Research Article

Evidence-based catheter selection for intermittent self-catheterization: systematic review.

Melita Peršolja¹* and Tjaša Hrovat-Ferfolja¹

¹Faculty of Health Sciences - Unit Vipava, University of Primorska, Pavla Rušta Square 6, Vipava, Slovenia

Submission: April 01, 2024; Published: May 16, 2024

*Corresponding author: Melita Peršolja, Faculty of Health Sciences – Unit Vipava, University of Primorska, Pavla Rušta Square 6, Vipava, Slovenia, Email: melita.persolja@fvz.upr.si

How to cite this article: Melita Peršolja* and Tjaša Hrovat-Ferfolja. Evidence-based catheter selection for intermittent self-catheterization: systematic review.. JOJ Nurse Health Care. 2023; 13(2): 555864. DOI:10.19080/JOJNHC.2023.13.555864

Abstract

Study design: A systematic review of the literature was used.

Objectives: To identify the types of catheters used and to find an optimal type of catheter for intermittent self-catheterization.

Setting: The search terms were self-catheteriz(s)ation, bleeding, injury, infection, material, catheter type, length, circumference, shape, coating, packing. Searches were limited to scientific journals, full text accessibility, English and Slovene language, and publication time between 1999 and 2019. We used a four-step PICO search strategy to obtain and validate the literature.

Methods: The synthesis of the review was done using the PRISMA tool. The quality of the studies was assessed by two reviewers using hierarchy of evidence.

Results: From 440 studies found, 41 were selected according to the quality and purpose of the study. The selected studies were 16 literature reviews, 4 randomized control trials, 20 cohort studies, and one case study.

Conclusions: This review may serve as a reference for healthcare workers in caring for a new person with urine retention. It is recommended that nurses and persons together firstly select the technique of self-catheterization, and only after that select the catheter type. The review found that none of the catheter types can be generally recommended for intermittent self-catheterization. Due to the lack of evidence, the selection of the catheter depends primarily on the persons’ preference of the catheter type considering selected technique of self-catheterization.

Keywords: Evidence-based nursing; Intermittent urethral catheterization; Patient outcome assessment; Quality assurance; Health care

Abbreviation: PVC: Polyvinyl Chloride; EVA: Ethylene-Vinyl Acetate; FG: French Gauge

Introduction

Intermittent catheterization is used as a gold standard to ensure optimum bladder emptying and is a good alternative to an indwelling catheter [1,2]. It is known as a safe method suitable for long-term use that can protect the upper urinary tract and improve the quality of patients’ life with significant voiding problems because of disturbance or injuries to the nervous system, non-neurogenic bladder dysfunction or intravesical obstruction with incomplete bladder emptying [3,4]. Intermittent catheterization is performed when a patient cannot completely empty the bladder with spontaneous urination, and leaving a residual amount of urine (> 100 ml) [2]. It’s indispensable for patients with neurogenic bladder, those with bladder prolapse, with obstruction and functional, iatrogenic and congenital malformations, and prostatic enlargement [2,5]. A special feature in the procedure of intermittent self-catheterization is that it can be performed by the patient himself, his relative or, health professional [3]. Standard guidelines for self-catheterization recommend a clean technique with hands washed. Sterile gloves must be used if intermittent catheterization is performed by a healthcare worker or anyone else other than the patient or a close family member [4]. Clean technique is sufficient when procedure is performed by patient himself, and sterile when is performed by health professionals or careers [3]. Catheter features that have to be considered when choosing a catheter are catheter material, packing, length, circumference, shape, coating and cleaning.

Various catheters are available for performing intermittent catheterization. They can be uncoated or coated with various coatings; and can be for reuse or single-use. Almost all catheters are available in pediatric and standard men and women measures. There are two types of uncoated catheters: a.) latex catheters, mostly made of polyvinyl chloride (PVC) or ethylene-vinyl acetate (EVA), b.) catheters from red rubber, also content latex and ethylene-vinyl acetate [6,7]. PVC is a cheap, durable, and flexible material. This thermoplastic polymer is usually for single-use and sometimes can be uncomfortable because causes stiffness and allergies. PVC can be produced in harder or softer versions, which affects the correct rigidity of the catheter. EVA is a soft and flexible polymer with good clarity and gloss, barrier properties, lowtemperature toughness, hot-melt adhesive waterproof properties, and resistance to UV radiation. The material has little odor and is competitive with red rubber and PVC products [7].

Uncoated catheters are usually used for clean intermittent self-catheterization with the lubricant gel. Coated catheters are intended for single-use, intended to facilitate the procedure and reduce the irritation of the mucous membrane. Therefore, the use of a lubricant gel is not required [7]. But a procedure using coated catheters requires some liquid and has to be water-soaked for about 30 seconds before use. One possibility is the water bag packed in the catheter’s wrapper. When the water is spilled by pressing the little water container, the top layer of catheter activates and becomes smooth. A coated catheter can also be already immersed in liquid, and ready for immediate use [7,8]. For watering, it is possible to use drinkable water or saline packed in sealed containers [6]. The length of the catheter is very important because of the anatomical differences in the length of the urethra in men and women, body mass, and special anatomical features of the patient [2].

