Catheterisation, particularly clean intermittent catheterisation (CIC), is now considered the mainstay of treatment for neuropathic bladder and other bladder issues associated with incomplete voiding, such as dysfunctional voiding (Schaeffer and Diamond, 2014).

Intermittent catheterisation, which was first described by Lapides et al in 1972, has revolutionised bladder care, as well as vastly improving continence and reducing associated urinary tract problems such as urinary tract infections (UTIs) (Lamin and Newman, 2016). However, for catheterisation to be of benefit and to give optimal results, it usually has to be carried out between four and six times per day. For this to happen, there needs to be good acceptability and adherence, particularly for those individuals who begin catheterisation beyond infancy. This paper looks at some of the factors that impact on those undertaking catheterisation.

INTRODUCING AND ACCEPTING CIC

The decision to offer CIC to patients and families is often based on underlying medical problems and the results of relevant bladder assessments. Although CIC is commonly used in patients with neuropathic bladders, with associated reduced urethral sensation, there is some belief that those with urethral sensation may be reluctant to start CIC (Alpert et al, 2005; Neel, 2010).

To test this theory, a study was carried out to evaluate the acceptability of CIC in boys who had urethral sensation (Alpert et al, 2005). The study reviewed a group of boys following the decision to start CIC, which was based on the child’s history and the results of a completed bladder diary, in accordance with the recommendations of the International Children’s Continence Society (ICCS) (Pohl et al, 2002). Initiating CIC was considered for those boys who had lower urinary tract (LUT) voiding dysfunction, with or without hydronephrosis, impaired renal function, and recurrent UTIs.

CIC was shown to be successful for bladder emptying in children without genital sensation with success rates of 94–100% in select groups. CIC was an easy technique for most sensate children to learn in one visit and master in a short time. Overall, comfort with the technique was excellent and few problems were encountered (Alpert et al, 2005).
Practice pointAnother similar study by Neel (2010) also reviewed the feasibility of CIC in children with a sensate urethra and came up with corresponding findings, but also suggested that the earlier the CIC is started, the more accepting the child is of the procedure.

At the other end of the age scale, a study by Pilloni et al (2005) investigated whether intermittent catheterisation is a valuable alternative to an indwelling catheter in patients older than 70 years. They reviewed the records of 21 individuals and found that for those relying on CIC, the UTI rate was reduced, and urinary continence was restored in all of the six previously incontinent patients. Eighteen of the 21 patients reported a significantly improved quality of life owing to the restoration of urinary continence, decreasing of daytime frequency, nocturia and urge, and the lowering of the UTI rate. They concluded that CIC is a safe and valuable technique in older people, particularly those with significant post-void residuals owing to detrusor underactivity and strongly recommended it.

PSYCHOSOCIAL FACTORS

A number of studies have looked at the psychosocial impact of catheterisation on individuals. A study by Lindehall et al (2008) explored the views of teenagers and young adults who had been undertaking CIC for at least five years. They found that the main issues were about the young people wanting to tell their peers about having to catheterise, but felt they did not have the courage to do so. The young people also wanted to have more information about catheterisation from the medical staff. The study did not find any negative psychosocial factors associated with catheterisation.

Another study by Edwards et al (2004) involved 40 children and their families and looked at the social and psychological impact of CIC on children and young people. Although faced with a number of practical, social and emotional challenges, both related to learning the procedure and incorporating it into day-to-day activities, all the children managed successfully to implement the procedure as part of daily life.

What did come out of the study was that very few children and young people felt that they were involved with the decision to start catheterising. Although it can be a challenge to convey the long-term benefits and rationale of CIC to children, it is important that they understand that not only will the procedure help keep them dry (enabling them to stop wearing pads and different clothes), but also that it will protect their kidneys in the long term. Motivating them long term may be an issue if they are unable to understand these potential ‘invisible’ benefits.

