Clean intermittent self-catheterisation (CISC) is used by people to empty the bladder. CISC is indicated in cases whereby complete bladder emptying cannot be achieved naturally or by non-invasive means. This often occurs because of bladder outlet obstruction, inadequate detrusor contraction or lack of co-ordination of the detrusor-sphincter function (Chapple et al, 2024). The European Association of Urology Nurses (EAUN) has stated that CISC is the gold standard treatment for people with voiding difficulties resulting in retention of urine (Vahr et al, 2013).
Before CISC was available, indwelling urethral and suprapubic catheters were used to manage voiding dysfunction. However, these were associated with recurrent urinary tract infections (UTIs), urosepsis, bladder stones and damage to the distal urethra in men. Although CISC allows for more independence it is not without its own set of complications, including UTIs, haematuria, discomfort and trauma and requires specialist nursing support and surveillance (Chapple et al, 2024). Disposable single-use catheters are used for CISC, which come in a variety of types, with different coatings and packaging to provide choice and individualised care for the service user. As people tend to lead active physical and social lives well into old age, nurses need an understanding of how service users of all ages experience CISC. They must support them to master the technique and be able to perform it in every conceivable situation outside of the hospital setting (Jaquet et al, 2009).
Although this article focuses more on the male experience it is also relevant to women's experiences when learning and living with CISC and it explores the barriers that may impact on adherence to therapy. The author has reviewed the literature, including the findings of her previous qualitative research studies (Logan et al, 2008; Shaw et al, 2008), to compare findings and to consider if the findings are still clinically relevant to nurses who teach CISC, as there is a paucity of new nursing research on this topic in the UK. Both studies involved interviews with CISC users, which were analysed to explore the views and service requirements of both males and females learning CISC and how it impacted on their quality of life (QoL) and the adaptive process. A further study was conducted by Logan and Shaw (2011) to specifically explore the experiences of people with spinal cord injury who were learning and adjusting to CISC. Although all this research was conducted several years ago, its findings are seminal and will be useful for nurse education as nurses may be unfamiliar with it. This article will identify other relevant qualitative research and the comparable findings that could impact clinical practice.
Quality of life, advantages and disadvantages of CISC
Shaw et al (2008) stated that there is an assumption that QoL will improve with any given treatment; however, the treatment itself may prove difficult and have a significant impact on people. CISC is one such therapy that has the potential to have negative QoL impacts. QoL is an important consideration in ill health and has become an important indicator of the success or failure of treatment for disease. The prospect of having to undertake CISC for a short period, or for the rest of one's life, can be daunting, and impacts on aspects of QoL such as an individual's social, sexual, work and family life (Rew and Lake, 2013). Despite its challenges and complications, CISC is a preferable alternative to a permanent indwelling catheter. CISC offers freedom from management of urine drainage bags, fixation straps and restrictions on the choice of clothing. CISC also offers freedom to express sexuality, which is particularly important to men who are sexually active (Rew and Lake, 2023). In the author and colleagues' studies (Logan et al, 2008; Shaw et al, 2008), the themes identified were around the psychological issues and the physical and practical problems encountered that can impact on QoL, including service provision and staff interactions (Logan et al, 2008; Shaw et al, 2008). The authors found that it is usually the first stage of learning CISC that poses the most physical and psychological challenges that impact on QoL and these negative impacts were sustained throughout the learning and adjustment phases.
Disadvantages
CISC has disadvantages compared with normal physiological micturition, although it is often described as simple and safe with improved QoL. Most studies report a range of negative QoL issues, which may be psychological, practical or environmental. These include shock, embarrassment, fear, shame, difficulty catheterising, issues with dexterity, pain, and suitable toilet access (McConville, 2002; Logan et al, 2008). The authors (Logan et al, 2008; Shaw et al, 2008) found that the first negative QoL impacts resulted from the practical or technical difficulties encountered with catheterisation and the psychological and cultural context of worrying and stigma. The factors influencing variations in QoL impacts were sex (men were less accepting and more frightened of the catheter than women), lifestyle, frequency and duration of carrying out CISC, catheterisation difficulties, type of catheter used, comorbidities and individual predispositions (Logan et al, 2008; Shaw et al, 2008).
