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While rarely life-threatening, urinary incontinence (UI) can have a deleterious effect

on the physical, psychological and social wellbeing of anybody affected by it (National Institute for Health and Care Excellence [NICE], 2013). The impact on the families and carers of people with UI can be equally serious, and the cost, in terms of health resources, can be considerable.

UI is defined by the International Continence Society (ICS, 2005) as ‘the complaint of any involuntary leakage of urine’. It has been shown to be more prevalent in women than men, with rising prevalence linked to increased body mass index (BMI) and diabetes (Markland, 2011). Specifically, women are 7–8 times more likely to be affected by UI than men (Millard, 1996; Foxley, 2007), with prevalence increasing with age in both genders (Doughty, 2000; Foxley, 2007).

UI affects a wide spectrum of women and has correlations with reduced quality of life (Harris, 1999; Howard, 2010). The Department of Health [DH] (2002) has estimated

Urinary incontinence and the importance of catheter fixation

that in people living at home UI affects: Up to one in 14 women

aged 15–44 Up to one in seven women

aged 45–64 Up to one in five women aged

65 and over Over one in 33 men aged 15–64 Up to one in 10 men aged 65

and over.

The numbers of people experiencing UI are even greater for those (of either sex) living in institutions: One-in-three in residential homes Nearly two in every three in

nursing homes One-half to two-thirds in

wards for elderly people and elderly people with mental health problems.

TYPES OF URINARY INCONTINENCE

Stress UI results from physical exertion, or bodily reactions like coughing and sneezing. Urgency UI is preceded or accompanied by a sudden impulse to micturate, which is difficult to control. Mixed UI is where the patient experiences both episodes of stress and urge incontinence

(although this does not have to occur simultaneously).

Overactive bladder (OAB) occurs with or without incontinence and is where the bladder muscle (detrusor) contracts suddenly without the individual having control, even when the bladder is not full. The condition known as ‘OAB dry’ is characterised by urgency UI, but without leakage — conversely, ‘OAB wet’ is urgency UI accompanied by leakage.

Nocturia (waking to go to the toilet more than once at night) and frequency (the urge to urinate often) are other factors that can complicate the overall UI picture.

TREATMENTS

Because of the variety of types and symptoms of UI, it follows that treatments are similarly varied. Treatment is dependent upon the type and aetiology of UI, as well as the existence (or not) of associated conditions (such as diabetes). Sexual activity and quality of life are also considerations.

In most cases it is recommended that non-invasive, conservative techniques be tried first, rather than moving straight to pharmacological or surgical intervention (NICE, 2013). These include avoiding triggers such as alcohol or caffeine, performing regular pelvic floor exercises or timing visits to the toilet, and ‘training’ the bladder to respond differently to cues by using bladder ‘drills’ (these can involve attempting to ‘hold on’ for increasing periods before visiting the toilet, for example).

Some treatments, such as intermittent self-catheterisation (ISC), have been used for 4,000 years (Nazarko, 2007), with the materials

Julian Spinks, Kent-based GP with a special interest in continence

Urinary incontinence affects quality of life in a large number of people of varying ages. For a significant number of patients the problem has to be addressed by catheterisation, a treatment method that can give rise to a host of potentially avoidable complications. Catheter stabilisation is an essential practice in avoiding unnecessary damage to the urethra and accompanying pain. While a number of products are available, there seems to be no preferred device for securing catheters. This article looks at CliniFix® (CliniMed, Buckinghamshire), a universal tube-securing device, which approaches tube fixation in a different way to strap-style-devices.

KEYWORDS:Continence Urinary incontinence Catheter fixation

Julian Spinks

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Wriggle control

CliniMed Ltd. is a company registered in England number 01646927. Registered office: Cavell House, Knaves Beech Way,Loudwater, High Wycombe, Bucks, HP10 9QY. Tel: 01628 850100 Fax 01628 527312 Email: enquiries@clinimed.co.uk or visit:www.clinimed.co.uk. CliniMed® and CliniFix® are registered trademarks of CliniMed (Holdings) Ltd. ©CliniMed Ltd. 2013.CliniFix patent number: GB 2 448 517B EP 1982743PID 28

CliniFix® - the Universal Hydrocolloid Securement Device

For a free sample of Clinifix, please call our free confidentialcareline 0800 036 0100 or visit www.clinimed.co.uk

CliniFix, the unique multi-purpose medical tube holder, is the most comfortable and secure way to hold catheters and most sizes of medical tubing in place. It can be used in two distinct ways for different security needs - a hook and loop securement device for some movement or an inner adhesive strip for extra security. The resealable design allows repeated access. With a skin-friendly hydrocolloid base it can remain in place for up to seven days and no rigid plastic edges, straps or clips means CliniFix fits like a second skin anywhere on the body.

