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Corey Knott is committed to helping her patients catheterise successfully. Learn about how and why she became a urology nurse, and get her intermittent self-catheterisation (ISC) tips.
Corey Knott started her nurse training in 1999, but soon gravitated from the broad range of specialties in surgical nursing towards urology. She took a nurse continence advisor course at McMaster University, and three years after that she joined the bladder care center at UBC (University of British Columbia) Hospital in Vancouver. In 2012 she changed hospitals and joined the Richmond Urological Care Centre in Richmond, BC. She’s worked there ever since, seeing patients and sharing knowledge and best practice with her colleagues and with professionals further afield.
With 2 young sons of her own, she’s passionate about opening up conversations about bladder care and busting the taboo that has always surrounded it. Corey lives in Canada.
How I got into urology
I gravitated towards urology quite early in my nursing career, as one of my mentors happened to work in the bladder care clinic. She spotted that I seemed interested and asked if I wanted to shadow her. Later, when she and her husband moved away, a position opened up and I moved to work there. At the clinic a new $100,000 testing machine had been left covered in a sheet as no-one was sure how to operate it. I was young and keen, and asked if I could take a course and learn how to use it, which I did. I loved how particular you had to be with it, and how it could give you a definitive answer to people’s bladder, whether that’s overactive bladder or stress incontinence. I also took additional courses on urodynamics to learn about complex urinary dysfunction.
I found urologists were good teachers; if I asked about surgery or function, they were keen to stop and take time so I learned a lot from them.
Why I love urology
It can make such a difference to patients, and they often make quick and remarkable recoveries. Urinary (and bowel) dysfunction is so overwhelming – when everything’s working fine it feels so unimportant, but any problems can take over your life. It is vital to try to help people manage for themselves if they can, and to make their journey dignified. Bladder dysfunction is something that causes huge mental and physical challenges – but these are often kept secret as people typically don’t like to talk about them. We need to have an open conversation about their struggles.
Such a huge impact on quality of life
I was always struck, when I worked with spinal cord injury (SCI) patients, by their broad acceptance of their injury and of their lives going forward as a wheelchair user or ambulatory. Mobility was not always their biggest hurdle, but bladder and bowel management often was. And if I asked which of those two challenges they’d want fixed, they’d choose bladder. It takes up the most time, and is the most likely to make them sick or get infections, to put them in hospital and to stop them doing what they want. It means they can’t live their life unhindered.
Important to share knowledge
We’re all stronger when we work together. I’ve been working in urology a long time and have learned so much about patient care, about teaching patients and about nursing education; in British Columbia (BC) we’re a fairly small group so we reach out to each other to keep improving our patient care.
I like to learn from patients – it’s a two-way street
Many years ago I did catheterize myself, just to get an idea of what it was like in a physical sense. But it’s not the same as being a patient and though I’m highly experienced and can guess what difficulties there are, it’s so important to hear from the patients themselves. They become experts on their own condition and will experience things we don’t know about. Every patient has a unique experience. Listening to people is huge, as is tailoring their care for them.
My passion for patient education was obvious!
When I met the Canadian Hollister representative, he could see how passionate I was about sharing knowledge and mentoring other nurses, and understanding different products and their benefits. He invited me to a talk when they launched a new catheter, and after that I was invited to join the Hollister ICEF (International Clinical Education Forum); I was thrilled and honoured.
The challenge is as mental as it is physical
Honestly, I believe it’s probably 50/50. If you have urinary dysfunction (whether that’s incontinence or retention or hypotonic bladder) everything becomes difficult, as well as making you feel unwell. Patients report being anxious about having accidents, or being unable to commit to being somewhere at a particular time – it might take you 45 minutes to use the bathroom, which is stressful. So people tend to turn down invitations, choose not to travel anywhere, not to be social or just stay home. And that’s not good for mental health. It becomes all-encompassing.
Just the idea of ISC is overwhelming
For some people, the thought of it is too much. I have new patients who fear doing damage, causing infection, puncturing their bladder, making their function even worse than it is. They say, can I really do this? It doesn’t seem natural – you wouldn’t stick anything up your nose or deep into your ear! Men especially struggle with the concept. But sometimes there’s no choice. I try to change the way people think about it, and remind them that using a catheter doesn’t mean they’re unwell – it’s part of them being well.
I have to get into their mind set
As a urology nurse, I have to think about how that person is feeling. They have other things going on in their lives – this is one of a multitude of issues they’re dealing with.
There is good news
It’s very daunting and we understand that, but the good news is that the vast majority, once they’ve learned how to ISC, say, huh, it’s not that bad! One lovely patient who nailed it after an anxious start said to me: “Well, it’s not in my top five things I want to do in my life, but I’m getting there...”
