A consensus statement on when to start clean intermittent self-catheterization: An untapped resource?

BACKGROUND: Clean intermittent self-catheterisation (CISC or ISC) is used by patients/carers to empty the bladder if needed. Sometimes the urethral lumen leading out of the bladder is blocked; sometimes, the bladder (detrusor) muscle itself or the autonomic motor nerves innervating the bladder are damaged, resulting in a failure of the detrusor muscle to work, leading to a failure of the bladder being able to empty adequately. Prior consensus as to the indications and timing of CISC has yet to be provided. This article aims to provide a multidisciplinary consensus view on this subject. CONCLUSION: It is evident that every patient needs to be considered individually, bearing in mind the symptoms and investigations to be considered. We emphasise the importance of considering the term Bladder Voiding Efficiency (BVE). One group of patients who might find CISC helpful are those with a neurological disorder; these include spinal injury patients, multiple sclerosis, Parkinson's, and a condition called cauda equina. Sometimes bladder problems are treated with anticholinergics, and others may be treated with Botox. These may cause the bladder not to empty at all, which is good for leaks but needs self-catheterisation to empty the bladder. In the past, hospitals used a permanent catheter called an 'indwelling' or a 'suprapubic' catheter. These can have side effects, including infections, stones, and pain. For CISC, disposable catheters are the best option for patients as they come in different sizes and styles to provide individualised care. In conclusion, we would like hospitals to consider each patient separately and not use a general 'one-size-fits-all' bladder function for these patients.

Effect of Kegel Pelvic Floor Muscle Exercise Combined with Clean Intermittent Self-catheterization on urinary retention after radical hysterectomy for cervical cancer.

Objectives: To investigate the effect of Kegel pelvic floor muscle training combined with clean intermittent self-catheterization on patients with cervical cancer, and to analyze the risk factors affecting urinary retention. Methods: A total of 166 patients with cervical cancer admitted to our hospital from October 2016 to December 2019, all of whom received radical resection of cervical cancer, were divided into two groups according to the random number table method: the observation group and the control group, with 83 cases in each group. The control group underwent clean intermittent self-catheterization, while the observation group underwent Kegel pelvic floor muscle exercise combined with clean intermittent self-catheterization. The catheter replacement rate, bladder residual urine volume, self-perceived burden scale (SPB), Kolcaba general comfort questionnaire (GCQ), incidence of urinary tract infection, and urinary retention after catheter removal were compared between the two groups. Logistics regression analysis was utilized to analyze the risk factors affecting urinary retention. Results: The incidence of catheter replacement, urinary retention, dysuria and bladder residual urine volume in the observation group were significantly lower than those in the control group (P<0.05). Postoperative SPB score of the two groups decreased significantly, while the GCQ score increased significantly. Postoperative SPB score of the observation group was significantly lower than that of the control group, while the GCQ score was significantly higher than that of the control group (P<0.05). Statistically significant differences can be observed in the comparison of catheter indwelling time, urinary tract infection, surgical incision infection and surgical margin between the two groups (P<0.05). Logistic regression analysis showed that catheter indwelling time, urinary tract infection, surgical incision infection and surgical margin were independent risk factors affecting urinary retention (P<0.05). Conclusions: Catheter indwelling time, urinary tract infection, surgical incision infection and surgical margin are the risk factors for postoperative urinary retention in patients with cervical cancer. With Kegel pelvic floor muscle exercise combined with clean intermittent self-catheterization, a variety of benefits can be realized, such as improved bladder function, reduced incidence of urinary tract infections and urinary retention, as well as increased patient comfort.

[Acute urine retention: Epidemiology, optimization of the care pathway and alternative to permanent bladder drainage]. / Rétention aiguë d'urines : épidémiologie, optimisation du parcours de soin et alternative au drainage permanent.