The authors also found that adherence to CISC was related to strategies of active acceptance rather than denial and avoidance; some men accepted CISC more easily than others. Acceptance was found to be variable due to personality type or predisposition, and the timescale at which individuals gained confidence varied from days to 5 years, but both psychological and technical difficulties diminished with time. Although they took time to adjust, it was frequently reported that the actual experience was less problematic than the anticipation of it (Logan et al, 2008; Shaw et al, 2008).
Advantages
Initial reactions to having to perform CISC were of shock; however, attitudes to CISC varied. Women tended to focus more on the benefits of CISC whereas men found it a nuisance and time consuming. The authors found that positive impacts were related to relief of previous lower urinary tract symptoms, voiding dysfunction and incontinence. CISC offered welcome relief from the discomfort of a full bladder and, for some, relief from recurrent UTIs. Participants found CISC empowering, enabling them to be in control of their bladder, avoiding bothersome bladder problems. It also allowed them to pursue more physical activities such as going to the gym. For men who had previous experience of an indwelling catheter, they found CISC a preferable option and it made them feel less disabled (Logan et al, 2008; Shaw et al, 2008).
Because using CISC is such a private affair, it was not openly discussed outside people's immediate family. Despite CISC being intrusive, especially for those who must catheterise regularly, they adapted to the regimen and CISC was gradually normalised and incorporated into daily routines.
Thorough and careful instruction in CISC by experienced nurses helped empower individuals to master the treatment. A thorough approach to teaching plays a part in supporting ongoing adherence and long-term bladder and urinary health. The excellent communication skills possessed by nurses experienced in teaching alleviated the embarrassment, thus facilitating information exchange and retention of information (Logan et al, 2008; Shaw et al, 2008).
If nurses are to help men undertake and comply with this treatment, then they must be aware of and understand the negative QoL impacts and the difficulties that are involved. Conversely, they must emphasise the benefits so that they can support and coach men to successfully incorporate CISC into their lives.
Barriers and importance of adherence to CISC
The barriers to learning and starting CISC, both psychological and physical, are well documented in the literature (McConville, 2002; Woodward and Rew, 2003; Logan et al, 2008; Shaw et al, 2008; Bolinger and Engberg, 2013). These include fear, embarrassment, the need for privacy, environmental factors such as problems in using public toilets, and the catheterisation difficulties that are linked to manual dexterity or negotiating the penile urethra (Logan et al, 2008; Shaw et al, 2008; van Achterberg et al, 2008). These barriers often overlap with issues of adherence, especially the environmental barriers. There are further barriers related to male sexuality, an area where further research is required.
Service user non-adherence to CISC is an important issue and it can become a problem over time, adding further to disease burden and posing renal health risks. There are several factors and barriers that can impact upon it. The determinants for adherence were studied by van Achterberg et al (2008). They reported problems relating to knowledge and the complexity of CISC; they found that the ‘simplicity’ of CISC was often assumed rather than factual. The other determinants of adherence related to misconceptions, fears, shame, motivation, and the continuity and quality of the professional care.
Debate continues over how frequently CISC should be recommended. It must be based on residual urine measurements and each case judged on its merits. A new consensus document has been published to aid clinicians with this important decision-making process (Chapple et al, 2024). Adherence to this health professional-prescribed frequency of catheterisation per day is significant because it directly impacts the function of both the lower and upper urinary tracts and, according to Kennelly et al (2019), adherence to CISC as recommended by health professionals was followed by just 76% of research responders. CISC must be carried out regularly and consistently into the future (Shaw et al, 2008) because not following the programme prescribed by the health professional results in a greater risk of developing UTIs. Adherence to CISC should not and cannot be assumed by the health professional who is instigating this treatment as it may lapse over time. Bolinger and Engberg (2013) asked study participants how they decided when to perform catheterisation. Only a few participants reported performing it based on the frequency prescribed by their health professional.
