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Impact of Introducing Intermittent Self-catheterisation to Individuals with an Injured Spinal Cord
catheterisation in 1833,
15
to indwelling transurethral catheters in 1910, cross-infection. Early self-catheterisation by patients at a mean of five
to suprapubic catheters in 1917,
16
to tidal drainage,
17
to non-touch weeks post-injury showed no difference in infection rate and another
intermittent catheterisation,
18
to clean self-catheterisation
19
and then big improvement in terms of cross-infection incidence between
to suprapubic drainage in select individuals today.
20
patients. ISC reinforced the feeling of active participation by patients
in their urological management.
28
Without doubt the introduction of intermittent catheterisation (IC) was
a major development. The important breakthrough came in the The intermittent emptying and filling of the bladder allows normal
second half of the last century. During World War Two, in the Centre elasticity of the detrusor muscle and normal muscle tone to be
for Individuals with SCI in Stoke Mandeville, UK, Ludwig Guttmann and retained, provided overdistention is avoided. To avoid overdistention
his co-workers proved that IC performed in sterile conditions and with one needs to monitor closely the urine output and regularly adjust the
intensive nursing did not lead to sepsis or early death, but offered a schedule to prevent volumes in excess of 500–600ml. As the SCI
good and safe method for drainage of the neurological bladder.
21
evolves, patients with high lesions may develop very irregular urine
output patterns, in which case the risk of overdistention increases.
26
Although originally IC was used as a temporary treatment until Most typically, the urine output is small during the day when patients
bladder activity re-started or alternative methods of drainage became are upright in a wheelchair. However, soon after assumption of the
possible, in the 1970s it also began to be used in the form of supine position, a strong diuresis may occur, which can require hourly
intermittent self-catherisation (ISC) for long-term treatment of all catheterization. It is not productive to limit fluid intake, but it is
types of bladder retention.
22
Today it is considered the method of preferable to adjust the catheterisation frequency.
choice for treating bladder retention, and as one of the biggest
achievements in neurourology. As will be described later, IC also allows the avoidance of
complications that have strong negative effects on the bladder wall,
Whatever the underlying pathology, the purpose of IC and ISC is to the urodynamic situation and sometimes general health. Some of our
empty the bladder regularly over the day. In this regard IC succeeds own data suggest that patients treated with IC/ISC in the acute care
well: the residual after catheterisation is small, with a mean of 6ml setting after SCI may become catheter-free earlier,
29,30
but very large
as measured with phelophtaleine washout.
23
Also, if catheterisations series would permit strong conclusions on this matter to be drawn.
are performed repeatedly, residual remains low, as demonstrated Moreover, as ISC is now mostly preferred as a chronic treatment, the
with ultrasonography.
24
speed at which an individual becomes become catheter-free has lost
much of its importance.
Complete evacuation of the bladder contents can have an impact on
other symptoms and signs, which constitute other indications for the Intermittent Self-catherisation During the
technique: improving continence, lowering infection rates, avoiding or Rehabilitation Period
improving distension of the upper urinary tract, avoiding autonomic As spinal shock dissipates, recovery of reflex activity occurs. This may be
dysreflexia and so on. noticeable by urine leakage between catheterisations – which is less
easy to spot with continuous bladder drainage
31
– but today this is of less
The ideal urodynamic indication for IC and ISC is a bladder with large value due to urodynamic testing. Urodynamic tests should be carried
capacity, low pressure, normal or high compliance and sufficient out early after SCI (within one month if possible) to obtain a more
outlet resistance to obtain continence between catheterisations but objective picture of bladder pressures, bladder neck behaviour and
not too high to cause problems for the introduction of the catheter. striated sphincter activity. Although IC can be used indefinitely in most
Such a urodynamic situation can be present already, or can be patients after SCI, some individuals will be able to profit from other
created by changing the less good urodynamic parameters with methods of bladder emptying that make catheterisation unnecessary,
pharmacological or surgical treatment.
25
such as voluntary micturition or low-pressure reflex micturition with
detrusor sphincter synergia; repeated urodynamics can demonstrate
Intermittent Catheterisation During the possible alternatives. In others, urodynamics will show the need for
Spinal Shock additional treatment, for example to improve leak-point pressure and
Spinal shock is the indication for which IC was originally developed. lower detrusor pressure. IC and ISC in individuals with SCI do not obviate
As soon as the phase of unstable diuresis
26
has passed, IC should be the need for regular and close urodynamic follow-up.
started, which may be within a few days post-injury. Originally, IC was
successfully applied in the acute care setting after SCI by using a Catheterisation Methodology
sterile non-touch technique. In the historical setting at Stoke Several types of catheter are used around the world, such as Nelaton,
Mandeville, a doctor together with a technical assistant performed all O’Neil, Tiemann and Foley. The choice is mainly down to local custom,
catheterisations. The doctor wore a sterile gown, mask and gloves. availability and cost. All catheters seem to give acceptable results
The assistant helped by handing over the necessary material. The provided that the catheters are used in accordance with best practice
genital area was prepared as for surgery with sterile drapes. protocols/guidelines in terms of short- and long-term applications.
The catheterisation material was taken from a pre-packed disposable Catheterisation involves lubricants, catheter manipulation and
set. Although this description might suggest that this technique was introduction, and rules are needed for both short- and long-term
very complicated, the practical application went smoothly, with each successful application.
catheterisation taking about 10 minutes. Later, the technique was
simplified and catheterisation was performed by a nurse wearing a In terms of size, the most commonly used catheters for adults are
mask and sterile gloves. The formation of a catheter team in an SCI 12–16 French, and for young children 8 French, gradually progressing
ward, as proposed by Lindan,
27
gave good results in the prevention of with age to 14 French.
EUROPEAN UROLOGICAL REVIEW
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