Difficulties of patients and caregivers in performing clean intermittent catheterization: scoping review

1. Universidade de São Paulo – Escola de Enfermagem de Ribeirão Preto – Programa de Pós-Graduação em Enfermagem Fundamental – Ribeirão Preto (SP), Brazil. 2. Universidade de São Paulo – Faculdade de Odontologia de Bauru – Curso de Medicina – Bauru (SP), Brazil. 3. Universidade Federal do Rio Grande do Norte – Escola Multicampi de Ciências Médicas – Caicó (RN), Brazil. *Correspondence author: leonardo.orlandin@usp.br Received: Jun. 19, 2020 | Accepted: Ago. 10, 2020 ABSTRACT Objective: To identify the main difficulties reported by patients and caregivers in the use of clean intermittent catheterization described in the scientific literature. Methods: Scoping review with studies published in Portuguese, English or Spanish, without date limit, in electronic databases and digital libraries, using descriptors and keywords. Results: 790 studies were identified, including 34 studies published between 1984 and 2019. The main difficulties reported in performing clean intermittent catheterization were related to catheter insertion, pain, discomfort, urethral trauma, public bathrooms with inadequate facilities, physical difficulties and lack of access to necessary inputs. Conclusion: The studies analyzed show the difficulties that patients who use clean intermittent catheterization and their caregivers face on a daily basis, which are related to intrinsic and extrinsic, institutional and governmental factors and can decrease satisfaction and adherence to rehabilitation programs bladder, with an impact on the quality of life of patients and their caregivers. Therefore, it highlights the need for health education for the proper teaching of performing clean intermittent catheterization, emphasizing the importance of the nurse’s role in this process.

Difficulties of patients and caregivers in performing clean intermittent catheterization: scoping review Because it is an invasive procedure, it can cause pain and discomfort, besides offering risks in its performance.
Urethral trauma is often related to the introduction of the nonlubricated catheter, the type of material used and the technique adopted to perform the procedure. Urethral trauma occurs by the friction of the badly lubricated catheter against the urethral mucosa and is characterized by urethral pain and/or bleeding. In addition, it offers a gateway for bacteria responsible for the development of urinary tract infections. When performed over a long period, it can result in urethral stenosis, urinary incontinence, erectile dysfunction and infertility 1,6,7 .
The characteristics of the materials used to perform the procedure may have an impact on the success or not of the technique, since some of these catheters may offer greater ease of handling and execution and less pain and discomfort to the introduction 1,[8][9][10][11] . In Brazil, patients have access to polyvinyl urinary catheter (PVC), a low-cost, flexible material without lubricants by the Unified Health System (Sistema Único de Saúde, SUS) 12 . Its use is usually associated with increased catheter friction against the urethral mucosa and, consequently, increased risk of urethral trauma. The use of prelubricated hydrophilic catheters can make the procedure more precise and safer 2,11,13-15 .
In this context of diversified materials and the need for patient compliance to carry out the treatment and risks inherent to the procedure, it is essential for professionals to master the ability to promote educational actions. Effective educational actions in health only come about when they recognize the reality and previous experiences of the individuals for whom they are intended, determining potentialities and susceptibilities, in an integral view, which establish teaching-learning objectives in face of the difficulties encountered. Thus, it is necessary to be aware of the difficulties encountered by patients and/or their caregivers in developing the technique, in order to identify errors and ensure better quality of life for CIC users 16 .
Some studies point out as the greatest difficulty in the realization of the CIC 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 of the urethral anatomy allow the patients and their caregivers to probe the urethra without trauma and pain, avoiding maneuvers that may damage the urethra 5,17 . Hence, the systematization of the procedure is fundamental.
In this sense, this study aims to identify the main difficulties reported by patients and caregivers in the use of clean intermittent catheterization described in the scientific literature.

METHODS
Study carried out using the scope review as proposed by the Joanna Briggs Institute ( JBI) 18 . For the construction of the research question, the PCC strategy that represents a mnemonic for Population, Concept and Context, thus defined, was applied: P = patients or caregivers, C = difficulties and C = performing clean intermittent catheterization. For the search and selection of studies, the following guiding question was established: "What are the difficulties of patients and/or caregivers during the performance of clean intermittent catheterization?" The search was performed by two independent researchers, according to JBI criteria 18 , without date limit, in the following databases and digital libraries: Scientific Electronic Library Online (SciELO) and  For the extraction of the data, the instrument structured by the researchers themselves was used according to the JBI's recommendations 18 . For the presentation of results, the studies were numbered and named "study". In the critical analysis of the selected articles, the outline of the studies was also analyzed.

RESULTS
From the searches carried out, 790 potential studies were identified. After reading the titles and abstracts, 95 studies were selected for full reading, 33 of which were excluded because they were repeated. After full analysis  it is slippery (9.0%), fear in performing the procedure (9.0%), the presence of menstrual flow in females (6.0%), the absence of the caregiver (6.0%), the presence of fecaloma (3.0%) and obesity (3.0%).
The occurrence of these complications in the procedure causes discomfort 3,28,31,33,35,39,40  The absence of the caregiver was mentioned as a difficulty to carry out the CIC in some studies of this search, especially when they are in environments outside the home, such as school or work 34,43 .
Regarding female CIC users, studies point out the difficulty of visualizing the urethral meatus. This difficulty is due to the anatomical characteristics of the female genitalia, which makes visualization more difficult than in men 5,[33][34][35]37,39,44,46 .
The female urethral meatus can be more distal or profound. In addition, older women generally have no clear knowledge of genital anatomy. To visualize more easily the urethral meatus, the use of the mirror is indicated 5,46 .
However, with the improvement of skills, women are able to leave the mirror and identify the urethral meatus only through touch 53 .
A situation also restricted to women, menstrual flow was mentioned as a factor of difficulty in the execution of the technique. However, after performing the intimate hygiene, the procedure can be normally performed 21,40 .
The use of CIC generates significant changes in the life activities of patients who need to make use of it 62  However, the resources made available to users are not the most effective and safe indicated in the literature and sometimes they are not enough to meet their needs 28,29,31 .
When facing scarcity of resources in the execution of the In more severe and unusual cases, fecal impaction can completely obstruct the urinary tract, blocking the urethra, ureters or both 80,81 .
These added facts can generate urine loss due to reduced bladder storage capacity and, rarely, can cause difficulty or hindrance during catheter insertion due to fecal impaction and intestinal distension leading to urinary tract obstruction by mechanical compression, as reported in study 11, which portrays the unusual case of a giant fecaloma 30,79 .
Complications of the neurogenic bowel can limit daily activities, causing psychosocial and economic impacts, and hinder the rehabilitation process 69  Although this study is a review of scope and has fulfilled its role in mapping the problems encountered by patients using CIC, it is possible to observe among the studies found that most of them are descriptive studies, conducted with different samples of patients and caregivers, mostly adults, but of different age groups, who were not stratified in this review. This can be considered a limiting factor of this work and should be explored in new research that also analyzes interventions.