Urinary catheters are commonly employed in healthcare and have been used to drain poorly emptying bladders for 3500 years (Community Matters, 2019). A quarter of patients admitted to hospital are catheterised but this is not necessary in all cases, and catheters may not get removed before discharge (Community Matters, 2019). ISC is considered the best alternative to an indwelling urinary catheter as it has a lower risk of catheter-associated urinary tract infection (CAUTI) and minimises harm from catheter-related complications (National Institute for Health and Care Excellence (NICE), 2012). It should be further promoted to reduce the prevalence and over-reliance of indwelling catheter use.
ISC is defined as a person passing a catheter into their bladder to drain urine, then removing the catheter when the urine has been drained. The process of clean intermittent self-catheterisation was introduced by Lapides et al (1972) and found to be a safe, clinically effective alternative to an indwelling catheter in the management of neuropathic bladders. ISC is also believed to be more physiologically normal and acceptable (McConville, 2002) than continuous bladder drainage with a permanent indwelling catheter, as it allows the bladder to fill and empty completely (Barton, 2000; Rigby, 2005).
A growing body of nursing research demonstrates that, once learned and accepted, ISC improves symptom control and quality of life (Logan et al, 2008; Shaw et al, 2008; Kessler et al, 2009). However, learning ISC involves challenges, both physical and emotional. Researchers have found that patients feel worried, shocked, frightened and even depressed when initially introduced to ISC (McConville, 2002).
The benefits and longer-term improvements to quality of life and symptom control far outweigh the early challenges (Logan et al, 2008; Shaw et al, 2008; Kessler et al, 2009). Once accepted, ISC enables patients to have greater independence with their own self-care by providing them with personal control of bladder function. In contrast to an indwelling urethral catheter, ISC can enable greater freedom of the expression of sexuality and promotes a positive body image because patients do not need to wear fixation straps and body-worn urinary drainage bags that need emptying and regular attention (Newman and Wilson, 2011). By choosing ISC, men can avoid many of the problems associated with indwelling catheters such as CAUTI and urethral trauma.
It is not controversial to claim that no one wants a urinary catheter until they cannot pass urine (Community Matters, 2019). For many patients embarking on ISC, they do not have much choice if they have voiding dysfunction with incomplete bladder emptying.
The purpose of ISC is to assist in bladder drainage. Men who are deemed suitable for learning ISC as a management option usually have lower urinary tract symptoms, such as benign prostatic hyperplasia, incomplete bladder emptying (residual urine of 150 ml or over), voiding dysfunction linked to a neurological condition or a urethral stricture.
This multicentre satisfaction survey and product evaluation offers new insights around the male experience of learning ISC, highlighting benefits and limitations of this particular type of catheter.
The survey
The survey aimed to explore men's views on using the Hydrosil Go intermittent catheter. It is also known as Magic3 Go™ intermittent catheter in some countries.
It is a ready-to-use silicone intermittent catheter with a lubricious coating that maintains the catheter in a hydrated state without requiring activation or lubrication before use, so can be used straight from the packet. The coating, called CleanGlide™, is designed to help the catheter glide easily and comfortably through the urinary tract. The device can be folded to fit discreetly into a man's pocket.
The survey questioned men who were new to ISC to explore their experience of learning ISC with this silicone catheter and to obtain their views about its acceptability, comfort, packaging, handling and disposal. This was to acquire information that could assist nurses in advising on catheter choice and other aspects of service delivery.
Material and methods
Structured questionnaires were used to explore the different features of the catheter and to capture men's views of using it. The data were collected in 2018 and 2019 by urology nurses working in UK NHS hospitals/urology units and from European (France, Netherlands and Italy) hospitals/urology units where this catheter is readily available. NHS ethical approval was not necessary for this type of satisfaction survey.
Only male patients new to ISC were approached and recruited. The questionnaire was completed by a nurse to record the data both at induction of ISC and at follow-up at 4-6 weeks (Tables 1 and 2).
| Age ≥18 years |
| Using a minimum of 2 catheters per day |
| Not previously conducted intermittent self-catheterisation |
| No urethral hypersensitivity |
| No major urethral strictures or congenital abnormalities in the urinary tract |
| No urinary tract infections or history of urinary tract infections |
| Sample size | Number interviewed: 153 |
| Age | Median age: 49 years |
| Number catheterised/intermittent self-catheterisations (ISC) conducted per day | Average frequency of ISC: 4.6 times per day |
| Indications for ISC | 83 had a neurological condition |
Results
The majority of participants found the catheter to be comfortable, discreet to transport and use, and easy to handle when learning to catheterise (Table 3).
