Evidence Supporting the Use of Urinary Catheters for Intermittent Catheterization - Diane Newman
May 5, 2022
Diane K. Newman, DNP, ANP-BC, FAAN, Adjunct Professor of Urology in Surgery, Perelman School of Medicine, University of Pennsylvania, and Former Co-Director of the Penn Center for Continence and Pelvic Health. She is the author of several books. The most recent is as lead editor of the 1st edition of the SUNA Core Curriculum for Urologic Nursing and of Clinical Application of Urologic Catheters, Devices, and Products.
Diane Newman: Hello, I'm Diane Newman. I'm a nurse practitioner and adjunct professor of urology and surgery, research investigator senior at the Perelman School of Medicine, the University of Pennsylvania in Philadelphia. This lecture is on urinary catheters for intermittent catheterization, what's the evidence? This was presented at the Chicago Metro SUNA Annual Spring Conference in March, 2022. These are my disclosures, especially my illustrations, which I do own the copyright. Here are the learning objectives for this presentation, to identify the indications in short and long-term complications of intermittent catheterization, or IC, classify components of IC, differentiate each catheter reuse and single use, identify current evidence-based research and application to clinical practice, and define the urologic nurse's role in educating and monitoring patients on intermittent self-catheterization, which I refer to ISC.
Now, the definition of intermittent catheterization is insertion of a catheter into the bladder, to allow for drainage. It's immediately removed after draining the bladder of all the urine that it contains, sometimes nurses will refer to this as in and out catheterization. There is benefit to regularly emptying the bladder, and this has been shown years ago by Dr. Lapides. He showed that keeping the bladder empty reduces intravesical pressure, it also improves the blood circulation to the bladder wall, the mucus membrane of the bladder wall, thus it's more resistant to infectious bacteria. And indications [inaudible 00:01:34] urinary tract dysfunction causing urinary retention or incomplete bladder emptying. There's a lot of terminology we see in the literature and we use in our practices, catheterization, or IC, clean intermittent catheterization, which is called CIC, intermittent self-catheterization, ISC, and then clean intermittent self-catheterization, either single use or reuse. So sometimes patients and clinicians will get the terms that we use interchangeably, but it's important to know what are the different terms that are used.
Now, throughout this lecture, I do have a little thing at the top of the slides that are evidence-based. So I want to provide you where the evidence is as far as I see it at the current time. Intermittent catheterization is the first line of treatment in neurogenic lower urinary tract function, or NLUTD, is what the initials that we used to now. So that would be anybody with any type of spinal cord injury, Parkinson's, multiple sclerosis, anybody that has an injury that's basically does not allow the bladder empty completely. It is the preferred method with these patients because there's less complications than having an intermittent urinary catheter, and that's been well-established, better outcomes as far as living longer lives and better quality of life, it's effective and safe. But the key factors for a successful outcome really, is that you catheterize yourself frequently, keep that bladder empty, you do not traumatize the urethra when you insert it, and this is very important for men, suitable catheter materials, and then of course, that you empty the bladder completely, you don't want to leave any urine in there because that sets up an environment for bacteria.
Now, the definition of neurogenic lower urinary tract dysfunction is on this slide, and I want to bring your attention to the fact that we now do have a new guideline from the AUA called adult neurogenic lower urinary tract dysfunction treatment and follow up. We also have one on diagnosis and evaluation. If you are involved in doing intermittent catheterization, I really suggest that you go and read these guidelines, because it gives you a lot of good information that I have found to be helpful in my practice.
Now, I want to give set up a history of intermittent catheterization. It started with Dr. Lapides back in 1972, who coined the term, intermittent clean self-catheterization, and that became CIC. But I really want to stress to you that if you read that original research, it was a very small study over only 12 women and two men, patients just washed their hands with soap and water, and his cleaning technique was using a small Tupperware container where you put the catheter or a margarine plastic container for sterilizing the catheter with a detergicide. So he used some type of bacteriocidal type of solution. However, infection still occurred if they were not using that solution or one of the women dropped the catheter and developed a UTI. So we've based this small study and how we move forward with clean technique, basically reusing catheters. So that really is a summary of Dr. Lapides' publication in 1972, and I really suggest if you want to learn more, to really go to that reference.
