Catheterization options following
radical surgery for cervical cancer
Abstract
This trial assessed the potential benefits of intermittent
self-catheterization (ISC) over standard care with suprapubic
catheterization (SPC) in the postoperative bladder care of women
with early-stage cervical cancer following radical hysterectomy. A
prospective randomized controlled trial of 40 women was carried
out. The urinary infection rate (catheter specimen of urine) was
significantly higher in the ISC group at day 3 and day 5 (42%
and 63%) compared to the SPC group (6% and 18%), p=0.05 and
p=0.004, respectively. Forty-seven per cent of patients randomized
to SPC documented having problems arising from the SPC site,
of which 23% were shown to have a positive wound swab. Despite
a greater urinary tract infection rate, the technique of ISC was
seen by women to be more acceptable, allowing fewer disturbances
at night, greater freedom to live a normal life and less anxiety/
embarrassment compared to SPC.
Key words: Urinary catheters n Cervical cancer n Hysterectomy
A
hysterectomy for benign disease may include
removal of the uterus and cervix; however, in
a radical hysterectomy, the upper part of the
vagina and supporting tissues are also removed.
Although nerve-sparing techniques are possible (Trimbos
et al, 2001), damage to the nerve supply of the bladder is
surgically induced and can cause a great deal of distress to
women who are often struggling with the emotional effects
of their cancer diagnosis. Many women experience problems
emptying their bladder following radical hysterectomy for
cervical cancer and this is estimated to be in excess of 30%
(Naik et al, 2001).
At present, most departmental and nursing practice
has been guided by personal experience, tradition and
anecdotal evidence. A definitive policy for the management
Karen Roberts is Nurse Consultant and Raj Naik is Consultant
Gynaecological Oncologist, Northern Gynaecological Oncology
Centre, Queen Elizabeth Hospital, Gateshead, Tyne and Wear
Accepted for publication: June 2006
1038
British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.034 on June 9, 2015. For personal use only. No other uses without permission. . All rights reserved.
Karen Roberts, Raj Naik
of postoperative bladder dysfunction is lacking, with current
practice varying between the use of long-term transurethral
indwelling catheterization (TUIC) to suprapubic
catheterization (SPC), and the more recently introduced
technique of intermittent self-catheterization (ISC).
ISC has been successfully introduced in other clinical
specialities, including urological and gynaecological practice
(Anderson and Grant, 1991; Kleeman et al, 2002). This
follows many papers that support the argument that the
technique can be taught to patients and carers without
difficulty (Madersbacher and Weissteiner, 1977; McConville
2002; Edwards et al, 2004; Pilloni et al, 2005). ISC is a
preferred intervention as patients are more able to carry
out their activities of daily living and feel more in control
of their own personal care (Anderson and Grant, 1991;
Woodward and Rew, 2003). The potential benefits to the
healthcare team would be the release of community nursing
time which is presently required in the management of
both TUIC and SPC.
This study explores whether the proven benefits of ISC in
non-cancer patients can be confirmed in the postoperative
bladder care of women with a mid-line laparotomy wound
following radical hysterectomy.
Methods
Forty women treated by radical hysterectomy for early-
stage cervical cancer between 1 July 1999 and 31 June
2002 were recruited to the study. Information leaflets
about the study were explained to the women to gain
informed and written consent before their surgery. Women
were then randomized into ISC (intervention group)
and SPC (control group), which was carried out using
a sealed envelope system and an independent research
nurse. Ethical approval for the study was obtained from
Gateshead Research Ethics Committee.
Baseline demographic data was collected preoperatively
from all women and included their preferred method of
bladder care and their perception of bladder care. A mid-
stream specimen of urine (MSU) for culture and sensitivity
was taken, and a residual urine volume (RUV) was measured.
The ability to manage ISC following nurse education
was also assessed preoperatively, a urinary symptom
questionnaire (USQ) and quality of life questionnaire
(EORTC QLQ C30) were completed. Figure 1 shows the
sequence of data collection.
Protocols were developed for both methods of bladder
management and care. The ISC protocol consisted of a
transurethral indwelling catheter at the time of surgery that
British Journal of Nursing, 2006, Vol 15, No 19
 urinary catheters