INTRODUCTION: The aim of this narrative review was to report the most relevant data on the contemporary management of Acute Urine Retention (AUR). METHODS: A narrative synthesis of the articles in French and English available on the Pubmed database was carried out in June 2021. We explored the registry of Surveillance sanitaire des urgences et des décès (SurSaUD®, Santé Publique France) to rise original data regarding the epidemiology of AUR in France. RESULTS: AUR is a therapeutic emergency that requires a rapid bladder drainage. The average age is 71 years, 87 % are men and the stay in the emergency department is >4hours. In France, the hospitalization rate for UAR is steadily decreasing from 42% in 2014 to 32% in 2019. The introduction of an α-blocker increases the chances to get rid of the urinary catheter of 47% to 77% versus placebo. A post-emergency AUR pathway allows lowering the number of people lost with follow-up and shortening the duration of bladder drainage. The first try for catheter removal should be organized within 48-72hours of the AUR. In case of unsuccessful catheter removal, it is recommended to teach self-catheterization to the patient. The placement of a temporary prostatic stent is a promising alternative that is under evaluation. Immediate surgery is associated with increased morbidity/mortality and is not recommended. CONCLUSION: AUR is a common disease. The management has been optimized in recent years to improve the prognosis and the quality of life of patients.

Intermittent Catheterization Adherence Scale (ICAS): A new tool for the evaluation of patient adherence with clean intermittent self-catheterization.

AIM: Patients who have successfully acquired the intermittent self-catheterization (ISC) technique can be expected to use it on a long-term basis. The aim of the present study is to present a validated evaluation scale, referred to as the ICAS (Intermittent Catheterization Adherence Scale), which can be used to assess long-term patient adherence to prescribed ISC treatment. METHODS: The scale was validated in neurologic and non neurologic patients in an experienced French neurourology center, between September 2014 and February 2016. Eight items were chosen, providing a relatively objective insight into the degree to which patients reduce the frequency of their ISC procedures. Various factors, including the patients' understanding of the procedure, its relevance to their specific condition, as well as their acceptance of its psychological and inherently time-consuming drawbacks, were evaluated. The ISC construct validity and reproducibility, based on internal test-retest consistency and test-retest reliability, were measured using the Intra-class Correlation Coefficient (ICC). RESULTS: The ICAS was validated in 222 patients (133 females, 89 males, mean age 53 ± 11 years). The patients' comprehension of the questions was found to be good, and the questionnaire was well accepted. Cronbach's alpha was 0.73. The ICC test-retest consistency was also found to be good. CONCLUSION: The ICAS is a simple, acceptable, valid and reproducible test, and in some cases it may facilitate the medical follow-up of ISC patients. In the clinical environment, it is found to be a valuable tool, which can assist medical staff in the prevention of complications related to ISC non-compliance.

Intermittent catheterization acceptance test (I-CAT): A tool to evaluate the global acceptance to practice clean intermittent self-catheterization.

AIM: In certain cases, a patient's anxiety, fear, or misconceptions can represent significant obstacles to the learning of Clean Intermittent Self Catheterization (CISC), and little is known about these psychological barriers. The aim of the present study is thus to construct and validate an "Intermittent Catheterization Acceptance Test (I-CAT)" to evaluate the psychological acceptance of CISC. METHODS: A study was carried out in nine neuro-rehabilitation and urology departments in French university hospitals. Fifty-five items were identified, following a comprehensive review of the literature and cognitive debriefing interviews with patients. Following an initial expert panel meeting (EPM) with a French-speaking neuro-urology study group (GENULF), this list was refined and reduced to a draft I-CAT comprising 34 items. The face validity of the draft I-CAT was determined, and the results were then analyzed in a second EPM, leading to the elaboration of a second version of the I-CAT (23 items, 5 dimensions). Psychometric validation of this second version was established from a longitudinal, non-randomized study involving 201 neurological and non-neurological patients. Linguistic validation was carried out in English. RESULTS: Following the construct validity analyses, several items were deleted due to item overlap, ceiling effects, or poor content validity and 14 items were retained. Confirmatory factor analysis shows that this version has 2 dimensions. Cronbach's alpha was 0.93. The ICC demonstrated good test-retest reliability and satisfactory responsiveness. CONCLUSION: The upstream identification and solving of potential psychological barriers prior to the learning of CISC could improve patients' acceptance of this procedure.

