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) 

In This Article

Catheter Design and Types

The number of catheter types and designs has increased with the advancement of new technology. This has added complexity to the catheterization process for both the nurse and the patient. Catheter types are now gender-specific, acknowledging the anatomical differences in urethral length between men and women. Design changes include the integration of all needed equipment (such as catheter, water-based lubricant, and drainage receptacle/bag) into a compact and user-friendly system (closed system). The clinician who instructs the patient usually recommends the catheter choice, so knowledge of the different types of catheters is important (Newman, Fader, & Bliss, 2004). The type of catheter packaging can be decisive in the choice of catheter. However, catheter choice more often depends on the general clinical situation of the patient, such as injury, manual dexterity, visual impairment, urethral sensibility, gender, and age, than on cause of the bladder dysfunction (Newman & Wein, 2009). The patient may need to try several catheters before finding the preferred type. Not all catheters are suitable for one individual's needs and circumstances. For example, some patients may require one type of catheter for home use and another for catheterizing outside the home (while at work).

Catheter Size and Length

Catheter sizes available for intermittent catheterization are similar to those available for an indwelling urinary catheter. Catheter diameter is measured in French (Fr or Ch) units, and sizes range from 6 to 12 Fr for children and 14 to 22 Fr for adults. The funnel end of the catheter is usually color-coded to easily identify Fr size. Intermittent catheters have different lengths and are gender-specific. Catheters with lengths of approximately 12 inches (about 40 cm) allow for adequate passage through a male urethra. Women and children, whose urethras are shorter in length, may find a shorter-length catheter of 6 to 12 inches (20 to 40 cm), which is easier to grasp and manipulate because it will not loop or kink, thus allowing easy flow and urine drainage through the catheter. Catheters have now been designed to be more compact so they can fit easily in a small purse or bag and are easy for the person to use (see Figure 1).

Figure 1.

Example of a Female Compact Catheter (Coloplast)
Source: Reprinted with permission from Coloplast.

Catheter Tips

The tip of a catheter used for intermittent catheterization can be either straight (HCPCS code A4351) or curved (referred to as Coudé-tipped [HCPCS code A4352] Tiemann). Most straight-tipped catheters are tapered so they can pass smoothly through the urethra. Using a curved catheter tip in the male patient with an enlarged prostate or a narrowed urethra (for example, from a stricture) may allow for ease of insertion (see Figure 2a). Mentor (now Coloplast) designed an additional tip called the olive-tipped catheter, which has been used in several different situations (such as it may help women locate the meatus) (see Figure 2b).

Figure 2a.

Catheter Tip Configurations – Straight and Coudé (Hollister)
Source: Reprinted with permission from Hollister.

Figure 2b.

Catheter Olive Tip (Coloplast)
Source: Reprinted with permission from Coloplast.

In the United States, some clinicians advocate the use of an introducer tip when performing intermittent self-catheterization (see Figure 3). The introducer tip was first studied in the 1990s (Bennett et al., 1997; Charbonneau- Smith, 1993). These tips, found inclosed-catheter systems, were originally used in obstetric patients, but have been tested in acute care and rehabilitation hospitals. By inserting this tip in the urethra before advancing the catheter, the first portion (1.5 cm) of the distal urethra is bypassed. This portion of the distal urethra can be colonized with perineal bacteria, particularly E.coli. Colonization of pseudo monas and klebsiella frequently occurs in the perineum and urethra in men with a spinal cord injury. To bypass the distal urethra area, the catheter is advanced into the introducer tip, the tip is inserted into the distal urethra, and then the catheter is passed through the tip into the urethra. This prevents contamination of the catheter and introduction of bacteria into the bladder (Hudson & Murahata, 2005). Bennett and colleagues (1997) found the use of an introducer- tipped catheter reduced UTI in hospitalized patients with spinal cord injury on intermittent catheterization.

Figure 3.

Introducer Tip (Hollister)
Source: Reprinted with permission from Hollister.

Catheter Materials

Catheters fall into several different categories and these are described in detail in Table 7.