Now, according to a lot of the guidelines that come out from the European nurses urologic association and others, they've tried to define the best practices when you are looking at aseptic, sterile, clean, single use, and clean, reused, and these are the definitions. I just want to stress to you that sterile is basically used in institutions like [inaudible 00:05:21] when catheterizing someone. Aseptic is now called no-touch, which means you don't touch the catheter, but you don't necessarily use gloves or anything like that as far as a gown or anything. Clean, single use is using a single catheter for each catheterization. Clean, reused, you can see, is reusing a catheter for multiple uses.
So I want to give you this summary of what we're looking at for definitions as far as how to perform catheterizations. Now, I want to go over a little bit about reuse versus single use. Reuse is off-label, of course, problem is you have to store it somewhere. There are no guidelines or reports on how many times you perform catheterization or what kind of cleaning technique. I talked to you about what Lapides did, but again, that was using some type of bacteriocidal type of solution, we believe, but there's no guidelines, but I'm going to show you a recent publication on that. Not supported by regulatory requirements, and then of course, with reuse, there's a risk for recurrent UTIs.
This is actually a publication by Leek that came out in 2013, where they looked at the distribution of UTIs in relation to reusing a catheter. And you can see under single use versus reusing, again, small study, but how many individuals actually had UTIs versus not. And I think this is something to really realize, is that we need more of this data as far as, is there a direct relationship with UTIs with reusing catheters? This one was actually published, I believe two years ago in 2020 now, about 18 months ago, and this was done by Wilks and Mandy Fader's group in UK. And basically, in the laboratory, they tested many different methods. So again, if you want to learn more about this, go to this reference. But what I highlight here is two methods which they found really did demonstrate node collection of bacteria or biofilms that was really helpful and possibly may help with reusing catheters far if you clean them in this method.
But look what they had to use, Milton concentrate, which I'm not so sure what that is and where we could get that here in the U.S, dilute it in tap water, follow the manufacturer's instructions, and then you see it comes up with a 0.6% sodium hypochlorite, finals concentration, you let the catheter soak for 50 minutes and then rinse with tap water. What they also tried was a Milton combination with washing with soap and water. So first, you wash this catheter with hot soapy water, then you dip in Milton solution, rinse with tap water. I think there's going to be more research on looking at how we can reuse these catheters, but again, how realistic this is for individuals who are now living years and years with performing intermittent catheter out there in the workforce, very independent, I'm not sure who's going to be able to possibly wash the catheters in between use with this types of methods. But there are problems with single use and we have to realize this, it is an increased cost to the healthcare system and to the patient, if they're paying for themselves.
And then we have all these catheters in the environment that are not disposed of, they don't disintegrate, right? You can't recycle them, so it does have a negative environmental impact. And I hope in my lifetime, I'm going to see one that is disposable and then just breaks down in time, well, that would be the best for using single use. Now, as far as the evidence versus single use and reuse evidence is poor to moderate for recommending multiuse catheters, and this is by the Infectious Disease Society of America, when they came out with their big guidelines in 2009, but there's insufficient data for recommending cleaning method, which is what I just said if you're going to reuse of catheter.
I want to share a little bit with you about why we are concerned about recent catheters, especially in relationship to possible UTIs. We have a growing problem in the world of antimicrobial resistance, and actually, this picture on the right down there on the bottom of the slide is from the Infectious Disease Society of America, they have guidelines on this and growing white papers on the concern about antimicrobial resistance. The greatest burden with catheterization is UTI, it's the most common complication, and people fear this if they practice intermittent cath, because what you have is bacteria adheres to the mucosal wall of the bladder, and it can be a real significant health burn to patients trying to find the antibiotics, seeing the provider. And UTIs after a spinal cord injury are a source of physical, emotional, social distress, and disruption, so we know that. So we want to prevent UTIs as much as possible.
