Intermittent Self-catheterization in Older Adults: Predictors of Success for Technique Learning

Internal and External Barriers to Bladder Management in Persons with Neurologic Disease Performing Intermittent Catheterization

People living with neurogenic lower urinary tract dysfunction (NLUTD) often have to use clean intermittent catheters (CIC) to manage their bladder function. The use of catheters presents multiple unique challenges, based on both the person's inherent characteristics and on the external limitations imposed by public toilets. We review the impact of age, sex, upper limb function, caregiver assistance, time required to perform CIC, and urinary incontinence on CIC in NLUTD, with special reference to their interaction with societal and public health factors. Public toilet limitations, such as lack of availability, adequate space and special accommodation for CIC, cleanliness, and catheter design are also reviewed. These potential barriers play a significant role in the perception and performance of bladder care in people living with NLUTD.

In multiple sclerosis, a Functional Independence Measure ≥ 107 is the best predictor of outcome after clean intermittent catheterization training

BACKGROUND

Assessment of motor and cognitive functions is recommended before clean intermittent catheterization training. Two validated instruments, the Functional Independence Measure (FIM) and the Pencil and Paper Test (PP-Test), are associated with the ability to learn self-catheterization in people with multiple sclerosis.

OBJECTIVES

We aimed to compare the performance of these tools in predicting the outcome of clean intermittent catheterization training in multiple sclerosis.

METHODS

All people with multiple sclerosis attending a tertiary neuro-urology department between 2011 and 2019 and eligible for clean intermittent catheterization were included in this retrospective study. The reference standard was the ability to perform at least 2 trials of self-catheterization at the end of the training session. The 2 index tests, the FIM and PP-Test, were administered before the teaching session. Their diagnostic performance was estimated by calculating sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). The AUC values were compared by a two-sided DeLong test.

RESULTS

We included 395 individuals (mean [SD] age 49.8 [12] years; 70% women). At the end of the session, 87% of the patients succeeded in learning self-catheterization. The optimal cut-offs for the FIM (107) and PP-Test (13) were estimated, resulting in sensitivity of 73% (95% confidence interval [68-77) and 73% (67-77) and specificity 73% (59-84) and 63% (49-76), respectively. The AUC values for the FIM and PP-Test were significantly different (0.79 vs 0.73, p = 0.049). The effect size was large for both the FIM (Cohen's d = 1.14) and PP-Test (Cohen's d = 0.87).

CONCLUSIONS

An FIM value ≥107 has the best specificity to predict outcome after clean intermittent catheterization training for people with multiple sclerosis. The sensitivity of the FIM and PP-Test is similar, and both have a large effect size for the outcome of self-catheterization training in multiple sclerosis.

Risk of Retention After OnabotulinumtoxinA Injection for Overactive Bladder in a Diverse Urban Population With High BMI and Comorbidity Rates

IMPORTANCE

OnabotulinumtoxinA (BTX-A) injection is a third-line therapy for overactive bladder (OAB). Patients undergoing treatment have a 6.5% chance of requiring clean intermittent catheterization (CIC) due to postoperative urinary retention (POUR).

OBJECTIVE

The aim of this study was to evaluate risk factors for retention after BTX-A injections for OAB to decrease treatment hesitancy and enhance shared decision-making.

STUDY DESIGN

This is a retrospective review of patients who underwent BTX-A injection for OAB at an urban university hospital between November 2015 and January 2021. Patients with neurogenic OAB, incomplete follow-up, or concomitant vaginal surgery were excluded. The primary outcome was POUR requiring CIC or postvoid residual volume (PVR) >200 mL at follow-up visit. Secondary outcomes included number of BTX-A injections, interval to reinjection, and whether patients reported symptom improvement.

RESULTS

Our sample (N = 185) was 84% female with high prevalence of obesity (50%) and diabetes (32%). Twenty-one (11.4%) met the criteria for POUR with 17 (9.2%) requiring CIC. The retention and nonretention groups were similar in age, sex, smoking history, body mass index (BMI), hemogloblin A1c, and birth history, but significantly differed in preoperative PVR. Logistic regression revealed that patients with preoperative PVR 100+ mL had nearly 4-fold higher odds of POUR compared with patients with PVR less than 50 mL (odds ratio, 3.77; 95% confidence interval, 1.08-16.19).

CONCLUSIONS

Our findings reassure patients with high BMI, as well as their physicians, that retention after BTX-A injection is not associated with BMI. However, patients presenting with high baseline PVR (100 + mL) should be counseled regarding a potentially higher risk of retention after BTX-A injection.