®®

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26 JCN 2013, Vol 27, No 5

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advancing while the technique remains largely the same (ISC involves patients periodically self-inserting a catheter).

Other treatments, such as the use of botulinum toxin A (which helps reduce bladder wall contractions) and sacral nerve stimulation for the treatment of OAB, are becoming more routine (NICE, 2013).

Treatment for stress UI can be approached by various pathways and many are equally applicable to mixed UI. As mentioned above, lifestyle interventions include dietary alterations (smoking cessation, weight loss), and a higher/lower fluid intake as appropriate. Physical therapies, such as pelvic floor exercises and electrical stimulation are also employed, sometimes in collaboration with biofeedback therapy (Burgio, 1990). Biofeedback uses visual displays and audible tones to demonstrate to the patient the muscles he or she is exercising, allowing muscle strength to be measured and exercise programmes to be individualised.

Pharmacological intervention for urge UI is possible through use of various drugs, and is in widespread use, although efficacy is variable (Rovner, 2004).

If conservative non-invasive approaches have proved ineffective, and/or are poorly-received by the patient with stress UI, surgery becomes the focus. Somewhere in the region of 200 different procedures exist in the surgical treatment of stress UI (Rovner, 2004), but most common is the use of tapes to support the mid-urethra.

CATHETERISATION AND THE 2013 NICE GUIDELINES

The management of urinary incontinence in womenUse of a catheter, whether intermittent urethral, indwelling urethral, or indwelling suprapubic, falls into what NICE define as an ‘alternative conservative management option’ (NICE, 2013), and is employed when an individual is not able to completely empty the bladder.

Such inability to void, whether due to detrusor dysfunction, urethral stricture, obstruction, or other problems, is commonly the result of interference with the spinal or bladder nervous pathways. This may be due to diseases such as Parkinson’s, multiple sclerosis, spina bifida, and diabetes mellitus, or to infection, trauma, constipation, or paraplegia (Nazarko, 2009).

The recently updated guidelines (NICE, 2013) on the management of urinary incontinence in women build upon the 2006 guidelines in light of advances in evidence and treatment. They form a best practice guideline on caring for women with UI, with specific recommendations expanding upon a selection of ‘key priorities for implementation’.

These cover all aspects of care from lifestyle-based advice to invasive surgical intervention. The following is a summary of the guidelines regarding the use of catheters: Bladder catheterisation, be it

intermittent, indwelling urethral, or suprapubic, should be considered for women who suffer from persistent retention of urine, giving rise to incontinence, related infections and renal malfunction, and which cannot be alleviated or corrected using any other method

Patients with urgency UI should be made aware that indwelling catheterisation will not necessarily result in continence

For those patients who are able to be taught self-catheterisation, or who have a carer, intermittent self-catheterisation should be offered

The long-term effects of indwelling urethral catheterisation should be considered with care. The patient, and the carer if applicable, should be made fully aware of the advantages, realities, and risks involved. Suitable

patients for such a treatment include:

Those who suffer from chronic retention of urine, and are unable to perform intermittent self-catheterisation

Those who suffer from pressure ulcers, skin wounds and other irritations being contaminated by urine

Those who experience distress and disruption from frequent bed or clothing changes

Those who elect to undergo this treatment.

As an alternative to long-term urethral catheters, indwelling suprapubic catheters (inserted through the abdomen directly into the bladder) may be considered. The nurse should inform patients that suprapubic catheters may be linked to lower rates of urethral complications — ‘bypassing’ — and lower incidence of symptomatic urinary tract infection compared to indwelling urethral catheters

Intraurethral and intravaginal leakage prevention devices should not be employed for regular management of UI, but rather only used occasionally, such as during exercise.

