Intermittent clean self-catheterisation (ICSC)

Intermittent clean self-catheterisation (ICSC) is the periodic insertion of a catheter into the bladder, via the urethra. When normal bladder function is impaired or absent, ICSC enables safe, effective and complete emptying of urine from the bladder, and is widely used by people who have difficulty voiding.

Intermittent clean self-catheterisation is still considered the best option for bladder management, as it protects the upper urinary tract through regular emptying, whilst maintaining low bladder pressures.

There is evidence to demonstrate that pre-lubricated catheters offer the best lubrication for preventing urethral complications, such as strictures.

General information

• Catheters are usually passed at regular intervals. The frequency may vary pending fluid intake and urine output. A guide for people starting ICSC can be consuming fluids (mostly water) of no more than 500ml every 4 hours or 100-150ml every hour.
• The amount of urine in the bladder should not be more than 500 ml. The goal is to remain continent between catheters.
• Over-distension of the bladder may reduce blood flow to the bladder wall therefore making it more susceptible to infection from bacterial growth. Overstretching the bladder can also cause long-term damage to the muscle and nerves.

Catheterisation times

• If ICSC is the primary means of emptying the bladder, the procedure is generally performed every 4 hours during the day and every six hours overnight.
• A catheter can be passed more often, if there is increased frequency, leaking and fluctuating fluid intake. Diuretics can increase urine volumes.
• Oedema in the lower limbs and obstructive sleep apnoea can increase the need for more frequent catheters to compensate for high urine output at night. Elevating feet in the early afternoon and evening may help to reduce night catheter volumes.

Catheter cleaning at home

Manufacturer’s guidelines should be followed for catheter use. Most catheters available to consumers are single-use items and should not be reused. However, there is one silicone-based intermittent catheter available that can be safely reused which can reduce costs and environmental waste. Below is a general guide for looking after this style of catheter.

Reusable intermittent catheters should be used for a maximum of 4 weeks, then discarded.

Cleaning a reusable intermittent catheter:

• After using the catheter, rinse under a running tap.
• A plastic container with a lid, such as the one that comes with the product or a sandwich box, is used to soak the catheters.
• Mix and use sodium hypochlorite (e.g. Milton) according to the instructions on the packaging. Tank and bore water should be boiled and cooled prior to use.
• The catheter shouldn’t be touched by hands when removed from the solution. Use the cap of the product or forceps to do this.
• The catheter does not need to be dried or rinsed before use.
• The container with the sodium hypochlorite solution needs to be emptied and the solution changed daily.
• Gloves may be used to handle the concentrated sodium hypochlorite solution to prevent skin irritations.
• Once a week, the container and forceps/cap should be sterilised with boiling water.

Basic principles of passing a catheter (male)

Equipment

• There are many different types and styles of products on the market. Some features are:
  • Nelaton (plastic) or silicone
  • Non-lubricated, pre-lubricated (water-soluble gel) or hydrophilic (with or without water added)
  • Additional features, such as double-wrapping, ‘slides’ or a closed bag system.
• Most males will use a 14Fg size catheter to allow quicker drainage of urine.
• Some catheters vary in length. The average male urethral length is 20cm.
• Ensure all equipment is available prior to commencing catheterisation.
• Wear personal protective equipment, as required.

Cleaning

• Clean hands with alcohol gel, baby wipes or soap and water prior to touching equipment and setting up.
• Clean the penis using mild soapy water or non-scented baby wipes. Alcohol-based solutions should not be used to clean the penis, as they may cause dryness and irritation. Retract the foreskin, if applicable, to ensure the penis is clean.

Passing the catheter

• The catheter should never be handled directly. Use a freezer bag, slide system, closed system or double-wrapped option to handle the catheter, to avoid transfer of bacteria from the hands into the urethra.
• With the less dominant hand, hold the penis upward, at approximately 60 degrees to the body. This is to straighten the urethra and allow for a smoother insertion of the catheter.
• Ensure good visibility of the urethral opening and slowly insert the catheter into the urethra. Take care not to let the catheter touch any other surfaces.
• Insert the catheter until urine begins to flow.
• If the catheter is difficult to pass through the sphincter, apply gentle pressure and ask the person to breathe deeply, until the sphincter relaxes enough to insert the catheter.

Draining the bladder and removing the catheter

• Applying pressure, using the hand over the lower abdomen, or a small cough can help to drain the remaining urine in the bladder.
• When urine ceases to flow, the catheter is slowly withdrawn to remove the last drops from the bladder.

Positions to perform ICSC

ICSC can be managed in either seated, standing positions or semi-reclined on a bed. This is a personal preference. Whichever position is used, please ensure that there is good visibility of the urethral opening and that the penis is not obscured by clothing or bedding.

Poor eyesight

Many people with poor eyesight can learn to pass catheters. Using well-washed hands, the urethral opening can be felt with the fingers and guided in this way.

Basic principles of passing a catheter (female)

Equipment

• There are many different types and styles of products on the market. Some features are:
  • Nelaton (plastic) or silicone
  • Non-lubricated, pre-lubricated (water-soluble gel) or hydrophilic (with or without water added)
  • Additional features such as double-wrapping, ‘slides’ or a closed bag system.
• Most females will use a 12Fg size catheter but a 14Fg can be used to allow quicker drainage of urine.
• Catheter lengths for females can range from 9cm to 23cm. The average urethral length is 5cm.
• Ensure all equipment is available prior to commencing catheterisation.
• Wear personal protective equipment, as required.
• Clean mirror/leg positioning device, if required, and hands with alcohol gel, baby wipes or soap and water, prior to touching equipment and setting up.
• Clean the perineal area using mild soapy water or non-scented baby wipes. Alcohol-based solutions should not be used to clean the perineal region, as they may cause dryness and irritation. Spread the labia and wipe in a downwards direction, away from the urethra.

Passing the catheter

• The catheter should never be handled directly. Females can be educated to hold the end or towards the end catheter without contamination to the urethra.
• With the less dominant hand, separate the labia and identify the urethra.
• The person can be supported with use of a mirror, to see the opening.
• Once the urethral orifice is identified, the catheter is slowly inserted into the urethra. Take care not to let the catheter touch any other surfaces.
• If the catheter is placed in the vagina, a new catheter must be used when reattempting catheterisation.
• Insert the catheter until urine begins to flow.
• If the catheter is difficult to pass through the urethra, apply gentle pressure and ask the person to breathe deeply, until the sphincter relaxes enough to insert the catheter.

Draining the bladder and removing the catheter

• Applying pressure, using the hand over the lower abdomen, or a small cough can help to drain the remaining urine in the bladder.
• When urine ceases to flow, the catheter is slowly withdrawn to remove the last drops from the bladder.

Positions to perform ICSC

ICSC can be managed either seated (chair, wheelchair or toilet), standing or semi-reclined on a bed. This is a personal preference. Whichever position is chosen, maintain good visibility of the urethra and ensure it is not obscured by clothing or bedding. Mirrors are often useful for women to achieve this. Equipment to position the legs may also assist, particularly if adductor spasticity is an issue.

Poor eyesight

Many people learn to pass the catheter without the use of a mirror, judging the urethra by feel and measurement. The first and third fingers of the less dominant hand are used to part the labia and the middle finger locates the urethral opening. The person may need to apply firm upward pressure to feel the opening, and some practice may be required to cleanly insert the catheter.

Trouble shooting ICSC issues