The bladder is roughly spherical in shape and its wall is made of thin muscle. It acts to store urine and, when it is full, the muscle in the bladder wall contracts, propelling the urine through the urethra. As the bladder is filling, a ring of muscle called the urethral sphincter contracts to prevent urine leakage. The bladder gradually fills, storing urine at low pressure and, when it reaches capacity, we become aware of the need to pass urine. When we urinate (pee), contraction of the bladder muscle is co-ordinated with relaxation of the urethral sphincter.
In patients with CES, the awareness or sensation of bladder fullness is absent or decreased, the bladder wall does not contract and urine stays in the bladder (retention). This is called bladder hypocontractility. Patients with bladder hypocontractility may take a long time to pass urine, pass small volumes frequently and are unable to empty the bladder completely. They are at an increased risk of urine infection and kidney damage.
To empty your bladder, you may have been taught to use abdominal straining (leaning forward and squeezing the stomach muscles to force out the urine) or to apply manual pressure to the lower abdomen (Crèdes manoeuvre). Because the bladder might not be emptied completely using these techniques, modern practice is to use catheter drainage.
Patients with bladder hypocontractility generally learn a technique called clean intermittent self-catheterisation (CISC), which will enable them to empty their bladder completely. If they are unable to perform CISC, a permanent indwelling catheter can be used to drain the bladder into a bag. Many of these patients use a valve (like an 'on/off' tap) on the end of their permanent catheter and drain the urine from their bladder at fixed intervals rather than continuous drainage into a urine bag ask your doctor or nurse about this.
Clean Intermittent Self-Catheterisation (CISC)
CISC was introduced in 1972 and has been shown to be a safe and effective method of emptying the hypocontractile bladder. Commencing CISC is a significant intrusion on a patient's daily routine, but it helps to reduce the risk of urinary tract infections and kidney damage, both of which are associated with a hypocontractile bladder in CES patients. A dedicated nurse or continence advisor who will teach CISC and provide follow-up and assessment of technique is crucial when commencing CISC.
Patients quickly get used to passing catheters, although this depends on many factors such as their attitude and manual dexterity. Catheter sizes vary in length (according to sex) and diameter (sizes 10-14 are most commonly used). Catheters suitable for children are also available. Smaller-sized catheters will drain urine more slowly and most patients therefore prefer a larger diameter. Catheters may be reusable or single-use.
Reusable catheters are rinsed under a tap before use and coated with a water-based lubricant (eg 'KY Jelly'). Single-use catheters have a hydrophilic coating that is activated on contact with tap water and acts as a lubricant. Ask your continence nurse for a selection to find the catheter that suits you best. CISC usually has to be carried out 3-4 times a day or more in patients with CES. The frequency of catherisation depends on factors such as fluid intake or whether the bladder is able to accommodate large volumes of urine at low pressure. You should discuss this with your doctor.
For patients on intermittent catherisation, it is very important to drink plenty of fluids to prevent urinary tract infection. Regular personal hygeine is also essential.
Common concerns regarding CISC:
Recurrent urinary tract infections:
Patients with a hypocontractile bladder are unable to empty the bladder completely. This increases the risk of urinary tract infection as the urine left behind in the bladder is a perfect place for bacteria (bugs) to grow. Bacteria will be introduced into the bladder by the catheter, but these do not cause serious problems and do not normally require treatment with antibiotics. If you have a temperature or develop symptoms of foul-smelling,
cloudy or bloody urine, you should see your doctor as you may require treatment. A new onset of incontinence can also indicate infection. If such infections are recurrent you must 'get back to basics' and review your CISC technique with your continence advisor or nurse, you must also increase your fluid intake and ensure that you are catherising frequently enough. Remember, in certain cases, catherising too frequently can actually cause infections. If recurrent infections persist, your doctor will perform investigations to check for stones in the urinary tract or other causes of infection. Rarely your doctor might prescribe prophylactic antibiotics to prevent infections.
Will the catheter weaken my urethral sphincter and cause incontinence?
There is no risk of damage to the external urethral sphincter by passing a catheter.
Will the catheter weaken my bladder?
In CES the bladder needs to be emptied regularly and CISC is the best method to achieve this. The bladder will not be weakened by CISC.
Illustrations reproduced with permission from E Versi and T Christmas.
Pictures - Bladder disorders. Oxford: Health Press, 1998
Page Last Updated: 10 June 2004