Catheters are packed individually in sterile packaging (see Figures 4 & 5). As per industry standards, all disposable catheters are intended for one-time use. However, uncoated catheters have frequently been re-used in the past because of cost or concern about the environment (Gray, 2009). Most catheters are used with a separate lubricant, although this is a matter of personal choice as some patients may just use water or nothing (Newman & Wein, 2009). Woodbury and colleagues (2008) found in their national survey of intermittent catheterization practice in a Canadian spinal cord injury group (N = 912) that 74% of the sample used uncoated catheters for intermittent self-catheterization, with 53% using it only once.

Figure 4.

Uncoated Catheter (Coloplast)
Source: Reprinted with permission from Coloplast.

Figure 5.

Hydrophilic Uncoated Catheter (Astra Tech)
Source: Reprinted with permission from Astra Tech

Coated catheters with hydrophilic or other coatings (such as antimicrobial or antibacterial) are sterile and not intended for reuse. Hydrophilic-coated catheters were introduced in an attempt to reduce long-term urethral complications. Recent CDC guidelines (Gould et al., 2009) have noted these coated catheters may be preferable to a standard catheter. Hydrophilic catheters are PVC catheters coated along the entire length with a hydrophilic polymer, primarily polyvinyl-pyrrolidone (PVP) and same with sodium chloride. When these catheters are exposed to water, the PVP coating attracts the water to the surface of the catheters, creating the biocompatible salt coating that binds the water to the surface of the catheter and forming an outer layer mainly consisting of water. This thick, slippery, smooth layer of water stays on the catheter, ensuring lubrication of the entire urethra during catheter insertion and withdrawal, thereby reducing the friction coefficient by at least 95% (Waller, Jonsson, Norlen, & Sullivan, 1995). PVP is a non-allergenic substance that has been used in medical products and cosmetics industries since the 1930s. However, there is an increasing demand for PVC-free materials, with efforts to avoid the use of medical devices that use PVC and its plasticizer (di [2-ethylhexyl] phthalate). There is ongoing research to test PVC-free catheters (Witjes et al., 2009).

PVP-coated hydrophilic catheters may be indicated for patients who experience particular discomfort during catheterization when using gel-lubricated uncoated catheters or patients who have difficulty with other types of catheters (Diokno, Mitchell, Nash, & Kimbrough, 1995). This outer layer has been designed to allow for easier insertion, minimize discomfort, and reduce friction between the urethra and the catheter during intermittent catheterization. In addition, it may minimize the risk of urethral trauma and other complications (Fader et al., 2001; Vapnek et al., 2003). Because of their low friction, PVP-coated catheters seem to be associated with a lesser degree of urethral inflammatory response when compared to PVC catheters (Biering-Sorensen, Bagi, & Hoiby, 2001; Stensballe et al., 2005; Waller et al., 1995). The use of hydrophilic catheters may also decrease the incidence of strictures (De Ridder et al., 2005; Giannantoni et al., 2002; Stensballe et al., 2005).

Nurses and patients have many hydrophilic-coated catheters from which to choose (see Figure 6). Some available products include sterile water in the package, making it easier to activate the catheter hydrophilic coating (see Figure 7a). A new hydrophilic catheter (see Figure 7b) utilizes water vapor inside the unique package to hydrate the catheter without adding water.

Figure 6.

Hydrophilic Catheter (Coloplast)
Source: Reprinted with permission from Coloplast.

Figure 7a.

Hydrophillic Catheter with Water (Astra Tech)
Source: Reprinted with permission from Astra Tech.

Figure 7b.

Hydrophilic Catheter (water vapor) (Hollister)
Source: Reprinted with permission from Hollister.

Hedlund, Hjelmås, Jonsson, Klarskov, and Talja (2001) found clinical evidence showing hydrophilic-coated catheters decrease urethral irritation and have a higher user satisfaction. In clinical practice, the reduction in the number of clinically significant UTIs is the most important issue with intermittent self-catheterization. Thus, there may be a beneficial effect regarding UTI when using hydrophilic-coated catheters.

