Although the etiology and pathogenesis leading to neurogenic bladder vary and the clinical presentation of different types of neurogenic bladder varies greatly, a significant number of patients with severe disease lose the ability to urinate on their own, such as those with congenital spinal cord bulge, paraplegia, and diabetes mellitus are often complicated by varying degrees of difficulty in urination, which, without proper management, may lead to complications such as urinary tract infection, urinary incontinence, and impairment of upper urinary tract function.
Many factors have an impact on the decision to manage neurogenic bladder, including neurogenic factors, urological factors, gender and requirements for sexuality, psychological factors and social factors. In patients with neurogenic bladder who present with chronic voiding difficulties and urinary retention, there are several options available to assist the patient in voiding, but each approach has its own advantages, disadvantages and target population. It is very unfortunate that the lack of quality care and the need for quality of life leads patients to ignore the drawbacks of long-term indwelling catheters, which become the primary treatment for many patients with progressive neurogenic disease. It has been reported that 30% of patients with progressive multiple sclerosis opt for long-term indwelling catheters, 40% of whom are transurethral, while 60% opt for suprapubic cystostomy.
I. Preparation before intermittent catheterization
1. Patient selection Before developing the intermittent catheterization program, the patient’s medical history and physical condition should be thoroughly evaluated, and urological examinations such as renal function, serum electrolytes, urinary routine, imaging of the upper urinary tract and urodynamic examination must be performed, and imaging urodynamic examination should be performed if available, or cystourethrography during voiding. The need for cystoscopy may be determined at the discretion of the patient based on mobility or the needs of the condition. The ideal candidate will have good compliance and understanding, and be able to operate the catheterization process with both hands on their own, or cooperate with family members in the process. Patients also need to have good urinary control, with bladder volume required to maintain a sufficiently low pressure bladder (<40 cmH2O) even at 350-400 ml, no urinary tract obstruction, no vesicoureteral reflux, and no serious urinary tract infection present.
Once an intermittent catheterization protocol has been developed, adequate communication should be made with the patient and his or her relatives to help the patient understand the purpose and procedure of intermittent catheterization and the importance of cooperation with treatment. If the patient cannot complete the catheterization operation by himself due to his age, body position, and upper limb mobility, experienced family members can master these techniques.
2. Dietary control. Patients with intermittent catheterization should have a water intake plan based on their individual condition to facilitate the formation of a regular urinary elimination schedule and to determine the daily interval of catheterization and the number of catheterizations.
The patient’s daily fluid intake should be strictly controlled within a certain range, and the total daily volume can be controlled at 1500-1800 ml in the beginning stage, and the fluid intake should be uniform, with an average of 100-125 ml/h, in order to prevent overfilling of the bladder caused by failure to catheterize in time, or increasing the number of unnecessary catheterizations because the volume of urine in the bladder at the time of catheterization does not meet the requirements of the need for catheterization. Drinking water includes all fluids, such as porridge, soup, and juice. Try not to drink after 8:00 pm to avoid excessive bladder distention at night. Do not drink diuretic drinks.
3.Timing and frequency of catheterization The interval of intermittent catheterization, starting with 4~6h catheterization is generally appropriate, and catheterization should be arranged before waking up, before meals, before bedtime, and 4~6 times a day. Half an hour before each catheterization, let the patient try to urinate once and then start catheterization, and record the volume of urine discharged and the volume of urine exported by the patient, and the sum of the two should not exceed 400~500ml.
During the implementation of intermittent catheterization in patients with paraplegia, attention should be paid to the clinical manifestations of autonomic hyperreflexia caused by high bladder pressure, such as sudden increase in blood pressure, skin flushing, sweating, headache and other reactions, and once they occur the bladder should be emptied quickly to relieve the symptoms.
Patients should be instructed to develop a water intake schedule including daily meals, replenish water daily according to the schedule, and keep records; at the same time, record the daily voiding time and urine volume, catheterization time and catheterization volume, and make appropriate adjustments to the water intake and time according to the time and frequency of intermittent catheterization and single urine volume, so that the frequency and duration of catheterization are within a reasonable range.
For patients whose vesicourethra still retains partial voiding function, partial intermittent catheterization can be performed. In patients with low compliant bladder, instability of the detrusor muscle and vesicoureteral reflux excluded by urodynamic examination and cystourethrography during voiding, various auxiliary techniques can be used to induce the patient to urinate before each catheterization, and the volume of urine expelled and the volume of urine exported by catheterization can be recorded separately. If, after a certain period of treatment, the amount of urine expelled by the patients themselves gradually increases and the amount of urine exported decreases, consideration can be given to extending the catheterization interval, and the patients can be instructed to use auxiliary methods to urinate by themselves between catheterizations.
