0 Guidelines for Intermittent Catheterisation in Children EUROPEAN SOCIETY FOR PAEDIATRIC UROLOGY NURSES
1 Written by: Hanny Cobussen-Boekhorst, Ellen de Bruijn-Kempe, Laurence Hermsen-Heilema, Jo Searles Peer reviewer: Ellen Janshen, Nathalie Fort, Brigitta Karanikas, Anka Nieuwhof. Prof. dr. Tom de Jong Prof. dr.Giantonio Manzoni Approved: September 2016 Review Due: February 2025 Review 2025: Hanny Cobussen-Boekhorst, Ellen de Bruijn-Kempe, Laurence Hermsen-Heilema Peer Reviewed 2025: ESPUN board: Ananda Nacif, Sigrid van de Borne, Sarah Boulby, Louiza Dale, Babett Jetzkowski and Jens Larsson Written by: Hanny Cobussen-Boekhorst, Ellen de Bruijn-Kempe, Laurence Hermsen-Heilema, Jo Searles Peer reviewer: Ellen Janshen, Nathalie Fort, Brigitta Karanikas, Anka Nieuwhof. Prof. dr. Tom de Jong Prof. dr.Giantonio Manzoni Approved: September 2016 Review Due: February 2025 Review 2025: Hanny Cobussen-Boekhorst, Ellen de Bruijn-Kempe, Laurence Hermsen-Heilema Peer Reviewed 2025: ESPUN board: Ananda Nacif, Sigrid van de Borne, Sarah Boulby, Louiza Dale, Babett Jetzkowski and Jens Larsson Written by: Hanny Cobussen-Boekhorst, Ellen de Bruijn-Kempe, Laurence Hermsen-Heilema, Jo Searles Peer reviewer: Ellen Janshen, Nathalie Fort, Brigitta Karanikas, Anka Nieuwhof. Prof. dr. Tom de Jong Prof. dr.Giantonio Manzoni Approved: September 2016 Review Due: February 2025 Review 2025: Hanny Cobussen-Boekhorst, Ellen de Bruijn-Kempe, Laurence Hermsen-Heilema
2 TABLE OF CONTENTS PURPOSE .......................................................................................................................... 3 INTRODUCTION ................................................................................................................ 4 CHAPTER 1 ....................................................................................................................... 6 CHAPTER 2 ....................................................................................................................... 9 2.1 INFECTIONS ......................................................................................................................................................................... 9 2.1.1 Urinary tract infection (UTI) .................................................................................................................................... 9 2.1.2 Urethritis ............................................................................................................................................................... 10 2.1.3 Epididymitis ........................................................................................................................................................... 10 2.2 TRAUMA ........................................................................................................................................................................... 10 2.2.1 False passage ........................................................................................................................................................ 10 2.2.2 Urethral stricture................................................................................................................................................... 10 2.2.3 Urethral bleeding .................................................................................................................................................. 10 2.3 OTHER ............................................................................................................................................................................. 10 2.3.1 Bladder stones....................................................................................................................................................... 10 CHAPTER 3 ..................................................................................................................... 12 CATHETERS ............................................................................................................................................................................. 12 3.1 Types of Catheters.................................................................................................................................................... 12 3.2 Drainage holes (eyes) ............................................................................................................................................... 13 3.3 Charrière................................................................................................................................................................... 13 3.4 Length ...................................................................................................................................................................... 13 3.5 Tip design ................................................................................................................................................................. 13 3.6 Catheters for non-touch technique........................................................................................................................... 14 3.7 Catheterisation Aids ................................................................................................................................................. 14 3.8 Continence containment products............................................................................................................................ 14 3.9 Use of catheters in poor financial circumstances ..................................................................................................... 15 CHAPTER 4 ..................................................................................................................... 16 4.1 TEACHING SELF-CATHETERISATION .......................................................................................................................................... 16 4.2 FREQUENCY OF CATHETERISATION 6 ................................................................................................................................ 17 4.3 COMPLICATIONS/DIFFICULTIES ASSOCIATED WITH CATHETERISATION ...................................................................................... 18 4.3.1 Problems with insertion......................................................................................................................................... 18 4.3.2 Pain/discomfort..................................................................................................................................................... 18 4.3.3 Constipation and faecal incontinence ................................................................................................................... 19 4.3.4 Cognitive Ability .................................................................................................................................................... 20 4.3.5 Physical ability ....................................................................................................................................................... 20 4.3.6 Practical/Social Considerations ............................................................................................................................. 20 4.3.7 Promoting Compliance .......................................................................................................................................... 21 4.4 DOCUMENTATION /PATIENT INFORMATION .............................................................................................................................. 21 4.5 FOLLOW-UP CARE ............................................................................................................................................................... 22 4.6 TRANSITION ....................................................................................................................................................................... 22 CHAPTER 5 ..................................................................................................................... 24 CHAPTER 6 ..................................................................................................................... 25 CHAPTER 7 ..................................................................................................................... 26 REFERENCES ................................................................................................................... 28 APPENDIX....................................................................................................................... 31
3 PURPOSE To provide guidance relating to the teaching and performing of intermittent catheterisation in order to maximise patient safety and comfort. Intended audience These guidelines and procedures are aimed at all healthcare professionals involved with teaching and performing intermittent catheterisation in hospitals and communities across Europe. Scope of guidelines The guidelines have been developed for nurse practitioners, continence nurses, and other nursing staff (referred to below as healthcare professionals) who practice and teach catheterisation and selfcatheterization to children and their parents/caregivers. For clarity, we will only use the word parents. For clarity, we have restricted the guidelines to catheterisation and self-catheterization via the urethra in children from birth to 18 years of age. Update of the guideline In 2016, this guideline was accepted by the ESPUN and published on the website of the ESPU(N) (https://www.espu.org/e-books/CIC_guidelines) Officially, these guidelines need to be updated every 2-5 years. Unfortunately, there was a delay due to the COVID-19 pandemic. All changes or new insights will be added with the year of the update to the 2016 guideline. When referring the guideline of 2016 will be the official guideline, added with the year of the latest update. Sustainability Nowadays, there is a need to invest in sustainability; in the production of catheters, there is already attention to more environmentally friendly products. However, there is an enormous waste of products. For the future, we recommend research on the reuse of biomedical products.
