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ORIGINAL ARTICLE
Year : 2018  |  Volume : 10  |  Issue : 4  |  Page : 395-399  

Assessment of quality of life in patients of urethral stricture on clean intermittent catheterization following direct vision internal urethrotomy


Department of Urology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission07-Mar-2017
Date of Acceptance07-Jun-2017
Date of Web Publication12-Oct-2018

Correspondence Address:
Dr. Ashok Kumar Sokhal
Department of Urology, King George's Medical University, Lucknow, Uttar Pradesh
India
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DOI: 10.4103/UA.UA_34_17

PMID: 30386093

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   Abstract 


Context: Clean intermittent catheterization (CIC) after direct vision internal urethrotomy (DVIU)
Aims: The aim is to assess the quality of life (QOL) in patients with urethral strictures on CIC following DVIU.
Settings and Design: Prospective study.
Materials and Methods: This prospective study was conducted between August 2013 and July 2015 in the Department of Urology at KGMU, Lucknow. We included patients above the age of 18 years with stricture urethra, who were on CIC following direct visual internal urethrotomy. Patients below the age of 18 years, noncompliance, concomitant neurogenic voiding dysfunction, multiple strictures, pan anterior strictures, and posterior stenosis were excluded from the study. A 16 French Foley catheter was used for CIC following DVIU. Patients were evaluated at follow-up visit at 3, 6, and 12 months. At each follow-up visits, patients were assessed using CIC-QOL questionnaire, maximum urine flow rate and complications related to CIC if any.
Statistical Analysis Used: Unpaired t-test was used to compare continuous data, and Fisher's exact test was used to analyze categorical data.
Results: Among total 144 male patients evaluated, we included 97 patients, who underwent DVIU. Mean age of the study population was 37.7 ± 14.03 years. Most urethral strictures were idiopathic (64.02%) followed by postinflammatory (24.25%). A significant number of patients reported difficulty in performing CIC, which hampered daily activities. No major procedure related complications were reported. Patients who were compliant to CIC reported no stricture recurrence till 6 months follow-up.
Conclusions: CIC following DVIU remains a reasonable adjunctive option. All the parameters of CIC-QOL questionnaire had improved on continuing CIC. Young men on CIC had greater impairment of QOL when compared to aged patients.

Keywords: Clean intermittent catheterization, direct vision internal urethrotomy, quality of life, urethral strictures


How to cite this article:
Jhanwar A, Sokhal AK, Singh K, Sankhwar S, Saini DK. Assessment of quality of life in patients of urethral stricture on clean intermittent catheterization following direct vision internal urethrotomy. Urol Ann 2018;10:395-9

How to cite this URL:
Jhanwar A, Sokhal AK, Singh K, Sankhwar S, Saini DK. Assessment of quality of life in patients of urethral stricture on clean intermittent catheterization following direct vision internal urethrotomy. Urol Ann [serial online] 2018 [cited 2018 Dec 15];10:395-9. Available from: http://www.urologyannals.com/text.asp?2018/10/4/395/243208




   Introduction Top


Urethral stricture is a common urological ailment and one of the oldest diseases known to humankind. Three most commonly performed procedures for the management of urethral strictures are urethral dilatation, optical urethrotomies, and urethroplasty. The treatment for urethral strictures has greatly changed after the introduction of minimally invasive procedures like direct vision internal urethrotomy (DVIU), described by Sachse.[1] DVIU is now the preferred procedure for short segment urethral stricture. Despite good immediate results of DVIU, it has been associated with high recurrence rate between 10% and 50%.[2],[3],[4],[5] To improve the success rate of DVIU, various adjunctive procedures have been adopted, most preferred is clean intermittent catheterization (CIC).

Objective

To assess the quality of life (QOL) in patients with urethral strictures on CIC following DVIU.


