Intermittent catheterisation in neurological patients: When do we start this conversation and how best to manage this pathway from suggestion to treatment?

Join Professor Jalesh Panicker, Uro-neurology academic director for our second Uro-neurology Academy webinar. This webinar will cover the challenges with the selection, education and initiation of intermittent self catheterisation in neurological patients. When do we start this conversation and how best to manage this pathway from suggestion to treatment? It will aim to tackle the current challenges in bladder and bowel management faced by healthcare professionals and people with a long term neurological condition and provide valuable management tips to ensure the success of intermittent self catheterisation. During the webinar, attendees will have the opportunity to participate in a question and answer session.

Webinar objectives

• While there is pressure on bladder and bowel services and on MS services, who should step up to cover this discussion with patients?

• What are the challenges for the person with MS?

• Tips and tricks for management to ensure ISC is successful for the pwMS

Summary

People with neurological disease may experience urine storage or voiding dysfunction, and sometimes a mixture of both, explained Professor Jalesh Panicker, consultant neurologist, at University College London Hospitals NHS Foundation Trust.

Lesion location drives the symptoms, he explained. Disease in the suprapontine region, such as stroke or Parkinson’s, can cause detrusor overactivity, and therefore storage symptoms.“As a broad generalisation, you will not see individuals with these conditions in an ISC clinic, though of course there are exceptions,” said Jalesh.

People with lesions in the spinal region, such as in MS or trauma, and the sacral/infrasacral regions, such as disc prolapse and spina bifida, can experience voiding symptoms. Voiding dysfunction can be classified as either low-pressure low-flow void, caused by detrusor underactivity, or high-pressure low-flow void, associated with impaired external sphincter relaxation, or detrusor sphincter dyssynergia. “But what we find in clinical practice is that voiding dysfunction often has multiple contributors,” said Jalesh.

Indication and assessment

Incomplete bladder emptying, Jalesh explained, can worsen storage symptoms, contribute to recurrent urinary tract infections (UTIs), and, particularly in spinal cord injury and advanced MS, heighten the risk of urinary tract damage. Indicators include symptoms, such as poor stream or a sensation of incomplete bladder, small volume voids, recurrent UTIs, or nocturnal enuresis. However, clinical signs are not enough, on their own, to accurately identify void dysfunction.

Guidelines from the European Association of Urology, International Continence Society (ICS) and the National Institute for Health and Care Excellence (NICE) all highlight the importance of measuring post-void residual (PVR) volumes as part of the assessment.“Though there may be indicators, measuring the PVR volume is crucial,” said Jalesh, explaining that this is achieved via an ultrasound or, less commonly, in and out catheterization.

Intermittent catheterisation should be initiated when incomplete bladder emptying is identified, as it can improve quality of life, reduce incidence of UTIs, and lower the risk of urinary tract damage. However, there is a lack of evidence on the precise PRV cut-off values. In general, a PVR volume of >100ml is accepted as significant, though “the exact volume depends on the characteristics of the individual patient”, said Jalesh.

Management tips and tricks

Talking to people with neurological disease about ICS can be a challenge, but getting it right is essential for patient satisfaction and compliance, said Sharon Gill, lead nurse for neuro-urology at University College London Hospitals NHS Foundation Trust.

At the start of the conversation, people may be anxious or in shock about how their condition is affecting them. “Be prepared for questions and don’t rush. You do not have to achieveeverything on that first consultation. This is a process where we are building a trusting relationship,” she said, adding that the goal was to give people all the information they need, including the risks and benefits, and how ISC would affect their everyday lives, to make an informed choice about ISC.

Sharon went on to outline the typical barriers to ISC. They included patient-related factors, such as physically being unable to manage the process due to poor eyesight, dexterity, or spasms, for example, and cognition. Pain, age and motivation can also all play a role, as well as stigma and a perceived lack of dignity. External factors include a lack of knowledge, training, or ongoing healthcare professional (HCP) support. Addressing all these barriers takes time and a strong patient/HCP relationship. “ I don't mind how many times they come back to clinic; they come back as often as they need to be comfortable. Just always have your facts to hand to answer their questions,” said Sharon.

Many different catheter types and sizes are now available, all of which are single use. Jill said she usually recommended a size 10 charrières (ch) to 12ch for women, and 12ch to 14ch for men, always using the smallest possible size. Aids, such as hand grips, leg spreaders, mirrors, labia dividers, penis holders and sheaths, are also available to assist in the process.

“With men, it's a little bit easier for them to identify the urethra. With women, a lot of the time you're teaching them to catheterize almost blind; they're doing it by feel. A mirror can help them to look at their anatomy before you start ICS, so they can understand what they look like,” said Sharon.

On-going follow up was essential, she added, recommending HCPs monitor and review the patient regularly to start, and then every three months.

Managing UTIs on ISC

ISC reduces the likelihood of UTIs. However, positive urine dipsticks are common in practice, said Sharon. “If you test it when you're doing ISC, it will show nitrates and leukocytes so therefore, we only treat symptomatic UTIs.” That means a temperature,shivering or shaking, offensive smelling urine, blood in the urine, pain on passing urine, or incomplete emptying. “It is not smell or colour. A whiff of urine or cloudy urine is not an infection. That's part of the patient education it is so important to give them, so that they're not overusing antibiotics and building up resistances.”

Infection prevention measures include drinking 2L of fluids a day, cranberry juice tablets for those not taking warfarin, and probiotic drinks. Bowel management, Sharon went on, is alsocrucial to reducing the risk of UTIs.

We respect the privacy of every person for whom we have personal data. The group privacy and cookies policy can be viewed here.