Intermittent self-catheterization (ISC) is a technique used to manage urinary retention, a condition where the bladder cannot empty completely on its own. This method requires the user to insert a thin, flexible tube into the urethra several times a day to drain urine, then immediately remove it. While ISC is often the preferred method for long-term bladder management because it mimics natural voiding, it is not ideal for everyone. Individuals may seek alternatives due to poor manual dexterity, discomfort during insertion, or concerns about the risk of urinary tract infections (UTIs) associated with insertion.
Indwelling Catheter Options
Indwelling catheters are devices designed to remain inside the body for an extended period, providing continuous drainage. They eliminate the need for multiple daily insertions, simplifying bladder management. These devices are secured within the bladder and require a healthcare professional for initial placement and routine changes.
Urethral Indwelling Catheters
The most common type is the urethral indwelling catheter, often called a Foley catheter, which is inserted through the urethra into the bladder. A small balloon at the tip is inflated to hold the catheter in place for up to three months before replacement. The continuous presence of a foreign object in the urethra carries a high risk of infection. Indwelling catheters are a leading cause of hospital-acquired UTIs, and the risk increases with the duration of catheterization.
Suprapubic Catheters
A suprapubic catheter is inserted directly into the bladder through a small incision in the lower abdominal wall. This surgical placement, known as a cystostomy, bypasses the urethra entirely, reducing the risk of urethral irritation and trauma. Suprapubic catheters are held in place by an inflatable balloon and are changed every four to twelve weeks by a medical professional. This option is chosen when the urethra is blocked or damaged, or when urethral insertion is too difficult or painful.
External Urinary Collection Systems
External urinary collection systems are a non-invasive approach designed primarily for individuals with incontinence, not complete urinary retention. These devices are placed over the external anatomy to collect urine as it leaves the body, diverting it into a collection bag. Since they do not enter the bladder, they avoid the infection risk associated with passing a tube through the urethra.
Male External Catheters
For men, external catheters are commonly referred to as condom catheters or penile sheaths, fitting over the penis like a condom. An adhesive or strap secures the sheath, which connects to a drainage tube carrying urine to a leg bag or bedside container. These systems are effective for managing urinary incontinence in men who retain some bladder function.
Female External Collection Devices
Newer external collection devices for women utilize a wicking system to manage urine. Systems like the PureWick use a soft, flexible material placed between the labia and connected to a low-pressure suction unit. The suction draws urine away from the skin and into a canister, helping to keep the perineal area dry and reduce skin breakdown. These wicking devices are designed for incontinence management and are contraindicated for individuals with acute or chronic urinary retention, as they do not reliably empty the bladder.
Surgical Urinary Diversion Procedures
Surgical urinary diversion procedures offer a permanent solution to bladder dysfunction. They are typically reserved for cases where the bladder is severely compromised, non-functional, or must be removed due to disease. These major operations reroute the flow of urine, providing a definitive alternative to lifelong reliance on catheterization. The choice of procedure depends on the patient’s overall health and preference for internal versus external collection.
Non-Continent Diversions
A non-continent diversion, such as an ileal conduit, uses a small segment of the small intestine (ileum) to create a passageway for urine. The ureters are connected to this conduit, allowing urine to flow continuously out of the body through a surgically created opening in the abdominal wall called a stoma. An external pouch must be worn over the stoma at all times to collect the urine, which requires a significant lifestyle change.
Continent Diversions
Continent urinary diversions aim to create an internal reservoir to store urine, giving the patient more control. The Indiana Pouch, for example, uses a piece of the intestine to construct an internal pouch connected to a stoma. The stoma includes a valve mechanism that prevents urine leakage, meaning an external bag is not required. However, the patient must still insert a catheter intermittently through the stoma to empty the internal pouch.
Pharmacological and Behavioral Strategies
The need for catheterization is often rooted in a functional problem that can be addressed through non-mechanical means. These strategies focus on restoring natural bladder function and are often used before or in conjunction with devices to minimize the need for mechanical intervention. They aim to treat the underlying cause of retention or improve the bladder’s ability to empty fully.
Medication Management
Pharmacological treatments target the specific cause of urinary retention or incontinence, such as an enlarged prostate (BPH) or an overactive bladder. For men with BPH, alpha-blockers like tamsulosin relax the smooth muscles in the prostate and bladder neck, improving urine flow and reducing retention. 5-alpha-reductase inhibitors can also be prescribed to shrink the prostate gland over time, offering a longer-term solution to outflow obstruction.
For issues related to poor bladder muscle function or spasticity, anticholinergic drugs or beta-3 agonists may be used to relax the bladder muscle. Anticholinergics block nerve signals that cause involuntary bladder contractions. Beta-3 agonists like mirabegron relax the detrusor muscle, helping to reduce urgency and increase the amount of urine the bladder can hold. These medications can sometimes reduce the frequency of ISC by improving the bladder’s storage and voiding capabilities.
Bladder Retraining and Timing
Behavioral strategies involve modifying lifestyle and voiding habits to regain control over bladder function. Bladder training involves following a timed voiding schedule, where the patient attempts to urinate at set intervals that are gradually lengthened. This helps the bladder hold more urine. A specific technique called double voiding involves trying to urinate again shortly after the first attempt to ensure the bladder is completely empty.
Pelvic floor physical therapy (PFPT) addresses urinary issues caused by an imbalance or weakness in the muscles supporting the bladder. A specialized physical therapist guides the patient through exercises, such as Kegels, to strengthen or relax these muscles. Strengthening improves sphincter control, while relaxation techniques reduce tension that prevents complete bladder emptying.