CLINICAL

Intermittent self-catheterization:
principles and practice
John Robinson
John Robinson is District Charge Nurse, Continence Advisory Service, Morecambe Bay Primary Care Trust,
Morecambe Email: john.robinson@mbpct.nhs.uk

C lean intermittent self-catheterization, or inter-

mittent self-catheterization (ISC), is today
becoming more widely used for patients with
bladder problems to drain their bladder of urine. In many
cases, ISC is preferable to having a long-term indwelling
catheter with all its associated problems.
History of catheterization
Intermittent urinary catheterization dates back to antiq-
uity. The earliest catheters were made of plant materials –
reeds, stems and wood – but these were eventually replaced
by metal catheters in gold, silver or bronze. The basic tech-
nique of passing a tube up the urethra into the urinary
bladder, draining it of urine then removing the tube,
remains unchanged.
Box 1. Reasons for use of ISC
w Neurogenic or hypotonic bladder
w Detrusor instability
w Detrusor-sphincter dyssynergia
w Detrusor hyperreflexia
w Overflow incontinence caused by obstruction
w Urethral obstruction (prostate enlargement/urethral stricture)
w Surgical augmentation cystoplasty
w Failed trial without catheter
Sources: Winder, 2002c; Getliffe and Dolman, 2003; Naish, 2003; Robinson, 2005
Abstract
Intermittent self-catheterization (ISC) is becoming more widely used by
patients to drain their urinary bladder rather than having a long-term
indwelling urinary catheter. ISC can be undertaken by people of all ages
to empty their bladder of urine or by a nurse or doctor to measure residual
urine after the patient has passed urine. Those patients unable to undertake
the procedure themselves may have the procedure undertaken by a
parent, spouse, carer or nurse to drain their bladder of urine. Modern day
intermittent catheters can be used almost anywhere when drainage of the
urinary bladder is required.
key words
Intermittent catheters w Teaching w Hygiene w Training
In 1844 Charles Goodyear discovered a method of
forming and shaping latex by vulcanization, and a decade
later, Auguste Nélaton used this method to produce a flex-
ible rubber catheter. However, if it had to be kept in situ it
was either taped or sutured to the body.
Self-drainage of the bladder in this way continued until
the development of the indwelling self-retaining catheter
in the 1930s by Dr Frederick Foley, an American urologist
(Murphy, 1972; Bloom et al, 1994).
Over time indwelling catheterization overtook ISC in
popularity. Up until the 1970s, urologists seemed to be
against using ISC to drain the urinary bladder because of
the risk of bacterial infection developing. Research by Jack
Lapides (1914–1995) Professor of Urology in Michigan,
USA, showed that bacteria were not the only cause of
urinary tract infections, but that infections were also caused
by persistent stagnant residual urine along with high blad-
der pressures (Lapides et al, 1972). Lapides introduced and
taught clean ISC, firstly to patients suffering from multiple
sclerosis. These patients were monitored performing this
procedure and Lapides found that patients began to take
control of their own daily life. Three decades later, many
thousands of patients with various medical conditions and
problems emptying their bladder (Box 1 and 2) manage
their condition using ISC (Bloom, 2000; Getliffe and
Dolman, 2003; Woodward, 2003).
Clean ISC is now increasingly an accepted method pro-
moted by urologists and surgeons to enable patients to
completely empty their own bladder. In some cases, the
spouse, parent (in cases of children requiring ISC) or carer
may be taught how to undertake this procedure on the
patient’s behalf. (However, in this situation, ISC is per-
formed as an aseptic technique to minimize the transfer of
non-indiginous skin flora to the catheterised person and
avoiding the possibility of cross infection). Undertaking
ISC helps prevent the urinary bladder from becoming
over-distended or residual urine becoming stagnant.
Like any medical intervention, ISC has its advantages
and disadvantages (Box 3). However, the advantages of ISC
generally outweigh the disadvantages.
Types of intermittent catheters
Intermittent catheters are made by many companies, and
are available in paediatric, standard (male) and female
lengths, with varying Charrière (gauge) sizes ranging from

