Clinical Guidelines (Nursing)

Teaching and supporting Clean Intermittent Catheterisation for parents and children

  • Introduction

    Aim

    Definition of Terms

    Assessment

    Management

    Potential Complications 

    Special Considerations

    Companion Documents

    Links

    Evidence Table

    References


    Introduction

    Clean Intermittent Catheterisation (CIC) is a method of draining urine via a catheter inserted into the urethra, past the sphincter into the bladder. Once the urine is drained the catheter is removed. CIC is vital in reducing bladder pressure or draining residual urine, and therefore preserving kidney health. Correctly performed, CIC can also reduce the risk of urinary tract infections (UTIs) and promote continence.

    This guideline does not refer to children and adolescents with an acute short term requirement for bladder emptying such as post-operative urinary retention, or need for an indwelling urinary catheter. Please refer to the Indewelling Urinary Catheter Guideline: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Indwelling_urinary_catheter_insertion_and_ongoing_care/

    This guideline does not refer to the child or adolescent using CIC through a stoma such as a Mitrofanoff. 

    Aim

    To provide information that will assist nursing staff to educate and support parents and carers of children who require ongoing CIC.

    Definition of Terms 

    • Clean Intermittent Catheterisation (CIC)
      Refers to the act of draining urine by passing a catheter through the urethra, past the sphincter into the bladder. The catheter is removed after the urine has been drained. This process is performed using a clean technique. A new sterile catheter is used for each episode.
    • Clean Intermittent Self Catheterisation (CISC)
      Performing CIC for oneself.
    • Clean Technique
      The process of performing a procedure under clean conditions in order to reduce the number of microorganisms. This includes handwashing, non-sterile gloves, a clean field and clean or sterile equipment.
    • Detrusor Overactivity
      A condition in which there is increased activity in the detrusor muscle of the bladder, often resulting in incontinence.
    • Detrusor Underactivity
      A condition in which there is ineffective contraction of the detrusor muscles of the bladder resulting in an inability to empty the bladder and incontinence.
    • Detrusor Sphincter Dyssynergia  
      Dis-coordination of the detrusor muscle of the bladder and the urethral sphincter muscles resulting urinary retention and incontinence in the context of neurological impairment.
    • Dysfunctional Voiding
      Dis-coordination of the detrusor muscle of the bladder and the urethral sphincter muscles resulting urinary retention and incontinence in the context of no neurological impairment.
    • Haematuria
      The presence of blood in the urine.
    • Hydrophilic Coated Urinary Catheters
      Urinary catheters which are coated, and either activated with water or pre-packed with a sterile gel or fluid reservoir.
    • Mitrofanoff
      A surgical procedure in which the appendix and bowel are used to create a connection between the bladder and the abdominal skin surface to allow for urinary catheterisation through a stoma.
    • Myelomeningocele
      A neural tube defect in which the bones of the spine do not completely form resulting in a defect in the spinal canal. This can cause lack of sensation and/or movement in the lower limbs and bladder and bowel dysfunction.
    • Neurogenic Bladder
      A dysfunction of the bladder due to a neurological condition. 
    • Sensate Urethra
      The experiencing of full or partial sensation in the urethra.
    • Urinary Tract Infection (UTI)
      An infection of the kidney ureter, bladder and/or urethra.

    Assessment

    This guideline applies to infants, children and adolescents who require ongoing CIC due to:

    • Dysfunctional voiding such as in the case of detrusor overactivity, detrusor underactivity, detrusor sphincter dyssynergia or dysfunctional voiding.
    • An ongoing condition that results in a neurogenic bladder such as myelomeningocele or congenital or acquired spinal lesions.
    • Spinal Cord Injury

    Physical Assessment

    Patient and family assessment should include:

    • The reason for CIC, including establishing past and/or ongoing urology involvement and initial CIC education given by Stomal Therapy/Continence Consultants. If family has not had initial education in CIC please contact the urology team for referral to the Stomal Therapy/Continence Consultants.
    • The person who usually performs CICs at home, the usual routine and frequency of CIC,  the equipment used
    • The level of comfort with parent/child performing CIC
    • The reason for hospitalisation and how this may impact ability to perform CIC
    • The current fluid Intake and urine output of child
    • The current discomfort/pain of child
    • Any specific psychosocial considerations

    Catheter type 

    • Catheters used for CIC are usually single-use polyvinylchloride or silicone catheters.
    • Single use hydrophilic catheters may be used where there is difficulty passing the catheter due to muscle spasm or anxiety, or where there has been urethral trauma. The coating may make hydrophilic catheters more difficult to grip where a child performs CISC, especially where manual dexterity is an issue. There is currently no established benefit in terms of reducing risk of UTIs between catheter types.
    • Tiemans or Coude tip catheters with an angled tapered end are occasionally used for boys if there are problems inserting straight catheters.
    • Very occasionally a child will be using a reusable catheter set: the Cliny safety catheter set. Cliny catheters are reused for 14 days. If a child has a Cliny set, consult Stomal Therapy/Continence Consultants to determine the correct cleaning/sterilisation procedure.