Thus, there are different lengths of catheters, the standard is from 40 to 45 cm. Firstly, the catheter of this length was used for both, men and women. Nowadays, special catheters are available also for women (length from 20 to 26 cm) [9]. Catheter external circumference is measured in Ch (Charriere), or the FG (French Gauge), and is available in a range from 6 to 24 [7]. The value below 12 FG is for children and from 14 to 22 FG is for adults. A catheter size of 12 to 14 Ch is suitable for women, and 12 to 16 Ch for men [4]. Larger sizes are used for treating strictures. The higher the Ch or FG value, the more the urethra is widespread when the catheter is inserted; the greater the irritation within the urethra; the greater the chance of the formation of urethritis; and the damage of the nearby glands [7]. Catheters can be straight or curved. Most straight catheters are tapered, so they can smoothly penetrate the urethra and allow easy insertion. Some of them have an introducer tip, through which the catheter passes with minimum risk for contamination [1]. The Nelaton catheter is the standard catheter and has a soft, flexible, rounded tip with a straight end. This type of catheter has two lateral eyes for drainage that are often polished for comfort [7]. Curved (Tiemann) catheters are used primarily in male patients with the enlarged prostate gland and also in cases of urethral stricture. The curved part of the catheter is more tapered and usually is the end of the catheter which facilitates the passage of the catheter through the urethra. This type of catheter has a slightly more bulbous or rounded tip on the end [7,10]. There are also some other shapes of catheter tips, such as flexible rounded tip, pointed tip which is squeezable and has a bendy end, rounded and angular (30 - 45°) concave tip [7].

Different methods are available to reduce the friction between the surface of catheter and urethral mucosa. A lubricating gel can be applied to catheter before each insertion, or a pre-coated catheter can be used to reduce friction without jelly [11]. Catheters could be coated with hydrophilic, antibiotic, antimicrobial, and other substances intended to reduce the damage and friction of mucosa when introduced through the urethra [1]. Hydrophilic catheters have a polymer coating, containing salt which absorbs and binds water to the catheter. Catheter surface becomes thick, smooth, and lubricated in contact with it. Hydrophilic catheters are described as the most sterile catheters because of the reduced possibility of infection due to unnecessary manual application of the lubricant gel [8]. It is also known that, patients who use coated catheters for clean intermittent catheterization suffer less urinary tract infections, asymptomatic bacteriuria, microhematuria, and have a high level of satisfaction [8].

Another important issue in intermittent self-catheterization is the reuse of the catheter. Reasons for reuse are many, in addition to the costs, there is environmental protection as well as lack of knowledge on the safety of single-use catheters [7]. Although there is no scientific information on how to properly clean the catheter for reuse, most patients do not disinfect the catheter between two consecutive uses [6]. Jeong & Oh [11] find out that 5-minutes disinfection with 70 % alcohol provides antimicrobial effects on all 3 different pathogens. Besides, alcohol disinfection does not affect on the catheter material. In general, it is suggested to clean the catheter for reuse with soap or detergent for dishwashing, boil it in water; sterilize it with microwaves for 12 minutes; and/or soak it in antiseptic solution (betadine, peroxide or vinegar) [6,8]. It is also advisable to rinse the catheters under lukewarm running water for at least 30 seconds immediately after use, and then dry it. Not all catheters are appropriate for all patients, and because of that, patients may need to try several different catheters before choosing the right one [1]. The patient should select a catheter with which they are competent and comfortable using [12]. Selfcatheterization procedure must be introduced to a patient by a competent nurse specialist who can demonstrate appropriate training and knowledge [1].

The selection of the appropriate catheter is therefore mostly in the hands of the patient [2] and a specialist nurse. Literature describes different types of catheters, but rare report a clear position on the optimal catheter which would be the first suggested for a new patient that needs intermittent self-catheterization. This paper aimed to perform a literature review related to the catheter selection for intermittent self-catheterization. The purpose was to describe in detail the types of catheters and their special features through benefits and limits for the patient. The following research question was developed: What is the evidence for recommending an optimal type of catheter for intermittent self-catheterization, considering patient outcomes?

Methods

A descriptive research method, through a systematic review of the literature, was used. The research focused on selfcatheterization, various types of catheters, the necessary material for intermittent self-catheterization, and patient outcomes. We used a four steps PICO search strategy [13]: P (patient, problem, population) patient performing self-catheterization; I (intervention)- self-catheterization; C (comparison, control); O (outcome) - bleeding, injury, infection. The search terms were selfcatheterization, bleeding, injury, infection; and the corresponding Slovene terms. Boolean operators (AND, OR) were used. Searches were limited to scientific journals, full-text accessibility, and English and Slovene language journals published between 1999 and 2019.

