I am Diane Newman. I'm an adult nurse practitioner and adjunct associate professor of urology and surgery, research investigator senior at the Perelman School of Medicine, University of Pennsylvania. I am also co-director of the Penn Center for Continence and Pelvic Health, Division of Urology at Penn.
This is a review of how to teach a patient how to self-catheterize (ISC). In my practice in urology, I've taught this for many, many years and it's always a challenge, so I hope that this webcast will give you maybe some tips on helping you teach patients how to self-catheterize.
Well, who's the ideal successful patient? Well, of course you want someone who has an unobstructed urethra, then it won't be difficult to pass it. Someone who may have an enlarged prostate, have a stricture, it's going to be a little bit more of a problem, especially to teach them initially.
The patient should have good vision. They have to be able to visualize the catheter, visualize the meatus, so this I think is an important thing.
Good perinatal care. You want their hygiene to be really kind of top notch. Okay? Because they could introduce bacteria into the bladder, so you want to review, again, soap and water. You don't want to have to use Betadine or anything to wash their genitalia, but they should be washing the area prior to catheterization.
They should be compliant, and this is important in children. Many times children under the age of say 15 even, may have to have their parent do it because they will not comply, and there's actually research on the fact that children are getting repeated urinary tract infections because they don't want to do the catheterization.
One of the hallmarks of knowing whether a patient can catheterize is can they perform self-care? So can they dress themselves and transfer? Those individuals who are more immobile, who have more other problems with ADLs is not going to be successful at performing self-catheterization.
Now, who is the problem patient?
Well, obesity, large abdominal girth. There's many times with men that I've had to teach them in front of a mirror because they cannot see over their girth. This is difficult women, though, because some of them may not be able to reach the perinatal area to insert that catheter into the meatus if they have a large abdominal girth or obese, so this can be a problem. And then a woman with abductor spasms that she really cannot separate her legs to really access the meatus, insert the catheter, can be a problem.
The other one that should be on this too is tremors. I've tried to teach patients say with Parkinson's disease who have tremors, and sometimes the tremors are so significant that they're not really able to pass the catheter. At the end of this slide deck I'll show you some aids that might help someone like that who cannot grip the catheter.
Barriers to Self-Catheterization
What are barriers to performing self-catheterization? Well, fear. Everyone fears this. I had to spend quite a bit of time in many of my patients, male patients, because they fear the catheterization, especially younger. And what happens is those patients will not be compliant.
- They fear that they're not going to be able to perform it.
- They fear the pain and they may not be able to do it.
So it's really helpful to really relay their fears, and I always say then it's the fear of the unknown. "Listen, let's try it." And sometimes you're successful, but there are times I haven't been successful. The patient's had to come back.
Or I say, can you get a caregiver? I always try to have someone else's significant other person in their lives to also be involved in the catheterization so if they can't do it on an individual day, so that's really important. A spouse or someone would be helpful.
Age should not be a barrier. I've taught patients in their 90s, so age is not necessary a barrier, whereas obesity may be.
If they have decreased perineal sensation, because with women I have them catheterize by touch, and if they don't have the sensation of being touched in certain areas so they can identify where's the vagina, where's the clitoris, they may not be able to self-catheterize.
Leg Spasms, Defects, & Balance
Leg spasms, defects, decreased flexibility or balance. If you're having a woman catheterize themselves say over a toilet, or a man, and they're off balance, that may not be the best. That may be a barrier.
Decreased finger, hand dexterity. This is very important. They have to be able to feel that catheter and be able to manipulate it.
Children as a whole is a barrier, their age, they can be frustrated, angry over that they have to do it. They just may become noncompliant. So close parental supervision is really important in those children.
Who Should Teach?
Now, teaching. Well, we're the ones that teach. I don't know in your practice, but I've had very few of my urologists teach patients. Even the residents call us into the room and say, "Hey, could you help me with this?" So it's really the nurses in the practice, whether it be a registered nurse, a nurse practitioner or physician assistant, is really who's teaching the patient.
