Intermittent bladder catheterization

What is it?

Urine is produced by the kidneys to remove waste from the body.
It flows from the kidneys to the bladder through tubes called ureters.
The urine accumulates in the bladder which is like a muscular sac.
The bladder regularly contracts (squeezes), causing the urine to empty through a tube at the bottom, called the urethra. The bladder contracts when the muscle wall is stretched. Bladder emptying (urination) is also controlled by the brain which controls the muscle.
The urethra ends with the urethral opening, an opening that is at the end of the penis in males and the center of the vulva in females. Urine leaves the body via the urethra.

Two muscles (sphincters) act as doors to open and close the urethra and bladder; the external sphincter is in the urinary meatus, close to the surface of the skin and the internal sphincter is at the junction of the urethra to the bladder. They remain closed, ie, contracted to keep urine in the bladder until we go to the toilet.
There are many reasons that the bladder might not empty properly. Examples include: side effects of some medications, neurological conditions, and spinal cord diseases. A bladder filled with urine too long prevents the kidneys from emptying normally and can cause urine to flow backwards into the kidneys. This damages the kidneys.
A bladder catheterization involves introducing a catheter (thin flexible tube) into the bladder to allow urine to empty out of it.
An intermittent catheterization means that the catheter does not remain in place permanently. It is inserted when the bladder is full and is then removed when the bladder is emptied. It is done on a regular schedule, several times a day, depending on the child’s needs, mimicking our natural bladder emptying patterns.
When a child is quite independent and able to manipulate objects, he can learn to do his own catheterization, under the supervision of an adult.

How does it work?

The catheter is inserted:
- in the urethra through the urinary meatus to the entrance of the bladder or,
- into a tunnel, surgically constructed, (called a “Mitrofanoff”) leading from the bladder to the outside of the body, on the surface of the abdomen, close to or through the navel. The opening of this tunnel is called a stoma.
Once the catheter is in the bladder, the catheter allows urine to flow out.
The Mitrofanoff stoma has a valve to prevent urine leaking between catheterizations and to prevent water from entering when bathing, showering or swimming.
When catheterization is properly performed, it allows your child to do his daily activities normally.
There are catheters of various types and different sizes. Your child’s catheter may change over time depending on age and weight. Your healthcare team will guide you based on your child’s needs.
A catheter may be disposable or reusable, plastic, silicone or latex, soft or firm, straight or angled, pre-lubricated or not, having an open drain end or an integrated drainage bag.
The catheter should be changed:
- if damaged,
- if there is a change in its appearance or texture (eg, if it becomes opaque, rigid or too soft) and,
- depending on the length of time it should be used as suggested by the manufacturer.
To clean the reusable catheters, follow the manufacturer’s recommendations and those of your healthcare team.

FAQ – Intermittent bladder catheterization

When to consult your healthcare team

Urine

The amount of urine collected by catheterization increases or decreases much more than usual, for more than a day and for no apparent reason.
Urine changes color, appearance or smells bad as compared to what is normal for your child.
There is no flow of urine through the catheter for a longer period of time than what has been recommended by the healthcare team.
The flow of urine through the catheter is much slower.
Your child has urinary incontinence between catheterizations.

Catheterization

You are unable to insert or remove the catheter.
The stoma is bleeding more than a few drops and does not stop.

Mitrofanoff stoma

The skin around the stoma is red or irritated (small bumps or skin injury).
The stoma changes appearance.
The stoma protrudes or sinks in more than 0.5 cm.

General state

When your child has any of the following symptoms or signs:

tummy pain,
your child has a stomach ache and feels uncomfortable,
frequency: feeling the urge to pee more often,
fever (rectal ≥ 38⁰C or oral/armpit ≥ 37.5⁰C),
nausea or vomiting,
dysuria: pain when passing urine,
general irritability, poor appetite, tiredness or wanting to sleep more than usual.

Do not hesitate to contact your healthcare team about any questions concerning your child.

WARNING: The information in this section is meant as a general guide to help parents and caregivers with common issues and is not intended to replace the care provided by your child’s healthcare team.

Discuss your child’s unique needs with your healthcare team, including WHO and WHEN to contact when problems arise.

