Which is an advantage of intermittent catheterization over indwelling catheters?

Intermittent Catheterization

Intermittent catheterization is a technique in which the bladder is drained of urine by catheterization by oneself or a caregiver usually every 4 to 6 hours, so the amount of urine obtained with each collection is generally no more than 500 mL.126 The schedule of intermittent catheterization is tailored for each individual to minimize the number of catheterizations while not allowing the bladder to become overdistended. Guttman and Frankel130 in 1966 described intermittent catheterization using sterile technique, and Lapides and colleagues131 later demonstrated that the clean (nonsterile) technique was safe and associated with a low incidence of complications in patients with neurogenic bladders. Intermittent catheterization is widely viewed to be associated with fewer complications than indwelling catheterization, including CA-bacteriuria, hydronephrosis, bladder and renal calculi, bladder cancer, and autonomic dysreflexia,127,132 and it has become the standard of care for appropriate women and men with SCIs. It is also a commonly used alternative in patients without SCI who need long-term assistance with voiding.46,133 However, there are no randomized controlled trials that have compared intermittent urethral, indwelling urethral, and suprapubic or condom catheterization in patients on long-term catheterization, including those with neurogenic bladders.127,128 On the other hand, a meta-analysis of trials comparing catheterization methods in patients (mostly postsurgical) undergoing short-term catheterization found that indwelling urethral catheterization was associated with more CA-bacteriuria than intermittent catheterization (relative risk [RR], 2.90; 95% confidence interval [CI], 1.44 to 5.84), even though indwelling catheterization was less costly.134 Nevertheless, intermittent catheterization is not commonly used for short-term catheterization because of the educational, motivational, and staff-time requirements necessary for its implementation.

Among patients undergoing long-term intermittent catheterization, randomized controlled studies in adults in hospitals, LTCFs, and outpatient settings with or without neurogenic bladders have shown no difference in risk of CA-ASB or CA-UTI with use of sterile technique compared with clean (nonsterile) technique, with use of sterile catheters versus multiple-use catheters with the clean technique, or with daily or weekly replacement of multiple-use catheters.133,135 Different techniques have been studied to reduce the microbial contamination of multiple-use catheters, including rinsing with tap water, air-drying, keeping it dry until reuse, and microwaving or soaking the catheter in disinfectants, but there are no published trials evaluating the effectiveness of these methods in preventing CA-bacteriuria. Although there are no data that reuse of catheters increases infection risk, it is inconvenient for many patients who find it difficult to clean their catheters away from home and others find it nonaesthetic.

Complications associated with long-term intermittent catheterization, although apparently less common than with indwelling urethral catheterization, include CA-bacteriuria, prostatitis, epididymitis, urethritis, urethral trauma with bleeding, and subsequent urethral strictures and false passages.126,132 Hydrophilic catheters, compared with standard catheters, reduce the friction of catheter insertion and urethral inflammation and are associated with improved patient satisfaction. These catheters have been widely used in Europe for many years in patients on intermittent catheterization. Previous studies have not supported the routine use of hydrophilic catheters to prevent CA-bacteriuria or sequelae of urethral trauma in patients managed with intermittent catheterization.135,136 However, in a recent prospective, randomized, parallel-group trial of 224 subjects with traumatic spinal cord injury (SCI) of less than 3 months' duration who used intermittent catheterization, the time to the first antibiotic-treated CA-UTI was significantly delayed in the hydrophilic-coated catheter group compared with the uncoated catheter group.137 During the period that subjects were hospitalized, the incidence of antibiotic-treated CA-UTIs was reduced by 21% (P < .05) in the hydrophilic-coated catheter group. Two recent systematic reviews and meta-analyses of hydrophilic catheter use in SCI have had conflicting results: one evaluated six randomized controlled trials that included the latter study and showed a significantly lower incidence of reported UTIs (odds ratio [OR], 0.36; P < 0.001) (the authors do not distinguish CA-bacteriuria from CA-UTI) and hematuria (OR, 0.53; P = 0.001) in the hydrophilic catheter–treated group compared with the control group,138 and the other evaluated eight trials (most in SCI patients) that did not include the latter paper and found no difference between hydrophilic and sterile noncoated catheters in mean monthly UTIs or total UTIs at 1 year.139