144 British Journal of Community Nursing Vol 11, No 4

© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 130.113.111.210 on January 19, 2018.
Use for licensed purposes only. No other uses without permission. All rights reserved.
CLINICAL

sterile water/saline in the hospital environment). The

Box 2. Some causes of incomplete emptying of the urinary bladder second is pre-hydrated and is ready for immediate use.
w Detrusor areflexia (or hypoflexia) w Nélaton re-usable.These are described in the Drug Tariff
as ‘ordinary cylindrical catheters’. Sterile lubrication
w Detrusor-sphincter dyssynergia
or anaesthetic gel must be added to the catheter surface
w Urinary obstruction e.g. prostate, urethral strictures
and urethra before insertion. Patients have to be taught
w Surgery, e.g. colosuspension how to introduce these gels into their own urethra and
w Spina bifida also cover the catheter surface prior to insertion. After
w Multiple sclerosis use, the catheter is washed through and stored until
w Diabetes mellitus required again. On average 5 catheters are issued for use
per month (Association for Continence Advice (ACA),
w Parkinson’s disease
2004).
w Cerebrovascular accident w Pre-lubricated for single use. This is a Nélaton catheter
w Congenital problems prepared in a sterile, pre-gelled package ready for use.
w Traumatic injury Once a catheter is inserted, the urine may be drained
w Medications into a toilet or jug or into a drainage bag attached to the
catheter. Some companies produce intermittent catheters
w Constipation
with a drainage bag attached.
w Urinary infections
w Aging Which catheter is best for ISC?
Sources: Barton, 2000; Getliffe and Dolman, 2003 The Medical Devices Agency (MDA) (now incorporated
into the Medicines and Healthcare Products Regulatory
Agency) conducted an evaluation of catheters for ISC in
8Ch–20Ch. Many are available on Drug Tariff. 2000 (MDA, 2000b). However, this only examined
The types of catheter suitable for ISC are: hydrophilic-coated catheters, and the UK literature on the
w Coated catheters for single use. These catheters have a clinical and cost effectiveness of all intermittent catheters
hydrophilic coating. There are two types of hydrophilic- remains sparse.
coated catheters.The first has to be rehydrated by adding A recent article by Pomfret and MacKenzie (2005),
water to the catheter packaging to activate the coating states:
and produce a smooth surface before insertion. (Domestic
‘There seems to be an ever-increasing range of
cold tap water can be used if in the home situation or
intermittent catheters available in the UK with
conflicting evidence in regard to the efficacy.’
Box 3. Advantages and disadvantages of ISC This article also raises several other related issues, sum-
Advantages marized in Box 4.
Patients take control of their care and being involved in clinical decisions While it is beyond the scope of the present article to
Improved quality of life
explore these issues in depth, it is of utmost importance
that studies and audits are undertaken to inform the choice
May help to regain continence
of appropriate catheter for this increasingly common pro-
Helps maintain bladder health cedure. However, in the meantime clinicians have to rely
Reduced risk associated with indwelling catheters on experience, guidance and published material by com-
No drainage bags panies or journals on intermittent catheters.
The upper urinary tract is protected from reflux
Positive body image is maintained
Patient suitability for ISC
Before considering ISC, a thorough nursing assessment
More freedom to express sexual expression needs to be undertaken to ascertain if the patient is suitable
Patient satisfaction for and capable of undertaking the procedure. Age is not a
Disadvantages barrier: the youngest patient the author has taught ISC was
Must have physical and mental dexterity to perform ISC: if not, must have 6 years old, the oldest 102. Practical necessities include
someone to do it on the patient’s behalf patient dexterity, cognitive ability and good eyesight, how-
Must have somewhere to prepare and undertake ISC ever, a blind person can be taught to undertake ISC.
In some cases emotional and psychological aspects, such
Must have water available
as embarrassment (of the genitalia being exposed), fear and
Need to carry catheters poor self-image can become a barrier (McConville, 2002).
Occasional infection/urethritis/urethral bleeding Education and counselling may help overcome such fears.
Occasional urethral false passage formation The MDA (2000) catheter evaluation provided a useful list
Sources: Doherty, 1998, 2000; Getliffe and Dolman, 2003 of questions to be considered regarding a patient using a
medical device, e.g. a catheter (Box 5).