    Catheter size

    Below is an approximate guide for catheter size:

    Age Weight (kg) Catheter Size (French)
    0-6 months 3.5-7 6
    1 year 10 6-8
    2 years 12 8
    3 years 14 8-10
    5 years 18 10
    6 years 21 10
    8 years 27 10-12
    12+years 30+ 12-14

     Positioning

    Assess the preferred positioning before commencing catheterisation.

    • For a baby or an infant lying supine is preferred. This position may also be preferred while a parent is learning to catheterise their child.
    • If the child is older, or performs CISC, the preferred option is usually sitting on the toilet. A child who is experienced at performing CISC may still require assistance to position their legs or to find a suitable surface on which to place equipment in an unfamiliar environment.

    Self-catheterisation

    All children who require long term catheterisation should be considered for education in CISC. Readiness to learn CISC should take into account:

    • Age: generally children can perform parts of the procedure from age 4 or 5 years but are not independent in CISC until age 6-8 years or older
    • Cognitive level
    • Physical dexterity
    • Level of urethral sensation: many children with neurogenic bladder have little or no urethral sensation. Children with sensate urethras may have increased anxiety about pain or discomfort
    • Anxiety level
    • Motivation to perform CISC

    Management

    Equipment needed:

    • Catheter
    • Alcohol -free wipes
    • Water soluble lubricated gel (unless using a hydrophilic catheter)
    • Container into which to drain urine (unless draining into toilet)
    • Alcohol based hand rub to use, if there is no facility to wash hands adequately with soap and water
    • Latex-free gloves (child and parents performing CIC may choose not to wear gloves)
    • Xylocaine gel if used for children with a sensate urethra

      Parent/carer directions for catheterising boys:

      1. Ensure the child is comfortably positioned.
      2. Wash hands with soap and water and dry, or clean with Alcohol based hand rub. Open catheter package half way, being careful not to touch catheter tip. Place lubricant gel on the inside of open packet. Put on gloves if preferred.
      3. Gently pull back child’s foreskin if he has one. You will be able to see the urethral opening. Hold penis pointing towards stomach.
      4. Wash tip of penis starting at urethral opening and work outwards in a circular motion with an alcohol-free wipe.
      5. Lubricate the tip of the catheter with the water soluble lubricating gel or xylocaine gel.
      6. Slide the catheter slowly into the opening of the urethra until urine starts to flow. If resistance is felt, stop for a few seconds then continue.
      7. Once urine starts to flow, point the penis and catheter downwards draining into a container or toilet. Pull the foreskin gently back over the penis.
      8. When urine flow stops, withdraw the catheter slowly. It may start to drain again. Wait until this ceases again, then remove the catheter. This ensures complete emptying.
      9. The catheter should be discarded into the yellow waste bin and hands washed with soap and water.

      CIC Boys

      Parent/carer directions for catheterising girls:

      1. Ensure the child is comfortably positioned.
      2. Wash hands with soap and water and dry, or clean with Alcohol based hand rub. Open catheter package half way, being careful not to touch catheter tip. Place lubricant gel on the inside of open packet. Put on gloves if preferred.
      3. Gently separate the labia with one hand and wash down from top to bottom using an alcohol-free wipe and discard. Repeat with a clean wipe.
      4. Lubricate the tip of the catheter with the water soluble lubricating gel/xylocaine gel and gently slide into the urethra. If resistance is felt gently rotate the catheter a little. Once urine is flowing push catheter in a few more centimetres to ensure that it is in the bladder.
      5. When urine flow stops, withdraw the catheter slowly. It may start to drain again. Wait until this ceases again, then remove the catheter. This ensures complete emptying.
      6. The catheter should be discarded into the yellow waste bin and hands washed with soap and water.

      CIC Girls


      Potential complications:

      Urinary Tract Infection (UTI):

      Signs and symptoms:

      • In addition, children who perform CIC may notice increased leaking of urine between catheterisation.

      Prevention and management:

      • Children may need to perform more frequent catheterisation until symptoms of the UTI clear.

      • If a child performing CICs has repeated UTIs, careful assessment of catheterisation technique is recommended. Observation of technique is more accurate than parent or child recall.

      Urethral trauma:

      Signs and symptoms:

      • Pain on passing the catheter (for children with sensate urethras)
      • Haematuria
      • Chronic UTIs
      • Inability to pass catheter

      Prevention and management:

      • Seek advice from the Stomal Therapy/Continence Consultants or the Urology Team
      • For mild trauma - consideration of the use of hydrophilic catheters
      • For severe trauma - the treating team may consider surgical options such as dilatation of the urethra or a surgical urinary stoma formation, such as a Mitrofanoff. 