   Materials and Methods Top


This prospective study was conducted between August 2013 and July 2015 in the Department of Urology at a tertiary care referral center, India. Ethical approval obtained from the Institutional Ethical Committee. Written informed consent was obtained from all patients. We included patients above the age of 18 years with stricture urethra, who were on CIC following DVIU. Patients below the age of 18 years, noncompliance, concomitant neurogenic voiding dysfunction, multiple strictures, pan anterior strictures, posterior stenosis were excluded from the study. Baseline demographic of patients were recorded [Table 1]. The patient underwent either conventional cold knife DVIU or holmium laser DVIU under local or regional anesthesia. A 16 F (French) Foley catheter was used for CIC following DVIU. We instructed the patients about CIC schedule. Patients were taught about CIC by proper education and demonstration of the technique. Patients were instructed to continue CIC once or twice a week. Patients were evaluated at follow-up visit at 3, 6, and 12 months. At each follow-up visits, patients were interviewed by CIC-QOL questionnaire (CIC-QOL), maximum urine flow rate (Qmax, ml/s) [Table 2] and complications related to CIC if any.
Table 1: Baseline patient characteristic of the study population (n=97)

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Table 2: Follow up variables and quality of life questionnaire score

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To the best of our knowledge, no validated questionnaire is available to assess QOL in patients on CIC. We designed a visual analog scale (1–10 scale) which was based on questionnaire previously used to assess the impact of CIC in a neurogenic population. Modifications were made to make this questionnaire suitable for urethral stricture. The responses of 1–3 were considered good, 4–6 as moderate and 7 or greater were interpreted as poor. Item assessed were frequency, difficulty, interference with daily activities and pain associated with the CIC. Impact on QOL was assessed using the level of patient interest in continuing CIC for the duration of life [Figure 1].
Figure 1: Patient clean intermittent catheterization-quality of life questionnaire

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   Results Top


A total of 144 male patients were enrolled during the study. A total of 47 patients were excluded from the study due to inadequate follow-up or discontinuation of CIC. Included 97 patients underwent DVIU either by cold knife or holmium laser. Mean age of the study population was 37.7 ± 14.03 years. Mean CIC frequency was 1.06 ± 0.66. Most urethral strictures were idiopathic (64.02%) followed by postinflammatory (24.25%), involving the bulbar urethra in majority patients (64.9%). Six patients underwent DVIU for anastomotic site stricture [Table 1].

QOL assessment of patients doing CIC demonstrated a significant impact. A significant number of patients reported difficulty in performing CIC, which hampered daily activities. Many patients described as a nightmare with significant painful experience [Table 2].

No major procedure related complications were reported. Only four patients had bleeding per urethra due to traumatic CIC, among them three patients developed fever [Table 1]. Patients who were compliant to CIC reported no stricture recurrence till 6 months follow-up [Table 2].


   Discussion Top


Urethral stricture is a common urological disorder, and it is one of the age-old urologic disease known to ancient time. The management of urethral stricture disease has changed over the centuries. It was believed that the results of urethroplasty were better than minimally invasive interventions. However, in the current era new minimally invasive intervention claimed results nearly approachable to conventional urethroplasties for short segment bulbar urethral strictures.

Most commonly performed the minimally invasive procedure for short segment bulbar urethral stricture is DVIU. It was popularized after the initial report of Sachse's in 1972. In 1980s, the concept of CIC following DVIU took shape to decrease the stricture recurrence rate.[6]

Since the first description of CIC for the prevention of recurrence after urethrotomy, several reports have advocated it as an acceptable procedure to reduce the failure rate of the DVIU. Many individualized regimens described and tapered within 3–6 months.[7],[8],[9],[10]

Later, other beneficial aspects of CIC have been evaluated, including early recognizing of recurrence, maintenance of the patency and has accepted as an adjunctive option tool for the management of urethral stricture following DVIU.[11] Extrapolating the results of CIC on the QOL in patients with urethral stricture was inevitable.

Some studies had assessed the QOL of neurogenic patients, who were on CIC and reported improved QOL associated with CIC.[12]

To the author's knowledge, there is a paucity of literature regarding the impact of CIC on QOL in patients of urethral stricture treated with DVIU.

