Product review - the drain pain
Self-intermittent catheterisation is a simple technique, yet it is revolutionary. Read on to find out why.
“During World War Two, the average life expectancy of a soldier with a traumatic spinal cord injury (SCI) was four years. The vast majority of deaths were caused by kidney failure. In 2013, the life expectancy of somebody with SCI will approach that of the average population. The reason? Self-intermittent catheterisation.” Dr Mohamed Haffejee, professor of urology and head of department at the Charlotte Maxeke Hospital in Johannesburg, is fond of recounting this anecdote because it illustrates just how life-changing a good catheterisation regime is.
SIC (self-intermittent catheterisation), also known as CIC (clean intermittent catheterisation) is a way to regularly empty your bladder every hour to six hours using a plastic tube known as a catheter. The catheter is inserted through the urethra and into the bladder, from which the urine drains. (Some people may have had urinary diversion surgery to drain urine through a stoma site, not the urethra. In such cases a conduit is created from the bladder opening out to the abdomen.)
The procedure does what it says on the box: it is done by the patient him- or herself, it is done intermittently, meaning the catheter is removed after the urine has drained, and it is done under clean but not sterile conditions.
Who can do SIC?
People who have neurogenic bladders, which means bladders that do not empty, or do not empty completely on their own, can practise SIC if they have adequate dexterity, or a caregiver can perform the procedure. You may have an inability to control urine flow (hold your urine in), or you may conversely not be able to empty your bladder, whether from a SCI or conditions such as spina bifida, motor neuron disease or multiple sclerosis.
Old urine that becomes stagnant in the bladder becomes infected and causes urinary tract infections (UTIs). Alternatively, trapped urine that accumulates can stretch and eventually damage the bladder muscle, or travel back through the ureters into the kidneys (reflux), even causing swelling and damage (hydronephrosis).
“Of the bladder and the kidneys, our kidneys do the real work, filtering fluid, excreting toxins, and conserving nutrients for the body,” says Dr Sean Doherty, a senior consultant urologist at Chris Hani Baragwanath Hospital. “In contrast, the bladder has no metabolic effect. It is really nothing more than a storage facility for already produced urine. So if there’s a choice, preserving a patient’s kidney function over the bladder is always the primary aim. The secondary aim is to make life as pleasant as possible for the individual.”
To catheterise yourself or your child is scary at first, that is an undeniable fact. However, as the saying goes, sometimes you find that the dog you fear the most is toothless. SIC is easy and safe once you know how to do it, and importantly, it has some significant advantages over indwelling catheters.
Indwelling catheters also known as Foley catheters, named after a US surgeon who designed them in the 1930s, are catheters with a balloon at the tip. When the catheter is not draining urine, the balloon is inflated to stop the catheter from falling out of the urethra. The catheter is not removed between urine drainings. By contrast, a non-indwelling catheter is known as a nelaton catheter.
SIC is appropriate for people who need catheterisation for permanent or long-term conditions, as opposed to those who are being catheterised for the duration of an operation.
However, an indwelling catheter might be used by long-term users who cannot self- catheterise.
“If at all possible, it is better to avoid an inwelling catheter, for several reasons,” says Dr Doherty. “It is associated with a much higher rate of infection, although all infections are not necessarily treated with medicine.”
“The bladder is a muscle that likes to expand and contract, so if you use an indwelling catheter, it means your bladder is always empty,” he continues. “The bladder is a compliant organ so it loses elasticity, tone and capacity over a period of months or years. So once that point is reached, you’ve burnt your bridges, and you can no longer go back to a more normal bladder function. In a male especially, an indwelling catheter can also slowly erode the urethra, eventually causing some erosion of the penis.”
Disadvantages of SIC
There is a small risk that very long term SIC can cause repetitive stress injury to the urethra. It is important never to force a catheter into the urethra because of the risk of creating what urologists call a false passage - a hole in the urethra.
Urine is sterile; this is why adventurers urinate on a dirty wound to wash grime away if they are not near health services. And because you are introducing a foreign body into the bladder when you catheterise, you also risk introducing bacteria into a previously sterile environment. You may still get occasional UTIs which may, or may not have to be treated. Many SIC practitioners live symptom-free with a colony of bacteria in their bladder. Using self-lubricating catheters, or a lubricant while catheterising is advised to reduce the chances of urine infection and damage to the urethra.
“SIC may or may not be painful in a sensate urethra,” says Dr Doherty. “You can’t be sure how it will be for you until you try yourself.” You can use a local anaesthetic lubricant such as Remicaine to numb the area before you insert the catheter.
Starting to catheterise a child, who cannot rationalise the reason for the procedure, can be very difficult indeed. It is for this reason that doctors advise parents to acclimatise children who potentially need SIC to the procedure earlier, rather than later. It is easy to stop catheterising a four year old, it is not so easy to start. “A child who is under two years old will generally accept the procedure as ‘normal’,” says Dr Doherty. Some children can even start to catheterise themselves by the age of four.
Having made all these points, the risks of not catheterising must equally be considered, and they usually outweigh the cons of SIC.
Which one to choose?
Catheters come in a range of shapes, sizes and varieties. The adult male urethra is on average about 30cm long, the female urethra 4cm on average, so in the first instance, the length of catheter varies between the genders. Some manufacturers make standard-size catheters (about 40cm) for men and women, while others sell gender-specific ones of different lengths.
Catheters come in different thicknesses depending on the width of the urethra. Catheter sizes are classified using the French catheter gauge, where 1Fr corresponds to 1/3mm in diameter. The most common adult sizes are between 8Fr and the largest 24Fr, the average adult size being about 16Fr. Paediatric sizes are generally available from size 6Fr.
Catheters are manufactured from materials such as coated latex, silicone, PVC, or neoplex. All are flexible materials, but as latex allergies are common with extended use, pure latex catheters are now rare. However, silicone catheters are somewhat harder and therefore a little more likely to cause damage to the urethra with continuous use. New compounds are constantly being developed – ask your manufacturer what their catheters are made of.
Some catheters are self-lubricating, which means they are coated with a hydrophilic substance which makes them very slippery when wet. Other have to be coated with a water-based lubricant such as KY jelly before use. Some have curved tips to aid insertion into the urethra. Some have “drainage eyes” along the pipe to drain liquid quicker, while others are solid. Catheters are marketed as single- or multiple-use, with most being sold as single-use catheters because of recent concerns in the European Union over infection rates. If you are registered for chronic medication on your medical aid, the cost of your catheters should be covered according to Cornia Ellis from Teleflex. “So if you have the resources, buy low-friction single use catheters,” says Dr Doherty.
How to catheterise yourself
- Wash your hands with soap and water.
- Clean the urinary meatus with saline or soap and water. The urinary meatus is found on the tip of the glans penis in men and in the vulva, between the vagina and the clitoris, in women.
- Use a water-based lubricant such as KY Jelly or Remicaine to lubricate the first 5cm of the catheter (unless it’s self-lubricating). Remicaine has a low dose of local anaesthetic and can be used if catheterising is painful.
- Gently slide the catheter in. When the urine begins to flow, insert it another few centimetres.
- Allow the urine to drain out.
- Remove the catheter, rinse, wash it and place it in a sealable plastic bag, or mild antiseptic solution if you intend to reuse it.