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.
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?
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.
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.
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
Clean intermittent catheterization: Single use vs. reuse.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Saadat SH, Shepherd S, Van Asseldonk B, Elterman DS.
Canada
Systematic review investigating urinary tract infection (UTI) rate and costs associated with intermittent catheter reuse vs single-use catheters.
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.
Systematic review demonstrating the benefits associated with single-use catheters, as opposed to reusable, in managing chronic urinary retention by intermittent catheterization.
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
Averbeck MA, Krassioukov A, Thiruchelvam N, Madersbacher H, Bøgelund M, Igawa Y.
Worldwide
Observational survey with 956 responders evaluating health states related to intermittent catheterization.
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.
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.
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
Newman DK, O'Connor RC, Clark R, Heriseanu R, Chung E, New P, Lee B.
US/Australia
Observational prospective study of single-use catheters in 39 patients who practiced intermittent catheterization with catheter reuse.
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.
Conference abstract from ICS 2018 presenting evidence on safety concerns associated with catheter reuse among intermittent catheter users.
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
Sun AJ, Comiter CV, Elliott CS.
US
Modeling study analyzing catheter use, costs, and waste for single-use intermittent catheters.
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.
Study identifying environmental impact as an important aspect of using intermittent catheters.
Prevalence and cost of catheters to manage neurogenic bladder.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Patel DN, Alabastro CG, Anger JT.
US
Review of epidemiology and costs of catheters for managing neurogenic bladder.
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.
Review that highlights costs and promotes catheter reuse for people with neurogenic bladder in need of intermittent catheterization.
Reuse of intermittent catheters: a qualitative study of IC users' perspectives.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Avery M, Prieto J, Okamoto I, Cullen S, Clancy B, Moore KN, Macaulay M, Fader M.
UK
Observational interview study exploring 39 users' perceptions of reusable and single-use catheters in intermittent catheterization.
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.
Qualitative study exploring perceptions on catheter reuse versus single-use among intermittent catheter users.
Summary of Publications: UTI
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
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
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.
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.
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.
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
Anderson CE, Chamberlain JD, Jordan X, Kessler TM, Luca E, Möhr S, Pannek J, Schubert M, Brinkhof MW; SwiSCI Study Group.
Switzerland
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.
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.
Epidemiological data on bladder management methods and UTI incidence during spinal cord injury rehabilitation.
Early urological care of patients with spinal cord injury.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Welk B, Schneider MP, Thavaseelan J, Traini LR, Curt A, Kessler TM.
Worldwide
Systematic review of urological management (i.e. safe storage, efficient emptying, maximized continence, and minimized complications) of new patients with spinal cord injury.
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.
Review recommending early adoption of a bladder emptying regimen (e.g. intermittent catheterization) for new spinal cord injury patients.
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
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
South African clinical guideline for bladder management of people with spinal cord injury.
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.
Clinical guideline reinforcing the benefits of intermittent (as opposed to indwelling) catheterization and exemplifying benefits associated with hydrophilic-coated catheters. Open access.
Non-surgical urologic management of neurogenic bladder after spinal cord injury.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Romo PGB, Smith CP, Cox A, Averbeck MA, Dowling C, Beckford C, Manohar P, Duran S, Cameron AP.
US
Systematic review of different bladder management methods for people with spinal cord injury.
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.
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.
Prevalence of urinary incontinence in women with spinal cord injury.
https://embase.com/search/results?subaction=viewrecord&rid=5&page=1&id=L622344460
Elmelund M, Klarskov N, Biering-Sørensen F.
Denmark
Observational survey evaluating urinary incontinence among 609 women with spinal cord injury.
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.
Epidemiological data showing that incontinence is common, affecting half of the women with spinal cord injury.
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
Tornic J, Sartori AM, Gajewski JB, Cox A, Schneider MP, Youssef NA, Mordasini L, Chartier-Kastler E, Bachmann LM, Kessler TM.
Worldwide
Systematic review of the efficacy and safety of catheterization for treating neurogenic lower urinary tract dysfunction (NLUTD) in patients with multiple sclerosis (MS).
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).
Review suggesting benefits associated with catheterization for people with MS.
The Management of Lower Urinary Tract Dysfunction in Multiple Sclerosis.
https://www.ncbi.nlm.nih.gov/pubmed/29956001
Tornic J, Panicker JN.
