Outcome comparison of different approaches to self-intermittent catheterization in neurogenic patients: a systematic review

Switching from intermittent catheterization with single-use catheter to a reusable catheter has a negative impact on quality of life

PURPOSE

It has been proposed that reusable catheters are more cost effective and environmentally sustainable than single-use catheters intended for intermittent catheterization (IC). However, the aspect of individuals' well-being and preference for catheter type is not considered. In this study, we investigated the impact on individuals' health-related quality of life (HR-QoL) when testing a reusable catheter.

MATERIALS AND METHODS

The study was an open-labeled, single-arm, multicenter investigation with a treatment period of 28 days. Forty subjects using single-use hydrophilic catheters were accustomed to a reusable catheter for managing IC. HR-QoL was evaluated by the Intermittent-Self Catheterization Questionnaire (ISC-Q). Additionally, satisfaction was evaluated by the Intermittent Catheterization Satisfaction Questionnaire (InCaSa-Q). The difference in total score was analyzed using a mixed linear model. Furthermore, preference for IC (single-use vs. reusable) was assessed and microbial evaluation of the catheters was performed.

RESULTS

The total ISC-Q score measuring HR-QoL decreased significantly by 28% (p < 0.001). Two of the four subdomains (ease-of-use and discreetness) also decreased significantly (p < 0.001). The total InCaSa-score and all four subdomains evaluating satisfaction decreased significantly (p < 0.005). The primary study results were supported by the fact that 90.9% of subjects preferred to use a single-use catheter for IC. Furthermore, 50% of reusable catheters were contaminated with bacteria.

CONCLUSION

Switching from single-use to reusable IC resulted in a significant decrease in HR-QoL and satisfaction. Moreover, the vast majority preferred the single-use catheter due to handling and convenience. The users' rights to their preferred bladder management method should be acknowledged.

Reduction in lower urinary tract mucosal microtrauma as an effect of reducing eyelet sizes of intermittent urinary catheters

Intermittent catheterization (IC) utilizing conventional eyelets catheters (CECs) for bladder drainage has long been the standard of care. However, when the tissue of the lower urinary tract comes in close proximity to the eyelets, mucosal suction often occurs, resulting in microtrauma. This study investigates the impact of replacing conventional eyelets with a drainage zone featuring multiple micro-holes, distributing pressure over a larger area. Lower pressures limit the suction of surrounding tissue into these micro-holes, significantly reducing tissue microtrauma. Using an ex vivo model replicating the intra-abdominal pressure conditions of the bladder, the intra-catheter pressure was measured during drainage. When mucosal suction occurred, intra-catheter images were recorded. Subsequently affected tissue samples were investigated histologically. The negative pressure peaks caused by mucosal suction were found to be very high for the CECs, leading to exfoliation of the bladder urothelium and breakage of the urothelial barrier. However, a micro-hole zone catheter (MHZC) with a multi-eyelet drainage zone showed significantly lower pressure peaks, with over 4 times lower peak intensity, thus inducing far less extensive microtraumas. Limiting or even eliminating mucosal suction and resulting tissue microtrauma may contribute to safer catheterizations in vivo and increased patient comfort and compliance.

Product evaluation of the Luja Micro-hole Zone Technology in clean intermittent self-catheterisation

Clean intermittent self-catheterisation is a common procedure undertaken by people with bladder dysfunction. However, it is not without its complications, the main one being urinary tract infection. The most common causes of urinary tract infections are poor hygiene, technique and adherence, excessive post-void residual urine and bladder trauma. A catheter with new Micro-hole Zone Technology has been developed, which can potentially improve bladder emptying and minimise these complications. A case study is used to illustrate its effects in practice.

Urinary Catheters: Materials, Coatings, and Recommendations for Selection

Urinary catheters have been used for more than 3000 years, although materials have changed from wood to silver to rubber. Research continues to try and find the optimal catheter materials, which improve safety and quality of life. Advantages when comparing newer catheter materials are not always obvious but catheters coated with a hydrophilic layer may reduce urethral trauma and the incidence of urinary tract infections. However, extrapolation of the data is limited by lack of end-point standardization and heterogenous populations.

Hygiene management of intermittent self-catheterization using reusable silicone catheters in people with spinal cord lesions: A cross-sectional Internet survey in Japan

OBJECTIVES

To investigate hygiene management and catheter maintenance of reusable silicone catheters for intermittent self-catheterization (ISC) in Japan and examine their relationship with symptomatic urinary tract infection (sUTI).