Use of clean intermittent self-catheterization in France: A survey of patient and GP perspectives.

AIMS: To estimate the prevalence of GP (general practitioner) patients performing ISC (intermittent self-catheterization), to describe GP and patient knowledge about ISC and to assess the patients' quality of life. METHODS: A cross-sectional study was conducted in metropolitan France between November 2012 and September 2013 with French Sentinelles GPs and their patients (≥18 years) performing ISC. Linear regression models assessed independent associations between quality of life scores (Qualiveen and SF-12 scores) and patients' characteristics. RESULTS: The prevalence of ISC performers was estimated to be 61.7 (95% confidence interval [CI] = 61.0-62.4) of 100,000 inhabitants. Patients were males in 58.8% of cases and 53.8 years of age on average. They performed 4.84 catheterizations per day for 10.5 years. Over 1 year, there were 118 (55.1%) cases of patient-reported urinary incontinence (UI) and 158 (63.3%) cases of patient-reported urinary tract infection (UTI). Symptomatic UTIs were treated with antibiotics in 79.7% of cases. The average Qualiveen score was 1.38 (95%CI: 1.23-1.53). The average SF-12 Physical Component Score (PCS) and Mental Component Score (MCS) were 38.6 (95%CI: 36.8-40.4) and 46.4 (95%CI: 44.3-48.5), respectively. According to multivariate analysis, a poorer Qualiveen score and constipation reduced the PCS and a urinary medication prescription reduced the MCS. A poorer Qualiveen score was also associated with UI and UTI on bivariate analysis. CONCLUSIONS: ISC seems to be significant in French general practice whereas practical skills remain heterogeneous. UI, UTI, and constipation are recurrent issues among ISC performers that significantly decrease their quality of life. Education and adapted guidelines for GP guidance could improve these patients' conditions. Neurourol. Urodynam. 35:528-534, 2016. © 2015 Wiley Periodicals, Inc.

Intermittent catheterization difficulty questionnaire (ICDQ): A new tool for the evaluation of patient difficulties with clean intermittent self-catheterization.

AIMS: Once a catheterization technique has been learned and acquired, psychological barriers have been overcome and a specific catheter has been selected, a patient will need to use clean intermittent self-catheterization (CISC) on a long-term basis. Over this long period of time, several technical or anatomical difficulties and local complications may be observed. The aim of this study was to construct and validate a specific test, referred to as the ICDQ (intermittent catheterization difficulty questionnaire), in order to evaluate and quantify patients' difficulties during CISC. METHODS: The questionnaire was validated in neurogenic patients. Thirteen items were chosen, concerning ease of catheter insertion and withdrawal, the presence of pain, limb spasticity, urethral sphincter spasms, and local urethral bleeding during catheterization. The frequency and intensity of these difficulties were scored. The comprehension, relevance, psychological and time consumption acceptance and face validity were evaluated. Reliability (internal consistency and test-retest reliability using the Intraclass Correlation Coefficient [ICC]) was carried out. RESULTS: The ICDQ was validated in 70 neurogenic patients (mean age 51.6 ± 13, 44 females, 26 males). Comprehension and acceptance of the questionnaire were good. Cronbach's alpha was α = 0.88. The ICC demonstrated good test-retest reliability. CONCLUSION: The ICDQ is a valid test for the evaluation of catheter use, and of patients' difficulties during CISC. However, in order to facilitate CISC, we propose the interpretation of ICDQ results, drug combinations such as the use of alpha-blockers or botulinum toxin injections in the external urethral sphincter, or a change of catheter.

