Abstract
Purpose
To review the literature and to clarify the recommendations for therapeutic education programs for intermittent self-catheterization.
Materials and methods
The literature on Medline, Pubmed, and Cochrane Library, with specific keywords, as well as the recommendations based on expert consensus.
Results
Clean intermittent self-catheterization (CICS) is the gold standard for managing chronic urinary retention, which allows the patients to improve their quality of life and to reduce the complications of upper urinary tract infections. Patient education needs to have a structured procedure in order to evaluate the ability to understand, accept and perform CISC.
Conclusion
Teaching self-catheterization is now well known; nevertheless, the effectiveness of CISC educational therapeutic programs remains to be demonstrated.
Résumé
Objectifs
Mise au point des recommandations de pratique liées à l’éducation thérapeutique du patient à l’autosondage (ETP-AS).
Matériel et méthodes
Revue de la littérature par recherche dans les bases de données Medline, Pubmed, et Cochrane Library ainsi que les recommandations de consensus d’experts.
Résultats
De nombreux travaux confirment l’indication de l’autosondage dans le traitement de la rétention urinaire, contribuant à améliorer la qualité de vie et le pronostic uronéphrologique. Son apprentissage relève d’une démarche éducative structurée, comportant une évaluation diagnostique, l’acquisition de compétences d’autosoins et la mise en œuvre d’un programme spécifique adapté au patient. Mais il n’y a pas, à ce jour, d’études scientifiques validées permettant de démontrer l’efficacité de l’ETP dans l’acceptance, la compliance, la réalisation de l’autosondage.
Conclusion
L’apprentissage de l’AS est aujourd’hui bien codifié, mais il reste à démontrer par des études scientifiques l’efficacité de programmes d’éducation thérapeutique.
1
English version
1.1
Introduction
Today, self-catheterization (SC) is the gold standard to guarantee optimal bladder drainage in cases of partial or complete urinary retention. This technique has considerably modified the therapeutic treatment of neurogenic bladders, whether it is a retention caused by causal neurological process (e.g., paralytic bladder, vesico-sphincterian dyssynergia), by medical treatments (e.g., parasympatolytic agent, endovesical botulinum toxin injection) or by surgical treatments (e.g., enterocystoplasty) [Grade A] . However, the indications of self-catheterization do not limit themselves to the treatment of the neurogenic bladders. Numerous conditions – be they urologic (e.g., bladder outflow obstruction), gynecological (e.g., post-partum prolapse obstruction) or functional, either iatrogenic or psychogenic, (e.g., congenital mega-bladder) – can require recourse to SC, at least momentarily.
By definition, SC is a delegated act, which must be learned and thus taught. This act requires diverse prerequisites: motor, sensory and visual possibilities, coordination, motor schema programmation, movement performance and cleanliness. However, because the technique is invasive and abnormal, the patient’s understanding of the technique’s advantages is just as necessary to obtain a perfect compliance for the treatment.
Proposed by the Haute Autorité de santé (HAS), the patient’s therapeutic education (PTE) is today one way to treat patients with a chronic disease with the aim of improving their quality of life and, at the same time, mastering health expenditures. The self-catheterization apprenticeship requires a structured educational approach, specifically targeted to comprehension, performance, follow-up and adaptation of the self-care, or self-catheterization. The education is essential; it remains the only possible guarantee of success and the continuation of this technique. However, this remains to be demonstrated by randomized studies. The goal of this article is to clarify the performance recommendations related to the PTE-SC, based on a review of the literature and the programs developed during conferences of experts.
1.2
Materials and methods
A review of the literature was conducted with assistance of Medline, Pubmed and Cochrane Library databases. The keywords used were neurogenic bladder, intermittent catheterization, teaching, self-care, educational needs, and therapeutic education.
