Intermittent catheterisation has long been cited as the gold standard approach to assisted bladder drainage with the least risk of infection compared to indwelling catheters. It is defined as the aspiration or drainage of the bladder or urinary reservoir using a hollow tube/catheter with subsequent removal of the catheter (Abrams et al, 2003; Vahr et al, 2013). As the intermittent catheter has no retention balloon and is removed within minutes of insertion, the risk of biofilm formation is eliminated. Commonly, the intermittent catheter is inserted by the patient themselves—intermittent self-catheterisation (ISC)—although on occasions it is necessary for someone else to assist, or take over this task for them.
Intermittent catheterisation procedures are not dependent on age or culture, and the technique can be adapted to suit many situations or scenarios. In paediatric practice it is common for parents/guardians to take on the initial catheterisation responsibility, with the child achieving competence and independence with the skill over time.
Intermittent catheterisation has a variety of approaches as defined by the European Association of Urology Nurses (Vahr et al, 2013):
Sterile intermittent catheterisation
Sterile intermittent catheterisation is carried out on an individual by another person. This technique is used in an operating theatre or diagnostic environment using all sterile equipment, materials and full personal protective equipment including gloves, sterile gown and mask.
Aseptic technique
Aseptic technique is defined as using a sterile catheter, use of a disinfection solution to cleanse the genitalia/stoma, sterile gloves or tweezers and use of sterile lubricant when the catheter material is not already lubricated. This is commonly carried out on an individual by another appropriate person, usually a health professional.
No-touch technique
The no-touch technique is a common approach taught to patients, and involves the use of a sterile, ready-to-use catheter with an adaptor, or packaging, designed to prevent the individual from touching the catheter material on insertion and removal. Cleansing of the urethral/abdominal opening involves standard hygiene using non-antimicrobial solutions. This approach may be carried out by the individual on themselves or by a nominated relative who assists with the insertion of catheters.
Clean technique
Clean technique refers to the procedure used by the patient, or a caregiver, within their own home environment using a sterile or reusable catheter and no gloves; cleansing of the genitalia or stoma opening requires standard hygiene using soap and water, rather than disinfectant.
Generally when a patient or family member is performing ISC, it is with a clean or no-touch technique
When to use intermittent catheters
There are many reasons the bladder may not empty fully, and they involve structural, physiological and psychological factors. Failure to regularly fill and empty the bladder effectively, may lead to significant health risks, including infection, sepsis, renal failure and death. Intermittent catheterisation can be considered for any situation where the bladder requires assistance with drainage.
Contraindications to the use of intermittent catheters are few, but mainly relate to high intravesical pressure, which requires continuous and free flowing drainage to avoid renal damage (Vahr et al, 2013). A relative contraindication would be the inability of the individual to carry out the procedure and the absence of an appropriate person to assist. This is more of a concern in adult practice, as with paediatric patients it is often the parent/guardian who carries out the procedure until the child is deemed competent and of an appropriate age to take over the task themselves. With paediatric patients, it is more of a concern to determine the appropriate age for the child to participate and eventually become independent with ISC. Other issues to resolve are who else to involve, and at what stage; for example, determining how involved school should become with the technique. In the authors' experience, it is common to teach identified support staff/teachers at school to assist or supervise ISC during school hours. This should be carefully planned and agreed with parents, family, child and school to ensure the best support system is in place. Access to specialist services and the option for review, or simply to ask questions, should be available.
Benefits and risks of intermittent catheters
The greatest advantage associated with the use of intermittent catheters is the reduction of catheter-associated urinary tract infections when compared with the infection rates associated with the use of indwelling catheters (National Institute for Health and Care Excellence, 2012). In paediatric practice, it is more common to use intermittent catheters as a first-line choice than indwelling catheters. This preference is reversed in adult practice, where there is a much higher incidence of indwelling catheters.
The bladder protects itself from infection by regularly filling and emptying throughout a 24-hour period. By using the intermittent catheter technique, these risks are greatly reduced and can preserve renal function by preventing overdistension of the bladder (Moore et al, 2007).
Body image for catheter users is an important area of concern, with many adults describing the indwelling catheter as a negative experience affecting their perception of their gender identity and self-awareness, creating a barrier to their ‘normal’ life. Intermittent catheters do not sit in place for longer than a few minutes and therefore have less effect on the perceived body image of users (Woodward et al, 2013; Rew and Lake, 2013). Intermittent catheter usage can promote self-control and management of the bladder issue, leading to independence and a protection of privacy as the user can adapt their technique and catheterisation schedule to suit their lifestyle.
According to the literature, there are relatively few associated risks or complications with performing intermittent catheterisation, many risks have been reduced with the improvement in the choice of products (Vahr et al, 2013). The risks are recognised as rare and are perceived to be of lesser concern than the benefit gained when using ISC (Newman and Willson, 2011). The risks have been identified as: infections, including urinary tract infection, prostatitis and urethritis; trauma, including false passageway formation, urethral stricture or meatal stenosis or bladder perforation; miscellaneous, including catheter knotting, pain, discomfort, bleeding and formation of bladder stones.
