bladder-related events can cause UTIs, bleeding, and stones. The most frequent complication of IC is urinary tract infection (UTI). It is unclear which catheter types, techniques or strategies, affect the incidence of UTI.

    Urethral Adverse Events

    Urethral problems, seen primarily in men, include urethritis or inflammation of the urethral meatus from frequent catheter insertion. Urethral bleeding is frequently seen in patients when initiating intermittent catheterization and can occur regularly in one-third of patients performing intermittent catheterization on a long-term basis. Persistent bleeding in a patient who has been performing intermittent self-catheterization long-term may be a sign of a UTI.

    A more common urethral adverse event seen primarily in men who self-catheterize for years is the creation of a false passage.  Men with persisting urethral strictures or who have an enlarged prostate are at increased risk. The false passage may occur at the site of the external sphincter, just distal to the prostate.

    Urethral trauma or injury can occur in both men or women due to the use of a poorly lubricated catheter or forcible catheterization in a urethra, causing spasms.
    It is believed blind catheterization may lead to both urethral bleeding and the formation of a false passage.

    Urethral strictures can occur in the anterior portion of the male urethra (meatus, penile-pendulous urethra, bulbar urethra) or in the posterior portion (membranous urethra and prostatic urethra). These strictures may be the result of an inflammatory response to repeated trauma and are seen more often in patients who perform intermittent self-catheterization. A difficulty with catheter insertion may be a sign of the presence of a urethral stricture. Increased frequency of catheterization may correlate with fewer urethral changes. This may be because individuals who regularly perform intermittent self-catheterization are more skilled in catheterization, and therefore, have less chance of urethral trauma. Repeat catheterization, however, may induce local traumatic reactions of the urethral wall, especially in male patients performing self-catheterization longer than 1 year. It is believed that the surface of the catheter is an important factor, with less stricture development when hydrophilic catheters are used. If a stricture is suspected, a retrograde urethrogram or voiding cystourethrogram should be considered. Prevalence of urethral strictures and false passages may increase with longer use of intermittent catheterization or with traumatic catheterization. 

    Scrotal Complications

    Epididymitis, or epididymo orchitis (inflammation of the epididymis and testes), is one of the most common genital infections in men with spinal cord injury who perform intermittent self-catheterization. This infection appears to be more common in men who have a urethral stricture. Prevalence of this complication of intermittent catheterization has been reported to be between 2% to 8%. Men may also experience prostatitis, which can cause UTIs.

    Bladder-related Complications

    Hematuria is frequently seen in the initiation of intermittent catheterization but should not be a persisting problem. New-onset hematuria may indicate a UTI or a stricture.

    Bladder stones are seen in both men and women and are thought to be caused by the introduction of pubic hair or loss of the catheter in the bladder.  Stone formation is more common in patients performing long-term intermittent self-catheterization. There have been anecdotal reports of short catheters with a smooth, soft funnel end being inserted and lost in the bladder. Only a few cases of squamous cell cancer of the bladder in patients performing intermittent self-catheterization have been reported in the literature.

    Pain

    Pain or discomfort is often experienced during catheterization in individuals with intact periurethral sensation, especially during initiation of intermittent self-catheterization. Pain may be worsened by tension or anxiety. Adequate catheter lubrication along the entire length of the catheter and in men, correct positioning of the urethra can decrease pain and discomfort. Pain and discomfort usually decrease over time.

    Urinary Tract Infections

    UTI is the most frequent complication in patients performing intermittent catheterization. Catheter-associated UTI (CaUTIs) is of concern because when urethral damage occurs, the mucosal barrier to infection is compromised. The bladder wall is susceptible to bacteria that circulate in retained urine. When the bladder becomes stretched from retained urine, the capillaries become occluded, preventing the delivery of metabolic and immune substrates to the bladder wall

    These patients are at higher risk than the general population for developing a UTI and renal deterioration. UTIs can be the result of re-use of the same catheter for multiple catheterizations, poor catheterization technique or the passing of the catheter through a normally very contaminated area of the urethra before the catheter reaches the bladder.

