Review of Intermittent Catheterization and Current Best Practices

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

Disclosures

Urol Nurs. 2011;31(1) 

In This Article

Teaching Catheterization

Any type of bladder catheterization is not a procedure to be undertaken lightly. Intermittent self-catheterization requires education and support, particularly during initial teaching and follow up. A knowledgeable and experienced clinician, in most cases a nurse, is an important component for successful self-catheterization teaching. The nurse should assess patient and/or caregiver knowledge about the urinary tract (Martins, Soler, Batigalia, & Moore2009). Providing an overview of anatomy with pictures or the use of an anatomic model of the perineum can be very helpful. Many catheter manufacturers have visual guides or videos that can be used when teaching patients and/or caregivers (Newman & Wein, 2009). Most adults learn best under low to moderate stress, so it is important to teach self-catheterization in a low stress setting. The nurse should also assess the patient's ability to learn intermittent self-catheterization, motivation to continue long-term catheterization, awareness of problems associated with catheterization, and the understanding of how to avoid possible complications. Disabilities, such as blind ness, lack of perineal sensation, tremor, mental disability, and paraplegia, do not necessarily preclude the ability to perform catheterization. However, these obstacles are difficult to overcome in some patients and caregivers (Moore et al., 2007). Teaching a patient with a spinal cord injury may be even more of a challenge because motor and sensory impairment may require changes to catheterization technique.

There is a lack of uniformity and standardization in nursing practice in terms of performing self-catheterization because most nurses use experience-based practice. Initially, many patients may be extremely reluctant to perform any procedure that involves the genitalia, but this is basically a "fear of the unknown." Determining acceptance of intermittent catheterization is vital because non-compliance is seen in many patients, particularly adolescents (Holmdahl et al., 2007). Teaching components include how to handle the catheter, identify the urinary meatus, and care for the catheter. It is important that patients and/or caregivers demonstrate understanding and/or ability or perform catheterization under supportive supervision of the nurse. For patients performing long-term intermittent self-catheterization, monitoring patients for adverse events is advised.

An assessment of the patient's personal hygiene (hand washing and cleansing of the genitalia) is important to avoid UTIs. Webster et al. (2001) found no benefit to the use of an antiseptic solution for daily periurethral cleansing prior to catheterization. A more recent study comparing the use of water versus providone-iodine solution for periurethral cleaning in women prior to an indwelling urinary catheter insertion found no significant differences in the rate of bacteriuria or UTIs 24 hours after insertion (Nasiriani et al., 2009).

Performing Intermittent Self-catheterization

A cooperative, well-motivated patient or family member and/or caregiver is essential for performing intermittent catheterization. Age should not be a deterrent to intermittent self-catheterization because older patients with adequate cognitive function, mobility, motivation, and manual dexterity can easily learn the technique. Patients who can feed themselves usually have the manual dexterity to self-catheterize.

Anatomic variations make self-catheterization difficult, particularly in obese women who are unable to reach the perineum (Williams, 2005). Similarly, men with large abdominal girths may be unable to visualize the urinary meatus or reach and grasp their penis. Some clinicians have taught men with large girths to catheterize by standing in front of a mirror. Women may find it difficult to perform intermittent self-catheterization in different locations and settings. Nurses can teach women to perform intermittent self-catheterization lying in bed using a mirror to see the meatus. Another technique recommends teaching women in the clinical setting by using a mirror to point out structures in the perineum (the vaginal opening, clitoris, and meatus). A mirror, however, is difficult to use in a toilet stall, so most women are also taught intermittent self-catheterization using the squatting technique. Lapides and colleagues (1972) found that women may initially use a mirror, but after several days, can locate the urethral meatus by palpation without this aid. Women may facilitate self-catheterization by placing a tampon or having a finger of the opposite hand in the vagina to isolate the location of the meatus.

Aids, such as mirrors, and handles can assist women in seeing the meatal opening, which can be helpful for the person performing catheterization (see Figure 15) (Newman & Wein, 2009). For individuals with limited dexterity, using a handle to insert the catheter may allow the user to hold the catheter firmly and direct it into the correct position (see Figure 16). Another aid helpful for women who have abductor spasms or inability to separate their thighs is the knee spreader with mirror (see Figure 17).

Figure 15.

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

Figure 16.

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

Figure 17.

Knee Spreader with Mirror
Source: Reprinted with permission from Diane Newman.

Figure 18.

Correct Penis Placement for Male Intermittent Self-Catheterization
Source: Reprinted with permission from Diane Newman

Schedule

The catheterization schedule or frequency should be based on frequency-volume records, functional bladder capacity based on urodynamics findings, ultrasound bladder scans for PVR, and the impact of catheterization on a patient's quality of life. As a general rule, bladder volume should not exceed 500 mLs, and some advocate not exceeding 400 mLs. Based on an individual's average output, catheterization is usually performed four to six times during the day. The bladder should be emptied completely with each catheterization. When starting intermittent catheterization, the patient and/or caregiver should record the amount of urine drained from the bladder. If the patient voids, catheterization should always be performed after voiding.

Catheter Use and Care

There are no clear guidelines about length of time for catheter use if the patient is re-using an uncoated catheter. Most patients re-use catheters for up to 7 days. The cleaning of the catheter between uses has no basis in research because there are no published randomized controlled clinical trials of cleaning methods. The comparative effectiveness of cleaning methods, therefore, is unknown. Actual practice is not well-understood. Woodbury et al. (2008) found close to 80% of all individuals in their sample who re-use their catheters do not disinfect them between uses.

A number of laboratory studies testing the sterility of catheters using different methods (for example, cleaning with soap and water, antiseptic soak, and microwave) have been documented. Prior to recent guidelines and policy changes, most clinicians instructed patients to clean catheters with soap and rinse with water (Duffy et al., 1995). There did not appear to be an increase in UTI occurrence using these methods, but it should be noted that most of this research is outdated (Duffy, 1995; King, Carlson, Mervine, Wu, & Yarkony, 1992; Sims & Ballard, 1993).

A more recent study has tested a microwave method for catheter cleaning (Bogaert et al., 2004). The microwave method may be less practical than other methods due to the risk of catheter melting. If future research supports the re-use of catheters, there will be a greater need for comparing cleaning methods with symptomatic UTI as the primary outcome variable. Currently, catheter manufacturers do not provide instructions for catheter re-use or cleaning. Best practices do not support the re-use of single- use catheters at this time.

Cleaning techniques suggested by nurses and reported by patients include soap-and-water washing, boiling, microwave sterilization, and soaking in an antiseptic solution (peroxide and povidone-iodine or Betadine®). If the patient prefers re-using the catheter, use of dishwashing soap or an antibacterial waterless product when catheterizing outside the home are adequate in these authors' opinion. A home microwave oven may be used as a method to sterilize red rubber catheters for re-use, with a recommended time of 12 minutes at full power (Bogaert et al., 2004).

To minimize encrustations and to wash away bacteria, patients should be encouraged to forcefully rinse the catheter lumen with tap water. The catheter should then be allowed to dry and stored in a convenient container.

Kovindha and colleagues (2004) recommend the re-use of catheters to reduce catheter costs, especially in developing countries where these devices are scarce due to economic restraints. They investigated the re-use of a silicone catheter manufactured in Japan. Catheter use was studied in men (N = 28) whose average usage time for one catheter was 3 years. Over this time period, 36% of men reported symptoms suggesting a UTI. In this study, patients soaked the catheter in an antiseptic solution (benzethonium chloride with sterile glycerine solution).

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