Urinary incontinence (leakage) between catheterizations

Possible cause(s)

Urinary tract infection
Catheterization not frequent enough
Malfunctioning Mitrofanoff valve

What to do?

Identify the time of the last catheterization.
Contact your healthcare team quickly.

The urine does not flow or flows more slowly than usual through the catheter

Possible cause(s)

Too frequent catheterization: therefore little urine in the bladder
Insufficient hydration
Inadequate functioning of kidneys
Mechanical blockage of the catheter (eg, kinked)
Catheter too small
Blockage of the Mitrofanoff stoma (eg, presence of mucus)
Poor technique

What to do?

Identify the time of the last catheterization.
Check how well your child is hydrated:
- review the amount of liquid drunk by your child in the last 2 days;
- look for the signs of dehydration: dry mouth and lips, sunken eyes, headache, weakness, dizziness.
Make sure the catheter is not stuck, bent or kinked.
Use a larger catheter after discussing it with your healthcare team.
Review the steps of catheterization and make sure to follow them well.
Contact your healthcare team quickly if the problem lasts for a longer period than what is agreed with your healthcare team.
Mitrofanoff: if your child has had surgery to enlarge the bladder, deposits can form and build up thus making the emptying difficult. To avoid this problem, the bladder must be irrigated regularly. Talk to your healthcare team.

The catheter is difficult to insert

Possible cause(s)

Resistance at the level of the sphincters
Mechanical blockage of the catheter (eg, kinked)
Mitrofanoff: injury at the level of the tunnel

What to do?

Natural ways: You may feel a slight resistance at the level of the urethral sphincter when trying to insert the catheter:

encourage your child to relax and breathe slowly;
roll the catheter itself with your fingers and push gently, but not forcefully;
ask your child to change position (eg, roll to the side).

If the resistance persists:

try a smaller catheter;
if this is not effective, remove the catheter to avoid hurting your child;
contact your healthcare team immediately.

Mitrofanoff:

follow the path of the canal between the stoma and the bladder with the catheter;
if there is some resistance at the entrance of the bladder proceed gently;
do not force the catheter in.

If the resistance persists:

remove the catheter;
contact your healthcare team immediately.

Urine has an unusual odor or is milky, not clear

Possible cause(s)

Urinary tract infection
Insufficient hydration
Bladder not completely emptied

What to do?

Make sure the bladder completely empties during catheterization.
If the problem is new, repeat the catheterization.
Check if your child has other symptoms that may indicate a urinary infection:
- change in the color of urine,
- need to empty the bladder more often,
- pain in the urethra or abdomen,
- nausea, vomiting,
- fever: rectal ≥ 38⁰C, oral or armpit ≥ 37.5⁰C,
- chills,
- irritability,
- tiredness, lack of energy.
If the problem persists after catheterization or if your child has other symptoms, quickly contact your healthcare team.

Bleeding after catheterization

Possible cause(s)

Irritation caused by frequent catheterizations
Urinary tract infection

What to do?

One or two small blood drops may be seen during catheterization: it is not worrying if it happens infrequently. Nevertheless, discuss it with your healthcare team.
If there is more bleeding or if it is more frequent:
- check if your child has a fever (rectal ≥ 38⁰C or oral/armpit ≥ 37.5⁰C),
- contact your healthcare team quickly.

Difficult catheter removal

Possible cause(s)

In rare cases, the catheter may have rolled up on itself

What to do?

Do not forcibly remove the catheter. Leave it in place.
Contact your healthcare team quickly.

Skin around the Mitrofanoff stoma is: red swollen itchy, burns, or there are small bumps, abrasions or bleeding

Possible cause(s)

Skin irritation around the stoma
Infection of the skin around the stoma

What to do?

The skin around the stoma your child should have the same appearance as that of the rest of the belly.
Contact your healthcare team quickly.

Movement of the Mitrofanoff stoma is more than 0.5 cm from its usual position, whether sinking in or protruding out

Possible cause(s)

Various causes

What to do?

Contact your healthcare team immediately.

Abdominal discomfort; pain and/or burning at the meatus or urethra

Possible cause(s)

Urinary infection
Irritation

What to do?

Contact your healthcare team quickly.

Fever with or without malaise: ≥ 38⁰C rectal or ≥ 37.5⁰C oral/armpit

Possible cause(s)

Urinary infection
Other infection

What to do?