146 British Journal of Community Nursing Vol 11, No 4

© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 130.113.111.210 on January 19, 2018.
Use for licensed purposes only. No other uses without permission. All rights reserved.
CLINICAL
Box 4. Issues concerning intermittent catheters raised by Pomfret and
MacKenzie (2005)
Some companies claim hydrophilic catheters are best suited for ISC. Therefore
are non-hydrophilic catheters inferior?
If so, should gel-coated and non-hydrophilic catheters be removed?
If gel-coated catheters are acceptable, why are more expensive hydrophilic-
coated catheters prescribed by health professionals?
Considerable work (research/audit) needs to be done as to which catheters
are warranted for single-use and which of these therefore, is the most cost/
care/user effective
ISC is not recommended if the residual urine after void-
ing is less than 50ml. In such cases, regular repeated bladder
scans may then identify if residual urine volume is increas-
ing and the possibility of using ISC reassessed. Patients
who may be incontinent or wetting with urine between
catheterizations may have to perform ISC more frequently.
Patients with detrusor instability may require anticholiner-
gic medication to help increase bladder capacity, as well as
ISC. Each patient has to be assessed individually to decide
how often ISC has to be undertaken and frequencies are
identified in Table 1.
Patient history and assessment
Taking the history from the patient, GP or consultant is
important before teaching and training the patient to
undertake ISC. The history obtained will identify the
patient’s bladder voiding history, any urological interven-
tion which has taken place and existing medical condition,
e.g. multiple sclerosis. Undertaking a daily fluid intake and
urinary voiding assessment, including the time and amount
of urine voided, is required and, if possible, night-time
voidings. Included in the assessment, a post-voiding resid-
ual urine measurement is undertaken. This can be under-
taken two ways:
Box 5. Medical Devices Agency’s suggested factors for consideration
regarding patients’ use of medical devices
What are the patient’s clinical and social needs?
Which medical device best suits the patient needs?
Are the risks associated with this device acceptable and be minimized?
The patient’s physical capabilities, e.g. manual dexterity in using the device?
The patient’s sensory capabilities, e.g. hearing and eyesight?
The patient’s ability to remember and understand how to use the device?
What is the patient’s previous experience with the medical device?
What are the patient’s expectations?
Is the environment in which the device will be used suitable, e.g. home or
work etc?
Level of responsibility in obtaining, storing and disposal of used catheters?
Does the manufacturer provide informal educational material for the patient?
Is the product available on prescription?
Source: MDA, 2000a
148
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 130.113.111.210 on January 19, 2018.
Use for licensed purposes only. No other uses without permission. All rights reserved.
1. Bladder ultrasound (bladder scan). Bladder ultrasound is
a simple-to-use and portable tool. However, the person
using it must be trained how to use this diagnostic tool
(Addison, 2000). Bladder ultrasound is undertaken
immediately after the patient has voided urine.
2. Urethral catheterization. If the practitioner is not trained
to use a bladder scanner or one is not available, bladder
residual measurement must be undertaken by catheteri-
zation using an intermittent catheter. One of the benefits
here is that it gives the patient the first insight into the
procedure and how it will feel. It must be undertaken
after the patient has voided urine.
By adding the patient’s pre-assessment voided volume to
the residual volume, the pre-voiding bladder volume can
be calculated. Patients suitable for ISC teaching and train-
ing will fulfil both the following criteria (ACA, 2004;
Winder, 2002a,b):
· The patient’s pre-voiding bladder volume is less than
500ml
· The patient’s residual urine exceeds 250ml and often
leads to recurring urinary infection.
Introducing ISC to the patient
Discussion should take place with the patient on the full
range of issues regarding ISC:
w What it is
w Why it is being undertaken
w What it involves, particularly with regard to hygiene and
preparing the catheter for insertion
w How often it is to be undertaken
w Types of ISC catheter available
w Storage of equipment
w Disposal of used catheters.
Introducing and teaching patients to perform ISC
should not be undertaken lightly, and patients need to be
provided with detailed and accessible information to sup-
port them in what for many will be a challenging new
experience, which some patients may have to undertake
for many years.
Catheter manufacturers produce good patient informa-
tion materials. At the very least, patients should be issued
with an information booklet about undertaking ISC. If