4 INTRODUCTION Background In order to promote the safety of children, parents, and healthcare users and to ensure quality, all care, wherever possible, should be based on research and scientific studies. In areas of practice where there is an absence of scientific research, care should be based on best practices formulated from recognised expert knowledge and skills. The development of guidelines based on scientific research and the expertise of healthcare professionals informs practitioners and helps them to provide high-quality, safe, and consistent care. Intermittent catheterisation or self-catheterisation is the gold standard for treating neurogenic bladder dysfunction (ICCS). Whilst there is literature evidence for some aspects of intermittent catheterisation, there is limited research-based evidence on the techniques of teaching catheterisation, compliance, and follow-up care. For these guidelines, where scientific evidence was absent/insufficient, the expertise of paediatric healthcare practitioners and review groups across Europe was utilised. These guidelines, therefore, use research, evidence, and best practice approaches to promote a uniform and consistent approach to performing and teaching intermitted catheterisation, which practitioners across Europe can use to inform and improve care for children and their families. Overview of contents The guideline clarifies terminology and discusses indications for catheterisation and potential complications. It outlines the types/materials of catheters and aids available for catheterisation and self-catheterisation and explains the procedure for male and female catheterisation. Specific information relating to approaches to teaching the procedure for various ages is provided, and issues of independence and compliance are also discussed. Potential complications, problems, and barriers to successful catheterisation are identified, and advice on how to overcome these difficulties is also considered. The impact of catheterisation on quality of life and issues of sexuality and self-image are also highlighted. Members of the working group These guidelines, produced by the European Society of Paediatric Urology Nurses, are adapted from the Dutch guidelines for intermittent catheterisation for children 2014 and the EAUN guideline 2024, "Urethral intermittent catheterisation in adults—Including urethral intermittent dilatation," European Association of Urology Nurses (EAUN) (uroweb.org). These guidelines have been peer-reviewed by members of ESPUN and by other practitioners involved in intermittent catheterisation in various countries to represent a consensus of paediatric practice across Europe and increase their relevance for European practitioners. The in-depth literature review was conducted by a multidisciplinary team within the Netherlands and included literature from worldwide. We would like to acknowledge the excellent and extensive work that the Netherlands team has done in compiling the guidelines, the update on which these are based, and the members of the other countries who have also contributed to their formation. The range of practitioners consulted in the original version from 2016 included: Nurse practitioners Continence nurses Paediatric urologists Child physiotherapists Urotherapists Psychological support staff Parent and child representatives
5 Participating countries in the original version from 2016 UK France Netherlands Germany Sweden Italy Government guidance To ensure the safety of healthcare users, most countries across Europe have Government guidance on who can perform intermittent catheterisation. These generally advise that the procedure should be carried out by appropriately qualified and competent professionals. Non-qualified personnel (e.g., parents, school staff, and respite staff) may perform the procedure in certain circumstances, provided that a skilled healthcare professional appropriately teaches them.