remained on free drainage until day 5, at which time it Figure 1. The sequence of data collection.
was removed and the woman commenced on ISC. Women
would pass urine normally of at least 200 mls every 4 hours, Recruitment to trial (n=40)
then insert the catheter to determine if there was any residual Baseline data collected
urine left in the bladder. ISC was continued until residual
urine volumes of less than 100 mls was achieved. ISC could
then be discontinued. A sterile aseptic technique for ISC Randomization
was advised by the urology nurse specialist while women
were in hospital, and they could then move to a non-sterile,
but clean, technique once discharged home. The catheter
used for ISC was a hydrophilic-coated LoFric® (Astra Tech Active intervention Control group SPC
Ltd, Stroudwater Business Park, Stonehouse). Women were group ISC (n=21) (n=19)
given an advice leaflet with education and support from a Preoperative
clinical nurse specialist. nurse education
The SPC protocol included insertion of a Bonanno
suprapubic catheter (Becton Dickenson, Franklin Lakes,
New Jersey, USA) (Figure 2) at the time of surgery
followed by free drainage until day 5 at which time it
was clamped. Nursing staff then asked the women to pass
urine normally at least once every 4 hours during the day, Postoperative data collection
• CSU/MSU at day 3, 5, 7,
and then measure the residual urine volume by releasing
14, 21 and when clinically
the clamp. SPC was continued until satisfactory residual indicated
urine volumes of less than 100 mls was achieved, then the • Urinary Symptom
catheter was removed. The nursing staff observed the SPC Questionnaire (USQ)
site daily to assess for signs of infection or urine leakage, at 3, 6 and 12 weeks
and an occlusive dressing was used without any antibiotic postoperatively
cream. All women received a single dose of intraoperative • EORTC QLQ C30
antibiotics; however, prophylactic antibiotics were not questionnaire at 3, 6 and 12
given at any other time during the study. Antibiotics were weeks postoperatively
prescribed when clinically indicated, i.e. a positive MSU/ • Documentation of all SPC site
catheter specimen of urine (CSU) culture or positive SPC problems, need for bladder
support and difficulties with
site swab.
bladder care
Data analysis was performed using the statistical package • All data reviewed on an
SPSS Version 11, and included Pearson’s chi-squared intention-to-treat basis
test and Fisher’s exact test for categorical data, and the • Compliance with ISC or SPC
Mann-Whitney U test for non-parametric continuous data. protocol documented
• Date of cessation of bladder
Results care.
All women recruited to the study had a stage 1B1 carcinoma
of the cervix and were treated with a radical hysterectomy.
The ages of women recruited were 20–78 years, and the

