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

Selecting the Appropriate Candidate for CIC

There are several key ways to ensure success in implementing CIC program.

Identifying the Appropriate Patient

The success of CIC is highly dependent on identifying the appropriate patient. First and foremost, the patient must be motivated to help him or herself, or in cases where the patient cannot help, a significant other should be willing do the task of catheterizing regularly and frequently. Without the proper patient understanding of the rationale for CIC and willingness to follow guidelines, it is not appropriate to proceed because the patient will not be successful.

Have a Fully Trained CIC Teacher

A patient can easily perceive negative vibes from the body language of a teacher who is uncomfortable teaching the technique. Thus, the program must have a fully trained CIC teacher who believes in the technique. An empathetic teacher will do his/her best and use all necessary resources to achieve the end result – a patient who can self-catheterize and understands the philosophy behind the program. It must be emphasized that regular and frequent catheterization is the key to success, and patients must find all means to catheterize on time to avoid bladder overdistention. The student of CIC must be cooperative, and the teacher must be resourceful to attain complete success in preventing recurrent urinary infection, abolishing urinary incontinence, and preventing renal function deterioration – the ultimate goals of CIC.

Asking the Patient the Right Questions

I have seen many patients referred to me as a last recourse because they failed to master the technique, have numerous urinary infections, have persistent urinary incontinence, and/or demonstrate bilateral hydronephrosis. In most cases, the solution may be answered by asking the patient the following questions.

  • How often do you catheterize? In many cases, they catheterize less often than needed, causing the bladder to be over-distended. My guideline is about every 4 hours or about 4 to 5 times a day.

  • How much fluid do you drink? Surprisingly, the problem may not be dehydration by drinking less but the opposite; they drink gallons of water and other beverages, and they are producing too much urine that causes bladder overdistention. My guideline is about eight to nine 8 ounce glasses of water and other beverages daily. It can be more or less depending upon activities and the weather. The more active the person is or the warmer the weather, the more fluid will be required.

  • Do you still wet yourself? Urinary incontinence in someone who is performing CIC could mean two things. One is that the bladder is getting overdistended because of too infrequent catheterization. This can be solved easily by measuring via bladder diary the volume of urine drained with each catheterization. By doing a 3-day voiding diary, the patient will also be able to determine total daily urine output and document the frequency of catheterization.

This diary is an eye-opener to many patients when they realize the bladder is holding over 500 ml. of urine prior to each catheterization or see the excessive total output. The diary helps patients recognize why they have overflow incontinence. The solution, therefore, is to catheterize more often or reduce overhydration. In some cases, the leakage is because of an overactive bladder despite normal bladder capacity. Here, the bladder goes into involuntary contraction even if the capacity is small, causing urine to pass through the urethra involuntarily. In this case, bladder relaxants or antispasmodics, such as oxybutynin, tolterodine, solifenacin, trospium, or the new beta-agonist drug mirabegron, may be prescribed in conjunction with CIC.

Persistent Infection

Persistent infection is the most serious and the most challenging problem. Worse, patients will present to me because they have exhausted all known antibacterial medications to treat and prevent urinary infections and even sepsis. I believe the problem starts by treating asymptomatic bacteriuria. My recommendation is that if the patient is not symptomatic in the presence of bacteria in the urine, do not treat the bacteria. Treating it will only cause production of resistant organisms that are more highly pathogenic.

Symptomatic Infections

If the patient is experiencing symptomatic infections despite adhering to regular and frequent catheterization and controlling fluid intake, the patient may be harboring foreign bodies in the bladder (stones, hair), kidney stones. Imaging and cystoscopy will explore these possibilities. Another possibility is the bladder may be silently developing high bladder pressures from involuntary bladder contractions. This patient will benefit from bladder relaxants, not more antibiotics. In some cases, the high intravesical pressure is created because the bladder is small and non-compliant. It may lead to vesico-ureteral reflux (Kass, Koff, Diokno, & Lapides, 1981). If the bladder is small and non-complaint, consideration must be given to expand the bladder with bladder augmentation. This is common among children with neurogenic bladder from myelodysplasia (Medel, Ruarte, Herrera, Castera, & Podesta, 2002).

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