For every person presented with the prospect of performing intermittent self-catheterisation (ISC), the fear of urinary tract infection (UTI) is not unfounded. Indeed, the average rate of UTI in ISC users may be as high as 2.5 per year (Vahr et al, 2013). A powerful adjunct for essential bladder management, ISC is vital to keep post-void residuals low while promoting self-esteem, discretion, independence and sexual freedom. ISC carries a much lower risk of UTIs than indwelling catheters (Kinnear et al, 2020) but unfortunately the concomitant UTI risk of using ISC exists nonetheless.
Although health professionals may be well versed in the benefits of ISC over indwelling catheters, patients may need a great deal of information to understand and fully embrace the technique in order to appropriately manage their bladder. When that information includes advice about managing UTI risk, the patient is more likely to adopt good therapeutic practices and adhere to their management plan.
This article discusses how health professionals can help to reduce the fear of UTIs for their patients performing ISC.
Urinary tract infections
A UTI is defined as the presence of bacteria in disproportionate levels, along with symptoms such as urinary frequency, urgency, dysuria and cystitis (National Institute for Health and Care Excellence (NICE), 2018a). When considering treatment for a UTI, care must be taken not to conflate bacteriuria (colonisation of bacteria without symptoms) or simple cystitis (a sensation of inflammation of the urothelium) with a true, symptomatic infection of the urinary tract. Indeed, asymptomatic bacteriuria is to be expected in those who have an indwelling catheter and also in those who use ISC (NICE, 2018b).
With specific regard to ISC, the mechanism of how a UTI happens is not clearly understood and is likely to be multifactorial (Edokpolo et al, 2012). Personal hygiene, technique and contamination have been suggested as causative factors notwithstanding the person's underlying medical conditions requiring them to perform ISC in the first place. Frequency of UTIs certainly seem to reduce when factors such as diabetes, constipation and lack of adequate hydration are adjusted (Bonkat et al, 2022). Therefore for each individual patient, individualised assessment can highlight the potential influential elements to be remedied. Furthermore, in so doing, the patient is not only armed with the tools to reduce the impact of UTIs, but also has the confidence to feel they have agency over what is otherwise a significantly troublesome complication when performing ISC. Crucially, therefore, this also promotes adherence.
Preventing contamination
Adequate hand hygiene remains the single most important intervention in performing ISC. However this, as well as bathing or showering at the time of passing a catheter, is not always achievable. In order to overcome such barriers to hygiene, many ISC products exist that include innovations to facilitate a non-touch technique. Catheters with attached sheaths, handles or sliders may give the person greater confidence that they are limiting contamination as much as possible. Of course, in our pandemic-conscious world, awareness of hand-hygiene gels is much greater than ever before. However, it is extremely important to avoid getting the gel on intimate areas because this can cause pain or a burning sensation, and as health professionals we must not assume that our patients are aware of this.
Product selection
The compelling evidence that hydrophilic catheters are likely to result in fewer urinary tract infections (Li et al, 2013) has been linked to a reduction in microtrauma in biomimetic trials. In selecting a product for the ISC patient, evaluation of both the quality and durability of lubrication is essential to limit urethral trauma (Humphreys et al, 2020). Furthermore, as ISC product packaging and product features may be difficult for some patients to manipulate, careful assessment of the product in use by the patient can confirm it is suitable and ensure its proper use.
Effective technique
Beginner ISC users may not be aware of the importance of effective bladder drainage. For many beginners, once the urine has stopped flowing the catheter may be immediately withdrawn, leaving a quantity of urine behind to stagnate. This is completely understandable, as is the attempt to bear down to make the flow faster, which of course it will not. Patients must be educated that it takes time to allow the bladder to drain passively when compared with normal detrusor function. Also, that the catheter must be withdrawn slowly once the first flow stops to allow the eyelets to once more rest beneath the fluid level and drain the bladder effectively.
Adequate hydration
Aiming for an intake of 2 litres of fluid daily (if not renally insufficient) allows flushing of the contents of the urinary tract, including any possible contaminants. Good hydration also helps to reduce constipation, another common factor in the development of UTIs. Many patients deliberately dehydrate themselves with the aim of reducing their urine output. ‘If I don't drink, I won't wee and then I'll need to do less ISC’ is a frequently heard comment when a patient discloses this particular approach. It can be very difficult to persuade a patient not to do this, but adequate hydration is, nonetheless, a requirement in resisting the development of UTIs.
Regimen and routine
Other tricky conversations can occur when encouraging a patient to stick to their required daily schedule and timing of ISC. ‘I've got it down to once a day’ is also commonly reported by those patients who have decided the planned 4-times-daily regimen is not for them. Once again, this approach is entirely understandable but it is incumbent on the ISC teacher that the patient understands the importance of adhering to their personal routine in line with post-void residual findings. Some ISC users avoid catheterisation in certain places and at certain times, which may allow residual volumes to increase incrementally. Discussion with the patient may unmask these barriers to compliance that may then be overcome with a simple addition of perhaps a product which is more discreet or can be resealed once used.
General factors
Other modifications that can create an environment inhospitable to further urinary tract infections include adding in vaginal oestrogen therapy for post-menopausal women. Oral methenamine hippurate may also be trialled Some patients find cranberry juice helpful. Adding in a stool-bulking agent such as macrogol or even adding a tablespoon of linseed to breakfast cereal each day can motivate the bowel sufficiently to prevent constipation building up and aid bowel clearance. There are other more major adaptations to help people to be more independent with their hygiene needs. As patients become older they may not be able to get in or out of the bath or may feel unsafe to have a shower. By discussing hygiene provisions the health professional may be able to signpost the person to obtain adaptations to their bathroom, perhaps with local authority funding.
Summary
UTIs may be a known risk for ISC users but frequent infections need not be inevitable. By taking time to assess the person's own presentation, their requirements, their values and their fears, patients may be educated about ways to reduce that risk. As the person's needs and abilities change over time, it is important that reassessments take place to ensure the person remains educated to manage their changing needs. Patients' own perceptions may need to be examined in the light of clinical evidence to inform safe and effective ISC practice. Many common factors that can underly a predisposition to developing UTIs should also be acknowledged in relation to the person's personal hygiene, dexterity, age, sex and medical presentation. In providing reassurance and advice, the health professional can help empower patients to adopt healthy ISC practices in everyday life.