The most common site of stricture in the present study was bulbar urethra in 67 patients (64.3%), followed by peno-bulbar region (23.28%) and 5.82% at postanastomotic site following urethroplasty and the most common cause was idiopathic in 64.02% and postinflammatory in 24% of cases which is in comparable to various studies in the literature.[13],[14]

The duration of catheterization in this study was 7 days in all cases. There is no convincing evidence that extending the duration of catheterization has a positive impact on the outcome.[15] Albers et al. reported that leaving the catheter in place for more than 7 days had a higher recurrence rate (65%).[16]

Girotti et al.[17] followed sixty patients up to 1 year and reported women, neurogenic voiding dysfunction and patient under 40 years old were significantly more adherent to CIC program. Malik et al.[18] reported that 89% of patients in their study were compliant to the procedure of CIC following DVIU, anastomotic and substitutional urethroplasties. Similarly, Rijal et al.[19] reported that the procedure of CIC was well tolerated by 84.1% of patients and 79.6% had no technical difficulty. In our study, 67.3% of patients were adhering to CIC program up to 6 months of follow-up which was less than the adherence rate reported by Malik et al. and Rijal et al. Possible explanations may be our strict inclusion criteria, low literacy status and younger age group patients who were not interested in continuing CIC further and opted for reconstructive surgery.

WHOQOL[20] and Igawa et al.[21] mentioned possible complications of CIC include bleeding, pain, fever which made or forced the patient to nonadherence.

In the present study, none of the patients suffered any major complication related to CIC. Eighty-nine (86.33%) patients did not suffer any major complication, 4 (3.88%) patients reported mild bleeding per urethra and 4 (3.88%) patients developed a fever (>100 F) which was managed conservatively. Thus, CIC is a safe procedure, if executed with proper instructions.

In this study, mean frequency of CIC per day was 1.06 ± 0.66 which is similar to study by Lubahn et al.[22] As there is no standard protocol and many patients may not follow the advised protocol for CIC. Hence, we calculate the mean number of catheterization per day. In this study, mean number of catheterization was nearly similar in all the age groups, which shows that it does not have a major adverse impact on QOL of patients included in the study. In this study, no patients had a recurrence of stricture who were on CIC following DVIU up to 6 months of follow-up. Among 47 patients, who was excluded, 9 (19.8%) had a recurrence at 3 and 19 (40%) patients had a recurrence at 6 months of follow-up. This is in accordance with various studies in the literature which suggest that CIC decreases the rate of recurrence.[7]

In the present study, the Qmax (ml/s) was significantly increased from the baseline value both at 3 and 6 months, and no statistically significant difference was observed between 3 and 6 months. Improvement in urinary flow might be a probable reason for the continuation of CIC for 6 months. Shaw et al.[23] found that the positive impacts of CIC were related to improvement in lower urinary tract symptoms, whereas the negative impacts resulted from the practical difficulties encountered, and the psychological and cultural context of worry and stigma.

Rijal et al. reported that CIC was well tolerated by 84.1% of patients and 79.6% had no technical difficulty. Lubahn et al. also reported similar results in their study, in which younger age group patient who were on CIC had poor QOL.

Patients of all ages (above 18 years) in this study found CIC a simple procedure and performed it without much difficulty and pain. With time, patients learned and adapted to the procedure well, as there was a statistically significant difference observed in this study between 3 and 6 months of follow-up. This observation suggested that patients of age above 18 years can perform CIC without much difficulty and pain. In this study, patients report difficulty and pain in performing CIC as moderate. Overall QOL reported by patients was moderate (3.56 ± 0.97) on CIC-QOL questionnaire.

This study strongly suggests that younger men, who performed CIC following DVIU had greater QOL impairment when compared to older age group patients. The reason for the underlying dissatisfaction in young men was not captured by the survey and may be related to poor psychosocial acceptance of the regimen or sexual concerns. Although the questionnaire was not validated for this usage, we believed that it was satisfactory initial attempt to assess patient perceptions in this poorly studied treatment modality. Our impression was that QOL was greatly enhanced after urethroplasty, but patients had not administered the same QOL questionnaire postoperatively for comparison.


