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Specific Aspects of using Intermittent Catheterization

Table 12 Specific Aspects of using Intermittent Catheterization

Author Year

Country
Research Design
Score
Total Sample Size

MethodsOutcome
Polliack et al. 2005

Israel

RCT

PEDro=6

N=24

Population: Study group: Mean age: 42.7 yr; Gender: males=9, females=4; Level of injury: paraplegic=5, tetraplegia=8; Control group: Mean age: 53.46 yr; Gender: males=6, females=5; Level of injury: paraplegic=6, tetraplegic=5. Injury severity: AIS A-D.

Intervention: Individuals were randomized to 1) volume-dependent intermittent catheterization (IC) as measured by a portable ultrasound device (PUD) or 2) time dependent IC; F/U period 12-30 d.

Outcome Measures: Frequency of catheterization, time to perform, total cost, complications.

1.     Compared to the control group, the study group had 6 fewer catheterizations/day (44% decrease), required 20 minutes less time to perform volume measurements and catheterizations (49% decrease), and experienced 46% less cost (p<0.001).
Oh et al. 2006

Korea

Prospective Controlled Trial

N=282

Population: SCI individuals =132:

Mean age: 41.8 yr (range 18-80 yr); Gender male=81, female=51; Injury level: cervical=36, noncervical=96; Severity of injury: paraplegic=24, tetraplegic=108; Duration of catherization use: 24.2 mo.

Controls=150: Mean age: 41.8 yr; Gender: male=90, women=60.

Intervention: Health related quality of life (HRQoL) questionnaire to determine psychological and social status of individuals.

Outcome Measures: HRQoL measured by the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36).

1.     SF-36 scores did not reveal significant differences between the men and women in the individual group.

2.     SF-36 scores of individuals were significantly lower compared to controls (physical functioning: p<0.001; role-emotional functioning: p=0.002; vitality: p<0.064; mental health: p<0.001; social functioning: p<0.001; bodily pain: p=0.025; general health: p=0.013).

Kriz and Relichova 2014

Czech Republic

Cohort

N=41

Population: Mean age: 33.3 yr; Gender: males=39, females=2; Level of injury: C4=8, C5=11, C6=15, C7=7.

Intervention: Individuals were separated into four cohorts based on level of injury and all received training to perform self-catheterization.

Outcome Measures: Urinary diversion method used, reason for not using intermittent catheterization (IC).

1.     Of the 8 participants in the C4 group, 7 had an indwelling suprapubic catheter and 1 had an indwelling transurethral catheter. Wrist extensor muscle strength varied between grade 0 and 1 in all subjects, except for one participant with grade 3.

2.     Of the 11 participants in the C5 group, 4 had independent IC, 2 had assisted IC, and 5 had an indwelling suprapubic catheter. Reasons for continuing to use an indwelling catheter included failure to develop a functional grip, repetitive severe autonomic dysreflexia, prompt reflex erection, and reduced wrist extensor muscle strength.

3.     Of the 15 participants in the C6 group, 10 had independent IC, 2 had assisted IC, and 3 had an indwelling suprapubic catheter. Reasons for continuing to use an indwelling catheter included failure to achieve a functional grip, repeated bladder surgery, and cognitive impairment.

4.     Of the 7 participants in the C7 group, 6 had independent IC, 0 had assisted IC, and 1 had an indwelling suprapubic catheter. The reason for continuing to use an indwelling catheter was severe abductor spasticity.

Perrouin-Verbe et al. 1995

France

Case Control

N=188

Population: Group 1 (clean intermittent catheterization, IC): Mean age: 38 yr; Gender: males=113, females=46; Level of injury: thoracic=67, conus medullaris syndrome=20, cauda equina syndrome=22; Severeity of injury: tetraplegia=50, Group 2 (Individuals who discontinued clean IC after 2 yr=8): Mean age: 38 yr; Gender: males=8; Level of injury: C=1, T=4, TL=1, LS=2; Severity of injury: Frankel grade: A=6, D=2; Group 3 (Individuals performing clean IC for over 5 yr, N=21): Mean age: 37.3 yr; Gender: males=21; Level of injury: C=2, T=10, TL=6, LS=3; Severity of injury: Frankel grade: A=17, B=1, C=2, D=1; Duration of cean IC=9.5 yr.

Intervention: Data of SCI individuals using clean IC was retrospectively reviewed.

Outcome Measures: Infection rate (urinary tract and genital), incontinence, duration of clean IC use, complications, procreation, individual satisfaction (visual analogue scale).

