Intermittent emptying of the bladder using a catheter (i.e. intermittent catheterization) is a first choice therapy for people with voiding dysfunctions.
This therapy can be practiced in many ways and there is a range of catheter types to choose from. However, not every practice is supported by clinical evidence, and there is currently an ongoing debate about what techniques and types of catheter are most recommended. Here is some new evidence touching on some of the hot topics relating to intermittent catheterization.
Single use vs. reuse of catheters
Almost every recent publication covering intermittent catheter use has commented on the lack of evidence on which to make proper recommendations for certain techniques and catheter types. The lack of strong data in a certain direction has raised the question of whether catheter reuse (as opposed to using disposable catheters) is a suitable way to save money and resources.
However, recently published studies reinforce the benefits of using disposable or single-use catheters. This is summarized by a new systematic review from Canada that concludes that single-use catheters pose a lower risk of urinary tract infection (UTI) and that cost-effectiveness has been confirmed in the cases studied. Furthermore, they recommend hydrophilic-coated catheters as the best option. Many other authors agree with these conclusions.
Another example of an international study that reinforces catheter single-use is based on the replies of 956 responders. The authors concluded that catheters that are both convenient and reduce pain and UTIs are likely to improve quality of life and long-term adherence. As a result, single-use catheters were associated with better health outcomes compared to reusable catheters.
There are still many stakeholders who continue to recommend catheter reuse for reasons of economy and resources. A recent modeling study points out the significant environmental impact of single-use catheters. Many authors acknowledge that in the end this must be a patient-driven choice. Or, as one user of single-use catheters puts it in a newly published qualitative study:
My honest opinion (about reusing) is I can understand why they’re trying to do it, it’s they’re trying to save money. But in my opinion there’s always a chance that that’s going to go wrong and I’m the one who’s gonna end up having a water infection or something like that.
Patient report from Avery et al. BMJ Open 2018
This quote brings us to the next hot topic. How can we prevent urinary tract infections (UTI) among catheter users?
UTI
An impressive new randomized controlled study has compared the efficacy of antibiotic prophylactic use among 404 intermittent catheter users. As this was not a routine recommended by clinical practice, the study may be questioned from an ethical perspective. Nevertheless, its results are important and can provide guidance on how to address problems with UTI in this group of people.
The authors noted that the frequency of symptomatic UTIs was reduced by 48% in patients who used antibiotics continuously for one year, compared to a control group. However, the efficacy was accompanied by a significant increase in antimicrobial resistance that seemed to grow over time.
The study did not reveal whether the antibiotics will continue to lower the UTI risk after the study period, but the alarming resistance patterns indicate that long-term antibiotic prophylaxis is not a suitable solution for life-long therapies. With this important evidence in hand, it appears that the UTI problem must be tackled with other preventive strategies instead of antibiotics in the future.
Indications of use
Intermittent catheterization is indicated for all kinds of voiding dysfunction, irrespective of cause. There is a debate about how early the treatment should be adopted after spinal cord injury (SCI). Both the South African Continence Advisory Panel (CAP) and the Joint SIU-ICUD (Société Internationale d'Urologie-International Consultation on Urological Diseases) identify intermittent catheterization as the gold standard of treatment and early start after injury is recognized as important by them and other international groups of experts.
Several reviews examine the use of intermittent catheterization in multiple sclerosis (MS) and rarer but related disorders such as neuromyelitis optica. Again, tailored treatments based on type of dysfunction (i.e. storage or voiding) are recommended, and conservative treatment options should be considered first.
Education and follow-up
There are many important barriers and factors to consider in connection with intermittent catheterization. There is, however, one that everyone seems to agree on: The importance of proper education and follow up. User-adapted catheter choice and standardized methods of teaching are often recommended for intermittent catheterization, and catheter reuse is rarely endorsed. One example was recently published by the American Clinical Advisory Board for Intermittent Catheterization (CABIC) in their guideline on intermittent catheterization.
Summary of Publications: Single use vs re-use
Title
Clean intermittent catheterization: Single use vs. reuse.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
Saadat SH, Shepherd S, Van Asseldonk B, Elterman DS.
Canada
Summary
Systematic review investigating urinary tract infection (UTI) rate and costs associated with intermittent catheter reuse vs single-use catheters.
