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
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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.

Further Related Content:
Watch: Intermittent Catheters - Complications

Written by: Diane K. Newman, DNP, ANP-BC, FAAN
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 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).