The technique of sterile IC was first used following World War II by Sir Ludwig Guttmann, in the bladder management of SCI patients. Guttmann and Frankel [7] proposed that routine bladder emptying was more physiologic and would provide better outcomes than indwelling catheters.

In 1972, urologist Dr. Jack Lapides introduced clean intermittent catheterization, since referred to as CIC, as a safe method of bladder emptying with low infection incidence. Dr. Lapides described a nonsterile technique for reusing a catheter for multiple catheterizations that involved sterilization of the catheter by soaking for 20 minute (min) before reuse.

IC is the preferred method of bladder management in the SCI population with LUTD and other conditions that cause incomplete bladder emptying [9]. IC is often referred to as the gold standard and is used to protect the bladder and kidneys by preventing over distention and urinary tract infections (UTI).

IC is favored over indwelling urethral or suprapubic catheters (IUC) because of evidence that it decreases the incidence of urinary tract infection (UTI) [10, 11]. IC has also been found to be associated with a lower occurrence of candiduria [12].

IC is considered a safe procedure with a lower rate of certain complications such as penile trauma and traction injuries or traction hypospadias, as compared to an IUC [11]. Ercole et al. [13] reported that CIC was associated with lower rates of UTI and complications of the lower urinary tract when compared to an indwelling catheter. The study also found a lower incidence of UTIs when sterile IC was compared to clean technique (see Table 2.1 for definitions of sterile and clean technique).

IC may be performed using sterile technique , but clean technique (CIC) is more commonly used. IC should be performed every 4–6 hours (h). Persons with spinal cord injuries and disorders (SCI&D) using IC need to catheterize frequently enough to keep volumes lower than predetermined levels defined by urodynamic studies . Generally, the urodynamic goal is a storage pressure lower than 40 centimeter (cm) H₂O [14]. Further studies are needed to determine the relative importance of management variables in influencing the rate of UTIs for those who perform IC.

IC is not for everyone, and a patient must first be assessed to determine if he or she is a good candidate. Assessment should determine if the person has a suitable bladder capacity and sufficient arm and hand dexterity, vision, cognition, and motivation to carry out the procedure [14]. In an IC program, the bladder acts as a reservoir for urine, so it is important that the person has reasonable bladder capacity. The greater a patient’s ability to store urine at safe pressures and without leaks, the greater chance the person has of success with IC. Adults who have small bladder capacity (100–200 milliliter (ml)) are not usually considered suitable for IC [14, 15]. IC requires a commitment to catheterize up to 6 times a day or more if needed. The person has to be dedicated to IC and must carry catheters and associated supplies when away from their home. IC takes longer than simply voiding, and the person may develop infections, bleeding, or trauma. Women who are chair fast (e.g., in a wheelchair) may find the procedure difficult or spill urine when catheterizing [14], so male length catheters or those with integrated bags could be considered in those cases.

Optimal management of the lower urinary tract is important in patients with NLUTD to prevent damage to the upper urinary tract and preserve renal function. Intermittent catheterization can be a practical and effective method of bladder management and is usually performed by the patient or their caregiver. Advantages of IC include avoidance of complications that can occur with indwelling catheters. These include: catheter-related trauma, urethral traction injury/hypospadias, and dilation of the bladder neck with subsequent leakage at low pressures. IC eliminates the need for tubing, leg bags, or bedside drainage bags and creates the freedom to wear shorts or skirts without exposed devices. IC has a lower risk of bladder stones or cancer than with an indwelling catheter. Not having a catheter in the urethra is also an advantage for persons who wish to be sexually active.

There are a wide variety of urinary catheters available including: uncoated polyvinyl chloride (PVC) that needs a separate lubricant for manual application (see Fig. 2.1), gel-coated (pre or self-lubricating) PVC (see Fig. 2.2), and hydrophilic-coated (HC) catheters. HC catheters includes those that require manual activation through addition of water or salt solution or those where the catheter comes ready-to-use, either coated with solution or with solution in a sachet in the package (see Fig. 2.3a) [16]. Catheter selection is dependent on insurance coverage, availability, and patient/caregiver preference. However, catheter type and/or material may be important for patient compliance with IC, which is required if the benefits are to be realized. With a long-term management strategy like IC, patient satisfaction is crucial, as it influences adherence to the IC regimen.