6 Chapter 1 Methods A systematic literature review was conducted using the databases: Cochrane, Medline, Pubmed, and Cinahl, searching literature between the dates 1998 and 2014 in both the Dutch and English languages. Relevant textbooks and existing guidelines and protocols were also reviewed. The following search terms were used: urinary catheteriz(s)ation, intermittent catheteriz(s)ation, intermittent selfcatheteriz(s)ation, teaching, learning, coaching, infection prevention, urinary tract infection, neuropathic bladder, children, anxiety, pain, complications, disinfection. For the update of 2024, we selected articles between 2014-2023 This information was used to formulate a draft guideline, which was then reviewed and amended by practitioners from a wide range of European countries. Grading and level of evidence The evidence used to support these guidelines has been graded according to the type and quality of the evidence, as indicated in Tables 1 and 2. This grading system is utilised throughout the document. Table 1 Level of Evidence Level of evidence Type of evidence 1a Evidence obtained from meta-analysis of randomised trials. 1b Evidence obtained from at least one randomised trial. 2a Evidence obtained from one well-designed controlled study without randomisation. 2b Evidence obtained from at least one other type of well-designed quasiexperimental study. 3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports. 4 Evidence obtained from expert committee reports or opinions or from the clinical experience of respected authorities. Table 2 Grade of Recommendation Grade of recommendation Type of evidence Nature of recommendation A Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial. B Based on well-conducted clinical studies, but without randomised clinical trials. C Made despite the absence of directly applicable clinical studies of good quality. Terminology 1,2 Aseptic technique This technique is performed with a sterile catheter, sterile gloves, and sterile lubricant (if the catheter is not pre-lubricated). The genitals are cleansed.
7 Bacteriuria Asymptomatic bacteriuria is a UTI without symptoms. Bladder neck stenosis A bladder neck stenosis is defined as an abnormal narrowing of the bladder neck. Dilatation The term dilatation refers to the condition of an anatomical structure being stretched beyond its standard dimensions. Catheterisation techniques Catheterisation techniques are the various ways used to perform catheterisation. Clean technique This is catheterisation with good hand hygiene, where a sterile catheter is used alongside genital cleansing. Note: The abbreviations CIC and CISC are often used interchangeably. CIC is the abbreviation for clean intermittent catheterisation. It is recommended that this term is used when carers carry out catheterisation. CISC is the abbreviation for clean intermittent self-catheterisation and is used when the child performs the catheterisation. No-touch technique Performed with a ready-to-use catheter without touching it. Post-void residual (PVR) Post-void residual is defined as the volume of urine left in the bladder at the end of micturition. Sterile technique It is an entirely sterile technique that is only used in operating theatres. This technique implies that all the materials are sterile. The person who carries out the catheterisation wears sterile clothes, including sterile gloves. It is often confused with the aseptic technique. Urethral intermittent catheterisation Urethral intermittent catheterisation (IC) is defined as drainage or aspiration of the bladder or a urinary reservoir with subsequent removal of the catheter. Urethral stricture/stenosis A urethral stricture or stenosis is a narrowing in the urethra. Urinary retention Acute urine retention is a painful, palpable, or percussive bladder where the patient is unable to pass urine. Chronic urine retention is defined as a non-painful bladder which remains palpable or percussive after the patient has passed urine. Such patients may be incontinent. Urine Incontinence (UI) Urinary incontinence is the involuntary leakage of urine, which can be continuous or intermittent. Subdivisions of incontinence include continuous, intermittent, daytime, and enuresis. Urinary tract infection (UTI) It is defined as a combination of clinical age-related features along with the presence of bacteria in a reliable urine culture. Generally, a UTI is caused by a single organism that is present in a concentration of more than 105 colony-forming units per millilitre (CFU/ml). This level has not yet been formally validated for use in children.
8 The following cut-off values are used: Urine collected via midstream or clean catch after cleansing the genitals with water: > 105 CFU/ml Urine collection via single-use catheter: > 104 CFU/ml Urine collection via ultrasound-guided suprapubic bladder puncture: > 103 CFU/ml Recurrent UTI A recurrent UTI is defined as: Two or more episodes of UTIs with fever and/or obvious flank pain or One episode of UTI with fever and/or obvious flank pain plus one or more episodes of UTI without a fever, or three or more episodes of UTI without a fever. Summary of Abbreviations ASD Autism Spectrum Disorders CIC Clean Intermittent Catheterization CISC Clean Intermittent Self Catheterization Ch Charrière CFU Colony Forming Units ESPU-N European Society for Paedatric Urology IC Intermittent Catheterization ICCS International Children’s Continence Society ITP Individual Transition Plan LE Level of Evidence MEC Male External Catheter PVC Poly Vinyl chloride PVR Post Void Residual UI Urine Incontinence UTI Urinary Tract Infection VR Virtual Reality QoL Quality of Life