Self-catheterization therapeutic education programs, to date, have not been studied specifically, and thus cannot be evaluated to validate their effectiveness. We selected articles that referred to the tools and evaluation scales used in the self-catheterization learning procedures, as well as the performance recommendations used by this approach ( Table 1 ).
| Author | Population | Type of study | Intervention | Evaluation criteria | Results |
|---|---|---|---|---|---|
| Cobussen-Boekhorst, 2000 BJU Int | 10 children, 10 parents | Prospective | Use of doll model | QOL questionnaire ; anxiety | Preliminary results |
| Akhavan, 2007 J Spinal Cord Med | 5 quadriplegics 3F 1H | Prospective | Questionnaire about the feasibility of self-catheterization after a continent cystostomy surgery | Only 2 patients were capable of self-catheterization | Weak cohort |
| Cobussen-Boekhorst HJ, 2010 J Pediatr Urol | 7 children | Prospective | Multidisciplinary Learning Program (registered nurse, physical therapist, psychologist) | No comparative study Preliminary results | |
| Oh S, 2006 Int J Urol | 132 patients | Prospective | Learning about self-catheterization in a specialized service versus a conventional service | Self-catheterization understanding & satisfaction questionnaire | Easy to perform a self-catheterization education program in a specialized service |
| Parmar S, 1993 Paraplegia | 40 caregivers | Prospective | Teaching session for catheterization performed by other people | Monthly therapeutic session | Better acceptance with illiterate population |
| Segal, 1995 J Pediatr Nurs | Children with spina bifida cystica with myelomeningocele | Literature review | Predictive factors for self-catheterization feasibility | ||
| Van achterberg, 2008 J Clin Nurs | 28 patients divided into 2 groups | Prospective | Patient Interview | Factors determining the acceptability of self-catheterization | Knowledge, fear, motivation, & psychological profile |
Because of the lack of evidence levels and the limitations of the available literature, a working group was set up, which allowed us to gather the opinions of medical and paramedical experts on self-catheterization performance recommendations. At the initiative of four learned societies – Sofmer, AFU, SIFUD-PP, GENULF – a methodological guide was written (http://www.sofmer.com/download/etp-as-final.pdf) , making it possible to gather the recommendations for implementing PTE-SC programs, as the HAS has recommended (http://www.has-sante.fr/).
1.3
Results
No randomized study has been able to demonstrate the effectiveness of the PTE for the patient’s acceptance, compliance, and performance of self-catheterization, especially for neurological patients. In this article, the various stages of a PTE-SC program implementation are dealt with, based on the recommendations of the Sofmer guide and the data for the available clinical studies: the educational diagnosis, both the theoretical knowledge and practical skills, and the program’s implementation (e.g., methods, structures, staff).
1.3.1
Educational diagnosis
The educational diagnosis is the first stage of the PTE-SC program. This diagnosis must evaluate the patient’s needs and learning capacities. This act requires diverse prerequisites: motor, sensory, and visual possibilities, coordination, and motor schema programmation. This stage must determine the patient’s environmental, socio-cultural and biomedical conditions in order to adapt the program’s implementation.
1.3.1.1
Socio-professional dimension
The socio-professional dimension evaluates the spatial environment and the socio-professional conditions.
1.3.1.1.1
The spatial environment
The evaluation of the spatial environment studies:
- •
accessibility of the toilets and the bathroom (if the patient is in a wheelchair, his/her capacity to transfer himself/herself needs to be examined);
- •
the existence of easily accessible source of water for the patient;
- •
an easy installation of the elements needed by the patient (e.g., trash can, a horizontal surface, stool, light source, washbasin);
- •
an occupational therapist may be needed to analyze and adapt the environment. This therapist can make certain that the movement is doable, and if necessary set up, technical assistance or environmental adaptations.
1.3.1.1.2
The socio-professional conditions
The socio-professional conditions define the location of self-catheterization (e.g., residence, work, leisure activity). Also, the family environment (e.g., spouse, relatives) can be integrated into the therapeutic educational program.