If the patient's unable to learn, you've got to think about really their understanding, because after I teach the patient, I give them handouts that are written. Can they read? That may be an issue in your practice as it is in mine in Philadelphia with certain cases. There are a lot of CDs that shows a patient catheterize themselves that the companies have available for teaching, and I recommend that you get some of those.
Who Should Learn How to Insert the Catheter
But the point is think about identifying someone else that can help that patient. They need to be available. It's not someone that comes in once a day or once a week, and so usually it's someone who's within the house.
But sometimes I have mothers who will not let their children catheterize them. I had a case recently of a woman who the daughters have been catheterizing their mother for over a year and the mother just said no more. I don't want you doing it. So that can be a problem. So you need to think about the whole family dynamics around this.
Hygiene & Intermittent Catheters
You want to pay attention to the patient's personal hygiene. I mean washing their hands before catheterization's important, cleaning the genitalia, especially if they have fecal problems. If they have diarrhea or they have fecal incontinence you need to ask about that.
How do they handle the catheter prior to insertion? They may need a touchless system where they don't touch the catheter because you're concerned about the personal hygiene. There's another webcast that we have here on the website that reviews different types of catheters, so be familiar with all the catheters available because it really is individualized which catheter you pick for which patient.
You want to really teach the patient, hey, you have to have good hygiene to avoid UTIs. They don't have to scrub the perineum. They don't have to use Betadine or whatever. Soap and water's fine. And you want to teach them the signs and symptoms of a UTI so that they're aware of it and if they feel they're developing one, they come in to see you immediately.
Identify a Position That Works in the Patients Environment
Now I'm going to show you a couple illustrations that I had drawn for my textbook I did on urinary incontinence, and I have these on my patient education tools and you can find them also on the website urotoday.com.
Once you can see, and probably none of your patients, including mine, are kind of nice and thin and easy access as this woman, but what I want to show here was the different places where that patient could catheterize. Yoga style, and they're using a self-contained system. This woman here is sitting on the bathtub. This woman's using a mirror. I think this is difficult, but there is a mirror that can attach to the toilet bowl that they can see.
This is the only mirror I would use because if you're going to use a mirror, where's the third hand? Because you want one hand separating the labia, identifying the clitoris, the other hand inserting the catheter. Well there's no hand to really hold a mirror. So this type of thing would be nice. Men. Men tend to just stand in front of a toilet. That's fine. But women can crouch or stand over a toilet and that may be the position. So these are all the different positions that can work.
I think it's important when you teach someone to self-catheterize, you try to work with them on identifying position, the one that works for them. That's difficult to do in the clinical setting in an office practice where I'm sure you, like I, have them on an exam table. Well they don't have an exam table at home.
So most of my patients, I hook them up with a home care nurse and I have a lot of good relationships with our home care agencies in the Philadelphia area. They know to call me and I tell them what I'd like them to try so that they go in the home and see, assess that environment in the home. What's the best way for that patient to catheterize? And also to have them demonstrate catheterization in their home to make sure the technique is good and is risk-free.
How is a Catheter Inserted Into a Female?
As far as self-catheterization, I usually do it by touch. Basically separate the labia, identify the meatus. I always have them feel the vagina, the opening. You don't want to go there. The clitoris is above the meatus, and have them try to feel the meatus, and then I guide them into passing the catheter.
Usually they can, if they have good perineal sensation, they'll feel that catheter being passed. And then because our urethras are so short, urine drains really quickly, and they insert the catheter into the urine begins to drain. Once it's drained they slowly pull it out.
How is a Catheter Inserted Into a Male?
Men, you want to make sure that you have them straighten out the curves. Remember a male urethra has two curves and sometimes that curve makes it difficult for that man to pass that catheter. So you want them to hold their penis kind of upright, to straighten out the shape of that male urethra and then to pass the catheter.
