THE SATISFACTION OF THE PERSON WITH URINARY RETENTION IN THE USE OF DIFFERENT TYPES OF URINARY CATHETERS

The the different ABSTRACT Objective: to assess the satisfaction of the person with urinary retention in the face of the use of different types of urinary catheters, as well as to compare and analyze different attributes of these after their use in clean intermittent catheterization (CIC). Method: descriptive exploratory cross-sectional study, developed in a reference clinic in the state of São Paulo, from February to March 2020. The sample consisted of 32 adults registered in the service, and who adopted the CIC as a form of bladder emptying . Data collection was performed through individual interviews using a semi-structured questionnaire. Data were analyzed using descriptive, inferential statistics and categorization of responses to open questions. Results: of the 32 users, 84% were male, with a mean age of 54.16 years, 81% performed the procedure between 1 and 5 years, with a frequency of 4 to 6 times a day (66%). Most respondents (73%) preferred the hydrophilic-coated polyurethane catheter, converging with the percentage of users satisfied with the same catheter. Conclusion: the most satisfying technology is the hydrophilic-coated polyurethane catheter due to several attributes such as lubrication, firmness, packaging, urethral slip, handling, rapid urine clearance and comfort. categorización satisfechos con el mismo catéter. Conclusión: la tecnología con mayor satisfacción es el catéter de poliuretano con revestimiento hidrófilo debido a diversos atributos, como lubricación, firmeza, embalaje, deslizamiento en la uretra, manipulación, eliminación rápida de la orina y comodidad. Vejiga


INTRODUCTION
Some diseases in the nervous system can affect and hinder or prevent regular emptying of the bladder, favoring partial, total, temporary or permanent urinary retention, as in the cases of patients who experience neurological or idiopathic problems of the lower urinary tract 1 .
The simplest and safest way to treat incomplete bladder emptying is clean intermittent catheterization (CIC), considered the gold standard, with a frequency of 4 to 6 times a day. The procedure is performed between 16 to 56% of the population with spinal cord injury, aiming to improve the functionality of the bladder and protect the upper part of the urinary tract, in addition to the positive impact on quality of life, but paradoxically the most prominent consequence is still relapse of urinary tract infections [2][3][4] .
It is a simple technique in which the user or his/her caregiver introduces the catheter into the bladder, through the urethra or catheterized conduit, without the use of antiseptics or sterile gloves. The procedure was described in 1970 by Jack Lapides et al., who demonstrated that the prevention of urinary tract infection in these patients occurs through the prevention of bladder distension and elimination of waste, and not through the asepsis of the technique. Hence the name of clean and non-sterile technique 5,6 .
In the Nursing category, the person responsible for carrying out the training of the CIC is the qualified generalist nurse or with a specialization in stomatherapy or rehabilitation, being the professional trained to take care of this patient profile with dexterity and safety, whether in the hospital, outpatient or in the home care. As well as acting in the training of patients regarding the best conduct and existing technologies for the practice of CIC, favoring their independence and better quality of life 7,8 .
The satisfaction of the person with urinary retention in the use of different types of urinary catheters that the indication of the most appropriate catheter to the client's needs and preferences is a determining factor for their adherence to the technique 9,10 .
In Brazil, users of intermittent urinary catheterization do not have, so far, a specific policy that guarantees the necessary resources for excellent care. The patient who uses a catheter has the same care as any citizen who uses the unified health system Sistema Único de Saúde (SUS): they are entitled to the materials necessary for the procedure, but these are not always obtained 9 .
The most frequently used catheters are uncoated polyvinylchloride (PVC) catheters, which require manual application of lubricant to facilitate introduction and reduce friction. When this reality is compared to that of other countries, changes in these policies are observed, which seem to support with greater intensity the use of more advanced technologies in carrying out the procedure 4,9 .
Given the above scenario, considering the fact that the CIC is the gold standard for emptying for urinary retention, because there are more advanced technologies that favor adherence to the procedure and, consequently, impact on the quality of life and autonomy of patients as well as on the reduction of risks of complications associated with the procedure, it is considered relevant to analyze the satisfaction of users in the use of different vesical catheters.
Thus, the objective of this study is: to assess the satisfaction of people with urinary retention in relation to different types of urinary catheters, and to compare and analyze their different attributes after their use in the CIC.

