Complications of CIC 

  • The benefits of CIC have been well established in neurogenic bladder dysfunction. Despite its widespread use, the incidence of associated genitourinary complications is not well described.
  • Overall complication rate secondary to CIC are known to be very low [Lindehall 2004]. However, the introduction of a catheter several times a day through the urethra or stoma channel during CIC can produce a few complications.
  • IC and ISC are very good techniques but the patient must be aware that complications can occur.
  • Complications of CIC can be summarized as the following categories (The prevalence and incidence figures vary widely according to IC technique, materials used, and investigation method.)

1. UTI

  • Patients using CIC had fewer infections than those with indwelling catheters [Shekelle 1999].
  • The catheter may introduce bacteria into the urethra and bladder, resulting in UTI. UTI can subsequently cause inflammation of the genital tract.
  • Improper CIC technique can cause lower UTI (urethritis and cystitis), upper UTI (pyelonephritis) and genital tract infection (prostatitis and epididymo-orchitis)
  • The prevalence of symptomatic UTI varied from 11.9% to 17.4% with a higher frequency in females and patients using antibiotics. [Bakke 1993]
  • Also refer to the other chapters

2. Trauma

  • Traumatic catheterization in the SCI patients with no/reduced sensory in the genitalia has a great chance to cause repeated irritation to the urethra, which may cause bleeding, false passage and scaring and/or stricture of the urethra. (example: urethra meatal stricture)
  • Forceful manipulation during catheter insertion and significant bleeding proved important contributory factors for the development of urethral strictures in patients on IC [Mandal 1993]

1) Bleeding and hematuria

  • Urethral bleeding is frequently seen in new patients, and occurs regularly in one-third on a long-term basis [Webb 1990]. This is most true for males in the prostatic age group. It is rare in women

2) False passage

  • Urethral trauma with false passages can successfully be treated with 5 days antibiotics and six weeks indwelling catheter [Michielsen 1999]. However, we use only two to three days indwelling catheter for false passages.
  • Once confirming the false passage disappears on a cystoscopic examination, IC can be safely restarted [Michielsen 1999]

3) Urethral stricture

  • The incidence of urethral strictures increases with a longer follow-up, with most events occurring after 5 years of CIC [Perrouin-Verbe 1995; Wyndaele 1990].

3. Bladder stone formation

  • Introduction of pubic hair into the bladder during self-catheterization can play a role as a nidus for bladder stone [Vaidyanathan 1999; Derry 1997]
  • Patient trying to limit fluid intake to reduce the frequency of catheterization tend to cause urine concentration and subsequent bladder stone formation.

Interesting Facts on the Importance of Proper CIC Practice

  • CIC interval/ catheterized volume and UTI
    • Clinical UTI were more frequent in patients with high mean catheterization volume [Bakke 1993].
    • A fivefold incidence when CIC was done 3 times a day compared to 6 times a day. [Shekelle 1999; Lapides 1976].
    • Bacteriuria was more frequent with low frequency of catheterization in men. [Bakke 1993].
    • CIC was performed less frequently and mean catheterization volume was greater in patients with worsening bladder function. [Yokoyama 1996]
  • Subject of CIC and UTI
    • Clinical UTI was more frequent in patients with nonself-catheterization in men [Bakke 1993].
    • Cross infection is less if CIC during hospitalization is done by a catheter team [Lindan 1971] or by the patients themselves [Wyndaele 1990].
  • Anti-infective agents and UTI
    • Patients using anti-infective agents had fewer episodes of bacteriuria but significantly more clinical UTIs compared to nonusers [Bakke 1993].
  • Urethral stricture
    • The higher the daily frequency of catheterization, the less the urethral changes. This might be due to the fact that those regularly performing CIC developed more skill in catheterization and therefore had less chance of urethral trauma. Moreover, with more catheterizations the chance of urethral dilatation increases [Wyndaele 1990]

