Urethral intermittent catheterisation in adults (2024)

5. INDICATIONS, CONTRAINDICATIONS AND ALTERNATIVES FOR INTERMITTENT CATHETERISATION

5.1 Indications

Table 5. Indications for intermittent catheterisation

[29-31]

It is important to acknowledge that if performed for a large residual volume, IC should only be performed in the presence of symptoms or complications (Table 6), arising from this residual volume of urine rather than being based on a post-micturition residual volume only.

Table 6. Complications of a large post-void residual volume of urine

There are generally four categories of lower urinary tract dysfunction requiring IC, according to the underlying reason for incomplete bladder emptying.

5.1.1 Detrusor dysfunction

Detrusor underactivity, or underactive bladder (UAB), is defined as a contraction of reduced strength and/or duration resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span. [32] The patient is therefore left with a post-micturition residual volume of urine. The most common causes are neurological or idiopathic disorders, but may also be due to drug therapy, such as anti-muscarinic and 3 agonists.

5.1.2 Bladder outlet obstruction

With obstruction or blockage of the bladder outlet, complete bladder emptying is prevented by physical obstruction despite an adequately functioning detrusor muscle. The most common causes of this are prostatic enlargement, high bladder neck, or urethral stenosis in women. Urethral stricture in men may also cause bladder outflow obstruction and is most often a consequence of infection or after instrumentation. For example, it can be caused by transurethral resection of the prostate (TURP), or bladder neck stenosis following radical prostatectomy (RP).

Detrusor sphincter dys-synergia is the most common cause of bladder outflow obstruction in patients with neurogenic bladder dysfunction, and occurs in the absence of co-ordinated sphincter relaxation and detrusor contraction. The sphincter therefore contracts and generates a functional obstruction at the bladder outlet. [33]

5.1.3 Postoperative

Operations for restoring continence all carry a risk of impairing bladder emptying and a need for IC if any residual volume results in symptoms or complications. Acute urinary retention is also seen postoperatively, especially when epidural anaesthetic is used.

a. Procedures for stress urinary incontinence (SUI)

Curative procedures for stress urinary incontinence (SUI) (Table 7) all work on the principle that SUI can be reduced, or hopefully resolved, by causing some bladder outlet obstruction. As a consequence, bladder emptying may be impaired, leading to a clinically significant residual volume of urine in some patients. The risk of residual volume increases with the use of transobturator tape (TOT) or tension-free vaginal tape (TVT), colposuspension, or fascial slings.

Table 7. Procedures with curative intent for stress urinary incontinence (SUI)

b. Procedures for urgency urinary incontinence (UUI)

Procedures for resolving urgency urinary incontinence (UUI) (Table 8) all work on the principle that episodes of UUI will be reduced or resolved by reducing intravesical pressure and increasing functional bladder capacity. Consequently, the ability of the bladder to empty efficiently and completely is impaired, leading to a residual volume of urine that may result in symptoms and complications that require IC.

Table 8. Procedures with curative intent for urgency urinary incontinence

c. Other procedures (e.g., Mitrofanoff)

Some reconstructive procedures involve the creation of a purpose-built channel, typically formed using non-terminal ileum, via which, IC is performed to drain the bladder, augmented bladder, or reconstructed neobladder. The Mitrofanoff principle involves the use of the appendix, refashioned non-terminal ileum (Monti procedure), or rarely, Meckel’s diverticulum to create a channel leading from the urinary bladder to the anterior abdominal wall. Typically, the bladder outlet is closed and the channel is tunnelled into the bladder such that there is a natural valve-type effect on bladder filling, which causes the channel lumen to occlude to prevent unwanted urinary leakage. An intermittent catheter is then inserted to drain the bladder when required. Such procedures may be performed for a variety of conditions, including bladder exstrophy and neuropathic bladder, and after cystoprostato-urethrectomy.

For a description of the Mitrofanoff procedure, please refer to the European Association of Urology Nurses Guidelines 2010 “Continent Urinary Diversion”, Section 3.6. [34]

5.1.4 Postpartum urinary retention

Postpartum urinary retention requiring IC may occur in up to 15% of deliveries and is variably defined as the absence of voiding 6 h postpartum with a residual volume of > 150 ml. When diagnosed promptly, most patients require only temporary IC, with < 5% still needing IC after 3 years. [35] The risk of postpartum urinary retention is increased in the presence of an epidural anaesthesia, episiotomy, prolonged second stage of labour, or instrument-assisted delivery.

The implementation of IC to manage postpartum urinary retention offers a faster return to normal bladder function compared with the use of an indwelling catheter. [36]

5.2 Contraindications

There are few contraindications to IC.

Absolute contraindication

• High intravesical pressure that would require continuous free drainage to avoid renal damage.

Relative contraindications

• Poor manual dexterity in the absence of an appropriately trained caregiver/attendant
• Urethral trauma
• Urethritis
• Prostatitis/urinary tract infection
• Significant visible haematuria

5.3 Alternatives for intermittent catheterisation

In case of residual volume and symptoms or complications, alternatives to IC are suprapubic catheterisation and indwelling urethral catheterisation. When catheterisation is only needed for a few days, both suprapubic drainage and intermittent urethral catheterisation have advantages over indwelling urethral catheterisation due to causing less discomfort. [37] Regarding symptomatic urinary tract infection, a suprapubic or intermittent catheter is preferable to an indwelling urethral catheter. [38, 39] Male external catheter drainage system catheters can be considered in patients with voiding problems without symptoms or complications and without residual volume. [26, 38]

Table 9. Alternative bladder emptying methods