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 Catheterization Methods

There are different catheterization techniques (sterile or clean), as well as different types of catheters (coated [pre-lubricated] or uncoated [separate lubricant] HCPCS code A4332), sterile (single-use) catheters, or clean (multiple use) catheters used for intermittent catheterization. Catheterization methods include self-catheterization or catheterization by others (such as parents, spouses, or care-givers). The literature reports various ways to clean catheters when used multiple times (Cottenden et al., 2009; Moore et al., 2007). Different catheterization techniques have been defined in Table 5. Research in the area of intermittent catheterization does not always distinguish between clean intermittent catheterization (CIC) and clean intermittent self-catheterization (CISC), and the general term CIC is most often used. According to a Cochrane Review (Moore et al., 2007), available data on intermittent catheterization do not provide convincing evidence that any specific technique (sterile or clean), catheter type (coated or uncoated), method (single-use or multiple-use), person (self or other), or strategy is better than any other for all clinical settings.

Sterile (aseptic) technique implies genital disinfection and the use of sterile catheters, catheter insertion kits, and gloves. In hospitals, sterile intermittent catheterization is preferred over a nonsterile procedure because fewer cases of bacteriuria and UTI occur (Prieto-Fingerhut, Banovae, & Lynne, 1997). According to Lapides et al. (1972), clean technique with cleansed, re-used catheters implies hand washing with soap and water, and cleansing the perineum only if fecal or other wastes are present. Intermittent catheterization with a single-use sterile catheter also infers good hand hygiene, and in many publications, the term clean is used when describing sterile, single-use catheterization.

CIC was introduced by a urologist, Dr. Jack Lapides, and has been used in the bladder management of patients for over 30 years. CIC has proved to be the most effective and practical means of attaining a catheter-free state in patients with a spinal cord injury and chronic, intractable urinary retention (Moy & Wein, 2007). Lapides method of intermittent self-catheterization was believed to be associated with low intravesical pressures and urinary bacterial wall translocation, and thus, less chance for infection in a variety of neurogenic and non-neurogenic bladder disorders. CIC has been successful in a large number of adults and children on follow up of more than 20 years (Lindenhall, Abrahamsson, Jodal, Olsson, & Sillén, 2007). CISC may be more suitable than the use of an indwelling urinary catheter in patients who require long-term bladder drainage as a means of minimizing the histological changes that can occur in the bladder mucosa, which predispose and lead to malignant transformation (Gould et al., 2009; Vaidyanathan, Mansour, Soni, Singh, & Sett, 2002). However, this may occur because the catheter is not left in place rather than the technique of intermittent catheterization.

With scheduled catheterizations, CIC has become the standard of care in this population. When compared to the use of an intermittent urinary catheter, this technique has resulted in improved kidney and upper urinary tract status, and improved continence in patients with neurogenic bladder dysfunction. It also is considered to be less expensive and more practical for individuals because the original sterile technique is believed to be more time-consuming and costly.

Sterile versus Clean versus Single-Use Intermittent Catheterization

There is little debate among urologic experts that patients with certain medical conditions (for example, immunosuppressed patients) should catheterize with sterile or aseptic technique and a single-use catheter on each catheterization. Catheterization in hospitals and nursing homes is performed aseptically because of the high risk of nosocomial infections. In cases in which a parent or caregiver is performing intermittent catheterization, use of sterile equipment is recommended to minimize the transfer of non-indigenous skin flora into the bladder and avoid the possibility of cross-infection. There is little evidence-based research upon which to base recommendations for catheterization in long-term care facilities, but because of the prevalence and incidence of nosocomial infections, aseptic intermittent catheterization should be used.

Debate continues on the use of sterile or clean intermittent catheterization technique in the clinical rehabilitation setting (Kovindha, Mai, & Madersbacher, 2004). Moore, Burt, and Voaklander (2006) compared the incidence of symptomatic UTI and asymptomatic bacteriuria in a small sample of quadriplegic individuals (N = 36) admitted from the acute care neurology unit to the spinal cord rehabilitation unit. Shortly after admission to rehabilitation, subjects were randomized to either clean (n = 16) or sterile (n = 20) intermittent catheterization technique, using time to symptomatic UTI (pyuria plus symptoms) as the study end point. In this study, clean technique with a sterile, single-use polyvinyl catheter (PVC) appeared safe and effective for this population. Of importance is the authors defined clean technique as the use of a new catheter with each catheterization, not the Lapides definition of clean technique (Moore et al., 2006).

Recommendations for Single Use of Catheters

Recent research comparing single, one-time use of a sterile catheter to repeated or reuse of the same catheter for multiple catheterizations is sparse, so one method cannot be recommended over the other (Getliffe, Fader, Allen, Pinar, & Moore, 2007). These authors believe there are few reliable sources that advocate for any type of re-use protocol (Getliffe et al., 2007). As per current manufacturer instructions and labeling, all disposable catheters are for single-use only. No recommendations have been made by Medicare or any other insurer for cleaning catheters between uses and for reusing the same catheter for multiple catheterizations. Table 6 reviews the new guidelines for intermittent catheterization. In time, sterile single-use intermittent catheterization may decrease health care costs because of a decrease in catheter-associated risks (such as UTIs, urethral bleeding) and may prevent the misuse of catheters by patients concerned about costs of these devices.

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