De Ridder and colleagues (2005) studied the prevalence of UTIs in male patients with spinal cord injury who were randomized to a PVC group (n = 62) and a hydrophilic (Coloplast SpeediCath) group (n = 61). Results over a 1-year period showed the number of patients with spinal cord injury free of clinical UTI (n = 57) was double in the hydrophilic catheter group as compared to the PVC group.

Cardenas and Hoffman (2009) conducted a study to determine if patients who used a hydrophilic-coated catheter would have less UTIs when compared to patients (control group) using a non-coated catheter with clean technique. Of the 56 subjects enrolled, 45 completed the study (22 in the treatment group, 23 in the control group). There were no significant differences in demographics (including sex) between the treatment group and the controls except for more tetraplegic subjects in the control group (p = 0.05). Seventy-one percent (71%) of the treatment group and 52% of the control group were men. The total number of symptomatic UTIs was the same in both groups, but the number of symptomatic UTIs that required antibiotics was significantly smaller in the treatment group than in the control group (p = 0.05). Seventy percent (70%) of the control group had at least one antibiotic treatment episode compared with only 50% with the hydrophilic catheter (p = 0.18). There was no significant difference in the incidence of bacteriuria or symptomatic UTIs among the two groups. Level of injury and years with injury were unrelated to symptomatic UTIs, but being female increased the risk of UTIs (p = 0.01).

There are disadvantages to using a hydrophilic-coated catheter for intermittent catheterization. The hydrophilic catheter is intended for one-time use, and may not be cleaned and re-used; surface drying times vary by product, and some become sticky when dry. Furthermore, the de - sign of these catheters varies in terms of material, length, and flexibility because there is no research comparing the different products.

Closed-catheter Systems

A closed intermittent catheterization system is available and has been designed to reduce contamination of the bladder because the catheter never comes in direct contact with the inserter's hands. These systems should not be re-used. These pre-lubricated products with an integrated (all-in-one) collection bag give flexibility for the user and are efficient for hospital use. Some closed systems are packaged as a sterile kit containing all the equipment required to do aseptic catheterization (for example, when traveling or while at work). Most systems have an introducer tip that is passed through a pre-lubricated plastic sleeve or guide, keeping the catheter straight and lubricated as it is advanced. When the plastic sleeve is squeezed, it prevents the catheter from slipping during insertion (Day, Moore, & Albers, 2003; Newman et al., 2004; Newman & Wein, 2009). The 15 mm introducer tip on the closed system has been shown to bypass the distal urethra where harmful bacteria reside (Hudson & Murahata, 2005), which is key in the prevention of UTI. The Centers for Medicare and Medicaid allows coverage for closed-catheter systems with introducer tips for those who self-catheterize, are immune-compromised, reside in a nursing facility, experience vesico-ureteral reflux while on an intermittent self-catheterization program, are pregnant females with spinal cord injury and a neurogenic bladder, and/or have developed two or more UTIs in a 12-month period in which they practiced self-catheterization. Reimbursement is under HCPCS code A4353. Figures 8 through 11 illustrate available closed-system choices. Figures 12 through 14 show closed-system sterile kits.

Figure 8.

Self-Contained Catheter and Bag (Bard)
Source: Reprinted with permission from C.R. Bard.

Figure 9.

Closed System (Hollister)
Source: Reprinted with permission from Hollister.

Figure 10.

Closed Advance Plus System with Hands (Hollister)
Source: Reprinted with permission from Hollister.

Figure 11.

Self-Catheter, Closed System (Coloplast)
Source: Reprinted with permission from Coloplast.

Figure 12.

Self-Contained Sterile Systems with Accessories (Cure Medical)
Source: Reprinted with permission from Cure Medical

Figure 13.

Closed Sterile System Kit (Astra Tech)
Source: Reprinted with permission from Astra Tech.

Figure 14.

Self-Contained Sterile Systems (Bard)
Source: Reprinted with permission from C.R. Bard.