   Conclusions Top


CIC following DVIU remains a reasonable adjunctive option for patients with stricture urethra who cannot undergo or do not elect major urethral reconstructive surgery. All the parameters of CIC-QOL questionnaire had improved on continuing CIC. Young men on CIC had greater impairment of QOL when compared to aged patients.

Acknowledgments

I acknowledge the cooperation of residents of Urology department of King George's Medical University who participated in data collection and evaluation of the patient. We also appreciate the commitment and compliance of the patients who reported the required data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest



 
   References Top

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Sachse H. Treatment of urethral stricture: Transurethral slit in view using sharp section. Fortschr Med 1974;92:12-5.  Back to cited text no. 1
    
2.
Smith PJ, Dunn M, Dounis A. The early results of treatment of stricture of the male urethra using the Sachse optical urethrotome. Br J Urol 1979;51:224-8.  Back to cited text no. 2
    
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Hjortrup A, Walter S, Kristensen JK, Bilde T. Stricture of the urethra treated by internal urethrotomy using the Sachse method. Ugeskr Laeger 1983;145:734-6.  Back to cited text no. 3
    
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Holm-Nielsen A, Schultz A, Møller-Pedersen V. Direct vision internal urethrotomy. A critical review of 365 operations. Br J Urol 1984;56:308-12.  Back to cited text no. 4
    
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Dubey D. The current role of direct vision internal urethrotomy and self-catheterization for anterior urethral strictures. Indian J Urol 2011;27:392-6.  Back to cited text no. 6
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Newman LH, Stone NN, Chircus JH, Kramer HC. Recurrent urethral stricture disease managed by clean intermittent self-catheterization. J Urol 1990;144:1142-3.  Back to cited text no. 8
    
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Robertson GS, Everitt N, Lamprecht JR, Brett M, Flynn JT. Treatment of recurrent urethral strictures using clean intermittent self-catheterisation. Br J Urol 1991;68:89-92.  Back to cited text no. 9
    
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Zambon JV, Delaere KP. Prevention of recurrent urethral strictures by intermittent low-friction self-catheterisation. Eur Urol 1990;18 Suppl 1:277.  Back to cited text no. 10
    
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Bødker A, Ostri P, Rye-Andersen J, Edvardsen L, Struckmann J. Treatment of recurrent urethral stricture by internal urethrotomy and intermittent self-catheterization: A controlled study of a new therapy. J Urol 1992;148(2 Pt 1):308-10.  Back to cited text no. 11
    
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Kessler TM, Ryu G, Burkhard FC. Clean intermittent self-catheterization: A burden for the patient? Neurourol Urodyn 2009;28:18-21.  Back to cited text no. 12
    
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Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA. Campbell-Walsh Urology: Expert Consult Premium Edition: Enhanced Online Features and Print, 4-Volume Set. Elsevier Health Sciences; 2011.  Back to cited text no. 13
    
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Alwaal A, Blaschko SD, McAninch JW, Breyer BN. Epidemiology of urethral strictures. Transl Androl Urol 2014;3:209-13.  Back to cited text no. 14
    
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Iversen Hansen R, Reimer Jensen A. Recurrency after optical internal urethrotomy. A comparative study of long-term and short-term catheter treatment. Urol Int 1984;39:270-1.  Back to cited text no. 15
    
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Albers P, Fichtner J, Brühl P, Müller SC. Long-term results of internal urethrotomy. J Urol 1996;156:1611-4.  Back to cited text no. 16
    
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Girotti ME, MacCornick S, Perissé H, Batezini NS, Almeida FG. Determining the variables associated to clean intermittent self-catheterization adherence rate: One-year follow-up study. Int Braz J Urol 2011;37:766-72.  Back to cited text no. 17
    
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Lubahn JD, Zhao LC, Scott JF, Hudak SJ, Chee J, Terlecki R, et al. Poor quality of life in patients with urethral stricture treated with intermittent self-dilation. J Urol 2014;191:143-7.  Back to cited text no. 22
    
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