Clean Intermittent Self catheterisation (CISC/CIC/ISC)

Self catheterisation to empty their own bladders is the truth for so many patients dealing with neurogenic bladder conditions and many other types of voiding dysfunctions (conditions where one is either unable to pass urine or it is not safe for him/her to pass urine on his/her own). According to estimates more than 50 adult men and women of every 1 lakh population may be doing so. This is the only way to maintain  safe storage of urine in many high risk neurogenic bladders ( covered in my earlier blog) or where the bladders have no reflexes and power to expel urine (atonic bladders).  Also, it may be advised in selected cases of urethral strictures to prevent stricture formation after after surgery (that will be covered in another blog separately). This writeup is intended mainly for neurogenic bladder population.

Some natural queries that arise from this are : Can I self catheterise at home? Is CIC possible for all where it is required? Could Self catheterisation result in injury? Is it painful to self catheterise? Can CIC lead to infection? How many times should I self catheterise? Can I live a normal life with self catheterisation?

Let me address them for you in this blog

Can I self catheterise at Home?

 Of course yes!. This is not meant to be the formal catheterisation that is performed in hospitals with antiseptic cleaning of genitals and the nurse or doctor wearing sterile gloves. Here the patient cleans his/her genitals with a swab and catheterises self with help of a lubricant without any gloves on. 

Does this mean that we are too fussy about it in hospitals and we overdo things? No, those are one time catheterisations in sick patients and they are meant to be done in a sterile manner minimising any bacterial entry in the bladder.

Does this mean that bacteria do not enter when one self catheterise at home? The bacteria might enter for sure but the premise here is that before the bacteria multiplies in the bladder, the next catheterisation again decreases the bacterial load and so on. In the bargain the patient gets freedom from all time catheter with minimal risk of infection.

Is self catheterisation possible for all?

Self catheterisation is a skill that one has to learn and develop. There are some prerequisites.

• Dexterity: This means that she she or he should be competent  and comfortable with hands to perform self catheterisation. A person who is bed ridden because of his neurologic condition l(e.g. a quadriplegic) or an extremely obese person for whom reaching for the urinary opening is difficult or a person with a non functional right (or dominant) hand won’t be able to catheterise self.
• the will and aptitude of a person towards own condition is also important. There should be absolute clarity in their mind that in their present scenario, this is the most feasible and practical solution to make them free from all time catheter or to keep themselves dry. A person fighting in his mind with the catheter will eventually drop out because of infection or other complications. One has to consider the catheter as their friend and not keep resisting the idea. Self catheterisation is successful in this who make it as their part.
• Availability and accessibility of resources : there should be availability of catheters and lubrication and it should be with in the reach if mobility is an issue (e.g. wheel chair bound person)

I personally do not like care giver intermittent catheterisation unless a parent is doing for their child because any care giver cannot be tied to the patient and they have their own life where they can fall sick, be unavailable due to more important life issues of their own compromising the catheter schedule of the patient. Children too should be made to learn as early as possible for them. I have been often surprised by the skill and understanding of 8-10 year old children who start handling their own catheterisation schedule during school or play. Also, I have been amazed by the will of an 85 year old father of a colleague who took the intermittent catheterisation in his own hands from the caregiver who was arranged for him and continued his gardening and social meetings till the age of ninety!.

Moreover, a care giver is less likely to understand the curves and bumps in the patients urethra which person catheterising self can negotiate better without bruising the tender urethral walls.

Is self catheterisation any different in male and females?

It is slightly difficult initially for women to learn but once learnt they can do it as effectively a men.

Can Self catheterisation result in injury to the urinary passage?

Yes, improperly performed self catheterisation can result in episodes of urethral bleeding, formation of false passages in the urethra and urethral narrowing. Moreover neurogenic bladder patients often lack sensations in their private parts or lower half of the body making them more prone to self injuring themselves without even their knowledge.

Use of proper lubrication, being gentle to self during the procedure without application of any force, taking deep breaths and having patience when experiencing any obstacles (which are mostly because of tight muscles around the urethra or the growing prostate in men) are some measures to decrease the incidences of damage to the urethra

Reporting any bleeding on withdrawing the catheter should alert the patient to seek a consult with their urologist or nurse practitioner.

Is it painful to self catheterise?

For most of neurogenic bladder patients in whom intermittent self catheterisation is advised, it is not painful because of they often lack sensations in lower half of the body or their private parts. However, it can often result in sweating episodes and episodes of spasms. In some if the procedure is painful even after required adequate lubrication and re learning the technique, it often becomes the reason to discontinue CIC and switch to alternative ways of bladder drainage.

Can self catheterisation cause Infections ?

Not properly performing CISC or not adhering to the timings of CISC can give rise to more severe infections than self catheterisation as such.  As previously mentioned Intermittent catheterisation works on the  premise that before the bacteria that goes in with the catheter multiplies in the bladder, the next catheterisation again decreases the bacterial load and so on.

However it is not uncommon in patients on self catheterisation to develop UTIs and presence of any fever or drainage of turbid and dirty coloured urine should act as a warning sign of infection and consult with the doctor should be taught. Generally, a period of rest from CISC by placing an all time draining catheter is advisable along with antibiotics suited to the bacterial growth. If this is a frequent occurrence, then the schedule of catheterisation or bladder medications need to be revisited. Often, a repeat urodynamic study is required to see if there are any new changes in the bladder behaviour over time.

How often should one self catheterise ?

The number of times one must self catheterise depends on the capacity and amount of urine production. For safe bladders (in which storage pressures do not rise with increasing volume of urine in bladder), generally a 4 to 6 hour gap is advised between catheterisations. Even in safe bladders one should never delay drainage beyond six hours as beyond that the multiplication of bacteria is significant.

For high risk bladders (where pressures in the bladder rise along with increasing volumes in the bladder) usually a “safe storage volume” is ascertained by bladder diaries and urodynamic studies by the treating Urologist. In such bladders, apart from the recommended time gap, the patient should self monitor the drained volumes whether they fall in the safe range. If not then the amount of fluid intake can be decreased or frequency of self catheisation can be increased to bring the drained urine volumes in the safe range every time.

If self catherisation is needed earlier than every 3 hours, then it often becomes impractical and needs to be discontinued for other modes of management.

Can I live a normal life on Self catheterisation ?

Many of my patients who  practice self catheterisation for bladder but have no other neurological damages and can walk on their own are living a normal life doing their business, taking their classes, going to gymnasiums and shopping . Patients who are bed ridden because of their neurological condition are able to remain dry and develop less serious infections since they are on self catheterisation.

The more they start understanding their own bladder behaviour, the easy it becomes for them to navigate their bladder management.

In a study of over 100 patients on Self catheterisation for over 5 years, it was found that 80% patients found it easy and not interfering with their daily activities and it helped improving the quality of life in more than 60% of patients (https://doi.org/10.1002/nau.20610)