The 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 should be determined by the individual, based on functional abilities, lifestyle, and ease of use. Most major insurance providers can accomdate all specific patient needs. 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.

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References

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Clinical Advisory Board for Intermittent Catheterization (2013) Clean Intermittent Catheterization: Guidelines for Healthcare Professionals
 
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