UK
Review of treatment options for lower urinary tract dysfunction (LUTD) in patients with multiple sclerosis (MS).
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.
Review summarizing treatment options related to management of LUTD in people with MS.
The Management of Lower Urinary Tract Dysfunction in Multiple Sclerosis.
https://www.ncbi.nlm.nih.gov/pubmed/29956001
Tornic J, Panicker JN.
UK
Review of treatment options for lower urinary tract dysfunction (LUTD) in patients with multiple sclerosis (MS).
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.
Review summarizing treatment options related to management of LUTD in people with MS.
Neurogenic lower urinary tract dysfunction in multiple sclerosis, neuromyelitis optica, and related disorders.
https://www.ncbi.nlm.nih.gov/pubmed/29956001
Sakakibara R.
Japan
Systematic review of occurrence of neurogenic lower urinary tract dysfunction (NLUTD) in people with multiple sclerosis (MS), neuromyelitis optica (NMO), and related disorders.
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.
Summary of bladder dysfunction in MS and NMO, suggesting use of antimuscarinics treatment for overactive bladder and intermittent catheterization for urinary retention.
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
Alencar VP, Gomes CM, Miranda EP, Dos Santos Lelis MA, Fera P, de Bessa J Jr, Srougi M, Bruschini H.
Brazil
Observational survey in 70 children with lower urinary tract dysfunction (LUTD), exploring the impact on quality of life associated with intermittent catheterization.
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.
Survey showing generally high satisfaction with intermittent catheterization among children with LUTD. 83% found catheterization very easy and 67% found it comfortable.
Clean intermittent catheterization: Barriers and adherence issues in a Muslim population.
https://doi.org/10.1016/j.rehab.2018.05.890
Kyal N, Hrar S, Moigny Gajou Y, Lmidmani F, El Fatimi A.
Morocco
Observational prospective study of 50 intermittent catheter users.
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).
Conference abstract from the World Congress of the International Society of Physical and Rehabilitation Medicine 2018 exploring culture-specific barriers to intermittent catheterization.
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
Tractenberg RE, Groah SL, Rounds AK, Ljungberg IH, Schladen MM.
US
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.
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.
Study suggesting validity and reliability of a new clinical/research instrument to evaluate patients with neurogenic bladder who use intermittent catheterization. Open access.
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
Guinet-Lacoste A, Charlanes A, Chesnel C, Blouet E, Tan E, Le Breton F, Amarenco G.
France
Observational survey in 222 patients evaluating the Intermittent Catheterization Adherence Scale (ICAS) and its use to assess long-term adherence to intermittent catheterization.
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.
Study identifying a new valid tool (i.e. ICAS) for evaluating adherence to intermittent catheterization.
Selecting an intermittent self-catheter: key considerations.
https://www.ncbi.nlm.nih.gov/pubmed/30088972
Davis C, Rantell A.
UK
Expert statement on features and properties for intermittent catheters.
Proper education is key for teaching patients intermittent catheterization.
Expert statement describing specific features for intermittent catheters.
Selecting an intermittent self-catheter: key considerations.
https://www.ncbi.nlm.nih.gov/pubmed/30089046
Collins L.
UK
Expert statement on indications, advantages, and techniques associated with intermittent catheterization.
Nurses are key in assessing ability and teaching patients intermittent catheterization.
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
Stewart E.
UK
Case report of a successful teaching experience of intermittent catheterization to a 55-year-old woman with fibromyalgia and overactive bladder.
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.
Case report exemplifying important catheter features and their possible contribution to successful experiences of teaching intermittent catheterization.
Clean intermittent catheterization: Single use vs. reuse.
https://www.ncbi.nlm.nih.gov/pubmed/30088975
Holroyd S.
UK
Expert statement on indications, advantages, and techniques associated with intermittent catheterization.
Before teaching intermittent catheterization, a full assessment of the patient's ability is recommended. Catheterization enables independence and this is considered to encourage adherence.
Expert statement on how nurses can guide patients in need of intermittent catheterization to select the catheter most suited to their individual needs.
Managing urinary tract infection in patients performing clean intermittent self-catheterisation.
https://doi.org/10.12968/bjnn.2018.14.4.166
Woodward S.
UK
Expert statement describing symptoms and treatments of urinary tract infections for people performing intermittent catheterization.
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.
Expert statement summarizing the basics around intermittent catheterization and avoidance of UTI.