A 50-Year Review of Lapides' Clean Intermittent Catheterization

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

Ananias C. Diokno

Disclosures

Urol Nurs. 2019;39(5):229-234. 

In This Article

Applications of CIC

Original Indications of CIC

Patients With Incomplete Bladder Emptying or Total Urinary Retention Secondary to Neurologic Abnormalities. The first example was his very first patient who had MS. In this condition, there are many different phases of bladder dysfunction, from complete urinary retention due to detrusor areflexia to frequent but incomplete emptying due to detrusor sphincter dyssynergia (Lapides et al., 1972; Piazza & Diokno, 1979). In this phase of bladder dysfunction, patients usually suffer with urgency incontinence and recurrent urinary tract infections, exactly what Lapides' first patient suffered. When there is detrusor sphincter dyssnergia, it is appropriate to prescribe anticholinergics to suppress the involuntary detrusor contraction, eliminating urgency and urge incontinence, but such a move will lead to worsening of urinary retention. This is where CIC is ideal because the bladder can be drained regularly, eliminating the overdistention of the bladder and the urge or overflow urinary incontinence.

Patients With Spinal Cord Injury. Another neurogenic bladder dysfunction to which this technique was originally applied was in patients with spinal cord injury (Koff & Diokno, 1979; Maynard & Diokno, 1982). This technique was applicable for both men and women, and for both upper (suprasacral/spastic bladder) and lower (sacral and peripheral/areflexic flaccid bladder) motor neuron type of neurogenic bladder. In suprasacral lesions, detrusor hyperreflexia is a dominant feature; thus, anticholinergics usually go hand-in-hand with CIC. However, in sacral or infrasacral lesions with areflexic bladders, CIC alone will suffice if done regularly because the bladder is flaccid, and the detrusor does not develop involuntary bladder contractions.

Children and Adolescents With Myelodysplasia Secondary to Various Degrees of Spina Bifida Congenital Anomalies. Another group where early application with CIC is quite successful are children and adolescents with myelodysplasia secondary to various degrees of spina bifida congenital anomalies (Diokno, Kass, & Lapides, 1976; Kass, McHugh, & Diokno, 1979). In most instances, the neurologic deficit is a combination of incomplete sacral and suprasacral lesions, leading to mixed urge and stress incontinence, with varying degrees of post-void residual urine. Here, urodynamic evaluation will be helpful to determine the state of the detrusor and urinary sphincter. Management may involve CIC only. There may be the addition of anticholinergics or even alpha-adrenergic drugs to augment the urinary sphincter because at times, the urethral sphincter is also paralyzed and will need augmenting to prevent urinary incontinence (Kass et al., 1979).

Men and Women With Chronic Urinary Retention Secondary to Bladder Atony. The other category that found early use of CIC was in men and women, young and old, with chronic urinary retention secondary to bladder atony usually due to prolonged urinary retention or long-standing under-recognized outlet obstruction (Bennett & Dionkno, 1984; MacGregor & Diokno, 1979). It is assumed the high voiding pressure over a long time ultimately caused the bladder to become atonic and underactive. In women, chronic total or partial urinary retention may be a consequence of prolonged unrecognized urinary retention, following radical hysterectomy or from multiple surgical procedures to relieve stress urinary incontinence. In all cases, regular CIC alone takes the place of regular voiding. In certain situations, normal voiding returned, sometimes months or years after regular CIC.

Additional Applications of CIC

Additional applications of CIC in cases that were originally considered contraindication for CIC or created because of the availability of CIC are listed below.

Patients With Artificial Device or Obstructive Sling Around the Urethra. Early on, patients with stress urinary incontinence secondary to damage (intrinsic sphincter deficiency) or paralysis of the urinary sphincter in association with detrusor neuropathic disturbance needing catheterization have been observed. The challenge is once the urethral resistance is increased to control stress urinary incontinence, urinary retention will manifest because the paralyzed or weak detrusor will not be able to evacuate the urine. Innovative surgeons have devised various approaches to keep the patient dry but able to continue CIC in one form or another. Implanting an artificial urinary sphincter (AUS) did not prevent the use of CIC, and CIC was compatible with an AUS in both men and women (Diokno & Sonda, 1981). In certain circles, rather than using an AUS, a tight pubo-vaginal sling was installed to mechanically obstruct the urethra and still permit regular CIC (Gonzalbez & Castellan, 1998).

Creation of Catheterizable Abdominal Stoma. In a similar situation as above, but with the addition of a patulous urethra or in opposite circumstance, where the urethra is impassable from severe strictures, others have closed the urethra at the bladder neck or an impassable stricture, and abandoned the urethra completely. In lieu of the urethra as the entrance point, a new catheterizable continent stoma is created in the abdomen where catheterization can be done through this new urethra (Gonzalbez & Castellan 1998). Catheterizable stoma may also be built for quadriplegics whose catheterization may be enhanced with a catheterizable stoma built in the abdomen rather than through the urethral meatus (Hackenberg, Eber mayer, Manseck, & Wirth, 2001).

Expand the use of Botulinum Toxin in Combination With CIC for Intractable Overactive Bladder Unresponsive to Anticholinergics While on CIC. Among patients with neurogenic bladder dysfunctions, anticholinergic drugs usually go hand-in-hand with CIC. However, when anticholinergics are not sufficient to control the overactive detrusor and cause persistent urge incontinence in between catheterization, botulinum toxin injected directly into the detrusor muscle can be effective in paralyzing the detrusor and eliminating urinary incontinence, even during the use of anticholinergics, while the patient continues regular CIC. The botulinum injection usually last 6 to 12 months and may be repeated to continue to achieve dryness while on CIC (Smith & Chancellor, 2016)

Surgical Innovations. Surgical innovations apply CIC in a newly created urinary reservoir following radical cystectomy, or in some cases, in a totally defunctionalized non-compliant bladder. The neobladder is created with a neourethra connected to the native urethra or to the abdomen accessible to the patient for catheterization. Locations include the umbilicus and the right lower quadrant of the abdomen (Lee et al., 2014).

Management of Intractable Strictures. Another extended application of CIC is in maintaining patency of the urethra after urethral dilation or after internal urethrotomy for the management of intractable strictures (Jhanwar, Sokhal, Singh, Sankhwar, & Saini, 2018; Morey 2017). The frequency of catheterization is gradually reduced as urethral healing progresses.

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