Most of the literature was found in the Cochrane Library, MEDLINE, CINAHL, and PubMed databases. We used various browsers, such as EBSCO Host, ProQuest, Springer Link, and Google Scholar. An archive of the Slovenian Nursing Review was also examined. The literature search was performed in July 2019. A total of 440 records were identified. The abstracts of these records were screened against the inclusion criteria and the research question. 399 were excluded. The remaining 41 articles were read in full and judged explicitly against inclusion criteria. This studies were published between 2002 and 2017. The literature review was conducted according to the international standard using Preferred reporting items for Systematic Reviews and Meta-Analyses (PRISMA) [14] (Figure 1).

After considering compliance with the research question, analysis considering the methodological characteristics followed [15]. Most studies were of good quality: namely 17 in category 1 (excellent), 23 in category 2 (good), and 1 in category 4 (poor). Line-by-line coding was undertaken. Codes were identified by the first author and afterward repeated by the second author. Inconsistencies were resolved by consultation. To synthesize the extracted data, we first divided the results into categories, and after that into themes that were found to be the most discussed in the literature. The findings were pooled and are presented in narrative form.

Results

From 440 records found, 41 were finally selected for analysis (Table 1). We included 14 literature reviews, 5 randomized control trials, 21 cohort studies, and one qualitative studies. The themes identified in this search were four (Table 2): urinary tract infections, period of use, technique, and patients’ satisfaction (Table 3).

Discussion

A dominant symptom in patients performing intermittent self-catheterization is the catheter-associated urinary tract infection [7]. However, the risk of urinary tract infection is lower in intermittent catheterization than with indwelling catheters [16]. Some studies, like Bermingham et al. [17], Shamout et al. [18] show, that the type of catheter cannot be a cause of increased risk for infection. But, at the opposite, De Ridder et al. [19] found that urinary tract infections happened to 64 % of patients using a hydrophilic catheter comparing to 82 % of patients who used uncoated PVC catheters. Many authors [17,20] conclude, that there is a difference in the incidence of urinary tract infection related to the catheter material, but it is not statistically significant. Also, a Cochrane review [21] revealed that there is no valuable evidence to link the frequency of urinary tract infections with a coated or uncoated catheter. Catheterization is certainly a mild but also unnatural activity which cannot be explained just from the catheter issues, but have to be concerned also about technique, and other supplements used. The main difference in catheters for self-catheterization concerns coated and non-coated catheters. It is known that coated catheters tend to be more comfortable and cause less urethral trauma than non-coated catheters [2]. Authors also agree [22,23], that the coated hydrophilic catheters reduce the irritation and bleeding during and after the procedure.

Another issue is the catheters’ period of use. Hydrophilic catheters can be used just once, but the uncoated catheters many times. The literature findings are inconsistent. Authors describe that PVC catheters are used at least 2 to 200 times [24], from 2 to 4 weeks [25], or on average 35 months in less developed countries [26]. The costs that patients have to pay for themselves play an important role in the timing of use and selection of catheters [27]. There are studies [18,26,28] claiming that the period of catheters’ use, is associated with the incidence of urinary tract infections. But the Cochrane review shows that there is no evidence to link the frequency of urinary tract infections with a catheter for reuse or single use [21]. The studies are inconsistent again, the incidence of urinary tract infections is not significantly related to the period of using the same catheter.

Also, when thinking about re-use catheters, we must include the manner of taking care of the catheter. There is no reliable evidence on the method of cleaning catheters for reuse, but in practice, patients rinse the catheter under running water using soap, chemically disinfect it or microwave it [25]. Kovindha et al. [26] recommend the disinfection of the catheter by soaking it in a 1: 100 solution of savlon (chlorhexidine 1.5 % and cetrimide 15 %), and then rinsing the lumen well under running water to prevent lining formation. Disinfection of the catheter with microwaves, with chlorhexidine or with iodine is not advised. As well as boiling, because it can causes damages to the catheter tip [26]. Microwaving the catheter up to 12 minutes is not sufficient to eradicate Pseudomonas aeruginosa or Staphylococcus aureus,although there is minimal change to its’ physical qualities [24]. According to differences in described cleaning methods we cannot suggest a reliable manner of taking care of the re-use catheters.