      Catheter obstruction:

      Signs and Symptoms:

      • Difficulty or inability to pass catheter

      Prevention and management:

      • This can be due to muscle spasm, do not force the catheter. Wait a minute or two to allow spasm to pass
      • Assess anxiety of child – anxiety can increase muscle spasm that prevents catheter passing smoothly – utilise deep breathing, visualisation or distraction techniques
      • If catheter unable to be passed contact the Stomal Therapy/Continence Consultants or Urology Team

      Special Considerations

      Psychosocial Considerations:

      • Families can find CIC an emotionally difficult procedure when it is first introduced. If a child has significant anxiety do not force the process. Consider assistance from Child life therapy in preparing the child and during the procedure. Allowing children to handle equipment, hold the catheter, clean themselves or assist in placing the catheter, even from the first catheterisation, can give them a sense of control. Use of diagrams and models can be helpful. Some children find the use of mirrors very confronting.
      • Ongoing anxieties for children who perform CICs regularly, include leakage, pain and peers finding out. Children who are proficient in CICs can still require assistance if in an unfamiliar bathroom or toilet, particularly with positioning. Most children who are independent performing CICs do not want others to perform it for them.

      Other:

      • On discharge assess if the family need extra support with CICs due to any change in physical status – refer to PAC
      • If there are any concerns with the family’s level of knowledge or ability to manage CIC please contact the Stomal Therapy/Continence Consultants.

      Companion Documents

      Links

      • The Continence Aids Payment Scheme

      http://www.continence.org.au/pages/continence-aids-payment-scheme-caps.html

      • Spina Bifida Foundation Victoria

      http://www.sbfv.org.au/

      • Continence Foundation of Australia

      http://www.continence.org.au/

      • State Wide Equipment Program (SWEP)

      http://swep.bhs.org.au

      • National Disability Insurance Scheme (NDIS)

      http://www.ndis.gov.au

      Evidence Table

      Click here for the Evidence Table for this guideline.

      References

      • Chaudhry, R., et al. (2017). Risk factors associated with recurrent urinary tract infection in neurogenic bladders managed by clean intermittent catheterization. Urology, 102: 213-218
      • DeFoor, W., et al. (2017). Results of a prospective randomized control trial comparing hydrophilic to uncoated catheters in children with neurogenic bladder. Journal of Pediatric Urology, 13(4): 373-375
      • Elzeneini, W., et al. (2019). Early start on clean intermittent catheterization versus expectant management in children with spina bifida. Journal of Pediatric Surgery, 54:322-325
      • Foster, C. S., et al. (2017). Utility of a routine urinalysis in children who require clean intermittent catheterization. Journal of Pediatric Urology, 13(5): 488.e1-488.e5
      • Hakansson, M. (2014). Reuse versus single-use catheters for intermittent catheterisation: what is safe and preferred? Review of current status. Spinal Cord, 52: 511-516.
      • Holland,J.E., et al. (2015). Self-cathing experience journal: Enhancing the patient and family experience in clean intermittent catheterization. Journal of Pediatric Urology, 11(4): 187.e181-186
      • Kiddoo, D., Sawatzky, B., Bascu, C. et al. (2015). Randomized cross-over trial of single use hydrophilic coated vs multiple use polyvinylchloride catheters to determine incidence of urinary infection in users of intermittent catheterisation. The Journal of Urology, 194(1):174-179
      • Li, Y., et al. (2018). Application of clean intermittent catheterization for neurogenic bladder in infants less than 1 year old. Neurorehabilitation, 42(4): 377-382
      • Our Lady’s Children’s Hospital Crumlin (2015). Clean intermittent catheterisation.
      • Nursing Practice Guideline on Clean Intermittent Catherisation. Accessed from:
        http://www.olchc.ie/Healthcare-Professionals/Nursing-Practice-Guidelines/Clean-Intermittent-Catheterisation-.pdf
      • Prieta, J., Murphy, C., Moore, K. & Fader, M. (2014). Intermittent catheterisation for long-term bladder management (Review). The Cochrane Database of Systematic Reviews, 9.
      • Seth, J., Haslam, C. & Panicker, J. (2014). Ensuring patient adherence to clean intermittent self-catheterization. Patient Preference and Adherence, 8, 191-198.
      • Zlatev, D. V., et al. (2016). How many spinal cord injury patients can catheterise their own bladder? The epidemiology of upper extremity function as it affects bladder management. Spinal Cord 54(4): 287- 291

      Please remember to read the  disclaimer.


      The development of this nursing guideline was coordinated by Carmen Akaoui, Stomal Therapy, and approved by the Nursing Clinical Effectiveness Committee. Updated June 2019.