Urethral intermittent catheterisation in adults (2024)

6. COMPLICATIONS

6.1 Infection

6.1.1 Nosocomial infection

Nosocomial infections also referred to as healthcare-associated infections (HAI), are infection(s) acquired during the process of receiving health care that was not present during the time of admission. [43] Intermittent catheters pose no risk of biofilm formation due to their short time in the body. Therefore, they have a lower risk of catheter-associated urinary tract infection (CAUTI), which is the most common complication of intermittent catheterisation (IC), especially among IC users with a neurogenic disorder. [44-46] Although the true incidence, prevalence and relative risk are difficult to determine because studies vary significantly in their definition of UTI, the time frame over which the UTIs were assessed and their means of reporting. [47] In addition, most studies have been confined to specific patient cohorts, for example, spina bifida and spinal cord injury.

The incidence of CAUTI as a consequence of IC is in the region of 2.6 and 2.7 per person per year, the 1-year incidence of UTI varied from 62% to 77% among IC users with a neurogenic disorder and 38% to 42% among IC users with a non-neurogenic disorder. [46, 48, 49]

Lamin and colleagues reported that asymptomatic bacteriuria was found in 50% of IC users and symptomatic CAUTI occurred in 10–15%. Welk and colleges reported that IC users with a neurogenic disorder compared with IC users with a non-neurogenic disorder were more likely to have a CAUTI (54.9% vs. 38.9%), be hospitalised for CAUTI (11.3% vs. 4.0%), or have ≥ 3 CAUTIs (17% vs. 9.6%) within the first year of starting IC. This suggests that neurogenic disease is an independent risk factor for CAUTI among IC users. [46] Symptomatic CAUTIs are most prevalent in patients who have higher residual urine volumes at the time of catheterisation. [46, 50]

The bladder volume should preferably not exceed 400–500 ml in IC users. [27, 48]. Incomplete bladder emptying increases the risk of UTIs. [51]

In IC users, only symptomatic UTI should be treated because of the risk of antibiotic resistance and adverse effects. [52, 53]

The use of hydrophilic or pre-lubricated catheters is associated with a reduced risk of CAUTI among patients using IC [23, 54, 55] In addition, Ye et al. found evidence indicating significant reduction of symptomatic CAUTI when using the non-touch technique in combination with ready-to-use catheters (a preactivated hydrophilic or gel-lubricated catheter). [56, 57]

It is unclear if the lower incidence of CAUTI found when using a hydrophilic catheter is due to high patient satisfaction, as the hydrophilic coating can reduce pain and decreases the risk of microtrauma. This makes the process easier, increases quality of life (QoL) and results in adherence to clean IC. The lower incidence of CAUTI may also be because the hydrophilic-coated catheters do not require additional external lubrication; thus, there is no additional need to touch the catheter before insertion. [45, 58]

Håkansson and colleagues reported that the incidence of pyelonephritis was < 1% per patient per year in patients with neurogenic or non-neurogenic bladder. [59]

6.1.2 Epididymo-orchitis

Epididymitis can be acute, chronic or recurrent and is often caused by an infection. When the testicles are also affected, it is called epididymo-orchitis. Acute epididymitis is common in patients performing IC and is clinically characterised by pain, swelling and increased temperature of the epididymis, which may involve the testis and scrotal skin. [23] In a retrospective study over 17 years (n=140) Ku et al. found that in people with spinal cord injury 27.9% are diagnosed with an epididymo-orchitis. The epididymo-orchitis was significant more often for patients using CIC than for patients using indwelling urethral catheterisation. [60]

6.1.3 Urethritis

Urethritis can be of either infectious or non-infectious origin. Inflammation of the urethra presents usually with LUTS. [23] Singh et al. and Wyndaele reported that urethritis had an incidence of 1–20% in spinal cord injury patients using IC. [61, 62]

6.1.4 Prostatitis

Bacterial prostatitis is a clinical condition caused by bacterial pathogens and it can be both acute or chronic. Acute bacterial prostatitis usually presents abruptly with voiding symptoms and distressing but poorly localised pain. It is often associated with malaise and fever. [23]

Prostatitis can be a cause of recurrent UTI. [61, 63]

Table 10. Factors increasing the risk of infection in IC

6.2 Urethral trauma/haematuria

Urethral trauma, especially in men, due to IC can cause false passage and meatal stenosis; however, the incidence is rare. [72] Trauma to the urethral mucosa can lead to long-term complications, such as urethral stricture or infection of the urethral mucosa. [33, 56]

