Indications for Intermittent Catheterization (IC)

Intermittent catheters are used in cases of voiding disorders as an alternative to short- or long-term indwelling urethral catheters. Generally, a short flexible catheter is used to drain urine. Longer-term intermittent catheterization may be preferred to indwelling urinary catheters or suprapubic catheters for patients with bladder emptying disorders. The infection risk for intermittent catheterization is lower compared to indwelling urinary catheters, at around 0.5% to 0.8%.

 

Urinary incontinence (overflow) Alternative to IUC Acute or chronic urinary retention Urine sample collection (when patient cannot void) Assessment of residual bladder volume As a part of management for severe pressure ulcers and wounds unprotected from urinary overflow

photo courtesy of Byram Healthcare

Indications for this type of catheterization include overflow urinary incontinence as an alternative to reduce risk of IUC-related bacteriuria or CAUTI, for medication installation, random urine sampling, post-void urinary retention assessment, and during management of stage III and IV pressure ulcers or wounds that cannot be protected from urinary overflow. It may not be appropriate to use ICs when the patient can void voluntarily, has incontinence-associated dermatitis, or for the care of patients with terminal illness due to potential discomfort, and others. Contraindications include catheterization spasticity, unhygienic conditions, limited dexterity and technique without a fully trained caregiver, and requirements for continuous drainage to prevent kidney damage.

 

Because this method requires patient or caregiver willingness, an appropriate and hygienic environment, and the patient’s ability to pay for supplies to be considered, these barriers may prevent their use for some patients. Several physical limitations and co-morbid conditions can also present challenges, such as the inability to feel the catheter, spasticity, obesity, visual limitations, upper extremity impairment, and others.

 

Intermittent catheterization tends to use standard PVC catheters, which can be washed with soap and water, air-dried, and stored in a sealed clean/dry plastic bag or container. They may be used up to five times. It has been suggested that patient comfort can be increased when using hydrophilic catheters that reduce friction.

 

Catheter-Associated Urinary Tract Infection (CAUTI)

 

The most important complication of urinary catheterization, and the majority of healthcare-acquired urinary tract infections is catheter-associated urinary tract infections, or CAUTIs. The definition of CAUTI includes a urinary tract infection that occurs when a catheter is in place or was in place within the previous two days with at least one sign/symptom that is not related to other conditions. The signs and symptoms may include fever, suprapubic tenderness, dysuria, frequency, urgency, or costovertebral pain. The term “Catheter-Associated bacteriuria” or CA-bacteriuria is a more non-specific term that more commonly refers to asymptomatic infection.

 

Infection of the urinary tract may happen through intraluminal contamination of the catheter tip during insertion or extraluminal contamination as organisms migrate into the bladder from the meatus, rectum, or vagina. It is estimated that about 20% of patients may be colonized shortly after catheterization because of poor technique. As one can imagine, women are at higher risk for extraluminal contamination.

 

In nursing homes more than 40% of infections are urinary tract infections. About 80% of those are related to catheterization and instrumentation. CAUTI affects both outcomes and treatment costs. In acute care hospitals, CAUTI accounts for more than 30% of healthcare-acquired infections. Apparently most of these infections may happen with some misuse or lack of adequate indications, including catheters used for convenience unnecessarily, as well as forgotten catheter placements. CAUTI is more common in women with a daily risk of (3%) and older adults (10%).4

 

A Cochrane Review evaluated the use of antibiotic prophylaxis for short-term urinary catheterization in adults. The review suggested that there was limited evidence that adults who were provided with antibiotics either before or during catheter use were less likely to have large numbers of urinary bacteria and pus cells and a lower incidence of infection. This held true for both surgical and non-surgical patients.5

 

A Cochrane Review evaluated policies that may be related to improvements in patient care for replacing long-term indwelling catheters. When catheters are required for longer than just a few days, care methods or policies, such as time between catheter replacements, use of antibiotics, cleaning solutions, and lubricants used during replacement, and environment and techniques for replacement can be very important to avoiding complications--and need to be adjusted accordingly. Unfortunately, very little evidence exists to support particular methods or policies and the effects on clinical, quality of life, and economic outcomes.6