There’s a huge difference between ISC and indwelling
It’s independence! One patient wanted to enjoy the summer, wear shorts, and go swimming. True, there are some smaller bags for indwelling catheters that hold 250ml, but that’s not much. If it works for your body and you learn to ISC, you can do what you like, when you like.
Remember it’s safe – and it may not be forever
It must be taught properly to each individual – and individualised care is really important – and then it is safe. It’s not always lifelong, sometimes it’s just for a period before surgery, or for a pregnant woman who may not need to continue ISC when her bladder function has resumed. Everyone is different.
Take your time
The first consultations need time. Lots of time. We schedule 90-minute sessions so we can take it slowly, because people are obviously nervous when they come in. Having a strong urology background and fully understanding bladder function and dysfunction, and all the surrounding issues, is vital for the nurses. It’s not only about teaching the practical side of catheterizing, there are private issues that come up about sexual function, bowels, diet. Patients need time to relax so they can ask questions, and I understand it’s daunting, so I’m always calm and unhurried and if there’s anything we feel we haven’t covered, we book more time to continue our conversation. I understand that in some countries and heathcare settings, this is not always possible.
I show my patients different catheters and ask if they have a preference (here in Canada not all types are covered under every health plan, so that has to be a consideration) though I streamline the options; too much choice can be overwhelming. Once they’ve understood how it all works, they can make informed choices and come to their own conclusions of what will be best for them. I always do a follow-up call and provide my contact details so people can ask questions further down the line.
Teaching ISC to women
Intermittent self-catheterization (ISC) for women can be difficult. Everyone is different and some won’t be able to do it, if they have poor dexterity for example. One patient I first saw at the age of 88 had poor balance but good hand dexterity, and she did it the first time. She was very keen! (Now at 94 she’s finding it more difficult, so has switched to an indwelling).
The main issue for women is finding their urethra. When I’m teaching them, I have a picture to show them where everything is, and then get them to lie down and use a mirror to look at themselves, so they have a visual idea of what they’re aiming for. Some women worry about inserting it into their vagina by mistake, so sometimes it helps to put a tampon or some toilet paper into the opening to the vagina and block it; they can then feel where the catheter is meant to go and it finds its way to the urethra by default.
If she has good balance, I usually teach women to stand and put one foot up on the toilet. If needed, they have a small mirror that fixes to their leg so they can see the perineum – some people can do it by touch. Others prefer to sit on the very edge of the toilet seat.
Younger women tend to find it easier for many reasons; they are more likely to have good balance, good hip flexibility, use tampons, have good dexterity and hand strength.
Women with higher BMIs sometimes find it more difficult as they can’t always physically reach their urethra. If they’re willing to try and have good hand dexterity, they can usually do it standing up, leaning on a wall with one foot up. I always recommend taking time, taking a breath. Keeping calm. If someone is anxious and starts to sweat, it can trigger a vasovagal effect and fainting.
Teaching ISC to men
In theory it should be easier for men, as the opening to their urethra is right before their eyes. Young men however have often never had a physical procedure before we see them, while most young women have had a pap smear or another genital examination. Men sometimes get a physical response to their fear and can’t relax their pelvic floor – so we have tips for them!
To kick off I get them to lay everything out, wash their hands thoroughly and then stand facing the toilet. With their non-dominant hand they retract the foreskin (if they have one), pull the penis tight and away from them at a slight angle, less than 45 degrees. Taking the catheter in their dominant hand they then insert the tip into the urethra. While putting it in, I tell them to think about urinating and imagine letting the urine go. That usually helps the pelvic floor relax and the internal sphincter will open a little. I tell them to wiggle their toes as if they’re on a beach and their feet are covered in sand. Take deep breaths, go slow.
Once urine flows they feel a relief, and I advise them to push in a further inch to make sure they’re right in the bladder, and not just in its neck. If we know they have a capacious bladder or a diverticulum, I get them to insert it even further. As the flow begins to slow, they remove the catheter slightly, and if the flow begins again, they should wait for it all to drain. Bearing down slightly as the urine slows ensures it all comes out.
There shouldn’t be pain on removing the catheter; the most discomfort might come when they approach the prostate if they’ve had a TURP (transurethral resection of the prostate) or there’s a blockage, stricture, or scar.
I’m happy to say that the vast majority, I’d estimate 98%, of male patients tell me: it’s not that bad. Others might say they have an emotional blockage, and I’m fine with that too, and respect it.
A few basic ISC hints and tips:
Keep seeing your healthcare professionals
I believe it’s good to support my patients, so I always offer my contact details when they leave, in case they have questions or worries that I can help with. Bodies change as we age, and products do too. As a patient’s condition develops, it could be worth trying something new, maybe to deal with a stricture, or a decline in hand dexterity or more limited mobility.
