Intermittent catheterization (IC) is a procedure used to empty the bladder when it cannot empty on its own. Clean intermittent self-catheterization (CISC) is a specific technique where individuals perform the catheterization themselves, typically at regular intervals throughout the day. This method is commonly used by people with various medical conditions affecting bladder function, such as spinal cord injury, multiple sclerosis, or urinary retention.

What is Clean intermittent self-catheterization?

CISC is a procedure used to empty the bladder in individuals who have difficulty urinating on their own due to various medical conditions. It involves inserting a catheter into the bladder through the urethra at regular intervals to drain urine. The “clean” aspect of the procedure emphasizes the importance of maintaining strict hygiene to minimize the risk of urinary tract infections (UTIs) and other complications.

How to do

Performing CISC involves several steps. It’s essential to follow proper technique and maintain strict hygiene to minimize the risk of complications such as urinary tract infections. Here’s a general guide on how to perform CISC:

• Clean the Genital Area: Use a clean towel or wipe to gently clean the area around the urethral opening (meatus). Wipe from front to back to avoid contamination from the anus.
• Insert the Catheter: Hold the catheter near the tip and gently insert it into the urethra. Relax your pelvic muscles and breathe deeply to ease insertion. Advance the catheter slowly and steadily until urine begins to flow. If you encounter resistance, pause and try to relax before continuing.
• Drain the Bladder: Allow urine to flow freely into the toilet or collection container. Once the flow stops, gently advance the catheter a little further to ensure the bladder is fully emptied.
• Remove the Catheter: Once the bladder is empty, slowly withdraw the catheter while continuing to drain any remaining urine. Dispose of the catheter properly according to healthcare provider’s instructions.

Indications

CISC is indicated for individuals who have difficulty emptying their bladder effectively due to various medical conditions. Some common indications for CISC include:

• Neurogenic Bladder Dysfunction: Conditions such as spinal cord injury, multiple sclerosis, Parkinson’s disease, and other neurological disorders can impair bladder function, leading to urinary retention or incomplete bladder emptying. CISC can help individuals maintain bladder health and prevent complications such as urinary tract infections (UTIs) and bladder over-distention.
• Urinary Retention: Individuals who experience urinary retention, either due to neurological issues or other factors such as bladder outlet obstruction, may benefit from CISC to empty their bladder regularly and prevent complications associated with incomplete bladder emptying.
• Neurogenic Bladder Rehabilitation: In rehabilitation settings, CISC may be part of a comprehensive program to help individuals with neurogenic bladder regain or maintain bladder control and independence in managing their urinary function.
• Spinal Cord Injury: CISC is commonly used in individuals with spinal cord injury at various levels, as these injuries often result in neurogenic bladder dysfunction and difficulty with voluntary bladder emptying.
• Multiple Sclerosis (MS): MS can affect the nerves that control bladder function, leading to urinary retention, urgency, and frequency. CISC may be recommended for individuals with MS who have bladder dysfunction as part of their overall management plan.
• Postoperative Care: In some cases, individuals may require temporary bladder drainage following certain surgical procedures, such as urological surgeries or pelvic surgeries. CISC can facilitate bladder emptying while the individual recovers.
• Chronic Urinary Retention: Chronic urinary retention, whether due to neurological or non-neurological causes, may require long-term management with CISC to maintain bladder function and prevent complications.
• Recurrent Urinary Tract Infections (UTIs): In some cases, CISC may be recommended as part of a strategy to reduce the risk of recurrent UTIs by ensuring complete bladder emptying and minimizing residual urine volume.
• Bladder Augmentation or Reconstruction: Individuals who have undergone bladder augmentation or reconstruction surgery may require CISC as part of their postoperative care to manage urinary function and prevent complications.