Conclusions
Single-use catheters were considered to pose a lower risk of UTI, while their cost-effectiveness was confirmed by all studies mentioned. Hydrophilic-coated catheters are recommended as the first treatment option.
Comments and Access
Systematic review demonstrating the benefits associated with single-use catheters, as opposed to reusable, in managing chronic urinary retention by intermittent catheterization.
Title
The impact of different scenarios for intermittent bladder catheterization on health state utilities: results from an internet-based time trade-off survey.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
Averbeck MA, Krassioukov A, Thiruchelvam N, Madersbacher H, Bøgelund M, Igawa Y.
Worldwide
Summary
Observational survey with 956 responders evaluating health states related to intermittent catheterization.
Conclusions
Health states seem to be dependent on intermittent catheterization preparations, time, pain, and frequency of associated urinary tract infection (UTIs). Single-use catheters resulted in better health states as compared to reusable catheters.
Comments and Access
Study exploring the impact of different catheters' features on health states. Catheters that reduce the number of steps, pain, and UTIs are likely to improve quality of life and long-term adherence.
Title
Intermittent catheter choice impacts quality of life: Clinical study on safety and preference of single vs. reuse catheters.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
Newman DK, O'Connor RC, Clark R, Heriseanu R, Chung E, New P, Lee B.
US/Australia
Summary
Observational prospective study of single-use catheters in 39 patients who practiced intermittent catheterization with catheter reuse.
Conclusions
There was a strong preference for single-use catheters instead of catheter reuse, and using single-use catheters raised patients' health-related quality of life. High levels of debris and bacterial contamination were found on collected reused catheters.
Comments and Access
Conference abstract from ICS 2018 presenting evidence on safety concerns associated with catheter reuse among intermittent catheter users.
Title
The cost of a catheter: An environmental perspective on single use clean intermittent catheterizations.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
Sun AJ, Comiter CV, Elliott CS.
US
Summary
Modeling study analyzing catheter use, costs, and waste for single-use intermittent catheters.
Conclusions
An estimated 300 800 people in the United States perform intermittent catheterization for neurogenic bladder management. With 5 catheterizations per day, the estimated waste is significant and the environmental impact should be considered.
Comments and Access
Study identifying environmental impact as an important aspect of using intermittent catheters.
Title
Prevalence and cost of catheters to manage neurogenic bladder.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
Patel DN, Alabastro CG, Anger JT.
US
Summary
Review of epidemiology and costs of catheters for managing neurogenic bladder.
Conclusions
Costs are largely driven by complications and the choice of technique, such as single-use catheters for intermittent use. The authors recommend using reusable intermittent catheters for patients with neurogenic bladder for a more cost-conscious care.
Comments and Access
Review that highlights costs and promotes catheter reuse for people with neurogenic bladder in need of intermittent catheterization.
Title
Reuse of intermittent catheters: a qualitative study of IC users' perspectives.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
Avery M, Prieto J, Okamoto I, Cullen S, Clancy B, Moore KN, Macaulay M, Fader M.
UK
Summary
Observational interview study exploring 39 users' perceptions of reusable and single-use catheters in intermittent catheterization.
Conclusions
Specific concerns associated with catheter reuse were raised, i.e. infections, cleaning, preparation, storage, and lack of discretion. Half of the respondents did not find reuse an acceptable option.
Comments and Access
Qualitative study exploring perceptions on catheter reuse versus single-use among intermittent catheter users.
Summary of Publications: UTI
Title
Continuous low-dose antibiotic prophylaxis for adults with repeated urinary tract infections (AnTIC): a randomised, open-label trial.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
Fisher H, Oluboyede Y, Chadwick T, Abdel-Fattah M, Brennand C, Fader M, Harrison S, Hilton P, Larcombe J, Little P, McClurg D, McColl E, N'Dow J, Ternent L, Thiruchelvam N, Timoney A, Vale L, Walton K, von Wilamowitz-Moellendorff A, Wilkinson J, Wood R, Pickard R.
UK
Summary
Randomized controlled trial and cost analysis investigating the efficacy of 12 months' continuous low-dose antibiotic treatment (antibiotic prophylaxis) in 404 people practicing intermittent catheterization.