These are all the risk factors, and this is out of an article by Mike Kennelly in 2019, and I like to use it because it shows you all the risk factors for someone who may be performing intermittent catheterization, this specifically relates to those with adult neurogenic lower urinary tract dysfunction. So you can see there's quite a bit of risk factors associated with developing a UTI. And a lot of these individuals may be immobile in wheelchairs, if they're a spinal cord injury and they need an antibiotic for a UTI, look at this, 30% get diarrhea, 1% C diff. The problem is not just the resistant with your antibiotics, it's also with the fact of the adverse events of an antibiotic, including diarrhean problems. So these are just not great things to be taking all the time, periodically maybe if you have UTI, but if you're intermittent cath and you get UTIs frequently, then using antibiotics can really create a lot of problems for you.
Now, I want to show you a small study that I did where we were looking at single versus reuse catheters, and this was a study supported by Wellspect. And basically, what we did was we enrolled 39 patients and it was done in the United States, you can see here, Philly, Milwaukee, North Idaho, in Australia, Sidney, Brisbane, and Melbourne. And we basically enrolled 39 patients, 55 years of age was their medium age, you can see a third had lower urinary tract dysfunction, two thirds had neurogenic, 79% had normal hand control, and as far as urethral sensitivity, normal was 31%, reduced, 31%, one third lack uretal sensitivity.
This is an important point because if you're catheterizing [inaudible 00:12:05], especially a male patient, if you don't have that urethral sensitivity, you're not going to know if there's problems with resistance, pain, or whatever. On average, they were catheterizing six times per day, and median was over 10 years, and they were reusing catheters for 21 days on average. Okay, so we took patients that were already performing intermittent cath reusing catheters.
I have to tell you that when they approached me to do the study, we were just going to do it at the neurology practice here at Penn Neurology, but the problem was, our exclusion criteria was that they could not be on antibiotics within four weeks prior to study inclusion. Almost most of the patients who I see or who are in our electronic records at Penn actually were on antibiotics, and I realize that this was a major problem, so that's why we went to Milwaukee and Idaho. They were not prescribing as many antibiotics the patients were using, but that just shows you how much of a stewardship with antibiotics, how bad we're doing, but these was the inclusion-exclusion criteria for this study. We looked at health related quality of life using the ISC-Q, which is a validated questionnaire, I'll show you in a minute. We looked at patient reported outcomes, safety, we actually sent the catheters they were using to a laboratory to look at biofilms and any urologic complications.
This was the intermittent self-catheterization questionnaire, and I'm now using this questionnaire for several different projects I've been involved in. And this basically is a validated questionnaire, it looks at ease of use, convenience, discreetness, and then psychological wellbeing. For healthy quality of life, single use was statistically more... They had a better health quality life than those that were reusing, for the mean total score. You can see in that questionnaire, domains, ease of use, convenience, discreetness, and psychological wellbeing were much higher in the single use individuals, and these were statistically significant. When you look at patient satisfaction as far as discomfort, or pain, or satisfied, or very satisfied, again, the single use basically were more satisfied than the reuse, not with discomfort and pain, though that was interesting.
I have to tell you that we did switch them to a hydrophilic catheter, they may not have been on a hydrophilic catheter when they were reusing, of course they probably were not because you do not want to reuse a hydrophilic catheter, so just switching them to the hydrophilic may have given patient more satisfaction, and that's a limitation of this study. As far as bacteria contamination, I think this is important, 100% debris contamination on those reused catheters that we took from those patients and sent to the lab. And you can see the contamination, and then 18% had biofilms.
So what this is saying is, whatever cleaning method they were using, and most were using soap and water, that it really wasn't getting rid of the bacteria in these catheters. Now, does this pose a problem or not? We don't really have the research on that. As far as urological complications, reuse, 64% complications during the last 12 months, 75% was single use, they were complication free, so 75% were free of complications for the past four weeks. Now, that's different time period, but you can see they didn't have any problems with doing it as far as using the new catheters.
