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

Intermittent Self-catheterization Complications

Although intermittent catheterization is the preferred catheterization method for ensuring bladder emptying, complications and adverse events can arise, especially in patients performing intermittent self-catheterization long-term. Urethral, scrotal, and bladder-related complications may occur. Urethral/scrotal events can include bleeding, urethritis, stricture, creation of a false passage, and epididymitis. Bladder-related events can cause UTIs, bleeding, and stones.

Urethral Adverse Events

Urethral problems, seen primarily in men, include urethritis or inflammation of the urethral meatus from frequent catheter insertion. Urethral bleeding is frequently seen in patients when initiating intermittent catheterization and can occur regularly in one-third of patients performing intermittent catheterization on a long-term basis (Igawa, Wyndaele, & Nishizawa, 2008). Persistent bleeding in a patient who has been performing intermittent self-catheterization long-term may be a sign of a UTI. A more common urethral adverse event is the creation of a false passage, which may occur in men with persisting urethral strictures or who have an enlarged prostate. The false passage may occur at the site of the external sphincter, just distal to the prostate. Urethral trauma can be secondary to the use of a poorly lubricated catheter or forcible catheterization in a urethra, causing spasms (Vapnek, Maynard, & Kim, 2003). It is believed blind catheterization may lead to both urethral bleeding and formation of a false passage.

Urethral strictures can occur in the anterior portion of the urethra (meatus, penile-pendulous urethra, bulbar urethra) or in the posterior portion (membranous urethra and prostatic urethra). These strictures may be the result of an inflammatory response to repeated trauma and are seen more often in patients who perform intermittent self-catheterization. Difficulty with catheter insertion may be a sign of the presence of a urethral stricture. Increased frequency of catheterization may correlate with fewer urethral changes. This may be because individuals who regularly perform intermittent self-catheterization are more skilled in catheterization, and therefore, have less chance of urethral trauma. Repeat catheterization, however, may induce local traumatic reactions of the urethral wall, especially in male patients performing self-catheterization longer than 1 year.

Some authors purport the surface of the catheter to be an important factor, with less stricture development when hydrophilic catheters are used (De Ridder et al., 2005; Stensballe, Loom, Nielsen, & Tvede, 2005). If a stricture is suspected, a retrograde urethrogram or voiding cystourethrogram should be considered. Prevalence of urethral strictures and false passages may increase with longer use of intermittent catheterization or with traumatic catheterization (Moore, Fader, & Getliffe, 2007; Wyndaele, 2002). Similar findings have been reported in children with spina bifida who had used intermittent catheterization with an uncoated PVC catheter for at least 5 years (Campbell, Moore, Voaklander, & Mix, 2004).

Scrotal Complications

Epididymitis, or epididymoorchitis (inflammation of the epididymis and testes), is one of the most common genital infections in men with spinal cord injury who perform intermittent self-catheterization. This infection appears to be more common in men who have a urethral stricture. Prevalence of this complication of intermittent catheterization has been reported to be between 2% to 8% (Igawa et al., 2008). Men may also experience prostatitis, which can cause UTIs.

Bladder-related Complications

Hematuria is frequently seen in the initiation of intermittent catheterization but should not be a persisting problem. New-onset hematuria may indicate a UTI or a stricture. Bladder stones, caused by the introduction of pubic hair or loss of the catheter in the bladder, are common in patients performing long-term intermittent self-catheterization. There have been anecdotal reports of short catheters with a smooth, soft funnel end being inserted and lost in the bladder. Only a few cases of squamous cell cancer of the bladder in patients performing intermittent self-catheterization have been reported in the literature (Casey, Cullen, Crotty, & Quinlan, 2009).

Pain

Pain or discomfort is often experienced during catheterization in individuals with intact periurethral sensation, especially during initiation of intermittent self-catheterization. Pain may be worsened by tension and anxiety. Adequate catheter lubrication and correct positioning of the urethra can decrease pain in men. In women, pain may be caused by hypoestrogenized urethral and perineal tissue. Over time, pain and discomfort during catheterization is typically reduced.