    A UTI may also be caused by the formation of biofilms (micro-organisms that colonize the internal surface of catheters). In patients with indwelling urinary catheters, these biofilms can contain up to 16 different strains of bacteria!  Common bacteria is Ecoli.   Under unfavorable conditions (re-use of a catheter), organisms can detach from the biofilm and become free floating in the urine, which can lead to symptomatic infection.

    In a large (N = 912) community-based population of individuals with spinal cord injury, half of which were women, women reported a significantly greater number of UTIs than men (p = 0.003). Predictor factors of UTI included high mean catheterization volumes and non-self-catheterization (someone other than the patient performs the catheterization).

    Busy patient lifestyles, especially for those who are mobility-impaired, and lack of access to more public places with restrooms may further increase the risk of UTI. Also, the longer the time frame an individual catheterizes, the incidence of UTI increases. Overlooking basic hygiene prevention techniques could lead to serious health problems.  In patients with an internal prosthesis (pacemaker, heart valve), the use of prophylactic antibiotic therapy is often recommended (American Urological Association, 2008).

    Causes of Intermittent Catheterization-related Urinary Tract Infections
    UroToday_IC_Complications.png


    Video Lecture - Complications


    ic complications part3

           

    References
    1. Casey, R.G., Cullen I.M., Crotty, T., & Quinlan, D.M.  Intermittent self-catheterization and the risk of squamous cell cancer of the bladder: An emerging clinical entity? Canadian Urological Association Journal, 2009; 3(5), E51-E54.
    2. Clarke, S.A., Samuel, M., & Boddy, S.A.  Are prophylactic antibiotics necessary with clean intermittent catheterization? A randomized controlled trial. Journal of Pediatric Surgery, 2005; 40, 568-571. 

    3. De Ridder, D.J., Everaert, K., et al.  catheters reduces the risk of clinical urinary tract infection in spinal cord injured patients: A prospective randomized parallel comparative trial Eu Urol, 2005; 48, 991-995.
    4. Heard, L., & Buhrer, R. How do we prevent UTI in people who perform intermittent catheterization? Rehab Nurs, 2005; 30, 44-45.
    5. Igawa, Y., Wyndaele, J.J., & Nishizawa, O. Catheterization: Possible complications and their prevention and treatment. International Journal of Urology, 2008; 15(6), 481-485.
    6. Moore, K.N., Day, R.A., & Albers, M. Pathogenesis of urinary tract infections: A review. Journal Clinical Nursing, 2003; 11(5), 568-574.
    7. Moore, K.N., Fader, M., & Getliffe, K..  Long-term bladder management by intermittent catheterisation in adults and children. Cochrane Database System Review, 2007; 4, CD006008.
    8. Moy, L.M.. & Wein, A.J. Additional therapies for storage and emptying. In A.J. Wein, L.R. Kavoussi, A.C. Novick, A.W. Partin, & C.A. Peters (Eds.), Campbell’s urology (9th ed., pp. 2288- 2304). 2007 Philadelphia: Elsevier Saunders.
    9. Saint, S., & Chenoweth, C.E. (2003). Biofilms and catheter-associated urinary tract infections. Infectious Disease Clinics of North America, 17, 411-432.
    10. S. tensballe, J., Loom, D., et al. Hydrophilic-coated catheters for intermittent catheterisation reduce urethral microtrauma: A prospective, randomised, participantblinded, crossover study of three different types of catheters. Eu Urol, 2005; 48, 978-983.
    11. Vapnek, J.M., Maynard, F.M., & Kim, J.  A prospective randomized trial of the LoFric hydrophilic coated catheter versus conventional plastic catheter for clean intermittent catheterization. Journal of Urology 2003; 169, 994-998.
    12. Wyndaele, J.J.  Complications of intermittent catheterization: Their prevention and treatment. Spinal Cord, 2002; 40(10), 536-541.

