Introduction
Clean intermittent catheterization (CIC) is the gold standard for bladder management in patients with neurogenic bladder (NB), especially those with spinal cord injury (SCI), multiple sclerosis (MS), spina bifida, or other neurogenic etiologies. CIC mimics physiological voiding by intermittently and completely emptying the bladder, thereby reducing intravesical pressure, minimizing urinary tract infections (UTIs), and preserving renal function [1,2].
Despite its clinical benefits and endorsement in urological guidelines (e.g., European Association of Urology), patient adherence to CIC remains suboptimal, with discontinuation rates ranging from 20% to 50% over time [3,4]. Patient compliance with CIC is influenced by multiple factors, including physical limitations, psychological barriers, technical difficulties, and social or environmental obstacles. A study by Weld and Dmochowski [5] reported that while most patients initially accept CIC, long-term adherence is hindered by manual dexterity issues, pain during catheterization, recurrent UTIs, or lifestyle disruption. In another large survey of SCI patients, 28% transitioned from CIC to indwelling catheters or other methods due to dissatisfaction or difficulty managing the procedure independently [6,7].
Discontinuation of CIC is not always due to patient preference but may reflect a mismatch between patient capability and support. In a prospective study of MS patients, nearly 40% stopped CIC due to progression of disability or lack of caregiver support [8,9]. Additionally, insufficient patient education or follow-up can lead to misuse or complications, prompting patients to switch to more passive but less optimal alternatives such as indwelling urethral or suprapubic catheters.
Although CIC remains the preferred method for bladder management in NB, long-term compliance is a complex, multifactorial issue. Thus, this study aimed to evaluate real-world CIC compliance, catheter preference, and reasons for discontinuation in a patient population initiated on CIC over a four-year period in single-center.
Methods
Participants and clinical assessment
We retrospectively reviewed 310 patients data from patients who visited Keimyung University Dongsan Hospital presenting with lower urinary tract symptoms such as voiding difficulty and incomplete bladder emptying between March 2019 and May 2023. All of these patients underwent urodynamic studies, which revealed detrusor areflexia, detrusor underactivity, or detrusor-sphincter dyssynergia, leading to the initiation of CIC. Underlying conditions associated with patients using CIC included as follows; diabetes mellitus, hypertension, SCI, spinal disc herniation, Parkinson’s disease, cerebrovascular disease, Guillain–Barré syndrome, history of hysterectomy, and benign prostatic hyperplasia (BPH).
When starting CIC for the first time, we provide patients with three types of catheter samples-typically including a hydrophilic-coated catheter (SpeediCathⓇ, SpeediCathⓇ Compact, Coloplast), a hydrophilic-coated catheter with the pure water sachet type (GentlecathⓇ glide, Convatec), a hydrophilic-coated catheter with salt solution sachet type (LoFric OrigoⓇ, LoFric SenseⓇ, Wellspect). Patients were instructed on aseptic technique by urology nursing staff. The key aspects of CIC education include: understanding the urinary system, why CIC is needed, the procedure, hygiene, choosing the right catheter (usually 12 Fr size of catheter is used), troubleshooting, regular follow-up. And they were allowed to trial each type at home before selecting their preferred catheter based on ease of use, comfort, and portability. During follow-up, patients were interviewed about: current catheter preference, continuation or discontinuation of CIC, duration of CIC use prior to cessation (if applicable), reasons for discontinuation, number and frequency of treated UTIs during CIC use.
Education level was categorized into four groups: middle school or lower, high school graduate, college graduate, and graduate school or higher. Occupational status was classified as unemployed, self-employed, office/service workers, farming/fishing, professionals, and others.
This study was approved by the Institutional Review Board (IRB) of Dongsan Hospital, Keimyung University, Daegu, Republic of Korea (IRB No. 2023-12-033). Written informed consent was obtained from all participants.
Statistical analyses
All statistical analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp.). Continuous variables were tested for normality using the Shapiro–Wilk test. Normally distributed data were presented as means ± standard deviations, while non-normally distributed data were expressed as medians with interquartile ranges. Categorical variables were reported as frequencies and percentages.
