Instruments and Catheters for CIC  

  • Nowadays CIC is widely accepted as the first line management option in patients with neurogenic bladder dysfunction and unbalanced voiding.
  • More information

Catheters

  • So far, wide varieties of urethral catheters have been available in the markets. The selection of catheter is dependent on availability, cost, and patient preference.

1. Disposable versus Reusable

  • Disposable catheters
    • Self-lubrication
    • In connection with jelly injected into the urethra
  • Purpose of reusable catheter:
  • The clinical outcome with reusable silicone catheters is as good as with a disposable one. However, increasing risk of UTI should be considered [Kovindha 2004]

2. Catheter Materials

  • Rubber:
  • Latex
    • Lower cost and good long-term outcomes
    • The catheter of choice for long-term CIC
    • Should not be used in latex-allergic patients [Shenot 1994]
  • Silicon (silastic):
    • Decreased incidence of urethritis and, possibly, urethral stricture
    • Significant difference in the development of urethritis after catheterization for 48 hr: 22% of patients using latex catheters vs 2% of those in the silicone catheter group [Nacey 1985]
    • The cost factor is less significant in patients not requiring frequent catheter changes.
  • Plastic (PVC):

3. Catheter design

  • Plain Nelaton
  • Coude
  • O’Neil
  • Tiemann
  • Fole

4. Impregnated catheters

  • Catheters impregnated with various substances have not proved to be beneficial in patients with long-term catheterization
    • Silver-impregnated catheters,
    • antibiotic-coated catheters and
    • electrified catheters
  • Clinical outcomes

5. Hydrophilic catheter:

  • Purpose
    • Improve the ease of catheterization
      • Without the necessity of catheter jelly
    • Decrease the incidence of associated genitourinary complications
      • Decreased friction
      • Thereby reducing urethral mucosal micro-trauma
  • Design
    • After immersion in water for 30-60s the catheter surface becomes slippery.
    • Osmolality of the outer layer of the catheters: Is it important to urethral trauma?
      • Highest osmolality (approximately 900 mOsm/kg) of the coating: significantly lower friction force [Waller 1997].
      • No difference [Biering-Sorensen 1999]
  • Clinical Outcomes
    • Short term effects (compared with conventional catheter):
      • Urethral inflammatory response: significantly lesser degree [Vaidyanathan 1994].
      • Hematuria: less [Vapnek 2003]
    • UTI rate:
      • Significant decrease [Vapnek 2003]
      • No difference [Pachler 1999]
    • Long-term effects:
      • Long-term urethral complications such as urethral strictures.
      • Present data suggests hydrophilic catheter may have advantages.
      • Need for a prospective, randomized controlled multicenter study
    • Patient convenience and insertion comfort
      • High satisfaction [Sutherland 1996; Wyndaele 2000]
      • No difference [Pachler 1999]
    • Cost-benefit and cost-effectiveness:
      • Should be considered since the patients should use CIC at least long term.
      • Non-hydrophilic PVC catheters are much cheaper [Pachler 1999]

6. Other Designs

  • Packed in a sheet/bag
  • Introducer tip catheter: bypass the colonized 1.5cm of distal urethra, decreased UTIs in hospitalized men with SCI on CIC. [Bennett 1997]

7. Conclusions

  • There is a wide selection of materials applied for IC but there is no one best material.
  • Materials chosen depend primarily on patient’s preference and economic reasons.
  • As long as the basic CIC principles are applied, catheter material does not seem to change the practical outcome significantly.

Lubricant

  • Materials and composition:
    • Jelly or aqueous solution, oil [Kovindha 1998] or just water [Orikasa 1976]
    • Local anesthetic jelly
  • Use by sex
    • Some kind of lubricant is necessary especially in men.
    • Many female patients do not use catheter lubrication.
  • Application
    • On the catheter
    • Instillation into the urethra: a local anaesthetic jelly especially in patients with preserved urethral sensation
  • Catheters with a hydrophilic and self lubricated surface need activation with tap or sterile water

Storage Bag

  • Resealable plastic bag (Ziploc) [Bogaert 2004]
    • Can be closed, leaving a corner open to allow for evaporation of excess fluids from washing the catheter

Assistive Devices

  • Mirror for females
  • Plamer band
    • Allowing for the patients to hold adaptive equipment in slit of band.
    • They can use large muscle groups to move their hand.
  • Catheter clips
    • Allowing patient to hold catheter with clip to insert into the urethral meatus.
    • Most often used for males.