The regularity and frequency of catheterisation prescribed can affect adherence because there will be occasions when it must be done outside of the home. For those catheterising up to four times daily, it is problematic because CISC and social occasions or outings do not go well together, and if service users are unsure of finding suitable toilets when going shopping or out and about, it leads to missing one or more catheterisations (van Achterberg et al, 2008). There can be no doubt that poor toilet facilities are of great importance to CISC. Men want access to clean toilets, sinks with running water, bins and privacy (Jaquet et al, 2009). Jaquet et al (2009) described how men felt it was important for them to find the right kind of toilet facilities, because they believed that they could contract infections from some dirty public toilets. The authors found that finding suitable public toilets to catheterise when away from home caused significant anxiety and was one of the reasons for avoidance of CISC (Logan et al, 2008; Shaw et al, 2008).
CISC is often promoted to patients as a painless procedure, although discomfort and bleeding are experienced by some, which can result in avoidance. This tends to be more common when men first start CISC and reduces with time (Barton, 2000). Physical problems such as muscle spasticity have also been found to be a barrier for people with multiple sclerosis (Bolinger and Engberg, 2013) who commonly use CISC to manage voiding disfunction.
Barriers and adherence are interconnected, so it is important to mention here that there were men in the author and colleagues' studies who had trouble inserting or withdrawing the catheter and experienced pain and occasional bleeding (Logan et al, 2008; Shaw et al, 2008). One man described spasms on withdrawal of the catheter (Logan et al, 2008). These physical problems were barriers that affected adherence, indicating that comfort in performing CISC is important. This demonstrates the importance of ease of use of a catheter and its appearance to men if they are to accept a catheter and perform CISC successfully and regularly.
Factors that impact adherence: finding solutions
A nurse possessing knowledge and experience is required for teaching CISC and providing aftercare to support adherence. These attributes are key to success as there is a vast amount of specific information and advice to impart. The author and colleagues' study found that poor information and instruction during the teaching session undermined confidence, co-operation and adherence to CISC. However, effective and efficient information offered by the nurse was empowering and greatly valued and was a determinant for successful acquisition of the skill. A good teaching experience led to good outcomes and improved adherence (Logan et al, 2008; Shaw et al, 2008).
Service users must be involved in decision making regarding the treatment plan; however, this involves detailed discussion and assimilating large amounts of information in one clinic session, which is challenging. Van Achterberg et al (2008) found that the complexity of CISC posed difficulties for remembering all aspects of the procedure after the instruction had taken place. For example, organising materials, remembering the correct sequence of steps required and knowing how to sit or stand. Fine motor skills involving dexterity and knowing how to act on sensory information is also required. Further practical information about the attributes of different catheters, disposal, prescribing details and travelling advice are all vital to success but take time to deliver and for men to assimilate. Failing to impart adequate information could mean failure to understand important aspects of CISC, thus leading to the avoidance of regular catheterisations.
Information must also be given about how to aim for regular and complete bladder emptying to avoid retaining urine (Kennelly et al, 2019). The cause of residual urine could be the removal of the catheter before complete bladder emptying. This is frequently encountered in clinical practice and is considered a significant risk for UTIs (Kennelly et al, 2019). Therefore, advice on successful bladder emptying should be given during training and include tips such as slow withdrawal or repositioning of the catheter to avoid residual urine and aid bladder emptying. Recurrent UTIs are painful and distressing and may promote aversive behaviours (Kennelly et al, 2019).