    Published February 1, 2013
  • Definition - Intermittent Catheters

    Intermittent catheterization (IC) is the insertion and removal of a catheter several times a day to empty the bladder. This type of catheterization is used to drain urine from a bladder that is not emptying adequately or from a surgically created channel that connects the bladder with the abdominal surface (such as Mitrofanoff continent urinary diversion). Intermittent catheterization is widely advocated as an effective bladder management strategy for patients with incomplete bladder emptying due to idiopathic or neurogenic detrusor (bladder) dysfunction (NDO).
     UroToday_IC.pngCatheterization is performed by the following methods

    UroToday_IC_def.png
    There is no benefit to the use of an antiseptic solution for daily periurethral cleansing prior to catheterization. In 1972, Jack Lapides, a Urologist at the University of Michigan, and his colleagues (Dr Ananias Diokno) determined that Clean Intermittent Self-Catheterization (CIC) is a safe and effective alternative method of emptying the bladder It continues to be used more than forty years later to help protect the kidneys, prevent incontinence and decrease the number of infections a patient may acquire by promoting adequate drainage of the bladder while lowering intravesical pressure. Catheterizations performed in institutions, such as acute and rehabilitation hospitals and nursing homes, are done aseptically.

    Since Dr Lapides first described CIC, intermittent catheterization has been performed by the patient in the home environment using a clean technique.  But re-using IC catheters for multiple catheterizations is no longer the preferred or recommended practice for many reasons.  Krassioukov et al 2015 concluded that reuse of catheters is associated with greater risk for catheter-associated urinary tract infection (CaUTI) and primarily occur in developing nations with an average frequency of UTI of 3.5 ± 3 per year as compared to 1.6 ± 2 per year for developed nations. DeFoor et al (2018) concluded that single-use hydrophilic-coated catheters significantly reduces the occurrence of UTI as compared to catheter reuse with uncoated catheters. Also, Averbeck et al. (2018) found that single-use catheters are associated with better health states as compared to catheter re-use. Avery et al. (2018) furthermore describe concerns associated with catheter reuse raised by users. These include concerns about catheter-associated UTIs (CaUTIs), cleaning, preparation, storage, lack of discretion. In April 2008, the Centers for Medicare and Medicaid Services (CMS) of the Department of Health and Human Services, USA eliminated the mandatory reuse of intermittent catheters for outpatients who receive such prescriptions from doctors. In short, no more cleaning and reusing catheters at home for people who self-catheterize. Healthcare professionals use their clinical judgment to determine which technique and type of catheter to use, in conjunction with patient preference. Differential costs and insurance coverage of catheters/techniques may also influence decision-making. So it is now recommended that patient’s who perform intermittent self-catheterization (ISC) not re-use the same catheter for multiple catheterizations.

    The rationale for using Intermittent Catheterization:

    • The bladder contracts and the pelvic floor muscles relax and the external urinary sphincter opens to allow voiding and the passage of urine through the urethra.
    • Normally, after the bladder empties, a small amount of urine may remain in the bladder and this is called the postvoid residual (PVR).
    • If the person cannot urinate or empty the bladder completely, the PVR increases and can contribute to CaUTIs, overflow UI, and permanent damage to the bladder and kidneys.
    • Research has shown that regular bladder emptying reduces intravesical (in the bladder) pressure and improves blood circulation in the bladder wall, making the bladder mucosa more resistant to infectious bacteria.
    • By inserting the catheter several times during the day, episodes of bladder overdistention are avoided.
    • In addition, the bladder wall is susceptible to bacteria that circulate in retained urine. When the bladder becomes stretched from retained urine in the bladder, the capillaries become occluded, preventing the delivery of metabolic and immune substrates to the bladder wall.
    • The key to avoiding CaUTIs is avoiding high intravesical pressure and overdistention of the bladder, thus preserving an adequate blood supply to the bladder wall.