So this was recently published in Neurourology and Urodynamics. So there's a preference for intermittent catheterization with single use hydrophilic when compared to catheter reuse, single use hydrophilic catheters were associated with a higher quality of life in this patient population, again, small study. Catheter reuse pose a potential patient safety issue as high levels of bacteria and debris contamination were detected on the collected reused catheters, and our results suggest single use hydrochloric catheters as first and standard choice for people practicing IC due to some type of lower urinary tract dysfunction. So again, this was published in 20... Actually 19, please, if you want more information, you can read this paper.
Now, let's talk a little bit about the use of prophylactic antibiotics, because I'm seeing more and more publications and presentations on this. And I want to show you this one study that was published in 2018 by Pickard, and is to assess the benefit, harms, and cost effectiveness of antibiotic prophylactics to prevent UTIs in patients who perform CISC. This was a parallel group, open-label, patient randomized 12 month trial of allocated intervention with three monthly follow up, okay? 404 adults performing intermittent cath for 12 months, they were doing it themselves, of course, suffered at least two UTIs in the previous years, so they did pick a group that had UTIs in their history, have been hospitalized for UTI in the previous year. Central randomization system used random block allocation, and the interventions, as you see, were antibiotics, 203 received antibiotics, you can see the antibiotics, and the control was no antibiotic prophylaxis.
And this publication was a health technology assessment out of UK for the National Institute for Health Research in UK. So this was funded by the National Health Service in England, and they wanted to look whether the use of prophylactic antibiotics would help with recurrent UTI, so the frequency of symptomatic antibiotic-treated UTI. So frequency of symptomatic antibiotic UTI was reduced in the group, they had prophylactic antibiotics by 48%, incurred extra cost of 99 pounds to prevent one UTI. And they found a clear benefit for antibiotic prophylaxis in terms of reducing frequency of UTI for people carrying out intermittent cath. Now, what they didn't address is antibiotic resistance of pathogens, a long term if you give prophylaxis antibiotic. And to me, that's my biggest concern with the study. I didn't see in this report, but I needed to probably study it closer, whether these individuals were reusing or single use, I think that's also very important.
I also want to bring to you some other new research that's being done that we are actually doing this protocol at Penn, And this is by Anne Cameron's group, she's a urologist up in Michigan, University of Michigan, and she is now... I think has a R01 from NIH to study this. So this is instillations of gentamicin in the bladder. In neurogenic patients who are catheterizing and who have recurrent UTIs that have been resistant to everything, putting gentamycin as an installation. Gentamicin's interesting because it does not absorb, so it really works on the bladder wall and you're not going to get any levels in the bloodstream, so the fact of resistance should not be in concern. So the aim of the study, in that one that they published, which was more of a pilot, was to determine if gentamicin bladder instillations reduce the rate symptomatic UTI, or the use of oral and intravenous antibiotics in neurogenic patients on intermittent cath who had a high rate of recurrent UTI.
So these are patients that really... And I know you've seen these patients, they come back for recurrent UTIs, and we're running out of the antibiotics because they're resistant, and they want to examine the effects of intravesical gentamycin and we're now seeing a new term, intravesical antimicrobials, that are... Gentamycin put in the bladder. I'm seeing a couple other different types of antibiotics use and what effect does it have on the bladder organisms. This is just a protocol, and this is what we're using at Penn, we teach a patient how to mix this up, we work with a compound pharmacist who can give out the gentamycin to dissolve, and then before they go to bed, they catheterize themselves, drain their bladder, instill the gentamycin solution, you see it's only 30, 60 mls, and that of course, depends on bladder capacity. And then they leave it in the bladder during the night, and then they cath the next morning, so it works so overnight.
And they saw a 58% to 47% multi-drug resistant organs decrease, so they decreased, these multi-drug resistant organism. And of course, there's no increase in gentamycin resistance. So I don't know if you're doing this, it's your practice, but something that we have now started to the point of where we're actually thinking of doing this in women who are not catheterizing, ambulatory women who have recurrent UTIs that we just ID'd. There's no other antibiotic that they can receive, some of them have even failed IV antibiotics.