Limitations to intermittent catheterization include limited staff to perform the procedure or educate patients, inability or unwillingness of patients to perform frequent catheterizations, or abnormal urethral anatomy such as stricture, false passages, or bladder neck obstruction. Upper extremity impairment due to cervical SCI or other abnormality, obesity, and spasticity also make intermittent catheterization challenging for both males and females.

Non-surgical interventions to improve bladder emptying

IC is increasingly used as a key means of bladder emptying. IC can be done either by a carer or by the patient (ISC). IC requires several factors for successful use. Firstly, bladder capacity needs to be sufficient that catheterization does not have to be done excessively frequently. More than six catheterizations daily is usually considered excessive; high urine volumes in polyuric patients can make this harder to achieve. Some sphincter function is needed so that leakage is absent or manageable. Secondly, storage pressures in the bladder need to be low, in respect of protecting renal function. Thirdly, the urethral meatus needs to be accessible. The urethra may be difficult to catheterize if it is very sensitive, or if there is distortion, constriction, kinking, or a false passage. Fourthly, access to supplies of catheters has to be reliable and affordable. For ISC, the patient needs adequate cognitive function, manual dexterity, and mobility. Generally “clean” IC is used, but sometimes a sterile non-touch technique is recommended; a systematic Cochrane review on strategies for catheter use emphasized that the evidence base is weak (Jamison et al., 2011b).

Indwelling catheterization may be necessary in more severe NLUTD, and it can improve quality of life (Bothig et al., 2012). There is a risk of complications and problems (Cameron et al., 2011). Crucially, indwelling catheters may stabilize chronic renal dysfunction caused by inadequately managed NLUTD (Drake et al., 2005). Bacterial colonization in chronic use is unavoidable, and can lead to recurrent blockage and systemic infection. Attempts at eliminating bacteriuria associated with indwelling or intermittent catheters are generally unsuccessful. Catheter-induced trauma to the urethra can be considerable, especially where there is sensory nerve impairment, so suprapubic catheters (SPC) are generally preferred, though comparative evidence is lacking (Jamison et al., 2011a). If the urethra is severely non-functional, urethral leakage can occur in patients with an SPC (Colli and Lloyd, 2011).

Oral medications have limited utility in this context. Alpha-adrenergic antagonists can decrease urethral resistance during voiding. Tamsulosin improves voiding in SCI (Abrams et al., 2003). The cholinomimetic agent, bethanechol chloride, seems to be of limited benefit for detrusor areflexia and for elevated residual urine volume.

Triggered reflex voiding (Fig. 26.4) is an option in SCI patients (after recovery from spinal shock) with preserved sacral cord function, and uses stimulation such as suprapubic percussion to provoke a bladder contraction at a time chosen by the patient. The aim is “balanced voiding,” indicating the attainment of adequate continence and urine storage under safe pressures. Most centers tend to initiate IC in preference to triggered reflex voiding in current practice.

Bladder expression involves raising the abdominal pressure by Valsalva, or direct manual suprapubic pressure (Credé), and can be used to increase the bladder pressure above outlet resistance, leading to emptying. This can be an option where outlet resistance is weak (due to the NLUTD, or using sphincterotomy). However, there is a recognized risk of incomplete bladder emptying, UTIs, VUR, and anal prolapse. Thus, bladder expression is no longer recommended for general use.

Botulinum neurotoxin type A was first employed in NLUTD for sphincter injections as a means to improve bladder emptying (Dykstra et al., 1988). Usually 100 U onabotulinumtoxinA or 150 U abobotulinumtoxinA has been delivered transperineally or transurethrally (de Seze et al., 2002; Chen et al., 2011). This approach has not become established, as demonstrable improvement in clinically relevant parameters is lacking (Gallien et al., 2005).

