Review of Intermittent Catheterization and Current Best Practices

Diane K. Newman, MSN, ANP-BC, CRNP, FAAN, BCIA-PMDB; Margaret M. Willson, MSN, RN CWOCN

Urol Nurs. 2011;31(1)

Management of Bladder Emptying

The preferred long-term management of neurogenic bladder is intermittent self-catheterization performed by the patient or a care-giver. The goal of neurogenic bladder management is to allow the bladder to store a reasonable volume of urine at low pressure and empty the bladder at appropriate time intervals. Long-term use of intermittent catheterization is preferable to an indwelling urinary catheter because intermittent catheterization has a lower risk of infection and other complications (Newman & Wein, 2009). Long-term intermittent self-catheterization is safe and well accepted. However, an early dropout rate of about 20% has been described in children and adolescents (Pohl et al., 2002), so good support, professional instruction on catheterization technique and periodic follow up is necessary to obtain and maintain patient compliance. According to Clayton, Brock, and Joseph (2010), children can independently perform intermittent self-catheterization between the ages of 8 and 12 years, with girls gaining independence sooner than boys.

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Table 1. Common Lower Urinary Tract Diagnoses Seen in Patients with Neurogenic Bladder
Diagnosis	Definition
Underactive bladder (sometimes referred to as atonic, hypoactive or hypocontractile bladder)	A bladder that is not able to contract and empty properly usually because of damage to the nerves that control the bladder. As a result, the bladder fills with urine and remains full. Excess urine the bladder cannot accommodate leads to urine dribbling through the urethra, causing overflow incontinence.
Neurogenic detrusor overactivity (NDO) (formerly detrusor hyperreflexia)	Hyperactivity or overactivity of the bladder muscle causing uncontrolled and involuntary bladder contractions, typically seen in neurological lesions above the sacral spinal cord.
Detrusor areflexia	Inability of the detrusor muscle to contract (referred to as noncontractile) due to abnormality of neural control typically seen in spinal shock or in lesions above the brain stem. Urinary retention may occur.
Detrusor-sphincter dyssynergia (DSD)	Bladder outlet dysfunction that causes a lack of coordination between the bladder and the striated sphincter. The sphincter contracts simultaneously with bladder contraction, clamping in on the urethra, and interfering with the flow of urine. The bladder attempts to empty against the closed sphincter. Urinary retention can occur. Very high bladder pressures may be generated, predisposing these individuals to reflux of urine into the ureters, and ultimately, to kidney damage.
Detrusor hyperactivity with impaired bladder contractility (DHIC)	A condition characterized by frequent but ineffective involuntary detrusor contractions. A person is either unable to empty the bladder completely or can empty the bladder completely only with straining. This abnormality of the bladder was first diagnosed in nursing home residents.

Source: Adapted from Newman & Wein, 2009.

Table 2. Advantages of Intermittent Catheterization over Indwelling Urinary Catheter
Improved self-care and independence
Reduced risk of common indwelling catheter-associated complications
Reduced need for equipment (such as drainage bags)
Less barriers to intimacy and sexual activities
Potential for reduced lower urinary tract symptoms (frequency, urgency, incontinence) between catheterizations

Source:Adapted from Newman & Wein, 2009.

Table 3. Causes of Intermittent Catheterization-Related Urinary Tract Infections
Cause	Reason	Solution
Inadequate frequency of emptying	Can lead to excessive bladder volumes with long periods of urine stagnation, increasing the risk of UTI.	Draining the urine regularly will prevent migration of bacteria into the bladder long enough to produce symptomatic infection.
Inadequate emptying at the time of catheterization	Residual volume left in the bladder after catheterization promotes an environment for bacteria proliferation.	To ensure adequate emptying, patients should perform a gentle Credé maneuver as the catheter is removed.
Inadequate fluid intake	Companion problem to inadequate frequency of emptying. When low urine volumes are produced (less than 1200 ml of urine per day), patients are less inclined to empty at desired intervals, producing urine stagnation and bladder distention.	Total daily fluid intake (from foods and all types of beverages) is approximately 2.7 L/day for women and 3.7 L/day for men. Most adults adequately meet their daily hydration needs by letting thirst be their guide.
Poor catheterization technique and catheter care	Inadvertent introduction of bacteria into the bladder.	Consider re-evaluation of catheterization technique of the person performing catheterization. Consider a sterile closed system or single-use catheters based on medical necessity.
Excessive fluid intake	If the person cannot or will not adjust fluid intake appropriately for the intermittent self-catheterization schedule, he or she risks periodic or regular bladder over distention and possible overflow UI. Excessive intake could produce bladder volumes greater than 500 mL at one time or would be evidenced by the need to catheterize more than six times a day.	Encourage regular fluid intake, small volumes spaced hourly between breakfast and the evening meal, and reducing to sips thereafter.
Nocturnal polyuria	Some patients (such as those with spinal cord injury and/or multiple sclerosis, and older patients) may have nocturnal diuresis related to inadequate antidiuretic hormone secretion at night or impaired cardiac condition.	Large fluid intake in the evening should be discouraged. Catheterize several times during the night. Consider a trial of desmopressin administration at bedtime with careful monitoring of serum sodium levels.
Traumatic catheterization	Breaks in the bladder urothelium and urethral lining increase the risk of infection. Difficulty passing the catheter may lead the person to avoid performing catheterization.	Assessment of catheterization technique to help correct faulty insertion technique. Consider an alternative catheter design (Coudé tip, hydrophilic coated) to ease passage. Consultation with urologist

Source: Adapted from Newman & Wein, 2009.