possible a video or DVD of the procedure being under-
taken should also be provided (several catheter companies
distribute these), which should be viewed together with
the patient.The information booklet will provide diagrams
of either the male or female anatomy as appropriate, which
is beneficial to patients with no prior knowledge of this
area, and instructions on how to undertake the procedure.
Patients should be encouraged to ask questions on the
procedure and be given clear understandable answers.
Hygiene
In teaching ISC to the patient, close attention should be
paid to the patient’s personal hygiene – particularly hand
washing, cleansing of the genitalia and preparation of the
catheter for insertion. In supervising and observing the
patient undertaking ISC, these issues should be repeatedly
British Journal of Community Nursing Vol 11, No 4
CLINICAL
Table 1. How often to undertake ISC
Unable to void 4–5 times per day to help maintain bladder
residual at approximately 500ml
Residual urine >500ml Three times per day
Residual urine 300–500ml Twice per day
Residual urine 150–300ml Once per day
Residual urine <150ml Possible on a daily basis on alternate days
Residual urine <150ml on Stop and reassess urinary residuals levels
three consecutive occasions
Source: Naish, 2003
reminded to the patient; cutting corners could result in
development of a urinary infection and trauma which
could encourage urethral strictures (Doherty, 1999). Carers
being taught to perform ISC on the person they care for
must follow an aseptic procedure, i.e. using sterile gloves to
avoid cross-infection.
Patients should keep their training booklet nearby, for
step-by-step guidance, until they are fully confident and
competent in undertaking ISC. The nurse undertaking
the training should also issue a telephone number for the
patient to contact should any problems that arise.
Teaching patients to perform ISC
The nurse responsible for teaching a patient ISC must be
fully trained and competent and be aware of local policies
and protocols regarding this procedure. Authorization must
be obtained from the patient’s GP or consultant before
teaching ISC (Doherty, 1999).
The author, where possible, prefers teaching and train-
ing patients ISC in their own home, as they tend to be
more relaxed than within in a clinical environment. The
author has undertaken the procedure on himself in
order to better understand how it feels from the patient’s
point of view. In the initial teaching and training stages
some patients may require more education and support
than others. The teaching and training process should be
done at the patient’s own learning pace and not rushed.
Some sections may have to be repeated to enable
the patient can gain the necessary self-confidence in
undertaking ISC.
The author, where possible, issues three different cathe-
ters for the patient to try to find their preferred choice.
Experience has shown that one type of intermittent cath-
eter may not be suitable for all the patient’s needs or cir-
cumstances; for example, some patients may require two
types of intermittent catheter, one for home use and
another for work.
In order to inform the discussion regarding the best type of catheter to use for
ISC, the author would like to hear the views and experiences of continence
advisors and district nurses.
If you would like to share your and your patients’ experiences or preferences,
please email the author at john.robinson@mbpct.nhs.uk
150
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 130.113.111.210 on January 19, 2018.
Use for licensed purposes only. No other uses without permission. All rights reserved.
Undertaking ISC
In the early stages of undertaking ISC, patients should keep
a diary of daily fluid intake and output (urine volumes
drained) to assess if ISC is appropriate. If possible, patients
should try to pass urine before inserting a catheter.
Women undertaking ISC can try different positions
when inserting the catheter to find which is best suited to
them. In males the procedure is easier. However, men with
a retracting penis must gently grasp the shaft of penis just
behind the glans area and gently pull forward during inser-
tion. If not the catheter may push the retracting penis
further back, which can cause discomfort and difficulty
inserting the catheter safely into the bladder. Patients in the
initial stages in undertaking ISC may find it a little uncom-
fortable, but this is usually caused by muscle tightness
resulting from anxiety (Barton, 2000; Simpson, 2002), and
with time, practice and patient confidence, the procedure
becomes quite routine.
Monitoring the patient for infection is important. A
urine sample is sent for culture/sensitivity testing 2 weeks
after starting ISC, again at 3 months and then every
6 months. If the patient feels they may have a urine infec-
tion, they are instructed to send a sample as required. By
periodically checking the patient undertaking ISC, nurses
and continence advisors will check the procedure is being
undertaken correctly and the patient not developing bad
