What is intermittent catheterization (IC)

Catheterization is perhaps one of the oldest urological procedures, dating back thousands of years ago. Using a urinary catheter is necessary when there is urine left in the bladder that cannot be emptied through normal voiding.

IC is a safe and effective method which means regularly emptying the bladder with a single-use urinary catheter, either by yourself or someone else helping you. During the 1970s, Dr. Jack Lapides established the importance and effectiveness of emptying the bladder regularly and intermittently using a clean technique, over a sterile one. He introduced the term clean intermittent catheterization (referred to here as IC), which is now considered the gold standard when managing urinary retention.

Clean Intermittent Self-Catheterization (CIC) is a safe and effective alternative method of emptying the bladder. - J Lapides

Why is it important to empty your bladder completely?

• Incomplete bladder emptying can be a serious health risk resulting in impaired renal function and infections
• Urine retention can also lead to inconvenience as a result of incontinence and symptoms like urgency and frequency
• The goal of treatment is to drain urine and preserve the function of the bladder and kidneys

Intermittent catheterization has a large psychological and emotional impact on a user, such as improved self-confidence and self-esteem, improved quality of life with less incontinence/urgency, better sleep, making physical activities possible, and less pain and discomfort. 

Conditions, where IC can make a real difference, are everything from having a spinal cord injury (SCI) to disorders like multiple sclerosis (MS) and enlarged prostate (BPH). It can also be key for different kinds of incontinence problems.

Indications for intermittent catheterization (IC) (EAUN summary guidelines 2013)

IC should only be performed in the presence of a residual volume of urine and symptoms or complications arising from the residual volume. Incomplete bladder emptying is generally due to one of three categories of lower urinary tract dysfunction: 

• Detrusor dysfunction: an underactive or atonic detrusor that fails to contract with sufficient duration or magnitude to completely empty the bladder.
• Bladder outlet obstruction: most common causes are prostatic enlargement, and high bladder neck, or urethral stenosis (in women). In men, urethral strictures may obstruct bladder outflow and are often found following instrumentation such as radical prostatectomy.
• Following surgery: surgery to restore continence can impair bladder emptying, and this technique may result in acute urinary retention. Procedures for reducing stress urinary incontinence introduce a degree of obstruction to the bladder outlet, while procedures for resolving urgency urinary incontinence aim to reduce intravesical pressure and increase functional bladder capacity. Both of these can impair the ability of the bladder to empty, possibly leading to residual volume.

The different types of catheters for IC are summarized in this diagram. 

Diameter size and length 

Intermittent catheters are available in male and female lengths, around 40cm and 7 to 22cm respectively. The external diameter is measured in millimeters (Charrière scale: Ch, CH), or the circumference can be used (French scale: F, FR, FG) and sizes range from 6 to 24: typical female adult sizes are 10 to 14, and male sizes are 12 to 14. Larger sizes can be used to treat strictures. Sizes are colored in the same way as connectors (below).

^{Corresponding catheter size and diameter according to the connector colour.}

Catheter technique

The choice of how IC is carried out will depend on the individual need and the period or length of time catheterization is indicated. The different techniques are as follows:

• Sterile technique - catheterization under operating theater conditions
• Aseptic technique - catheterization with a sterile catheter, disinfection/cleansing of the genitals, sterile gloves, tweezers (as applicable), and sterile lubricant (as applicable)
• Clean technique - catheterization with a ‘non-sterile’ technique by patients/caretakers in the home setting

Contraindications to intermittent catheterization

There are few contraindications to IC. High intravesical pressure is an absolute contraindication and poor manual dexterity in the absence of an appropriately trained caregiver - is a contraindication.

Complications of IC

Complications can include infection, bleeding, urethritis, stricture, the creation of a false passage, and in males, epididymitis. Bladder-related events can cause UTIs, bleeding, and stones. The most frequent complication of IC is urinary tract infection (UTI). There are multiple reasons for infection to occur.

Possible complications with IC:

• Insertion – sometimes a catheter can be difficult to insert, usually, because the sphincter muscle is not relaxed – coughing can help with this
• Removal –sometimes the catheter is difficult to remove, which is uncomfortable for the patients and may be harmful to the urethra
• Urethral strictures – can occur as a long-term complication in some patients, usually after 5 years or more of catheterization
• False passages – these are not acute and result from long-term intermittent catheterization

Some common problems with IC:

• Although bacteriuria prevalence is lower than in patients with indwelling catheters, prevention of cross-infection remains important. Patients need to be aware of changes in their urine that may indicate a UTI which requires treatment and a review of the technique
• Females can often insert the catheter into the vagina by mistake. In this instance, the catheter should be disposed of and a new catheter used

Alternatives to intermittent catheterization 

Alternatives to intermittent catheterization are suprapubic and urethral indwelling catheterization. However, an indwelling catheter is an invasive procedure, it will be placed either through the abdominal wall (suprapubic) or urethral and has a continuous emptying. Catheter-associated UTIs are the most common complication with all catheterization. IC is reported to reduce the risk of infection compared to indwelling catheters – for example, a 20% reduction after short post-operative use.

Bacteria attach to catheter surfaces, forming a biofilm, which means that treatment becomes more difficult since the antibiotics cannot penetrate this biofilm. Leakage is often a consequence of bladder irritation caused by the catheter which can cause powerful bladder contractions.