Sacral neuromodulation in patients with idiopathic overactive bladder after initial botulinum toxin therapy.

PURPOSE: We evaluated whether patients with overactive bladder and incontinence who discontinued intravesical botulinum toxin therapy can be successfully treated with sacral neuromodulation. MATERIALS AND METHODS: All patients who were referred to our center after discontinuation of botulinum toxin-A between 2005 and 2010 were included in this observational study. All patients underwent test stimulation with sacral neuromodulation and were evaluated with voiding diaries. Success was defined as more than 50% improvement in leakage episodes. Successful test stimulation was subsequently followed by a definitive implant. Patient satisfaction with sacral neuromodulation therapy was evaluated 1 year after the definitive implant. RESULTS: A total of 20 patients were included in the study. Of these patients 17 (85%) had discontinued botulinum toxin-A because of lack of efficacy and 3 had been treated successfully with botulinum toxin-A but requested a more permanent solution. The mean interval between the botulinum toxin-A and the sacral neuromodulation test stimulation was 23 months. In 14 patients (70%) the test stimulation was successful and they received a definitive implant. Of the 14 patients 5 even showed a decrease of greater than 90% in leakage episodes. One year after implantation 11 patients (79%) were satisfied with the sacral neuromodulation treatment. CONCLUSIONS: Despite the small sample size, this study indicates that patients who are dissatisfied with or in whom botulinum toxin-A treatment fails can respond successfully to sacral neuromodulation. The success rate of the test stimulation was comparable to that of patients who have never been treated with botulinum toxin-A. The 1-year satisfaction rate was comparable that of patients without a history of botulinum toxin-A treatment.

Management of complex ischial-urethral fistula in neurogenic patients performing clean intermittent self-catheterization.

INTRODUCTION: Neurogenic patients performing clean-intermittent self-catheterization (CIC) may develop an urethral erosion, resulting in ischial-urethral fistulas (I-UF). In this work we present our single-center experience in dealing with this peculiar complication. METHODS: In this work we included all neurogenic patients performing CIC treated at out Institution for I-UF. All patients had a spinal cord injury or myelomeningocele. We extracted from the patients' medical records the surgical management and postoperative clinical data. We defined failure the persistence of the fistula at X-ray contrast fistulography, retrograde urethrography, or uretrocystoscopy. RESULTS: We treated 11 patients (8 spinal cord injury, 3 myelomeningocele). Four patients have been treated with the placement of a new generation urethral stent (Uventa) after surgical toilette of the skin ulcer and placement of a temporary suprapubic catheter. All patients demonstrated a complete healing of the urethral lesion at stent removal and continued CIC without any difficulty. Four patients have been treated with perineal urethroplasty, requiring a buccal mucosal graft in two cases. In two patients a suprapubic permanent catheter was placed for a simpler bladder management due to the patients' comorbidities. In one case the incidental finding of an high grade muscle invasive urothelial bladder cancer, made it mandatory to perform an uretheroileocutaneostomy. CONCLUSIONS: This work represent a unique series of I-UF in neurogenic patients performing CIC. Surgical urethral reconstruction, often with the use of buccal mucosa in large lesions, may be a difficult solution in neurogenic patients, new generation stents (Uventa) represent a minimally invasive, effective, and safe alternative.

The effect of colpectomy on lower urinary tract function in transgender men.