The NICE guidelines advise catheterisation when other methods have not been effective, and Newman (2007) provides the following indications for the use of an indwelling catheter: Short term for acute

urinary retention Sudden and complete inability

to void Necessary for immediate and

rapid bladder decompression.

Indwelling catheters can also be used to provide temporary relief of bladder outlet obstruction secondary to (Newman, 2007): Enlarged prostate gland Urethral stricture Obstructing pelvic organ prolapse Urologic or prolonged

surgical procedure Chronic urethral obstruction or

urinary retention with surgical interventions and/or where the use of intermittent catheterisation is either not practical or has failed

‘The NICE guidelines advise catheterisation when other methods have not been effective.’

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The thought of catheterisation is a daunting one, but the procedure needn’t be painful or traumatic. Instillagel anaesthetises the urethra whilst providing broad-spectrum antimicrobial coverage that helps protect her against UTIs,

as well as giving essential lubrication. Tried and trusted for 25 years, Instillagel is the triple action urethral gel that you can both rely on.

For further information please contact the CliniMed® Careline on 0800 036 0100

Prescribing information: Composition: Each 100g of Instillagel contains: Lidocaine Hydrochloride 2.0g, Chlorhexidine Digluconate solution 0.25g, Methyl Hydroxybenzoate 0.06g, Propyl Hydroxybenzoate 0.025g. Uses: Catheterisation, cystoscopy. Exploratory and intra-operative investigations, exchange of fi stula catheters, protection against iatrogenic damage to the rectum and colon. Gynaecological investigations. Dosage and administration: Unless otherwise prescribed by a doctor: Urethral catheterisation: instil 6-11ml of gel into the urethra. The anaesthetic effect begins after 3-5 minutes. Contraindications, Warnings, Precautions and Interactions: Instillagel® must not be used in patients with known hypersensitivity to the active ingredients

(amide-type anaesthetics, chlorhexidine and alkyl hydroxybenzoates) or any of the excipients. It should not be used in patients who have damaged or bleeding mucous membranes. Use with caution in patients with impaired cardiac conditions, hepatic insuffi ciency and in epileptics. Diffi culty in swallowing may occur with an increased risk of aspiration and biting trauma. Use with caution in patients receiving antiarrhythmic drugs. Undesirable effects: In spite of the proven wide safety range of Instillagel®, undesirable effects of lidocaine are possible where there is severe injury to the mucosa; for example, anaphylaxis, fall in blood pressure, bradycardia or convulsions. Presentations: Pre-fi lled disposable syringes; for single use only. 6ml and 11ml; packs of 10.

NHS Price: 10 x 6ml £14.05, 10 x 11ml £15.76. Legal category: Pharmacy P. Marketing Authorisation Number: PL 03377/0002. Marketing Authorisation Holder: Farco-Pharma GmbH, Gereonsmühlengasse 1 - 11,D-50670 Cologne, Germany. Further information is available from: CliniMed Limited, Cavell House, Knaves Beech Way, Loudwater, High Wycombe, Bucks. HP10 9QY. Tel: 01628 850100. Date: February 2012.

Anaesthetic - Antiseptic - Lubricant

Information about adverse event reporting can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Farco-Pharma on 0049221594061

CliniMed Ltd, a company registered in England number 01646927. Registered offi ce: Cavell House, Knaves Beech Way, Loudwater, High Wycombe, Bucks HP10 9QY Tel: 01628 850100 Fax: 01628 527312 Email: enquiries@clinimed.co.uk or visit www.clinimed.co.uk. Instillagel® is a registered trademark of Farco-Pharma GmbH. CliniMed® is a registered trademark of CliniMed (Holdings) Ltd. ©2012 CliniMed Ltd. 1475/1211/1

is a licensed medicineInstillagel ®

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In the presence of irreversible medical conditions (e.g. terminal cancer, vegetative states)

Where healing of category three or four pressure ulcers is impeded because of urine leakage

Where healthcare staff (often in the home care setting) are not available to provide incontinence care.

IMPORTANCE OF FIXATION

The indications for catheterisation listed above cover a diverse range of conditions and patients, many of whom may well have serious debilitating illnesses. Catheter usage will be common among these groups and, therefore, the importance of securing them properly is paramount.

Complications of varying severity can arise from catheter usage, whether from infection, the presence of bacterial biofilm within the catheter itself (Newman, 2007), or because of poor, or total lack of, catheter fixation.

Despite the availability of various fixation devices (specialised tape, fixation retainers), some nurses may be tempted to use products that are not meant for the express purpose of securing the catheter, such as sticking plaster. Because the correct fixation devices are not always used, or practical in every case, urethral traction due to catheter movement often results in tissue damage, inflammation and significant pain (Centers for Disease Control and Prevention [CDC], 2002; Billington et al, 2008). This can further complicate a physical environment that is already at risk from the very presence of the catheter

to address and resolve such issues (Figure 1).

Using a hydrocolloid adhesive strip (Figure 2), CliniFix adheres to the skin securely as well as allowing CliniFix to stay in place for up to seven days at a time without irritation. The hydrocolloid adhesive also facilitates atraumatic removal. Hydrocolloid has been incorporated into wound dressings and stoma care flanges for over 25 years and widespread use has shown it to be an effective and skin-friendly adhesive (Berry et al, 2007).

The incorporation of a hydrocolloid strip means that CliniFix avoids any possible incidence of deep vein thrombosis (DVT), which has been identified as a potential problem in strap-style devices that tighten around the entire leg (Gray et al, 2006).

CliniFix’s design allows for a choice of two fixation methods — using the ‘hook and loop’ fastening, tubes of different diameters can be attached, held in place, or removed without the device having to be removed from the skin. The hook and loop can be closed without adhesion to the catheter tube, preventing tension and ‘pulling’ on the catheter tube itself. Alternatively, if a rigid fixation to the tube is desired, an inner film can be removed to reveal an adhesive contact layer for extra security. This inner adhesive is free from solvents, so the catheter’s integrity is not affected.

Overall, CliniFix provides a solution to any community nurse’s

(Newman, 2007). Indeed, Plowman et al (2001) note that around 80% of UTIs are associated with catheter use.

Furthermore, catheter-associated urinary tract infection (CAUTI) is more likely in women (Gray et al, 2006), thus stabilisation of the device is arguably even more important. As well as the problems of movement-induced pain and tissue damage, lack, or absence, of catheter fixation can also result in urine leakage, which may contaminate pressure ulcers or other wounds, further increasing the risk of infection.

Unstabilised catheters can be sufficiently irritating to cause detrusor muscle spasm in patients with detrusor hyper-reflexia (involuntary bladder contractions), potentially resulting in dislodgment, or even expulsion of the catheter (Hanchett, 2002). Re-insertion of catheters is a process that inevitably costs time and money and can cause distress and increased infection risk.

Therefore, it is important that community nurses are aware of the problems of catheter fixation and take measures to reduce the chances of movement, dislocation and traction.

CLINIFIX

As has been discussed above, some methods of catheter fixation, whether institutional practices or ‘off-the-cuff’ DIY solutions, can result in catheter movement, which in turn may cause urethral traction (Fisher, 2010), CAUTI, and encrustation (Newman, 2007). CliniMed’s CliniFix® product seeks

Figure 1.CliniFix product packaging.

Figure 2.CliniFix tube-fixing device in place.

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catheter fixation needs as it has the following benefits: Skin-friendly hydrocolloid

adhesive: provides the optimal combination of adhesion and skin friendliness; reduces skin irritation; does not cause trauma on removal

CliniFix’s hook and loop-type securing device aids application: simply and easily secures most sizes of medical tubing; prevents accidental tension and catheter removal; permits repeated access to tubing

Safe and simple to use: CliniFix gently adheres to skin, without straps or clips; it can be positioned precisely where needed; it does not slide or cause pressure; is safe to use on patients of all age groups.

CONCLUSION

UI affects the quality of life of a large number of people of varying ages. For a section of these patients, the problem of urinary retention has to be addressed by catheterisation, a treatment method that can give rise to a host of potentially avoidable complications. Catheter stabilisation is an essential practice in avoiding unnecessary damage to the urethra and pain.

CliniFix approaches tube fixation in a different way to strap-style devices.

By using a skin-friendly hydrocolloid adhesive, rather than an around-the-leg strap or a regular tape adhesive, any concerns around hampered venous flow or lymph return are circumvented, while irritation-free wear time and atraumatic removal are ensured. The option for a fixed or secure hold means CliniFix exerts an additional degree of control over catheters with varying tube diameters.

Investing in this type of technology not only helps nurses to reduce adverse incidents, it also means that they can provide more cost-effective care as choosing the correct product for a clinical scenario avoids costly equipment wastage and exacerbation of symptoms. More importantly, having the right equipment helps community nurses to provide patient-centred care. JCN

REFERENCES

Berry J, Black P, Smith R, Stuchfield B (2007) Assessing the value of silicone and hydrocolloid products in stoma care. Br J Nurs 16(13): 778–82

Billington A, Crane C, Jownally S, Kirkwood L, Roodhouse A (2008) Minimising the complications associated with migrating catheters. Br J Comm Nurs 13(11): 502–6

Burgio KL, Engel BT (1990) Biofeedback-assisted behavioral training for elderly men and women. J Am Geriatr Soc 38: 338–40

CDC (2002) Guidelines for the Prevention of Intravascular Catheter-Related Infections. Available online at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm (accessed on 4 October, 2013)

DH (2000) Good Practice in Continence Services. NHS Executive, London.

Doughty DB (2000) Urinary and Faecal Incontinence: Nursing Management. Mosby, London

Fisher J (2010) The importance of effective catheter securement. Br J Nurs 19(18 suppl): 14–18

Foxley S (2007) An overview of urinary incontinence. Br J Healthcare Ass 1(1): 35–8

Gray M, Newman DK, Einhorn CJ, Reid-Czarapata BJ (2006) Expert review: best practices in managing the indwelling catheter. Perspectives (Special edition): 1–11

Hanchett M (2002) Techniques for stabilizing urinary catheters. Am J Nurs 102(3): 44–8

Harris A (1999) Impact of urinary

KEY POINTS Urinary incontinence (UI), is

defined as ‘the complaint of any involuntary leakage of urine’ .

Women are more likely to be affected by UI than men.

Catheters are commonplace and the importance of securing them is paramount.

Urethral traction due to catheter movement can result in tissue damage, inflammation and significant pain.

CliniFix, a universal tube-securing device, approaches tube fixation in a different way to strap-style devices.

Answer the following questions about this, either to test the new knowledge you have gained or to form part of your ongoing practice

development portfolio.

1 – What is urinary incontinence?

2 – Name some of the main symptoms of urinary incontinence.

3 – What are some of the reasons for urinary catheterisation?

4 – Name some of the dangers associated with urinary catheterisation.

5 – Why is catheter fixation so important?

Five-minute test

incontinence on the quality of life of women. Br J Nurs 8(6): 375–80

Howard F, Steggall M (2010) Urinary incontinence in women: quality of life and help-seeking. Br J Nurs 19(12): 742–9

ICS (2005) Evaluation and Treatment of Urinary Incontinence, Pelvic Organ Prolapse and Faecal Incontinence. Available at http://www.ics.org/Publications/ICI_3/v2.pdf/summary.pdf (accessed on 4 October, 2013)

Markland AD, Richter HE, Fwu C-W, Eggers P, Kusek JW (2011) Prevalence and trends of urinary incontinence in adults in the United States, 2001 to 2008. J Urol 186(2): 589–93

Millard R (1996) Bladder Control. MaClennon and Petty, Sydney

Nazarko L (2009) Managing bladder dysfunction using intermittent self-catheterization. Br J Nurs 18(2): 110–15

Nazarko L (2013) Intermittent self-catheterisation and catheter fixation. Br J Comm Nurs 18(7): 322–5

Newman DK (2007) The indwelling urinary catheter; principles for best practice. J Wound Ostomy Continence Nurs 34(6): 655–61

NICE (2013) Urinary Incontinence: the management of urinary incontinence in women. Available at: guidance.nice.org.uk/cg171 (accessed 2 October, 2013)

Plowman R, Graves N, Esquivel J, Roberts JA (2001) An economic model to assess the cost and benefits of the routine use of silver alloy coated urinary catheters to reduce the risk of urinary tract infections in catheterized patients. J Hosp Inf 48: 33–42

Rovner ES, Wein AJ (2004) Treatment options for stress urinary incontinence. Rev Urol 6(Suppl 3): S29–S47

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