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Intermittent Catheters and Clean Intermittent Catheterization (CIC)

Clean intermittent catheterization (CIC) is the preferred method of bladder management for patients with incomplete bladder emptying. The AUA / SUFU NLUTD guideline gives a Strong Recommendation for CIC over indwelling catheterization, anchored on lower complication rates and substantially better quality of life.[1][2] CIC is the lifelong bladder-management foundation for neurogenic bladder, augmentation cystoplasty, and continent catheterizable channels (Mitrofanoff, Monti) — making the catheter selection, technique, and complication profile core knowledge for the reconstructive urologist and urogynecologist.

Concept​

CIC involves the periodic passage of a single-lumen, non-balloon "straight" catheter through the urethra (or a continent catheterizable channel — see Catheterizable Channels) into the bladder for drainage, with immediate removal after emptying. Unlike indwelling drainage, the catheter does not remain in the body — it mimics the normal filling-and-emptying cycle.[3]

CIC can be performed by the patient (clean intermittent self-catheterization, CISC), by a caregiver, or by a clinician. Self-catheterization is associated with the best quality of life when feasible.[1]

Indications​

Neurogenic bladder (primary indication)​

  • Spinal cord injury — gold standard once precise output measurement is no longer required.[2]
  • Multiple sclerosis — preferred for incomplete emptying and retention; essential after intravesical onabotulinumtoxinA causes complete retention.[4][5]
  • Parkinson disease — though manual-dexterity limitations may be barriers.[6]
  • Spina bifida / myelomeningocele — lifelong CIC often initiated in childhood.[7]
  • Cauda equina syndrome.[8]
  • Stroke — when voiding dysfunction persists.

Non-neurogenic indications​

  • Acute urinary retention with PVR > 300 mL without outlet obstruction.[8]
  • Chronic urinary retention as alternative to indwelling drainage.[8]
  • Postoperative urinary retention — CIC is the most cost-effective initial strategy after pelvic surgery ($79 per patient vs $128 for self-removal of indwelling catheter vs $185 for office voiding trial).[9]
  • Overflow incontinence secondary to BPH or other causes.
  • Post-onabotulinumtoxinA retention.[4]
  • PVR assessment / sterile urine sampling.
  • Bladder voiding efficiency (BVE) impairment — Chapple 2023 consensus emphasizes individualized BVE assessment to determine when to initiate CIC.[10]

Reconstructive contexts​

  • Augmentation cystoplasty — lifelong CIC is the expected postoperative course.
  • Continent catheterizable channels — Mitrofanoff (appendicovesicostomy), Monti / Yang-Monti, Indiana pouch.
  • Continent cutaneous urinary diversion — required for emptying.
  • Bladder neck closure — CIC via channel is mandatory.

Contraindications​

  • Inability to adhere to a catheterization schedule (cognitive impairment without caregiver support).[2]
  • Abnormal urethral anatomy precluding safe passage.[2]
  • High-pressure bladder requiring continuous drainage to protect kidneys.[8]
  • Persistently very high fluid intake making frequency impractical.[2]
  • Tendency to develop autonomic dysreflexia with bladder filling despite catheterization.[2]

Catheter design and types​

Intermittent catheters differ from indwelling Foleys: single-lumen, no balloon, designed for brief insertion and immediate removal. Major categories[3]:

1. Uncoated (standard PVC)​

  • Clear polyvinyl chloride body; sterile individual packaging.
  • May be supplied pre-lubricated, used with separate water-soluble lubricant, or with water alone.
  • Most basic and least expensive option.
  • Available as both single-use and (in some regions) multiple-use designs.

2. Hydrophilic-coated​

  • PVC base with a bonded polymer coating that absorbs water for a slippery, lubricious surface.
  • Either ready-to-use (pre-activated with saline in the package) or requires user water activation.
  • Always single-use.
  • AUA / SUFU notes hydrophilic catheters may be associated with lower UTI and urethral-trauma rates in SCI patients.[1]
  • Examples: SpeediCath (Coloplast), LoFric (Wellspect), Cure Catheter.

3. Gel-reservoir​

  • Pre-applied gel lubricant in the package coats the catheter on use; ready-to-use without water activation.[11]

4. Closed-system (no-touch)​

  • Catheter housed within a protective sleeve / introducer tip that prevents hand / periurethral contact during insertion; some include an integrated collection bag.
  • In vitro: no-touch designs dramatically reduce bacterial transfer (~ 5 CFU/plate vs 210–440 CFU/plate for traditional hydrophilic, p < 0.001).[12]
  • Caregivers make fewer sterility errors, are 92 seconds faster, and report higher comfort vs standard aseptic technique.[13]
  • Newer designs with insertion tips show reduced bacterial displacement in simulated urethral models.[14]

5. Coudé-tip intermittent​

  • Angled-tip variant for men with BPH or elevated bladder neck. See Coudé Catheter.

Sizing and length​

ParameterMaleFemalePediatric
Typical size12–16 Fr12–14 Fr6–12 Fr (age-dependent)
Standard length40 cm (16 in)15–20 cm (6–8 in)Variable
Compact / short option30 cmAvailable—
Tip typesStraight (Nelaton), coudéStraight (Nelaton)Straight

Shorter / female-length catheters are also used by some wheelchair-bound men for discretion; multiple cross-over trials in SCI populations exist.[3]

Clean vs aseptic technique​

Two fundamental approaches[3]:

SettingTechniqueStandard
Community / self-catheterizationClean — clean ungloved hands; soap-and-water genital cleansing; clean (or sterile) lubricant if catheter not pre-lubricatedWorldwide standard for CISC
Healthcare facilitiesAseptic — sterile gloves, sterile single-use catheter, antiseptic genital cleansing, sterile lubricantAims to minimize introduction of pathogens

The 2021 Cochrane review found no certain difference between aseptic and clean techniques in symptomatic UTI risk (RR 1.20, 95% CI 0.54–2.66; one study, 36 participants; low certainty).[3] This supports widespread use of clean technique for self-catheterization.

Self-catheterization technique​

  1. Hand hygiene with soap and water.
  2. Prepare supplies. Open package; if uncoated, apply water-soluble lubricant to tip and shaft.
  3. Position. Men — sitting or standing; women — sitting on toilet, standing with one foot elevated, or lying down (initial mirror may help).
  4. Genital cleansing with soap and water or moist wipe.
  5. Insertion. Men — penis perpendicular to body; advance ~ 15–20 cm until urine flows. Women — advance 5–8 cm until urine flows.
  6. Drainage. Allow complete emptying; gentle Credé maneuver to ensure full emptying.
  7. Removal. Slowly withdraw, pausing if more urine drains.
  8. Disposal / cleaning. Single-use → discard; multi-use → clean per protocol.[6]

Frequency and volume targets​

Catheterization frequency should be individualized based on fluid intake, bladder capacity, PVR, and urodynamics[3][2][6]:

  • Complete urinary retention: 4–6 times / 24 hours.[2]
  • Incomplete emptying with some voluntary voiding: 1–3 times / 24 hours after voiding.[6]
  • Target bladder volume: avoid > 400 mL per catheterization to reduce UTI risk.[2]
  • Frequency should approximate normal voiding rhythm (every 4–6 hours awake).[3]
  • Patients needing CIC more often than every 4 hours or with output > 500 mL every 4 hours may be candidates for transition to indwelling drainage.[15]

Single-use vs multiple-use​

The Cochrane 2021 review found no certain difference between single-use and multiple-use catheters in symptomatic UTI risk (RR 0.98, 95% CI 0.55–1.74; two studies, 97 participants; low certainty).[3] An 11-study comparative review found no appreciable evidence that reusable multi-use catheters were inferior to single-use from an infection or usability standpoint.[16]

Reuse practices vary widely — prevalence ~ 50% in some regions (Australia, Canada, US), with reuse periods ranging from 24 hours to one month and no consensus on cleaning method or reuse limit.[17]

Cost / environment: a patient performing CIC 5×/day uses ~ 1,825 single-use catheters / year. The BMJ systematic review concluded that clean non-coated catheters are most cost-effective, with offering hydrophilic or gel-reservoir as a precautionary alternative.[11][16] Health Quality Ontario reached the same conclusion — in the absence of clear superiority, the lowest-cost catheter is likely the most cost-effective.[3]

Hydrophilic vs uncoated — the UTI question​

Evidence is conflicting and of low certainty:

SourceFindingCertainty
Cochrane 2021 (Prieto)No certain difference in symptomatic UTI (RR 0.89, 95% CI 0.69–1.14)[3]Low
Plata 2023 meta-analysisLower UTI risk with hydrophilic in adults (RR 0.78, 95% CI 0.62–0.97)[18]Moderate
Bermingham 2013 BMJ SRNo difference in mean monthly or total annual UTIs[11]Low
AUA / SUFU 2021 NLUTDHydrophilic "may be associated with lower UTI and urethral trauma" in SCI[1]Grade C

Urethral trauma — Cochrane 2021 found uncoated catheters probably slightly reduce trauma / bleeding compared with hydrophilic (RR 1.37, 95% CI 1.01–1.87; moderate certainty) — somewhat counterintuitive.[3] Plata 2023 found no hematuria difference (RR 1.02, 95% CI 0.66–1.60).[18]

Complications​

CIC has fewer complications than indwelling catheterization overall, but is not risk-free.

UTI​

  • The most common complication of CIC.
  • ~ 25% of CISC users experience repeated symptomatic UTIs.[19]
  • A cross-sectional NLUTD study found no significant difference in UTI prevalence between IC (8%) and indwelling-catheter users (8%, p = 0.782) — challenging the traditional assumption.[20]

Urethral stricture​

  • In men with NLUTD on IC, stricture rate ~ 25% (95% CI 21–30%) at median 5.9 years, significantly higher than with other evacuation methods (14%, p = 0.0001).[21]
  • A different SCI cohort reported only 4.2% at mean 9 yr — case-mix variability.[22]
  • ~ 1/3 of strictures require surgical intervention.[21]

Other​

  • Hematuria — common at CIC initiation, typically not long-lasting.
  • False passages — long-term studies report low rates (5 false passages over 438 patient-years in boys / young males with neurogenic bladder).[7]
  • Prostatitis, epididymitis — uncommon.
  • Urethritis from repeated passage.
  • Channel stenosis of Mitrofanoff / Monti channels — periodic dilation or revision may be required.

CIC vs indwelling Foley vs SPT​

FeatureCICUrethral FoleySPT
UTI riskLowestHighestLower than urethral
Bladder-stone riskLowestModerateHigher
Urethral traumaLow (4–25% stricture long-term in NLUTD)High (erosion, stricture)None
Upper-tract preservationBestWorstIntermediate
Quality of lifeBest with self-cathPoorestIntermediate
IndependenceHighNoneNone
Bladder-cancer risk (long-term)LowerElevatedElevated
Manual dexterity requiredYesNoNo
AUA / SUFU recommendationPreferred (Strong)Only if CIC infeasiblePreferred over urethral if indwelling needed

UTI prevention in CIC users​

Antibiotic prophylaxis — AnTIC trial​

The landmark AnTIC trial (Fisher 2018, Lancet Infect Dis; n = 404 adult CISC users with recurrent UTI) demonstrated that continuous low-dose antibiotic prophylaxis reduced UTI frequency by 48% (IRR 0.52, 95% CI 0.44–0.61, p < 0.0001).[19] However, antibiotic resistance increased substantially at 9–12 months in the prophylaxis arm:

ResistanceProphylaxisControlp
Nitrofurantoin24%9%0.038
Trimethoprim67%33%0.0003
Co-trimoxazole53%24%0.002

The AUA / SUFU NLUTD guideline states clinicians may offer oral antimicrobial prophylaxis to NLUTD patients on CIC with recurrent UTI, with explicit shared decision-making about resistance risk (Conditional, Grade C).[1]

Non-antibiotic strategies​

  • Cranberry products — not effective specifically in CISC users.[19]
  • Methenamine hippurate — not specifically tested in CISC users; for non-CIC populations see UTI Suppressive & Prophylactic.
  • Increased fluid intake / increased catheterization frequency — commonly recommended; limited direct evidence.
  • Hydrophilic catheters — may reduce UTI risk; conflicting evidence (above).[3][18]

Asymptomatic bacteriuria​

Do not screen for or treat — bacteriuria is universal in CIC users; treatment does not reduce symptomatic UTI and drives resistance.[19]

Special populations​

Spinal cord injury​

  • CIC is the gold standard for SCI bladder management.[2]
  • 4–6 times / 24 hr; varies with intake.
  • Hydrophilic catheters may be particularly beneficial.[1]
  • Transition from indwelling to CIC once precise output measurement is no longer needed.[2]

Multiple sclerosis​

  • Preferred option for incomplete emptying.[5]
  • Barriers: dexterity, weakness, tremor, spasticity, vision.
  • Portable bladder ultrasound allows switching from time-based to volume-based catheterization, reducing incontinence frequency.[4]
  • Essential after intravesical onabotulinumtoxinA causes complete retention.

Postoperative urinary retention​

The URECA algorithm (Chrouser 2024 JAMA Netw Open) recommends intermittent straight catheterization (ISC) before indwelling for POUR — appropriate at lower bladder volumes and earlier than IUC. Catheterization of any type is considered inappropriate in asymptomatic patients with bladder volumes < 300 mL.[15]

Pediatric​

CIC is widely used in children with spina bifida / myelomeningocele, often initiated in infancy with parental assistance. Long-term data (median 16 yr) show overall low complication rates; self-catheterization and use of catheters ≥ 12 Fr appeared protective against major urethral lesions.[7]

Patient education and barriers​

Successful CIC requires comprehensive education, ideally by a continence adviser.[6] Teaching points: hand hygiene and clean technique, catheter selection / lubrication, anatomical landmarks (mirrors for women initially), frequency and volume targets, recognition of UTI vs ASB, when to seek care (inability to pass, significant hematuria, autonomic-dysreflexia signs in SCI).

Barriers[3][2][6][10]: poor manual dexterity (arthritis, tremor, spasticity, weakness), cognitive impairment, visual impairment (alone should not preclude CIC), obesity, psychological barriers, catheter cost (a leading reason for reuse), lack of accessible clean catheterization environments.

Cost and reimbursement​

In the US, Medicare covers intermittent catheters under the Durable Medical Equipment benefit, typically allowing up to 200 single-use catheters / month (~ 6–7/day). Cost differential is substantial — hydrophilic and closed-system catheters cost markedly more than uncoated PVC, with implications for both individual patients and healthcare systems.[11][16]

See Also​

Foley Catheter · Coudé Catheter · Suprapubic Catheter · Council Tip Catheter · Catheterizable Channels · UTI Suppressive & Prophylactic · Acute Urinary Retention

References​

1. Ginsberg DA, Boone TB, Cameron AP, et al. The AUA/SUFU guideline on adult neurogenic lower urinary tract dysfunction: treatment and follow-up. J Urol. 2021;206(5):1106-1113. doi:10.1097/JU.0000000000002239

2. Schroeder GD, Vaccaro AR, Welch WC, et al. Best practices guidelines: spine injury. American College of Surgeons; 2022.

3. Prieto JA, Murphy CL, Stewart F, Fader M. Intermittent catheter techniques, strategies and designs for managing long-term bladder conditions. Cochrane Database Syst Rev. 2021;10:CD006008. doi:10.1002/14651858.CD006008.pub5

4. Feinstein A, Freeman J, Lo AC. Treatment of progressive multiple sclerosis: what works, what does not, and what is needed. Lancet Neurol. 2015;14(2):194-207. doi:10.1016/S1474-4422(14)70231-5

5. Phé V, Chartier-Kastler E, Panicker JN. Management of neurogenic bladder in patients with multiple sclerosis. Nat Rev Urol. 2016;13(5):275-288. doi:10.1038/nrurol.2016.53

6. Panicker JN, Fowler CJ, Kessler TM. Lower urinary tract dysfunction in the neurological patient: clinical assessment and management. Lancet Neurol. 2015;14(7):720-732. doi:10.1016/S1474-4422(15)00070-8

7. Lindehall B, Abrahamsson K, Hjälmås K, et al. Complications of clean intermittent catheterization in boys and young males with neurogenic bladder dysfunction. J Urol. 2004;172(4 Pt 2):1686-1688. doi:10.1097/01.ju.0000138847.14680.7d

8. Fletke KJ, Jeong DH, Herrera AV. Urinary catheter management. Am Fam Physician. 2024;110(3):251-258.

9. Wang R, Tunitsky-Bitton E. Short-term catheter management options for urinary retention following pelvic surgery: a cost analysis. Am J Obstet Gynecol. 2022;226(1):102.e1-102.e9. doi:10.1016/j.ajog.2021.07.025

10. Chapple C, Abrams P, Lam T, et al. A consensus statement on when to start clean intermittent self-catheterization: an untapped resource? Neurourol Urodyn. 2023. doi:10.1002/nau.25353

11. Bermingham SL, Hodgkinson S, Wright S, et al. Intermittent self catheterisation with hydrophilic, gel reservoir, and non-coated catheters: a systematic review and cost effectiveness analysis. BMJ. 2013;346:e8639. doi:10.1136/bmj.e8639

12. Hudson E, Murahata RI. The 'no-touch' method of intermittent urinary catheter insertion: can it reduce the risk of bacteria entering the bladder? Spinal Cord. 2005;43(10):611-614. doi:10.1038/sj.sc.3101760

13. Goessaert AS, Antoons S, Van Den Driessche M, et al. No-touch intermittent catheterization: caregiver point of view on sterility errors, duration, comfort and costs. J Adv Nurs. 2013;69(9):2000-2007. doi:10.1111/jan.12062

14. Meredith K, Pollard D, Mason V, Ali A. The bacterial displacement test: an in vitro microbiological test for the evaluation of intermittent catheters and urinary tract infection. J Appl Microbiol. 2024;135(8):lxae201. doi:10.1093/jambio/lxae201

15. Chrouser K, Fowler KE, Mann JD, et al. Urinary retention evaluation and catheterization algorithm for adult inpatients. JAMA Netw Open. 2024;7(7):e2422281. doi:10.1001/jamanetworkopen.2024.22281

16. Zhao CC, Comiter CV, Elliott CS. Perspectives on technology: single-use catheters — evidence and environmental impact. BJU Int. 2024;133(6):638-645. doi:10.1111/bju.16313

17. Håkansson MÅ. Reuse versus single-use catheters for intermittent catheterization: what is safe and preferred? Review of current status. Spinal Cord. 2014;52(7):511-516. doi:10.1038/sc.2014.79

18. Plata M, Santander J, Zuluaga L, et al. Hydrophilic versus non-hydrophilic catheters for clean intermittent catheterization: a meta-analysis to determine their capacity in reducing urinary tract infections. World J Urol. 2023;41(2):491-499. doi:10.1007/s00345-022-04235-5

19. Fisher H, Oluboyede Y, Chadwick T, et al. Continuous low-dose antibiotic prophylaxis for adults with repeated urinary tract infections (AnTIC): a randomised, open-label trial. Lancet Infect Dis. 2018;18(9):957-968. doi:10.1016/S1473-3099(18)30279-2

20. Neumeier V, Stangl FP, Borer J, et al. Indwelling catheter vs intermittent catheterization: is there a difference in UTI susceptibility? BMC Infect Dis. 2023;23(1):507. doi:10.1186/s12879-023-08475-7

21. Krebs J, Wöllner J, Pannek J. Urethral strictures in men with neurogenic lower urinary tract dysfunction using intermittent catheterization for bladder evacuation. Spinal Cord. 2015;53(4):310-313. doi:10.1038/sc.2015.15

22. Cornejo-Dávila V, Durán-Ortiz S, Pacheco-Gahbler C. Incidence of urethral stricture in patients with spinal cord injury treated with clean intermittent self-catheterization. Urology. 2017;99:260-264. doi:10.1016/j.urology.2016.08.024