 
 

"Older adolescents may have concerns about relationships and intimacy, for example, while younger children may have concerns about the practicalities of catheterising in school or at a friend’s house."

 


Therefore, it is vital to recognise the importance of providing information in a format that the child or young person can understand, and that any information given will need to be amended and adapted as the child matures. Facilitating an open relationship between the child or young person and the clinician will hopefully enable them to feel confident to ask questions about catheterisation that may worry them. Older adolescents may have concerns about relationships and intimacy, for example, while younger children may have concerns about the practicalities of catheterising in school or at a friend’s house.

PATIENT SATISFACTION

Very few papers were found that specifically related to formally examining patient satisfaction with CIC, with the use of a patient satisfaction survey. Guinet-Lacoste et al (2014) carried out a study to validate a new tool for evaluating patient satisfaction of using an intermittent catheter. This tool looked at a number of aspects, including packaging, the type of lubrication of the catheter and disposal. They concluded that the tool (InCaSaQ) was a valid test of patient satisfaction with using the catheter and it could also be used as an objective measure to compare different catheters in trials.

Practice point 2Another study looked at both patient and healthcare professional self-confidence in undertaking CIC by using a 16-item checklist (Biaziolo et al, 2017). Knowing how self-confident an individual is in performing CIC will not only improve teaching outcomes and compliance, but also treatment success. Self-confidence may be related to the self-efficacy theory that is constantly associated to a behaviour or task (Perry, 2011). It originates from repeated experiences and realistic perception of individual difficulties and potentials. Those individuals with a higher sense of self-confidence are both more able to undertake any challenges and correct any failures.



IMPROVING SELF-CONFIDENCE AND ADHERENCE

Healthcare professionals are in an ideal position to help improve adherence and self-confidence with CIC and a number of studies have identified their important role. Faure et al (2016) described how the urology nurse provided therapeutic education and practical hands-on instructions in the successful teaching of CIC to boys. They used a number of educational materials including anatomical drawings, information booklets and dolls, and provided practical tips aimed at making the procedure as easy as possible.
It has been recognised that nurses play an important role in preparing the patient who needs to start CIC, in relation both to their capability and self-management. When patients and healthcare professionals develop self-confidence for the procedure, performance is more efficient, which encourages compliance during the rehabilitation process (Biaziolo et al, 2017).

For those that have an indwelling catheter, where the risk of complications (such as UTIs and blockages) is higher than in CIC (Wilde et al, 2015), having strategies in place to help reduce any of those complications is important. A randomised control study was carried out by Wilde et al (2015) to assess whether teaching catheter users self-management skills could decrease short-term catheterrelated problems, and whether improvements could be sustained over 12 months. They found that a simplified intervention using a self-monitoring calendar with optimal and consistent fluid intake was likely to add value in reducing complications.

The type of catheter that the patient uses has also been shown to influence compliance. Taskinen et al (2008) carried out a study to review patient experience of using a range of different hydrophilic catheters. Questionnaires were completed by 100 participants with a median starting age of CIC of four years. The questionnaire looked at a number of factors, including packaging, handling of the catheter, and any discomfort. Although there was no real difference between any of the catheters, the patients did have their own catheter preferences. Due to the demanding nature of CIC and the long-term commitment required, the study concluded that the patient is justified in selecting the best catheter for their own use.

CATHETERISATION AND SEXUALITY

Incontinence is often a taboo subject in our society and the use of catheters, particularly indwelling catheters, may have an impact on body image and feelings of sexuality. A study by Chapple et al (2014) found that for some individuals having an indwelling catheter resulted in feelings of negative body image and reduced sexual self-esteem. They concluded that although for some individuals sex was not an important part of their lives because of old age or illness, other patients would benefit from information on how to have a sexual relationship with a catheter in place and a chance to discuss the subject with their doctors.
 
Top tip:
Assessing a patient’s health related quality of life can help clinicians gain an understanding of the potential effect that urinary incontinence is having on their activities of daily life and wellbeing.
 