A Multicenter, Open-Label, Observational Study Evaluating the Quality of Life After Using a Hydrophilic-Coated Catheter (SpeediCath) With Self-Intermittent Catheterization

PURPOSE

We evaluated the change in patient quality of life after the use of a hydrophilic-coated catheter (SpeediCath) in adults requiring intermittent catheterization (IC).

METHODS

This was a multicenter, open-label, observational study using the Patient Perception of Intermittent Catheterization (PPIC) questionnaire and the Intermittent Self-Catheterization questionnaire (ISC-Q) and safety at 12 and 24 weeks in adult patients who had already used other type of catheters prior to switching to SpeediCath or in patients undergoing self-IC for the first time for any reason.

RESULTS

Among a total of 360 subjects, 215 (59.7%) were women, and the mean age was 62.0±13.2 years. At 24 weeks, the satisfaction rate after using SpeediCath was 84.1%, and 80% of patients responded that they could easily perform IC. In total, 81.6% of patients were willing to continue using SpeediCath. The mean ISC-Q score was 54.90±18.65 at 24 weeks. Men found less interference in their daily life by performing IC than women and found it easier to handle the catheter before it was inserted into the urethra. At week 12, the mean change in ISC-Q was significantly greater in patients <65 years (20.24±23.55) than in those ≥65 years (7.57±27.70, P=0.049), but there was no difference at 24 weeks. The most common adverse events were urinary tract infection in 9.72%, gross hematuria in 2.78%, and urethral pain in 1.39%.

CONCLUSION

The use of a SpeediCath provided good quality of life for patients who needed self-IC regardless of age or sex.

Short-term catheter management options for urinary retention following pelvic surgery: a cost analysis

BACKGROUND

Several studies have compared short-term catheterization approaches and have demonstrated no difference in patient satisfaction, but no study has evaluated their costs.

OBJECTIVE

To evaluate the costs of 3 pathways for short-term catheter management in patients diagnosed with urinary retention following pelvic surgery.

STUDY DESIGN

We utilized a Markov decision tree to model costs from the society's perspective. In pathway 1, patients have an indwelling catheter and return to the office for a voiding trial. In pathway 2, patients have an indwelling catheter and discontinue the catheters at home. In pathway 3, patients are taught clean intermittent catheterization postoperatively. We accounted for office visits, emergency department visits, urinary tract infection testing and treatment, transportation, caregiver time, teaching time, and supplies.

RESULTS

Clean intermittent catheterization is the least costly catheterization method at $79 per patient, followed by self-removal of the catheter ($128) and office voiding trial ($185). One-way sensitivity analyses showed that the distance between the patient and office and the rates of spontaneous voiding following catheterization had the greatest impact. When patients need to travel >5 miles to the office for catheter removal, self-removal of a catheter is less costly than an office voiding trial. Once it has been determined that patients have urinary retention and require catheterization, clean intermittent catheterization is the most cost-saving option only if the patients are taught clean intermittent catheterization postoperatively. If all patients were to be taught clean intermittent catheterization routinely before surgery, it becomes the most costly option. Based on annual surgical volume, if even $30 were saved per patient with postoperative urinary retention, the estimated total societal savings would be $420,000 to $7.2 million.

CONCLUSION

Clean intermittent catheterization as initial management of urinary retention following pelvic surgery is the most cost-saving option when it is only taught postoperatively to patients after determining the need for catheterization. When this is not possible, self-removal of an indwelling catheter is the most cost-saving option, especially as the distance between the patient and provider increases. Choosing the optimal management guided by patient and provider factors can lead to substantial cost savings annually in the United States.

Functional independence measure predicts the outcome of clean intermittent catheterization training in patients with multiple sclerosis

BACKGROUND

Clean intermittent catheterization (CIC) is the reference treatment of urinary retention in people with multiple sclerosis (pwMS). Predicting which patients could use this treatment, based on their motor and cognitive abilities, is crucial.

OBJECTIVES

To determine whether the Functional Independence Measure (FIM), used to assess degree of disability, can predict the outcome of CIC training in pwMS.

METHODS

All pwMS attending a tertiary neurourology department between 2011 and 2019 and eligible for CIC were included in this retrospective study. Level of disability was assessed with the FIM by an occupational therapist. Success for learning CIC, defined as the ability to perform at least 2 trials of the technique, was recorded at the end of the session by a continence nurse and a physiatrist. The association between the FIM and success for learning CIC was assessed by multivariable analysis.