1.3.1.2
Biomedical dimension
During this educational diagnosis stage, the patient’s knowledge will be evaluated (e.g., the knowledge about the anatomy of the perineum, the technique’s advantages, and the patient’s disease). Using the urinary symptom profile (USP) and the Qualiveen questionnaire about the quality of life allows health care professionals to evaluate the functional repercussions of urinary disorders.
Using the Paper and Pencil Test (PPTest) has been validated for evaluating the patient’s physical and cognitive resources for self-catheterization . The movement itself requires gripping and coordination. When the motor handicap requires a continent derivation principle of the Mitrovanoff type, specific functional evaluation scales are proposed to evaluate the feasibility of self-catheterization by the new stomy .
Determining the patient’s cognitive resources is fundamental. The presence of a dysexecutive syndrome, comprehension troubles, and/or frequent motor or mnesic disorders in the evolutionary neurological pathologies can be an obstacle for therapeutic education . Simple screening tests can be useful (e.g., Rock-Paper-Scissors Test). In certain cases, more detailed psychological expertise will make it possible to evaluate the attentional capacities (Trail Making Test) , the motor disorders, the psycho-emotional repercussion of urinary disorders (Hamilton Rating Scale for Depression) , Osgood’s semantic differential scale, or Folstein’s Mini Mental Test . Beyond the patient’s motor, sensory, visual, or cognitive resources for self-catheterization, anxiety is often the main obstacle to self-catheterization. This anxiety is related to the invasive character of the movement, with nervousness about the hypothetical pain, the risk of injury and the modification of the patient’s self-image .
The acceptance of the self-catheterization remains to be evaluated. A clinical hospital research program (PHRC) began to evaluate this fundamental acceptance . Two studies, with teenagers and adults, who used self-catheterization for a long period, show that this technique is well accepted . Only a few people would choose to resume their previous way of doing things , and most consider that the procedure is easy to perform . This stage allows health care professionals to evaluate the difficulties of apprenticeship: cognitive disorders, depression, acceptance of the handicap, the socio-cultural and environmental conditions or motor, sensory, and/or visual obstacles. During this essential stage, the self-catheterization position and the type of catheter will be chosen.
1.3.2
The knowledge and skills to be acquired
1.3.2.1
Theoretical knowledge
Understanding of the advantages of SC implies a minimal knowledge of the anatomy of the perineum (e.g., location of the urinary meatus in women), the vesico-sphincterian dysfunctions and its consequences in case of neurological attack. The patient will want to know the various complications related to the SC movement so that he/she can develop appropriate skills (e.g., behavior in cases when the patient feels he/she is forcing the catheter in; behavior in cases of small or large amount of hematuria). The monitoring of a urinary infection, as well as the appropriate behavior, must be understood in terms of the infection’s seriousness . If bacteriuria is inevitable in patients who self-catheterize, only a clinically significant urinary infection would justify a urinalysis and an appropriate antibiotic treatment. On the other hand, the presence of a urinary infection with a fever is an uro-nephrology risk factor and must be seen as a “red flag” that alerts the patient to the necessity of an emergency treatment. Neurological patients need to know the signs of distended bladder, which can correspond to signs of autonomous hyperreflexia (e.g., headaches, sweating, shivering, cutaneous erythema), especially in people with spinal cord injury whose lesion level is over D6.
1.3.2.2
Practical skills
1.3.2.2.1
The methods
Among three methods of intermittent self-catheterization, defined in the literature (e.g., sterile, aseptic or clean), only two methods are appropriate for PTE:
- •
aseptic intermittent self-catheterization, which recommends the use of a single-use catheter, preceded by disinfecting the perineum with an antiseptic solution and without direct manual contact with the catheter (e.g., No Touch Technique);
- •
clean intermittent self-catheterization, which recommends the use of a single-use or reusable dry catheter, with a non-antiseptic solution for cleaning the hands and perineum.