This is really important and this is why I always have patients demonstrate to me how they're going to catheterize. Men will just kind of be pushing down on their penis as they try and insert the catheter. That doesn't work. So they really need to pull their penis up and out as they pass the catheter and do it slowly.
They need to pass the catheter almost the entire length, because that male urethra is very long and they want to make sure that they pass it the entire length and not to just stop when they get urine, to make sure they're in there and then just slowly pull it out so they get all that urine, especially here at the base of the bladder.
This is just some examples of, okay, what are the steps? First, patients should wash their hands. Here they're wiping them with Betadine. I put this slide in here because I don't recommend that. Betadine can be very drying, so you really do not want them to use it. Soap and water's fine. And this guy, just have him wash tip of his penis here.
Here they're using a type of hydrophilic catheter that has actually water in the packaging, and then you can see that he's catheterizing himself standing and into a little container, so that may be an option.
There are different types of catheter holders. And remember we talked about maybe patients who don't have good dexterity, maybe utilizing this kind of a grip, and you can find these on the internet. I've actually ordered some of these for patients. This is as far as keeping the penis, because they may not be able to do that. This one kind of to direct and hold the penis, because they may not be able to grasp that thinness of the catheter, and then this. And sometimes with spinal cord injury patients, and here's the ones that have some problems with their contracted or whatever, with their dexterity, this may be something that you recommend.
So a lot of aids out there. I suggest that you look for them. I find them all on the internet and a lot of rehab centers will have them also.
How Often Should You Cathertize?
Now, how often do you catheterize? This is a common question I get from nurses. Well, it's really based on the urine volume. There's no such thing as they must catheterize five times a day or they must catheterize six. It's really on how much urine they're producing, and of course that depends on intake.
The rule of thumb is that the catheterization volume should not exceed 400 milliliters, so usually that comes out to about four to six times a day.
I recommend that they catheterize:
- Before they go to sleep.
- When they awaken in the morning.
At nighttime is going to be the largest catheterization volume because the kidneys produce most urine at night, especially with aging patients, with the adult, older adult. So that's what patients will do.
I have some older adults who have some heart failure that they really need to wake up at night to catheterize, or they may have incontinence during the night. So the real fun though is before they go to bed and when they wake up in the morning.
Maintain a Record
I do have them record and I have them do this for a period of time. So this is our catheterization record, and you'll find this on the UroToday website. And basically I ask them please put down the date, the time, I want you to try to void if they're able to void prior to catheterization, because I want the catheterization volume to be a post void, and in some cases who they have temporary retention, say, that will resolve, you want them to initiate voiding and then only catheterize what's left in the bladder. So it's really a PDR catheterization.
The point is though that you hope whenever they come back in, I want to see these volumes below 400 mls, and then I go over with them are their voider volumes increasing, and then they maybe need to catheterize less or do they have to catheterize more often? This is very important. All of our staff use this and I scan this into their medical record so I have a record of what they've done.
I showed you some of the aids and there are pictures, there's videos, like I said. Videos can be very helpful. Most of the companies have them.
There are mirrors. This mirror here can be used as a patient's catheterizing even on the toilet. They can prop it. There is a leg spreader with mirror attached that rehab centers have. You can find that on the internet and it cost, I think, about 29.99, so that helps keep a patient who is not able to separate their legs. They fall in. Sometimes MS patients who have weakness of their lower extremities, this will keep those legs apart.
And then children. There's dolls, there's coloring books, instructional models, so there's a lot of aids out there to help parents or help children learn how to catheterize.
So I want to end this webcast with the fact that one of the most important things is the frequency and the fact that you really need to follow up on patients.
Whenever I teach a patient how to catheterize, I have them come back usually within two weeks with their catheterization record and I have them demonstrate for me how they're catheterizing so I can pick up any problems that they're having. I go over with them, again, frequency.
And why I think this is important and why I want you to see this slide again is that catheterizing to keep those volumes low will prevent urinary track infections, will prevent problems, and that's the most important thing to teach patients. So they need to really keep catheterization on a schedule and you need to really follow up with them on a consistent basis.