METHOD
This is an exploratory descriptive cross-sectional study with a quali-quantitative approach, involving Users who presented contraindications for the use of the technologies of the study, who did not perform selfcatheterization, who were dependent on third parties (family, caregivers, friends and others) and who did not use a catheter with a diameter of 10 or 12 were excluded. The calibers nº10 or nº12 of the catheters were used as inclusion criteria as they were produced by all companies included in the research.
Of the total of 88 patients with urinary retention registered in the service, 65 were using catheters with calibers nº10 or nº12, but only 32 patients met all the inclusion criteria. All patients over 18 years of age, with urinary retention and who performed the CIC as a form of bladder emptying, registered in the service, using a catheter with calibers nº10 or nº12, performed self-catheterization, 27 of the patients (84%) were male.
In the pre-collection stage, users included in the study were randomized so that each researcher was responsible for guiding, monitoring and collecting information from four patients. The researchers organized the "research kits" composed of catheters included in the study in a sufficient number to be used for 24 hours, due to the amount received through a donation from the manufacturing companies and respecting the recommended interval between catheterizations; instruction for use of each catheter; the "step by step" form; the "note" form; in addition to scheduling a return for the third moment.
Also in this phase, there was theoretical and practical training, totaling 16 hours spread over 4 afternoons, carried out with the support of companies and with the participation of all members included in the project, with the aim of aligning knowledge on the topic and the particularities of each catheter used in the study.
Each participant evaluated four bladder catheters of different technologies, provided according to their records in the service, respecting the number of catheterizations performed on the day, following a sequence of use determined Bonello A, Faci MC, Mello MP by randomization, conducted by the researcher together with the person responsible for the health unit, which had spontaneous participation, and in the presence of the participants involved in the study.
The sequence of use of the catheters was as follows: Day 1 − Urethral catheter, made of PVC, provided with a substance with lubricating properties, by Bbraun-Actreen Lite Cath, respective brand and model. It is a pre-lubricated, single-use, sterile, water-and glycerin-based catheter.
Available in male and female versions. It is noteworthy that of the catheters involved in the research, only two were standardized and provided by the service regularly: the urethral catheter with a hydrophilic coating, made of polyurethane and ready for use, and the conventional PVC urethral catheter without lubrication. Then they received guidance from the researchers themselves on the use of each of the catheters, the schedule and sequence of use, taking home a "research kit"; the "step by step" form; the "notes" form; and scheduling a return for the third moment -interview.
In the second moment, the patients, at their homes, underwent the CIC, following their daily routine, using the different types of catheters included in the research, according to the established sequence, adopting the guidelines received from the researchers, at first, as well as the written guidelines provided within the "research kit". At the end of each day, after having performed all catheterization procedures using the catheter determined for use on the day, they recorded the device's specificities in the "notes" form in order to record their perception.
In the third moment, after the period for using the different catheters, the individuals returned to the study site, or as needed, those involved in the project went to the user's home, on a pre-scheduled date at the time of delivery of the catheters (first moment ) to answer the questions of the research instrument "satisfaction" through the interview that was carried out by the researchers. At this time, the "annotation" forms were also collected, recording the specifics of each of the devices.
Those who for some reason were unable to develop the actions relevant to the moments of the research were instructed to return to the health unit on a scheduled date for a new interview. If the situation persisted, they would be classified as "impossible for the research procedure", and would then be excluded from the study along the way. There was no impediment to participation for the reason in question.
The research kit included the quantity of catheters included in the study, sufficient for use within 24 hours, according to the registration in the service, according to the frequency of catheterizations performed by the patient in one day.
Data collection took place through individual interviews with users at the health service or at their own homes, carried out from February to March 2020, being held on Mondays and Tuesdays, from 1:00 pm to 5:00 pm or from according to the need for the service and availability of the researchers involved.
A semi-structured questionnaire already validated in Brazil was used as a reference for the construction of the collection instrument: "Instrument for the Assessment of User Perception in the Use of Vesical Catheters" 11 .
The satisfaction of the person with urinary retention in the use of different types of urinary catheters This questionnaire was constructed by the researchers and nursing professionals of the service with the participation of the stomatherapist nurse from that unit. Seeking a good interpretation and understanding of the elaborated instrument, a pilot study was carried out in three stages, with research members, health unit employees and users registered in the service, thus allowing adjustments to be made for a better understanding of the interviewee and the interviewer before your application. The