| Learning self-catheterisation | 84% of patients said it took them a couple of days to master self-catheterisation |
| Confidence in performing the catheterisation | 86% were confident in performing the catheterisation after a few weeks |
| Packaging appearance | 84% of the patients found the packaging appealing |
| Packaging size | 96% of the patients felt that the packaging made it easy to accommodate ISC into daily routines |
| Noise when opening the packaging | 91% of the patients did not find it to be loud when manipulating, folding and opening the packaging |
| Ease of folding the packaging using the adhesive tab | 82% of the patients found it easy to fold the catheter and keep it folded using the sticky tab |
| Ease of opening the pouch | 87% of the patients found it easy to open the pouch using the finger loop |
| Attaching the packaging to a surface | 68% of the patients found it easy to attach the packaging to a neighbouring surface |
| Inserting and withdrawing the catheter | 74% of the patients found insertion and withdrawal of the catheter easy |
| Comfort of catheterisation | 12% of 153 patients found the catheterisation uncomfortable or very uncomfortable |
| Discomfort after the catheter was removed | 80% had no discomfort following removal |
| Limiting the use of the catheter because of urethral sensation | 80% of the patients did not need to limit the use of the catheter because of urethral sensation |
| Messiness when using the catheter | 70% of the patients never or rarely got messy catheterising |
| Replacing the catheter into its packaging for disposal | 80% of the patients found replacing the catheter into its packaging and disposing of it easy |
| Packaging in your pocket after use | 86% of active patients were confident to put the catheter packaging back in a pocket after usage |
| Number of steps of each catheterisation | 0.65% of 153 found that the number of preparation steps was unacceptable |
| Desire to continue using the Hydrosil Go intermittent catheter | 83% of the patients were keen to continue using the catheter |
| Recommending the Hydrosil Go intermittent catheter | 90% of patients were likely to recommend the catheter and 10% were not |
| Limitation to social life or activities because of catheterisation | 5% limit their social life or activities because they have to catheterise |
| Compliance with the prescribed number of catheterisations | 87% of the patients stated that they were able to comply with the prescribed number of catheterisations |
| Compliance with catheterising outside the home environment | 88% of the patients did not limit the use outside the home |
Focus group
Despite the favourable results of the survey, it is predominantly a product evaluation so cannot address the underlying issues of learning ISC. A guided focus group with six UK patients was held to further explore themes in more detail about aspects of learning and living with ISC that are not immediately apparent to nurses but are important to men.
Invitations to take part in the survey were sent to all men receiving intermittent catheters via Script-easy™ (a prescription dispensing service operated by Bard Limited), living near where the focus group was to be held. Those who wished to participate were invited to attend the focus group.
This focus group involved a roundtable discussion with patients who consented to take part, discuss their views and share their experiences of learning ISC (Tables 4 and 5). Three of the men used a silicone catheter, one used a polyvinyl chloride catheter, one used a polyolefin-based elastomer catheter and one used a catheter made of a polyurethane.
| Patient # | Age (years) | Reason for use | Period of use | Frequency of use | Catheter type |
|---|---|---|---|---|---|
| 1 | 78 | Retention | 3 years | 1/day | Silicone |
| 2 | 21 | Tetraplegia | 2 years | 3–4/day | Silicone |
| 3 | 64 | Retention | 3 years | 6/day | Silicone |
| 4 | 58 | Enlarged prostate | 1 years | 2/day | Non-silicone |
| 5 | 69 | Enlarged prostate | 3 years | 5/day | Non-silicone |
| 6 | 63 | Retention | 4 years | 4/day | Non-silicone |
| Theme | Explanation |
|---|---|
| Psychological issues | Anxiety when learning, fear, privacy using public toilets, impacts on sexuality and relationships |
| Physical issues | Practical/anatomical difficulties during catheterising, skill acquisition, complications |
| Information giving and communication | Information wanted about hygiene, reducing catheter-associated urinary tract infection, and sexual impacts of ISC |
Focus group narratives
The group talked about a range of issues, starting with their introduction to ISC. It was apparent that this triggered some powerful emotions in the men. One participant said he was petrified and shaking when first catheterising; another said he felt depressed. Participants went on to discuss how they eventually adapted to ISC over time and moved towards acceptance, and how they now considered ISC to be the best treatment to manage their urinary symptoms.