Various French, European, and American societies recognize intermittent self-catheterization as the gold standard for urine retention, with either a lubrified catheter or a hydrophilic catheter [Grade B] . However, the opinions diverge about the self-catheterization method. In 2009, the European Association of Urology (EAU) recommended using the aseptic intermittent self-catheterization, whereas the 2006 report of the French Association of Urology recommends using the clean intermittent self-catheterization, with a single-use catheter or a reusable clean catheter, without a preliminary antiseptic disinfection . To date, there is no scientific proof based on randomized, controlled studies allowing us to retain a preferred method (pre-lubrified or dry catheter, the antiseptic or non-antiseptic method) .
Every stage of the self-catheterization procedure will be shown to the patient and then will be reevaluated with the patient: hands and perineum hygiene without an antiseptic, installation of the equipment, urinary meatus localization, and the manipulation of the equipment. The choice of the equipment has to be appropriate to the patient’s functional, cognitive and psychological capacities. The performance of the movement itself and the hygiene modalities will be done according to a codified educational approach:
- •
show the equipment and the various stages of self-catheterization (e.g., cleaning of the hands and perineum, installation of the equipment, the position, the catheterization movement itself and draining the reservoir);
- •
perform the catheterization with the patient;
- •
leave the patient to perform the catheterization without the assistance of the caregiver.
A minimum interval of 4 hours is recommended between two catheterizations. The number of catheterizations will be fixed in terms of the medical indications and appropriate for the micturition time chart. The PTE will also adapt the catheterization to the various environmental conditions (e.g., work, voyage, sport activities).
1.3.2.2.2
The choice of the equipment
The health care professional (e.g., nurse, doctor), with the patient, will analyze the degree of the patient’s handicap and the situation, which allow the self-catheterization procedure to be adapted according to the patient’s specific constraints. Then, the patient will choose between different pieces of equipment.
Indeed, several types of urinary catheters can be proposed:
- •
dry catheters are preferred by women because of the shortness of the urethra and the natural lubrication with the local secretions. Using a lubricant is recommended for men (e.g., petroleum jelly, paraffin wax, glycerin, or xylocaine) to facilitate the passage of the catheter;
- •
hydrophilic pre-lubrified catheters (hydrophilic surface treatment integrated into the catheter’s wall) or non-hydrophilic catheters (simple addition of a non-hydrophilic external lubricant, such as paraffin wax or glycerin) present in the catheter’s wall or in the catheter’s liner;
- •
straight or elbowed catheters, short or long, with or without collection pockets, with diameters varying from CH10 to CH16 (CH: charrière ).
The use of hydrophilic pre-lubrified catheters is recommended for men when there is a high rate of urinary infections. However, there are no current data allowing us to conclude on the catheter superiority in the long term [Grade D].
1.3.3
Implementation
A therapeutic education program for self-catheterization requires appropriate structures and a staff trained to teach this procedure. It is in this domain that we found the most studies related to PTE.
1.3.3.1
Pedagogical methods
Various pedagogical methods have been developed for teaching the procedure, especially for children. They can be applied to self-catheterization. The combination of several methods limits the differences between patients and the risks of failure :
- •
simulation methods: the child uses a doll model to improve the precision of the movement and his/her speed or uses a reproduction of a bladder filled with water . The advantage lies in the playful aspect of the movement, allowing the errors to be located and the movement to be demystified ;
- •
communication methods:
- ∘
role-playing games ,
- ∘
verbal information or an interpretative framework appropriate for the patient’s development and understanding ,
- ∘
a representation, or a drawing, of the body ,
- ∘
video with contents appropriate for the patient’s psycho-emotional development, supervised by the therapist ;
- ∘
- •
cognitivo-behavioral methods: these methods are based on individual interviews, based on a closed list of objectives with increasing difficulty . This approach is appropriate when there are attentional disorders and learning difficulties. The technique is mastered during personalized interviews, including caregivers whatever their cultural level .