METHODS

We conducted a cross-sectional Internet survey of people performing ISC using reusable silicone catheters owing to spinal cord lesions in Japan. Hygiene management and catheter maintenance of reusable silicone catheters and the incidence and frequency of sUTI were evaluated. We also examined the significant risk factors for sUTI.

RESULTS

Of 136 respondents, 62 (46%), 41 (30%), and 58 (43%) washed hands with water, washed hands with soap, and cleaned or disinfected the urethral meatus every time or most of the time before ISC, respectively. No significant difference was observed in the incidence and frequency of sUTI between respondents who adhered to these procedures and those who did not. There were no significant differences in the incidence and frequency of sUTI in respondents who changed their catheters every month and in those who changed their preservation solution within 2 days compared with those who did not. In multivariate analysis, pain during ISC, inconvenience of indoor mobility, bowel management problems, and participants' feeling of never having received instruction on catheter replacement were significant risk factors for sUTI.

CONCLUSIONS

There are individual differences in hygiene management and catheter maintenance of reusable silicone catheters, but the influence of these differences on the incidence and frequency of sUTI is not clear. Pain during ISC, bowel management problems, and inadequate instruction on catheter maintenance procedures are factors associated with sUTI.

A randomized, single-blind, multi-center clinical observational study of a new super lubricath coating catheter latex catheters using in urethral catheterization

Polymer polyvinylpyrrolidone (PVP) can be described as the main coating. After heating and curing, it is able to build a strong adhesion to the latex catheter for creating a durable and effective hydrophilic coating. In this study, we aim to explore the advantages and disadvantages of the new super lubricath latex catheter PVP coating compared with the common latex catheter. 148 patients who participated in the study were completely randomly divided into two groups, the observation group and the control group. When the urinary catheter was incubated, indwelling in subjects' body, and removed from the subjects, the researchers accordingly recorded the subjects' comfort feedback, device safety evaluation and the patient's vital signs, relevant blood and urine examination index, electrocardiogram (ECG) changes and recorded various adverse events. PVP super lubricath coating latex catheter offered better comfort, less damage to the urethra, and no significant disadvantage in safety compared to regular latex catheters, improving quality of care and patient satisfaction compared to regular latex urinary catheters.

A scoping review on the impact of hydrophilic versus non-hydrophilic intermittent catheters on UTI, QoL, satisfaction, preference, and other outcomes in neurogenic and non-neurogenic patients suffering from urinary retention

Background

For patients suffering from urinary retention due to neurogenic [e.g., spinal cord injury (SCI), spina bifida (SB), multiple sclerosis (MS)] or non-neurogenic [e.g., cancer, benign prostate hypertrophy (BPH)] causes, intermittent catheterization is the primary choice for bladder emptying. This scoping review compared hydrophilic-coated intermittent catheters (HCICs) with non-hydrophilic (uncoated) catheters in neurogenic and non-neurogenic patients with respect to satisfaction, preference, adverse events, urinary tract infection (UTI), quality of life (QoL), cost effectiveness, pain, and discomfort.

Methods

A systematic literature search was conducted using PubMed, Cochrane Library, Google Scholar, Embase, and available clinical practice guidelines and was limited to systematic reviews/meta-analysis and clinical studies (randomized trials, cohort and case–control studies) published in English between 2000 and 2020. A narrative synthesis was performed, comparing HCIC with non-hydrophilic catheters in each pathology. The articles where critically appraised and weighted according to their level of evidence based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence grading.

Results

Thirty seven original articles and 40 reviews were included. The comparison of HCICs versus non-hydrophilic catheters was well-documented in patients with mixed pathology, SCI, and to some extent SB. The available evidence predominantly indicates better outcomes with HCICs as reported by study authors, particularly, greater UTI reduction and improved satisfaction, cost-effectiveness, and QoL. However, SB studies in children did not report reduction in UTIs. Children complained about slippery catheters, indicating possible touching of the surface during insertion, which may compromise cleanliness of the procedure and affect outcomes such as UTI. Limited studies were available exclusively on BPH and none on MS; however, most studies performed on mixed pathologies, including BPH and MS, indicated strong preference for HCICs compared to non-hydrophilic catheters.