The characteristics of catheters used intermittently are similar to IUCs (see Chap. 1) and are described below. Types of catheter material are discussed later in this chapter.

Catheter lengths for IC are gender specific, with male, female and pediatric lengths available to accommodate the length of the urethra. Standard male catheter length is 16″ (~40 cm), whereas female catheters range in length from 6–12″ (see Fig. 2.4). Pediatric catheter lengths are 6–10″. Many women find that shorter catheters do not shift and are easier to grasp and insert (see Fig. 2.5a, b) [1]. The funnel colors of the newer female short catheters may not indicate the size. Catheters are sold individually packaged and some require the addition of lubrication. Catheter lengths can now accommodate more compact designs that are discrete and can be easily carried in a purse or pocket (see Fig. 2.6a–d) [12]. Chartier-Kastler and colleagues [17] reported on a randomized, 2-way crossover, multicenter study in patients with NLUTD (n = 125) that evaluated discreet design compact HC catheters compared to standard catheters. The study showed 63% of patients preferred compact HC catheters because of their positive effect on quality of life.

Catheter diameter is measured in French (Fr) units , similar to the size of IUC diameter. Sizes range from 6 to 12 Fr for children and 14 to 22 Fr for adults. The funnel end of the catheter is often color coded to allow for easier size identification (see Fig. 2.7).

Catheter tips are curved and tapered (Coudé/Tiemann/Olive tip) or straight (see Fig. 2.8a, b). They are most often referred to by the generic term Nelaton (after Auguste Nelaton, inventor of the Nelaton rubber catheter) (see Fig. 2.9). This is often the catheter that patients will begin to use during their initial transition to IC [18]. A Coudé or Tiemann tip intermittent catheter is firmer and curved at a slight angle to assist in navigating of the male urethra (see Fig. 2.8b). The curve is tapered to the tip. The shape and stiffness of the catheter help to ease the passage through the bladder in patients with an enlarged prostate. Carson and olive tipped catheters (see Fig. 2.10) have a slightly larger bulb at the end that may assist in negotiation of a urethral stricture or to assist female patients in locating the meatus [1].

Catheter drainage openings (“eyes” or “eyelets”) are placed on one side or on opposing sides of the tube (see Fig. 2.11). Opposing drainage eyes generally facilitate better drainage. Some patients have problems with sediment or mucus that can clog the drainage eye and larger openings may be needed. Catheters have been designed with smoother eyelets, either polished or ultrasonically smoothed eyelets to minimize urethral abrasion during passage.

Although IC has decreased the incidence and severity of UTIs in hospitalized patients, hospital acquired gram-negative organisms in the urine, many of which are resistant to antibiotics have become a major concern. Catheter-associated UTIs (CAUTI) remains the most common hospital acquired infection (HAI) [19]. Such infections result in increased morbidity, loss of patient therapy time, prolonged hospital stays, and increased rehabilitation costs [20]. Healthcare facilities have gone to great lengths to reduce the incidence of CAUTI, driven by denials in reimbursements from insurers.

Introducer tips are preferred by some clinicians for certain patients. Many systems are catheters enclosed in a bag with a urethral introducer tip (see Fig. 2.12) that protects the catheter from contamination as it passes through the first 1.5 cm of the urethra, where larger numbers of microorganisms are present [21, 22]. This portion of the distal urethra can be colonized with perineal bacteria, particularly E. coli. Colonization with other pathogens, such as Pseudomonas and Klebsiella species, frequently occurs in the perineum and urethra of men with a SCI (see Fig. 2.13a–c Introducer tips instructions).

The MMG/O’Neil catheter (Medical Marketing Group) was the first example of an intermittent catheter system with an introducer tip (see Fig. 2.14). It was originally developed in Australia in 1982 for use in obstetric patients, but has been tested in acute and rehabilitation settings on SCI patients. Other manufacturers have incorporated introducer tips in their products.

Reuse of catheters for IC is controversial Manufacturer guidelines state that a catheter designed for intermittent drainage of the bladder is single-use and is to be discarded after use. According to the US FDA, all sterile urethral catheters are single-use devices and not approved for reuse. Many patients and providers argue that there is a theoretical increased infection risk if a catheter is reused. Despite the wide use of IC, two Cochrane reviews [23, 24] noted that there are no definitive studies showing improvements in the incidence of UTI by catheterization technique, type, or strategy. Data are also lacking for recommending a cleaning method for multiple-use catheters. However, one of these reviews has recently been withdrawn [24] and their findings have been questioned [http://​online.​liebertpub.​com/​doi/​pdfplus/​10.​1089/​neu.​2017.​5413]. The most recent guidance from Infectious Disease Society of America also rated the evidence for multiple-use as poor [25].