Comparisons between groups (e.g., CIC continuation vs. discontinuation) were conducted using the independent samples t-test or Mann–Whitney U test for continuous variables, depending on distribution. Chi-square test or Fisher’s exact test was used for categorical variables, such as gender distribution, catheter type preference, education level, occupational category, or reasons for CIC cessation.
Kaplan–Meier survival analysis was performed to estimate the duration of CIC use over time, and the log-rank test was used to compare CIC retention between subgroups (e.g., male vs. female, catheter type). Multivariate logistic regression analysis was performed to identify independent predictors of CIC discontinuation, including age, sex, underlying conditions, catheter type, and history of URIs. A p-value of < 0.05 was considered statistically significant for all tests.
Results
Among the 310 new CIC patients (mean age: 72 years) who began CIC between March 2019 and May 2023, of whom 165 (53.2%) were male and 145 (46.8%) were female. The underlying conditions associated with patients using CIC included as follows; hypertension (n = 131, 42.4%), diabetes mellitus (n = 110, 35.6%), SCI (n = 105, 33.9%), Parkinson’s disease (n = 17, 5.5%), cerebrovascular disease (n = 15, 5.1%), history of hysterectomy (n = 15, 5.1%), BPH (n = 21, 6.8%) and Guillain–Barré syndrome (n = 5, 1.7%) (Table 1).
Of the 310 patients, 263 (84.8%) selected Coloplast catheters, predominantly SpeediCath and SpeediCath Compact models. The reasons for not choosing other companies’ products were due to the difficulty in popping the water bag and the wait time for lubrication activation and bulkier packaging. The median duration from symptom onset to initiation of CIC was 5.9 months, and the median duration of CIC use was 12.5 months.
Demographic characteristics of clean intermittent catheterization discontinuation group
Of the 186 (60.0%) patients who discontinued CIC, 122 (65.6%) were male and 64 (34.4%) were female, indicating a higher discontinuation rate among males. The median duration of CIC use prior to cessation was 3.5 months (Fig. 1).
Kaplan–Meier analysis stratified by underlying conditions demonstrated that patients with hypertension (median 8 months) and BPH (median 4 months) discontinued CIC earlier than those with SCI (median 11 months) and diabetes mellitus (median 13 months).
Stratification by sex revealed a steeper decline in CIC continuation among males compared to females, highlighting the higher discontinuation rate in males. Education level significantly influenced adherence: patients with middle school education or lower (median 4 months) showed the shortest median duration, whereas those with college or graduate-level education exhibited longer CIC persistence (median 9 months).
Occupation also affected adherence patterns. Unemployed patients (median 2 months) discontinued CIC earlier than those employed in office/service work (median 13 months) or self-employed (median 16 months). Patients engaged in farming, fishing, or other occupations showed intermediate continuation rates (median 8 months).
The most common underlying conditions included hypertension (n = 79, 42.5%), diabetes mellitus (n = 48, 25.8%), and SCI (n = 30, 16.1%). Less frequent conditions were Parkinson’s disease (n = 8, 4.3%), BPH (n = 7, 3.7%), Guillain–Barré syndrome (n = 4, 2.1%), post-hysterectomy status (n = 2, 1.0%), and cerebrovascular disease (n = 1, 0.5%).
In terms of educational attainment, the majority were high school graduates (n = 102, 54.8%), followed by college graduates (n = 51, 27.4%), middle school graduates or lower (n = 26, 14.0%), and graduate school or higher (n = 7, 3.8%).
Regarding occupational status, most patients were unemployed (n = 131, 70.4%). Other occupations included self-employment (n = 10, 5.3%), office work or service industry (n = 9, 4.8%), farming or fishing (n = 14, 7.5%), and other unspecified occupations (n = 22, 11.8%). Notably, no patient in the discontinuation group reported working in a professional field (Table 2).