Group 1:

1.     95 individuals had asymptomatic cytobacteriological infection; 45 had symptomatic lower urinary tract infection.

2.     Males had a significantly higher rate of infection than females (p<0.05); epididymitis (n=16), stricture (n=8).

3.     Deterioration of the upper urinary tract was seen in 3 individuals and was correlated with high intravesical pressure.

Group 2:

1.     Even with use of anticholinergic drugs, 5 individuals were incontinent.

2.     Mean time before discontinuance of catheterisation was 5.25 yr.

3.     Reasons for discontinuance included persistent incontinence (n=5), upper urinary tract deterioration (n=1), catheterisation difficulty (n=4), urethral stricture (n=1).

Group 3:

1.     Group comprised of 10 with detrusor areflexia; 11 with DESD (7 used anticholinergic drugs)

2.     Symptomatic infections less than once every two yr in most individuals but 2-4/yr in 4 individuals.

3.     Catheterization was difficult (n=11) or impossible (n=5) for some.

4.     Rate of urethral stricture was 19% and epidydimitis was 28.5%; these rates increased with the number of yr of clean IC use.

Wilde et al. 2016

United States

Pre-Post

Ninital=29; Nfinal=23

Population: Mean age: 43.52 yr; Gender: males=15, females=14; Level of injury: cervical=7, thoracic=17, cervical/thoracic=1, lumbar/sacral=2, thoracic/lumbar=1, unknown=1; Severity of injury: complete=13, incomplete=13; Mean time post-injury: 16 yr; Injury etiology: spinal cord injury=26, other spinal cord disease=3.

Intervention: Web-based intermittent catheter (IC) self-management intervention, intended to teach awareness, self-monitoring, improve adherence to IC frequency, and to balance fluid intake with activity. This program included web-based information, an online educational booklet, an interactive urinary diary, three nurse phone consultations, and peer-led discussion forums.

Outcome Measures: Frequency and intervals of IC, average urine output estimate, material used to contract catheter, adverse events, acceptance and usability of intervention, website usage, Stanford Chronic Disease Self-Management Program (CDSMP), self-management questions, Intermittent Self-Catheter Questionnaire (ISC-Q), Psychological Well Being Scale.

1.     At 3 mo follow-up, no significant improvements were observed for ISC-Q, Psychological Well-being Scale, and CDSMP. There was a significant increase in the self-management scale (p=0.032).

2.     Mean typical catheterizing output increased from 323.4 to 355 ml.

3.     All pages of the educational booklet were viewed but every participant did not look at the whole booklet. The most viewed sections pertained to optimal fluid intake, best IC intervals, and recognizing symptoms of urinary tract infection. Over half of the total time spent on the website was devoted to urinary diary use.

4.     A majority of participants agreed or strongly agreed that the intake and output diary, journal, educational materials, and nurse calls were useful. However, responses to the forum were mixed.

5.     Scores for the usability of the web-based information were high and most people enjoyed working with the study nurse.

6.     At 3 mo follow-up, many participants reported changes in the intervals with more catheterizing every 2-3 h. However, the majority performed the procedure every 4-6 h and 4-6 times/d at both baseline and follow-up.

7.     Frequency of urinary tract infection and pain did not change significantly.

Pannek & Kullik

2009b

Germany

Post-test

N=41

 

Population: Mean age: 39.5 ±14 yr;

Gender: male=31, female=10; level of injury: C=9, T=23, L=9; Level of injury: Paraplegia=28, Tetraplegia=13; mean time post-injury=4 yr

Intervention: Bladder management via intermittent self-catheterization, anticholinergic therapy, BTX-A

Outcome Measures: the Qualiveen questionnaire, urodynamics, treatment success

1.      Bladder management was successful in 14 individuals. Of the 27 individuals with treatment failure, 16 reported decreasing efficacy of BTX-A injections and 11 reported significant detrusor over activity despite anticholinergic therapy in both groups.

2.      Qualiveen scale ratings concerning individual’s fears and feelings were greater for individuals with suboptimal bladder function; all individuals listed as having treatment failure were incontinent.

3.      Depression has an impact on QoL, but only continence was directly related to QoL. Level of injury was not significant to influence QoL.

Subramanian et al. 2016

United Kingdom

Case Series

N=5

Population: Mean age: 41.6 yr; Gender: males; Level of injury: paraplegia=2, tetraplegia=3.

Intervention: Transurethral catheter.

Outcome Measures: To describe individuals with an incorrect placement of a Foley catheter leading to inflation of Foley balloon in urethra.