New_Reed_ads.indd 3 4/7/06 11:12:24

British Journal of Nursing, 2006, Vol 15, No 19 1039

British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.034 on June 9, 2015. For personal use only. No other uses without permission. . All rights reserved.
Figure 2. Bonanno catheter suturing in place to ensure it remained secure.
median was 45 years. Before randomization, 19 women
stated a preference to a specific technique of bladder
care, 14 (74%) to ISC and 5 (26%) to SPC. Following
recruitment and randomization, 13 women (32%) were
positive in their attitude towards bladder management, 22
Table 1. Positive CSU/MSU rate
ISC (n=19) SPC (n=17) Fisher’s exact
Day 3 CSU 8 1 P
Day 5 CSU 12 3 P
Day 7 CSU/MSU 7 6 P
Day 14 CSU/MSU 4 9 P
Day 21 CSU/MSU 2 2 P
CSU=catheter specimen of urine, MSU=mid-stream specimen
of urine
1040
British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.034 on June 9, 2015. For personal use only. No other uses without permission. . All rights reserved.
(55%) were unsure or anxious and 5 (13%) were negative in
their views. There was no statistically significant difference
in attitude/perception between the two groups, p=0.267
(Fisher’s exact). Preoperative baseline RUVs were 0–75 ml,
mean 10 ml. There was no significant difference between
the two groups, p=0.246 (Mann–Whitney U). The baseline
preoperative USQs and EORTC QLQ C30 questionnaires
showed no statistically significant differences between
the two groups. One woman was treated with antibiotics
following a positive MSU test. All women randomized
to the ISC group were considered to be performing this
technique without difficulty within 2 days of removal of
the indwelling urethral catheter, which followed a period
of preoperative training by a nurse.
Four women were withdrawn from the study following
surgery, 2 from each group, as 1 woman developed a
ureteric fistula, 1 developed postoperative confusion,
1 had a stroke and 1 woman died. All women in the
SPC group managed to follow the clamping/unclamping
regimen easily except one woman who required additional
nursing support. No women randomized to ISC required
reinsertion of the catheter; however, 2 (12%) women
randomized to SPC required conversion to a transurethral
indwelling catheter due to SPC site problems. In addition,
1 woman (6%) requested removal of her SPC and transfer
to ISC due to discomfort.
Table 1 contains the positive CSU/MSU rates for days
3, 5, 7, 14 and 21. The organisms grown included: E coli,
enterococcus feacalis, Klebsiella and mixed growth. These
results show that more women in the ISC group developed
urine infections in the first 5 days following surgery than
the SPC group, and these results were significant. At 21 days,
8 of 17 SPC women (47%) were documented as having had
symptoms/problems arising from the SPC site, of which 4
(23%) had a positive wound swab requiring treatment by
antibiotics. The organisms grown included: staphylococcus
aureus, pseudomonas, haemolytic streptococcus and mixed
faecal/skin flora.
No significant differences were identified in the women’s
length and requirement for bladder care between the two
groups, p=0.83 (Mann-Whitney U); ISC range 7–90 days
(median, 17 days); SPC range 7–28 days (median 20 days).
There were no significant differences in questionnaire
response rates between the two groups, with 27 women
(p=0.7), 23 women (p=0.7) and 19 women (p=0.5)
respectively, completed and returned the week 3, week 6
and week 12 USQs, patient acceptability questionnaires
(PAQ) and EORTC QLQ C30 questionnaires. The results
are shown in Tables 2, 3 and 4.
= 0.05 Discussion
= 0.004 This unique study comparing ISC with a standard SPC
= 0.4 technique of bladder care following radical hysterectomy
= 0.16 identified significant benefits of ISC for women. They
= 0.21 reported greater acceptability, fewer disturbances at night,
greater freedom to lead a normal life during the day, less
anxiety/embarrassment and the avoidance of SPC site
problems during the postoperative period. There would
appear to be only two disadvantages of ISC reported.
British Journal of Nursing, 2006, Vol 15, No 19
 urinary catheters

Table 2. Urinary symptom questionnaire at 3, 6, and 12 weeks (ISC vs SPC)