Table 4. Suggestions for Prevention of UTIs Associated with Intermittent Catheterization
Maintenance of hygiene, particularly of the hands and perineum Hands should be thoroughly washed before attempting catheterization. The genitalia should be washed daily with soap and water and always Cleansed from front to back. Preferable to perform catheterization before bowel program to minimize E. coli bacteria contamination of the urethra. Immediate perineal hygiene is recommended after vaginal intercourse because the act of intercourse may push anal bacteria into the urethra. Avoidance of spermicidal lubricants in sexually active females because these products may alter normal vaginal and lower urethral flora. Teach male patients the correct positioning of the male urethra during insertion of the catheter to minimize trauma as the catheter passes through curved portions of the urethra (see Figure 18). Be careful to avoid touching the tip of the catheter and/or letting it touch other surfaces. If a postmenopausal female patient has hypoestrogenized perineal tissue, consider transvaginal estrogen medication. Use a generous amount of lubricant along the length of the catheter (especially male patients) since dry catheters may cause excoriations in the urethra, leading to an entry point for bacteria contamination. Keep bladder as empty as possible by having patients catheterize at least four to six times a day or to maintain bladder urine volume less than or equal to 400 mls. Keeping the bladder as empty as possible will prevent over-distension of the bladder and increases in intravesical pressure that can lead to inadequate blood supply to the bladder wall. Encourage use of a new catheter each time performing intermittent catheterization. Most catheters are manufactured and packaged for single-sterile use. Acidification of the bladder may prevent bacteria growth. In non-catheterizing populations, cranberry capsules and juice have been shown and recommended to help prevent the growth of bowel bacteria in the urethra and the bladder. Cranberry ingestion may be contra-indicated in some patients (for example, patients prone to oxalate or uric acid calculi). Cranberry is contraindicated in patients on anticoagulation therapy and should not be recommended to this group. Lactobacillus in the diet (yogurt) has been shown to prevent E. coli from growing in the urethra. Hiprex® 1000 mg combined with vitamin C 1000 mg capsules twice daily is thought to acidify urine enough to prevent bacterial growth in the bladder and is recommended in patients with recurrent UTIs.

Source: Adapted from Newman & Wein, 2009.

Table 5. Defining Catheterization Techniques
Type	Technique
Clean re-used	Use of a sterile, disposable catheter and with good hand hygiene. After use, catheter is washed and rinsed Catheter is then air dried and stored in a ventilated container or ziplock plastic bag. Catheter is re-used by the same patient for a limited period of time (usually 1 week) as directed by clinician
Clean, single-use	Use of a sterile, disposable catheter and good hand hygiene. Catheter is disposed after single use
Sterile or aseptic	Use of sterile gloves, disinfectant wipes or swabs, sterile single-use catheter, sterile drainage tray, or closed collection bag.

Source: Adapted from Newman & Wein, 2009.

Table 6. Recommendations for Intermittent Catheterization
In 2007, the Veterans Administration (VA) issued the following recommendations: Clinicians should follow the manufacturer's instructions for catheter use, which recommend single-use devices should not be re-used in any setting. Patients should be provided with an adequate number of catheters to allow the use of a sterile catheter for each catheterization. Clinicians should inform patients, family members, and caregivers that catheters are for single-use only (Department of Veterans Affairs, 2007; Newman, 2008). The Centers for Medicare and Medicaid Services (CMS) has not made a recommendation on re-use of catheters, but in the spring of 2008, increased coverage of monthly catheter utilization up to 200 catheters (Muller, 2009). CMS catheter reimbursement policy change supports the VA recommendation that clinicians should follow manufacturer's instructions, which are for single-use of these catheters. Most other insurers will cover only four catheters per month

Table 7. Types of Catheters Available for Intermittent Catheterization
Type	Characteristics	Concerns
Uncoated catheters Latex free Red rubber	Used for clean technique Latex free Most commonly used catheter – made of medical-grade plastic, such as polyvinyl (PVC) or silicone Available in a range of stiffness Red rubber Natural rubber latex is very soft and flexible	Latex free Packaged and labeled for single use PVC is produced in firm and soft versions and has a larger diameter Red rubber Not appropriate for individuals with latex sensitivities Flexibility can make them difficult to insert
Coated catheters Hydrophilic Antibiotic	Depending on design, used for clean, sterile, or aseptic technique Hydrophilic Have an outer layer of polymer coating bound to the catheter surface, which becomes smoother when hydrated Coating on catheter surface becomes slippery when wet Antibiotic Antibacterial coating (nitrofurazone) on surface of a silicone catheter to produce local antibacterial activity Some antibacterial catheters also have a hydrophilic coating Some hydrophilic catheters require water to be added	Hydrophilic Can be slippery if catheter does not have a sleeve, making it difficult for the patient to grasp and manipulate for insertion Cannot be re-used Antibiotic Risk of superinfection Patient may become sensitized to antibiotic coating Minimal data to support effectiveness Cannot be re-used
Closed systems Gel Hydrophilic Antibacterial	Pre-lubricated intermittent catheter with an attached collection bag and often includes a protective introducer tip All inclusive – includes gloves, drape, underpad, antiseptic wipe, or swaps Allows user to catheterize without touching the catheter Used for sterile or aseptic technique	Can be difficult for some with limited dexterity to advance catheter through collection bag. Cannot be re-used

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Review of Intermittent Catheterization and Current Best Practices

Management of Bladder Emptying

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