Now, let's talk a little bit about intermittent self-catheterization, I want to go through the basics of it. And I want to take you to the fact that I did publish some articles in Urologic Nursing Journal on intermittent self-cath, and if you email me, I can share the article with you, or you can go to the SUNA website and get them. But I have a checklist, I have an article on materials, and then we have actually how to perform catheterization. So let's look at the ideal successful patient, you want someone who's urethra's not obstructed. Now, I know we have to teach IC in obstructed urethras, but ideally, we hope patients are not obstructed. Good vision, good peroneal hygiene, compliance, so they do do it, or they have a caregiver that's going to do the catheterization. And I always say rule of thumb is, are they going to be successful? Can they do ADL? So can they transfer, dress themselves, feed themselves? So they have all the mechanisms we need for inserting that catheter.
Problem patients are those are obese, or large abdominal girth, and those with abductor spasms who cannot separate their thighs to insert that catheter. Barriers to IC, age should not be a barrier, I've trained women in their '90s, so age is not a barrier. However, most men fear and they have reservations because they fear they're not going to be able to perform inside that catheter. Barriers could be decreased perineal sensation, because they don't feel if they're running into a problem and that could be a concern. So they hit resistance, or pain, or resistance when they're removing the catheter, and that could be a problem. Leg spasms, decreased flexibility or balance is an issue, decreased finger-hand dexterity, intentional hand-arm tremors, if they're shaking.. And I remember a Parkinson patient I had that literally, his hand just kept shaking, to try to get the catheter into the urethra, and I'll show you some aids that might help that.
And then in children, they may not want to do it, not want to comply, it may get to be a problem between the parent and the child, and they should be supervised from a parent. Now, these goes over, I want to go over some catheter material, and basically they are non-latex, the most popular have been material called PVC, polyvinyl chloride, these tend to be ones that you put the gel on. Latex, red rubber, we are not using those anymore, that used to be a staple catheter in urology practices, but we have such problems with latex allergies, We don't recommend red rubber anymore. Pre-gel, gel, so those are ones that you have the gel within the package, but some of these, they're coefficient of friction, so how much friction do they have when you insert? It's not as low as hydrophilic, which is becoming a much more popular catheter, and that's where the catheter is hydrated, either with water, or it comes through a sleeve, or basically, has a satchel in the packaging, which is broken and coats the catheter.
No-touch is really what we're talking about, is when you don't touch a catheter. A lot of great new technology and designs here, we have the finger slides, ConvaTec has those, BART has those. We have introducer tips, which means that you put that introducer tip within the urethra pry to passing the catheter, Hollister has a nice product there, the VaPro for that. That is some data to show that if you put that introducer tip in the urethra, you bypass, so that tip is in the first part of the urethra, whereas there's a lot of microbial especially in women, because of sitting there in the [inaudible 00:24:21] and the catheter bypasses, that might help with someone with recurrent UTIs. And then we have Coloplast One, that has the catheter and the disposal bag with it also.
So we have a lot of choices for catheters and no-touch is really, maybe somewhere we want to recommend, especially if someone's out there at work, vacation, in their car, performing catheterization, we don't expect them to use gloves, but we may be concerned about they're not able to really wash your hands or it's not a really clean environment that using a sleeve or something to protect so you don't touch a catheter may be really something that you, as the urologic nurse teaching wants to recommend.
We also have different lengths, and I just wanted to show you some different lengths here, especially concentrating on those that are becoming nicely packaged that you can put them in your pocket or the short ones for women. We have a lot of different ones now, most companies make them, they can put them in their purse, go in the bathroom, catheterize themselves through touch and not be a big issue. So I do recommend that the length is important, especially with women, I would not use a shorter length catheter in a male patient. I like the fact that catheters have tips on the end, so I like the fact that you're going to see that it does stop, so it's not smooth to the funnel end where it drains so that it doesn't maybe get lost in the bladder, and I've seen that happen with certain catheters that do not have that funnel at the end.