Self-catheterization should be done with an aseptic technique in the hospital care, but a non-touching clean technique in a home environment [4,25,29,30]. The aseptic technique did not prove to be safer compared to clean [18]. Peršolja [31] wrote that until it is possible to develop guidelines for intermittent self-catheterization in the home environment based on scientific evidence, only the use of sterile catheters is safe for patients that use the non-touching technique. Considering vague evidence, we therefore could suggest the non-touching clean technique, which involves working with or without gloves, a non-sterile solution for meatal cleaning, the single or multiple-use catheter, and lubricants [25]. Comfort catheterization is affected by different selection criteria: catheter size, type, and material [32], ease in handling, and the onset of pain due to the adhesion of the catheter to the mucous membrane [33]. Patients who perform intermittent selfcatheterization consider as an appropriate catheter the one that is the right size, easy to insert, and that reduces the risk of infection. Coated catheters were found to be the most desirable [27]. Tzortzis et al. [34] and Siderias et al. [35] did not find sufficient evidence to recommend the use of a lubricant or the anesthetic. As the literature is not clear what it is better for the patient, we have to consider nursing guidelines. Therefore, we can suggest, that the anesthetic should be applied in a sufficient amount (6 ml for women and 11 ml for men) at least five minutes before catheterization to take effect [35].

An important part of the procedure is also meatal cleaning. According to the study of Cunha et al. [36], the use of antiseptic and anti-microbial solutions for disinfection of the urinary meatus does not reduce the risk of urinary tract infection. Water, saline, or antiseptics are equally effective in cleaning or disinfecting the meatus.

Considering patient satisfaction, catheters with hydrophilic coating significantly reduce irritation of the urethra and increase patient satisfaction [17,18,37]. Patients also report that singleuse catheters make catheterization away from home easier [38]. Logan [32], for example, has found that for the packing of the hydrophilic catheter is important to be silent to open. This is very important when performing intermittent self-catheterization in public toilets. But the opponents of hydrophilic catheters, mention handling problems resulting from a slippage of catheter surface [22,39]. Although there is insufficient evidence to indicate whether hydrophilic catheters are associated with improved patient satisfaction [40]. Bermingham et al. [17] suggested that patients should be offered a choice between reuse and single-use and different catheter types. Because, one product is unlikely to suit everyone, and intermittent catheterization users require products that meet their individual preferences and needs [38].

Self-catheterization requires motor, sensory, and visual abilities, coordination, effective movement, and care for cleanliness from the patient. Patients performing long-term intermittent self-catheterization need the involvement of nursing staff in equipment choice. The findings of this review underscore the shared responsibility of health care professionals and patients. Concerns about the safety and reliability of equipment need to be acknowledged and overcome. Due to inconsistent terminology, different living standards, and thus access to different materials and tools, scientific evidence does not reduce uncertainty in practice. This review highlights the need for further research that employs rigorous study designs using valid and reliable instruments. The analyzed studies are difficult to discuss in terms of the diversity of the selected environment (rehabilitation centers, home environment, long-term care centers, hospitals), patient groups (by gender, degree of disability, duration of intermittent catheterization, antibiotic prevention), self-catheterization provider (medical staff, relatives, patient), patient abilities (sensory, motor, educational, material).

Therefore, it is necessary to define the details of atraumatic catheter insertion: long-term and comprehensive importance of choosing a sterile or non-sterile catheter, a time frame of repeated catheter use, to give guidelines for catheter care, justify the choice of moisturizing gel, its quantity, clean or sterile technique, potential risks with multiple daily long-term uses of lidocaine, choice of material for periurethral hygiene. There is also a need for experimental studies on catheter selection using artificial genitalia. Our study has several limitations. This review only included papers in English and Slovene. The research design used in the studies affected the quality of evidence. Studies from different countries have been included, among which the rights to health accessories vary. With this literature review, we were not able to find reliable evidence to support the choice of an optimal catheter.

Conclusion

The main finding of this study is that there is a lack of scientific evidence to support the choice of a particular catheter for intermittent (self-)catheterization in advance. Clinical evidence is insufficient for powerful decision-making. There is no reliable evidence that any technique of self-catheterization is prior to others concerning urinary tract infection incidence, and they, therefore, suggest to use the cheaper technique – the clean method, with reuse (non-sterile) catheters where the timing of use and neither the assessment of catheter are defined, and all gadgets used for catheterization are clean but non sterile. On the other hand, many studies support the use of hydrophilic catheters to reduce urethral trauma, but the evidence is insufficient to indicate whether these catheters are associated with improved patient satisfaction and less urethral infections. It is shore however, that hydrophilic catheters are the most preferred from patients.

Though we were unable to find enough evidence supporting the selection of an optimal catheter, the results tend to propose the single-use of hydrophilic catheters to reduce urethral trauma and the non-touching technique with sterile equipment to lower infections incidence. The selection of the catheter should depend primarily on the: a.) patients’ preference (of the catheter type, material, catheterization technique), anatomy, and hands functionality; b.) catheter availability and ease of use. It is recommended that nurses together, with the patient, firstly select the technique of self-catheterization, try it, and only after that select the optimal catheter.

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