A few individuals wanted to talk about the way using a catheter affected intimate relationships and sexual function, and they voiced concern about the sexual impact of doing ISC. Sex was clearly important to this group, but they said that no one had offered information about sex or talked about whether performing ISC could affect their sex life or relationships. Roe and May (1999) and Chapple et al (2014) said nurses may be embarrassed about discussing sexuality with people who use devices or other appliances related to continence. However, by not raising the subject, nurses will put their patients in the uncomfortable position of having to bring it up themselves.
In studies on patients with indwelling catheters, professionals tend to focus on only the technical aspects and neglect the sexuality issues (Roe and May, 1999). Sexual self-esteem is likely to be tied to how individuals define masculinity and having or using a catheter is not considered masculine (Chapple et al, 2014). One of the participants in the focus group said he worried that he may never be able to have sex again because of performing ISC.
No studies have been carried out on the effect of ISC on patients’ sexuality but there is no practical or anatomical reason why ISC would affect sexual function; indeed, it is the preferred option for those who require a catheter and are sexually active. As ISC imposes a psychological burden affecting perceptions of masculinity and sexual self-esteem, it is important to explain this to men; otherwise, they have a tendency to believe their sex life may be over.
There were other shared issues relating to matters of privacy or lack of it regarding using public toilets. Concerns were raised about embarrassment in relation to the sounds made when undertaking ISC, particularly when opening the catheter packaging, as the men were concerned about what other people thought was happening behind closed doors. The lack of lockable doors and the issue of having to queue to use a toilet cubicle could also pose barriers to performing ISC outside the home. The limitations of performing ISC and access to handwashing facilities in a public toilet has been reported by Bolinger and Engberg (2013). It also threatened personal hygiene routines, as public toilets were perceived as dirty and handwashing facilities fell below the standard required.
What was encouraging was the importance these men placed on cleanliness and the lengths they went to in order to minimise contracting a UTI. Evidence suggests that CAUTI is a common complication for patients of ISC (Bolinger and Engberg, 2013). The focus group participants were familiar with what to look out for in regards to the signs and symptoms of UTIs but some were prone to them. They all followed fairly strict handwashing routines and strived to maintain a non-touch catheterisation technique to avoid catheter contamination. Those using the Hydrosil Go intermittent catheter praised the gripper device because it helped to facilitate a non-touch catheterisation technique.
Bolinger and Engberg (2013) reported a range of barriers to compliance with ISC, including poor dexterity, weight/size issues, visual problems making insertion difficult, time limitations, problems with the size, type or material of catheter and not being comfortable with performing catheterisation. The importance of complying with the recommended frequency regime as stipulated by the nurse was discussed in the focus group and they appeared to understand that, to help reduce infection rates and drain residual urine, regular catheterisation was necessary. An anatomical problem was volunteered by one of the participants who said because of a distended abdomen and a small penis, he experienced difficulty visualising the urethra and catheterising; however, by using a mirror, he had learnt to overcome his problem.
The delivery of adequate information was essential to urology service patients as they said this helped them to feel empowered and more confident they would succeed and comply with self-catheterisation. In summary, they were especially interested in receiving more information about infection prevention measures and the impact that learning and undertaking ISC could have on sex and sexuality.
Discussion
Learning ISC and initial anxiety
Urinary catheters may be commonplace to nurses but learning and living with ISC is not easy for all patients. The introduction to ISC is the most challenging time, as it evokes a variety of emotions, embarrassment and shock as men are unfamiliar with and fearful of the concept of ISC, and they worry about causing damage to themselves (Logan et al, 2008). The focus group participants described experiencing similar strong emotions. On induction to ISC, these men expected and required detailed information from the nurse to gain an understanding about ISC and why it had been recommended to address their condition. There are guidelines on the assessment and teaching of ISC for nurses, which can be used as a checklist and aide-memoire to guide them through the complex process (Logan, 2010; Vahr et al, 2013).
Most of the participants wanted to know about the effects ISC could have on their relationships and sex lives but they felt that this information was not forthcoming. One reason ISC is considered better to an indwelling catheter is that it allows sexually active men to have a normal sex life. However, inserting a catheter into this intimate part of the body can affect men's perceptions of masculinity (Chapple et al, 2014) and this became apparent from the focus group discussion. Imparting the right amount of information tailored to individuals involves a fine balance but one that nurses who teach ISC need to develop if they are to enhance the patient experience.