Teaching ISC
There are many essentials to consider when teaching intermittent catheterisation techniques to individuals or nominated care givers. If a patient is not motivated or willing to carry out intermittent catheterisation, or does not understand the implications of poor bladder management, compliance with the technique will be affected (Woodward and Rew, 2003; Woodward et al, 2013). Determining the age at which a child is capable and willing to learn ISC varies greatly. Most children using ISC from a young age will start to become involved, with parental encouragement, at the earliest opportunity. Handling the catheters, playing games with opening and closing the packaging and use of adapted dolls/toys can be encouraged from a young age but will need support from appropriate health professionals to guide practice and improve parental confidence.
An awareness of the signs and symptoms of infection, and the management of any related issues is essential. Hand hygiene and personal hygiene are a component part of teaching about intermittent catheterisation, but may be overlooked, or taken for granted that the patient/caregiver already knows how to effectively wash their hands (Robinson, 2006). Ensuring children have access at school to appropriate areas at appropriate times to carry out ISC needs to be agreed with school officials. Toilet passes are useful and teaching/support staff should be informed and know what to expect.
Fluid intake needs to be addressed with advice provided on what constitutes a good or appropriate volume. Consideration of the patient's ability to access fluids needs to be included in the assessment and teaching phase. Most schools do allow students to drink during lesson times, but it is important that a member of staff is monitoring the child who needs to undertake ISC to ensure they are drinking adequate volumes of fluid to maintain bladder health.
The frequency of using intermittent catheters needs to be determined and the patient or caregiver should be encouraged to become confident at adapting this, dependent on the underlying cause of bladder issues, social or environmental restrictions, and patient choice. This is usually led by a health professional during the initial stage of ISC, evolving to more parental control and eventually handing the responsibility to the child themselves.
Other challenges for paediatric patients
Childhood to adolescence to adulthood is a rapid, evolving transition with many challenges along the way. Puberty presents a challenge emotionally and behaviourally as the child strives for greater autonomy and independence. They want adult privileges but may not be sufficiently developed, socially or emotionally, to cope with the responsibility. Teenagers are categorised as being 12–19 years of age, with a recognition that brain development continues throughout this time. Common behaviours demonstrate that teenagers are highly sensitive, and believe they are always right and indestructible. Often, they are starting to explore their own sexuality and gender identity but using catheters can set them apart from peers. This can have a negative impact on self-worth and social interactions. Teenagers may avoid activities requiring sleepovers, or school trips because of their need to use catheters. They are embarrassed to let their peers know they are different. They may need special permissions within the school day to enable them to use their catheters discreetly and at appropriate times. Use of toilet areas can be difficult because many schools restrict student access during lesson times and disposal of products within public school toilets can be problematic. Recognition of adequate drinking volumes, and complying with this, can also cause concern in teenagers.
Paediatric patients are often retained within specialist paediatric services until they reach their mid to late teens. Under the Mental Capacity Act 2005, they become adults at the age of 18. Paediatric services are hugely supportive and very involved with both parents and children for many years. Adult services can be a shock to the child and family as the priorities and delivery of services are different, with self-management a high priority.
Optimum time for transition?
Generally speaking the transition from child to adult services should be completed by the age of 18 as this is when the Mental Capacity Act recognises the child as an adult. However, every child is different, and needs vary depending on physical, social and cultural issues.
‘Young people should not be transferred fully to adult services until they have the necessary skills to function in an adult service and have finished growth and puberty.’
Encouraging parents to release control and allow the child to take on more responsibility is essential in achieving compliance with the use of catheters and transitioning to independence. Cohesive working between child and adult services helps to prepare the child and family for greater independence, but the attitudes of the patient, parents and professionals may impact on this. There is often a fear among adult service health professionals when dealing with a child. A lack of awareness of the differing needs of children, adolescents and adults can adversely affect treatment concordance when switching between services. Multidisciplinary team meetings over multiple contacts may ease the transitional period and ensure continuation of best practice and concordance with using intermittent catheters.
Ask young people what they want
The process of getting young people involved in their own care should be carefully planned, with key milestones identified. Responsibility for decision-making should be increased, gradually moving away from parents/guardians, and more towards the child making their own decisions. This should involve discussions about when a child could attend appointments unaccompanied. Any processes should be discussed and supported by formal documentation, including details of clinical care, a record of the needs assessment, goals, and inter-agency agreements. These documents should be accessible to the young person as a personal hand-held record.
Conclusion
Intermittent catheterisation is considered the gold standard, first-choice method for bladder drainage, to avoid the risks associated with an indwelling catheter. The process can be frightening for the individual child/adolescent to consider and requires a robust and individualised assessment undertaken by an experienced specialist health professional. The assessment and teaching process requires time and patience, and should be delivered in an environment that is suitable, appropriate and offers privacy. Support is required for parents, family and teachers to encourage compliance and consistency with ISC. A cohesive combined approach from a multidisciplinary team across child and adult services will ultimately lead to improved health outcomes and quality of life in the individual.