So these are all available and I'm hopeful that you here listening have a lot of these samples in your office, because not one fits all, so that you can try different types of catheters for patients and really what works for them. Now, I talked about the coating before, there is more and more evidence on hydrophilic coded catheters that they reduce trauma and possibly infection, maybe because they're just single use, you would not reuse a hydrophilic catheter, and that they are preferable to those with non-hydrophilic coating. Patients love these types of catheters, patients tell me they're smooth to pass, but there's variations in the different companies and the technology that we see. This was published in 2013, so it is an older meta-analysis now, it's almost what? Almost 10 years old, but it really went through all of the publications on hydrophilic catheters and what they did show as far as inventory and UTI, so you can see this.
But we do have more data now on this showing exactly how health will... And how improved as far as decreased trauma in the hydrophilic catheters, in those patients using these types of catheters. So I think you can see more and more research on their use. There is new technology out there, and this slide shows you a new technology by ConvaTec where you have the actual coating is not adhered to the catheter, therefore it's called FeelClean technology, so when you remove it, you may not have any stickiness with it, because there is some data that show that some patients, when they remove the catheter, especially the male patient, feels that it sticks, and they have some resistance to removing the catheter after draining the bladder. So look for this new technology that's out there, the FeelClean technology.
Now let's talk a little bit about actual catheterization when the patient does it themself. And I show you this slide because where do they do it? This picture on the left is a patient in my office who I taught him in the bathroom, he showed me how he caths himself there, there he's using a VaPro. These other ones, you can see, they have some problems with dexterity as far as their hand movements and that, so you got to think about that if you want them to wipe themselves, if they have to open the packaging, and all these things really factor into when you teach a patient.
Positioning, where is that patient going to catheterize? Find that out, is it in the toilet? I'll show you a study we did, it was just recently published, talked about positioning, where they do the catheterization. Women may not want to stand to catheterize. I've had women on... Not all my patients can put their leg on the toilet seat, but how are they doing it? But you can do it in a wheelchair too, you can use a mirror also. You see that one picture where the mirror's propped up against the back of the toilet cover, that's fine. With men, do they need a coude tip? And when a male catheterizes, you're going to teach them the proper positioning of the penis. So the penis has an S curve, so you want to straighten that out so that they don't butt up against the prostate, which is a little bit narrow. So this is a really important thing to teach a patient and make sure that they know to pull that [inaudible 00:29:20]. And again, this is the male patient.
As far as how is the male patient doing, most of them, I think stand in front of the toilet, but again, you can do it in a chair. I think men have an easier time because the penis sticks out so they can really access that urethra. But I have taught patients who have a large girth that cannot see their meatus to catheterize in front of a long mirror very successfully. And I usually teach patients by touch and not mirrors, but there's a lot of options, and what I have in this slide set is some of the aids.
So these aids are everywhere, catheter holders, grips, and you see that green thing up there, that's what I actually used with a patient who had the tremors with Parkinson's, he very successfully used this. Penis holder, so that you keep the penis in place as they try to start inserting it. The one down the bottom in the middle was actually developed by a physician assistant who I think is now practicing in Florida, but that's also available, that he developed for spinal cord injury patients so that they could set that on their thighs, the catheter's right between their thighs and then they can pass the catheter.
Now, how do you know if a patient can do it as far as dexterity? That's, I think the million dollar question really, when teaching a patient. Well, there's a nice study that came out by this group where they said that if the patient can use a pencil and paper and be able to write, then they should be able to catheterize. So look at this and see what you think about it, but you really do need this dexterity and then being able to hold the catheter, opening the catheter packaging up, prepare it, if they need to break a satchel, whatever, and be able to advance the catheter okay, but of course, be able to access those meatus.