The focus group participants eventually became skilled at ISC and in paying attention to their bodies and learning to solve practical problems; an example is the man who used a mirror to catheterise. Once ISC is normalised and integrated into a person's lifestyle, it can improve quality of life (Shaw et al, 2008) and the men in this group were happy to continue to use ISC and this catheter as long as this managed their symptoms.
Catheter features and choice
The Hydrosil Go intermittent catheter is more flexible than other catheters as it is made of silicone rather than plastic, and it has a gripper device, which facilities non-touch technique, avoiding contamination of the catheter during insertion. The catheter has a CleanGlide coating and no water sachet is needed, which prevents messiness. The packaging has a finger loop to make it easy to open and is designed so it does not look like a medical device. Evaluation demonstrated that both the catheter and the packaging were well received by the patients in this survey. They found the device easy to use and open and non-messy; the gripper was viewed as a good feature and valued by the participants as it allowed them to use a non-touch technique.
There are already a vast variety of ISC catheters for nurses to choose from. Nonetheless, there is always room for improvement and a need for product development, as not finding a suitable catheter can be a barrier to compliance with ISC (Bolinger and Engberg, 2013). Feedback from participants in surveys such as this encourages continued development to tailor catheter design to suit all shapes and sizes and to help people with compromised manual dexterity. Nurses need to stay abreast of product developments as they have such an important role in helping patients to choose a catheter that suits their individual lifestyles.
Imparting information and communication
The initial distress and aversion to ISC described by these focus group participants and, indeed, researchers (Bakke et al, 1993; Bradley, 2000; McConville, 2002; Logan and Shaw, 2007; Logan and et al, 2008; Shaw et al, 2008) indicate how important the nurse's role is in communication, motivating and supporting men through this time. The more hidden aspects of living with a catheter, such as managing equipment, ordering and carrying stock, catheterising outside the home, making adjustments in sexual activity or worrying about these issues, are challenging (Shaw et al, 2008; Wilde, 2003).
Some nurses may be reluctant to discuss issues of sexuality with men because they fear causing embarrassment to them or being embarrassed themselves (Roe and May, 1999), which was highlighted from the focus group. However, it is an essential conversation to hold to allay men's fears over this aspect. Chapple et al (2014) also found that health professionals involved in catheter care, including GPs, were reluctant to talk about sex and that no professionals had voluntarily brought up sex with patients using indwelling catheters in their study. Sex is not a subject that can be ignored for patients living with catheters.
Long-term compliance with ISC regimens is often a problem (van Achterberg et al, 2008). Compliance was not an issue for this sample in the short term at least. There is evidence that ISC is not always continued in the long term, and that follow-up care is insufficient (Bolinger and Engberg, 2013). However, provided that patient education, training and follow-up supervision for ISC are good, then longer-term compliance can be improved (Van Achterberg et al, 2008; McClurg and Ishrad, 2012).
The lack of access to clean public toilets has been highlighted and this can make going out, travelling and compliance with ISC outside the home challenging (Shaw et al, 2008). Therefore, information and advice will be welcomed around travelling, finding discreet catheters, disposal of catheters in public toilets and how to access a Radar disabled toilet key.
Managing all these issues requires support, open communication, excellent information giving and sensitivity from the nurses who teach ISC (Wilde, 2003; Shaw et al, 2008; van Achterberg et al, 2008). Therefore, experienced nurses are required to teach ISC and to deliver a good service in relation to meeting patient expectations. Nurses need a sound knowledge base to be able to advise on all the aspects of ISC and to minimise UTIs and aid compliance with ISC. Catheter suppliers can also help with information provision as they produce booklets, videos and websites (such as www.bardcare.uk) that patients can be told about in addition to the verbal information supplied by nurses.
Conclusion
ISC has become the method of choice for draining the bladder for voiding dysfunction in men. The majority of men in this survey found ISC using the Hydrosil Go catheter to be easy and comfortable. It was found to be a patient-friendly catheter and can be considered by nurses who are involved in teaching and supporting men with urological or neurological conditions to carry out ISC.
Exploring the patient's experience of ISC offers useful insights into what matters for men when learning and living with ISC. Further exploration and explanation of sexual issues are clearly required.
This paper is important in highlighting the nurse's role in information giving and offering specialist support helping men to adopt and adapt to ISC. It has discussed some practical considerations for nurses involved in teaching ISC.
Furthermore, it has explored the psychological impacts of the male experience of learning ISC, which illustrates patients’ needs and expectations.
It is hoped that this article will offer opportunities to reflect on the nursing role and responsibilities in supporting men with ISC, and addressing issues specific to men in this way will help guide nursing practice in this therapy area.