1.     Five cases of intra-urethral Foley catheter balloon inflation due to unskilled catheterisation were described.

2.     Symptoms manifested include bypassing and unsatisfactory drainage, kidney pain, urethral bleeding, increased spasms and sweating, urine infection, erosion of urethra, breakdown of skin in perineum, and urinary fistula.

3.     Risk factors include lack of sensation in urethra, trauma to urethra during previous catheterisations, spasm of pelvic floor muscles or urethral sphincter, altered anatomy due to past surgery, and habit of using spinal cord injury individuals for clinical skill practice by student nurses and trainee doctors.

Ku et al. 2006

Korea

Case Series

N=140

Population: Gender: males=100, females=40; Severity of injury: complete=34, incomplete=106; Time post-injury= 17 yr.

Intervention: Review of urological medical records from January 1987 to December 2003 on individuals with SCI. Methods of bladder management included spontaneous voiding, clean intermittent catheterization (IC), suprapubic or indwelling catheters.

Outcome Measures: Individuals with epididymo-orchitis, variables associated with risk.

1.     Overall, 39 individuals had epididymo-orchitis.

2.     Epididymo-orchitis was more common for individuals on IC than with indwelling urethral catheterization (p=0.03).

3.     Rate of urethral stricture: 0% urethral catheterization, 4.3% voiding spontaneously, 18.2% IC, and 2.8% suprapubic catheter.

4.     Individuals on IC had a 7 fold higher risk (odds ratio, 6.96; 95% CI, 1.26-38.53, p=0.026).

5.     IC was an independent risk factor for epididymo-orchitis.

Ord et al. 2003

England

Case Series

N=457

Population: SCI with >6 mo on any 1 form of management: Mean age: 29-40 yr for various groups; Gender: males=402, females=55; Level of injury: T3 – T9; Severity of injury: complete, incomplete; Follow-up time=48-107 mo.

Intervention: Assessment of various bladder management methods (i.e., sphincterotomy, condom, intermittent catheter (IC), indwelling urethral catheter, suprapubic catheter+ combinations of each).

Outcome measures: Bladder stone formation rate.

1.   Both forms of indwelling catheterization had an increased risk of getting bladder stones and requiring hospitalization for bladder stones over IC and condom drainage with or without sphincterectomy.

2.   Relative to IC, hazard ratio was 10.5 for suprapubic catheters and 12.8 for indwelling urethral catheters.

3.   Incidence density ratio (like odds ratio) was 40.7 for developing bladder stones for indwelling catheters relative to IC. Condom incidence density ratio was 7.5 relative to IC.

4.   % Annual risk for stone formation: Condom & Sphincterotomy 0%; IC 0.2%; Expression voiding with or without condom 0.5%; Indwelling catheter 4% (first stone), 16% (subsequent stone).

Weld & Dmochowski 2000

USA

Case Series

N=316

Population: SCI: Mean age: 33.9-41.0 yr; Gender: males=313, females=3; Level of injury: suprasacral=269, sacaral=47; Severity of injury: complete=45, incomplete=271; Mean follow-up=17.8-19.3 yr for various groups.

Intervention: Assessment of various bladder management methods (i.e., intermittent catheterization (IC), voiding spontaneously, indwelling urethral catheter, suprapubic catheter).

Outcome Measures: Urological complication rate (epididymitis, pyelonephritis, upper tract stone, bladder stone, urethral strictures, periurethral abscess, vesicoureteral reflux, abnormal upper tracts).

1.     Frequency of those managed by IC, voiding spontaneously, suprapubic and urethral catheterization was 92, 74, 36 and 114 subjects respectively.

2.     Complication rates for the above groups were 27.2%, 32.4%, 44.4% and 53.5% respectively.

3.     Urethral catheter users had the highest rates for epididymitis, pyelonephritis, upper tract stone, bladder stone, urethral strictures and periurethral abscess.

4.     Suprapubic catheter users had the highest rates for vesicoureteral reflux and abnormal upper tracts.

Jensen et al. 1995 Norway

Case Series

N=12

Population: Age Range 17-72 yr; Gender: males=11, females=1; Severity of injury: complete, incomplete; Time post-injury: 3-7 mo.

Intervention: Three ultrasonographic measurements of residual urine after Intermittent catheterization

Outcome Measures:  Residual urine volume; urinary tract infections (UTI).

1.     7 individuals had 50-100mL residual urine; 2 individuals had >100mL residuals.