Moore et al. [26] found that 87% of patients (62/71) cited concerns over infection as the main reason for refusal to reuse catheters. Since 2008, single-use, disposable catheters for ISC has become the standard in the US as health insurers and providers, including Medicare and the VA system have changed reimbursement to allow the purchase of single-use catheters. Medicare, now allows purchases of up to 200 catheters per month [2].

This is also the case in other countries but reuse after cleansing may be the only option in certain circumstances (e.g., lower income countries) [27]. Health care providers should advocate a single use of catheters in individuals with SCI, especially as there is no standardized or universally accepted cleaning method [http://​online.​liebertpub.​com/​doi/​pdfplus/​10.​1089/​neu.​2017.​5413]. If UTIs become problematic in an individual reusing a catheter, he/she should be encouraged to use a new catheter each time.

In patients on IC , bacteriuria is more likely caused by ascending bacteria into the bladder colonizing the urethra, than introduction of new bacteria [14, 25]. Rinsing with water, microwaving, boiling or soaking catheters in various agents and then air-drying are all thought to be effective in reducing bacteria on catheters. However, there are no published trials evaluating the effectiveness of any of these cleaning-methods in preventing bacteriuria or CAUTI [28]. Many experts discourage microwaving and boiling catheters as increased temperatures may alter properties of the catheter.

Currently, no high-level evidence demonstrates sterile technique as superior to clean technique for reducing CAUTI. Likewise, no evidence has demonstrated closed or pre-packaged catheter kits containing all accessories (e.g. gloves, –antiseptic, –solution, etc.) (see Fig. 2.15) to be superior to closed self-contained (catheter in the collection bag, tip pre-lubricated) catheter systems (some are referred to as “no-touch” or “touchless”) (see Fig. 2.16). Both systems are sterile. Use of the “no-touch” technique (in which the catheter and pre-attached collecting system are not touched by the patient) reduces microbial contamination of the catheter (see Chart 2.1) [22]. There is some evidence that use of sterile prepackaged catheter collection kits can reduce the frequency of UTIs in SCI patients [27, 29]. However, these kits are expensive and insurers require justification for them. At least two CAUTIs in a patient in 12 months would be medical justification for prescribing a sterile catheter kit or closed system [30]. These kits are also justified if the patient is immunosuppressed (e.g. post-transplant), has AIDS, on cancer chemotherapy, documented vesicoureteral reflux and/or resides in a nursing facility.

Catheter surface material and properties can be important when it comes to UTIs, urethral complications, and patient satisfaction and preference. A number of different polymers are used for the construction of catheters, including PVC, rubber, nylon, and silicone (see Fig. 2.17). PVC is the most common as it is inert and does not react when it comes in contact with bodily fluids. The Nelaton, Coudé/Tiemann, and O’Neil catheters can be made of different types of materials which include red rubber latex, PVC or other plastics, or silicone. One concern with the manufacturing of flexible PVC devices is that plasticizers, such as di-2-ethylhesxylphthalate (DHEP), must be added. PVC and DEHP both implicate environmental and health concerns, so alternative materials have been developed. PVC-free catheters are available including polyolefin-based elastomer (POBE), such as the LoFric ^® catheter, used since 2008 [31], and polyurethane tube material of SpeediCath ^®. Catheters made of POBE have lower environmental impact [32]. Although more expensive, silicone catheters have increased in popularity due to increased latex allergies. However, unlike the silicone material used for IUCs, silicone catheters manufactured for intermittent use are softer and more flexible.

Some persons may have trouble advancing the softer silicone catheters, while stiffer catheters (e.g. PVC) may cause urethral trauma. One new composite catheter design has three layers, with a soft outer silicone, a stiffer silicone middle layer, and an inner, pliable silicone layer (see Fig. 2.18 M³ Technology). The design is also available with both hydrophilic and antimicrobial coatings.

