Bombay Hospital Journal Issue SpecialContentsHomeArchiveSearchBooksFeedback
ROLE OF INTERMITTENT CLEANSELF CATHETERIZATION

Bakhtawar K Dastur
Head, Urodynamic Dept., Bombay Hospital and Medical Research Centre, Mumbai 20.

Intermittent catheterization was first popularised by Jack Lapides in 1972, and marked a great advance in management of neurogenic and non neurogenic bladder dysfunctions. The aim is to keep the bladder completely empty at regular intervals at least 4-5 times a day. It is useful in cases where bladder is unable to empty at all or partially, leaving behind fair amount of residual volume.

Causes of post void residue are

  1. Bladder outlet obstruction
  2. Underactive detrusor.
  3. Neurogenic failure of bladder muscle to contract.

Sequelae of post void residue are

  1. Recurrent Infection.
  2. Back pressure changes on the upper urinary tract leading to renal failure.

Indications of intermittent clean self catheterization

  1. Neurogenic bladder : as in congenital spinal dysraphism, meningomyelocoele, intradural/extradural lipomas, diastometamyelia, traumatic paraplegia, inflammatory diseases like tuberculosis, myelitis, arachnoiditis, prolapsed intervertebral discs, diabetic autonomic neuropathy, hypothyroidism, or metastatic lesions in the spine.
  2. Post radical pelvic surgeries like Wertheim’s hysterectomy, abdominoperineal resection, etc.
  3. Decompensated bladders with acontractile detrusor as in chronic bladder outlet obstruction (BOO) due to benign prostatic enlargement, Ca prostate, bladder neck obstruction, chronic stricture urethra, posterior urethral valves, or in patients with BOO and are unfit for surgery.
  4. Post vaginal repair, bladder neck suspension surgery, post haemorrhoidectomy or perianal surgery, retention of urine occurs with failure to void naturally lasting upto 1 to 3 months.
  5. Psychological disorders; marital discord or death in the family may precipitate retention of urine.
  6. Infrequent voiders tend to hold urine for long duration due to inappropriate toilet facility at work or school resulting in large capacity bladder which damage the sensory nerve endings in the bladder due to overstretching; resulting in accommodation of large volume of urine till the bladder wall loses its elasticity and muscle loses its power to contract. Over a period of years these bladders fail i.e. detrusor fails to contract during attempts at micturition.
  7. Clean intermittent self catheterization is also indicated in cases of retention of urine following consumption of certain medicines like, antispasmodics, antidiarrhoeals, antidepressants, or cough medicines containing bronchodilators.

Requirements for doing intermittent clean catheterization.

  1. Patient must be fully motivated to carry out himself or herself.
  2. Use of hands; and proper eyesight are essential if the patient is going to do intermittent clean catheterization himself.

In quadriplegics, or in aged, a relation or attendent can be taught to do ICC.

  1. Access to clean tap water and a little sense of hygiene to be cultivated in lower socio-economic class.
  2. Instruction sheet to be provided to the patients in case one may forget.

Type of Catheters

Any type of catheter, from plain rubber catheter to disposable self catheters called K-90, K-91, P-90, P-91, Nelatons, infant feeding tubes or even foley catheter can be used.

Rubber catheters can be boiled. Disposable catheters are stored in Savlon lotion after use and changed once a week or a fortnight.

Procedure

Catheterization can be done in either erect, sitting or supine position. Patient is instructed to wash hands with soap and water for five minutes. Glans penis, the external meatus is cleaned with piodin, germidin or betadine lotion once a day, and rest of the time the part can be cleaned with tap water, so as not to disturb the normal flora of organism which help in combating infection.

Catheter is lubricated with K-Y jelly, or Lignox jelly or paraffin and inserted in the urethra till urine starts pouring out.

Pressure on suprapubic region assists in emptying the bladder faster. Catheter is pushed in and out once or twice before removal and is always pulled out in a downward direction so that urine from the catheter does not enter the bladder again.

Catheter is washed with soap and water and preserved in a clean container with diluted savlon lotion. Catheter is wa shed each time before using. Interval of catheterization varies from 3 hours to 6 hours depending on the bladder capacity.

Aims of Clean Intermittent Catheterization.

  1. To facilitate bladder filling and thus ensure low bladder filling pressures.
  2. To prevent upper tract damage.
  3. To reduce incidence of overflow incontinence in cases of low compliant acontractile bladders.
  4. To reduce incidence of recurrent infection secondary to large post void residue.

Complications

  1. If catheterization is not done hygienically and at regular intervals there are chances of infection.
  2. Occasionally there may be trauma if sphincter is spastic or occurrence of stricture along with acontractile detrusor.
  3. Haematuria secondary to trauma or severe urethritis.
  4. Formation of false passage in rare occasions.

Advantages of Intermittent clean self catheterization over indwelling catheter

  1. Incidence of urethritis, fistula formation is less.
  2. No question of stone formation and encrustation over the catheter.
  3. No embarrassment of carrying urine drainage bag at work.
  4. Easy and better rehabilitation in neurogenic patients where physiotherapy is concerned.
  5. No fear of catheter getting blocked at midnight and leakage by the side of the catheter.
  6. Intermittent clean self catheterization makes patients feel confident, normal and independent.
  7. In non neurogenic acontractile decompensated bladders - or bladders in recovery stage patients can attempt voiding prior to catheterization and thus helps in further management of cases. Clean intermittent catheterization is known to facilitate rapid improvement in detrusor function.
  8. Normal sexual life is restored.

CONCLUSION

Clean intermittent self catheterization is more easily accepted mode of management for chronic retention of urine of neurogenic or non neurogenic origin. While shifting from chronic indwelling catheterization to clean intermittent catheterization it is important to cover the patient with strong antibiotics and continue maintenance dose for at least 3-6 months otherwise the fear of recurrent infection with fever may discourage them to continue with clean intermittent self catheterization. It is simple, easy, economic and a quick way of emptying the bladder.

It is contraindicated when there is false passage and fistula formation, lower limb spasticity, or patient is unable to use hands - quadriplegic, and has no one to help him.


To Section TOC
Sponsor-Dr.Reddy's Lab