RESULTS

We included 395 patients (mean [SD] age 49.8 [12.0] years; 70% women). More than half of patients had relapsing-remitting disease, and the Expanded Disability Status Scale score was ≥ 6. Mean FIM total, motor and cognitive scores were 108.0 (14.2), 75.9 (12.3) and 32.1 (3.7), respectively (maximal scores: 126, 91 and 35). At the end of the session, 87% of patients were successful in learning CIC. After adjustment of potential confounding variables including age, sex, obesity and EDSS score, FIM total, motor and cognitive subscores were significantly associated with success (odds ratio [95% confidence interval] 1.06 [1.03-1.08], 1.05 [1.03-1.08], 1.21 [1.12-1.32], respectively).

CONCLUSIONS

FIM was an independent predictor of successful CIC training in pwMS. A 1-point increase in FIM was associated with 6% increased odds of successfully mastering the CIC technique. A widespread use of the FIM could help determine the different cognitive and/or motor objectives that need to be improved before CIC teaching.

Determinants and impact of the time to perform clean intermittent self-catheterization on patient adherence and quality of life: A prospective observational study

AIMS

To measure the time required to perform clean intermittent self-catheterization (CISC) in daily life and to assess its impact on adherence and quality of life.

METHODS

Patients performing CISC for more than 1 month were invited to participate. At home, patients were asked to complete a 1-day diary to assess the specific duration of the CISC (time from when the equipment and environment are brought together to perform CISC) and the next day to complete a second diary for the total duration of the CISC (starting when the patient intent to self-catheterize to the return to the initial activity, including the displacement, and gathering the required device). Adherence, difficulties with CISC, and quality of life were measured with validated questionnaires: Intermittent Catheterization Satisfaction Questionnaire, Intermittent Catheterization Difficulty Questionnaire, Intermittent Catheterization Adherence Scale, and SF Qualiveen Questionnaire.

RESULTS

Thirty-six patients agreed to participate but only 25 patients completed the entire protocol. The participants performed CISC for an average of 7 years. The median specific duration of CISC was 2 min and 23 s (ranging from 47'' to 11'50''). The median total duration of CISC was 3 min and 40 s (1'35''; 18'47''). No significant correlation was found between the duration of CISC and patient characteristics, adherence, difficulty to self-catheterize, or quality of life.

CONCLUSION

The time to perform CISC was brief, and less than 2-3 min on average. The impact on adherence and quality of life should be assessed in a larger cohort.

A lasting impression: telemedicine in urogynecology during the coronavirus disease 2019 pandemic

PURPOSE OF REVIEW

Amidst the worldwide coronavirus disease 2019 pandemic, a new medical landscape revolving around telemedicine has arisen. The purpose of this review is to describe and analyze current urogynecologic guidelines for optimizing usage of telemedicine when treating women with pelvic floor disorders.

RECENT FINDINGS

Women managed by urogynecologists are on average older, and hence more likely to have comorbidities that make them susceptible to developing coronavirus disease 2019 with severe symptoms. Telemedicine is key in minimizing exposure without sacrificing treatments and quality of life. Recent studies published prior to the pandemic helped set the stage for successful components of virtual care. Nonsurgical options are crucial to beginning a treatment plan while elective surgeries are still restricted in many hospitals. Medication management and innovative technology, such as smart telephone applications, play a prominent role. The comprehensive literature review discussed here describes the degree of evidence supporting each management option, while also noting the limitations of telemedicine.

SUMMARY

Telemedicine has opened a new door for the field of urogynecology allowing for continued safe, evidence-based care. The pandemic culture has tipped the balance away from surgery and toward nonsurgical treatments while attempting not to sacrifice outcomes or quality of care.

Difficulties of patients and caregivers in performing clean intermittent catheterization: scoping review

Objective: To identify the main difficulties reported by patients and caregivers in the use of clean intermittent catheterization described in the scientific literature. Methods: Scoping review with studies published in Portuguese, English or Spanish, without date limit, in electronic databases and digital libraries, using descriptors and keywords. Results: 790 studies were identified, including 34 studies published between 1984 and 2019. The main difficulties reported in performing clean intermittent catheterization were related to catheter insertion, pain, discomfort, urethral trauma, public bathrooms with inadequate facilities, physical difficulties and lack of access to necessary inputs. Conclusion: The studies analyzed show the difficulties that patients who use clean intermittent catheterization and their caregivers face on a daily basis, which are related to intrinsic and extrinsic, institutional and governmental factors and can decrease satisfaction and adherence to rehabilitation programs bladder, with an impact on the quality of life of patients and their caregivers. Therefore, it highlights the need for health education for the proper teaching of performing clean intermittent catheterization, emphasizing the importance of the nurse’s role in this process.