Coated and non-coated are two main designs of catheters used for intermittent bladder drainage. Some catheters are sterile, individually packaged and intended for one-time use (see Fig. 2.19 Individually packaged PVC). But some uncoated catheters, primarily PVC catheters, have been reused, when insurance coverage is not available and cost is a factor [34]. Noncoated catheters require separate external gel lubrication, before insertion. Catheters with a coating and flexibility are self-lubricated and thus are designed to improve catheter lubrication and ease of insertion and, may reduce trauma and UTIs. The most common coating is hydrophilic [35].

Antimicrobial coated catheters : Intermittent catheters, like IUCs, may also be coated with antimicrobial agents. Nitrofurazone and silver are the two most commonly used.

Hydrophilic coated (HC) catheters have become increasingly popular. They were introduced in 1983 to reduce catheter-related complications and have demonstrated the potential to decrease UTIs in persons who use IC for bladder management [36]. HC catheters (discussed later) have a polymer coating that adheres to the catheter surface and becomes slippery and smooth when wet . They were developed with the goal of reducing friction, thereby reducing trauma during the catheterization process. HC catheters include those that require the addition of water by breaking or bursting a water packet or salt solution in the packaging which activates the hydrophilic coating (see Fig. 2.20a–c). Prehydrated and ready-to-use HC catheters also exist. Both types of HC catheters remain strictly for one-time use and should never be reused. The lubrication helps to ensure more comfortable insertion and decrease friction and trauma to the urethra. Hydrophilic catheters (see Figs. 2.21 and 2.22) contain a coating made of polyvinylpyrrolidone (PVP) , which is a non-allergic material that has been used in medical devices since the 1930s. When exposed to water, the PVP coating attracts water to the surface of the catheters, creating a biocompatible coating that binds water to the surface of the catheter and forms an outer layer mainly consisting of water . This thick, slippery, smooth layer of water stays on the catheter, ensuring lubrication of the entire urethra during the catheter insertion and withdrawal, thereby reducing the coefficient of friction by at least 95%. A recent study compared PVC versus a PVC-free material (POBE) catheter (e.g. LoFric^®) [37]. Low rates of discomfort were found with both, but the PVC-free HC catheters had fewer instances of discomfort.

A “touchless” catheter is a one-time use catheter that is either enclosed in a collection bag (see Figs. 2.14, 2.15, 2.16, and 2.20), has a protective sleeve that covers the catheter preventing direct hand contact with the catheer during preparation and catheterization [38] (see Fig. 2.23), or has an insertion aid (gripper) (see Fig. 2.3b, c). This type of catheter is recommended for patients with a history of frequent CAUTIs (e.g. secondary to poor technique). Many use this product when away from home. Although more expensive, these products are generally covered by Medicare and private insurance, if justification and medical necessity is provided.

Gel coated IC kits contain a water soluble gel reservoir or chamber, which provides lubrication as the catheter passes through the gel chamber at the tip of the catheter. This helps to prevent contamination; as direct contact is not needed to apply the lubricant. A disadvantage of these catheters is that they can be slippery and messy, making it difficult for the patient to hold the catheter during insertion.

Noncoated catheters are generally packaged with a separate gel, usually in a foil packet that must be opened and applied directly to the catheter prior to insertion. This requires an extra step, can be messy, and can be difficult to ensure complete lubrication of the entire catheter. Some female patients use only water to lubricate the catheter.

Hydrophilic coated catheters have been developed with the goal of reducing friction and thereby reducing trauma during the catheterization process. Chartier-Kastler and Denys [39] published a review of experimental and observational evidence, including randomized controlled trials that noted a large body of evidence to support the benefits of HC catheters in patients with NLUTD [10]. This data indicates that HC catheters may be preferable to PVC catheters in terms of safety and quality of life. Most of the research on IC has focused on the LoFric ^® and SpeediCath ^®, and as compared with PVC catheters, include reduced UTIs [10, 40, 41], reduced micro-hematuria [41, 42], and high levels of patient satisfaction [40, 41]. De Ridder and colleagues [40] found, in a randomized 1-year prospective trial in 2005, a statistically significant reduction in UTIs with hydrophilic coated versus noncoated catheters. However, 64% of persons using HC catheters (versus 82% for noncoated catheters) still had one or more UTIs during the study period. Furthermore, there was no significant difference in bleeding, bacteriuria, or pyuria between the two groups. Stensballe et al. [43] found a reduction in hematuria, pain, and higher patient preference, for HC catheters . One study found no difference in the number of symptomatic UTIs versus noncoated catheters [10]. However, a study by the same group [44] found that the use of a HC catheter reduced the risk of UTI in the acute period and significantly delayed the time to first UTI for HC versus a plastic uncoated catheter. A systematic review of RCTs that compared HC catheters and PVC catheters was performed by Rognoni and Tarricone [45]. The authors conducted a separate data analysis to combine data on frequencies of UTIs and hematuria. The separate analyses took into account reused standard catheters. The results showed that HC catheters were associated with reduced risk of UTIs. These authors considered both single-use and single-use plus reused catheter scenarios. HC catheters with high osmolality (e.g., LoFric^®) seemed to lower the risk of hematuria. HC catheters may also be useful for persons with urethral strictures or discomfort during catheterization [28].

