Research has revealed uncertainty among catheter users about the signs and symptoms of urinary tract infection (UTI) and at what point they should seek help (Okamoto et al, 2017). In this study, the researchers recommended development of a self-help tool for patients that could assist with the identification of infection, as well as improve communication between patients and health professionals. The tool could prevent excessive or unnecessary contact with practitioners by ensuring that patients have the tools and abilities to self-manage, while providing the knowledge for patients to know when it is time to seek help.
A tool has been developed that requires a health professional to carry out the assessment (Lauridsen et al, 2022). A UTI risk factor model was used as the basis to inform the content included in the tool and the authors used the Design Thinking Process to guide its development, in terms of its content and format.
Twenty-two articles in the literature search met the criteria for informing the tool development, and the team conducted three rounds of meetings with approximately 90 nurses throughout Europe from Nurse Advisory Boards. The researchers also looked at insights generated from Coloplast Nurse Advisory Boards, and explored user perspectives and practices in relation to infection by conducting qualitative evidence synthesis.
From their research, they developed a UTI assessment tool for ISC users, made of the following three parts:
- A guide for health professionals
- A dialogue board
- A notepad.
The dialogue board contains six sections to help individuals to confirm if they have a UTI, and various other informative sections that help to pinpoint knowledge required surrounding other aspects of the process and procedures surrounding infection and catheter usage management. The tool consists of questions that focus on health, adherence, technique, and the catheter, as well as a section for cases in which a patient needs further support.
The most recent guidance from the National Institute for Health and Care Excellence (NICE) that covers intermittent self-catheterisation (ISC) was published back in 2012. It notes that long-term (over 28 days) urinary catheterisation is most often used in patients who are elderly or with a neurological condition. The prevalence of use of long-term catheterisation is 0.5% in people over the age of 75 and 4% in people receiving care at home. Long-term catheterisation could involve a continuous-flow catheter or suprapubic catheter, or ISC.
Despite how common long-term catheterisation is among patients it is, in fact, a last resort. More and more people are living with chronic conditions and the cost has to be considered, alongside the health considerations given that catheterisation is costly in the long term due to the amount of catheter devices and associated products needing to be used, but also because it can serve to take some independence away from the person – all other alternatives should be explored first. NICE (2012) acknowledges that for a certain group of patients this will be the necessary option.
When considering the type of long-term catheterisation, it will usually be an individualised choice regarding what best suits the needs and preference of the patient. There will be a risk of complications, infection being one, and others involving structural or physiological damage, urological cancer or psychosocial issues (NICE, 2012). Infection is caused primarily by encrustation and blockage, which need to be accounted for in the management of the catheter device the patient receives in their treatment. The NICE (2012) guideline noted that single-use gel reservoir and hydrophilic catheters have been associated with a slight reduction in incidence of infection. The guidelines also stated that the decrease was not enough to justify such large costs of these types of catheters in replacement of the original multiple-use non-coated catheter.
The latter, therefore, was determined to be the most cost-effective type of catheter, but not if the patient is using an average of two catheters each day. This comes down to the behaviour and compliance of the patient, which NICE (2012) states is therefore essential to consider when the prescriber is working out what option of catheter is more suited to each patient, with regard to their ability to use it and manage it while reducing their risk of infection and cost to the NHS. Therefore, self-catheterisation may suit some people while multiple-use catheters suit others.
Self-catheterisation was also noted to not be linked to a higher rate of infection where the technique to insert was clean rather than sterile, which should increase the ease and confidence the patient has on inserting this type of catheter option. NICE (2012) reported that clean intermittent catheterisation is unlikely to lead to additional infections, making the additional cost of the technique having to be sterile unjustified.
Approaches to self-catherisation
Shamout et al (2017) explored and compared the different approaches to ISC in adult neurogenic patients. They carried out a systematic review, studying all types of self-intermittent catheters, while analysing their impact on infection rates, urethral trauma, patient satisfaction and quality of life, as well as cost effectiveness of each option. There were 31 articles included and most participants had experienced spinal cord injury, or were women with multiple sclerosis. The preferred catheter for the patient's satisfaction was hydrophilic coated, and these were also found to reduce incidence infection and urethral trauma. Pre-lubricated catheters also had better outcomes than the traditional polyvinyl chloride catheters. Usually, self-lubricating/hydrophilic coatings are used for intermittent self-catheterisation, but a lubricant would be required where this is not the case. The team did note that sterile technique may reduce infection rate but this appeared unjustified given the exponential rise in cost caused by using catheters involving this technique.
Patient behaviour and adherence
Okamoto et al (2017) explored the ability of someone using ISC to identify symptoms of, describe and manage UTI. The patients were assessed on their understanding of terminology in relation to such infection, and were asked about their understanding of causes and management strategies for this qualitative research, conducted using semi-structured interviews. The transcriptions then underwent thematic analysis to identify themes in the text of all the interviews, that could infer a patient's understanding of the various topics. The study was set across 12 GP surgeries and all patients had at least one UTI since starting intermittent self catheterisation.
Okamoto et al (2017) found that participants reported various symptoms of infection, such as cloudiness of urine and smell, which they identified as indicators of infection. These terms often differed from those listed in the modified National Institute on Disability and Rehabilitation Research (NIDRR) symptom set. There were noted difficulties in the catheter user interpretation of possible UTI in contrast to symptoms of their other comorbidities – they sometimes got the two mixed up. This contributed in part to some patients being reliant on their GP for support, although others saw pragmatically that infection is a possible consequence of catheterisation and can be managed. The patients described a range of management strategies, such as drinking more fluids and paying better attention to personal hygiene, along with taking antibiotics.
ISC provides an option for patients who are able to understand and comply well with the clean technique required, although an individualised approach should be taken when assessing the most appropriate method of long-term catheterisation with a patient. Patients have had some misunderstanding according to research about how to identify and manage infection associated with ISC; however, a tool has been developed that assists in the professional management of this common problem.
ISC is preferred where hydrophilic or coated catheters are used as these have been reported to increase comfort, reduce trauma and contribute to overall higher levels of satisfaction when compared to traditional non-coated catheters. The coated catheters also have a slightly lower incidence of infection.
Further help for patients to independently self-manage catheter use is available from the Royal College of GPs at: https://elearning.rcgp.org.uk/mod/book/view.php?id=12647&chapterid=443.