Background: In transgender men, effects of colpectomy on voiding function are unknown, except for the incidence rates of urinary tract infections and urinary retention. Aims: To provide insight into the effect of colpectomy on Lower Urinary Tract Function (LUTF) in transgender men. Methods: A retrospective chart review was conducted among transgender men who underwent colpectomy between January 2018 and October 2020. Primary outcomes were objective and subjective changes in voiding. Secondary outcomes were transurethral catheterization length and the need for clean intermittent self-catheterization (CISC). Results: Of 132 men, 89 (67%) underwent Robot-assisted Laparoscopic Colpectomy (RaLC) and 43 (33%) Vaginal Colpectomy (VC). Maximum flow rate on uroflowmetry decreased following RaLC (mean of 29.1 vs. 38.3 mL/s, p = 0.002) and VC (mean of 29.2 vs. 40.3 mL/s, p < 0.001) after a median of four months postoperatively. An increase in total International Prostate Symptom Score was seen more frequently following VC compared to RaLC. Subjective changes were indicated by 39%, more often by men who underwent VC, of which the majority improved during the first months postoperatively. Trial without catheter (TWOC) on the first postoperative day was more successful after RaLC (79/89, 89%) than VC (24/43, 56%). Secondary TWOC was successful in 22/132 (17%) patients after a median of eight days postoperatively. In 5/132 (4%) men (three VC and two RaLC), temporary CISC was necessary for a period ranging from 5 to 21 days. The last 2/132 (2%) men after RaLC were still performing CISC at end of follow-up. Eventually, 5% (two VC and four RaLC) had to refrain from genital gender-affirming surgery with urethral lengthening due to voiding dysfunction. Discussion: After colpectomy, most objective and subjective worsening in LUTF is of a temporary nature, however, 5% had to refrain from genital gender-affirming surgery with urethral lengthening due to persistent voiding dysfunction, despite the desire to void while standing.

Effects of clean intermittent self-catheterization on late bladder dysfunction after radical hysterectomy in cervical cancer.

OBJECTIVE: To identify the benefits of clean intermittent self-catheterization in women who have late bladder dysfunction caused by radical hysterectomy in cervical cancer. METHODS: Thirty women who underwent radical hysterectomy with late bladder dysfunction were recruited. A nursing intervention program focusing on clean intermittent self-catheterization and a drinking plan was implemented. We recorded urinary times during the day and night, post-voiding residual urine volume, positive catheter specimen of urine rate, and quality of life instruments for patients with cervical cancer . RESULTS: All patients were able to satisfactorily manage clean intermittent self-catheterization following video-based operational training. Bladder function was significantly increased after 3-month intervention compared with before the intervention. Urinary times during the day and night, and post-voiding residual urine volume were greatly decreased post-intervention compared with pre-intervention. The rate of a positive catheter specimen of urine test significantly decreased over time. There was significant improvement in quality of life in five dimensions between weeks 1 and 12 following the intervention. CONCLUSIONS: Patients are able to learn the technique of clean intermittent self-catheterization without any difficulty. This technique is effective together with a drinking plan to decrease late bladder dysfunction caused by radical hysterectomy in cervical cancer.

Efficacy of Use of Triamcinolone Ointment for Clean Intermittent Self Catheterization following Internal Urethrotomy.

INTRODUCTION: Internal urethrotomy is recommended for the treatment of urethral strictures shorter than 1.5 cm but has been associated with high recurrence rates. The aim of this study was to evaluate the efficacy of use of triamcinolone ointment for clean intermittent self catheterization in the prevention of urethral stricture recurrence after internal urethrotomy. METHODS: Total of 60 male patients undergoing internal urethrotomy were assigned into two groups and clean intermittent self catheterization was performed using either triamcinolone ointment or a water-based gel for lubrication of the catheter in this randomized clinical trial. Clean intermittent self catheterization regimen was continued for 6 months and patients were followed for 12 months. Urethrocystoscopic evaluation was done 6 and 12 months postoperatively. RESULTS: The recurrence rates were compared between the two groups. There were no significant differences in patient characteristics and etiology of the stricture between the two groups. There was a 6 (22.22%) recurrence rate in the patients of the triamcinolone group against 13 (46.42%) in those of the control group after the first internal urethrotomy (P=0.04). After second internal urethrotomy, the urethra was stabilized in 5 (83.3%) of the patients in the triamcinolone group and 8 (61.5%) those in the control group (P=0.05). We also found a significant correlation between recurrence and stricture length (P=0.02) but the time to recurrence was not statistically significant (P=0.16). CONCLUSIONS: The use of triamcinolone ointment in patients on CISC regimen after internal urethrotomy significantly decreased the stricture recurrence rate.

