cath-blog-(1).PNGThe first step for the implementation of a successful bladder management program is to educate and inform the individual.
 

Review anatomy – never assume that the individual knows all of the names or anatomical landmarks and terms. Discuss the benefits and provide input regarding the effectiveness of a bladder program relative to their daily routines. Clinicians must have a full understanding of the individual’s bladder needs, in order to promote independence, compliance, and quality of life.
 
Catheter selection is dictated somewhat by insurance coverage. However, the clinician and the individual work together as a team to determine an appropriate product. Selection of the most appropriate product will be based on factors such as the individual’s hand function, body habitus, balance, strength, environment for CIC, lifestyle, and routines. Furthermore, it is essential to assessing the type of preferred lubricant, rigidity of catheter, length, and circumference (French) in promoting compliance and independence.

Positioning and Techniques
 

As previously stated, it’s important to note that not every individual will perform CIC in a bed, nor will they have access to hospital bed functions (elevating head, bed-rails). To set patients up for success, they must perform CIC in various, “real-life”, everyday settings, and positions that will be most common for their lifestyle.
 
With regard to pediatric CIC, the primary consideration is who will be performing CIC: parent, school nurse, caregiver, or the individual. It is important to understand that when the child shows interest in CIC, and has the functional capacity to learn, autonomy should be promoted as they are usually keen learners of a new skill. However, supervision is advised for optimal technique is important for prevention of incontinence and UTIs. The pediatric patient should be catheterized every 4 hours, and schedule maintenance is key.

There are a multitude of factors to assessing and determining best practice for CIC:
  • The feasibility of the bladder management program and compatibility with the individual’s lifestyle
  • Physical abilities 
  • Dexterity
  • Core flexibility 
  • Strength
  • Balance / posture 
  • Cognitive function
  • Sensation 
  • Tone
  • Willingness to learn / anxiety 
  • Personal factors
  • Environmental factors 
  • Cultural and spiritual beliefs
  • Roles 
  • Routines
  • Bowel function 
  • Support of family/caregivers
  • Financial considerations
  • Storage of products and supplies

Environmental Factors
 

CIC is more dynamic than just bladder drainage. It’s important to consider the individual, as well as where they will be performing CIC: bed, manual or power wheelchair, over the commode, public restroom, etc. As clinicians, it’s easy to become desensitized on how much we facilitate success in the hospital setting; however, the “real-world” is not as conducive to the ease of CIC. It’s also crucial to trial strategies and techniques for clothing management, including the implementation of adaptive equipment.

Factors to Consider

  1. Is the individual more successful managing their clothes in their wheelchair or over the commode?
  2. When is the individual going to assume proper positioning for CIC, before or after their clothes are managed? 
  3. Are they ambulatory?

 Adaptive Equipment
 
There are several adaptive equipment items to assist with CIC. It is important to explore which of the items encourage and promote ease of use and success.
Below are some examples.
 
Mirrors: Great tool for initial education during CIC (anatomy, technique/strategies), or long term use for females. Helpful for - individuals who need visual feedback during CIC.
 
Pants holder, Betty hook, Bungee: Keeps clothing out of the way during CIC. Top hook goes into the waistband of pants, bottom bar is inserted between wheelchair cushion and seat. Helpful for - males performing CIC.
 
Catheter inserter: Maintains grip and coordinated insertion of catheter. Easy clamp allows for independent use.
Helpful for - individuals with impaired hand function who have difficulty grasping catheter.
 
Penis stabilizer, Household: Keeps the penis stable and in proper position for CIC. Allows for hands-free approach during CIC management. Helpful for - males with impaired hand function.
 
Asta-Cath: When inserted into the vaginal canal, the urethral opening will coincide with one of the holes, guiding the catheter and promoting independence. Helpful for - females performing CIC.
 
In conclusion, clean intermittent catheterization (CIC), has been proven to be an effective method of bladder emptying and infection prevention, when proper technique is followed. Transitioning from sterile technique to clean technique is less cumbersome, and more adequate for implementation into “real-life” circumstances. It is important to continuously assess products and techniques for compliance and success, to determine optimal product solution and strategies. CIC is dynamic, and requires input from the interdisciplinary team for patient success, independence, and quality of life.


