A 50-Year Review of Lapides' Clean Intermittent Catheterization

A Revolutionary, Life-Saving, Quality-of-Life Improving Technique for Bladder Management

Ananias C. Diokno


Urol Nurs. 2019;39(5):229-234. 

In This Article

History of Clean Intermittent Catheterization

The CIC technique evolved from the long-held concept of Jack Lapides (1965) in the early 1960s regarding host resistance. He believed that most urinary tract infections are due to some underlying structural (i.e., obstruction) or functional abnormalities (i.e., neurogenic bladder), leading to urinary retention and bladder overdistention. The overdistended bladder causes decreased blood flow to the tissue of the urinary tract, which leads to decreased resistance of tissue to bacterial invasion (Lapides & Diokno, 1970). Lapides and Diokno (1970) postulated that maintaining good blood supply to the bladder wall by avoiding bladder overdistention, as what occurs in prolonged urinary retention, is the key to prevention of urinary tract infection. Likewise, preventing overdistention and high intravesical pressures also prevents development of high kidney pressures, avoiding hydronephrosis and pyelonephritis. Preventing infections and kidney damage can avoid terminal end stage kidney disease and/or death. Another benefit is prevention of overdistention and avoidance of urinary incontinence, leading to improvement of self-esteem and quality of life.

During a video-taped interview of Jack Lapides, as part of the Eminent Urologist Series sponsored by the American Urological Association (Diokno, 1995), Lapides recalled the first patient for whom he applied the technique of intermittent self-catheterization. A young woman had multiple sclerosis (MS), and she presented to him with recurrent urinary tract infections and urinary incontinence of the mixed type, stress, and urge. She had multiple unsuccessful surgical procedures and was adamantly opposed to any surgical intervention. Lapides was waiting for the opportunity to apply his concept, and this patient, he thought, was the right candidate. She was taught CIC without gloves, using her bare hands after washing with soap and water. The lesson was developed and implemented by the senior urology clinic nurse Bette Lowe, RN, under the guidance of Dr. Jack Lapides (Lapides, Diokno, Gould, & Lowe, 1976). The patient was provided several 14-French Robinson catheters, a tube of water-soluble lubricant, and a sterile solution to soak the catheters. She did very well, had no infections, and reported no problem locating the urethra for easy catheterization. This report emboldened Dr. Lapides to expand the technique to men, as well as children, with children's parents doing the catheterization. During follow-up visits of the woman with MS, she confided that on several occasions, she had dropped the catheter to the floor, and merely washed it with water and proceeded to catheterize herself. Yet no untoward complication had developed. Jack Lapides said, "That was it!" The concept worked!

Dr. Lapides described how grateful the patient was because she no longer had to contend with the difficulty of emptying her bladder, but also the elimination of her stress and urge urinary incontinence. She was able to resume normal sexual activity with her husband because she no longer had urinary incontinence during intercourse. She also provided several helpful hints as how to make self-catheterization easy, such as using a vaginal tampon or having a finger of the opposite hand in the vagina. Of significance is that the technique worked not only for ambulatory adult men and women with no neurological deficits, but also for children and adults with neurological deficits, such as children with myelodysplasia (spina bifida) and patients with different levels of spinal cord injury and in wheelchairs. Many had negative urines without taking any medications, and their incontinence was eliminated or greatly reduced. Lapides stated he had never seen a more grateful group of patients.

The University of Michigan Department of Physical Medicine and Rehabilitation cautiously embraced this technique (Maynard & Diokno, 1982). At first, each inpatient bed was provided with a solution of benzalkonium chloride to soak the catheter after each use, but it was soon found this step was not necessary. An interesting event occurred when Professor Guttman, who introduced the sterile CIC technique in England (Guttman & Frankel, 1966), visited the department and was horrified to learn of our CIC program for our patients with spinal cord injury. I explained our rationale and early good result. He was shaking his head, and I did not feel he was convinced at that time.