9 Chapter 2 Indications for Catheterisation The technique of clean intermittent catheterisation was introduced by Lapides et al. in 1972 3 for patients with different diagnoses of bladder emptying disorders. Several years later, Hannigan et al.4,5 adapted the clean technique and described how to teach IC to children. Intermittent catheterisation is applied in the case of persistent, recurring residual urine and/or an inability to empty the bladder. This may occur in the following disorders: Neurogenic bladder dysfunction.6 Combined with the administration of anticholinergic medication, CIC/CISC maintains a low-pressure bladder, which grows along with the child. CIC/CISC, combined if necessary with a maintenance dose of antibiotics, also reduces the risk of urinary tract infections and preserves renal function. 2,6,7 Bladder dysfunction is caused by an anatomical or functional disorder or urethral pathology. CIC/CISC prevents both recurrent obstruction and urinary tract infections.8 Operations to improve continence also carry a risk of temporary or permanent bladder emptying impairment for which CIC/CISC may be indicated. Complications and Management 2.1 Infections 2.1.1 Urinary tract infection (UTI) The most common complication of intermittent catheterisation is a catheter-related UTI.9 Asymptomatic UTI is seen in 42-76% of children who catheterise. The true incidence is difficult to determine, however, because of the variety between studies with regard to the different catheter techniques, the different types and sizes of catheters, and levels of hygiene. In specific cases (vesicoureteral reflux, congenital disorders of the genital tract, and recurring UTIs), antibiotic prophylaxis may be given.10 However, antibiotic prophylaxis does not reduce the frequency of symptomatic UTIs in children with neurogenic bladder dysfunction relative to those not receiving prophylaxis.11 In adults performing intermittent catheterisation there are a number of identified factors that can increase the risk of UTI (see Table 3). There is no equivalent data in children; however, it is pertinent to expect it may be very similar, if not the same, in children. Table 3 (Guideline EAU) Risk factor for UTI Level of Evidence (LE) Low frequency of IC 2b Bladder over distension 1b Female 1b Poor fluid intake 3 Non-hydrophilic coating 1b Poor technique 3 Poor instruction 2b …Recommendations LE GR In CIC/CISC, only symptomatic UTIs should be treated 4 C Antibiotic prophylaxis in case of reflux, congenital disorders of the urogenital tract, and recurring UTIs 1b A
10 2.1.2 Urethritis In the past, research has demonstrated that inflammation of the urethra occurs in 1-18% of patients who catheterise. However, catheter techniques and catheter materials have improved greatly since then. These research findings are, therefore, no longer valid, and new studies on children have not yet been conducted. 2.1.3 Epididymitis Epididymitis is not commonly seen but can occur in cases of poor compliance. It can be the result of an infection of the urethra and UTI with reflux of infected urine in the genital tract. Treatment with antibiotics for at least two weeks is indicated. In adults, the short-term incidence is 3-12%, and the long-term incidence is more than 40%.12 However, the incidence in children is not known. 2.2 Trauma 2.2.1 False passage A false passage is the formation of a false route, often in the region of the bladder neck or the prostate, which prevents the catheter from being inserted into the bladder. Treatment consists of leaving an indwelling catheter in situ for several weeks and administering antibiotics if necessary. Following this, intermittent catheterisation can be continued once more. If this is unsuccessful, a surgical investigation may be required. Adequate training of health professionals can help reduce the formation of false passages by up to 78%.13 For persistent catheterization problems due to false passages, construction of a catheterise stoma may be needed in selected cases. … Recommendation LE GR A false passage should be treated by placement of an indwelling catheter and with antibiotics if necessary 4 C Healthcare professionals should be well-trained (according to protocol, and competent means qualified) as well in performing catheterisation, as in passing on the responsibility of catheterisation to the healthcare user, as in recognising complications 4 B Children and healthcare users learning CIC/CISC should be adequately instructed according to these guidelines 4 B 2.2.2 Urethral stricture A urethral stricture as a complication of catheterisation is uncommon (5%) and seen only in men. The risk can be reduced by using hydrophilic catheters. 14 2.2.3 Urethral bleeding Urethral bleeding is seen more in boys than in girls. Persistent bleeding can be an indication of a UTI. 2.3 Other 2.3.1 Bladder stones The risk of developing bladder stones is known to be higher in patients who are long-term users of catheters via a Mitrofanoff stoma, those who have undergone ileocystoplasty, or those who do not completely empty their bladder when catheterising. Catheterisation via a stoma is not included in these guidelines. However, it is recognised that there is a risk of developing bladder stones in patients who have undergone ileocystoplasty and who catheterise via the urethra. 15,16 This is due to the mucous produced by the patch of bowel inserted into the bladder. It is important, therefore, that mucous is regularly removed to minimise the risk of stone formation. Wash out the bladder with a saline solution, which can be either readymade or cooled boiled water with salt added. If mucous is particularly problematic, acetylcysteine or chondroitin sulfate installations may be used to help break down the
11 mucous. Acetylcysteine is also available in an oral tablet formulation. Catheters with wider openings or additional eyes (for example, four eyes rather than the usual two) are also practical recommendations to effectively drain urine and mucous. For patients with ileocystoplasty, using size 14 Ch catheters or larger is generally effective in evacuating all the mucus. For patients with residual urine after catheterisation, siphoning of the bladder twice a day with a longer tube into a lower-positioned receptacle prevents stone formation. … Recommendations LE GR In case of mucus the bladder can be washed out with a saline solution or acetylcysteine, or chondroitin sulphate can be instilled. Catheters with wider openings can also be used 4 C
