Nonsurgical Therapy; Catheters; Devices

Fig. 5.1

Urethral indwelling catheter

Fig. 5.2

Suprapubic indwelling catheter

Table 5.1

Complications of indwelling catheterization

Complication	Prevention
Bacteriuria – most patients with long-term catheterizations develop bacteriuria. The incidence is 3–8 % per day and duration of catheter is the most important risk factor	Ensure sterile technique Maintain a closed system Do not treat unless patient is symptomatic
Catheter-associated urinary tract infections (CAUTI) – incidence varies based on definitions used. The Center for Disease Control (CDC) has come out with new definitions for use http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf	Ensure proper insertion technique (see Appendix 1) Use sterile technique Use ample lubrication Following aseptic insertion, maintain a closed drainage system Maintain unobstructed urine flow Practice good hand hygiene
Biofilms and encrustations – biofilms are a result of colonization with uropathogens creating adhesions and adhering to the catheter wall. Encrustations are formed by organisms in biofilms and usually associated with alkaline urine. Encrustation can cause catheter blockage	Maintain natural pH Ensure sterile technique Maintain a closed system Change catheters when blockage occurs; it is not recommended to irrigate
Urethral damage – occurs primarily in men. Risk increases with the length of catheterization	Ensure proper technique is used Ensure liberal lubrication Ensure stability of catheter to leg May use antibiotic ointment at tip of meatus

Intermittent Catheterization (IC)

IC is the insertion of a catheter several times daily to empty the bladder. Once the bladder is empty, the catheter is immediately removed. There is no evidence that recommends frequency of IC, other than to prevent overdistention of the bladder. See Appendix 1 for a discussion on teaching catheterization to patients.

According to the European Association of Urology (EAU) Guidelines on Neurogenic Lower Urinary Tract Dysfunction, the gold standard for management is intermittent catheterization. The guidelines recommend using a 12–14 French catheter four to six times per day (Stohrer et al. 2009). CIC is also the preferred method of patients who have neurogenic bladder (Tubaro et al. 2012; Newman and Wilson 2011).

Newman and Wein (2009) stated that the advantages of CIC over indwelling included improved self-care and independence, reduced need for equipment, less barriers for intimacy and sexual activities, and potential for reduced lower urinary tract symptomology. According to evidence-based guidelines, CIC is preferable to indwelling or suprapubic catheters in patients with bladder-emptying dysfunction (AUA 2015).

Cochrane review discusses the complications of CIC that include bleeding, urethritis, stricture, creation of false passage, epididymitis, UTIs, and formation of bladder stones (Jamison et al. 2013) (Table 5.2). Maintaining low intravesical pressure and avoidance of bladder over distention are key components in successful CIC.

Table 5.2

Complications of clean intermittent catheterization

Complication	Prevention
Bleeding – more frequently seen in new patients and prevalence is about 1/3 of patients	Ensure patient is using proper technique (see Appendix 1) Encourage liberal lubrication
Urethritis – prevalence varies widely but is below 8 %	Ensure patient is using proper technique Change catheter material
Stricture –the incidence of stricture increases with longer follow-up with most events occurring 5 years after initiation. Prevalence is around 4 %	Ensure gentle introduction of the catheter Use of hydrophilic catheters may benefit
False passage – creation of a false passage. Trauma especially in men can create false passages; however incidence is rare	Ensure patient is using proper technique Gentle slow introduction of catheter
Epididymitis and prostatitis – both are rare and can be related to recurrent UTI	Ensure patient is using proper technique Ensure adequate hydration Ensure bladder is being emptied frequently to maintain residuals less than 500 ml Treat only when symptomatic
UTI – prevalence is between 12 and 88 % secondary to definition used and patient populations	Ensure patient is using proper technique Ensure adequate hydration Ensure bladder is being emptied frequently to maintain residuals less than 500 ml Treat only when symptomatic
Bladder stone – incidence of stone formation is rare and is usually related to introduction of a foreign body into the bladder such as a pubic hair or prolonged catheterization	Ensure patient is using proper technique Ensure adequate hydration

Sterile vs. Clean Catheterization

One question that always comes up with IC is if the technique needs to be performed with sterile technique with new catheter each time or can clean technique be used with reusable catheter. This remains a controversial topic and most experts probably agree that clean intermittent catheterization (CIC) is appropriate for the majority of patients. Sterile catheterization is required for those with immunosuppression, those at risk for developing UTIs, and patients in acute or long-term care facilities (Stohrer et al. 2009; AUA 2015; Newman and Wein 2009).

Preventing Infections

There are no consistent guidelines available on the rationale or method for obtaining urine for culture from a chronically catheterized patient. Once urine is obtained, there are no consistent guidelines on what constitutes a true urinary infection versus asymptomatic bacteriuria. Using the white count on a urinalysis to predict infection in the underactive bladder is not predictive due to the low correlation with symptoms (AUA 2015). Patients with underactive bladder frequently do not experience typical symptoms of a UTI due to an altered afferent nervous system. When evaluating these patients for UTIs, a thorough understanding of their baseline bladder sensation is imperative (Newman and Wein 2009). See Table 5.3 for a list of symptoms associated with UTIs in the neurologically compromised patient (AUA 2015).

Table 5.3

Signs and symptoms associated with UTIs in the neurologically compromised patient