All About Bladders and Catheters.

There is so much I want to share for example, a ‘What not to say to a long term catheter user’ blog has been brewing in my head for the last few weeks and I’d love to talk about how to manage the little emergencies that can happen when out and about. But, for those of you who might be reading who are new to all things bladder management, I thought I would start with the basics and describe, in layman’s terms, the urinary system and the different forms of catheterisation. This information is readily available on the internet (and if you are really interested in learning about the urinary system, I would recommend researching, as my explanation is by no means comprehensive and is put together from my knowledge as a patient. I am not a medical expert) but I thought it might be useful to have it here so that there is no or little need for research before reading future posts where some of the terms discussed below will be mentioned.

From top to bottom we have the kidneys. A healthy person will have two of these bean shaped organs that filter our blood to remove toxins and excess fluid to produce urine. Urine travels to the bladder via thin pipes called the ureters. The bladder itself is a hollow balloon shaped organ, which normally holds between 200/300 mls of urine before sending a message to the brain to tell us we need to go potty. When we go, urine travels via the urethra to the urethral or urinary meatus/orifice. In woman, the urethra is short and the urethral meatus is the little hole just above the vagina. In men, the urethra is longer and runs along the penis, with the hole at the tip. In between toilet visits a bunch of muscles work to keep us dry. The urethral sphincter keeps the urethra shut but will relax when we tell our brain to pee, at which point the detrusor (bladder muscle) will contract to push urine out. People with healthy bladders will start feeling the need to go to the toilet when there is between 200/400 mls stored. They will then have control over when they go.

A healthy bladder will only be able to hold so much before the detrusor muscle gives out. It’s the bladder’s failsafe to stop urine flowing back into the kidney’s or urine stagnating and developing bacteria. In people with retention (for which there are many causes), the bladder cannot empty and so urine builds up, sometimes to over 2/3 litres. This is dangerous for the reasons mentioned above but also is extremely painful and must be treated as a medical emergency. When a person first goes into retention, a catheter will need to be placed to drain the bladder – which brings me on to catheters.

Urethral Indwelling Catheter

There are a few different catheter techniques out there. The most common, and the one most people are likely to have heard of is an indwelling urethral catheter. A tube, called a Foley catheter is inserted into the bladder via the urethra (pee pipe). Once there is urine draining, a small balloon is inflated using sterile water which keeps it in place. It is called an indwelling catheter as it stays within the bladder.

The tube is then connected to a bag, which will collect the urine.

(From left to right - night bag, day bag and a catheter valve)

(My leg bag in the top photo and the bag connecting to the catheter)

There are different types of bags. Hospital inpatients will often have a large bag that can clip to bed rails/ wheelchairs etc and are designed to help staff measure urine output.

People who are living with a long-term catheter will often use a smaller bag, often called a leg bag as it sits/ is worn on the leg or thigh. During the night, or if a person is bed/chair bound, then a larger bag may be used (usually simply called a night bag). Less commonly used are belly bags (which, funnily enough are worn on the belly). Bags allow for ‘free drainage’ or continuous flow of urine into the bag, keeping the bladder empty. Free drainage is often recommended when there is a urine infection present.

It is possible to have a catheter and not have a bag, in these cases a valve is used. Urine is stored in the bladder as normal, and when the bladder needs drained, it is simply a case of opening the valve over the toilet. Using a valve can be more discreet than bags and can help the bladder keeps its tone and capacity. Urethral catheters are often the first line of therapy in those presenting with urinary retention. These will often be kept in for a couple of weeks before being removed for what is called a TWOC (or a trial without catheter). Some people will be able to pee normally after having the catheter removed or investigations may show a cause for the retention that can be rectified (for example, blockage of the urethra due to a bladder stone) but if a person is still in retention the catheter will need to be replaced and long term options considered. Its important to note that urinary retention is not the only reason an indwelling catheter is used – hospital patients who have undergone major surgery or who are particularly unwell may have a catheter placed and sometimes catheters are used to manage severe urinary incontinence. However, most of my blog will be from the perspective of someone in retention as that is what I suffer from myself.

Intermittent Self Catheterisation

Long term indwelling catheters are avoided as much as possible because of the increased risk of infections and injury to the bladder and urethra. That being said, if someone can’t go, someone can’t go and often an indwelling urethral catheter is used on a long-term basis. However, another option is Intermittent Self Catheterisation or ISC for short. ISC catheters are designed to be inserted into the bladder via the urethra to drain the bladder and then immediately removed, so there is no need to for a catheter to be in situ all the time. A person who ISCs will insert a catheter between 3-6 times per day. The catheters are generally smaller and the technique, for most, is relatively pain free. There is still a higher risk of infection and injury to the urethra but the risk is generally not as high as having a long-term indwelling catheter. Good hand and personal hygiene is key. Like any bladder management option, ISC takes time to get used to. It can be overwhelming to begin with and to learn the technique, you need to throw dignity to the wind for a while as a nurse will need to spend time with you, while you are semi-naked as he/she shows you the technique and then supervises on your first few attempts.

Supra-pubic Catheter

The third option is a suprapubic catheter or SPC. This is the most invasive form of long-term catheterisation and involves a small surgery. In many ways, SPCs are similar to urethral catheters. They are still attached to bags/valves and the same type of catheter (folley catheter with the inflatable balloon) is used. The difference is that the catheter does not enter the bladder through the urethra but through a small incision in the abdomen just above the pubic bone. There is generally a decreased risk of urine infections, although for many these are still quite common. It carries its own risks, such as an infection of the tract/site and over granulation (overgrowth of skin) but for many, SPCs are a much easier long term option. For me, SPC is the least painful option as the condition I have affects the urethral sphincter, which is not happy at all when anything is rammed up through it. I am also hoping that I will have less urine infections and therefore kidney infections, as these are a huge problem for me and my precious kidney function. SPCs also frees up ‘down there’ for all things bedroom related. Although sex with urethral catheters is possible, I was told not to because of the risk of damaging my urethra further.

In future I hope to write posts about the intricacies with living with each type of catheter.

It's worth mentioning here that besides catheterisation there are other forms of bladder management. For retention Sacral Nerve Stimulation (SNS) may be an option for some (I am currently waiting for a SNS trial). There are also more permanent options such as mitrofanoff procedure (which is the creation of a stoma using appendix or bowel that creates a channel from the bladder to the surface of the abdomen which users can self-catheterise) or removal of the bladder all together. There is also penile sheaths or condom catheters for older men with incontinence problems - but seen as I am not a man, I will not discuss this type of catheter (although, I may find a guest writer to contribute in future).