Intermittent Self-Catheterization (ISC) is a method of temporary, periodic bladder drainage that mimics the natural cycle of filling and emptying. It involves inserting a flexible tube through the urethra to empty the bladder several times daily, then immediately removing it. While ISC carries a relatively low risk of infection, it is not viable for everyone. Individuals with physical limitations, cognitive impairment, or conditions requiring continuous drainage need alternative strategies. When practical barriers outweigh the benefits of ISC, or when continuous relief is medically required, different methods for bladder management must be employed.
Continuous Indwelling Catheterization
Continuous Indwelling Catheterization provides constant bladder drainage by leaving a tube in place for an extended period. The most common form is the Urethral Catheter, or Foley catheter, which is inserted through the urethra into the bladder. A small, water-filled balloon is inflated inside the bladder to anchor the catheter. This method is frequently used for both short-term and long-term drainage needs.
A Suprapubic Catheter is inserted directly into the bladder through a small surgical incision in the lower abdomen, bypassing the urethra entirely. This option is often preferred for long-term use when the urethra is blocked, damaged, or irritated by a Foley catheter. Avoiding the urethra, a suprapubic catheter can reduce the risk of trauma and offer greater comfort and ease of hygiene.
The primary drawback for both types of indwelling catheters is the increased risk of complications compared to intermittent catheterization. The continuous presence of the catheter makes Catheter-Associated Urinary Tract Infections (CAUTIs) the most common complication. Patients may also experience uncomfortable bladder spasms, which are involuntary contractions attempting to expel the balloon holding the catheter in place.
External Collection Devices
External collection devices offer a non-invasive way to manage urinary leakage, primarily for individuals who experience incontinence but can still empty their bladder spontaneously. For male patients, the most common device is the condom catheter, also known as a urinary sheath. This flexible sheath rolls over the penis and drains urine into a collection bag, usually strapped to the leg.
These devices are generally considered less risky for infection than internal indwelling catheters because they do not enter the bladder. They are a practical option for managing incontinence in cooperative patients without urinary retention or bladder outlet obstruction. For female patients, external collection is more challenging due to anatomical structure, but disposable devices using gentle adhesive or low suction are available to wick urine away from the perineal area.
Non-Invasive Management Strategies
Many alternatives to catheterization focus on improving the bladder’s natural function through behavioral changes and pharmacological treatments. Behavioral therapies involve strategies like timed voiding, where a patient attempts to urinate on a fixed schedule to prevent the bladder from becoming overly full. Fluid management is also important, including scheduling fluid intake and limiting bladder irritants like caffeine and alcohol to reduce urgency and frequency.
Pelvic floor muscle training, often aided by biofeedback, is a physical therapy designed to strengthen the muscles that support the bladder and urethra. These exercises, such as Kegels, can significantly reduce leakage by providing better support and control over the sphincter muscles. Another technique is double voiding, which involves attempting to empty the bladder a second time shortly after the first attempt, helping to reduce residual urine.
Pharmacological interventions use medications to address the underlying causes of poor bladder function. For men experiencing urinary retention due to an enlarged prostate, alpha-blockers can be prescribed to relax the smooth muscles in the prostate and bladder neck, improving urine flow. Conversely, for issues like an overactive bladder causing incontinence or urgency, anticholinergics or antimuscarinics may be used to reduce unwanted bladder muscle contractions.
Surgical Urinary Diversion
Surgical urinary diversion is a permanent alteration of the urinary tract anatomy, reserved for cases where other management methods, including catheterization, have failed or are unsuitable. This procedure is typically performed when the bladder must be removed, such as for cancer, or when the bladder is severely non-functional due to disease or injury. The goal is to create a new pathway for urine to exit the body.
One category is Incontinent Diversions, with the Ileal Conduit being the most common type. In this surgery, a segment of the small intestine (ileum) is used to create a passage connecting the ureters to an opening on the abdomen called a stoma. Urine drains continuously through the stoma into an external collection bag worn on the body.
The second category is Continent Diversions, which create an internal reservoir for urine, such as the Indiana Pouch or a Neobladder. A neobladder is constructed from a section of the bowel and connected directly to the urethra, allowing for near-normal voiding, though patients may need to use abdominal muscles to assist emptying. Other continent reservoirs, like the Indiana Pouch, are created internally and drained by the patient periodically inserting a catheter through a small stoma in the abdomen.