Conclusions

The findings generally support HCICs over non-hydrophilic catheters; however, most studies were fairly small, often used a mix of pathologies, and the conclusions were often based on studies with high drop-out rates that were therefore underpowered. Larger studies are needed to support the general finding that HCICs are the preferred choice in most populations. Additional training in children or redesigned catheters may be necessary for this age-group to fully benefit from the advantages of HCICs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-022-01102-8.

Effects of hydrophilic coated catheters on urethral trauma, microtrauma and adverse events with intermittent catheterization in patients with bladder dysfunction: a systematic review and meta-analysis

Background

Hydrophilic coated catheters are recommended to reduce the side effects of intermittent catheterization (IC) in patients with bladder dysfunction. However, there is lack of Level one evidence to support the use of this intervention.

Search methods

Several electronic databases were systematically searched to evaluate complication incidences for hydrophilic coated (HC) and non-hydrophilic catheters (NHC).

Results

Twelve studies were eligible for inclusion in the review. The meta-analyses exploring microscopic hematuria frequencies (RR = 0.69; 95% CI 0.52–0.90) and urethral stricture frequencies (RR = 0.28; 95% CI 0.13–0.60) showed a lower risk ratio associated with HC in comparison to NHC, whereas gross hematuria was no statistically significant difference in two groups. Subgroup analyses of gross hematuria which was grouped according to "catheterization frequency", "single/multiple catheterization" and "self/other catheterization” were performed and the values of combined RR were also no statistically significant difference.

Conclusions

Compared with non-hydrophilic catheters, the hydrophilic coated catheters have positive significance in reducing the incidence of urethral microtrauma and the urethral stricture. However, more studies are warranted for evaluating effects of hydrophilic coated catheters on the incidence of gross hematuria.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11255-022-03172-x.

Transvaginal closure of urinary bladder opening and Mitrofanoff technique in a neurologically impaired female with chronic indwelling catheter: a case presentation

Background

Chronic catheterization remains the only attractive option in specific circumstances, especially in neurologically impaired patients. Complications produced by the indwelling catheters, like patulous urethra and bladder neck destruction, usually lead to severe incontinence and significant nursing difficulties. Here, we describe a rare case, a urinary bladder opening representing massive and extensive destruction of the urethra and bladder sphincter due to an indwelling catheter.

Case presentation

We present a 46-year-old paraplegic woman complaining of recurrent febrile urinary tract infections and severe urinary incontinence. She suffered from persistent malodorous urine and skin breakdowns from constant urine leakage. The vaginal examination revealed extensive destruction of the urethra and a 10 cm opening permitting the urinary bladder wall to prolapse into the vagina. The patient underwent a combined surgical approach; a transvaginal bladder closure with anterior colporrhaphy and a Mitrofanoff procedure to ensure a continent stoma for future clean intermittent self-catheterization (CISC). The patient is compliant with CISC and, remains continent twelve years after surgery.

Conclusion

This case demonstrates that in the era of CISC, there are still neurologically impaired females suffering from rare but critical adverse effects of indwelling catheters. The urethra and bladder neck erosion represent a demanding treatment assignment. The Mitrofanoff procedure for continent stoma and the transvaginal closure of urinary bladder opening produced a lifesaving potential treatment.

Evaluation of patient-reported outcome measures in intermittent self-catheterization users: A systematic review

OBJECTIVE

To identify patient-reported outcome measurements (PROMs) for intermittent self-catheterization (ISC) users, critically assess and summarize the quality of the measurement properties, and describe the application scenarios on each instrument.

DATA SOURCES

PubMed, EMBASE, Medline, PsycINFO and relevant reference lists were systematically searched until December 2019 (updated May 2020).

STUDY SELECTION

Two reviewers independently identified original English language publications that evaluated the psychometric properties of specific PROMs used in ISC patients.

DATA EXTRACTION

The following data were obtained: author and publication year, content of domains/subscales, number of items, response options, constructs measured, language and information on measurement properties.

DATA SYNTHESIS

Eleven publications were deemed eligible, including 6 PROMs for measuring patients' ISC-related quality of life, self-confidence, satisfaction, difficulties, acceptance and adherence to treatment. The Intermittent Self-Catheterization Questionnaire provided the most detail, and the Intermittent Catheterization Acceptance Test could be evaluated on the most COSMIN properties.