Now, where do we stand? Well, we know that patient satisfaction is important, but we don't really understand use, what are patients doing? And what happens is that we may them in urology, but then they're lost to follow up. Even rehab centers, they mainly only come back once a year, once a couple years. We now have patients out there, men and women living for years, 10, 20, 30 years by catheterizing themselves independent. So the point is, is that, what are they doing? We need understand this better, and there's very small studies, and mostly outside the U.S. So we really want to understand attitudes and practices, and I think this is where a lot of people are going to find out what are people doing? I'm very proud to state that we're doing a registry with Hollister, it's called the Continence Care Registry, that's going to start fairly soon in several countries. We've done a pilot study that we've presented to SUNA and at the Association of Rehab Nurses.
And why we want to do this registry, and it really is an exhaustive registry, the many surveys, we're going to do the two validated questionnaires I mentioned, and basically, we want to find out what patients are doing. So you may be seeing and be told about this registry by your Hollister rep, we want anybody who's catheterizing themselves, so this will be done and started fairly soon, and I'm hopeful this is going to generate hundreds and hundreds of patients out there real life, what are patients doing with catheterization? We tried to do a study, and this was a study that took me quite a bit of time, it's called PRICE, Patient Report of Intermittent Catheterization Experience. I got an educational grant from Wellspect, and I think I was naive when I started this study, because it took a long time to get the patients, I wanted 200 of them, and I wanted to understand practices, attitudes toward intermittent self-cath, and I wanted patients who'd been performing catheterization at least six months.
I had them complete both the ISC questionnaire, the one I showed you, but also there's another questionnaire that looks at difficulty catheterizing that is also validated, that I also used, I wanted to know what was ease of use, discreetness, any difficulty they were having. So actual patients experience and their quality of life with it. This was done across six distinct rehabilitation urology practices, the patient had to be 18 years or older and of course, performing self-cath for greater than six months. And let me show you some of the data. This was recently published in Neurourology and Urodynamics, I'm very proud the publication, And by the way, I note all the individuals from the different centers who were involved in this study. These were the sites, University of South Florida in Tampa, Shepherd in Atlanta, Chesapeake Urology in Maryland, Case Medical Center in Ohio, here at Penn Urology in Texas, Baylor Scott and White Institute for Rehab in Dallas, so you can see the breakdown here.
Participants, we had 200, 70% men, because we had several rehab centers, so mostly spinal cord injury, 73.5% Caucasian, 90% have been performing intermittent cath for at least one year, 49% for five years or more, spinal cord injury is most common. The 90% used single cath, so they were using single cath, not reused, and they do not require assistance. And you can see the overall satisfaction core was 70.4%, ease of use was 82%, and I think that's interesting, I thought that would be higher, so many of them found them the catheters not as easy using, discreetness, 75.4, psychological wellbeing, only 64.3%, convenience was only 60%.
So I think this is important, these numbers were lower than I thought I would see with this population, but I think it gives us a little bit of an idea. This was the breakdown of those who were being catheterized, as I said, spinal cord injury was the most common. Since a lot of them were from my Penn Urology practice, 23% had some type of urinary retention, and you can see the other breakdown.
Now, number of UTIs in the past six months, we asked them, and basically, you can see about half were none, but look at that, one UTI, a quarter of them, two, and they may have had more than one or two, you can see the breakdown of the UTIs in the past month. What were they using? You can see the breakdown with clear. I don't know about this data because what I found from doing this study was that most patients did not know what they were using, but you can see the breakdown. So they would check something, but I'm not so sure they were using actually mostly PVC, because most of them were using single use, so about a fourth were using PVC clear. Frequency of catheterizations per day, you can see that 16% were catheterizing more than six per day, 22.5% were six per day, and you can see that breakdown.
So I think that they actually were being pretty compliant with catheterization because the majority were doing more than four times per day, with basically over 50% doing it five times or more. As far as they were mostly men, but only about a third were using a coude tip, which I again, found somewhat surprising, I thought there'd be more, but only about a third. And most of them, the men sitting on a chair or wheelchair, whereas what most of them were doing, and that's I think, because again, we saw spinal cord injury, mostly males, sitting on a toilet was 22%, 29.5% was standing in front or over the toilet. Do they touch a catheter during insertion? About 60% said no. Only 6.5% were using insertion aid.