Dificuldades de pacientes e cuidadores na realização do cateterismo intermitente limpo: revisão de escopo

Objetivo: Identificar as principais dificuldades relatadas pelos pacientes e cuidadores no uso do cateterismo intermitente limpo descritas na literatura científica. Métodos: Revisão de escopo com estudos publicados em português, inglês ou espanhol, sem limite de data, em base de dados eletrônicas e bibliotecas digitais, utilizando descritores e palavras-chave. Resultados: Foram identificados 790 estudos, sendo incluídos 34 estudos publicados entre 1984 e 2019. As principais dificuldades relatadas na realização do cateterismo intermitente limpo foram referentes a inserção do cateter, dor, desconforto, trauma uretral, banheiros públicos com instalações inadequadas, dificuldades físicas e falta de acesso aos insumos necessários. Conclusão: Os estudos analisados evidenciam as dificuldades que os pacientes usuários do cateterismo intermitente limpo e seus cuidadores enfrentam no dia a dia, que estão relacionadas à fatores intrínsecos e extrínsecos, institucionais e governamentais e podem diminuir a satisfação e a aderência aos programas de reabilitação vesical, com impacto na qualidade de vida dos pacientes e seus cuidadores. Portanto destaca-se a necessidade de educação em saúde para o adequado ensino da realização do cateterismo intermitente limpo, enfatizando a importância do papel do enfermeiro nesse processo.

A guide for urogynecologic patient care utilizing telemedicine during the COVID-19 pandemic: review of existing evidence

Introduction and hypothesis

The COVID-19 pandemic and the desire to “flatten the curve” of transmission have significantly affected the way providers care for patients. Female Pelvic Medicine and Reconstructive Surgeons (FPMRS) must provide high quality of care through remote access such as telemedicine. No clear guidelines exist on the use of telemedicine in FPMRS. Using expedited literature review methodology, we provide guidance regarding management of common outpatient urogynecology scenarios during the pandemic.

Methods

We grouped FPMRS conditions into those in which virtual management differs from direct in-person visits and conditions in which treatment would emphasize behavioral and conservative counseling but not deviate from current management paradigms. We conducted expedited literature review on four topics (telemedicine in FPMRS, pessary management, urinary tract infections, urinary retention) and addressed four other topics (urinary incontinence, prolapse, fecal incontinence, defecatory dysfunction) based on existing systematic reviews and guidelines. We further compiled expert consensus regarding management of FPMRS patients in the virtual setting, scenarios when in-person visits are necessary, symptoms that should alert providers, and specific considerations for FPMRS patients with suspected or confirmed COVID-19.

Results

Behavioral, medical, and conservative management will be valuable as first-line virtual treatments. Certain situations will require different treatments in the virtual setting while others will require an in-person visit despite the risks of COVID-19 transmission.

Conclusions

We have presented guidance for treating FPMRS conditions via telemedicine based on rapid literature review and expert consensus and presented it in a format that can be actively referenced.

Intermittent catheterization: Clinical practice guidelines from Association Française d'Urologie (AFU), Groupe de Neuro-urologie de Langue Française (GENULF), Société Française de Médecine Physique et de Réadaptation (SOFMER) and Société Interdisciplinaire Francophone d'UroDynamique et de Pelvi-Périnéologie (SIFUD-PP)

INTRODUCTION

Our objective was to provide guidelines covering all aspects of intermittent catheterisation (intermittent self-catheterisation and third-party intermittent catheterisation).

MATERIALS AND METHODS

A systematic review of the literature based on Pubmed, Embase, Google scholar was initiated in December 2014 and updated in April 2019. Given the lack of robust data and the numerous unresolved controversial issues, guidelines were established based on the formal consensus of experts from steering, scoring and review panels.

RESULTS

This allowed the formulation of 78 guidelines, extending from guidelines on indications for intermittent catheterisation, modalities for training and implementation, choice of equipment, management of bacteriuria and urinary tract infections, to the implementation of intermittent catheterisation in paediatric, geriatric populations, benign prostatic hyperplasia patients and continent urinary diversion patients with a cutaneous reservoir as well as other complications. These guidelines are pertinent to both intermittent self-catheterisation and third-party intermittent catheterisation.

CONCLUSION

These are the first comprehensive guidelines specifically aimed at intermittent catheterisation and extend to all aspects of intermittent catheterisation. They assist in the clinical decision-making process, specifically in relation to indications and modalities of intermittent catheterisation options. These guidelines are intended for urologists, gynaecologists, geriatricians, paediatricians, neurologists, physical and rehabilitation physicians, general practitioners and other health professionals including nurses, carers….