habits or cutting corners.
In time, whether as a result of deteriorating health,
mobility or dexterity, many patients may no longer be
able to undertake ISC themselves. To avoid having an
indwelling catheter inserted, it is worth considering in
such cases whether the spouse or carer could undertake
the procedure.
When to stop ISC
There is no definite time limit on how long patients can
perform ISC. Some patients may have to do it for the rest
of their lives, others may only have to undertake ISC until
normal bladder function returns, or they become conti-
nent with limited or no residual urine post-voiding.
ISC may have to be stopped due to poor patient com-
pliance. This can arise if the patient does not accept the
necessary changes to their lifestyle or finds ISC difficult to
undertake, although ideally, these issues should have been
recognized at the initial assessment and teaching stage.
If a patient is having difficulties, he or she must not feel
pressurised into undertaking ISC. Nurses should allow the
situation to calm down for a few days, then re-contact the
patient to see if their thoughts and ideas have changed.
Clinical reasons to stop ISC are urethral or bladder neck
obstruction, urethral spasm and bleeding which may cause
concern (Addison, 2001; Winder, 2002c). The author has
not encountered any such problems, but they may occur.
Conclusion
ISC should be taught, where clinically appropriate, to more
patients than it currently is, in order to avoid the com-
plications of a long-term indwelling catheter. Even if the
British Journal of Community Nursing Vol 11, No 4
CLINICAL
patient cannot perform ISC themselves, provided a carer
is willing to undertake it and the patient agrees, intermit-
tent catheterization is still an option, and preferable to an
indwelling catheter. BJCN
Association for Continence Advice (2004) Notes On Good Practice 7: Intermittent
Catheterisation. ACA, London
Addison R (2000) Bladder ultrasound. Nurs Times 96(39): 49–50
Addison R (2001) Clinical assessment for intermittent catheterisation. AstraTech
Ltd, Glasgow
Barton R (2000) Intermittent self-catheterisation. Nurs Stand 15(9): 47–52
Bloom D, McGuire E, Lapides J (1994) A brief history of urethral catheterisa-
tion. J Urol 151(2): 317–25
Bloom D (2000) Catheterization: a steadfast treatment for urinary disorders.
www.hisandherhealth.com/aua2002/6.html (Accessed 16 January 2006)
Doherty W (1998) The Aquacath hydrophilic coated single-use urinary catheter.
Br J Nurs 7(21): 1332–6
Doherty W (1999) Indications for and principles of intermittent self-catheteri-
sation. Br J Nurs 8(2): 73–84
Doherty W (2000) Intermittent catheterisation: draining the bladder. Nurs Times
96(31 suppl): 13
Getliffe K, Dolman M (2003) Catheters and catheterisation. In: Getliffe K,
Dolman M (2003) Promoting Continence a Clinical and Research Resouce.
(2nd edn) Bailliere Tindall, London: 259–301
Lapides J, Diokno A, Silber S, Lowe B (1972) Clean intermittent self-catheteri-
zation in the treatment of urinary tract disease. J Urol 107(3): 458–61
McConville A (2002) Patients experiences of clean intermittent catheterisation.
Nurs Times 98(4): 55–6
Medical Devices Agency (2000a) Equipped to care. The safe use of medical devices in
the 21st century. MDA, London
Medical Devices Agency (2000b) Hydrophilic coated catheters for intermittent self-
catheterisation. MDA, London
Murphy L (1972) The History of Urology. Charles C. Thomas Publishing,
152
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 130.113.111.210 on January 19, 2018.
Use for licensed purposes only. No other uses without permission. All rights reserved.
KEY POINTS
w Intermittent self-catheterization is increasingly
favoured over indwelling catheterization for urinary
bladder drainage in the community.
w Teaching and training regarding ISC must only be
undertaken with the approval of the patient’s GP or
consultant.
w Patients suitable for ISC must have sufficient manual
dexterity, cognitive ability and good eyesight.
w Good hygiene is essential to reduce the risk of
infection.
w A carer may be able to undertake intermittent
catheterization for a patient who is unable to do it
himself or herself.
Springfield, Illinois, USA
Naish W (2003) Intermittent self-catheterisation for managing urinary prob-
lems. Prof Nurse 18(10): 585–7
Pomfret I, MacKenzie R (2005) Questioning practice – the need for research in
continence care. Journal of Community Nursing 19(11): 32–6
Robinson J (2005) Removing indwelling catheters:Trial without catheter in the
community. Br J Community Nurs 10(12): 553–7
Simpson L (2002) Intermittent self-catheterization. Nurs Stand 16(29)
Winder A (2002a) Intermittent self-catheterisation. Nurs Times 98(48): 50
Winder A (2002b) Teaching ISC technique. Nurs Times 98(48): 51
Winder A (2002c) Intermittent self-catheterization. Urology News 6(3): 16–7
Woodward S, Rew M (2003) Patients’ quality of life and intermittent self-cath-
eterisation. Br J Nurs 12(18): 1066–74
British Journal of Community Nursing Vol 11, No 4