Follow up and review
Developing a follow-up plan after the teaching session is considered best practice and essential to prevent lapses in the treatment programme. However, this is dependent on access to and time spent in the clinic with the nurse. The limitations in staffing and diminishing resources imposed by cost efficiencies within the NHS in the UK can compromise the time allocated for teaching and reviewing CISC. New and creative ways of working are called for, exploring ways of encouraging user-initiated follow up and individualised follow-up plans that meet their needs. In the author and colleagues' studies (Logan et al, 2008; Shaw et al, 2008) and subsequently in clinical practice, offering telephone reviews as opposed to face-to-face appointments after the initial face-to-face teaching session was found to be both helpful and valued by service users. A minimum of a yearly review would be considered optimum in the longer term to trouble shoot, monitor CISC technique and to help with adherence to therapy (Logan, 2012). This is not the reality for many users, who report follow-up care as insufficient. Logan et al (2008) and van Achterberg et al (2008) found that people were unsure if they could contact health professionals after the teaching appointment when experiencing problems or needing advice. A follow-up plan is not only important to support and aid concordance but also because circumstances, lifestyle, physical and cognitive abilities change over time, due to disease progression and ageing (Shaw et al, 2008). Van Achterberg et al (2008) suggested that follow-up care needs to be improved to re-evaluate the catheterisation technique, help integrate CISC into daily activities and in developing the necessary coping strategies required for long-term adherence.
Further work is needed to explore new ways of teaching that can aid adherence. Although some solutions are out of the clinician's hands as they are due to the individual personality and disposition of the person, specialist education for both nurses and service users could help.
Education
Specialist education is important for nurses to gain knowledge and further develop the necessary skills required in teaching and supporting CISC. This training may be delivered in-house by nurses or specialists who are already highly skilled and experienced and/or by manufacturers who make and sell catheters. Manufacturers not only help with the delivery of good-quality education and training but also with the development of competency frameworks and care pathways that can act as guidance to nurses. They can also help provide patient information materials to help in the delivery of the information to aid catheter users in accepting and adapting to this complex therapy. Easy access to useful and practical teaching aids and service user information literature is important and these should be available in a range of online and paper formats. EAUN (Vahr et al, 2013) states that best practice involves the use of a wide range of visual and written aids as useful adjuncts to the verbal and practical teaching session.
Implications for practice
After the COVID-19 pandemic, when some services were suspended, it is now important to revisit this specialist aspect of urology and continence nursing practice. It is important to raise awareness of the need to support nurses who are involved in teaching CISC. Refresher sessions and ongoing education will be necessary for nurses to maintain competence in running clinics for teaching and follow up of CISC to result in a good experience and outcome for service users. Ethical partnerships between industry and clinicians in the delivery of specialist education should be considered, where a deficit in education exists.
The author and colleagues' qualitative research findings are still relevant to current practice, showing that adopting CISC is an adaptive process, and it takes time to build adherent behaviour (Logan et al, 2008; Shaw et al, 2008). The nurse's role is crucial in supporting the service user with this adaptive process. The challenge for nurses today is that service delivery is affected by diminishing NHS resources, where competing healthcare priorities and time pressures threaten the delivery of best practice.
Conclusion
CISC is an established treatment in urology and in spinal cord injury rehabilitation. It is a complex therapy with both negative and positive impacts on QoL. There are several challenges to overcome and barriers to face by men learning and living with CISC. There are also drivers to adherent behaviour. Nurses must be able to recognise acceptance of and avoidance of CISC and react empathetically, aware of all the complex issues that may be present, if they are to guide men through this experience and support the adaptive process. Adequate follow-up care is also essential in helping to integrate CISC into lifestyles and sustain long-term concordance. Access to training and education for nurses in this specialist therapy is necessary for them to develop and maintain expertise in catheter selection and the skills required not only to teach CISC but to support its integration into everyday life.
KEY POINTS
- Clean intermittent self-catheterisation (CISC) has a lower risk of complications and urinary tract infections than an indwelling urinary catheter
- CISC is safe and the preferred option to an indwelling catheter for men with voiding dysfunction
- CISC has both positive and negative impacts on quality of life
- There are barriers to carrying out CISC away from home
CPD reflective questions
- What are the negative impacts of clean intermittent self-catheterisation (CISC) on quality of life experienced by men in your clinical area?
- What have been the positive impacts of CISC on quality of life for men in your experience?
- Why is concordance/compliance with the recommended frequency of catheterisation by the health professional important? Think about how you have approached patients who have been non-compliant in this way