Intermittent catheterisation is the oldest form of catheterisation. The ancient Egyptians used reeds to empty a patient's bladder, and in 1752 diplomat and inventor Benjamin Franklin, one of America's founding fathers, created a flexible silver coil catheter to treat one of his brothers (Buckley et al, 2015). Intermittent catheterisation remained the only way to catheterise until Frederic Foley designed an indwelling catheter in the early 20th century (Bloom et al, 1994).
Today, the situation has changed, with the vast majority of patients having an indwelling catheter. A study by Shackley et al (2017) found that 12.9% of NHS patients have an indwelling urinary catheter. But how many of those patients could have been managed with intermittent catheterisation instead?
Case study
A combination of medical conditions left Paul Carter (not his real name), who is in his mid-fifties, chair/bed bound. He lives in his own home, supported by a full package of carers. Due to a poor gag reflex, he had a percutaneous endoscopic gastrostomy (PEG) inserted. He is visited three times a day by a district nurse team, of which I am a member, to administer his medicines and feeds, via the PEG, and to provide the other nursing care he requires.
Three years ago, Mr Carter was admitted to hospital. He was discharged home with an indwelling catheter. He quickly told the district nurse team how much he disliked having a urinary catheter. He complained that it was constantly uncomfortable and that it was very painful when it was pulled, which happened a lot when his carers did not secure his leg bag.
I provided him with a catheter securement device, but that only worked when the carers attached the catheter to it.
Through Mr Carter's GP arrangements were made for him to have a trial without catheter (TWOC). Unfortunately, this was 6 months after he had been discharged home with the catheter, and this failed. His bladder was unable to fully empty, and the residual amount of urine was so large that he had to be catheterised again.
The catheter continued to cause problems for Mr Carter. He developed regular urinary tract infections, which were treated with antibiotics. He developed diarrhoea several times while on the antiobiotics, which caused him to soil himself. The catheter also regularly blocked and required changing. Unfortunately, not all the district team nurses were competent in male urinary catheterisation. A nurse would visit Mr Carter to administer his medication, find his catheter was blocked, but would not be able to change it and so they would have to arrange for another nurse to do this. Once Mr Carter's catheter was blocked, it would often bypass and soil him with urine. Understandably, Mr Carter became frustrated and his mood was often low because of this.
One evening the catheter blocked again, but that night the district nurse twilight service did not have any nurses competent in male urinal catheterisation. Consequently, Mr Carter had to be taken to hospital to have his catheter changed. In the emergency department (ED), once the catheter had been removed, he refused to be re-catheterised. He spent the night in ED and was discharged the next morning with a urinary sheath in place.
The urinary sheaths proved no better than the catheter. Mr Carter found wearing them uncomfortable for long periods, which he often had to; they would also fall off if he passed a large amount of urine at once, which again resulted in him soiling himself.
Offering a new option
On one occasion, when I visited Mr Carter to administer his morning medications and feed, he complained about his urinary sheaths and asked me if anything could be done. I mentioned the possibility of intermittent self-catheterisation (ISC). He liked the idea of this option and being able to manage his own bladder.
I contacted the Trust's bladder and bowel service, but this was during COVID-19 lockdown and the service was not offering home visits. They agreed that I could teach Mr Carter to carry out ISC because I had previously taught other patients to perform the procedure. They gave me a plan to follow to teach Mr Carter and provided supplies of intermittent catheters.
It was discussed whether Mr Carter's carers should be trained to perform intermittent catheterisation, but this was dismissed. It would have meant that Mr Carter would have required second-level carers, for whom the care agency would charge more, requiring his continuing care budget to be reassessed. Everyone agreed that this would take too long, especially if Mr Carter was able to perform ISC himself. But Mr Carter was warned that, if he wasn't able to perform ISC, then he would require to be re-catheterised with an indwelling catheter.
One morning I visited Mr Carter along with a trainee nursing associate (TNA), bringing the intermittent catheters provided by the bladder and bowel services. The advantage of working in a district nursing team is that I get the opportunity to get to know my patients very well. I knew that Mr Carter was motivated to learn this new skill, and I also knew that he had the cognitive ability to learn and remember it.