CONCLUSION

Several tools are available for ISC users, but at present there is no comprehensive, concise and robust instrument with good psychometric properties. Further research on psychometric properties is needed to verify the remaining properties of existing scales and to develop novel tools for clinicians, researchers and patients.

The evidence supporting single-use intermittent catheters in people with spinal cord injury

Intermittent catheterization (IMC) is the accepted evidence-based best practice for bladder management in people with voiding dysfunction due to neurogenic bladder. The two methods for performing IMC over the decades since this practice was introduced are reuse and single-use catheters. There are perceived advantages and disadvantages of each method of performing IMC. There is considerable evidence that single-use IMC is associated with better health outcomes, including reduced risk of urinary tract infection, urethral trauma, and quality of life. People performing IMC also indicate a preference for single-use, although there are advantages of reuse that need to be acknowledged. Ideally, further research is needed in this area, particularly around the washing and storage of reuse catheters, as well as an adequately powered multicenter RCT comparing reuse with single-use IMC, but there are numerous challenges associated with progressing this research.

Barriers and facilitators to optimising inpatient bladder management after spinal cord injury

STUDY DESIGN

Qualitative survey.

OBJECTIVES

Examine clinicians' perspectives on adherence to published evidence-based guidelines and clinician-perceived barriers, and facilitators to optimising inpatient bladder management within one Spinal Cord Injury (SCI) service.

SETTING

Surgical Hospital (acute care) and SCI Unit (sub-acute, rehabilitation) in Western Australia (WA).

METHODS

Clinicians reviewed an 'Evidence Matrix' summarising published clinical practice guidelines and recommendations for SCI bladder management. Focus groups examined the extent to which current practice adhered to recommendations and identified perceived barriers and facilitators to optimal management. Data were analysed thematically using a deductive approach.

RESULTS

Current management closely mirrors published recommendations. Key facilitators included long-standing prioritisation of rapid progression from urethral indwelling (IDC) to a 6 hourly intermittent catheterisation (IC) protocol; regular competency audits of catheterisation technique; and a Spinal Urology Clinical Nurse Consultant (CNC) position. Barriers included limited resources/staffing; restricted access to Neuro-urology consultation; inter-disciplinary communication gaps; and delays in determining and implementing long-term bladder management.

CONCLUSIONS

Inpatient SCI bladder care in WA closely emulates published evidence, although adherence at other sites may reveal different practices. Bladder management was found to have been facilitated by a strong culture of practice led by Neuro-urologists, informed by evidence and embraced by Senior Clinicians. Further reduction in duration of initial IDC, provision of early and ongoing Neuro-urology consultations as part of standard care, increased interdisciplinary communication and dedicated SCI Urology theatre lists would further optimise management.

Intermittent catheterization with single- or multiple-reuse catheters: clinical study on safety and impact on quality of life

PURPOSE

Intermittent catheterization (IC) is a proven effective long-term bladder management strategy for individuals who have lower urinary tract dysfunction. This study provides clinical evidence about multiple-reuse versus single-use catheterization techniques and if catheter choice can have an impact on health-related quality of life (HRQoL).

METHOD

A prospective, multi-center, clinical trial studied patients who currently practiced catheter reuse, and who agreed to prospectively evaluate single-use hydrophilic-coated (HC) (i.e. LoFric) catheters for 4 weeks. A validated Intermittent Self-Catheterization Questionnaire (ISC-Q) was used to obtain HRQoL. Reused catheters were collected and studied with regard to microbial and debris contamination.

RESULTS

The study included 39 patients who had practiced IC for a mean of 10 years, 6 times daily. At inclusion, all patients reused catheters for a mean of 21 days (SD = 48) per catheter. 36 patients completed the prospective test period and the mean ISC-Q score increased from 58.0 (SD = 22.6) to 67.2 (SD = 17.7) when patients switched to the single-use HC catheters (p = 0.0101). At the end of the study, 83% (95% CI [67-94%]) preferred to continue using single-use HC catheters. All collected reused catheters (100%) were contaminated by debris and 74% (95% CI [58-87%]) were contaminated by microorganisms, some with biofilm.

CONCLUSION

Single-use HC catheters improved HRQoL and were preferred over catheter reuse among people practicing IC. Catheter multiple-reuse may pose a potential safety concern due to colonization by microorganisms as well as having reduced acceptance compared to single use.

TRIAL REGISTRY NUMBER

ClinicalTrials.gov NCT02129738.