Reasons for clean intermittent catheterization discontinuation
The most common reasons of CIC cessation were symptom improvement and recovery of spontaneous voiding (evaluated using subjective measures such as questionnaires and objective tests such as uroflowmetry) in 44 patients (24.0%), pain or discomfort during catheterization in 15 patients (8.0%), recurrent UTI in 8 patients (4.3%), declining general condition in 25 patients (13.5%), fear of CIC in 24 patients (12.9%), hand tremor or manual dexterity difficulty in 6 patients (3.3%), and death due to unrelated causes in 12 patients (6.5%). Among those who discontinued CIC: 37 patients (19.9%) transitioned to indwelling urethral catheters and 52 patients (27.5%) were lost to follow-up, a critical consideration in outpatient adherence monitoring (Table 3). These findings suggest that both clinical (e.g., UTI, pain, general health deterioration) and non-clinical factors (e.g., fear, follow-up loss) contributed significantly to CIC cessation. Additionally, symptom resolution was reported in nearly one-fourth of patients, indicating that for some individuals, CIC was implemented as a short-term management strategy rather than a lifelong intervention.
Discussion
CIC is a widely accepted bladder management strategy, particularly for patients with neurogenic and non-neurogenic voiding dysfunction. Despite its well-established clinical benefits—preservation of upper urinary tract function, reduction in UTIs, and enhanced patient autonomy—long-term adherence to CIC remains a major challenge in real-world practice. In this retrospective cohort study, we evaluated CIC usage patterns, catheter preferences, and discontinuation factors among 310 new CIC patients over a four-year period.
The mean age of our study population was 72 years, reflecting the typical older adult population commonly requiring CIC due to age-associated lower urinary tract dysfunction. Underlying conditions included both neurogenic and non-neurogenic etiologies such as SCI, spinal disc herniation, Parkinson’s disease, BPH, diabetes, hypertension, and post-hysterectomy states. These findings are consistent with previous reports that have identified age-related degenerative and neurologic conditions as common indications for CIC initiation [10,11].
Notably, 85% of patients selected Coloplast products, primarily SpeediCathⓇ, SpeediCathⓇ Compact models. This overwhelming preference for hydrophilic-coated, pre-lubricated catheters reflects prior findings that such products are associated with improved patient satisfaction, reduced urethral trauma, and ease of use, especially among elderly patients and those with compromised dexterity [3-5]. In contrast, patients who rejected other catheter brands frequently cited difficulty in activating the water sachet, long wait times for lubrication activation, and inconvenient packaging. These barriers have similarly been reported in comparative studies evaluating user satisfaction and real-world utility across catheter types [6].
Among the 310 patients, 186 (60.0%) eventually discontinued CIC. The median duration of CIC use prior to cessation was 3.5 months, substantially shorter than the overall median duration of CIC use (12.5 months) across the entire cohort. This is consistent with existing literature reporting high dropout rates within the first 6 to 12 months of CIC initiation [7,8]. A Kaplan–Meier survival analysis of our cohort demonstrated a sharp decline in CIC continuation during the first few months, emphasizing the importance of close monitoring and early intervention.
Male patients comprised two-thirds (65.6%) of those who discontinued CIC. In our study, analysis of discontinuation rates by sex revealed that 73.9% of male patients and 44.1% of female patients discontinued CIC. Previous studies have suggested that anatomical and functional differences may influence CIC success rates, with some studies reporting greater tolerance among female users [9]. However, sociocultural factors, urinary tract anatomy, and perceived invasiveness may all play roles and warrant further investigation.
Sociodemographic characteristics of the CIC discontinuation group offer important insights. Over 70.4% were unemployed, and more than half had only completed high school. Previous studies have identified lower education and socioeconomic status as significant predictors of CIC non-adherence, likely due to limited access to resources, reduced health literacy, and dependency on caregivers [10]. In addition, no patient who discontinued CIC reported working in a professional field, supporting the notion that more physically or cognitively demanding employment may be less compatible with the continued use of CIC.