    Written By: Gina B. Carithers December 19, 2018 

    References:
    1. Averbeck MA, Krassioukov A, Thiruchelvam N, Madersbacher H, Bogelund M, Igawa Y. The impact of different scenarios for intermittent bladder catheterization on health state utilities: results from an internet-based time trade-off survey. J Med Econ.2018:1-8.
    2. Avery M, Prieto J, Okamoto I, et al. Reuse of intermittent catheters: a qualitative study of IC users' perspectives. BMJ open.2018;8(8):e021554
    3. Beauchemin L, Newman DK, Le Danseur M, Jackson A, Ritmiller M. Best practices for clean intermittent catheterization. Nursing.2018;48(9):49-54.
    4. DeFoor W, Reddy P, Reed M, et al. Results of a prospective randomized control trial comparing hydrophilic to uncoated catheters in children with neurogenic bladder. J Pediatr Urol.2017;13(4):373.e371–373.e375.
    5. Goetz LL, Droste L, Klausner AP, Newman DK. Catheters Used for Intermittent Catheterization. Clinical Application of Urologic Catheters, Devices and Products. Cham: Springer International Publishing; 2018:47-77.
    6. Heard, L. & Buhrer, R. How do we prevent UTI in people who perform intermittent catheterization? Rehabilitation Nursing, 2005: (30): p 44–45. 
    Krassioukov A, Cragg JJ, West C, Voss C, Krassioukov-Enns D. The good, the bad and the ugly of catheterization practices among elite athletes with spinal cord injury: a global perspective. Spinal Cord.2015;53(1):78-82.
    7. Lapides, J., Diokno, A.C., Silber, S.J., & Lowe, B.S., Clean, intermittent self-catheterization in the treatment of urinary disease. 1972. Urology:107;  p458.
    8. Lapides, J., Diokno, A.C., Silber, S.M., & Lowe, B.S. Clean, intermittent self-catheterization in the treatment of urinary tract disease. 1972. Journal of Urology: 167; p1584–1586.
    9. Newman DK. (2017). Devices, products, catheters, and catheter-associated urinary tract infections. In: Newman DK, Wyman JF, Welch VW, editors. Core Curriculum for Urologic Nursing. 1st ed. Pitman (NJ): Society of Urologic Nurses and Associates, Inc; 439-66.
    10. Newman DK, Willson MM. Review of intermittent catheterization and current best practices. Urol Nurs. 2011 Jan-Feb;31(1):12-28, 48; quiz 29. PubMed PMID: 21542441
    11. Vahr S, Cobussen-Boekhorst H, Eikenboom J, et al. Evidence-based guideline for best practice in urological health care. Catheterization. Urethral intermittent in adults. Dilatation, urethral intermittent in adults. . EAUN guideline. 2013.
    Published February 1, 2013
  • Indications - Intermittent Catheters

    Intermittent catheterization (IC) can be indicated as treatment for voiding problems due to disturbances or injuries to the nervous system, non-neurogenic bladder dysfunction, or intravesical obstruction with incomplete bladder emptying.

    Intermittent catheterization should be performed in the presence of a residual urine volume and symptoms or complications arising from this residual volume of urine.  

    Common complications caused by a large residual urine volume includes:

    • Urinary tract infection
    • Bladder calculi
    • Renal failure
    • Patient discomfort
    • Incontinence
    • Lower urinary tract symptoms (frequency, urgency or night time voiding)

    Lower urinary tract symptoms of neurogenic bladder include either UI or incomplete bladder emptying and urinary retention caused by outlet obstruction, poor detrusor contraction, or compliance.

    A common cause of a neurogenic bladder is spinal cord injury.  The use of intermittent catheterization in this population has eliminated many complications associated with an indwelling urinary catheter.

    Advantages of intermittent catheterization over an indwelling urinary catheter include:

    • Improved self-care and independence
    • Reduced risk of common indwelling catheter-associated complications
    • Reduced need for equipment (such as drainage bags)
    • Less barriers to intimacy and sexual activities
    • Potential for reduced lower urinary tract symptoms (frequency, urgency, incontinence) between catheterizations

     Written By: Gina B. Carithers

    References:

    Cottenden, A., Bliss, D., Buckley, B., Fader, M., Getliffe, K., Paterson, J., Pieters, R., & Wilde, M. Management with continence products. In P. Abrams, L. Cardozo, S. Khoury, & A. Wein (Eds), Incontinence (pp. 1519-1642), Proceedings from the 4th International Consultation on Incontinence, 2009 Plymouth UK: Health Publication.
    Newman, D.K., Fader, M., & Bliss, D.Z. (2004). Managing incontinence using technology, devices and products. Nursing Research, 53(6, Suppl.), S42-S48.
    Newman, D.K., & Wein, A.J. (2009). Managing and treating urinary incontinence (2nd ed). Baltimore: Health Professions Press.
    Pohl, H.G., Bauer, S.B., Borer, J.G., Diamond, D.A., Kelly, M.D., Grant, R., Retik, A.B.. (2002). The outcome of voiding dysfunction managed with clean intermittent catheterization in neurologically and anatomically normal children.
    British Journal of Urology International, 89(9), 923-927.

    Published February 1, 2013
  • Prevention Strategies - Intermittent Catheters

    Adherence to basic daily prevention habits may help avoid UTIs in the higher-risk intermittent catheterization population.  The table below summarizes this information.

    The most important prevention measures in preventing a UTI are: 

    • adequate education
    • patient compliance
    • the use of appropriate catheter type and material
    • consistent catheterization technique 

    Less frequent catheterization results in higher catheterized urine volumes and places the patient at increased risk for developing a UTI.  More frequent catheterization and the avoidance of bladder overfilling is an extremely important prevention measure.

    Catheterization between four and six times a day is recommended for most individuals. More frequent catheterization, however, increases the risk of introducing harmful bacteria.

    Another measure that may reduce infection is the acidification of urine with cranberry juice or capsules, foods containing lactobacillus, and vitamin C capsules.

    Cranberries inhibit bacterial adherence to the uroepithelial wall and have been primarily studied with Escherichia coli (E. coli). In a community-based survey of patients with a spinal cord injury on intermittent catheterization, it was found that those who ingested cranberry or vitamin C agents decreased their incidence of UTI.

    Suggestions for Prevention of UTIs Associated with Intermittent Catheterization

     

    Maintenance of hygiene, particularly of the hands and perineum

    1. Hands should be thoroughly washed before attempting catheterization
    2. The genitalia should be washed daily with soap and water and always cleansed from front to back
    3. Preferable to perform catheterization before bowel program to minimize E. coli bacteria contamination of the urethra
    4. Immediate perineal hygiene is recommended after vaginal intercourse  
    5. Avoidance of spermicidal lubricants in sexually active females because these products may lower urethral flora

      2.   Teach male patients the correct positioning of the male urethra during insertion of the catheter to minimize trauma 

      3.   Be careful to avoid touching the tip of the catheter and/or letting it touch other surfaces

      4.   If a postmenopausal female patient has hypoestrogenized perineal tissue, consider transvaginal estrogen medication

      5.   Use a generous amount of lubricant along the length of the catheter, since dry catheters may cause excoriations in the
            urethra, leading to an entry point for bacteria contamination

      6.   Keep the bladder as empty as possible by having patients catheterize at least four to six times a day 
            Keeping the bladder as empty as possible will prevent over-distension of the bladder 

      7.   Encourage use of a new catheter each time performing intermittent catheterization  
            Most catheters are manufactured and packaged for single sterile use

      8.   Acidification of the bladder may prevent bacterial growth 
            In non-catheterizing populations, cranberry capsules and juice have been shown to help prevent the growth of bowel
            bacteria in the urethra and the bladder
            Cranberry ingestion may be contra-indicated in some patients (patients prone to oxalate or uric acid calculi) 
            Cranberry is contraindicated in patients on anticoagulation therapy and should not be recommended to this group
            Lactobacillus in the diet (yogurt) has been shown to prevent E. coli from growing in the urethra
            Hiprex® 1000 mg combined with vitamin C 1000 mg capsules twice daily is thought to acidify urine enough to prevent
            bacterial growth in the bladder and is recommended in patients with recurrent UTIs