Although sexuality is considered to be an important aspect of holistic care, research has demonstrated that it is not routinely addressed in healthcare services. Dyer and das Nair (2013) undertook a study to look at clinicians’ experience of discussing sexuality with patients. Nineteen interconnected themes emerged relating to discussing sexuality with service users, including:
  • Fear about ‘opening up a can of worms’
  • Lack of time, resources, and training
  • Concern about knowledge and abilities
  • Worry about causing offence
  • Personal discomfort
  • Lack of awareness about sexual issues.
To improve an individual’s feelings of ‘normality’ and wellbeing, healthcare professionals need to address this issue and facilitate discussion around sexuality for those for whom intimate relationships are an important part of their life.

ISSUES FOR ADOLESCENTS

RememberWhen working with adolescents with long-term medical conditions, the management of these conditions is often played out against a background of rapid physical, psychological and social changes. As a result, it can often result in unique communication and management challenges. Previous studies have identified how teenagers find it difficult to accept and discuss ‘invisible’ problems (for example, the need to catheterise) with their peers (Michaud et al, 2004; Lindehall et al, 2008).

Not wanting to be seen to be different often means that they will avoid taking part in some social activities, as well as not regularly complying with the catheterisation regimen. Poor compliance to treatment is not uncommon in this age group, and is seen as a developmental component of adolescence (Michaud et al, 2004).

It is important that healthcare professionals involved with adolescents give plenty of opportunity for open discussion without being judgemental and provide as much support as possible. Opportunities to link in with their peers with similar problems should be explored and there are a number of support groups where adolescents can link up with young people with similar problems, to help them make sense of some of their feelings and concerns. Transition to adult services should be planned for as early as possible. Initiatives, such as ‘Ready Steady Go’, have been shown to improve long-term outcomes (Nagra et al, 2015).
 

DISCUSSION

Overall, the literature appears to suggest that, although for some individuals indwelling catheters can have a negative affect on body image, CIC in fact improves patient quality of life and psychosocial factors, as it enables many individuals to gain continence and maintain their independence. However, this assumption could potentially affect long-term compliance if patients concerns are not fully understood and acknowledged. Nurses have an important role in educating and supporting patients to carry out CIC and providing ongoing advice and information. Clinicians working with adolescents need to be mindful of the particular developmental needs of this group and provide appropriate support as necessary.

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Useful resources

References

All Party Parliamentary Group for Continence Care (2013) Continence Service. England, Survey Report. Available online: www.appgcontinence. org.uk

Alpert SA, Cheng EY, Zebold KF, et al (2005) Clean intermittent catheterization in genitally sensate children: patient experience and health related quality of life. J Urol 174(4 Pt 2): 1616–9; discussion 1619

Biaziolo CFB, Mazzo A, Martins JCA, et al (2017) Validation of a self-confidence scale for clean urinary intermittent self-catheterization for patients and health-caregivers. Int Braz J Urol 43(3): 505–11

Chapple A, Prinijha S, Salisbury H (2014) How users of indwelling urinary catheters talk about sex and sexuality. Br J Gen Pract 64(623): e364–71

Dyer K, das Nair R (2013) Why don’t healthcare professionals talk about sex? A systematic review of recent qualitative studies conducted in the United Kingdom. J Sex Med 10(11): 2658–70

Edwards M, Borzyskowski M, Cox A, Badcock J (2004) Neuropathic bladder and intermittent catheterization: social and psychological impact on children and adolescents. Developmental Med Child Neurol 46: 168–177

Faure A, Peycelon M, Lallemant P, et al (2016) Pros and cons of transurethral self-catheterization in boys: a longterm teaching experience in a pediatric rehabilitation centre. Urol J 13(2): 2622–8

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Taskinen S, Fagerholm R, Ruutu M (2008) Patient experience with hydrophilic catheters used in clean intermittent catheterization. J Pediatr Urol 4(5): 367–71

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