RESULTS
In total, 32 patients with urinary retention registered in a reference clinic in the State of São Paulo were approached, with 84% of the sample being predominantly male. Table 1 shows the data on the profile of the sample, which was predominantly aged over 60 years (40.63%) and the average age of the total sample was 54.16 years. All those registered had been linked to the service for more than 500 days. Of the total number of patients, 40.62% reported undergoing the procedure within a time interval of 1,501 to 3,000 days and 87% performed 4 to 6 catheterizations daily.  Regarding the analysis of urethral slippage, most respondents (41%) considered the sliding of a PVC catheter with lubricating properties "easy", and the same perception was found in relation to the polyurethane catheter, but by a larger number of patients (53%), with statistical significance when compared to the PVC catheter with lubricating properties (p=0.001), the polyolefin elastomer catheter (p=0.002) and the conventional PVC catheter (p=0.000). In this same analysis, catheter 1 compared to 4 was also statistically significant (p=0.007), and catheter 3 compared to The satisfaction of the person with urinary retention in the use of different types of urinary catheters In the evaluation of removal from urethra, the 'easy' response was most frequently mentioned by respondents in the evaluation of all studied catheters, with the PVC catheter with lubricating properties (50%) and with significance when compared to catheter 4 (p=0.008) . The hydrophilic coated polyurethane catheter (47%) is compared to catheter 1 (p=0.015) and catheter 4 (p=0.000). As for the polyolefin elastomer catheter (41%), and significance when compared to catheter 4 (p=0.002). And finally the conventional PVC catheter (28%), with no relevance when compared to the others.
At the time of the procedure, the answer "very easy" was reported more frequently among respondents when evaluating the polyurethane catheter (81%), being relevant in minutes when compared to catheter 4 (p=0.003).
For this same analysis, catheter 1 when compared to 4 had significance (p=0.002) and catheter 3 when compared to 4 (p=0.035).
When analyzing the same item, without considering the minutes, the polyurethane catheter also maintained a significant difference when compared to the PVC catheter with lubricating properties (p=0.002), the polyolefin elastomer catheter (p=0.002) and the conventional PVC catheter (p=0.000). There was also a significant difference between the PVC catheter with lubricating properties compared to the conventional PVC catheter (p=0.022) and the polyolefin elastomer catheter compared to the conventional PVC catheter (p=0.025). The open questions were categorized into "positive points" and "negative points", as shown in Table 3. Among the positive points mentioned by respondents in relation to the evaluation of the different catheters studied, the following stood out: ease of opening the package, good lubrication , the firmness and easy slippage in the urethra, present in PVC catheters with lubricating properties, polyurethane catheter and polyolefin elastomer catheter. The PVC catheter with lubricating properties also received praise as being "easy" to handle, transport and remove from the urethra. It was mentioned that the hydrophilic-coated polyurethane catheter presents qualities such as practicality, handling, independence, ease and speed in the elimination of urine and removal of the urethra. Regarding the positive points mentioned for the conventional PVC catheter, the following stood out: the fact that it has a cap that facilitates handling and makes transport easier. The negative points of the PVC catheter with lubricating properties were the difficulty in opening the package and removing the catheter, lack of firmness in handling and the lack of a cap on the catheter. Regarding the polyurethane catheter, the fact that the packaging was too large, the lack of a guide and cap on the catheter were pointed out. In the polyolefin catheter, opening and handling of the package, activation of lubrication, lack of cap and difficulty in transport.
In the conventional catheter, the delay in the procedure, lack of lubrication and difficulty in handling and removing the catheter were highlighted.
The satisfaction of the person with urinary retention in the use of different types of urinary catheters Regarding catheter preference after the survey, most respondents (73%) reported preferring a ready-to-use polyurethane catheter with hydrophilic coating, converging with the percentage of users satisfied with the same catheter in all aspects evaluated. The preference is justified by good lubrication, firmness, easy opening of the package, practicality, the fact that it "doesn't hurt", sliding in the urethra, handling, manipulation, rapid elimination of urine and comfort. It is noteworthy that 20 respondents (62.5%) already use the polyurethane catheter in the practice of CIC.

