Take Charge! A Guide to Home Catheterization

Sven Nicholson

I am now forty-four years old. When I was eleven, I had three operations to repair hypospadias. These operations were performed by a competent physician who considered my family a charity case and never sent us a bill. The artistry of his work has been commented on by most urologists who have subsequently examined me. He sincerely believed this was the best treatment for me, and did the best job he could. However, a stricture developed within two months of the final operation, and ever since my life has been drastically altered.

After these operations, my family moved. The next physician used a dilating procedure where a thin catheter was inserted, curling up inside the bladder, followed by a thicker catheter. Each increase in thickness required the lead catheter to curl up inside the bladder. It drove me crazy, but then we moved again, and the procedure used by the physician in the new neighborhood was worse.

He used steel probes to force the stricture open. The gruesome procedure had the same outcome every week: urine passed freely but painfully immediately after the procedure; then the stricture clammed up again a few hours later. Again and again my father had to drive me to the physician’s home in the evening in order to open me up again. Though this physician was a professor at a research hospital, he never varied his technique or tried to solve the post-procedural problem.

Finally, I began to commute to a physician in another city who used a different set of catheters, made of rubber. Including the commute, the visits took about ten hours, but the problem of “clamming up” did not recur, to my great relief.

Throughout my teenage years, physicians seemed to take the attitude that my condition could be somehow healed through a catheterization regime. In my early twenties, the physicians dropped this pretense. When I finished college, I became a lay missionary for my church. The mission board physician asked my urologist for a letter stating that my condition would not cause problems overseas. The physician gave me a set of silicon-coated catheters and instructed me in their use. His casual attitude reassured me, “You can live anywhere in the world, as long as there’s soap and warm water.” However, he was extremely reluctant to commit this to writing; in retrospect, I think that he did not want to create any written statement that a medical condition such as mine can be casually and easily treated by the patient himself. In any case, he wrote the letter (which I never saw) at the last minute and gave me a generous supply of anti-bacterial sulfa drugs and anesthetic lubricant, and I was on my way.

For several years I continued to visit physicians in order to receive prescriptions for anesthetic jelly and antibacterial sulfa drugs (gantrisin or gantinol) to protect against bladder infection while catheterizing myself. In my midthirties, I visited a urologist who refused to prescribe these drugs unless he first performed another surgery on me, to the tune of several thousand dollars. I determined to learn how to open my urethra without any prescription drugs.

I consider self-catheterization a vast improvement over visits to the urologist’s office. The physician who gave me the catheters did so reluctantly, only because I was traveling overseas, and resisted making any kind of statement in writing about the ease with which this procedure could be performed by the patient himself. This reluctance probably has two sources; the first and obvious motivation is financial gain. The second is that any professional has seen amateurs botch things up, and naturally feels that s/he can do a better job. Regardless of the physician’s attitude, I believe the patient is best served by obtaining his own set of catheters and treating himself.

I still use the set of silicon-coated catheters (sizes 14 to 24) I received before going overseas; they remain in perfectly good condition. The following paragraphs describe my “theory” and “method” of self-treatment, using this set of catheters.

Long-term Problems

I catheterize myself about once a week. The urinary tract is normally sterile; though it involves no cutting, this is a surgical procedure performed at home, and I take it seriously. The problems encountered in treating urethral stricture by catheterization are: bladder infection; physical pain; various involuntary rejection reactions, including desire to urinate; and unnecessary stimulation of the prostate gland.

Bladder infection

The key is not drugs but simply to force fluids. On the day of catheterization I drink a lot of water and acidic fruit juices. On some occasions when I have been careless, I have developed infection serious enough to cause fever, but cleared it out simply by forcing fluids.

A frequent desire to urinate may be a sign of bladder infection.

Another reason for forcing fluids is the soothing effect of passing a large amount of water soon after catheterization. This always makes me feel better. Diuretic teas, available in health food stores, help the body to expel liquid by irritating the bladder. If you do develop a bladder infection, you may want to use these teas, but I think the irritation is a negative factor (this is true of caffeine, too).

To better understand the principle of forcing fluids to avoid bladder infection, envision bacteria: they like to live in colonies. A single bacterium by itself cannot produce enough chemicals to destroy the mucosal lining of the bladder, but a colony can do this. By constantly diluting the colony and the chemicals they produce, you make it impossible for them to live and reproduce.