Complications

While clean intermittent self-catheterization is generally considered safe and effective when performed correctly, there are potential complications associated with the procedure. It’s important for individuals who perform CISC to be aware of these risks and to seek prompt medical attention if they experience any problems. Some complications of CISC may include:

• Urinary Tract Infections (UTIs): UTIs are one of the most common complications of CISC. Bacteria can enter the urinary tract during catheterization, leading to infection. Symptoms of UTIs may include increased urinary frequency, urgency, burning with urination, cloudy or foul-smelling urine, and fever.
• Urethral Trauma or Injury: Improper insertion or removal of the catheter can cause trauma to the urethra, leading to irritation, bleeding, or even urethral strictures (narrowing). Using excessive force during catheterization or using catheters that are too large may increase the risk of urethral injury.
• Bladder Trauma: In rare cases, repeated catheterization or improper technique may cause trauma to the bladder, such as perforation or bladder wall damage. Symptoms may include severe abdominal pain, blood in the urine, or difficulty passing urine.
• Bladder Stones: Prolonged urinary retention or incomplete bladder emptying can lead to the formation of bladder stones (calculi). These stones may cause pain, discomfort, and urinary symptoms such as hematuria (blood in the urine).
• Bladder Spasms: Some individuals may experience bladder spasms, which are involuntary contractions of the bladder muscle. These spasms can cause discomfort, urgency, and difficulty with catheterization.
• Urinary Retention or Incomplete Emptying: Inadequate catheterization technique or catheter blockage may result in urinary retention or incomplete bladder emptying. This can lead to symptoms such as urinary urgency, frequency, and overflow incontinence.
• Allergic Reactions or Irritation: Some individuals may experience allergic reactions or irritation from the materials used in catheters or lubricants. Symptoms may include rash, itching, redness, or swelling at the catheter insertion site.
• Psychological or Emotional Distress: Regular catheterization may cause psychological or emotional distress for some individuals, particularly if they feel uncomfortable or embarrassed about the procedure.
• Fluid and Electrolyte Imbalance: In rare cases, frequent catheterization may disrupt the normal balance of fluids and electrolytes in the body, leading to dehydration or electrolyte abnormalities.

Is prophylactic antibiotic or antiseptic use necessary?

The use of prophylactic antibiotics or antiseptics for individuals performing CISC is a topic of debate among urologists. While some studies suggest that prophylactic antibiotics or antiseptics may reduce the risk of UTIs associated with CISC, others indicate that routine use may not be necessary and could contribute to antibiotic resistance or other complications.

Here are some considerations regarding the use of prophylactic antibiotics or antiseptics for individuals performing CISC:

• Risk of UTIs: Individuals performing CISC are at an increased risk of developing UTIs due to the introduction of bacteria into the urinary tract during catheterization. Prophylactic antibiotics or antiseptics may help reduce this risk, particularly in individuals who have a history of recurrent UTIs or are at higher risk for complications.
• Antibiotic Resistance: The overuse of antibiotics can contribute to the development of antibiotic-resistant bacteria, which poses a significant public health concern.
• Individual Risk Factors: The decision to use prophylactic antibiotics or antiseptics for CISC may depend on individual factors such as the patient’s medical history, underlying health conditions, susceptibility to UTIs, and previous response to antibiotic therapy.
• Alternative Strategies: In addition to prophylactic antibiotics or antiseptics, there are other strategies to reduce the risk of UTIs associated with CISC. These include maintaining strict hygiene practices, using sterile catheters and lubricants, drinking plenty of fluids, and ensuring proper catheterization technique.
• Evidence and Guidelines: Urologists may consider current evidence-based guidelines and recommendations when determining whether prophylactic antibiotics or antiseptics are warranted for individuals performing CISC. These guidelines may vary depending on the specific patient population and clinical context.

Summary

CISC is a procedure used by individuals who have difficulty emptying their bladder due to various medical conditions such as spinal cord injury, multiple sclerosis, or urinary retention. During CISC, individuals insert a clean catheter into the bladder through the urethra at regular intervals to drain urine. The procedure aims to maintain bladder health, prevent complications like urinary tract infections, and improve quality of life. Proper hygiene, training, and follow-up with healthcare providers are essential for successful implementation of CISC. While complications such as UTIs or urethral trauma may occur, the benefits of CISC often outweigh the risks for individuals with bladder dysfunction.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE