A Cathing Primer:
Everything the Doctor Forgot to Mention
Everything the Doctor Forgot to Mention
My daughter was sent to the urologist for urological testing after several Urinary Tract Infections (UTIs). When her testing showed she retained urine, urinated with high pressure, and was at very high risk for kidney damage, we were told to begin cathing.
The only problem was that no one ever showed me how to cath.
I was handed a few Mentor catheters of different lengths to try and was sent home with an order to cath her every four hours around the clock. Perhaps they figured the presence of her home nurse at the appointment meant teaching was not necessary. In any case, I had to figure it out all on my own, from locating an itty-bitty urethra on a three-year-old to finding the right supplies and equipment.
Hopefully most others received better instructions than I did, but if not, here is a general primer on cathing to get you started.
Have the Right Equipment
I was given three catheters and a prescription for a box of 30 more and told to reuse those caths, soaking them in a weak betadine solution between caths. First of all, reusing catheters is really not a good idea, and thankfully insurers and the Centers for Medicare and Medicaid Services have finally agreed with what has been total common sense to parents for years. It is essential to use a new catheter each time, especially if your child is complex and has concurrent issues such as a central line, immune deficiency, or frequent Urinary Tract Infections (UTIs). Most children are allowed 180-200 catheters per month by insurance.
I was also given one big tube of lube and no other supplies for cathing. Upon switching to a specialty Urological Supplier, I was instead supplied with a sterile kit for each cath. Each kit, which costs only about $1, contains everything you need to do a sterile cath, including wipes, povidone-iodine, an underpad for catching spills, lube, and sterile gloves. These kits allow for the safest cath possible and are routinely covered by insurance without a problem. Even Medicare reimburses for them in individuals with a history of infections.
A Multitude of Styles and Sizes
The initial box of catheters I was given were about as basic as you can get: silicone-coated straight catheters. While they worked just fine, I would later find out how many options are available to make cathing easier and safer.
We began trialing hydrophilic catheters and found these to be much less traumatic for my daughter as well as easier to use. Coated with a material similar to contact lenses that becomes extraordinarily slippery when exposed to water, they are so slick that bacteria cannot even stick to them, making them a great choice for children who get frequent UTIs.
In addition, most hydrophilic catheters are very convenient to use. We use a style called Flocath Quick made by Rusch that contains a package of sterile water right inside the wrapper. All you do is pop the bag and the catheter is fully "lubed" up and ready to use. There are many other brands available, both ones that require water to be added and self-lubricating catheters.
Catheters come in varying lengths and styles. Most individuals use straight catheters that are somewhat stiff and can be inserted easily. Flexible catheters are available, but will probably be more difficult to use for most families. For boys, in some cases a Coude tip catheter, which has an angled tip, may be helpful for removing the urine. Catheters typically come in female lengths (about 6 inches long) or longer lengths (12 or more inches). Most families seem to prefer the longer catheters, especially for children who cannot sit on the toilet during cathing. Lastly, parents of boys may want to use lubricant containing a numbing agent to make the experience more tolerable.
Closed System Catheters
We were introduced to closed system catheters shortly after my daughter began cathing. What a blessing these were! These kits come with everything you need to cath on-the-go. The catheter itself is attached to a leak-proof (usually) bag that collects the urine without any spillage or mess. The kit that comes along with the catheter typically includes wipes, an underpad, and a garbage bag for everything once you are done. These kits make it easy to cath in awkward locations, such as at school, in the car, or on a bathroom changing table. We send these catheters to school with our daughter and use them exclusively when we are cathing away from home.
Get a Good Urological Supplier
My daughter's first order for catheters was called in to her regular Home Health Agency, who promptly sent me a box of 100 8F respiratory suction catheters. While it is perfectly possible to cath with a suction catheter or even an NG tube, I really don't recommend it. The stiffer straight catheters are much easier to use and tend to empty the bladder better.
It turns out that a large majority of Home Health Agencies do not supply urological items such as catheters, cath kits, or urine collection bags. Unless you have a Home Health Agency with exceptional customer service and you know exactly what you need, I would recommend using a specialty Urological Supplier. I highly recommend 180 Medical, a company that not only is run by people who cath, but also is willing to work with you on obtaining exactly the types of catheters you need for your child. They can help you figure out what supplies are necessary and give you advice on different styles and sizes of catheters.