1.3.3.2
The structures
Public or private, all the structures involved in the evaluation of lower urinary tract dysfunction are concerned; physical medicine and rehabilitation, urology and gynecology departments are the main ones. This education will take place while the patient is hospitalized for day, week or longer.
A minimum of 2 hours is recommended at the time of the first evaluation phase, the length of which will be adapted to the patient profile during the educational diagnosis. At the end of the evaluation, carried out jointly with the various participants (e.g., doctors, nurse, occupational therapist), the schedule of the therapeutic educational sessions is then organized. The patient is informed when these sessions will take place. A minimum of two sessions is necessary to evaluate the theoretical knowledge and the practical skills of the patient.
Several studies showed the advantages of a service, specialized in the care of lower urinary tract dysfunctions, to carry out the SC therapeutic educational sessions rather than an unspecialized service in this domain . In a prospective study about 132 hospitalized patients, Oh et al. compared the effectiveness of a PTE-SC in a specialized care unit compared to an unspecialized care unit . The results showed a better acceptance of self-catheterization, a better understanding of the instruction, and less follow-up visits when the learning was done in the specialized service.
1.3.3.3
The staff
The resource people are involved from the phase of educational diagnosis according to various criteria and principles:
- •
the nurse is, for the most part, the designated person. He/she is specifically trained in therapeutic education. For that purpose, a level of knowledge necessary for this “course” is indispensable: knowledge about vesico-sphincterian physiology, anatomy of the perineum, and various self-catheterization methods. Self-catheterization movement instruction can be delegated to nurses (decree #2002-194 of 11 February 2002; Art 1-5-14);
- •
the occupational therapist and the psychologists participate in the educational diagnosis and the adaptation of the environmental conditions;
- •
the doctor (e.g., PMR doctor, urologist, gynecologist) defines the self-catheterization modalities (e.g., indications, advantages, alternative treatments, frequency) and can, according to the case and the structures, carry out the SC therapeutic education;
- •
the mobile care teams give care at the patient’s domicile.
The skills acquired by the patient, as well as the self-catheterization experience, must be evaluated. An appointment is made in the 3 to 5 weeks after the therapeutic education, and then renewed according to the objectives and the acquired skills. The evaluation objectives are related to:
- •
the technique itself (e.g., the movement, the regularity of self-catheterization reported on the micturition time chart);
- •
the comprehension of the advantages of the technique;
- •
the management of the difficulties and the possible complications;
- •
the self-catheterization experience: urinary symptoms (e.g., USP questionnaire) and functional repercussions on the quality of life (e.g., Qualiveen questionnaire).
1.4
Discussion
The indication of the self-catheterization for the treatment of chronic urinary retention, especially in neurological diseases, no longer needs to be demonstrated. It is easy to perform, as well as effective at controlling the risk of infections, compared to the other widely-documented drainage techniques, especially for people with spinal cord injuries . Numerous studies were able to demonstrate the impact of SC on renal function (e.g., suppression or diminution of the uro-nephrologic risks via residual urine drainage and the management of high endovesical pressure) and on the quality of life (e.g., disappearance or improvement of the leaks and urgency) , compared with the other drainage methods or urine evacuation methods for patients with neurological conditions (e.g., Credé’s method, abdominal pushes, catheterization by other people, permanent catheter, suprapubic catheter) (NP1) . The most numerous works are related to people with spinal cord injury, where the indication to begin SC is recommended after a period of hyperdiuresis [Grade C] and is established as soon as the gestural function allows it . This indication extends to all urinary retention cases, whatever the age, and can begin with children from the age of 6 years .