Conclusions
The frequency of symptomatic antibiotic-treatable urinary tract infection (UTI) was statistically significantly reduced by 48% using prophylaxis. Antimicrobial resistance was seen more frequently in participants allocated to antibiotic prophylaxis.
Comments and Access
Study concluding efficacy in UTI reduction but also raising a public health concern about increasing antimicrobial resistance. Studies of non-antibiotic preventive strategies are recommended.
Open access.
Title
Bladder emptying method is the primary determinant of urinary tract infections in patients with spinal cord injury: results from a prospective rehabilitation cohort study.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
Anderson CE, Chamberlain JD, Jordan X, Kessler TM, Luca E, Möhr S, Pannek J, Schubert M, Brinkhof MW; SwiSCI Study Group.
Switzerland
Summary
Observational retrospective study of 369 patients with spinal cord injury during rehabilitation. The aim was to describe demographic data associated with urinary tract infections (UTI) and bladder management.
Conclusions
Bladder emptying method was identified as the main risk factor for UTI in patients with SCI. As spontaneous voiders have the lowest UTI rate, further research is warranted to reduce voiding dysfunction, for instance using neuromodulation procedures.
Comments and Access
Epidemiological data on bladder management methods and UTI incidence during spinal cord injury rehabilitation.
Summary of Publications: Indications for use
Title
Early urological care of patients with spinal cord injury.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
Welk B, Schneider MP, Thavaseelan J, Traini LR, Curt A, Kessler TM.
Worldwide
Summary
Systematic review of urological management (i.e. safe storage, efficient emptying, maximized continence, and minimized complications) of new patients with spinal cord injury.
Conclusions
Immediate appropriate bladder emptying is key and a neuro-urological assessment is recommended within 3 months after injury. Spontaneous voiding and/or intermittent catheterization is recommended for medically stable patients.
Comments and Access
Review recommending early adoption of a bladder emptying regimen (e.g. intermittent catheterization) for new spinal cord injury patients.
Title
Best Practice Recommendations for Bladder Management in the Spinal Cord Afflicted Patient
in South Africa.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
The Continence Advisory Panel (CAP): Theron F, Wilson V, Scriba E, Campbell R, van Zyl M, Terry D, Visser A, Louw G, Seirlis A.
South Africa
Summary
South African clinical guideline for bladder management of people with spinal cord injury.
Conclusions
Intermittent catheterization is identified as the gold standard during all phases after spinal cord injury, i.e. early management, rehabilitation, and post-discharge. A safe, non-infecting and non-traumatic technique is recommended.
Comments and Access
Clinical guideline reinforcing the benefits of intermittent (as opposed to indwelling) catheterization and exemplifying benefits associated with hydrophilic-coated catheters. Open access.
Title
Non-surgical urologic management of neurogenic bladder after spinal cord injury.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
Romo PGB, Smith CP, Cox A, Averbeck MA, Dowling C, Beckford C, Manohar P, Duran S, Cameron AP.
US
Summary
Systematic review of different bladder management methods for people with spinal cord injury.
Conclusions
Intermittent catheterization is recommended as the preferable method. Non-invasive medical therapies are the key to improving incontinence, urodynamic parameters, and quality of life in this population.
Comments and Access
Clinical recommendation about bladder management methods in patients with spinal cord injury from the Joint SIU-ICUD (Société Internationale d'Urologie) (International Consultation on Urological Diseases) International Consultation.
Title
Prevalence of urinary incontinence in women with spinal cord injury.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
Elmelund M, Klarskov N, Biering-Sørensen F.
Denmark
Summary
Observational survey evaluating urinary incontinence among 609 women with spinal cord injury.
Conclusions
49% experienced urinary incontinence (27% daily, 13% weekly, and 9% monthly) and it had a negative impact on their quality of life. Urinary incontinence was more common among women who use a wheelchair or walking aids, and who do not live with a partner.
Comments and Access
Epidemiological data showing that incontinence is common, affecting half of the women with spinal cord injury.
Title
Catheterization for treating neurogenic lower urinary tract dysfunction in patients with multiple sclerosis: A systematic review. A report from the Neuro-Urology Promotion Committee of the International Continence Society (ICS).
