Clean intermittent catheterization (CIC) is a standard of care in patients with neurogenic lower urinary tract dysfunction (NLUTD) who are unable to void spontaneously.  There have been few reports regarding differences of quality of life (QoL) between CIC and spontaneous voiding (SV).  In patients with NLUTD who need CIC, heterogeneities of underlying diseases and physical disabilities due to the diseases, such as spinal cord injury, make an evaluation of QoL difficult.  The impact of CIC on QoL might be better evaluated when QoL is evaluated in otherwise healthy ambulant patients with a homogenous underlying disease.  For example, in contrast to the spinal cord injured patients, QoL in patients after radical hysterectomy (RH) showed similar QoL in control subjects [1].  Therefore, in the present study, we selected a relatively homogenous female patients’ group to elucidate the short term and long term impact of CIC on QoL.  Our hypothesis is that based on our real world clinical experience, in the long term QoL in patients with CIC does not clinically differ from QoL in patients with SV.

The subjects of the present study were seventy-one otherwise healthy female ambulant patients who underwent modified Okabayashi’s RH for localized cervical cancer and were referred to our NLUTD clinic because patients needed CIC at discharge from the hospital.  At the referral a neurourologist and a urologic nurse thoroughly gave an explanation to patients which included the pathophysiology of NLUTD, the methods of lower urinary tract management, and a reason why the patient should perform CIC.  Because lower urinary tract function is usually recovered around 12 months after radical pelvic surgery, urodynamic study was performed at that time.  If sufficient detrusor contraction was present or if sufficient detrusor contraction was not demonstrated but a continuous flow pattern was evident on repeat uroflowmetries, CIC was gradually stopped.  On the other hand, if detrusor contraction was not demonstrated and an intermittent flow pattern with a poor flow rate was shown on repeated uroflowmetries, CIC was continued.  QoL was cross-sectionally measured with SF-36 and King’s health questionnaire (KHQ), and was compared between CIC (n=50) and SV (n=21).  At the evaluation of QoL none of the patients had a recurrent disease and suffered from long term post-operative complications.  We divided postoperative elapsed time into two periods, that is, less than 24 months and more than 24.  We performed analysis of variance in each subscales/domains and p<0.05 was considered as statistically significant.

Mean age at RH was 42.7 years old in SV and 44.7 years old in CIC.  Results were graphically presented in Figure 1 and 2. In SF-36, general health perception (GH, p=0.0355) and social functioning  p=0.031) were significantly worse in CIC than SV less than 24 months after RH.  In contrast, significant differences were not revealed in each subscales between CIC and SV more than 24 months after RH.  In SV, norm-based scoring revealed that physical functioning (PF), role physical (RP), and role emotional (RE) were below average scoring of Japanese people less than 24 months after RH.  On the other hand, only PF in SV was below average more than 24 months after RH.  In CIC, QoL was much more deteriorated than in healthy Japanese people less than 24 months after RH, because all subscales were below average.  However, QoL was improved with time.  More than 24 months after RH, PF, RP, RE, and GH remained below average in CIC.  In KHQ, general health perceptions (p=0.0285) and incontinence impact (p=0.0096) were significantly worse in CIC than SV less than 24 months after RH.  In contrast, significant differences were not revealed in each domains between CIC and SV more than 24 months after surgery.

QoL in patients with CIC was significantly worse than in patients with SV in short term, but similar in long term.  This would represent a response shift [2].  Patients with CIC would adapt to a new situation, which would allow them to maintain acceptable QoL in spite of continuing CIC.  Patients with CIC should be provided comprehensive supports at an early period after introducing CIC, and supports for keeping their works or daily activities during continuing CIC.

In patients with CIC QoL is probably improving with time.  Therefore, adequate supports for patients from the medical team seem to be essential for patients to accept and continue CIC, especially during an early period after starting CIC.

J Clin Oncol. 23:7428-36, 2005
Gynecol Oncol. 102:563-72.