Bladder management

Intermittent catheterization is the standard management for young people with SCI and a neurogenic bladder (Lapides et al., 1972; Vogel, 1996a; Vogel and Pontari, 1997; Patki et al., 2006; Merenda and Brown, 2007). A catheterization program is initiated when the child is about 3 years old, or earlier if the child is experiencing recurrent urinary tract infections (UTIs) or is exhibiting renal impairment. For those with adequate hand function, self-catheterization is initiated when they are developmentally 5–7 years of age.

Antimicrobial therapy for positive urine cultures should be limited to those with asymptomatic bacteriuria and concomitant compromised renal function or those with symptomatic UTIs, manifested by systemic toxicity (fever, chills, dysreflexia, or exacerbation of spasticity), incontinence, or cloudy and foul-smelling urine. Usage of fluoroquinolones should be limited in children younger than 18 years of age because of the potential of cartilage and tendon damage (Schaad, 1999). Prophylactic antibiotics should not be routinely used, except for individuals who experience recurrent and severe UTIs and in those with obstructive uropathy or compromised renal function (National Institute on Disability and Rehabilitation Research Consensus Statement, 1992).

Urinary continence and independence are important aspects of bladder management of young people with SCIs. Incontinence may necessitate the use of anticholinergics, modification of fluid intake and catheterization schedule, or botox (Akbar et al., 2007). Children and adolescents with limited bladder capacity unresponsive to anticholinergics may be candidates for a bladder augmentation (Kass and Koff, 1983).

A continent catheterizable conduit involves creating a catheterizable conduit using the appendix or a segment of small bowel, which is used to connect the bladder in a nonrefluxing manner to a stoma, either in the umbilicus or on the lower abdominal wall (Mitrofanoff, 1980; Chulamorkodt et al., 2004; Merenda et al., 2007). Continent catheterizable conduits are an option for young people who are not independent in performing intermittent catheterization (Mitrofanoff, 1980; Vogel, 1997), such as those with limited hand function (C6 or C7 lesions) (Chaviano et al., 2000; Pontari et al., 2000). Additionally, continent catheterizable conduits may be useful for individuals who have difficulty accessing their urethra, such as females who have difficulty transferring to a toilet or who cannot actively abduct their legs.

Clean Intermittent Catheterization

Intermittent catheterization with a sterile technique was introduced by Guttmann and Frankel in the 1950s for the management of patients with acute SCI. Lapides et al.48 in 1972 proposed a nonsterile but “clean” technique for the management of chronic retention and infection. The technique has since been used extensively for neurogenic bladder disease. However, it is important to recognize that no catheter has ever been approved for reuse by the U.S. Food and Drug Administration (FDA). An intermittent catheter program requires a low-pressure bladder of adequate capacity (greater than 300 mL) and enough outflow resistance to maintain continence with normal daily activities. If the bladder is not sufficiently compliant, antimuscarinic anticholinergic medications can be used. People with SCI lesions at C6 and below can often manage self-catheterization. Although attendants and family members can perform intermittent catheterization in persons who cannot manage self-catheterization, the program often breaks down if the patient is at school or work. Patients should restrict fluid intake as needed to allow reasonable catheterization intervals. Some patients have enough sensation to be able to catheterize based on urge, but most must do so on a timed schedule. A minimum of three catheterizations per 24 hours is recommended because longer intervals between catheterizations theoretically increase the risk of symptomatic bacteriuria.57 Many patients do wash their catheters with soap and tap water and reuse them. In those patients with recurrent UTIs, other types of catheters (touchless, enclosed systems, or hydrophilic catheters) or sterilization of catheters can be helpful in reducing infections.11,23A completely sterile technique can also be used but is rarely done in clinical practice.