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Author and Origin
Tornic J, Sartori AM, Gajewski JB, Cox A, Schneider MP, Youssef NA, Mordasini L, Chartier-Kastler E, Bachmann LM, Kessler TM.
Worldwide
Summary
Systematic review of the efficacy and safety of catheterization for treating neurogenic lower urinary tract dysfunction (NLUTD) in patients with multiple sclerosis (MS).
Conclusions
There is a general lack of high quality evidence, but catheterization is reported to increase quality of life and have beneficial effects on urological outcomes (e.g. post-void residual and incontinence episodes).
Comments and Access
Review suggesting benefits associated with catheterization for people with MS.
Title
The Management of Lower Urinary Tract Dysfunction in Multiple Sclerosis.
https://www.ncbi.nlm.nih.gov/pubmed/29956001
Author and Origin
Tornic J, Panicker JN.
UK
Summary
Review of treatment options for lower urinary tract dysfunction (LUTD) in patients with multiple sclerosis (MS).
Conclusions
Tailored treatments based on type of dysfunction (i.e. storage or voiding) are recommended and conservative treatment options (e.g. intermittent catheterization) should be considered first.
Comments and Access
Review summarizing treatment options related to management of LUTD in people with MS.
Title
The Management of Lower Urinary Tract Dysfunction in Multiple Sclerosis.
https://www.ncbi.nlm.nih.gov/pubmed/29956001
Author and Origin
Tornic J, Panicker JN.
UK
Summary
Review of treatment options for lower urinary tract dysfunction (LUTD) in patients with multiple sclerosis (MS).
Conclusions
Tailored treatments based on type of dysfunction (i.e. storage or voiding) are recommended and conservative treatment options (e.g. intermittent catheterization) should be considered first.
Comments and Access
Review summarizing treatment options related to management of LUTD in people with MS.
Title
Neurogenic lower urinary tract dysfunction in multiple sclerosis, neuromyelitis optica, and related disorders.
https://www.ncbi.nlm.nih.gov/pubmed/29956001
Author and Origin
Sakakibara R.
Japan
Summary
Systematic review of occurrence of neurogenic lower urinary tract dysfunction (NLUTD) in people with multiple sclerosis (MS), neuromyelitis optica (NMO), and related disorders.
Conclusions
Bladder dysfunction is often seen in MS and NMO, usually as a combination of overactive bladder and large post-void residuals/urinary retention. Careful considerations of bladder management are recommended.
Comments and Access
Summary of bladder dysfunction in MS and NMO, suggesting use of antimuscarinics treatment for overactive bladder and intermittent catheterization for urinary retention.
Summary of Publications: Education and follow-up
Title
Impact of the route of clean intermittent catheterization on quality of life in children with lower urinary tract dysfunction.
https://www.ncbi.nlm.nih.gov/pubmed/30134322
Author and Origin
Alencar VP, Gomes CM, Miranda EP, Dos Santos Lelis MA, Fera P, de Bessa J Jr, Srougi M, Bruschini H.
Brazil
Summary
Observational survey in 70 children with lower urinary tract dysfunction (LUTD), exploring the impact on quality of life associated with intermittent catheterization.
Conclusions
Catheterization was performed through the urethra in 73% of cases and through a stoma in 27%. Quality of life and other factors (such as continence and dependence on caregivers) were different for the stoma and urethra subgroups.
Comments and Access
Survey showing generally high satisfaction with intermittent catheterization among children with LUTD. 83% found catheterization very easy and 67% found it comfortable.
Title
Clean intermittent catheterization: Barriers and adherence issues in a Muslim population.
https://doi.org/10.1016/j.rehab.2018.05.890
Author and Origin
Kyal N, Hrar S, Moigny Gajou Y, Lmidmani F, El Fatimi A.
Morocco
Summary
Observational prospective study of 50 intermittent catheter users.
Conclusions
Adherence to intermittent catheterization was 80% after 1 month but dropped to 58% at 1.5 years. One identified barrier was anxiety and fear of hurting themselves (and of losing their virginity for women and girls).
Comments and Access
Conference abstract from the World Congress of the International Society of Physical and Rehabilitation Medicine 2018 exploring culture-specific barriers to intermittent catheterization.