With the assistance of the TNA, I talked him through the physical process of ISC while he performed it on himself. I did warn him that ISC was not pain free and could cause an unusual sensation.
At first, he found the process daunting, especially inserting a catheter into his own penis, but when he found how easy it was, he began to relax. He successfully performed ISC and drained his bladder.
I visited Mr Carter that afternoon, again to administer his medications, but I also asked him to repeat the ISC procedure, so I was sure he was competent and did not need any more support. Mr Carter aided by his carer, demonstrated that he was able to perform ISC without any problems.
Follow-up
Over the following weeks, members of the district nursing team checked that Mr Carter was not having any problems with performing ISC, but repeatedly he reported having no problems. Neither did he develop any urinary tract infections.
Recently, I visited him for his regular nursing care and he told me how great it was to have control of his urination again. Only later did I realise how important this was for him. It wasn't just that he was no longer soiling himself but, due to his medical conditions, he has little control over his life. He is washed and dressed when carers arrive, he has his medications and feeds when the nurse arrives, but he can empty his bladder himself when he feels it is right, when he feels his bladder is full. This is something that he has control over.
Discussion
Indwelling urinary catheters can cause pain and trauma to a patient's urethra and, in severe cases, they can cleave it and the penis itself in men (Billington et al, 2013). However, the biggest potential complications are catheter associated urinary tract infections (CAUTIs).
This will affect 52 085 patients a year (Smith et al, 2019). Of these, 4.8% will developed a catheter-associated blood stream infection (CABSI), which has a mortality rate of 19.5% (Smith et al, 2019) and carries an annual cost to the NHS of £99 million (Fisher et al, 2017). Consequently, anything that can be done to reduce the number of CABSIs will benefit not only patients but also the NHS.
ISC is seen as the gold standard for urinary catheterisation (Royal College of Nursing (RCN), 2019). It can greatly reduce the risk of CAUTIs and trauma to the urethra, and can also help maintain renal function and bladder tone (RCN, 2019). However, indwelling catheters are still the treatment of choice for patients who have problems with emptying their bladders. But why is this the case?
ISC can be used to empty a patient's bladder when they have gone into urinary retention, with patients who have failed a TWOC and those who have a bladder dysfunction, often due to a neurological disorder or a spinal cord injury (RCN, 2019). ISC can also greatly reduce the risk of urinary infection, especially with patients who need a long-term aid to empty their bladder. So why is ISC not used more frequently?
Before ISC is considered it is necessary to assess the patient for suitability (RCN, 2019) and consider a range of factors, such as:
- Does the patient have the dexterity to physically perform ISC?
- Does the person have the cognitive ability to understand, learn and remember how to perform ISC?
- Is the patient's urethra and bladder physically capable of having ISC performed?
Not all patients are suitable for ISC: the RCN (2019) advises that it is not appropriate to consider the procedure in the following cases:
- Following prostatic, bladder neck or urethral surgery
- Female genital mutilation
- Suspected urethral tumours, an injury to the urethra, such as any strictures/narrowing of the urethra or even the creation of a false passage in the urethra (both more common in men)
- Injury or diseases of the penis (tumours or infection)
- Patients with a stent or artificial prosthesis.
Unfortunately, there is no easily accessible assessment to aid patients suitability for ISC, such as a Waterlow score.
There is also a national shortage of urology nurses: the NHS is short 300 urology nurses, and 41% of those currently in post are planning to retire in the next decade (Mora, 2020). These are the people who could be leading on promoting the use of ISCs and educating staff on how to assess patients and teach the procedure, yet there is now a national shortage of these specialist nurses. The national shortage of nurses doesn't just affect staff nurses, it is affecting all areas of nursing.
Indwelling catheterisation can be easier and quicker to perform than ISC, and it takes less time to assess a patient and then teach them ISC, but is it always the right option? For patients who require one-off bladder emptying or a long-term urinary catheter, ISC could be the best option—it could certainly reduce the risks that come with having an indwelling catheter in situ.
However, to enable patients to perform ISC, it is vital that they are correctly assessed and provided with relevant education on performing the, procedure themselves, which can be time consuming. Unfortunately, the quicker option is often the one that is chosen, because time and resources are currently in short supply in the NHS.