12 Chapter 3 Materials Catheters Catheters for intermittent catheterisation are available in various diameter sizes (Charrières) and lengths. They can have a variety of lubrication and/or coatings. There are also a variety of shaped tips that may come with or without integral drainage bags. Catheters can be specially designed for men, women, or children. For intermittent use, single-use catheters and reusable catheters are available. Types of catheters may vary from country to country depending on local practice, availability and economics. Single-use catheters are often made of polyvinyl chloride (PVC) and are packed in sterile and single packs.17 They are usually discarded after use. There is an increasing demand for PVC-free materials in medical devices. The phthalate components in PVC can be harmful to the human body (REACH/EU chemical regulation). More and more phthalate-free alternatives are available (the information can be found on suppliers’ websites). Intermittent catheters have no balloons and are generally somewhat stiffer than indwelling catheters. When choosing which catheter to use, the following factors should be considered: medical safety, preference of patient/healthcare professional, physical disabilities and/or cognitive limitations, ease of use, and possible need for urine collection. In children, the length and Charrière size will depend partly on the child’s age. Still, more importantly, the catheter should be long enough and large enough to provide easy, quick, and complete bladder-emptying without damaging the urethra.18 Effective intermittent catheterisation is the result of compliance with both technique and frequency. It is, therefore, important that the patient is guided in selecting the best product. Sometimes, it may be necessary to try a few different catheter types and systems. 19 3.1 Types of Catheters Some single-use catheters require the addition of sterile lubricant. These lubricants are available with or without a local anaesthetic (lignocaine/lidocaine) and with or without chlorhexidine (antiseptic). These catheters may be reused in certain circumstances, but this should only be in agreement with the child’s clinician. Only catheters without a coating should be used in this instance, as coatings may cause catheters to stick as they dry out and cause trauma. There are also single-use catheters that contain gel either contained around the catheter or in a separate pack, which requires activation to provide lubrication. In addition, there are catheters with a hydrophilic coating (liquid) within the catheter or in a package, which again requires activation or filling with tap water. ‘Compact’ catheters are so-called because the packaging is small and discreet. Some types of catheters mentioned above are also available as catheter sets, consisting of a catheter with an integrated drainage bag. These sets can be useful for wheelchair users or if the toilet facilities are limited or unhygienic. They are designed for a ‘no-touch’ technique. Opening these catheter systems requires a certain level of hand function and manual dexterity, and they are also more expensive. They are a valuable additional aid but should be used only if indicated. Finally, there are catheters with Luer Lock connectors that allow the administration of medication. Some female patients prefer to catheterise with a non-disposable metal catheter that can be used for years with daily cleaning.
13 3.2 Drainage holes (eyes) The drainage holes (eyes) are positioned about 1 to 2 cm beneath the catheter tip. They allow the drainage of urine. It is, therefore, important that the catheter is placed far enough into the bladder (when urine starts to flow, the catheter should be advanced at least 1 cm further). There are usually two drainage eyes, which are polished to avoid sharp edges. The size of the eyes increases with Charrière size. Catheters with additional eyes (3 to 4) and extra-large eyes, which may be recommended to assist with mucous drainage (e.g., in an augmented bladder), are available from Ch 8. There is also a catheter with micro-hole Technology, which means that the catheter has a lot of micro-eyes. The urine stream comes out in a continuous stream (Luja, Coloplast.) 3.3 Charrière The external diameter (size) of catheters is measured in millimetres and is known as the Charrière scale. 1 Ch corresponds to 0.33 mm. Generally, most types of catheters are available in sizes from 6 to 20 Ch for intermittent catheterisation (Table 4). The size is commonly represented by the international colour coding of the connector at the end of the catheter, and the Charrière is stated on the package. Additionally, for small or premature babies/neonates or difficulties with inserting size six catheters, there are non-coated smaller catheters available: a size four male length (Vygon) and a size five pediatric length (Wycath). The use of feeding tubes is not recommended due to the incidence of knotting in the bladder20 Recommended size by age can be seen in Table 5. Table 4 Catheter connector colour chart Catheter size 6 8 10 12 14 16 18 20 Colour Diameter 2 2.7 3.3 4 4.7 5.3 6 6.7 Table 5 General overview of recommended Charrière per age category Age Charrière 0-1 years Ch 6-8 1-8 years Ch 8-10 8-12 years Ch 10-12 12 years and older Ch 12-14 As the urethra is able to tolerate large sizes of catheter, e.g., a 3-year-old boy can tolerate a size 12 catheter, clinicians may recommend larger sizes than those in the table above in order to promote more effective emptying, reduce time to empty, and minimise infection risks. 3.4 Length A catheter with a length of 20 cm is normally suitable for most boys up to 6 years old. In Charrière sizes 8, 10, and 12, there are catheters available with an ‘in-between’ length of 30 cm (e.g., Wellspect, Coloplast, Teleflex). When boys become older, they can move on to the ‘adult’ length of 40 cm. There is a male compact version available for teenage boys who graduated from a size 12 to 18 within the same catheter. These catheters should only be used in consultation with health professionals.22 For girls, catheter lengths from 7 to 20 cm are available. These lengths can basically be used by children of all ages, with the shortest sizes intended especially for catheterisation when sitting on the toilet. The short catheters are packed in a way that ensures they are easy and discreet to carry. 3.5 Tip design
