Indication of Catheterization for Intermittent Catheters (IC)

Intermittent catheterization (IC) is the “gold standard” for individuals with bladder dysfunction caused by neurologic or non-neurologic causes, a significant and growing population in the United States.  Intermittent catheterization is the recommended method for individuals who are unable to void or completely empty the bladder.  According to the 6th International Consultation on Incontinence, IC has replaced long-term indwelling urinary catheterization for patients with neurogenic lower urinary tract dysfunction (NLUTD) resulting in incomplete bladder emptying as it is associated with less urologic and non-urologic complications.

The following are the terms and their definition for understanding this type of bladder dysfunction.

  • Neurogenic means “originating in the nervous system”
  • Lower Urinary Tract (LUT) refers to the bladder, urethra (and prostate in men)
  • Dysfunction refers to abnormal or difficult function
  • Adult neurogenic lower urinary tract dysfunction (ANLUTD)” refers to abnormal or difficult function of the bladder, urethra (and/or prostate in men) in adults (> 18 years of age) who have a disease related to the nervous system (nerves, spinal cord, brain). Diseases in the nervous system include:
  • Spinal cord injury (SCI): 80% per year, 80% are men, and 90% adults at the time of injury. Most will develop some type of bladder dysfunction
  • Multiple sclerosis: 70% have some degree of bladder dysfunction
  • Stroke: 15% are reported to have bladder problems
  • Parkinson’s disease: 40% develop dysfunction
  • Diabetes: 50% will have neurogenic bladder symptoms.

Normally, after the bladder empties, a small amount of urine (<75 ml), called the post-void residual (PVR), may remain in the bladder.  If a person cannot urinate or empty the bladder completely, the PVR increases and can contribute to urinary tract infections (UTIs), overflow urinary incontinence (UI), and permanent damage to the bladder and kidneys. Incomplete bladder emptying or urinary retention may lead to the development of a neurogenic bladder.

Not all individuals with NLUTD will develop urinary retention or incomplete bladder emptying and need to perform IC. Some will develop bladder “storage” symptoms which include urinary incontinence, urinary urgency, or frequency. Others will develop bladder “emptying” or voiding symptoms like a slow voiding (peeing) stream, hesitancy, or a delay in starting to void or a sprayed stream.  These may be symptoms of incomplete bladder emptying with an elevated post-void residual (PVR) or urinary retention. According to the International Continence Society, PVR is defined as the volume of urine left in the bladder at the end of micturition.

Individuals with urinary retention requiring IC are diagnosed with neurogenic detrusor overactivity (NDO), a urodynamic observation characterized by involuntary detrusor contractions during the bladder filling phase which may be spontaneous or caused by a neurologic disease.

Indications for Intermittent Catheterization:

Current Association of French Urologists, European Association of Urology (EAU), American Urological Association (AUA), and the Healthcare Infection Control Practices Advisory Committee (HICPAC), guidelines recommend IC over other catheter-based options (Gamė et al, 2020; Groen, 2016, Averch, 2014, Gould, 2009).  

Advantages of IC over an indwelling urinary catheterization include the following:
  • incomplete_bladder.pngResidual urine/PVR volume > 400mls.  
  • Neurogenic lower urinary tract dysfunction causing incomplete bladder emptying, detrusor-sphincter-dyssynergia, underactive bladder, or atonic bladder which leads to incomplete bladder emptying or urinary retention.  Neurological conditions include multiple sclerosis, Parkinson’s disease, stroke, diabetes, spinal bifida, spinal tumors, cerebral palsy, multiple system atrophy, spinal cord injury, and motor neuron disease.
  • IC is the recommended bladder management in persons who have a SCI, paraplegia, or males with tetraplegia and sufficient hand function
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  • Urinary retention, inability to properly empty the bladder, can be divided into acute, chronic, complete and incomplete:
    • Acute retention is an acute event of painful, palpable or percussive bladder, when the patient is unable to pass any urine when the bladder is full.
    • Chronic retention is the inability to empty any amount of bladder volume or the requirement for use of a catheter, consciously or unconsciously due to anatomical or functional bladder outlet obstruction
    • Incomplete urinary retention is impaired bladder emptying due to anatomical or functional bladder outlet obstruction, detrusor underactivity or both, when the voided volume is smaller than Post Void Residual.
  • Preferred treatment option following urethrotomy and stricture dilatation to prevent recurrence and maintain urethral patency and catheterization method of continent urinary diversions.    In men, method for managing recurrent urethral strictures to help maintain urethral patency and prevent or prolong the time between recurrences.
  • Surgery: Postoperative urinary retention following major and genito-urinary surgery.
  • Following procedures used to manage urinary urgency and urgency incontinence, e.g. botulinum toxin injections to the bladder
  • Bladder outlet obstruction (i.e., gross hematuria, enlarged prostate, strictures).
  • Administration of drugs directly into the bladder (e.g. chemotherapeutic medication to treat bladder cancer).

There are contraindications to IC including:
  • Priapism, where catheterization can result in fractures of the corpus cavernous of the penis.
  • Previous false passage or infection
  • Injury (trauma resulting in urethral bleeding, strictures or false passage) or tumor in urethra or penis
  • High intravesical pressure, which requires continuous and free-flowing drainage to avoid renal damage
  • Insufficient bladder capacity to remain continent between catheterizations.
  • Demonstrated inability of the individual to carry out the procedure and the absence of an appropriate person to assist

March 2021
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Written by: Diane K. Newman, DNP, ANP-BC, FAAN
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