2.     9 individuals had >1 UTI during hospital stay.

3.     No correlation between residual urine volume and UTI incidence (r=0.19 (mean), p=0.52; r=0.16 (max), p=0.63).

Nanninga et al. 1982

USA

Case Series

N=85

Population: Gender: males=71, females=14, Level of injury: paraplegia=56, tetraplegia=29; Severity of injury: complete=64, incomplete=21

Intervention: Individuals on intermittent catheterization followed for 11 mo (range 6-72).

Outcome Measures: Excretory urogram and cystogram at 6 mo intervals. Urine culture. Serum urea and creatinine

1.     12 developed reflux, 16 developed ureterectasis or hydroureternephrosis. 11 of these 28 had elevated creatinine.

2.     64 had at least 1 urinary tract infection (UTI), 1 had bladder calculi.

3.     Treatment in 15: Increased frequency of catheterization. Avoiding short duration high fluid intakes. 3 had sphincterotomy. 10 were converted to indwelling catheterization.

Discussion

Intermittent catheterization is the mode of bladder management generally associated with the fewest long-term complications (Groah et al. 2002; Weld & Dmochowski 2000; Ord et al. 2003). However, there are some complications that occur with higher frequency in patients who intermittently catheterize. For example, increased urethral complications (19% incidence) may lead to urosepsis and epididymorchitis (28.5% incidence) and may result in increased morbidity and reduced fertility (Ku et al. 2006). Despite IC-related higher rates of complications, there is good consensus among the larger retrospective studies available that IC programs are still preferred for the protection of the upper urinary tract through regular emptying with low bladder pressures (Giannantoni et al. 2001). Episodes of pylonephritis and UTI are also reduced when bladder emptying is conducted consistently and completely in the absence of indwelling catheters (Groah et al. 2002; Weld & Dmochowski 2000; Ord et al. 2003; Giannantoni et al. 2001; Woodbury et al. 2008).

Perrouin-Verbe et al. (1995) showed that patients most likely to continue with IC would be those who are able to independently catheterize and those who have an acceptable level of continence. In line with this finding, Pannek & Kullik (2009b) showed that in patients who employ self-IC and have optimal bladder function, perceived QoL is higher than those with suboptimal function. Akkoc et al. (2013) compared individuals using various bladder management methods; those with normal spontaneous micturition had the highest QoL whereas those using an attendant to perform IC had the lower QoL. The authors reported, however, that there was no difference in personal relationships, general health perception, and sleep/fatigue among groups. These findings are in contrast to those by Oh et al. (2006) who found significant differences in many variables measured by the SF-36 between individuals with SCI and able-bodied controls. It is essential to consider an individual’s activities of daily living, psychological factors (and other concurrent comorbidities) and potential caregiving needs when IC is being introduced early after SCI.

A very low incidence of bladder stones and hydronephrosis were reported in Perouin-Verbe et al. (1995; 2%), consistent with previously discussed studies. However, Nanninga et al. (1982) reported upper tract changes in 33% of patients. While this range is large, it is possible that management of patients in 1982 involved less stringent control of high bladder pressures which is the cause of upper tract disease in many cases (Nanninga et al. 1982). Nanninga noted that high bladder pressures may occur even in patients who remain continent or nearly continent between catheterizations, and that the problem can at least be partially avoided by increasing the frequency of catheterization. Other options for patients with persistently elevated pressures already on IC programs are detrusor OnaBTx injections and/or anticholinergic medications. It is important to note that regular follow-up of these patients including tests of bladder physiology and upper tract function is recommended to monitor for changes and for increasing incidence of complications with time (Perrouin-Verb et al. 1995; Nanninga et al. 1982).

Finally, in a small RCT, Polliak et al. (2005) used a portable ultrasound device to measure bladder volumes among a group of individuals post SCI. Compared to those who used time-dependent IC, those using volume-dependent IC had significantly fewer catheterizations which resulted in a significant reduction in cost (p<0.001).

Conclusion

There is level 4 evidence (from many non-randomized controls) that urethral complications and epididymoorchitis occurs more frequently in those using IC programs for bladder emptying, but the advantages of improved upper tract outcome over those with indwelling catheters outweigh these disadvantages.

There is level 1b evidence (from one RCT; Polliack et al. 2005) that using a portable ultrasound device reduces the frequency and cost of intermittent catheterizations.

Urethral complications and epididymoorchitis occur more frequently in those using intermittent catheterization programs.

Portable ultrasound device can improve the scheduling of intermittent catheterizations.