The most frequently cited reasons for discontinuing CIC were diverse, encompassing both clinical and psychosocial factors. Clinical factors included pain (8.0%), recurrent UTIs (4.3%), and declining general health (13.5%). While CIC is known to reduce UTI risk compared to indwelling catheters, its effectiveness is heavily dependent on proper technique and regular hygiene. Poor technique or inconsistent practice may paradoxically increase infection risk, especially among older adults or those with cognitive impairment [11,12].
Psychosocial factors also featured prominently. Fear of self-catheterization (12.9%), manual dexterity issues (3.3%), and loss to follow-up (27.5%) highlight the burden of CIC beyond physical health. Fear, embarrassment, and dependency on caregivers are common barriers, particularly in the elderly or socially isolated [13]. These findings echo those by Bolinger et al. [14] and Logan et al. [15] who emphasized the role of psychological support, training, and individualized catheter education in sustaining CIC adherence.
Interestingly, symptom improvement was reported by 24.0% of patients as a reason for discontinuation, suggesting a temporary role of CIC in some cases. This aligns with studies demonstrating reversible voiding dysfunction in certain patient groups, such as those recovering from acute urinary retention, infections, or post-surgical voiding dysfunction [16]. In such patients, short-term CIC may serve as a bridge until spontaneous voiding resumes, reinforcing the need for individualized plans and regular reassessment.
Among patients who discontinued CIC, 19.9% transitioned to indwelling urethral catheterization. While this may reflect clinical deterioration, lack of caregiver support, or functional limitations, it is concerning given the higher long-term risk of complications associated with indwelling catheters, including UTI, bladder stones, and urethral erosion [17]. Furthermore, 27.5% of CIC cessation patients were lost to follow-up, underscoring the critical need for proactive outpatient monitoring and community-based support programs.
Our findings highlight several actionable insights. First, catheter selection and early experience strongly influence adherence. Providing options, especially pre-lubricated or hydrophilic types, and facilitating patient comfort may enhance long-term use. Second, targeted education and training for patients with lower health literacy or physical impairments are essential. Third, regular follow-up visits during the first 3 to 6 months after initiation could identify early discontinuation risks and allow for timely intervention.
Future research should explore sex-based differences in CIC outcomes, develop predictive models for discontinuation, and evaluate the impact of structured CIC training programs. Additionally, integration of telemedicine or remote nursing support may improve monitoring, reduce follow-up loss, and address complications earlier, particularly in underserved populations.
This study has several limitations that should be acknowledged. First, the retrospective nature of the study limits the ability to establish causal relationships between patient characteristics and CIC discontinuation. Second, the findings are based on patients from a single institution, which may reduce generalizability to broader populations with differing healthcare access, demographics, or cultural factors. Third, reasons for CIC cessation were based on patient or caregiver reports, which may be subject to recall bias or incomplete reporting. Fourth, objective data such as urodynamic studies, renal function trends, or standardized quality of life scores were not available for inclusion.
In conclusion, this study provides novel insights into the real-world patterns of to CIC among patients with diverse underlying neurological conditions. Despite initial support and catheter choice flexibility, a significant proportion of patients (60.0%) discontinued CIC, often within the first few months of initiation. Factors contributing to discontinuation were multifactorial, including symptom improvement, pain, fear, functional decline, and poor follow-up compliance.
Unlike prior studies that primarily report general adherence challenges, our findings highlight the predominance of discontinuation among male, older, and unemployed individuals with lower educational attainment underscores the importance of identifying at-risk populations. Moreover, we identified that initial catheter choice, particularly preference for pre-lubricated hydrophilic catheters, appears to influence early adherence, while psychosocial and clinical factors heavily impact sustained use.
Interestingly, a subset of patients discontinued CIC due to symptom improvement or transient voiding dysfunction, emphasizing the potential for CIC as a temporary bridging intervention rather than a permanent management strategy in selected cases. These observations support a more personalized, dynamic approach to CIC management.
These findings emphasize the need for personalized CIC education including technological solutions such as remote monitoring and telemedicine support, proactive follow-up strategies, and multidisciplinary support—especially in the early months following CIC initiation to improve adherence and outcomes in this vulnerable population.
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