Water is really the best, being free of nutrients for the bacteria. Pure cranberry juice (almost undrinkably sour) is next, but it’s difficult to obtain. Sweetened cranberry juice is useful, but contains lots of energy for the colonies you wish to destroy.

It is not advisable to insert the catheter all the way into the bladder. This is what causes bladder infections. As long as the widest part of the catheter is acting against the stricture, that’s the main thing.

Physical pain

Involuntary rejection reactions

Unnecessary stimulation of prostate

I don’t understand these completely, but they are all factors that I consider in living my life and developing my procedure. There are psychological links between physical pain and stimulation of the prostate, but I don’t think in “psychosomatic” terms. Rather, I have noticed that my urethra has a mind of its own, and I need to pay attention. Sometimes it wants to clam up, to prevent the introduction of any catheter. At other times it’s yielding. Sometimes it gets inflamed, even angry. I don’t think of it as a “voice” that I must “listen” to, but over the years I’ve developed some ideas about what it wants and what makes it happy. Similarly, my bladder and my prostate also have their own ideas about the things that get done to them.

Basically my approach is to reduce stress and make the experience as pleasant as possible for everybody.

My Procedure

If I have gone, say, two or three weeks without catheterization and I know my urethra is getting tight, I will be especially careful to use over-thecounter analgesics such as aspirin, Tylenol, and Ibuprofen twenty minutes before catheterization (sometimes I use all three; I’ve never checked if this actually increases effectiveness or not). I do not use wine or marijuana because these drugs throw the judgment off.

Alcoholic beverages deaden the sense of touch. Under the influence of alcohol, I might force the catheter in roughly, only to feel the effects later on. Caffeine enhances the effect of aspirin, but it also makes the hands jumpy and irritates the bladder. This might cause a “spastic” desire to urinate later on. (The effect is slight; I usually have coffee every day whether I plan on therapy or not.)

Relaxing atmosphere

At first I simply sat on the commode and treated myself, but this is an extremely uncomfortable position for catheterization and psychologically reinforces the inherent ugliness of the act.

It’s far better to think of catheterization as one type of personal grooming. I like to shave when I’m taking a bath or shower. My skin is more relaxed and cooperative, and I seem to be able to shave an extra millimeter or two off each whisker. I recommend that catheterization be integrated into the bathing routine. In detective novels, one sometimes reads about someone who slashed their wrists in the bathtub. The reason? The hot water deadens the pain.

I rate locations as follows: (1) hot bath; (2) hot shower; (3) in bed while e.g. reading an absorbing book. Warmth during and after the operation are essential. During the winter, plan on staying indoors afterwards.

I have noticed that if a “spastic” desire to urinate occurs, it usually happens during cold or chilly weather.

Choice of salve

After forsaking prescription drugs, I first used KY jelly. Then medicated jellies began to appear in the drug stores for males who had difficulty maintaining an erection during coitus. The jelly works by deadening the penis. This is an inexpensive way to treat the immediate pain. Medicated jellies might not be available over-the-counter in foreign countries, so bring extra tubes when you travel. In an emergency, you might use almost any household oil to lubricate the catheter, even butter or olive oil. However, the oil will heat up due to friction when the catheter is introduced, so in this case, you must be extra slow.

Some commercial brands of medicated jellies are Detain and Maintain. The Maintain label says: “desensitizing lubricant for men. Active Ingredient: Benzocaine 7.5% in a water washable base. Also contains Carbomer, Polyethylene Glycol.” The carrier jelly itself is water soluble, but one of the other ingredients seems to be insoluble in water and soap. I find this ingredient slightly irritating and I hope I never develop an allergy to it, because it would be hard to live without it.

The insoluble ingredient seems to cling to the skin, and the urethra produces a mucous to wash it out; this process takes a little over 24 hours, during which time mucous will likely come in contact with the scrotum and adjacent areas. For this reason, plan to change underwear after the operation (say, 4-6 hours later), and take a shower before you go to bed. Although the ingredient doesn’t seem to be water- or soap-soluble, it does respond to washing; perhaps it is the mechanics of sluicing water.

Catheterization

When I was visiting physicians during my teenage years, a major emphasis was placed on dilation up to 24 Foley. I’m not sure that my masculinity depends on the internal diameter of my urethra; in terms of plumbing, anything about 14 is fine.

I prefer to perform the operation in the bathtub. Immediately prior to inserting a catheter, I wash it with warm water and mild soap (e.g. “Dove”; I’m allergic to stronger soaps). I also wash the area around the genitals more than once. Sometimes I hold the catheter in my teeth while I wash my genitals (so it doesn’t have to touch anything); in this case, I hold the “distal” end (not the end to be inserted).