A therapeutic education program allows the quality of care and the treatment compliance to be improved [Grade B]. It is, above all, the improvement of the quality of life and the treatment of the incontinence that will be a success factor for compliance in the intermittent self-catheterization . It can be recommended during the hospitalization phase, as well at home, and it will be begun as soon as the patient’s gestural function will allow it . The PTE-SC procedure is well codified with expert consensus (e.g., Sofmer guide). Although many PTE models have been proposed, it remains to be demonstrated the advantages of these programs, especially in terms of economic impact.
1.5
Conclusion
Self-catheterization education is a given. This requires structures and staff specifically trained in this type of education. The analysis of the feasibility, the immediate acceptance and the medium- and long-term compliance necessitates a structured educational approach aimed at the patient’s comprehension, performance and appropriate follow-up of the self-care that is self-catheterization. However, for future, the PTE-SC offers an unexplored research field, where the healthcare professionals involved in the care and follow-up of neurogenic bladders will be brought to evaluate simultaneously the procedure and the effectiveness of the PTE-SC programs in an objective and scientific manner, via randomized studies.
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
2
Version française
2.1
Introduction
La pratique des autosondages vésicaux (AS) est aujourd’hui le traitement de référence, permettant d’assurer un drainage vésical optimal en cas de rétention urinaire complète ou incomplète. Cette technique a considérablement modifié la prise en charge thérapeutique des vessies neurologiques, qu’il s’agisse d’une rétention liée au processus neurologique causal (vessie paralytique, dyssynergie vésico-sphinctérienne) ou qu’elle soit induite par les traitements médicaux (parasympatolytiques, toxine botulique endovésicale) ou chirurgicaux (enterocystoplastie) [Grade A] . Mais les indications de l’autosondage ne se limitent pas au traitement des vessies neurologiques et nombre de situations urologiques (obstruction sous vésicale), gynécologiques (obstruction par prolapsus, post-partum), fonctionnelles (méga vessie congénitale) iatrogènes ou psychogènes peuvent nécessiter au moins transitoirement le recours au AS.
Par définition, l’AS est un acte délégué. Cet acte doit être appris et donc enseigné, ce qui nécessite divers prérequis techniques : possibilités motrices, sensitives, visuelles, de coordination, de programmation du schéma moteur; acquisition du geste lui-même et des modalités d’hygiène. Mais la compréhension de l’intérêt de la technique, en raison de son vécu invasif et non naturel par le patient, est tout autant nécessaire afin d’obtenir une parfaite compliance au traitement.
L’éducation thérapeutique du patient (ETP) est aujourd’hui une des modalités de traitement et de prise en charge des patients, porteurs d’une maladie chronique dans le but d’améliorer la qualité de vie des patients et de maîtriser les dépenses de santé, proposé par l’Haute Autorité de santé (HAS). L’apprentissage de l’autosondage s’inscrit donc dans cette définition et nécessite une démarche éducative structurée, spécifiquement ciblée sur la compréhension, la réalisation, le suivi et l’adaptation de l’autosoin qu’est l’autosondage. L’enseignement est primordial, possible gage de réussite et de pérennité de la technique, mais cela reste à démontrer par des études spécifiques.
L’objectif de cet article est de faire une mise au point sur les recommandations de pratique lié à l’ETP-AS à partir d’une revue de la littérature et de programmes élaborés lors de conférences d’experts.
2.2
Matériel et méthode
Une revue de la littérature a été réalisée par interrogation des bases de données Medline, Pubmed et Cochrane Library. Les mots-clés utilisés sont : neurogenic bladder, intermittent catheterization, teaching, self care, educational need, therapeutic education .
Les programmes d’éducation thérapeutique à l’autosondage n’ayant pas à ce jour fait l’objet d’études spécifiques permettant d’évaluer et de valider leur efficacité, nous avons sélectionné les articles faisant référence aux outils et échelles d’évaluation utilisés dans les procédures d’apprentissage à l’autosondage ainsi que les recommandations de pratique utilisées dans cette démarche ( Tableau 1 ).
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