Life on Wheels (28 page)

With intermittent catheterization, you insert a catheter when it is time to empty the bladder, performing the process several times per day. A nurse or therapist trains you in the proper techniques for self-catheterization. In the hospital, a fresh catheter is used each time. After discharge, the same catheter can be reused, assuming you practice very clean habits. If you use intermittent catheters, you would carry catheters and supplies for cleaning; these can be carried in a pack on the back of your wheelchair.

Historically, bladder catheterization programs have been based on a time model. Such a program encouraged you to empty your bladder every four to six hours. At times, there would be a small amount of urine, meaning that the invasion of a catheter was an unnecessary act. In that interval between catheterizations, the bladder might also have become very full and distended, an even more undesirable state. Without sensation, there was no way to know how full the bladder was.

There are new catheterization products being developed. For example, Diagnostic Ultrasound Corporation has released a product based on volume-dependent catheterization. The BladderManager™ PCI 5000 is an ultrasound device that can be worn continuously and can warn you when your bladder reaches a selected percentage of fullness. The company’s research found that 67% of timed intermittent catheterizations were performed prematurely and 16% were performed too late. The BladderManager is promoted as a means to limit infections, upper urinary tract damage, and costs for healthcare and supplies.

The O’Neil catheter is designed to limit UTIs. It is a catheter already placed inside a sterile collection bag. The special tip is first inserted into the opening of the urethra. The manufacturer claims that its opening goes beyond the area where bacteria are most likely to invade. The sterile catheter is then extended from inside the drainage bag and enters the urethra beyond the entry tip, supposedly bypassing the place where it could pick up bacteria from the urethral opening and carry it into the bladder. O’Neil catheters are portable, and the integrated drainage bag is convenient. The company claims that it considerably reduces the incidence of UTIs. O’Neil catheters are a single-use product and cost more per unit. The cost of such catheters might be covered by your private insurance carrier, Medicare, or Medicaid.

Intermittent catheterization can be more costly than an indwelling catheter if you rely on additional personal assistance services to change them. Dr. Alex Barchuk of the Kentfield Rehabilitation Hospital in California observes:

For someone with sufficient hand dexterity to do the intermittent procedure themselves, the cost might not be a concern, particularly with good insurance coverage.

Many men with spastic bladders or a degree of manual control of the urinary sphincter can manage well with a male urinary condom, also known as an external catheter. Men using condoms will need to catheterize only occasionally, if at all, to remove residual urine. The condom is changed or reapplied at least once a day to provide the skin a chance to breathe and be inspected for irritation. It is a good general practice to swab the penis for hygienic reasons. There are three types of male urinary condoms:

The Texas catheter is held in place with an external strap, either made of sticky foam or with a Velcro tab at the end. The strap must be applied carefully. If it is too loose, the catheter will leak. If it is too tight, the skin of the penis can become irritated or break into a sore.

Another design uses a two-sided sticky foam strap that is first applied to the penis and then adheres to the condom as it is rolled over the strap.

The third type is self-adhesive and adheres as it is rolled onto the penis.

Some urinary condoms are supplied with a small pad of skin protector. The skin protector is also available as a separate product you can order from a medical supply store or catalog.

Condoms are typically made of latex. Some men develop latex sensitivity, in which the skin of the penis becomes dry, red, and irritated. Some men experience a temporary allergy and are able to return to the use of latex. Silicone catheters are available in the self-adhesive type only. Latex, as with balloons, is capable of stretching. Silicone has very little elasticity.

Urinary condoms come out of the package rolled up, just as with condoms for sexual use, although they include a tubed end for drainage of urine. The tube might be an extension of the material of the condom or a separate plastic tube attached at the end of a latex catheter. Urinary condoms come in several sizes, and the latex types are flexible enough to accommodate the changes in size that some men experience throughout the day.

When a man has severe ongoing problems with bladder infections and other complications, a urologist might recommend a sphincterotomy. Surgeons cut the bladder sphincter muscle and release its capacity to keep the bladder closed. The bladder empties continuously, and a condom and leg bag system collect the urine. This very invasive procedure should be considered a last resort. Take care not to allow your physician to overly influence you. Consider him a provider of information. Take time to understand the full implications of such a measure, talking to others who have been through it. A sphincterotomy is not reversible.

Bacteria grow like crazy on the appliances used for bladder management. Indwelling and external catheters and leg or bedside drainage bags are environments in which the
E. coli
that cause infection grow. Cleanliness must be a high priority to protect yourself from chronic UTIs—and the increased risk of developing bladder cancer that is associated with having chronic UTIs.

Use new internal catheters as often as you can, employing the best clean practices you can in the meantime. Always wash your hands before and after you insert a new catheter, and store the catheter in an antibacterial solution such as Betadine
^®
. Know that indwelling catheters harbor bacteria after only days, so the catheters need to be replaced often. External condom catheters should be replaced daily—some urine inevitably remains on the inner surface, breeds bacteria, and can migrate back up the urethra.

Each time you remove a catheter from a collection bag, clean the end of the catheter and the collection bag with alcohol before replacing them. Keep a bottle of alcohol and cotton balls in your bathroom, and carry individual alcohol wipes with you everywhere you go. This commitment to the cleanest practices—along with drinking sufficient amounts of water and ensuring that you are efficiently emptying your bladder—will help ensure your greatest protection from immobilizing and ultimately life-threatening UTIs.

If you don’t have a bowel movement every day, you don’t necessarily have constipation. It can be normal to have a bowel movement every two to three days. What counts is that you have a routine and that you manage your stool consistency. You need to establish a pattern in a managed bowel program that depends on what kind of neurogenic bowel you have. Evacuate your bowels often enough to ensure that you do not become impacted, yet not so often that you unnecessarily disrupt your schedule or risk the health of the tissues of the rectum and colon, especially if your bowel program regularly involves manual removal. Without an effective bowel program, some people can eventually require a colostomy—whereby the bowels must empty into an external bag—after falling into patterns of constipation and impaction.

The less your nervous system allows you control of the sphincter muscles, the more you need to train it to prepare for defecation at a time when you can control and induce it by the use of one or more following techniques:

Digital stimulation. Gentle massage of the area around the anal sphincter muscle encourages it to relax.

Manual removal. Wearing a latex glove, you or your PA gently scoops out stool with a finger.