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Trauma Spinal Cord Injury
The search for the ideal material is not yet over. Rubber, latex, plastic in the bladder wall has become very popular.
41
It has few side effects,
(polyvinyl chloride [PVC]), silicone, siliconised or Teflon
®
-coated although temporary general paresis can occur.
42,43
Surgery for bladder
rubber, glass and stainless steel have been or are still used. The augmentation may be necessary.
44
When a too high diuresis is noted
hydrophilic coated catheters probably cause less irritation to the during the night due to diurnal variation of antidiuretic hormone,
45
urethral mucosa and fewer urethral complications in the long term,
32
desmopressin acetate (DDAVP) can safely and effectively be used.
46
In
and facilitate the healing of minor epithelial damage.
33
An impact on cases of catheterisation difficulty at the striated sphincter, botulinum
urinary tract infection has been suggested.
34
The osmolarity of the toxin injection in the sphincter can help.
47
In individuals with
coating is thought to be important.
35
For those with preserved urethral tetraplegia, reconstructive hand surgery may be indicated.
48
For those
sensation, a local anaesthetic jelly may be needed, instilled into the with poor hand function or difficulty reaching the meatus, assistive
urethra before catheterisation. Many female patients do not use devices might be needed.
catheter lubrication. Catheters with a hydrophilic and self-lubricated
surface need activation with tap water or sterile water. Education is very important. Patients and carers must understand
what is wrong with the bladder/sphincter and why IC is proposed for
Two main techniques have been adopted: sterile IC (SIC) and a clean treatment. They have to learn how to catheterise properly. Teaching
IC (CIC). The sterile non-touch technique has been described above. In programmes have been shown to be successful in non-literate
the majority of cases nowadays a clean technique is used, as persons in developing countries
49
and in quadriplegic patients.
50
described below.
Not all patients starting with IC continue this treatment. This can be
Self-catheterisation can be performed in many different positions: because voiding becomes possible again; however, persistent
supine, sitting or standing. incontinence, especially in conjunction with a lack of availability of
external collective devices for female patients, dependence on care-
The basic principles of urinary catheter introduction are well known: the givers, social inconvenience, infections, physical conditions such as
catheter must be introduced in a non-infecting and atraumatic way. The spasticity interfering with catheterisation and personal choice can
requirements for this have been described before. Not infecting means also influence the decision.
51–53
Bakke and Malt
54
found that among
cleaning hands, using a sterile catheter and lubricant and cleaning the those who practised IC independently, 25.8% were sometimes and 6%
meatal region before catheter introduction. Atraumatic insertion always averse, especially young patients and females. In many,
requires a proper catheter size, sufficient lubrication and gentle aversion seemed to be related to a subjective evaluation of their
introduction through the urethra, sphincter area and bladder neck. The situation, to emotional status and, above all, to non-acceptance of
catheter has to be introduced until urine flows out. Urine can be their chronic disability.
drained directly into the toilet or into a urinal, plastic bag or other
reservoir. The catheter should be kept in place until the urine flow Few studies have evaluated whether IC is cost-effective.
55
Some have
stops; it should then be pulled out slowly, while performing gentle compared sterile with non-sterile
56
and IC with suprapubic catheters.
57
Valsalva or bladder expression in order to completely empty the Cost-effectiveness will depend on social and economic possibilities.
bladder of residual urine. When properly performed, the amount of
residual urine should be minimal. Finally, the end of the catheter should Complications of Intermittent Catheterisation
be blocked to prevent backflow of the urine or air into the bladder. and Intermittent Self-catheterisation
Hydrophilic catheters can be left in place for a short time to prevent Urinary Tract Infection
suction by the urethral mucosa, which may make removal difficult. Hydrokinetics can play a preventative or, if they are disturbed, a
causative role that relates directly to ISC: diuresis, the completeness
When resources are limited, catheters have been re-used for up to of bladder emptying, the frequency of bladder emptying and the
weeks and months.
36
Some re-sterilise or clean them by soaking them grade of bladder distension.
58
The importance of the frequency of
in an antiseptic solution or boiling water. Microwaving to re-sterilise catheterisation is therefore obvious. Anderson found five times more
rubber catheters has been described.
37
The findings of Van Hala et al.
38
infection in patients who were catheterised three times a day than if
suggest that re-used supplies are not related to an increased catheterisations were performed six times a day.
59
Infection incidence
likelihood of urinary tract infection. varies widely in the literature, with some studies showing always
sterile urine in up to 88%, and others in only 12%. Such discrepancy is
The frequency of catheterisation required can depend on many probably related to definitions, the use of prophylaxis and other
factors, such as bladder volume, fluid intake, post-void residual and factors. There is an overall need for better studies on ISC methodology
urodynamic parameters (bladder compliance, detrusor pressure). and urinary tract infection.
60,61
Usually it is recommended to catheterise four to six times a day
during the acute phase after spinal cord lesion. Some will need to The use of antibacterial prophylaxis has been debated for a long
maintain this frequency if IC is the only way of emptying the bladder; time, and no final conclusion has yet been reached. Several authors
others will need to catheterise one to three times a day to check and have seen a lowering of the infection rate when antibacterial
evacuate residual urine after voiding or on a weekly basis during medication is given even at a low dose, but resistance to antibiotics
bladder re-training.
39
With a portable ultrasound device it is possible to is a great risk.
reduce the number of required catheterisations.
40
Genital Infections
Adjunctive therapy to overcome high detrusor pressure is often Urethritis can occur in up to 19% of cases and has an increasing
needed. Antimuscarinic drugs or bladder relaxants are often indicated incidence with longer follow-up.
62
The incidence of prostatitis is
in patients with bladder overactivity. The injection of botulinum toxin mostly underestimated.
63
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EUROPEAN UROLOGICAL REVIEW
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