DISCUSSION
There are few studies that focus on user satisfaction, the greatest emphasis is on research that proves the efficiency and cost-effectiveness of the devices. Thus, to discuss the results of the evaluation carried out, works conducted in the same line of research were incorporated, however with different objectives and outlined methods.
A study that sought to assess the satisfaction of people with spinal cord injury in relation to the use of a conventional, hydrophilic and pre-lubricated catheter with a bag in the performance of CIC showed results similar to those of this work, pointing out that the hydrophilic catheter was considered superior to the conventional one for opening the packing and slip on insert. The pre-lubricated catheter with a bag was superior to the conventional one in terms of opening the package, introducing, sliding and removing. The evaluation of the conventional catheter was divergent from this study, as it mentioned as a positive point of the PVC catheter the fact that it has a lid that facilitates handling and transport12.
When the catheter with hydrophilic polyurethane coating was compared with the conventional catheter and the lubricated PVC catheter in relation to user satisfaction in a survey carried out, it gained prominence in the packaging opening item, which was also demonstrated in the data obtained in this study 12 .
The research showed similar results to this study, concluding that the risk reduction for the development of urinary tract infections (UTI), ease of insertion and convenience are the most appreciated attributes for intermittent catheters among patients 13 .
Another recent meta-analysis demonstrated the advantages of hydrophilic catheters in reducing the risk of UTI and urethral trauma, in addition to patient satisfaction 14 .
Results of a randomized controlled clinical trial comparing hydrophilic and uncoated catheters in children with neurogenic bladder also showed similar aspects to this study about satisfaction with the hydrophilic catheter, however with some reservations, according to the user profile, on the hard-to-handle slippery cover 15 .
Another study with a result similar to this research shows when identifying the main difficulties reported by patients and caregivers in the practice of CIC that catheter insertion, pain, discomfort, urethral trauma, public restrooms with inadequate facilities, physical difficulties and lack of access to necessary supplies are aspects related to the degree of satisfaction and adherence to bladder rehabilitation programs, with an impact on the quality of life of patients 16 .
Some patients consider that the time spent preparing the materials and performing the procedure are factors of difficulty in performing and complying with the CIC, as they change the routine, limiting the activities of daily living 17 .
Studies indicate that the greatest difficulty in performing the CIC is the lack of mastery of the technique by patients and/or their caregivers. The positioning of the patient during the procedure, the adequate visualization of the urethral meatus, the knowledge of the method and the urethral anatomy allow patients and their caregivers to perform a urethral probe without trauma and without pain, avoiding maneuvers that could injure the urethra 16,18 .
Difficulty in handling the devices and performing the correct CIC technique, as well as the lack of prior educational guidance were mentioned as obstacles to the correct and safe adherence to the procedure, in a research carried out involving 11 patients who undergo the CIC for the bladder emptying 19 .
Although catheter technologies have advanced and are scientifically supported, and CIC is the gold standard, the nonadherence rate among patients remains alarmingly high. 2,4,10,20 .
Non-adherence can lead to serious complications. It is recommended that the drained volume should not exceed 400 mL and a reduced frequency of catheterizations in 24 hours can result in an increased risk of urinary infections, in addition to bladder distension and risk of long-term renal impairment 20 .
It is of fundamental importance that the specialist or qualified nurse performs the training of the patient, family members and caregivers on the need for intermittent catheterization and the correct execution technique, as well as the risks inherent in its non-performance and potential complications 20 .
Among the limitations of this research, we highlight the development of the study with patients already registered in the service, therefore, with their own vices in the procedure, in the preference for the device, and in the use of catheters involved in the evaluation, in addition to the time available for experimentation with different catheters. Added to this, errors in the registration of patients, with loss of possible inclusions in the study with an increase in the number. Perhaps the patient's subjective interpretation of the different devices needs to be better explored in future studies including newly registered patients.
The findings of the study show that the different catheters were evaluated by the patients involved, both positive and negative aspects being identified in relation to each one of them. The preference of patients for the catheter with a hydrophilic polyurethane coating was confirmed, however we have to consider the limitations of this work and recognize that most patients were already using this device at the time of the research..
It is worth noting that the preferred technology in the current study was also the same one incorporated in 2019 by the National Commission for the Incorporation of Technologies (Comissão Nacional de Incorporação de Tecnologias-CONITEC) on SUS. And, also, in 2020 there was a process for the publication of a "Clinical Protocol of Therapeutic Guidelines for Neurogenic Bladder", further reinforcing the need and importance of the topic in question on the national scene 21 .
In Brazil, there is still no specific policy to guarantee the materials used in carrying out the CIC. However, the Brazilian population is assisted by the SUS, which sees health as a fundamental right of every human being and attributes to the State the duty to provide all the fundamental conditions for its full exercise, as well as ensuring a reduction in the risk of diseases and injuries. The SUS principles also provide for comprehensive therapeutic assistance. Thus, the development of public policies that ensure access to the device of choice of the patient to perform the procedure is imperative 9,22 .

CONCLUSION
User satisfaction with the technology must be allied to better meeting their needs, and in this study, the most preferred polyurethane catheter with hydrophilic coating was identified, with positive attributes when compared to the others.
Finally, it was considered that the opportunity given to patients with urinary retention to know, use and evaluate the different devices was beneficial, since it should be the right of patients to have access to all technologies available on the market and choose the one that best corresponds to your needs and preferences.
Thus, it is necessary to improve the knowledge of professionals who indicate and guide this profile of patients, in addition to the development of public policies for access to the best technology, thus favoring the adherence of these patients to the correct technique, autonomy, reduction of risks of complications associated with the procedure, directly impacting their quality of life.

DATA STATEMENT AVAILABILITY
All data were generated or analyzed in this study.