Title
Preliminary validation of a Urinary Symptom Questionnaire for individuals with Neuropathic Bladder using Intermittent Catheterization (USQNB-IC): A patient-centered patient reported outcome.
https://www.ncbi.nlm.nih.gov/pubmed/29990375
Author and Origin
Tractenberg RE, Groah SL, Rounds AK, Ljungberg IH, Schladen MM.
US
Summary
Validation study of a newly developed Urinary Symptom Questionnaire (USQNB-IC) for individuals with neurogenic bladder due to spinal cord injury (SCI) and spina bifida (SB) who manage their bladders with intermittent catheterization.
Conclusions
The USQNB-IC was evaluated in individuals with neurogenic bladder (spinal cord injury; n = 336, spina bifida; n = 179), caregivers (n = 66), and three sets of different control groups.
Comments and Access
Study suggesting validity and reliability of a new clinical/research instrument to evaluate patients with neurogenic bladder who use intermittent catheterization. Open access.
Title
Intermittent Catheterization Adherence Scale (ICAS): A new tool for the evaluation of patient adherence with clean intermittent self-catheterization.
https://www.ncbi.nlm.nih.gov/pubmed/29953666
Author and Origin
Guinet-Lacoste A, Charlanes A, Chesnel C, Blouet E, Tan E, Le Breton F, Amarenco G.
France
Summary
Observational survey in 222 patients evaluating the Intermittent Catheterization Adherence Scale (ICAS) and its use to assess long-term adherence to intermittent catheterization.
Conclusions
The ICAS contained 8 questions describing adherence. It was found to be a simple, acceptable, valid, and reproducible test with potential to facilitate clinical follow-up and prevent complications related to non-adherence.
Comments and Access
Study identifying a new valid tool (i.e. ICAS) for evaluating adherence to intermittent catheterization.
Title
Selecting an intermittent self-catheter: key considerations.
https://www.ncbi.nlm.nih.gov/pubmed/30088972
Author and Origin
Davis C, Rantell A.
UK
Summary
Expert statement on features and properties for intermittent catheters.
Conclusions
Proper education is key for teaching patients intermittent catheterization.
Comments and Access
Expert statement describing specific features for intermittent catheters.
Title
Selecting an intermittent self-catheter: key considerations.
https://www.ncbi.nlm.nih.gov/pubmed/30089046
Author and Origin
Collins L.
UK
Summary
Expert statement on indications, advantages, and techniques associated with intermittent catheterization.
Conclusions
Nurses are key in assessing ability and teaching patients intermittent catheterization.
Comments and Access
Expert statement summarizing the basics around intermittent catheterization for managing voiding dysfunction.
Title
Case Study: Teaching intermittent self-catheterisation.
https://www.ncbi.nlm.nih.gov/pubmed/30088977
Author and Origin
Stewart E.
UK
Summary
Case report of a successful teaching experience of intermittent catheterization to a 55-year-old woman with fibromyalgia and overactive bladder.
Conclusions
The patient preferred hydrophilic-coated over gel catheters and appreciated an outer package that was easy to use and had features for enabling no-touch technique.
Comments and Access
Case report exemplifying important catheter features and their possible contribution to successful experiences of teaching intermittent catheterization.
Title
Clean intermittent catheterization: Single use vs. reuse.
https://www.ncbi.nlm.nih.gov/pubmed/30088975
Author and Origin
Holroyd S.
UK
Summary
Expert statement on indications, advantages, and techniques associated with intermittent catheterization.
Conclusions
Before teaching intermittent catheterization, a full assessment of the patient's ability is recommended. Catheterization enables independence and this is considered to encourage adherence.
Comments and Access
Expert statement on how nurses can guide patients in need of intermittent catheterization to select the catheter most suited to their individual needs.
Title
Managing urinary tract infection in patients performing clean intermittent self-catheterisation.
https://doi.org/10.12968/bjnn.2018.14.4.166
Author and Origin
Woodward S.
UK
Summary
Expert statement describing symptoms and treatments of urinary tract infections for people performing intermittent catheterization.
Conclusions
Low catheterization frequency is identified as an important UTI risk factor. Proper patient and/or carer education is key to ensure good adherence and, as a consequence, reduction of infection risks.
Comments and Access
Expert statement summarizing the basics around intermittent catheterization and avoidance of UTI.