The most common problems with self-catheterization are symptomatic bacteriuria, urethral trauma, and incontinence. Occasionally a bladder stone formed on a nidus of hair or lint is found. Patients should be warned to avoid introducing foreign material into the bladder with the catheter. Urethral trauma and catheterization difficulties can be caused by sphincter spasm. This can be managed with extra lubrication and local anesthetic urethral gel (lidocaine 2%). Sometimes a curved-tip (Coudé) catheter is helpful. Hydrophilic catheters may also be useful for persons with urethral strictures, bleeding, or discomfort with catheterization.67

Repeated urethral bleeding suggests the presence of a break in the urethral mucosa or a false passage, and using an indwelling urethral catheter for a period of time might be necessary for this to resolve. Urethroscopy and unroofing of a false passage are occasionally necessary.

Urinary Tract Infection

Urinary stasis, CIC, mucus production, and urinary pH changes all may contribute to a high incidence of bacteriuria after enterocystoplasty. Consistently sterile urine is found in some patients who void spontaneously and to completion after creation of an orthotopic neobladder, but bacteriuria is nearly universal in patients using CIC after augmentation.45,46 Symptomatic urinary tract infection is less common, but the incidence depends on how carefully signs or symptoms are sought. All patients catheterizing to empty after augmentation should be told to expect that they will sometimes develop cystitis. At Indiana University, symptomatic lower urinary tract infection requiring treatment occurred in at least 22.7% of patients with ileocystoplasties, 17.3% of patients with sigmoid cystoplasties, and 8% of patients gastrointestinal cystoplasties. Febrile infections occurred within all groups in about 10% of patients.32

Treatment of asymptomatic bacteriuria in most patients performing CIC is typically not indicated except in the presence of a urea-splitting organism on culture. Bacteriuria is otherwise treated when it causes signs or symptoms, such as hematuria, discomfort with catheterization, suprapubic pain, incontinence, remarkably increased mucus production, or a foul odor. Treatment with a short course of oral or intravesical antibiotics is usually effective.

Intermittent Catheterization

Many patients with SCI use intermittent catheterization (IC) as either a short- or long-term strategy. One primary reason for using an IC strategy may be the presence of a PVR that exceeds a reasonable volume.16 This may be a time-limited need early in the establishment of a bladder program or may become a lifetime strategy. A second reason for using an IC strategy may be the inability to initiate voiding. In the case of upper motor neuron lesions, hyperreflexia may result in either the presence of PVR requiring intermittent catheterization or in an inability to initiate voiding. IC is not an option for patients with complete lower motor neuron deficits because their bladders cannot store urine.

Initially, IC may be performed by the nurse. If IC is to be part of the long-term bladder program, on the basis of the level of the patient's injury, the goal is to teach the patient to perform IC himself or to supervise an assistant. When the IC is being performed by a nurse in a hospital setting, sterile technique is required. Self-catheterization or catheterization by a family member or friend in the home environment can be done as a clean technique. Although there is some risk of infection as with any invasive technique, the risk is substantially lower for IC than for an indwelling catheter.

For a female, the urinary meatus may be challenging to locate, and a mirror should be used for good visualization. Initially, this procedure may be upsetting and offensive to the patient or family care person. After the initial objections are addressed with a rationale and the IC has been performed several times, the patient and family generally adjust reasonably well to the idea. A long-term strategy with a family member performing the IC may be very burdensome and should be carefully discussed before a final decision is reached.

BLADDER MANAGEMENT

After SCI, normal bladder function is typically impaired but may be managed in several ways (see Chapter 3). According to Yavuzer et al,12 the patient's family should be involved in decisions regarding a bladder program. The technique chosen, however, should reflect the preference of the patient.

For those individuals who have sustained C1 to C5 SCI, bladder management requires caregiver assistance. The individual should be able to instruct caregivers in all steps clearly and concisely and he should take responsibility for making sure the caregiver uses proper technique.

