Key Points Requiring Attention During Clean Intermittent Catheterization

Clean Intermittent Catheterization — Clinical Practice Notes

During clean intermittent catheterization (CIC), urine volumes collected from the same patient by different operators during the same period may vary by 50–100 mL. This variation is attributable to differences in technique, angle of insertion, and catheter manipulation among operators. Improper technique may result in incomplete bladder emptying, leading to increased post-void residual (PVR) volume and a heightened risk of urinary tract infection (UTI). Inaccurate assessment of residual urine volume may also result. The key practice points for intermittent catheterization are described below.

Optimal Catheter Insertion Depth

The catheter should be inserted to a depth at which urine is first observed, then advanced slightly further (an additional 1–3 cm). A satisfactory depth is confirmed by observing a steady, robust urine stream — not merely by inserting to a fixed depth (e.g., 4–6 cm in female patients) and then stopping, as was traditionally done.

Abdominal Pressure Application — Timing and Technique

During the initial phase of catheterization, abdominal pressure should NOT be applied. At this stage, the bladder is distended; applying pressure may cause a sudden increase in intravesical pressure, risking vesicoureteral reflux (VUR). Additionally, patients who retain sensation will experience significant discomfort or pain from the pressure.

Abdominal pressure should only be applied once the bladder has become less tense. As intravesical pressure gradually decreases (evidenced by a slowing or thinning urine stream), pressure should be increased progressively. The applied pressure should remain within the patient's tolerance and must not cause abdominal injury. An effective pressure is confirmed when the urine stream becomes faster and fuller.

During the final stage of catheterization, some patients may have sediment or debris present in the catheter lumen. At this point, the hand applying abdominal pressure must be maintained — do NOT release pressure before the catheter is fully withdrawn. Only after the catheter has been removed should pressure be released. Premature pressure release creates negative pressure within the bladder, which may cause sediment and residual urine to flow back into the bladder.

Managing Slow or Thin Urine Flow

If the urine stream slows or thins despite abdominal pressure, the following measures should be taken:

① Rotate the catheter gently to reposition the side holes of the catheter tip within the bladder, changing the angle of the catheter.

② Adjust the catheter insertion depth (advance or withdraw slightly) until the catheter tip is re-immersed in the urine pool.

③ Once the urine stream resumes or becomes faster and fuller, the catheter should be held in that position (the adjusted depth and angle) to continue drainage.

④ If repeated measures yield no further urine flow, the bladder is considered effectively empty. If the patient's condition permits, a change in body position (e.g., elevating the head of the bed) may be attempted before final catheter withdrawal.

Catheter Withdrawal Technique

During catheter withdrawal, the catheter must be kept below the level of the urethral meatus at all times. The hand applying abdominal pressure must maintain its supportive pressure throughout the entire withdrawal process.

Patient Positioning

Patients are typically positioned supine (lying flat on the back) during catheterization. If the patient is able to sit up, a semi-recumbent or seated position may be adopted. Male patients who are able to stand may perform self-catheterization in the standing position. Important note: the supine position typically yields 50–150 mL less urine than the seated or standing position.

Managing Urethral Spasm During Catheterization

If the patient experiences urethral or bladder spasm during catheterization, abdominal pressure should NOT be applied, as this may exacerbate the spasm.

For male patients experiencing difficulty with catheter insertion due to spasm: wait until the spasm subsides, then select a catheter of a slightly smaller diameter, apply abundant lubricant, and insert quickly. When the catheter meets slight resistance at the prostatic urethra, gently lift the penis toward the abdominal wall — this maneuver reduces resistance and facilitates insertion.

If resistance is too great to allow catheter passage, do NOT force repeated insertions, as this may cause urethral bleeding, mucosal injury, and worsening spasm. Manual techniques to suppress spasm or pharmacological antispasmodic agents may be used under clinical guidance.

Catheter Selection

Select the largest-diameter catheter that is appropriate for the patient's urethral caliber. A larger catheter facilitates the expulsion of sediment and debris, produces a stronger urine stream, and reduces the duration of catheterization.

Special Considerations During Menstruation

During menstruation, female patients may opt for an indwelling catheter if appropriate, or reduce the frequency of intermittent catheterization if spontaneous partial voiding is possible.

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