Urethral bleeding or haematuria is an acute form of urethral trauma that manifests as blood in the urine. Urethral bleeding is a complication of IC and is more frequently seen in patients starting IC. Håkansson and colleagues reported a 2.2% frequency of bleeding per year. [59]

Addition of a hydrophilic coating or use of a pre-lubricated catheter significantly reduces the risk of microscopic haematuria. [54, 56, 73, 74] However, there is still no evidence supporting the use of hydrophilic catheters to reduce gross haematuria. [56, 57, 75] Similarly, the use of lubrication, either incorporated into the catheter device or externally applied reduces the risk of trauma. [74, 76]

6.2.1 False passage

A false passage is when an object, such as a catheter or surgical device, passes through the wall of the urethra. Urethral trauma resulting in a false passage is almost certainly under-reported but may result in the patient being unable to continue with IC as a consequence of the catheter entering the false passage in preference to the bladder. [77]. A scoping review by Engberg et al. reported an incidence of 2.2–9% annually; however, limited research is available on prevalence and intervention. [47, 59, 62]

6.2.2 Urethral stricture

A urethral stricture is a narrowing of the urethra, which can lead to various urinary symptoms and complications. Urethral stricture is more common in men than women and is caused by repeated trauma from IC. Urethral stricture in women is rare and estimated at about 0.1–1% [78], compared with 4.2–25% in men. The occurrence of urethral strictures in men increases with time. [79, 80]

A review conducted by Liao et al. supported the use of hydrophilic catheters to reduce the incidence of urethral strictures. They found that the incidence of urethral stricture was 3.1% in patients using hydrophilic catheters and 11.5% in those using non-hydrophilic catheters. [74]

For more information on dilatation for strictures, see Chapter 15.

6.2.3 Meatal stenosis

Meatal stenosis is an abnormal narrowing of the urethral opening (meatus). If the narrowing becomes significant, voiding will be impaired and may cause incomplete bladder emptying. Meatal stenosis is a rare complication with only a few reported case series in the ‘90s. [81, 82]

6.2.4 Bladder perforation

Bladder perforation is a rare complication with only sporadic reports, which occurs in augmented bladders along the anastomotic site. [83, 84]

6.3 Miscellaneous

6.3.1 Catheter knotting

Catheter knotting happens when the catheter coils around itself and then the catheter end loops through these coils. It is an extremely rare complication and more commonly reported in children. [85] This complication may be prevented by careful selection of the catheters and ensuring understanding of urethral anatomy and safe insertion lengths of catheters. [86]

6.3.2 Formation of bladder and prostate stones (calculi)

The risk of developing bladder stones is increased by recurrent UTI with urease-producing organisms, incomplete bladder emptying, and use of permanent catheters, immobilisation and hypercalciuria.

Bartel et al. found a 2% incidence of bladder stone formation in spinal cord injury patients using IC, compared with 11% for suprapubic catheters and 6.6% for indwelling catheters), with a mean period of stone development of ~10 years. The time to recurrence was 26 months. [87]

Long-term IC is associated with an increased risk of bladder calculus formation in children and adults [88, 89], with a higher risk in patients performing IC via a Mitrofanoff procedure. [89] The pathogenesis can be related to the introduction of pubic hair that acts as a nidus for stone formation. [90, 91]

A recent study by Ecer et al. found an association between the incidence of prostate calculi in patients with a neurogenic bladder using IC compared to those not using IC. CAUTI and prostatitis are the most important factors causing an increase in the frequency of prostate calculi. [92]

6.3.3 Pain/discomfort

Pain may be experienced during or after catheter insertion or removal, and as a consequence of bladder spasm or UTI. Painful insertion and removal can be caused by incomplete relaxation of the pelvic floor muscles, mucosal atrophy in post-menopausal women, or lack of lubrication. There is a lack of evidence on the topic of pain and discomfort during IC. [47]

Fear of pain can hinder relaxation and learning during the instruction period. [58] When removing the catheter, vacuum suction can occur, probably because the catheter adheres to the bladder wall.

Johansson et al. reported that patients using a hydrophilic PVC catheter reported significantly more burning sensation and pain compared to patients using a PVC-free catheter. [93]

Severe pain when inserting the catheter has a significant impact on QoL. [94]

Pain can be reduced by appropriate training of the person carrying out the catheterisation.