Summary

The description by Lapides of CIC revolutionized lower urinary reconstruction. It opened the door for primary reconstruction in children, allowing the urinary tract to remain intact. It virtually eliminated permanent incontinent urinary diversion with the social stigma of ostomy drainage, leaving only rare indications for temporary incontinent diversion. The Mitrofanoff principle allowed for an even more aggressive approach to achieving complete dryness in these children. Although there have been enormous gains in independence and social well-being in the affected children, the reconstructions have provided an entire new set of complications, some of which are potentially lethal. It is clear that the most important aspect is patient and family motivation. They must be willing and able to catheterize at 4-hour intervals, daily, forever. These reconstructions require a team approach, from the family, surgeon, and nursing, and they require lifelong follow-up evaluation.

The complete reference list is available online at www.expertconsult.com.

Intermittent catheterization

For more than 60 years, intermittent catheterization has been the method of choice to empty the bladder, achieve continence, and maintain a normal bladder volume and detrusor compliance in SCI patients. This method greatly reduces the incidence of renal failure, urinary reflux, stone formation, urothelial cancer, and probably UTIs compared to other indwelling catheterization (Weld and Dmochowski, 2000b; Groah et al., 2002b; Ord et al., 2003). Ruz et al. (2000) found, in patients with SCI, that the number of UTIs/100 person-days was 2.72 for indwelling catheterization in males and only 0.41 for intermittent catheterization. As early as 1947, intermittent catheterization during spinal shock was strongly advocated by Sir Ludwig Guttmann, who first published in 1949. He was an energetic supporter of a no-touch, sterile technique to reduce the risk of UTIs (Guttmann and Frankel, 1966). Some years later, Lapides et al. (1972) published a paper, which is still considered a milestone in neurourology, defending the use of CISC. The conceptual basis of his work was that a healthy urothelium is more resistant to infections than a sick one. Accordingly, bladder distension with increased intravesical pressure may create an ischemic environment, which fosters infections. Lapides’ concept was that frequency was more important than sterility. CISC is nowadays the method of choice to empty the bladder in all types of neurogenic bladder and, independently from spinal shock, as soon as detrusor overactivity is under control.

There is nowadays enough evidence to say that sterile intermittent catheterization is not superior to the clean technique in reducing UTI risk, both in the rehabilitation setting (Moore et al., 2006) and at home (Moore et al., 2007). Pathogenesis and strategies needed to reduce the risk of UTI are still not completely understood and clearly need more research, as pointed out in a comprehensive review on CISC and UTIs (Wyndaele et al., 2012). It should be considered that, even if CISC is the modality of choice for many SCI patients and it carries the lowest risk of long-term renal complications, it has some risk of urethral complications (mainly lesions, abrasions, and hemorrhage, with an incidence of 19%) with further development of infections (urethritis or epididymoorchitis, with an incidence of 28.5%) (Groah et al., 2002a). Moreover, in male patients, these complications can also hamper fertility (Ku, 2006). If CISC is chosen as bladder management, urodynamic evaluations are warranted to ensure that filling is achieved at low pressure and that no vesicorenal refluxes are present, and an early adequate management of high pressure detrusor overactivity is mandatory.

To summarize, at present CISC is considered as the technique of choice in the management of bladder voiding after SCI. It can be utilized early, during the phase of spinal shock and throughout the patient's life, for every patient who is willing to learn the technique, has enough motor control of the hand (or has a caregiver willing to perform clean intermittent catheterization for the patient) (Giannantoni et al., 1998; Consortium for Spinal Cord Medicine, 2006).

PATIENT PREPARATION

Patients with neuropathic lower urinary tract dysfunction require intermittent catheterization after myomectomy. Patients with idiopathic, non-neurogenic bladder contractile incontinence do not require intermittent catheterization after myomectomy. Patients with a low-compliance bladder related to radiation therapy or chemotherapy usually require intermittent catheterization after myomectomy.9,10 Selected patients are informed that a conventional enterocystoplasty can be performed if detrusor myomectomy is not a technical option intraoperatively. This option is discussed in detail before the operative date so that mechanical and antibiotic bowel preparation can be performed before surgery in these selected patients. Preoperative intravenous antibiotics are also administered.