How to minimize serious complications

  • Nursing education
    • The most important factor
    • Simple and cost-effective mean to decrease the risk of complications
    • Education points:
      • Atraumatic technique:
        • gentle introduction of the catheter
        • substantial lubrication of the catheter
      • Clean technique:
        • Cleaning of the urethral meatus and hands
        • Decreaseing UTI risk
      • Complete emptying of the urine: As residual urine plays a role in infection, attention must be made to empty the bladder completely [Shekelle 1999].
      • Frequency and volume of catheterization
      • Instructing the need of close followup
  • Patients' compliance:
    • ability to properly perform CISC,
    • mental capability and self-discipline
  • Catheter and supplies
    • Catheter materials:
      • may be safer to use silicone catheter, hydrophilic
    • Cleaning the catheter (if reused):
Key Points of This Section
  • CIC can be safely and effective but there are rules that must be followed. As noted in the data above. Patients who do CIC in the prescribed manner have less trouble with bacteriuira, with symptomatic infections, with bladder compliance, and incontinence and with stricture formation.
  • There is a lesion here: do CIC often enough to keep pressures low and the bladder empty and you will have far less complications.

References

  • Bakke A, Vollset SE. Risk factors for bacteriuria and clinical urinary tract infection in patients treated with clean intermittent catheterization. J Urol. 1993 Mar;149(3):527-31.
  • Bakke A. Clean intermittent catheterization--physical and psychological complications. Scand J Urol Nephrol Suppl. 1993;150:1-69.
  • Derry E. and I. Nuseibeh, Vesical calculi formed over a hair nidus. Br J Urol 80 (1997), p. 965
  • Lapides J, Diokno AC, Gould FR, Lowe BS. Further observations on self-catheterization. J Urol. 1976 Aug;116(2):169-71.
  • Lindan R, Bellomy V. The use of intermittent catheterization in a bladder training program, preliminary report. J Chron Dis 1971; 24: 727-735.
  • Lindehall B, Abrahamsson K, Hjalmas K, Jodal U, Olsson I, Sillen U. Complications of clean intermittent catheterization in boys and young males with neurogenic bladder dysfunction. J Urol. 2004 Oct;172(4 Pt 2):1686-8.
  • Mandal AK, Vaidayanathan S. Management of urethral stricture in patients practising clean intermittent catheterization. Int Urol Nephrol 1993; 25: 395-399.
  • Perrouin-Verbe B et al. Clean intermittent catheterization from the acute period in spinal cord injury patients. Longterm evaluation of urethral and genital tolerance. Paraplegia 1995; 33: 619-624.
  • Shekelle PG et al. Systematic review of risk factors for urinary tract infection in adults, with spinal cord dysfunction. J Spinal Cord Med 1999; 22: 258-272.
  • Shekelle PG, Morton SC, Clark KA, Pathak M, Vickrey BG. Systematic review of risk factors for urinary tract infection in adults with spinal cord dysfunction. J Spinal Cord Med. 1999 Winter;22(4):258-72.
  • Vaidyanathan S., G. Singh, P. Sett et al., Bladder stones of unusual shape in a male with paraplegia due to spinal cord injury who has been performing self-catheterization. Spinal Cord 37 (1999), pp. 375–376.
  • Webb RJ, Lawson AL, Neal DE. Clean intermittent self-catheterisation in 172 adults. Br J Urol. 1990 Jan;65(1):20-3.
  • Wyndaele JJ, De Taeye N. Early intermittent self-catheterization after spinal cord injury. Paraplegia 1990; 28: 76-80.
  • Wyndaele JJ, Maes D. Clean intermittent self-catheterization: a 12-year followup. J Urol. 1990 May;143(5):906-8.
  • Yokoyama O, Hasegawa T, Ishiura Y, Ohkawa M, Sugiyama Y, Izumida S. Morphological and functional factors predicting bladder deterioration after spinal cord injury. J Urol. 1996 Jan;155(1):271-4.

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