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Diane Newman: Welcome to UroToday in our online medical education program. I am Diane Newman, a urology nurse practitioner, and I'm really excited today to introduce our speaker, Leah Holderbaum. She's an occupational therapist that I've actually done some research with in the past, and she's really knowledgeable because she deals with patients with intermittent catheterization, which she's going to talk about in a few minutes. Currently, she's the medical supply educator for Numotion. Welcome, Leah.

Leah Holderbaum: Thank you so much, Diane. I'm so excited to be here. What we're going to be discussing today is intermittent catheterization and the role of the occupational therapist. To reiterate, I am an occupational therapist, and I worked at a large model rehab here in Dallas, Texas. And it was while I was there that I really became aware of the critical role that occupational therapists play in bladder management.

And I began pouring into research and books. And that's when I really connected the dots about the importance of the interdisciplinary approach to intermittent catheterization. There are going to be a few products that I am going to discuss today. That being said, I do not endorse one particular product over another. I am a firm believer in providing patients with choice and options so that they can make the best decision for them.

The presentation outline: Over the next few moments, we are going to discuss patient factors and considerations for intermittent self-catheterization, or ISC. We will review catheter features and benefits and functional implications, and we will incorporate techniques and strategies to promote independence and long-term outcomes for intermittent self-catheterization. It's very important to first understand the assessment of the entire individual and look at them with a holistic approach.

That being said, first and foremost, consider what is the functional performance of that individual. This may encompass dexterity regarding opening packages or managing their catheter and supplies. This may include balance required to complete a transfer or to stand at the commode, if possible, for their intermittent self-catheterization. There are so many different facets that carry into the functional performance dynamics involved with intermittent catheterization.

Specifically with the population that I work with, individuals are typically in wheelchairs. Primarily, I've worked with individuals who have had a spinal cord injury or spina bifida. So considering all of those individual facets that accompany wheelchair use on an everyday basis is going to be important to consider as well.

Next, getting into who is the person needing the solution. Really looking at the personal factors. What does that person do for work? Do they go to school? What are their roles and routines? Are they a single mother who is getting their kids to and from dance practice and soccer games? Do they have to break down a wheelchair to get in and out of a vehicle? Really looking at all of these different facets of their everyday life and their lifestyle is going to help make appropriate recommendations so that person can be independent and ultimately as healthy as possible.

Next, getting into where will the bladder management be completed. That being said, again, I work with individuals primarily in wheelchairs. So it's important that individuals know how to cath from their wheelchair as well as potentially from a bed. They also need to be able to problem solve in public restrooms. Where are they going to be laying out their supplies for management? How are they going to make sure that they are implementing the appropriate technique and strategy to reduce and prevent infections?

And lastly, financial considerations. How much is that person going to be responsible for? Every single year, as we all know, insurance restarts, and we're responsible for deductibles. The higher-quality products are going to be more costly. And it's also important to note that different insurances will have some different medical guideline requirements in order for those insurance qualifications to be met. For example, Medicare has very specific features that are required in order to obtain certain catheters.

Next, it is important to understand the features and benefits of catheters. These all tie directly into the functional performance skills of the individuals. Over the next few moments, we are going to discuss the length, the French or the diameter of the catheter, different tips, different types of lubricants, grippers, and rigidity.

Looking at the length of catheters, this is attributed directly to the length of the urethra. For example, someone with male anatomy typically is going to use a 16- to 25-inch catheter, whereas someone with female anatomy is typically going to utilize a 4- to 6-inch catheter. That being said, it is very possible for someone with female anatomy to use a male-anatomy-length catheter should the incident arise where it's going to be more beneficial for them to use. If you think about it, once that catheter is inserted into the urethra for someone with female anatomy, they're not going to have a lot of surface area to be working with. So using a longer-length catheter can be conducive to helping them be independent.

Also, pediatric-length catheters are usually about 6 to 16 inches in length. Again, someone with female anatomy may choose to utilize that length as well. The different French or diameter size—typically, someone with a pediatric anatomy is going to utilize a 6- to 12-French catheter. So this is going to be a smaller diameter. It's going to be a smaller size, which attributes to the more narrow urethra of someone with a pediatric anatomy. Whereas someone with adult anatomy is typically going to be utilizing a 14- to a 16-French. These French sizes are standard across all manufacturers, and they are all color-coded based on the funnel that's going to correlate directly to the French size of that catheter.

Getting into the different tips: a straight tip catheter is basically just what you would think—that catheter tip is going to be straight, and that is going to be the standard catheter that is utilized for initiating intermittent self-catheterization. The next tip is a coudé tip, which is used to bypass any sort of urethral obstructions or barriers. This could be an enlarged prostate. It could be urethral narrowing or any buildup of scar tissue due to any bladder diversion procedure. Last is the introducer tip, and the introducer tip is utilized to actually go into the urethra itself. That way, that tip actually bypasses the distal portion of the urethra where the majority of bacteria collects. That way, it's not going to be dragging bacteria through the entire duration of that urethra.

Next, getting into lubricant, we're going to be looking at uncoated versus coated. This could be a difference in hydrophilic, or it could be a gel catheter, just depending on the different manufacturers. There could be a gel pouch that is in the catheter for someone to utilize prior to intermittent catheterization, or there could be a sachet. There are sometimes little silver pouches within the catheter packaging, and that is for a coated catheter. With that coated catheter, once that sachet is popped within that packaging, it is going to coat the entire duration of that catheter. It's going to activate that lubricant to help reduce a lot of that friction with insertion.

Next, you could have a pre-lubricated gel catheter. This is ready to use out of the package. Or you could have a pre-lubricated hydrophilic catheter. This is one that is typically a bit more watery-based, and that catheter is going to be ready to use out of the package as well.

Next, getting to the gripper. A gripper is a type of sleeve that is going to go over the catheter, and it can actually extend the entire length of the catheter. They are typically made of various different materials, and they are used to reduce contamination because it promotes easier insertion by allowing the user to handle the catheter without direct contact.

Last, catheter rigidity is based solely on the catheter material. Typically, catheters made of PVC are going to be a bit more rigid, whereas catheters that are latex are going to be very, very significantly less rigid—almost floppy, for lack of better terms.

These are all important facets to consider when looking at an individual's dexterity. For example, if they have any sort of dexterity issues, are they able to actually pop the sachet within a coated catheter? Or are they able to even open the packaging of the catheter? Does that catheter packaging have different types of thumb holes or finger loops to help with easy opening? Also, rigidity—the more rigid the catheter is—typically, individuals that do have impaired dexterity benefit from a more rigid catheter, because if it was less rigid, it might actually cause some coiling and buckling. So being familiar with the different types of catheters that are on the market and some of the different features and benefits can help you make appropriate recommendations for your patients.

Next, getting to positioning. At the top, you can see my friend Anthony—he is demonstrating the male anatomy positioning in bed. Typically, it's just a very slight posterior pelvic tilt. They may choose to prop up against their headboard or have a few pillows back there. And the idea is that it just opens up that angle so as not to put pressure on the bladder, allowing for optimal emptying.

Next, you'll see my friend Anthony demonstrating intermittent catheterization at the wheelchair level within a public restroom. I do want to point out that in these photos, it's important to take into consideration that once that catheter is inserted into his body, he's only going to have a few inches that are exposed. So in that instance, he would either need to utilize a urinal or a drainage bag, or he may choose to use an extension tube to drain directly into the commode.

Down on the bottom, you see my friend Catherine demonstrating female anatomy positioning. First and foremost, I typically recommend beginning in bed, just because it's important to become familiar with the individual's anatomy and allowing them to get comfortable with the entire process. Again, with my friends typically being in chairs, this works out very nicely as they're learning their bed mobility and lower body dressing strategies. So again, beginning in bed, it's really important to have a very drastic posterior pelvic tilt, making sure that the patient is on their tailbone so that they do have optimal access to the urethra.

My personal favorite is problem-solving through intermittent catheterization in a wheelchair. Typically, what I recommend is for the individual to move herself forward onto the seat of her wheelchair. If she looks between her legs and sees any portion of that seat, she's probably not far enough forward for optimal urethral access and needs to scoot further forward. In that photo, you can see how drastic that posterior pelvic tilt is, meaning Catherine has to have enough strength, enough coordination, enough balance, the cognitive capabilities, and safety awareness to achieve this position. And this is after, of course, she has managed her clothes to get into the appropriate position.

Lastly, you can see Catherine demonstrating over the commode. Again, considering, is she going to do a slide board transfer, or a squat pivot, or a sit pivot transfer over to the commode? When is she going to be managing her clothes—before she transfers or after she transfers? What type of product is going to be optimal to ensure that she's maintaining clean technique, not getting her hands in the commode, but she's also optimally independent?

Here is a video. Catherine is demonstrating administering lower body dressing from her wheelchair. And what I love about this video is that it truly depicts the dynamics of intermittent catheterization from a wheelchair level. That being said, Catherine had to have the functional capabilities to advance her hips forward in the wheelchair. She needed to have the strength, balance, and stability to manage her clothes, maintain that proper position.

She also needs to have the strength to be able to potentially manage her legs onto the commode should she choose to, or into various positions. You can see here, she does utilize a mirror for this simulated intermittent self-catheterization. This is actually a skin inspection mirror, and it has a rigid handle that is bendable. So it's very, very beneficial for her. Catherine does have an introducer tip on this catheter. I do want to point out that you do not advance the catheter prior to inserting. You actually do insert that entire blue portion into the urethra.

That being said, there is a lot of problem-solving and a lot of troubleshooting that happens when it comes to intermittent self-catheterization. This is where working with an occupational therapist could really come into play.

Getting to adaptive equipment: As occupational therapists, we love adaptive equipment. And if there is an activity of daily living that is difficult for someone, I guarantee there is a piece of adaptive equipment out there that can assist. And if there isn't, I guarantee an occupational therapist has fabricated one or attempted.

The first object that you see is a catheter inserter, and that is geared towards individuals that have dexterity issues. That being said, that clamp is very easily manageable, so an individual can insert the catheter directly into that clip, and then they can insert the catheter directly into their urethra. They do not need to have any dexterity or finger function to be able to utilize that cuff.

The next option that you see is a penis stabilizer. For many of my friends in wheelchairs, it's very difficult to hold your clothing out of the way, manage the penis, manage all of the parts and pieces of your supplies, and the products. So anything we can do as therapists to eliminate one step and promote independence, we're going to do it. That being said, the penis stabilizer holds the penis in place in the appropriate position for intermittent catheterization.

The next option is a pants holder. You may have also seen it referred to as a Betty hook. There are different versions. One is metal, one is plastic, and this holds pants out of the way. Again, in conjunction with any of the other components of adaptive equipment, this is going to help someone with male anatomy be more independent in their overall intermittent self-catheterization. I've actually had friends in wheelchairs put Velcro on one side of the pants holder and the other side of Velcro on the bottom of their urinal to hold it in place while they're cathing—again, eliminating one step to make the whole process easier.

Next is a bungee cord. That is the same purpose. If you tie the bungee cord to the frame of that wheelchair, you can actually hook the other end in the pants, and that resistance is going to pull the pants downward, holding the pants out of the way.

Next is the Asta Cath. This is actually designed by a nurse. Her name is Linda Asta, and that triangle portion, once that is lubricated, will go directly into the vagina, and then the sides serve as a labia spreader, while one of those holes is going to always line up with her urethra, giving her visual feedback of where she needs to aim.

The next, Thinkx. These are washable and reusable incontinence panties.

The last four objects were actually made by my friend Mark, and he has a company called AbilitEASE. And he himself is a tetra, and so he utilizes his 3D printer to fabricate pieces of adaptive equipment based on what has been difficult for him. And he has a whole series of adaptive equipment for bladder management.

You can see his catheter clamp. Again, that is geared towards individuals with dexterity issues. There's different ways that you can utilize it for independence. The Uri-Luge is valuable because that can actually serve as the extension tube to guide the urine directly into the commode. It also has that comma-shaped hole, and that is to hold the funnel in place of that catheter so he can be more hands-free.

Next is the Lap-system. You can see there that it actually goes across his lap, and it can either hold a urinal or it can actually hold the catheter, managing a hands-free approach for his intermittent self-catheterization. And lastly, you can see, again, that urinal cap with that comma design, allowing for the funnel of the catheter to be wedged in there so that the catheter doesn't move around while the person is performing intermittent self-catheterization.

In summary, ISC must be interdisciplinary. There are reasons why occupational therapists, physical therapists, ATP, nurses, doctors, dietary, psychologists—it truly is an interdisciplinary approach to achieve independence. It must be responsive, meaning the person must respond positively to it, meaning urine is removed from their body in a healthy fashion. And it must be reality-based. It must meet their lifestyle need, whether it is providing a product mix or trialing different sizes and different products with features and benefits to help meet the appropriate need.

ISC is dynamic. It is so much more than just inserting a catheter to drain the bladder. Especially if individuals are in wheelchairs or have other comorbidities, there are so many things to take into consideration. And catheter features and benefits, having knowledge on that, as well as adaptive equipment and just some different problem-solving strategies, can really be beneficial in facilitating independence and overall health.

ISC is not one size fits all or most. I have worked with many, many patients, and none of them have ever had the same bladder management strategy or utilized the same adaptive equipment. So making sure that you're working with the individual to see what is going to best meet their lifestyle need.

Take-home message: Collaboration with OTs for ISC can facilitate increased independence, health, quality of life, and so much more. And when I say that there is nothing I love more than problem-solving through and troubleshooting through the intermittent self-catheterization process, I mean it. I may not be currently practicing in the clinic, but it is still within me. And I think it's very, very powerful to be able to give patients the tools and the access to succeed so that they can be ultimately healthy and improve their quality of life.

Diane Newman: Thank you so much, Leah. That was really, really excellent presentation. It's so much usable information that a patient who's performing catheterization can use. Do you think that most rehab centers do have occupational therapists that have your expertise in teaching patients, I see?

Leah Holderbaum: My experience, I will say no. There are a lot of rehabs that do have clinicians that do have a focus on intermittent catheterization. However, I will say, in my experience speaking at many of these rehabs, I have been able to see gaps in education and knowledge. So anything I can do to empower clinicians, I am trying to do it just to provide that advocacy and education.

Diane Newman: If someone who's performing catheterization and wants to find adaptive equipment—I always am asked, where do you find it? Because I know a lot of urology nurses are not aware of it. And a lot of times, patients will have searched the internet and then they come in and say, oh, I found this. And then you're seeing, then, like, wait a minute, what is that? Like that mirror you have that attaches on the leg, where do you get this equipment? I mean, is it something that occupational therapists kind of have a website they go to, or how can they access it?

Leah Holderbaum: There are some sites that do have a series of equipment. For example, I mentioned AbilitEASE. He does have some of his adaptive equipment, adaptive devices there. You can get some on Amazon. Most of the things that I've come across, I've gone to Google and just typed things in and kind of seen what came up. Also, I do have an Excel spreadsheet that I just keep going with adaptive equipment, so I am always more than happy to share that information if it helps to empower independence in that education.

Diane Newman: That would be wonderful because I would love to maybe put that on at the end of your slides. Or we can post it on UroToday because I get asked this a lot. And like you said, with women—and you gave so much important information on someone who's in a wheelchair—you don't have to necessarily take off all your clothes, especially a man does not. And if you have some of these, just these aids that can assist you, you can perform catheterization very safely.

Leah Holderbaum: Yes.

Diane Newman: So, I mean, you really provide a lot. And doing research with you and also the fact that your knowledge—like, I just could not believe how much I've learned from you. So we really appreciate you sharing this.

Leah Holderbaum: Thank you so much. It was my pleasure, Diane.

Diane Newman: Thank you.