The decision to start intermittent self-catheterisation (ISC) is rarely an easy one for patients. Urology nurses can provide them with the clinical rationale and the goal of an appropriate regimen, but, for almost every patient, the physical and psychological hurdles to reach that goal can be daunting and multifarious. A key role of the nurse is to equip the patient with the correct tools to overcome these difficulties and to build a therapeutic relationship that can support them to integrate ISC into their daily life. This article aims to show how this relationship can be built, with the focus on exploring the individual needs of each patient and matching them to appropriate ISC products and techniques. For the purpose of this article ISC regimens relate to the management of urinary retention.
Start with the person
Some patients who are required to start ISC are already aware of the significant symptomatic impact of their urinary retention on their daily activities. These patients may be struggling with urinary leakage, feelings of discomfort and voiding difficulty. In this situation, the introduction of the concept of ISC may be somewhat welcome, although still alarming. It is easy to see how troublesome symptoms of post-void urinary retention may be easily alleviated by eliminating the cause.
Conversely, for those patients who have asymptomatic urinary retention, the prospect of performing ISC can be particularly difficult to accept. The patient has sought help because they have bothersome symptoms such as poor flow or urinary frequency, but otherwise might imagine they have a healthy functioning bladder. It may seem particularly unfortunate that often these very patients go on to lose all natural voiding ability as their bladder volumes, once safely managed with regular ISC, never reach the point where ‘natural’ voiding can take place.
It is almost always men with painless chronic retention who fall into this category, who will often say at follow-up ‘I tried it but it wasn't for me’. Explaining to such men that the importance of reducing dangerously high post-void residual volumes relates to preventing renal failure is particularly important and cannot be overemphasised. For such patients, a newly instituted ISC regimen is an unwelcome and unnecessary intrusion rather than a lifeline for relief of life-limiting leakage symptoms.
The first consultation where ISC is introduced is of great importance as it is here that the tone for the patient's relationship with self-catheterisation is set. However, having timely and effective follow-up support can do much to encourage the new starter to cope well. One further way of increasing patient confidence is knowing that the nurse has performed ISC on him- or herself. While mindful of the risk of urinary tract infection (UTI), it can be useful for the nurse to try a range of ISC products. This has the duel benefit of allowing a first-hand appreciation of each product and also helps the patient to feel that self-catheterisation is something achievable.
Box 1 provides some points to consider when starting a patient on ISC.
Different people need different solutions
Just as every patient is different in terms of physical capability, working or caring responsibilities, personal relationships and symptoms, there is an enormous range of ISC products with something to suit every need. The basic design of all catheters remains the same in that they comprise a sterile tube with eyelets and a smooth tip for insertion that, when introduced into the bladder, enable the drainage of urine. It is important to tell the patient not to strain and to allow the urine to drain passively.
Intermittent catheter manufacturing has now evolved to include a wide variety of designs and features. By listening closely to the patient's needs, an understanding of which individual features of one ISC product may make it more appropriate than another for that patient will become clear. And, although as nurses we may be aware of a product's individual selling points, the patient may not see those details as important. For example, if a patient is particularly concerned about discretion of the product in a social situation, lubrication or whether it can be recycled may not be a priority for them.
Common patient fears
Many patients have fears about ISC that the nurse can help to alleviate
Fear of urinary tract infections
Preventing UTIs remains the holy grail for all ISC product manufacturers. Unfortunately, to date, the mechanism for developing UTIs in patients who perform ISC remains unclear. Theories postulated include (Igawa et al, 2008):
Nurses can help the patient try to overcome their fear of developing a UTI by promoting best hygiene practices, adequate hydration and an effective drainage regimen. These are within the power of almost every person who performs ISC.
Fear of contaminating the catheter
If there is a fear of primary contamination of the catheter with the environment or fingertips, many manufacturers now produce catheters that have a sleeve that stays in place during catheterisation and prevents direct touching of the catheter itself. It is unclear whether this product feature prevents UTIs, but it certainly improves patient confidence, particularly when catheterising in environments such as public toilets, situations where patients are unable to wash their hands, or in cases where the catheter may inadvertently be dropped on the toilet floor.
Fear of the catheter being obvious to others
Almost every product for patient use is designed with discretion in mind these days. Quiet rustle-free packaging makes it much easier for someone to open a catheter in a toilet cubicle without it being obvious what they are doing. Equally, catheters are packaged is small, pocket-size cases that are designed to resemble make-up bags and sunglasses cases. This means that even if a catheter were to fall out of a person's bag or pocket its purpose would not be obvious to others.
Fear of disposal difficulties
As many public or workplace toilets do not include appropriate disposal facilities, manufacturers have also considered this in design specifications. Some catheters can be repackaged after use and resealed for disposal at a later time. Particularly important here, however, are product design features that ensure a catheter cannot be reused once it has been repackaged.
Fear of medicalisation
Some patients are concerned that starting to perform a regular regimen of ISC may make their lives feel more medicalised. It is important to emphasise that, apart from the need to perform ISC when necessary throughout the day, they retain their personal freedom that those with an indwelling catheter do not. It can be difficult for some patients to accept at first, but, for those with painless chronic retention, performing ISC will prevent further medicalisation.
Box 2 lists some positive aspects of ISC that can be emphasised to reluctant patients.
Conclusion
ISC can provide a lifestyle-enhancing solution to the debilitating problem of urinary retention when performed appropriately. Discovering each patient's key issues and concerns can help reconcile them to self-catheterisation. Equally, a knowledge of the range of product specifications available can help to make the prospect of performing ISC on an ongoing basis more palatable for patients by aligning each product with the person's individual needs.