Intermittent self-catheterisation is a safe and effective way of managing patients with urinary retention or incontinence due to a neuropathic or hypotonic bladder. It has transformed the lives of people rendered housebound by bladder problems and has preserved the kidneys of children with spina bifida, and of adults with spinal cord injury.¹

Indications

• Chronic urinary retention from a neuropathic bladder condition, e.g. multiple sclerosis,² diabetic neuropathy, spina bifida, spinal cord injury or spinal tumour.
• Detrusor hyperactivity and functional obstruction: many have sphincter dysfunction and are at risk for pyelonephritis and upper urinary tract injury.
• Urge incontinence and co-existing weak detrusor function: for example, some patients with diabetes and with bladder neuropathy may have instability requiring bladder-relaxing drugs but also have intermittent weak detrusor function with poor emptying. The addition of bladder-relaxing drugs may worsen the baseline poor detrusor function, resulting in retention and overflow incontinence. In some cases, the solution may be to combine bladder-relaxing medical therapy with intermittent self-catheterisation.
• Intermittent low-friction self-catheterisation is effective in preventing recurrences of urethral strictures.^3,4

Patient assessment

• Patients should be referred to a urologist for full assessment and to initiate the patient in using self-catheterisation.
• Physical examination should include testing for pinprick sensation in the saddle area.
• Sensory loss in the second to fourth sacral dermatomes implies diminished awareness of a full bladder.
• Sensory loss that extends to the third lumbar dermatome suggests that catheterisation will be painless.¹

Investigations

• Urinalysis
• Blood urea and electrolytes, creatinine and glucose
• Ultrasound of the urinary tract
• Plain X-ray to show urinary calculi and spinal abnormalities
• In children, urodynamic assessment should include a cystogram to detect vesicoureteric reflux

Requirements

• Severe disability is not a contra-indication since patients in wheelchairs have mastered the technique despite paraplegia, an anaesthetic perineum, spinal deformity, intention tremor, mental handicap, old age or blindness.⁵
• Patients, and/or carer, must be highly motivated.
• Adequate and effective education and support.
• Catheterisation can be performed by the patient or carer, but must be gentle, especially if lacking sensation, and must be used more than four times a day.
• They should always keep their catheter with them and not wait for urge before using.

Intermittent catheters

Patient choice and ease of use are major considerations in the decision-making process regarding which catheter to prescribe, as are lifestyle and the underlying bladder problem. Providing patients with a range of suitable intermittent catheters will allow them to make informed choices and reduce wastage.

• Nélaton's catheters: come in a range of sizes and lengths.
• Single use catheters are sterile and have either a hydrophilic coating, which requires immersion in water for 30 seconds to activate, or a gel coating, which does not require any preparation prior to use.
• Reusable catheters are made out of polyvinyl chloride and are non-coated. They can be washed and reused for up to a week.
• Catheter kits: combine an intermittent catheter with a urine containment pouch. This system is useful for travelling or when access to a toilet would be difficult.
• Scott catheters: female length, more rigid catheter for women who find a Nélaton's catheter difficult to handle.
• Metal catheters: female length, stainless steel catheters that can be sterilised. Some girls and women find the rigid catheter easier to handle.

Complications

Are infrequent, particularly in female patients.⁶

• Urinary tract infection (UTI) (but actually self-catheterisation reduces the number of UTIs because of reducing residual urine in the bladder and reducing reflux obstructive uropathy)
• Bladder calculi
• Urethral bleeding
• Urethritis
• Urethral stricture
• False passage
• Epididymo-orchitis

Document references

1. Hunt GM, Oakeshott P, Whitaker RH; Intermittent catheterisation: simple, safe, and effective but underused. BMJ. 1996 Jan 13;312(7023):103-7.
2. Fowler CJ, Panicker JN, Drake M, et al; A UK consensus on the management of the bladder in multiple sclerosis. J Neurol Neurosurg Psychiatry. 2009 May;80(5):470-7. [abstract]
3. Harriss DR, Beckingham IJ, Lemberger RJ, et al; Long-term results of intermittent low-friction self-catheterization in patients with recurrent urethral strictures. Br J Urol. 1994 Dec;74(6):790-2. [abstract]
4. Gnanaraj J, Devasia A, Gnanaraj L, et al; Intermittent self catheterization versus regular outpatient dilatation in urethral stricture: a comparison. Aust N Z J Surg. 1999 Jan;69(1):41-3. [abstract]
5. Oakeshott P, Hunt GM; Intermittent self catheterization for patients with urinary incontinence or difficulty emptying the bladder. Br J Gen Pract. 1992 Jun;42(359):253-5. [abstract]
6. Lapides J, Diokno AC, Gould FR, et al; Further observations on self-catheterization. J Urol. 1976 Aug;116(2):169-71. [abstract]

Internet and further reading

• Nursing Standard; Patient information; Intermittent self-catheterisation. April 3 2002 Volume 16 Number 29.

Acknowledgements