I usually begin catheterization by applying the medicated jelly to a 14 catheter and introducing this to deaden the tissue in the urethra. At the same time, I apply it to the outside of the penis; the chemical seems to penetrate through the tissue. The purpose is to make the tissue numb, not to widen the stricture.

Then I wash my hair. Then rinse. Now the urethra is numb. Then I wash the 16 catheter and coat it with jelly. While that’s inside, I might shave or use a pumice stone to remove dead skin from my feet.

You get the idea. Because I’m scrubbing my back, stimulating my scalp, and tending my toes, my mind is not focused on the area of the operation, except at those moments when I’m actually inserting a catheter. I don’t go beyond 18. Catheterization is a type of personal grooming. I expect as much pain and pleasure from it as I do from shaving or brushing my teeth.

I keep the water as hot as the water heater will let me. When I’m done, I run the shower for a bit to sluice off the irritating “active ingredient.”

Usually, I don’t actively remove the catheters. The urethra seems to expel them naturally while I’m washing other parts of my body. (Or, the effect of gentle washing movements is to cause the catheter to be expelled). I often leave the bathtub without removing the final catheter.

Post-op

After the operation, I always plan on doing something sedentary: respond to e-mail, read, have a meal with a friend. I can circumspectly leave the catheter in for these activities. I think leaving the catheter in for a longer period of time increases the effectiveness of the operation. The urethra seems to have a mind of its own, sometimes tightening around the catheter, sometimes relaxing and allowing it to drop out. Promote relaxation. Usually, the catheter will be expelled within thirty minutes, depending on my level of activity.

I usually have something hot to drink right away, preferably an herbal tea (but not diuretic). The main thing is the fluid, and secondarily the relaxation. Some teas, such as echinacea, stimulate the immune system and thus have a positive effect in preventing bladder infection. Obviously, there is no reason why you can’t have alcoholic beverages at this time, if you so choose. The major consideration is not the type of beverage, but the amount. A large Evian Spring Water bottle contains 1.5 liters of water. Try to drink two. Passing large quantities of water has a soothing effect, both psychologically, physically, and chemically (it helps to expel the irritant in the salve).

Your physician has probably already given you a list of activities which should be avoided: riding bicycles, equestrian sports, sliding down banisters, etc.

Reflections

As I mentioned earlier, the surgeon who treated me did not charge for his services. I’m sure he sincerely felt that this was the best course of action for me. In retrospect, I wish that the operations had never happened, that I had simply been allow to live out my life with the plumbing system originally given to me by my Creator.

The operation was explained briefly to me at the outset, but alternatives were never discussed, no scenario other than the desired outcome was ever presented. I had never heard of “informed consent,” and it would not have applied to my situation.

The hypospadias repair was performed in three stages, when I was eleven years old. Between the ages of twelve and sixteen, I lived a life of denial alternating with acute crises. Under the care of one physician, a urology professor at a medical university, my urethra would actually become completely occluded after dilation, rather than become more open. Yet he never varied his procedure in the slightest way, which suggests that he also continued teaching his students the same counter-productive methods. So much for research hospitals.

During my high school years, while all this was happening, popular culture was full of references to Freud, to counselors and therapists and psychoanalysts and pastors who had a counseling ministry, etc., etc., etc. Yet none of this affected my life. Not once did I discuss my problem with a trained counselor. Nor did my parents. And probably my doctors never looked at the problem in psychological terms.

No literature existed. I was encouraged to deny reality, to think that the cure lay in just a few more visits to the doctor.

I’ve never heard of a contest where men parade the internal diameters of their urethras, and I’m not sure how it would be done. However awkward the concept might be, much of the therapy I received for the first ten years seems to have been designed with the intention to prepare me to become a world champion.

When I started treating myself, my first act was to abandon this concept. Which is not to say that I stopped denying reality. But my weird world is more comfortable to live in now. I open my urethra just as far as necessary to allow me to pass urine.

I’m sure I’ll have more problems as I grow older, but I don’t know what they are, and I suspect that doctors don’t understand them either. In any case, I have no desire to become a world champion in a masculine beauty contest, a ticker tape parade down Fifth Avenue as the challengers for widest urethra in the welterweight division for sixty-five years old and older head towards Madison Square Garden.