Urinary Tract Infections

UTI is the most frequent complication in patients performing intermittent catheterization. UTI is of concern because when urethral damage occurs, the mucosal barrier to infection is compromised (De Ridder et al., 2005). In addition, the bladder wall is susceptible to bacteria that circulate in retained urine. When the bladder becomes stretched from retained urine, the capillaries become occluded, preventing the delivery of metabolic and immune substrates to the bladder wall (Heard & Buhrer, 2005).

These patients are at higher risk than the general population for developing a UTI and renal deterioration. UTIs can be the result of poor catheterization technique or the passing of the catheter through a normally very contaminated area of the urethra before the catheter reaches the bladder (Moore, Day, & Albers, 2002). A UTI may also be caused by the formation of biofilms (micro-organisms that colonize the internal surface of catheters). Under unfavorable conditions (re-use of a catheter), organisms can detach from the biofilm and become free-floating in the urine, which can lead to symptomatic infection (Saint & Chenoweth, 2003).

Woodbury, Hayes, and Askes (2008) reported on a large (N = 912) community-based population of individuals with spinal cord injury, half of which were women. Women reported a significantly greater number of UTIs than men (p = 0.003). Predictor factors of UTI included high mean catheterization volumes and non-self-catheterization (someone other than the patient performs the catheterization). Busy patient lifestyles, especially for those who are mobility-impaired, and lack of access to more public places with restrooms may further increase the risk of UTI. Moy and Wein (2007) noted the longer the time frame an individual catheterizes, the incidence of UTI increases. One reason may be that catheterization habits become less of a priority as their lives become busier outside the home (Wyndaele, 2002). Wheelchair-dependent para plegic individuals are often seen entering highly contaminated public bathrooms in which to perform intermittent self-catheterization. Overlooking basic hygiene prevention techniques could lead to serious health problems. Table 3 details other common causes of intermittent catheterization-associated UTIs and solutions.

According to a Cochrane Review (Moore et al., 2007), there are no definitive studies showing the incidence of UTIs is improved with any catheter technique, type, or strategy. Recurrent symptomatic UTIs can be a problem for many patients performing intermittent self-catheterization long-term (Heard & Buhrer, 2005). If a clinical infection occurs in these individuals, treatment should be considered. In patients with an internal prosthesis (pacemaker, heart valve), however, the use of prophylactic antibiotic therapy is often recommended (American Urological Association, 2008; Clarke, Samuel, & Boddy, 2005).

Prevention of UTIs

Adherence to basic daily prevention habits may help avoid UTIs in the higher-risk intermittent catheterization population (see Table 4). The most important prevention measures are adequate education, patient compliance, the use of appropriate catheter type and material, and consistent catheterization technique (Wyndaele, 2002). Less frequent catheterization results in higher catheterized urine volumes and places a patient at increased risk for developing a UTI. Thus, more frequent catheterization and the avoidance of bladder overfilling is an extremely important prevention measure. Catheterization between four and six times a day is recommended for most individuals. More frequent catheterization, however, increases the opportunity for introduction of harmful bacteria. Cardenas and Hoffman (2009) noted individuals with a solid education and understanding about intermittent catheterization technique and who follow a strict catheterization protocol have fewer UTIs.

Another measure that may reduce infection is the acidification of urine with cranberry juice or capsules, foods containing lactobacillus, and vitamin C capsules (Newman, 2008; Newman & Wein, 2009). Cranberries inhibit bacterial adherence to the uroepithelial wall and have been primarily studied with Escherichia coli (E. coli) (Jepson & Craig, 2008). In a community-based survey of patients with a spinal cord injury on intermittent catheterization, Woodbury et al. (2008) found those who ingested cranberry or vitamin C agents decreased their incidence of UTI. Hess and colleagues conducted a small, randomized, double-blind, placebocontrolled study in patients who had a spinal cord injury (N = 57) and neurogenic bladder who received cranberry tablets over six months. Bladder management differed with only eight subjects performing intermittent self-catheterization. The authors found a reduction in the likelihood of UTIs and symptoms for any month in the group taking cranberry tablets versus the control group. All patients on intermittent self-catheterization were in the treatment group and had fewer UTIs than the control group (Hess, Hess, Sullivan, Nee, & Yalla, 2008).

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