14 There are a variety of catheters available with different tips. Nelaton This is the standard tip. The catheter is straight and has a rounded tip. Tiemann The tip is slightly curved. This catheter is sometimes recommended in case of an obstruction near the prostate, after specific surgery (sling), or a high bladder neck. The curved tip should be inserted with the tip pointed upward. Pointed tip/olive tip). The pointed tip has a bendy part and ends in a ball. It can be recommended for obstruction or pain in the sphincter region. Flexible tip This catheter has a tip that is somewhat narrower than the rest of the catheter. It can be recommended for a narrow meatus or a stricture. 3.6 Catheters for non-touch technique There are currently an increasing number of systems available whereby the catheter can be inserted with the help of an applicator. This prevents the catheter from being touched. There is evidence that using the no-touch technique reduces the risk of UTIs especially in patients with an increased risk of UTIs. The literature, however, indicates that some patients have difficulty handling the applicators, packaging, and slippery surfaces of coated intermittent catheters. These factors should be considered when selecting the most appropriate catheters for each individual. 3.7 Catheterisation Aids There are a variety of aids and devices to enable easier insertion for children with limited dexterity or a physical disability. For example, there are mirrors for girls to obtain a good view of the urethral orifice. Some can be attached to the leg, and some can help to fix the legs in a position that keeps them apart, leaving both hands free to catheterise. It can be difficult, however, to direct the mirror correctly and sometimes for the child to manage the reversed image in a mirror. They are less compact and, therefore, not very convenient to carry. Some of these mirrors also come with a light as an accessory product but these can be relatively expensive and are not usually provided free of charge in the majority of countries. There are special grips or handles available to help hold the catheter. These may be useful if the abdomen is large, the arms are too short, or a firmer grip of the catheter is needed. There are also ‘clothing holders’ to help keep clothes out of the way. In addition to catheters and aids, educational support materials are available in many countries. These include dolls to practice catheterisation, animations, DVDs or apps, often designed by catheter firms. These items contain instructions to catheterise and discussions about children’s experiences with self-catheterisation, kits containing show-and-tell items for holding talks in school and card games, etc.23-25 When transurethral catheterisation is too complicated, the construction of a catheterised stoma in the umbilicus or lower abdomen may be recommended. 3.8 Continence containment products Some children suffer from leakage of urine and/or faces in between catheterisations and may require additional advice on appropriate containment products. There are disposable and washable products available depending on the volume of leakage. The types of products available will vary from country to country. For boys, drainage systems such as sheaths (male external catheter / MEC systems) may also be useful if they are available. It is important to consider the children’s lifestyle, cognitive abilities and independence when selecting the most appropriate aid or product for each individual case. To ensure children and families can make informed choices and get the best available products for their individual needs, it is important that healthcare professionals keep informed of existing and new developments and products that leave the market. They must also consider the financial implications
15 and discuss these with the child/family. Consideration of further the factors around containment products is outside the remit of this guideline. 3.9 Use of catheters in poor financial circumstances In many countries, the cost of long-term use of catheters can be an issue, as single-use catheters can be very expensive. Overall studies currently do not provide sufficient evidence to recommend or to contradict the use and reuse of non-coated catheters over single use/coated catheters.17
16 Chapter 4 Nursing interventions 4.1 Teaching self-catheterisation CIC/CISC is currently an important therapeutic procedure in paediatric urology and is carried out in all age groups. The aim of CIC/CISC is to enable adequate and safe bladder management, which is necessary for children to be healthy, have self-esteem, and promote independence as they grow up. 7,23 We know that CIC/CISC does not cause any major emotional or behavioural problems.24,27,35 CIC/CISC can give children freedom and self-respect, facilitating an independent life. The positive experiences of CIC/CISC reported by Lopes et al. 2011 may result from achieving continence and no longer requiring incontinence products. 25 However, learning and teaching CIC/CISC can be challenging. A specialist nurse is indispensable when teaching a child CIC/CISC. The nurse should be familiar with the emotional and psychological impact of CIC/CISC on children, adolescents, and adults and aware of the child’s level of development. The age at which a child can learn to self-catheterise depends on the cognitive level of both the child and the parents, which must be considered when teaching children and parents. It is important to take account of any resistance to the procedure, concerns of embarrassment and fear of possible pain. The child and family's existing knowledge of the anatomy of the urinary tract, the reason for CIC/CISC, and insight into the medical condition, along with other possible treatment options, is also important. 23 Nowadays, new virtual aids are being developed rapidly, such as virtual reality (VR) glasses or Qwiek-up (https://www.qwiek.eu). With a growing body of evidence supporting VR distraction, clinicians, notably nurses, will be able to leverage VR technology to reduce the high rates of pain and anxiety associated with medical procedures. 