  • Wrist splint
    • Allowing for patient to utilize large muscle in arm to catheterize.
    • This may be used in conjunction with palmer band and catheter clips.
  • Knee spreader
    • This is sued to keep the knees apart to allow for easier access to catheterize.
    • Often used in females
    • Demonstration of the use
  • Adaptive clothing
    • There are a variety of companies that make adaptive clothing for patient who have decreased function with upper and lower extremities.

Problems

  • Non compliance: Patients sometimes just will not do CIC in the prescribed manner. This can be dangerous as these patients are bacteriuric and failure to empty may be associated with high to very high detrusor pressures and a risk of severe urosepsis (click here for more detail)
  • Trouble inserting the catheter: This is uncommon but occasionally occurs in male patients. The causes are:
    • A pendulous or bulbous urethral stricture
    • A false passage
    • Activation of the somatic sphincter by passage of the catheter to that point. This can make catheterization very difficult. A Coude catheter may help, but if all ease fails injection of botulinum toxin into the sphincter
Key Points of This Section
  • Catheters types vary, and no one catheter is appropriate for every one
  • As long as basic CIC guidelines are adhered to outcomes do not vary significantly by catheter type.
  • Anything that facilitates intermittent catheterization is good: lubricants, catheter types: coude catheters etc.

References

    • Bennett CJ, Young MN, Razi SS, Adkins R, Diaz F, McCrary A. The effect of urethral introducer tip catheters on the incidence of urinary tract infection outcomes in spinal cord injured patients. J Urol. 1997 Aug;158(2):519-21.
    • Biering-Sorensen F, Nielsen K, Hansen HV. Urethral epithelial cells on the surface on hydrophilic catheters after intermittent catheterization: cross-over study with two catheters. Spinal Cord. 1999 Apr;37(4):299-300.
    • Bogaert GA, Goeman L, de Ridder D, Wevers M, Ivens J, Schuermans A. The physical and antimicrobial effects of microwave heating and alcohol immersion on catheters that are reused for clean intermittent catheterisation. Eur Urol. 2004 Nov;46(5):641-6.
    • Kovindha A, Mai WN, Madersbacher H. Reused silicone catheter for clean intermittent catheterization (CIC): is it safe for spinal cord-injured (SCI) men? Spinal Cord. 2004 Nov;42(11):638-42.
    • Nacey JN, Tulloch AG, Ferguson AF. Catheter-induced urethritis: a comparison between latex and silicone catheters in a prospective clinical trial. Br J Urol. 1985 Jun;57(3):325-8.
    • Orikasa S, Koyanagi T, Motomura M, Kudo T, Togashi M. Experience with non-sterile intermittent self-catheterization. J Urol. 1976 Feb;115(2):141-2.
    • Pachler J, Frimodt-Moller C. A comparison of prelubricated hydrophilic and non-hydrophilic polyvinyl chloride catheters for urethral catheterization. BJU Int. 1999 May;83(7):767-9.
    • Shenot P, Rivas DA, Kalman DD, Staas WE Jr, Chancellor MB. Latex allergy manifested in urological surgery and care of adult spinal cord injured patients. Arch Phys Med Rehabil. 1994 Nov;75(11):1263-5.
    • Sutherland RS, Kogan BA, Baskin LS, Mevorach RA. Clean intermittent catheterization in boys using the LoFric catheter. J Urol. 1996 Dec;156(6):2041-3.
    • Vaidyanathan S, Soni BM, Dundas S, Krishnan KR. Urethral cytology in spinal cord injury patients performing intermittent catheterisation. Paraplegia. 1994 Jul;32(7):493-500.
    • Vapnek JM, Maynard FM, Kim J. A prospective randomized trial of the LoFric hydrophilic coated catheter versus conventional plastic catheter for clean intermittent catheterization. J Urol. 2003 Mar;169(3):994-8.
    • Waller L, Telander M, Sullivan L. The importance of osmolality in hydrophilic urethral catheters: a crossover study. Spinal Cord. 1997 Apr;35(4):229-33.
    • Wyndaele JJ et al. Evaluation of the use of Urocath-Gel catheters for intermittent self-catheterization by male patients using conventional catheters for a long time. Spinal Cord 2000; 38: 97-99.

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