The focus in most cath training videos or demonstrations is simply getting the catheter into the urethra, especially for girls. What the doctor or nurse often neglects to tell you is how to get the urine out, especially if you have a child with a floppy bladder or a tight sphincter.
One technique I was taught that has helped enormously is to push the catheter in quite far until it reaches all the way to the back of the bladder. Don't worry about going too far...the catheter will simply curve around. Allow the urine to flow from this area and then slowly pull the catheter out a small distance. Once again, allow the urine to flow out. Continue slowly removing the catheter, allowing for the urine to empty as you go along, until the catheter is completely out.
Another technique I learned that is very helpful for children who retain urine, pocket urine in corners of their bladders, or clamp down on the catheter, is to press firmly with the palm of your hand on the bladder to help express the urine. This technique should only be done with a catheter in place since it can cause reflux to the kidneys if the urine does not have an easy route to exit the body. I often find I get an additional 30-60ml of urine out when employing this technique.
My daughter's urologist also suggested attaching a 60ml catheter-tip syringe to her catheters and sucking out any additional urine. While this may be helpful for some children, my daughter found it very painful and it could potentially injure the bladder. Slight pressure on the bladder seems a safer and more comfortable technique for most children.
Yet another technique for children who clamp down and stop the flow of urine is to trigger a reflex that forces them to release and relax. Simply run a finger from the heel to toe of one foot, triggering the child to spread her toes, and effectively forcing her to stop clamping down.1
Don't neglect simple things like letting gravity help the urine flow. Propping the child's body up at an angle can help the urine to flow more freely. Make sure not to tilt the catheter upward when trying to collect the urine, since gravity will prevent the urine from leaving the bladder. Finally, don't be afraid to cath "head-on" instead of sideways as most nurses show you during training. It is often easier to see the urethra if you are looking straight at it instead of trying to access it from the side.
It is common to be told to cath your child every three or four hours. Unfortunately, most children do not make the same amount of urine throughout the day, and a strict schedule may not work for your child. This is especially true if your child receives tube or IV feeds during the night. You may need to cath very frequently in the morning and less frequently in the afternoon and evening. For children on a continuous drip at night, you may need to cath very frequently during the night.
It can be helpful to create a cathing journal. Keep track of when you cath, how much urine you got out, and whether the child voided between caths. You may also want to note if the child urinated around the catheter (which can signal that you waited too long to cath) or if the child had discomfort before or during the cath. After keeping track of all your caths for a week or two, you will begin to see patterns that may help you determine a schedule for your child. Don't worry if the schedule is not every three or four hours. We used to cath my daughter every one to two hours in the morning and every four hours in the afternoon. It may be unusual, but that is what worked best for her body.
The Messy First Few Weeks
The first few weeks of cathing are always messy, problematic, and frustrating. Don't give up! It does get easier as you and your child become more accustomed to cathing and find the right cathing schedule.
Our first week involved urine flooding around the catheter and even shooting into my face. We were changing bedding four times a day! Not only that, we had multiple misses when the catheter went in the wrong hole or when she peed the catheter out completely, shooting it across the room on several occasions. Once we figured out she needed additional cathing in the mornings and her body got used to cathing, things became much, much easier.
Don't Let Cathing Run Your Lives
When the federal government was coming up with regulations to make public bathrooms accessible, they obviously forgot about children who cannot sit up and need to be cathed or changed throughout the day. Cathing while you are out and about is definitely not the easiest thing to do. Closed system cath kits help enormously, but there is still the issue of finding a place to cath for children unable to sit, stand, or walk.
If we had to be home for all of my daughter's caths we would never leave the house. We have developed strategies for cathing outside the home that make things a little easier. One is to cath on the floor of the van (after removing the wheelchair from the van) whenever possible. If we are traveling without the van, then I take along a folding blanket that has a soft fuzzy material on one side and a waterproof plastic on the other. I lay the blanket on whatever surface is available, such as a resting couch in the bathroom, a public bathroom counter, or, if I am really desperate, on the bathroom floor. Once I am done, the blanket folds compactly and velcroes closed, and can simply be hooked on the back of the wheelchair or stuffed in a backpack.
When we began cathing, I scoured the internet for articles and support forums and found very little information. Cathing is commonly a procedure done as a part of another condition such as a Spinal Cord Injury or Spina Bifida, so most discussions on cathing are found on sites specific to these conditions.
I hope this primer helps smooth the road a little bit.
1Thanks to Erin for suggesting this technique.