28 For VR glasses, literature is available for managing paediatric procedural pain and anxiety. But also comfort talk, which is done through structured attention and self-hypnotic relaxation, has proven beneficial during invasive medical procedures.29 Teaching CIC/CISC can take place individually or in a group.21,26 Taking a relaxed approach, giving them sufficient time, offering them privacy and respect for intimacy are needed to overcome embarrassment and anxiety and make it easier to exchange and acquire information. 26,27,29 The ideal place for teaching CIC/CISC is usually the home setting as it is familiar territory, and the patient feels safer there.26 However, in daily practice, this is not always possible. It is also very important to motivate and compliment parents and children to boost self-confidence.27 Holland J et al. 2015 describe a pilot study evaluating the safety, feasibility, and usefulness of the SelfCathing Experience Journal (SC-EJ), an online resource for patients and families to address issues and stigma surrounding clean intermittent catheterisation.30 It is a psychoeducational tool designed to facilitate healthy coping and acceptance of the medical benefits of self-catheterization for patients and families who are recommended to initiate CIC. (The SC-EJ can be viewed at http:// www.experiencejournal.com/journals/self-cathing) It is essential, when teaching catheterisation, that the healthcare professional is knowledgeable about the types of catheters available and can give advice and information regarding the most suitable options for the child and family depending on their underlying medical problem, individual circumstances and surgical procedures, which the child may have undergone.26 These factors may dictate specific types or lengths of catheters which may be needed. Other factors such as frequency of catheterisation, hygiene issues, predisposition to UTIs, medication, physical problems such as dexterity, access due to wheelchairs, and additional need for continence aids may also influence the choice of catheter and teaching of CIC/CISC.
17 The catheterisation technique should be discussed and practised with the child and family.6 A step-bystep teaching plan for teaching parents and children is advised; examples of these can be seen in Appendices A to C, for healthcare professionals undertaking catheterisation in the hospital, and similar procedure is shown in Appendices D and E. An instructional model or doll is a very useful aid for explaining things to children and parents. It improves accuracy and reduces anxiety because it means the child can practice non-invasively and make errors without experiencing pain.24 Because children associate dolls with play, participation is encouraged. 24, 34 The child can gain self-confidence through role-play, playing the role of the nurse with the doll being the patient. Baby models may also be available for parents to learn about catheterisation. For adolescents, sharing their experiences of catheterisation without their parents being present is also a good way of encouraging participation and promoting long-term compliance. 41 Bauer et al. performed a qualitative study (Aug. 2018 - Oct 2019) in 40 families/ 52 individuals via a semi-structured interview guide with five major themes and several subthemes. 31 The following recommendations are being promoted: (1) Employ behavioural health providers (psychologists, social workers) who can conduct assessments and support the healthcare team in tailoring CIC teaching to a patient's or family's personality, learning styles, developmental needs, and other cultural or environmental factors that impact the implementation of CIC in each family. (2) Ensure a healthcare team's differential approach to each family's learning requirements by tailoring interventions accordingly. (3) Consider the inclusion of peer mentors, for example, Teen Empowerment Camps, where patients and parents can talk with each other to aid in adaptation and as another source of emotional support. (4) Offer as much information as is currently available and dialogue as early as possible when CIC might be needed to allow families to process and prepare for CIC. (5) Initiate CIC as early as clinically indicated. (6) Encourage multiple primary and/or secondary caregiver participation during CIC teaching and subsequent management. (7) Support caregivers as they navigate issues related to employment, insurance coverage, financial burden, and daycare. (8) Devise quantitative studies to assess how effective the implementation is between the healthcare team, the primary care physician, and the family based on what has been learned from this qualitative study and the aforementioned recommendations proposed when introducing and initiating IC. Another article by Bauer et al. 2023 on the same study population studied the impact of CIC on students and families in the school environment. 32 A phenomenological approach utilising semi-structured interviews was performed to understand the impact of CIC on students. This study identifies potential areas of intervention in meeting the needs of students who require CIC and the importance of collaborative efforts by caregivers, healthcare providers, and school personnel to address and meet CIC needs. Care coordination that involves consistent communication and careful planning between healthcare teams, school personnel, students, and caregivers can optimise a student's educational experience. 4.2 Frequency of catheterisation 6 The frequency of catheterisation depends on the indication for catheterisation and on factors such as the volumes obtained during catheterisation and the fluid intake. It should take place with a frequency that is sufficient to prevent UTIs and overfilling of the bladder while being socially acceptable. Everyone will make a decision together with the urologist, paediatric urologist or nurse practitioner. In adolescents (with an adult bladder capacity), a general rule is that the bladder capacity should not exceed 500 mL,