Record your childs other symptoms: pain, irritability, loss of appetite, fatigue, etc.
Contact your healthcare team quickly.

For specific advice on your child or any other questions, do not hesitate to contact your child’s healthcare team.

Everyday tips

Clothing

Choose clothes that will facilitate access to the genitals (vulva, penis) when there is a need to undress.
For independent children in wheelchairs, consider clothing with elastic or Velcro closures. Talk to your healthcare team for specific suggestions.
Children with a Mitrofanoff stoma should wear comfortable clothes that are not too tight. It is not necessary to cover the stoma with a bandage; urine should not leak from the stoma because of the valve.

Bathing and swimming

Clean your child’s genitals or the Mitrofanoff stoma every day, when bathing and showering, and before each catheterization. Your child should participate in this care, if able.
Use a washcloth, warm water and mild body soap, that is fragrance and additive free (eg, “Dove”).
Do not use antiseptic soap because it can irritate the skin and cause infection.
Girls: open the labia gently, clean the vulva, inner labia and the perineum to the anus (going from front to back); rinse with water in the same way.
Boys: clean the penis, including the area under the fold of the foreskin if uncircumcised; rinse with water.
Mitrofanoff stoma: gently wash the stoma and the skin around the stoma and rinse with water.
Baby wipes that are fragrance and additive free can be used, without rinsing, for cleaning or before catheterization.
Your child may take a bath, shower or swim without special care.

Sleeping

Consider meal times and your child’s need for hydration to determine, with your healthcare team, if it is necessary to do catheterizations during the night.
For some children, wearing a diaper at night may help.

Nutrition and hydration

With your healthcare team, determine the schedule of daily catheterizations for your child according to:
- the organization of the activities planned for the day (eg, travel, school, medical care, social activities, sports),
- the best length of time in between two catheterizations, considering the child’s comfort and the risks of urine flowing backwards into the kidneys.
Take note your child’s liquid intake and the amount of urine collected during the day, as recommended by your healthcare team.
Encourage your child to drink throughout the day; smaller amounts in the evening may allow for the child to not need catheterization during the night.

Activities

Your child can usually continue his regular daily activities.
It is recommended to do a catheterization immediately before play or engaging in a sport.
Follow the recommendations of your team which are tailored to the specific needs of your child.

Travel and transportation

Always carry a ”spare kit” in case a catheterization is needed outside the house:

hand soap
cleaning wipes
two clean catheters
water-based libricant
container to collect urine

Methods of care

Methods of care : Intermittent catheterization: boys

Indications

An intermittent catheterization is necessary to help your son to empty his bladder of urine.
The steps in the method below may serve as a guide; speak to your healthcare team about the specific equipment that your child uses.

Considerations:

This technique should be done in or close to a bathroom, depending upon the age and mobility of your child.
If your son is physically able, he can learn to do his own catheterizations (self-catheterization), under the supervision of an adult.
The internal and external sphincters are sometimes contracted, which can create a sensation of resistance when inserting the catheter. In boys, the external sphincter is reached when the catheter is inserted up to the length equivalent to that of the penis. Refer to section: What is it?
Your son may feel a sensation of pressure during catheterization. This feeling should not be painful. If it is, talk with your healthcare team. If necessary, they may suggest another type of catheter or other steps to do the technique, based on the needs of your son.
Good handwashing is essential before and after providing care.
Optimize your child’s comfort during care with appropriate positioning and the use of distraction.

Frequency

The frequency of catheterizations required depends on the capacity of the bladder, the schedule of activities, hydration level, age, and health condition of your son. It is determined with your healthcare team.
Your son may also request another catheterization when he feels pressure or the urge to urinate.
If there is incontinence between catheterizations, talk with your healthcare team.

Required materials

2 catheters of the type and size recommended by your healthcare team
Gel water-based lubricant. DO NOT use any type of Vaseline petroleum jelly
Clean, dry container for storage of the reusable catheter

If needed:

Towel/absorbent cloth (eg, diaper) or container to collect the urine (if toilet is not used)
Container for measuring urine
Soap and syringe to clean the reusable catheter

Refer to your child’s healthcare team if the material or the sequence of steps you have been taught is different than those described.

Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

Create the right moment: integrate the care in a routine.
Alert your child to the needed care and communicate together.
Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

Safety: Carefully follow the care practice steps as you have been taught.
Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Prepare the materials

If you need to measure the amount of urine, make sure the container to collect the urine is on a flat surface in front of your son, at a level below his bladder.
Open the new catheter wrapping or take the reusable catheter from its container without touching the end.
Put a small amount of water-based lubricant on the tip of the catheter. *DO NOT use any type of Vaseline petroleum jelly.

Why ?

This step is done to prepare for the procedure.

The lubricant permits smooth entry of the catheter.

Step 5: Position your son

Based on what has been agreed with your healthcare team, ask your child to try to urinate before catheterization, if possible.
Then place your child in one of the positions discussed with your healthcare team, according to comfort, age and ability to cooperate.
The changing table can be used for a baby.
As soon as he is able, sit him on the toilet seat.
If your son is older, he can stand up in front or on the side of the toilet.

Why ?

This step optimizes comfort and efficiency.

Step 6: Locate the urethral opening

With one hand, hold the penis under the glans loosely at a 90 degrees angle with the belly.
If necessary, retract the foreskin.
Hold the penis in this position for the procedure.
If your son catheterizes himself, he should do it the same way.

Why ?

This step facilitates the procedure.

Step 7: Clean the area around the urinary meatus, as needed

Wash the penis with warm water and mild soap, including the area under the fold of the foreskin (if not circumcised).
Rinse with warm water.
You can also use a baby wipe.

Why ?

This step is necessary to prevent infections.

Step 8: Insert the catheter

With your free hand, hold the catheter like a pencil: about 3-4 cm from the end that will be inserted.
Direct the other end of the catheter to the toilet, the towel or the container to collect urine if the amount of urine is to be measured.
Ask your child to take a deep breath and relax.
At the same time as he exhales, gently insert the catheter into the urethra through the urinary meatus.
When you feel resistance:
- encourage your son to relax and breathe slowly,
- move the penis towards the thighs,
- roll the catheter with your fingers, and push gently, but not forcefully,
- ask your son to change position (eg, roll to one side or sit up).
Insert the catheter until urine starts to flow.
If the resistance persists:
- try a smaller catheter.
If the insertion remains impossible:
- remove the catheter to avoid hurting your son,
- contact your healthcare team immediately.

Why ?

This step is necessary to safely enter the bladder without irritation or injury.

Step 9: Empty the bladder

Hold the catheter in place and allow urine to flow into the towel, the toilet or container.
If necessary, press gently on the belly of your son to help empty the bladder completely.

Why ?

This step is necessary to make ensure the bladder is emptied.

Step 10: Remove the catheter

Slowly withdraw the catheter when the urine stops flowing.
While removing the catheter, stop each time that urine begins to flow again.
Remove the catheter then quickly place it on a clean surface.
Wipe the penis; there may be lubricating gel or urine in the catheter as it leaves the urethra.

Why ?

This step is necessary to make sure that the bladder is emptied.

Step 11: Clean and store the catheter

Follow the manufacturer’s and your healthcare team’s recommendations about maintenance and the frequency of re-using catheters at home.
If the catheter can be reused, it must be cleaned after each use:
- inject soapy water (eg, hand soap or dish washing liquid) with a syringe into the catheter,
- rinse with water until there is a clear return,
- wipe the outside of the catheter with a clean towel,
- dry the inside by injecting air using the syringe,
- place the clean catheter in the clean and dry container,
- wash the catheter storage container at least once a week.

Why ?

This step is necessary to prevent infections.

Step 12: Measure and record the amount of urine collected, if necessary

According to the recommendations of your healthcare team:

pour the urine in the container provided for its measurement,
note the amount,
observe the color and appearance,
write the information on the tracking sheet.

Why ?

This step is necessary to monitor the functioning of the kidneys and bladder.

Step 13: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

Listen to what your child says about the parts of the procedure that were difficult or painful.
Comfort your child and recognize your child’s collaboration with positive feedback.
Highlight your child’s specific strengths that helped make the procedure positive.
Discuss with your child what might be done the same or differently the next time the care is needed.
Keep your promises if you have promised a reward, follow through.
Reward yourself too.

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