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The goal of bladder management is to maintain and preserve a functional, infection-free genitourinary system through prevention of upper and lower tract complications with a management system compatible with an injury-free lifestyle (Lisenmeyer, 2006).


There is no “gold standard” for bladder management (Clinical Practice Guidelines); the implemented strategy must be specific to the individual, and enhance their quality of life. The ideal model is interdisciplinary, responsive, and reality-based in pro-actively meeting the individual’s needs.
 
Intermittent Catheterization (IC)
 
Intermittent catheterization is one of the oldest urologic procedures, dating back ~3000 years (Lamin, E. & Newman, D., 2016), as reeds were the initial tool for bladder drainage. In 1971, Dr. Jack Lapides, also known as the Pioneer of CIC, determined that “Host resistance factors were sufficient to prevent symptomatic urinary infection provided the bladder was emptied frequently” (Lapides, 1972). It was at this time that he described the procedure for CIC, which has become a life-saving and first line of management for those individuals who are unable to empty their bladder spontaneously, when desired (Urology Care Foundation).
 
There are 2 techniques for IC: sterile technique and clean technique.
 
Sterile technique was founded in 1954 by Sir Ludwig Guttman, and was described as a way of reducing infection. This method has limitations as it is typically utilized only for a restricted period of time, primarily administered by nursing staff in institutional settings. This technique is not intended to be a long-term method of bladder management.

Clean technique, referred to as clean intermittent catheterization (CIC), or “cathing” as it is commonly referred to, accommodates for the difficulty of completing the sterile technique, in a “real life”, everyday living environment. The benefits noted are a prevention of high residual volumes and a reduced risk of developing a urinary tract infection (UTI). This technique results in a lower rate of infection when compared to indwelling catheters.
 
In order to optimally complete CIC, a simple yet essential hygiene procedure should be completed; hands should be washed or aseptic towelettes used both before and after catheterization. The penis or labia should be cleansed prior to cathing using appropriate wipes, or soap and water. It’s important to note that for women, the labia and urethral orifice must be cleaned front to back, to reduce the risk of infection.
 
CIC can either be performed by the individual, caregiver, or healthcare professional. IC is the best solution for bladder decompression for motivated individuals who can physically and cognitively participate in their own care (Gill, 2018). In addition, this technique is preferred by men and women, over the use of an indwelling catheter, as a healthy alternative for bladder management.
 
Further benefits include that it can be performed anywhere, and promotes the individual’s autonomy as it provides greater freedom from alternatives such as catheters, tubes, or bags. Individuals may have unimpeded sexual relations, as CIC provides a means of complete bladder emptying without an indwelling catheter. CIC preserves function of upper tract, while preventing over-distention of the bladder. Furthermore, decreasing the risk of UTI and urethral trauma, increasing independence in self-care.
 
The use of CIC promotes and simulates a normal voiding schedule and helps to maintain continence (Dorsher & McIntosh, 2012). Just as before the injury or diagnoses, the bladder must be drained on a regular basis at timed intervals (every 4, 6, or 8 hours), depending on bladder volume (Taweel & Seyam, 2015).
 
 The average adult bladder holds approximately 400- 500 ml of urine. In a clinical setting, post-void residual volumes (PVR) may be monitored to assess need for CIC: <50 ml is “normal”, >50-100 is “abnormal” and must be managed with IC (Ballstaedt & Woodbury, 2019). Ideally, the amount drained should not exceed 500 ml. If the volume is produced is more or less, then fluid intake and frequency of catheterization will need to be re-assessed and adjustments implemented.
 
With CIC, the incidence of bacteria in the bladder is 1-3% per catheterization (Ljubovic & Hukic, 2009), compared to 3-10% increase daily, with a foley. Research shows that there are 1-4 episodes of bacteriuria occurring per 100 days of intermittent catheterization, if performed 4 times daily (Gill, 2016). However, infections that do occur are usually managed without complications. Studies show that the use of a hydrophilic-coated catheter for IC delays the onset of the first antibiotic-treated symptomatic UTI (Cardenas, et al, 2011). Overall, CIC as a means for bladder management shows a reduced incidence of symptomatic UTI.
 
Catheter Selection
 
Just as each individual has differing anatomy, and different level of functional performance, there are a multitude of components that aid in catheter selection, such as length, diameter, type of material (which impacts rigidity), type of lubricant, straight- tip or coude (angled) tip, and more. Based on the anatomical differences in urethral length, there are 2 primary lengths for catheters, 16” for men, and 6” for women. A woman can use a
male-catheter for ease of management; however, a male cannot use a female-catheter.
 
A good starting point to determine appropriate diameter for adults is 14 French (Fr). Changes can be made based on discomfort or if urine leaks around the catheter, resulting in the need for a larger diameter catheter. That being said, if cathing is painful, alternative products should be assessed, and technique should be re-evaluated.
 
Use of a coude tip is beneficial if there are anatomical barriers that do not allow a straight catheter to pass optimally. For example, if a man has an enlarged prostate, or if a woman has had an augmentative bladder surgery, he or she may qualify for a coude tip.
 
Another consideration is the type of lubricant utilized during CIC. One example is a separate package of lubricant that the individual opens and self-applies to the catheter prior to insertion. A water-soluble gel is another form of lubricant that is often pre-applied by the manufacturer, resulting in the catheter being ready to use. A hydrophilic catheter is one in which the lubricant is water activated and allows for a smooth insertion and removal, ultimately reducing urethral trauma.

Catheter selection should be determined by the individual, based on functional abilities, lifestyle, and ease of use. Some things to consider are dexterity with regard to how the individual will open and manage the product packaging, rigidity and ease of insertion, use of catheters with “grippers” to reduce risk of infection, and the storage of catheters prior to use.
 
In conclusion, the benefits of CIC as a means of promoting bladder health and management, by reducing the incidence of UTI is vital to enabling individuals to participate in everyday 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.