18 and catheterisation should take place on average 4 to 6 times a day if this is the only or recommended method of voiding. If spontaneous voiding is still possible, catheterisation is usually 1 to 3 times a day. 4.3 Complications/difficulties associated with catheterisation Problems sometimes occur during learning and adherence to catheterisation or self-catheterisation. Despite this, it appears that most children tolerate catheterisation with few complications. Even in children who are sensitive, it appears that they (or their caregivers) are also able to learn the technique rapidly and with good long-term results.36 Success of catheterisation, however, can be affected by numerous factors, including: Difficulties with insertion and/or removal of the catheter Pain/discomfort Constipation/faecal incontinence Cognitive ability Physical difficulties Psychological and emotional Practical/social considerations Such problems can lead to an inability or complete refusal to perform catheterisation or difficulty with long-term compliance. Below are a number of practical problems and solutions that may have an impact on successful catheterisation. 4.3.1 Problems with insertion Difficult insertion In children, particularly those with neurogenic bladder dysfunction, it is sometimes difficult or impossible to get a catheter past the sphincter, especially if they are unable to relax the sphincter muscle due to sphincter dyssynergia. It can help to ask the child to take a deep breath or to change position (sitting, standing, lying). It can sometimes help to hold the catheter against the sphincter using light pressure and to wait a little while. Often, the sphincter will relax after a while. If the problem only occurs when the bladder is full, it can be helpful to catheterise a bit earlier or more regularly. A change of catheter to one with a different tip can also help ease insertion, and if there is difficulty opening the packaging or if the catheter is too slippery, preventing a good grip, a change of catheter type may also be beneficial. 19 … Recommendation LE GR When there are problems inserting a catheter, discuss and practise alternative options (deep breaths, changing position, applying light pressure to the sphincter, catheterising earlier, another catheter or other tip 4 C 4.3.2 Pain/discomfort Pain may be felt during insertion and removal of the catheter. This can be the result of bladder spasms or a urinary tract infection but can also be related to insufficient relaxation of the pelvic floor when inserting or removing the catheter. Different types of catheters may cause possible discomfort and stinging due to the type of coatings, lubrication, and stiffness, which may irritate some individuals. Vacuum suction caused by “tenting “of the bladder may also cause discomfort on withdrawal of the catheter, and a smaller Charrière, less deeply inserted catheter, may help to overcome this. Trying different types of catheters will help individual children to select the most comfortable one for them. Nowadays Coloplast, with the ‘luja’ catheter that has multiple small eyelets, claims that vacuum is no problem with this catheter. (see Appendix I). But look out in case of mucus!
19 Anxiety and a fear of pain (justified or not) can hamper the learning process. It is important to discuss fears and how they can be overcome. Additional psychological support may be used if available. 21 In children with non-neurological disorders who cannot relax their pelvic floor sufficiently when inserting and removing the catheter, teaching pelvic floor relaxation exercises may be helpful. Additional help from a paediatric pelvic floor physiotherapist, where one is available, may also be very useful. In children with both neurological and non-neurological disorders, additional pelvic floor physiotherapy aimed at relaxation can also be helpful in overcoming anxiety related to catheterisation.21 In the case of bladder spams, the urine must always be tested for the presence of an infection and treated with antibiotics where appropriate. If there is no infection or spasms, it is sometimes necessary to prescribe anticholinergics. … Recommendations LE GR For irritation caused by the catheter: if necessary, use additional lubrication and/or a catheter with a different coating, a different thickness, or different stiffness 4 C In case of vacuum suction, try using a catheter with a larger Charrière or placing the finger on the end of the catheter during removal 4 C For children with non-neurogenic disorders, it can be helpful to do pelvic floor relaxation exercises when inserting or removing the catheter. Additional paediatric pelvic floor physiotherapy can also be helpful 4 C In children with both neurological and non-neurological disorders, additional paediatric pelvic floor physiotherapy can be helpful 4 C In the case of bladder spasms: check the urine and if necessary, prescribe antibiotics; anticholinergics are sometimes needed 4 C 4.3.3 Constipation and faecal incontinence Constipation and faecal incontinence can affect the success of a self-catheterisation program. Severe constipation can put pressure on the urethra, making insertion and drainage more difficult. It is, therefore, important to pay attention to bowel function. Faecal incontinence can make it difficult to maintain good hygiene. Children may also find it difficult to adequately wipe away stool after a bowel movement, which can increase the risk of urinary tract infection. For these reasons and social reasons, it is important to address both bladder and bowel continence simultaneously wherever possible. Bowel management may consist of a high-fiber diet and adequate fluid intake, laxative therapy, and in some instances, rectal irrigation or ACE procedures can be considered. It should also be noted that a potential side effect of anticholinergic therapy (commonly used in children with neuropathic bladder) is constipation. … Recommendations LE GR Before starting catheterisation in a child, evaluate bowel function and where necessary apply additional interventions or consult a specialist 4 C Be aware that social continence can only be achieved if both bladder and bowel function are treated, and discuss this with the child and caregivers 4 C
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