Week 3 Week 6 Week 12

During the day how many times do you urinate on average? p = 0.8 NS p = 0.4 NS p = 1.0 NS
During the night, how many times do you get up to urinate, on average? p = 0.4 NS p = 0.006 p = 0.006
Do you have to rush to the toilet to urinate? p = 0.7 NS p = 0.8 NS p = 1.0 NS
Does urine leak before you can get to the toilet? p = 0.5 NS p = 0.7 NS p = 1.0 NS
Do you have pain in your bladder? p = 0.2 NS p = 0.4 NS p = 1.0 NS
Does urine leak when you are physically active, exert yourself, cough or sneeze? p =0.3 NS p = 0.7 NS p = 0.5 NS
Do you ever leak urine for no reason & without feeling that you want to go? p = 0.7 NS p = 0.2 NS p = 1.0 NS
Do you leak urine when you are asleep? p = 0.7 NS p = 0.2 NS p = 1.0 NS
Overall, how often do you leak urine? p = 1.0 NS p = 0.6 NS p = 0.7 NS
Overall, how much urinary leakage occurs? p = 0.8 NS p = 0.8 NS p = 1.0 NS
Do you wear some type of protection for your leakage? p = 0.3 NS p = 0.7 NS p = 1.0 NS
How many times a day do you change the above items because of leakage? p = 0.2 NS p = 0.4 NS p = 0.7 NS
Do you need to change your outer clothing during the day because of leakage? p = 0.1NS p = 0.4 NS p = 1.0 NS
Is there a delay before you can start to urinate? p = 0.2 NS p = 0.9 NS p = 0.5 NS
Do you have to strain to urinate? p = 0.4 NS p = 0.7 NS p = 0.5 NS
Do you stop and start more than once while you urinate? p = 0.9 NS p = 0.4 NS p = 0.3 NS
How would you say the strength of your urine stream is? p = 1.0 NS p = 0.7 NS p = 0.4 NS
Do you have a burning feeling when you urinate? p = 1.0 NS p = 0.8 NS p = 1.0 NS
How often do you feel that you bladder has not been emptied completely p = 0.2 NS p = 0.05 p = 0.1 NS
after you have urinated?
Can you stop the flow of urine if you try? p = 0.2 NS p = 0.5 NS p = 0.2 NS
Do you cut down on the amount of fluid you drink so that your bladder p = 0.5 NS p = 0.2 NS p = 0.7 NS
function improves?
To what extent have your urinary symptoms affected your ability to perform p = 0.05 p = 0.4 NS p = 1.0 NS
everyday tasks? (e.g. cooking, laundry)
Do you avoid places and situations where you know a suitable toilet is not p = 0.4 NS p = 0.9 NS p = 1.0 NS
nearby because of your urinary symptoms? (e.g. shopping, travelling, church)
Do your urinary symptoms interfere with physical activity? (e.g. walking, p = 0.6 NS p = 0.9 NS p = 1.0 NS
dancing, swimming)
To what extent has your sex life been spoiled by your urinary symptoms? p = 0.8 NS p = 0.8 NS p = 1.0 NS
Overall, do your urinary symptoms interfere with your relationship with p = 0.5 NS p = 0.9 NS p = 1.0 NS
your partner?
Overall, do your urinary symptoms interfere with your relationships with p = 0.7 NS p = 0.4 NS p = 1.0 NS
other people apart from your partner?
If you had to spend the rest of your life with your urinary symptoms as they p = 1.0 NS p = 0.8 NS p = 0.7 NS
are now, how would you feel?

All statistical tests performed using Pearson’s chi-squared test. NS = not significant

New_Reed_ads.indd 5 4/7/06 11:14:37

British Journal of Nursing, 2006, Vol 15, No 19 1041

British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.034 on June 9, 2015. For personal use only. No other uses without permission. . All rights reserved.
 Firstly, a greater incidence of urinary tract infections
within the first 5 days following surgery, during which time
women randomized to ISC were managed with a urethral
catheter, and secondly, nursing support is required initially
with ISC as women are still limited in their mobility due to
a large mid-line abdominal wound.
The results of this study supports previous work, as all
women were able to learn the technique of ISC without
difficulty, and prior to randomization, the majority of
women with a preference preferred the option of ISC
compared to SPC. A clinical nurse specialist in the hospital
setting the day before the radical hysterectomy procedure
taught the technique of ISC. However, it can also be
safely taught at home or in a clinical setting (Parmar et al,
1993; Bennett, 2002; Winder, 2002). The nurse teaching
the procedure must be alert to both verbal and non-verbal
behaviour of the woman throughout the procedure and be
able to respond positively. Women who require ISC face
a change in both lifestyle and body image, therefore the
communication skills of the nurse are as important as being
skilled in this technique. Psychosexual awareness is necessary
as women may also have sexual concerns in relation to her
bladder care (Nwabineli et al, 1993) for which the nurse
may provide advice and support.
The high incidence of urinary tract infections in the
present study was concerning, although it is interesting that

Table 3. Patient acceptability questionnaires at 3, 6 and 12 weeks (ISC vs SPC)