References

Ballstaedt, Levi & Woodbury, Blair, (2019). Bladder Post Void Residual Volume, March 31, 2019
 
Brusch, John L. Catheter Related Urinary Tract Infection, September 8, 2017
 
Cardenas, DD; Moore, KN; Dannels-Mcclure, A; Scelza, WM; Graves, DE; Brooks, M; Busch, AK (2011).
 
Intermittent catheterization with a hydrophilic-coated catheter delays urinary tract infections in acute spinal cord injury: a prospective, randomized, multicenter trial. PM R. 2011 May;3(5):408-17
 
Cleveland Clinic (2017) Neurogenic Bladder https://my.clevelandclinic.org/health/diseases/15133- neurogenic-bladder
 
Clinical Advisory Board for Intermittent Catheterization (2013) Clean Intermittent Catheterization: Guidelines for Healthcare Professionals
 
Consortium for Spinal Cord Medicine. Bladder Management for Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Providers. Journal of Spinal Cord Medicine, 29 (5)
 
Ljubović, Amela Dedeić- & Hukić, Mirsada (2009). Catheter-Related Urinary Tract Infection in Patients Suffering from Spinal Cord Injuries. 2009 Feb; 9(1): 2–9
 
Peter T. Dorsher & Peter M. McIntosh (2012) Neurogenic Bladder, Advances in Urology February 8, 2012
 
Gill, Bradley C (2016). What is Intermittent Catheterization for the Treatment of Neurogenic Bladder December
6, 2018

Ginsberg, David (2017) The Epidemiology and Pathophysiology of Neurogenic Bladder Lamin, E., & Newman, D (2016).
 
Clean Intermittent Catheterization Revisited. International Urology and Nephrology, March 8, 2016
 
Lapides J, Diokno AC, Silber SJ, Lowe BS. Clean, intermittent self-catheterization in the treatment of urinary tract disease. J Urol. 1972 Mar;107(3):458-61
 
Lisenmeyer, Todd (2006). Bladder Management for Adults with Spinal Cord Injury, A Clinical Practice Guideline
for Health-Care Providers. The Journal of Spinal Cord Medicine, 2006; 29 (5): 527-573
 
Newman, DK (2017) Catheters, devices, products and catheter-associated urinary tract infections. Core Curriculum for Urologic Nurses. AJ Janetti Inc.
 
Newman, D., Willson, M. (2011) Review of intermittent catheterization and current best practices
 
http://www.spinalcordessentials.ca/handouts/female- intermittent-catheterization/
 
http://www.spinalcordessentials.ca/handouts/male- intermittent-catheterization/
 
Taweel, Waleed & Seyam Raouf (2015). Neurogenic bladder in spinal cord injury patients. Research and Reports in Urology, 2015; 7:85-99
 
Urology Care Foundation. What is Neurogenic Bladder. https://www.urologyhealth.org/urologic-conditions/ neurogenic-bladder
 
Yates, A. (2013) Teaching Intermittent catheterization: barriers. Nursing Times; 109; 44, 22-25
 
Leah Holderbaum, OTR, CBIS, ATP

Author

Leah Holderbaum, OTR, CBIS, ATP

Leah Holderbaum, OTR, CBIS, ATP received both her Bachelor of Science in Occupational Science, and Master of Science in Occupational Therapy from Eastern Kentucky University. Leah has 10 years of clinical experience, which began with Kettering Health Network in Ohio at the Neuro Rehab and Balance Center. Leah expanded her career to Texas in 2012, as an occupational therapist on the Spinal Cord Injury Team at Baylor Scott & White Institute for Rehabilitation-Dallas, where she served as the clinical specialist. While at Baylor, Leah facilitated a national research study, in conjunction with the University of Pennsylvania, regarding compliance with intermittent cathing. Leah has developed and instructed continuing education courses on the therapeutic management of the spinal cord injured patient, and the distinct role of the OT in bladder management, and has provided lectures at Texas A&M and TWU on SCI. Leah currently works for Numotion as Medical Supply Account Manager, where she has the opportunity to share her love for bladder management, and promote quality of life and independence for customers she encounters.