Now, this study was done probably about five years ago, so I'm not sure the technology was as prevalent at that time, but I think this gives us an idea. And then as far as intermittent self-catheterization, majority indicated catheters are easy to use, they're discreet, they have confidence when they do it. Some report their challenges with carrying enough catheters when traveling, a feeling of self-conscious due to the need to do it, and then concern about long-term problems, because these patients have been doing it for years.
So PRICE study is somewhat unique, I tried to do a perspective observational study of patients who were performing cath. There was variability in the catheter type, frequency of intermittent cathing per day, UTI experience, noble conclusions, chronicity of ISC dependence, so these patients are dependent on it, chronically. their confidence, discreetness, and ease of use. I think future directions, what we need to look is how can we improve travel convenience? What are long-term invocations for intermittent self-cath? Commonalities in those who develop UTIs? I'm sure there's certain risk factors, are there commonalities? And then I'd like to analyze more of the second questionnaire, which is not in this slide set, what we need to analyze is what was difficulties with it.
So in summary, that PRICE study, 90% participants have been performing ISC for greater than one year, demonstrating the chronicity of the conditions that commonly lead to intermittent self-cath, and thus the importance of understanding quality of life in these patients. We think this is the first survey of its type that really combined urology in rehab patients at 200, I think we got a good number, and the UTIs were common and may contribute to concerns about long-term implications of performing intermittent self-care, okay? The other thing that this data shows is that there is a preference for single use hydrophilic catheters, and they may be the standard for first choice in this population.
So I think that the implications of urologic nursing are important. I think you can successfully conduct research, you saw the two studies I was involved in, you saw some of the other research. We have validated questionnaires now, so you can do your own research and collect some of that data on your patients to find out what they're doing. And you want to have confidence in really understanding the different catheters so that when you teach, you know what to teach, you know what's important to the patients. And I really do believe the research that I presented here can inform your practice, my practice, and can lead us for ideas for future research in this area, because the one thing I'm learning is that this population is only increasing and urologic nurses play a really important part in this population.
Now, I want to end with this because it's a negative outcome that I found. When we have done both studies, particularly the PRICE study, some of the data that we needed was in the patient charts. I could tell you, the documentation was really bad, within even my practice at Penn Urology. We couldn't find the correct catheter site to confirm, because what we did is we had cath history coming from the patient's record, and then what the patients say, and we wanted to actually compare those two to see how accurate it was.
Well, the notes documentation didn't help me. Basically, they didn't know what kind of catheter, they didn't note the size, the fringe size, they didn't know what was the make of the catheter, hydrophilic or not, what was the manufacturer, which would've been important, the length of the catheter was not noted, whether there is a coude day tip being used, where the patient catheterizes, do they have difficulty? I just have to tell you, the documentation is terrible, and what I've always learned since I started at my registered nursing career back in the '70s is that if it's not in the notes, you didn't do it.
And I just showed you some information here, and this is actually out of a case, nursing documentation, court faults nurse for failing to note time of catheter removal, even. So the point is, we really need to make sure we document, an that's my end comment to you, that's, I think one of the most important comment of this lecture. Know the information, document, do a Smartset if you have electronic records so that you can just pull it in and add in 14 fringe, long length, okay? Or short length for female catheter type of thing, so that you can put that in. But I really recommend that you consider that as part of your... This is important part of catheter care and teaching. These are my references, and I want to thank you very much for allowing me to present this.
I did write what I call my picture book that came out several years ago that has pictures on almost all these catheters I've shown, that's where some of these pictures came from. Also, the SUNA core curriculum has a chapter in catheters and I will be updating that, so that's also good reference for you. Email me if you want more information. I've also created a website called Awaken Pelvic Health that actually has a lot of my information on behavioral treatment for impotenence. But also, you can go to your urotoday.com as I have an actual catheter center there for intermittent cath indwelling and other information for you, so thank you very much for listening.