Clean intermittent catheterization: Single use vs. reuse

INTRODUCTION

Intermittent catheterization (IC) is one of the fundamental aspects of managing patients with chronic urinary retention. Although reuse of catheters has been allowed to be chosen as the first option for IC, the optimal method of IC and the type of catheter has been a long-standing debate. We conducted a literature review regarding risk of urinary tract infection (UTI) and the costs associated with different methods and catheters.

METHODS

A MEDLINE search via PubMed, EMBASE, and EBSCO host was conducted in March 2018. The date of publication was limited to 2014 to present/current.

RESULTS

Single use of catheters (hydrophilic-coated [HC] or uncoated [UC]) was considered to impose a lower risk of UTI in all studies, except in one study that included children, but did not test their dexterity to handle HC catheters. Cost-effectiveness of single-use catheters was confirmed by all studies during this period.

CONCLUSIONS

Reuse of catheters exposes the patient to a plethora of possible cleaning techniques and duration of catheter use. Patient adherence to cleaning method cannot be predicted and this further amplifies the risk of complications and their burden on the healthcare system. We recommend a patient-centred approach to consider HC catheters as the first option, while considering the patient's/caregiver's ability to accommodate the usage technique. Single-use UC catheters, and finally reuse of catheters are considered as next options if HC catheters are found difficult to handle (especially in children doing self-catheterization). Larger trials investigating this matter are required.

Cost-effectiveness of hydrophilic-coated intermittent catheters compared with uncoated catheters in Canada: a public payer perspective

STUDY DESIGN

A Markov model was used to analyze cost-effectiveness over a lifetime horizon.

OBJECTIVE

To investigate the cost-effectiveness of hydrophilic-coated intermittent catheters (HCICs) compared with uncoated catheters (UCs) among individuals with neurogenic bladder dysfunction (NB) due to spinal cord injury (SCI).

SETTING

A Canadian public payer perspective based on data from Ontario; including a scenario analysis from the societal perspective.

METHODS

A previously published Markov decision model was modified to compare the lifetime costs and quality-adjusted life years (QALYs) for the two interventions. Three renal function and three urinary tract infection (UTI) health states as well as other catheter-related events were included. Scenario analyses, including utility gain from compact catheter and phthalate free catheter use, were performed. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of the model.

RESULTS

The model predicted that a 50-year-old patient with SCI would gain an additional 0.72 QALYs if HCICs were used instead of UCs at an incremental cost of $48,016, leading to an incremental cost-effectiveness ratio (ICER) of $66,634/QALY. Moreover, using HCICs could reduce the lifetime number of UTI events by 11%. From the societal perspective, HCICs cost less than UCs, while providing superior outcomes in terms of QALYs, life years gained (LYG), and UTIs. The cost per QALY further decreased when health-related quality-of-life (HRQoL) gains associated with compact HCICs or catheters not containing phthalates were included.

CONCLUSION

In general, ICERs in the range of CAD$50-100,000 could be considered cost-effective. The ICERs for the base case and sensitivity analyses suggest that HCICs could be cost-effective. From the societal perspective, HCICs were associated with potential cost savings in our model. The results suggest that reimbursement of HCICs should be considered in these settings.

Catheterization for treating neurogenic lower urinary tract dysfunction in patients with multiple sclerosis: A systematic review. A report from the Neuro-Urology Promotion Committee of the International Continence Society (ICS)

AIM

To systematically assess all available evidence on efficacy and safety of catheterization for treating neurogenic lower urinary tract dysfunction (NLUTD) in patients with multiple sclerosis (MS).

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were identified by electronic search of Embase, Medline, Scopus, Cochrane register (last search March 3, 2018) and by screening of reference lists and reviews.

RESULTS

After screening 7'015 articles, we included four studies (one prospective and two retrospective cohort studies, one retrospective cross-sectional study), in which a total of 445 patients were enrolled. No randomized controlled trial was available. Catheterization substantially increased quality of life, post void residual, and incontinence episodes in all included studies. Pooling of data for meta-analysis was not possible due to the heterogeneity of reported outcomes. Adverse events were reported in two studies only. Risk of bias and confounding was intermediate.

CONCLUSIONS

Preliminary data suggests beneficial effects of catheterization on the urological outcome in patients with MS. However, although intermittent and indwelling catheterization is used frequently in daily clinical practice in the MS population, the evidence base is very limited and well-designed, properly sampled, and powered studies are urgently needed.