In order to reduce the number of catheterizations and improve the efficiency of catheterization, there are now commercially available small ultrasonic diagnostic devices that are easy to operate, and patients can detect the volume of urine in the bladder by themselves with the help of this device after receiving simple training to guide the determination of catheterization time.
II. Intermittent catheterization operation
1.Catheterization position Male patients with no physical mobility problems can take a sitting position, or standing position; female patients can use a sitting or squatting position. Patients with high spinal cord injury requiring relative-assisted catheterization can adopt the lateral recumbent position.
2.Choice of catheter and treatment Intermittent catheterization mostly uses 12F or 14F catheter. Sterile catheterization requires the use of sterile catheter and auxiliary sterile apparatus. Clean home-based intermittent catheterization does not require sterilization operation or disinfection of the catheter, only that the catheter used is cleaned with neutral soap solution and dried, and the unused catheter is stored in a clean and dry place. Each catheter should preferably not be used at home for more than 1 week and needs to be used in a single session in the hospital.
For patients who have the conditions, it is best to use disposable polyvinyl chloride (PVC) catheters with lubricating gel, which are more comfortable for patients and reduce the chance of urinary tract infection and trauma during operation.
Therefore, this section focuses on the training and operation of clean self-intermittent catheterization, which can be done by washing hands before insertion without sterilizing the catheter and aseptic operation. However, it is not true that sterilization and aseptic operation are not beneficial. For patients who are able to do so, it is best to use pre-lubricated disposable catheters to increase the comfort of catheterization and to reduce complications such as urethral injury and infection due to intermittent catheterization.
(1) Training of female patients in self-intermittent catheterization.
Female patients wash their hands and pubic area with soap and water and swab them dry. Take a semi-recumbent position on the examination table with thighs bent and knees abducted to expose the vaginal and urethral orifices. The head end of the examination table is swung up several feet so that the patient can see her perineum in the mirror placed at the foot end of the table. The patient is given a clean 14F catheter and instructed to empty the bladder by placing it into the urethra and then into the bladder.
(2) Operation of self-intermittent catheterization in female patients.
(3) Training of male patients in self-intermittent catheterization.
The instruction for male self-catheterization is relatively simple. The patient takes a sitting or standing position and must lubricate the catheter with a water-soluble lubricating paste. With one hand, lift the penis upward at an angle, turn the foreskin up if the foreskin is long, and with the other hand, insert the catheter into the urethral orifice, insert the catheter gently inward until there is urine flow, then insert it slightly 1cm~2cm, maintain the position until the bladder is completely emptied, and gently drag the catheter outward.
(4) Operation of self-intermittent catheterization in male patients.
4. Problems encountered during catheterization.
(1) Hematuria: If there is only occasional small amount of bleeding, there is no need to worry too much about it. However, if the bleeding is persistent, or if the bleeding increases, the patient must go to the hospital promptly.
(2) Difficult insertion: The patient should relax, fully lubricate the catheter later, and repeat the insertion with gentle movements; if insertion is still difficult, professional help needs to be sought.
(3) Urine has a foul odor or is cloudy. Go to the hospital to check for urinary tract infection.
(4) Difficulty in removing the catheter after emptying the bladder: it may be due to bladder spasm. The patient should relax for a while and then try to remove the catheter.
III. Intermittent catheterization follow-up
The efficacy of IC is related to its early or late application and the length of adherence. Since IC requires patients to perform catheterization several times in 1 day, which brings some inconvenience to patients’ life and has some complications, long-term adherence is more difficult for many patients. Therefore, it is important to insist on long-term regular follow-up for each patient receiving IC treatment. During the follow-up period, we need to communicate with the patients and their families frankly and fully, so that the patients can understand the importance of adhering to IC treatment, so that the patients can actively adhere to and cooperate with the treatment.
During the follow-up visits, the patient should be kept informed of the problems encountered in IC, understand the changes in the patient’s voiding function, and summarize the records of the patient’s fluid intake, self-discharge and catheterized urine output. Patients are also required to undergo regular comprehensive urological examinations, including upper urinary tract function, urinary routine, and urine bacteriological culture, as well as imaging examinations such as ultrasound of both kidneys or upper urography, urodynamic examinations (or imaging urodynamics), and cystoscopy to exclude stones and tumors if there is non-infectious hematuria. The protocol for intermittent catheterization is adjusted appropriately based on follow-up, as well as the amount of water the patient drinks, the number of catheterizations and the amount of urine exported, and the amount of residual urine in patients with partial voluntary voiding.