Week 3 Week 6 Week 12

Has the method of bladder drainage (catheter) been acceptable to you? p = 0.000 p = 0.002 p = 0.009
Have you seen a community nurse at home? p = 1.0 NS p = 0.2 NS p = 0.4 NS
How much support from your community nurse have you required? p = 0.3 NS p = 0.1 NS p = 0.5 NS
Have you needed to seek advice about your catheter from the hospital or GP? p = 0.2 NS p = 0.3 NS p = 0.2 NS
Has it been necessary for you to revisit the hospital because of your bladder p = 0.4 NS p = 0.3 NS p = 1.0 NS
problems?
Have you required another person, e.g. a family member, to assist in care p = 0.6 NS p = 0.6 NS p = 1.0 NS
of your catheter or bladder care?
Has the use of a catheter caused you anxiety or embarrassment? p = 0.04 p = 0.03 p = 0.005
Have you experienced any difficulty in obtaining equiptment, e.g. pads, p = 0.5 NS p = 0.07 NS p = 1.0 NS
dressings, catheters, bags, etc?
Has the method of bladder drainage enabled you the freedom to lead p 0.000 p = 0.006 p = 0.000
a normal life?

All statistical tests performed using Fisher’s exact test. NS = not significant

Table 4. EORTC QLQ C30 preoperaive and 3, 6 and 12 weeks postoperative (ISC vs SPC)
Domains Preoperative Week 3 Week 6 Week 12

Global health status/QOL p = 0.707 NS p = 0.134 NS p = 0.161 NS p = 0.083 NS

physical function p = 0.537 NS p = 0.183 NS p = 0.053 NS p = 0.075 NS
Role function p = 0.557 NS p = 0.647 NS p = 0.238 NS p = 0.272 NS
Emotional function p = 0.577 NS p = 0.222 NS p = 0.161 NS p = 0.573 NS
Cognitive function p = 0.94 NS p = 0.095 NS p = 0.185 NS p = 0.122 NS
Social function p = 0.752 NS p = 0.149 NS p = 0.301 NS p = 0.146 NS
Fatigue p = 0.798 NS p = 0.183 NS p = 0.972 NS p = 0.442 NS
Nausea/vomiting p= 0.283 NS p = 0.015 p = 0.268 NS p = 0.657 NS
Pain p = 0.460 NS p = 0.572 NS p = 0.5 NS p = 0.272 NS
Dyspnoea p = 0.775 NS p = 0.317 NS p = 0.336 NS p = 0.395 NS
Insomnia p = 0.22 NS p = 0.085 NS p = 0.02 p = 0.395 NS
Appetite loss p = 0.684 NS p = 0.572 NS p = 0.547 NS p = 0.968 NS
Constipation p = 0.752 NS p = 1.0 NS p = 0.697 NS p = 0.633 NS
Diarrhoea p = 0.490 NS p = 0.851 NS p = 0.414 NS p = 0.968 NS
Financial problems p = 0.775 NS p = 0.467 NS p = 0.645 NS p = 0.897 NS