Analysis of measurement electrode location in bladder urine monitoring using electrical impedance

Purpose

The aim of this study was to document more appropriate electrode location of a four-electrode-based electrical impedance technology in the monitoring of bladder filling, and to characterize the relationship between bladder filling duration and the measured electrical impedances.

Methods

A simulation study, based on a 2-dimension computational model, was conducted to determine the preferable locations of excitation and measurement electrodes in a conventional four-electrode setup. A human observation study was subsequently performed on eight healthy volunteers during natural bladder urine accumulation to validate the result of the simulation study. The correlation between the bladder filling time and the measured electrical impedance values was evaluated.

Results

The preferable location of measurement electrodes was successively validated by the model simulation study and human observation study. Result obtained via the selected electrodes location revealed a significant negative correlation (R = 0.916 ± 0.059, P < 0.001) between the measured electrical impedance and the urine accumulation time, which was consistent with the result of simulation study.

Conclusions

The findings in this study not only documented the desirable electrodes location to monitor the process of bladder urine accumulation using four-electrode measurement, but also validated the feasibility of utilizing electrical impedance technique to monitor and estimate the bladder urine volume for those with urological disorders.

[Use of botulinum toxin A in pelvic floor dysfunctions in the elderly: A review]

INTRODUCTION

The present article is the final report of a multi-disciplinary meeting supported by the GRAPPPA (group for research applied to pelvic floor dysfunctions in the elderly). The objective was to conduct a comprehensive review on the role of botulinum toxin A (BonTA) in the treatment of pelvic floor dysfunctions in the elderly.

METHODS

The present article, written as a comprehensive review of the literature, combines data issued from the scientific literature with expert's opinions. Review of the literature was performed using the online bibliographic database MedLine (National Library of Medicine). Regarding intra-detrusor BonTA injections, only articles focusing on elderly patients (>65 yo) were included. Regarding other localizations, given the limited number of data, all articles reporting outcomes of BonTA were included, regardless of studies population age. In case of missing or insufficient data, expert's opinions were formulated.

RESULTS

Although, available data are lacking in this specific population, it appears that BonTA could be used in the non-fraily elderly patients to treat overactive bladder or even neurogenic detrusor overactivity, with a success rate comparable to younger population at 3 months (88.9% vs. 91.2%), 6 months (49.4% vs. 52.1%) and 12 months (23.1% vs. 22.3%), as well as a significant decrease in number of voids per day (11.4 vs. 5.29 P<0.001) and in the number of pads per day (4.0 vs. 1.3, P<0.01). Furthermore, BonTA is likely to be offered in the future as a treatment of fecal incontinence and obstructed defecation syndrome symptoms. Concerning bladder outlet obstruction/voiding dysfunction symptoms, intra-urethral sphincter BonTA should not be recommended.

CONCLUSION

BonTA injections are of interest in the management of various pelvic floor dysfunctions in the elderly, and its various applications should be better evaluated in this specific population in order to further determine its safety and efficacy.

Predictive factors of adherence to urinary self-catheterization in older adults

AIMS

The primary aim is to explore the adherence predicting factors in clean intermittent self-catheterization (CISC) in patients aged over 65 years. The secondary aim is to assess whether in this population, the non-adherence risk is greater, compared with patients under 65.

METHODS

All patients older than 65 that successfully learned CISC between January 2011 and January 2016 were included. A control population younger than 65 matched with sex, body mass index, and pathology was selected.

RESULTS

One hundered and thirteen (66.9%) out of the 169 patients older than 65 included were adherent at 1 month, and 80 (47.3%) at 6-12 months. Obesity (P = 0.027), a low PP test (Pencil and Paper test) score (P = 0.037), significant urinary stress incontinence (SUI) (P = 0.048), and prescription of CISC less than three per day (P = 0.03) were the risk factors predicting stopping CISC at 1 month, but none was associated with non-adherence at 6-12 months. Compared with the younger group, age was a risk factor for poor adherence at 1 month.

CONCLUSION

Obesity, low PP test score, and important SUI are factors of poor adherence to CISC at 1 month in older adults. Necessity of more than three CISC per day is in favor of treatment continuation, possibly due to absence of spontaneous voiding in these patients. Long-term adherence to CISC in older adults in this study remains close to adherence to other treatments prescribed in urinary disorders, and thus shows that CISC could be an easily purposed therapeutic option in this population, either on a long-term or transitory basis.