HC catheter with lower osmolality however, have the disadvantages of varying surface drying times and some become “sticky” when dry. Also, the design of these catheters varies in terms of material, length, and flexibility, and there is no research comparing the different products.

Assistive devices have specific features that may facilitate a patient in successful self-catheterization. They include mirrors, catheter holders, and devices to aid in meatal location (see Fig. 2.24). Some IC kits have features to facilitate IC by persons with impaired hand function (e.g., persons with quadriplegia). For example, some kits have loop holes or an adhesive tab to allow the kit to be hung on the wheelchair or on a wall (see Fig. 2.25), or to insert a thumb for easy opening (see Figs. 2.20b and 2.23a). A physician with tetraplegia developed a device to hold the penis in place during catheterization (see Fig. 2.26 House Hold) [46]. The PerfICath (see Fig. 2.27) single-use catheter kit was also developed by the same physician. The sleeve is designed to be placed between the fingers and the catheter is advanced with the sleeve, not requiring the use of a finger grip. It is designed to allow the catheter to be pulled back into the sheath after use. It contains a gel reservoir, introducer tip, and two drainage ports for either fast or slow drainage. A hydrophilic version is being developed. Other catheter manufacturers have developed devices to facilitate gripping slippery HC catheters (see Fig. 2.28 U-Cuff Universal cuff or Fig. 2.29 LoFric^® gripper tool) or other catheters. Devices exist that either hold the catheter steady for insertion (see Fig. 2.30) or spread the female labia to ease insertion (see Fig. 2.31).

Other IC kits have special features to facilitate advancing a catheter with use of gross, rather than fine grasp (see Fig. 2.32 Gripper catheter). Mike Ritmiller, a physician assistant who specializes in urology, developed a device that is designed to lie on the man’s legs, to serve as a platform to hold and advance an IC closed system (see Fig. 2.33).

Many persons who perform IC use external or “condom” catheters to collect urine in between catheterizations. These are discussed in Chap. 3. Persons who use individual catheters not in kits may empty their urine into a variety of receptacles, including typical hard plastic urinals. However, these receptacles are often bulky and not well suited to carrying. The Uribag^® (see Fig. 2.34 Uribag^® 2 views) was designed for use by campers and is not marketed as a medical device. It consists of a flexible rubber bag attached to a hard plastic tube, with a cover that can be closed, allowing urine to be stored if necessary for later emptying in a suitable location. If the bag is pushed into the sleeve, it is compact and unobtrusive and looks like a large roll of camera film. Both male and female versions exist (see Chap. 7).

The health care provider and the patient must adhere to IC recommendations. Adherence to the prescribed IC frequency is important as it can directly impact the function of both the lower and upper urinary tracts, and may influence UTI risk [47]. According to Drake et al. [3], no guidelines or consensus exist on suitable intervals for bladder emptying. Ideally, catheterization frequency should be based on a diary (see Table 2.2), which records fluid intake, voided and catheterization volumes. If the patient is voiding and performing IC, recording and monitoring both volumes would assist with determining returning bladder function, and catheterization adherence. Additionally, PVR, and urodynamic parameters should be assessed, if available (detrusor pressure, bladder compliance) [16]. Inadequate catheterization frequency and elevated PVRs will lead to UTIs [16]. The largest catheterization volumes may occur in the morning, especially in older adults and those with edema. These persons should consider performing catheterization right before going to bed.