Safety issues associated with using medication to treat overactive bladder.

INTRODUCTION: The mainstay of overactive bladder treatment is the use of anticholinergic medication with its common side effects well known. This review focused on three less well-known safety issues when treating OAB. Areas covered: Patients with increased anticholinergic load are at risk of cognitive decline, dementia or even death. The elderly are particularly at risk due to polypharmacy. Botulinum toxin carries the risk of high urinary residuals, urinary tract infection and need to self catheterise. The use of vaginal oestrogens may improve OAB symptoms, but there is concern in those with a history of breast cancer. Studies have shown that the systemic absorption is negligible and does not increase the risk of recurrence. Expert Opinion: Improvement in assessing anticholinergic load is needed with the development of a universal drug scale. To avoid increasing load, Mirabegron or botulinum toxin can be used instead. There is no consensus of the use of prophylactic antibiotics when injecting botulinum toxin and at what residual to initiate self catheterisation. Despite evidence showing that the use of vaginal oestrogens is safe in those with a history of cancer, it is not fully supported by any health body. Further work is needed in those using aromatase inhibitors.

Ensuring patient adherence to clean intermittent self-catheterization.

Patient performance of clean intermittent self-catheterization is a crucial component of the management of incomplete bladder emptying, which can arise from a variety of conditions. This allows patients to have more control over their bladder emptying, and avoids the inconveniences that come with an indwelling urethral catheter. There are, however, barriers that patients face when performing this task which may ultimately limit adherence. In this article, these barriers are discussed in more detail with potential solutions to counter them.

Self-intermittent catheterization in multiple sclerosis.

Clean intermittent self-catheterization (CISC) is considered the method of choice for treating urinary retention as of neurologic origin. Also, in multiple sclerosis (MS) the method is widely applied. Proper application needs sufficient hand function, possibility for proper positioning, sufficient sensation, cognitive function and as always the choice of the optimal material. The overall results are good. Specifically for MS patients more than average attention has to be given to training and follow-up in case of cognitive function impairment. Complications are acceptable with urinary tract infection having the highest incidence. MS being a progressive disease treatment possibly needs to be changed during follow-up.

Validation of the InCaSaQ, a new tool for the evaluation of patient satisfaction with clean intermittent self-catheterization.

AIMS: In neurourology, the choice of catheter is of paramount importance. At the time of our study, no simple validated questionnaire has been published, evaluating patient satisfaction with the use of urinary catheters. Our objective was to construct and validate a specific tool referred to as the Intermittent Catheterization Satisfaction Questionnaire (InCaSaQ), for the purposes of evaluating patient satisfaction with intermittent self-catheterization. METHODS: A simple tool was developed and validated in a neurourology referral centre, with 113 patients affected by a neurological bladder condition, between November 2011 and February 2012. Eight items, separated into four categories ("packaging", "lubrication", "catheter itself", "after catheterization") were selected. The mean score obtained with the eight-question questionnaire was calculated for each patient. Face validity was evaluated. Reliability based on internal consistency and test-retest reliability using the intraclass correlation coefficient (ICC) was carried out. RESULTS: The patients' comprehension and acceptance of the questionnaire were good. The questionnaire appears to have been well designed, with a significant Cronbach's alpha coefficient, and the ICC demonstrated good test-retest reliability. CONCLUSIONS: The InCaSaQ was found to be a valid tool for the evaluation of patient satisfaction with a urinary catheter. It is thus possible to compare the comfort and effectiveness of different types of catheter, and to objectify the need to change the type of catheter, in cases where patients express their dissatisfaction.