All statistical tests performed using Mann-Whitney U. NS = not significant

1042 British Journal of Nursing, 2006, Vol 15, No 19

British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.034 on June 9, 2015. For personal use only. No other uses without permission. . All rights reserved.
 the differences in infection rates between ISC and SPC
appear to be greatest within the first 5 days, during which
the ISC women were managed by a transurethral indwelling
catheter. There were no differences in urinary tract infection
rates after this period and following the introduction of
ISC, although this may be accounted for by the higher use
of antibiotics for confirmed infections in the preceding
period. In light of these results, a logical step may be to
introduce SPC for these first 5 days postoperatively instead
of an indwelling urethral catheter, as this may reduce the
urinary infection rates in this ISC group. SPC site problems
occurred during a later period.
The SPC catheter used in this study was a Bonanno
catheter which required suturing of the plastic base to
the surrounding skin to ensure it remained secure and
prevent it falling out (Figure 2). In light of the SPC site
problems seen during this study, it may be possible that an
alternative SPC that did not require suturing would be a
better choice of catheter. There are other SPC products
available which avoid the need for suturing to the skin
by using an inflatable balloon, similar to the transurethral
indwelling catheter. The picture also shows the large mid-
line laparotomy wound, which women had to cope with
in their postoperative recovery alongside learning the
technique of ISC.
This study did not show any significant difference in length
of period for bladder care between the two groups; however,
this would not be expected as the women all had stage 1B1
cancer of the cervix and had undergone the same surgical
procedure. The results also showed no major differences in
urinary symptoms, quality of life or any further need for
nursing support between the two groups. The poor response
rates to the questionnaires may explain this negative result,
with only 19 women returning the questionnaire at the
12-week time frame. However, the urinary symptoms
questionnaire was able to detect differences in attending to
daily tasks and disturbances during the night, which was also
supported by the results of the PAQ.
Women clearly indicated in the PAQ that the technique
of ISC was preferable to SPC, and the questionnaire
highlighted that general acceptability, freedom to lead a
normal life and reduced anxiety/embarrassment were the
areas of particular relevance. The median age of women in
this study was 45 years old, and with this relatively young
group of women, the results of this study do suggest that
ISC should be the preferred technique for bladder care
Key Points
n Clean intermittent self-catheterization (ISC) is an acceptable technique for bladder management following radical surgery
for cervical cancer.
n Although mobility is difficult with a mid-line laparotomy wound, all patients were able to learn the technique of ISC
without difficulty.
n ISC was more acceptable to women allowing fewer disturbances at night, greater freedom to lead a normal life during the
day and less anxiety and embarrassment compared to suprapubic catheterization.
1044
British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.034 on June 9, 2015. For personal use only. No other uses without permission. . All rights reserved.
following radical hysterectomy. These results should be
considered in context to the full physical, psychological
and sexual problems that cervical cancer and consequent
surgery can cause.
Conclusion
This study has shown that ISC is a simple bladder care
technique that women prefer and are able to learn easily.
Although this study found the incidence of urinary tract
infection rates were higher with ISC, this has to be offset
against the SPC site problems that women experienced.
More importantly, women prefer to have fewer disturbances
at night, greater freedom to carry out normal activities
during the day, and felt less embarrassed and anxious about
their bladder care when compared to SPC. BJN
Acknowledgements: The authors would like to thank Margaret
Matthew and Gerry Thompson for their help with recruitment of
patients and data collection.
Anderson JB, Grant JB (1991) Postoperative retention of urine: a prospective
urodynamic study. BMJ 302: 894–6
Bennett E (2002) Intermittent self-catheterisation and the female patient. Nurs
Stand 17: 37–42
Edwards M, Borzyskowski M, Cox A, Badcock J (2004) Neuropathic bladder
and intermittent self-catheterisation: social and psychological impact on
children and adolescents. Dev Med Child Neurol 46: 168–77
Kleeman S, Goldwasser S,Vassallo B, Karram N (2002) Predicting postoperative
voiding efficiency after operation for incontinence and prolapse. Am J Obstet
Gynaecol 187(1): 49–52
Madersbacher H, Weissteiner G (1977) Intermittent self-catheterisation, an
alternative in the treatment of neurogenic urinary incontinence in women.
Eur Urol 3: 82–4
McConville A (2002) Patients’ experiences of clean intermittent catheterisation.
Nurs Times 98(4): 55–6
Naik R, Nwabinelli J, Mayne C, Nordin A, de Barros Lopes A, Monaghan JM
(2001) Prevalence and management of (non-fistulous) urinary incontinence
in women following radical hysterectomy for early stage cervical cancer. Eur
J Gynaecol Oncol 22(1): 26–30
Nwabineli J, Walsh DJ, Davis JA (1993) Urinary drainage following radical
hysterectomy for cervical carcinoma – A pilot comparision of urethral and
suprapubic routes. Int J Gynaecol Cancer 3(4): 208–10
Parmar S, Baltej S, Naidyanathan S (1993) Teaching the procedure of clean
intermittent self-catheterisation. Paraplegia 31: 298–302
Pilloni S, Krhut J, Mair D, Maderbacher H, Kessler TM (2005) Intermittent
catheterisation in older people: a valuable alternative to an indwelling
catheter? Age Aging 34(1): 57–60
Trimbos JB, Maas CP, Deruiter MC, Peters AA, Kenter GG (2001) A nerve-
sparing radical hysterectomy: guidelines and feasibility in Western patients. Int
J Gynaecol Cancer 11(3): 180–6
Woodward S, Rew M (2003) Patients’ quality of life and clean intermittent self-
catheterisation. Br J Nurs 12(18): 1066–74
Winder A (2002) Teaching ISC technique. Nurs Times 98(48): 51
British Journal of Nursing, 2006, Vol 15, No 19