    References

    Hess, M.J., Hess, P.E., Sullivan, M.R., Nee, M., & Yalla, S.V.Evaluation of cranberry tablets for the prevention of urinary tract infections in spinal cord injured patients with neurogenic bladder. Spinal Cord, 2008; 46(9), 622-626. 
    Igawa, Y., Wyndaele, J.J., & Nishizawa, O.  Catheterization: Possible complications and their prevention and treatment. International Journal of Urology, 2008; 15(6), 481-485.
    Jepson, R.G., & Craig, J.C.  Cranberries for preventing urinary tract infections. Cochrane Database System Review, 2, 2008 CD001321.
    Newman, D.K., Fader, M., & Bliss, D.Z. (2004). Managing incontinence using technology, devices and products. Nursing Research, 53(6, Suppl.), S42- S48.
    Newman, D.K., & Wein, A.J.  Managing and treating urinary incontinence (2nd ed). 2009 Baltimore: Health Professions Press.
    Woodbury M.G., Hayes K.C., & Askes H.K. Intermittent catheterization practices following spinal cord injury: A national survey. Canadian Journal Urology, 2008; 15(3), 4065-4071.
    Wyndaele, J.J. Complications of intermittent catheterization: Their prevention and treatment. Spinal Cord, 2002; 40(10), 536-541.
    Published February 1, 2013
  • Techniques and Procedures for Use - Intermittent Catheters

    Techniques & Procedures for Use
    Type Technique
     Sterile   
    • Use of sterile gloves, disinfectant wipes or swabs, sterile single-use catheter, sterile drainage tray, or closed collection bag
     Clean, single-use
    • Use of a sterile, disposable catheter and clean hand hygiene
    • Catheter is single-use and is disposed after use
    • Product does not feature a protective sleeve or collection bag. 
     *Clean re-used  
    • Re-use of a sterile, disposable catheter and with good hand hygiene
    • *After use, catheter is washed and rinsed
    • Catheter is then air dried and stored in a ventilated container or ziplock plastic bag
    • Catheter is re-used by the same patient for a limited period of time (usually 1 week) as directed by clinician

     * Manufacturer guidelines state that a catheter designed for intermittent drainage of the bladder is single-use and is to be disposed after its catheterization.  

    Medicare Changes Reimbursement Policy to End Re-use of Intermittent Catheters

    On April 1st, 2008, Medicare changed its reimbursement policy on intermittent catheterization. The previous policy only allowed reimbursement for one intermittent catheter per week (4 per month), unless the individual user had lab results or medical documentation stating the existence of at least 2 urinary tract infections (UTIs) in the course of one calendar year. This new policy now allows reimbursement for up to 200 intermittent catheters per month per individual.

    This change allows for up to 6 catheter changes a day in hopes to stop re-use of FDA labeled "single-use" catheters. The old policy made individuals sterilize and clean their catheters any way they knew how which lets a very high-risk opportunity to have the individual get infected with catheter-associated bacteria to arise.  No longer will catheter users suffer from severely painful UTIs.


     


    Video Lecture - Techniques


    ic techniques part2


    References
    1. Beauchemin L, Newman DK, Le Danseur M, Jackson A, Ritmiller M. Best practices for clean intermittent catheterization. Nursing.2018;48(9):49-54.
    2. Goetz LL, Droste L, Klausner AP, Newman DK. Catheters Used for Intermittent Catheterization. Clinical Application of Urologic Catheters, Devices and Products. Cham: Springer International Publishing; 2018:47-77.
    3. Lapides, J., Diokno, A.C., Silber, S.J., & Lowe, B.S. Clean, intermittent self-catheterization in the treatment of urinary tract disease. Journal of Urology, 1972;107(3), 458-461.
    4. Lindehall, B., Abrahamsson, K., Jodal, U., Olsson, I., & Sillén, U.  Complications of clean intermittent catheterisation in young female patients with myelomeningocele: 10 to 19 years follow up. Journal of Urology, 2007; 178, 1053-1055.
    5. Moore, K.N., Burt, J., & Voaklander, D.C.  Intermittent catheterization in the rehabilitation setting: A comparison of clean and sterile technique. Clinical Rehabilitation, 2006; 20, 461-468.
    6. Moore, K.N., Fader, M., & Getliffe, K..  Long-term bladder management by intermittent catheterisation in adults and children. Cochrane Database System Review, 2007; 4, CD006008. 

     

    Published February 1, 2013
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