Getting the right product for each patient
I’m determined that each patient gets the product that’s right for them, but sometimes it’s not automatic, so I’m happy to help write letters and make calls to health insurance companies. For many patients it’s a huge win to use a hydrophilic-coated catheter and not have to fiddle with the lube and so on. The end user will know what they need and they deserve support from professionals, and financial support too – which I know doesn’t happen in every country.
World Continence Week (WCW)
As WCW approaches (every year in June) there’s still so much to be done to help people. Men and women alike shouldn’t feel overwhelmed or anxious about supplies and information, shouldn’t feel alone on their journey. They deserve to have support even if there isn’t a urology nurse to sit and teach them, and should know what their options are, what other catheters are out there, what coverage there is – that’s the big thing in Canada. I’d like to focus on wellness too, because for some people incontinence can be intermittent, while for others it’ll be a chronic, lifelong condition.
What goes on behind closed doors?
It’d be great to promote bladder health (and bowel health) not just for people with dysfunction, but for the general public. If we talked to kids about it when they’re young, like we do in schools with teeth-brushing and hand-washing, it’d become normal. It wouldn’t need to be about things going wrong but could be covered within overall health and wellness, as well as guidance on sleep, the importance of a varied diet, how much water should be drunk each day and so on. In my house it’s general conversation!
Educating the wider public
Public campaigns, when they’re done well, are so powerful. “See red?” was a campaign launched in Canada for bladder cancer awareness, reminding people that any blood in your pee should be checked by a doctor. It was seen everywhere and made a huge difference. Any education for the broader public on continence would be a good thing; just understanding the issues would help to chip away at the taboo that hides behind phrases we all use like “I’m going to the washroom.” When people ask about my work and what I do, very few of them had even thought that multiple sclerosis, for example, could affect the bladder or the bowel.
Here comes the science...how urination happens
Knowing the mechanics can really help. In a functioning bladder, the internal sphincter is closed until your brain sends a signal to the bladder. The bladder contracts, the pelvic floor muscles relax, the internal sphincter opens, the bladder squeezes and urine comes out. When the bladder is empty, it contracts and the sphincter closes again.
When you have a voiding dysfunction – whether male or female – the pelvic floor isn’t relaxed, the bladder squeezes but the sphincter struggles to open fully and this fight between them all results in intermittent or incomplete emptying. Sometimes it’s about anxiety and relaxing the pelvic floor, and the fix is as simple as pelvic floor physio. Other times those muscles are too tight, and we have to teach patients to “downtrain” the pelvic floor.
Don’t push it
Teaching people to void properly is helpful but you should never have to push – you should relax and the bladder will do the squeezing for you. If small children are sitting on the big toilet and having to concentrate on holding themselves steady, they’re not relaxing their pelvic floor. Better to use a potty or overlay a smaller kid’s seat on top of the toilet seat.
The Squatty Potty is a big thing in North America – the manufacturer must have made millions! It helps people achieve the right angle to urinate and defecate anatomically...equally you can use a small stool in front of the toilet to put your feet up at 90 degrees and do the same thing.
It’s hard when finance means we can only offer limited catheter options to a patient. Here in Canada ostomy supplies are covered by insurance, but only one region, Saskatchewan, includes catheters. It’s forward-thinking of them. I’d love to get behind a campaign to get them covered everywhere – and if we raise the profile of bladder care that could only help.
Single-use catheters should be standard
Most research articles on hydrophilic coated single-use catheters focus on people with spinal cord injuries (SCI) – which is fair, as they are the majority who are using catheters. Urologists point out that SCI patients are more at risk of UTI than other patients so it’s important that they have single-use catheters.
For a long time in Canada, though, people were re-using catheters – there was an eye-opening article about it from the Canadian Urological Association in 2020. We could really use some evidence-based research to show that ambulatory urogenic patients need the same single-use catheters, rather than re-using. With strong research behind us we could push for single-use catheters across the board, and promote health and wellness for both SCI and ambulatory patients.
The urology product companies and associations often hold talks and seminars, and I attend as many as possible, from an education and a product development point of view. There’s lots of research from urologists, presentations about best practice and new catheters to look at. Hollister is an excellent example of this. They share information that isn’t only product-focused, they also provide information that health care professionals can share with other nurses and with their patients.
Teach the nurses and they can pass it on
More education for nurses would make a huge difference; a homecare nurse can’t cover every specialty and advise patients in detail. Specialist nurses with an interest in continence promotion and wellness could then disseminate the knowledge around their teams, and make sure it’s the right kind of information. There are nurse educators on the urology unit, for example, but they are teaching about post-op health and wound care, and don’t have the knowledge about products and resourcing for life after hospital. And we’re all spread very thin.
I became a nurse to help people
One new patient of mine has struggled with dysfunction and infections for years, and it’s stopped her doing so much she wanted to do. She always longed to travel back to the Netherlands but couldn’t imagine it would ever happen; how could she travel anywhere, let alone get on a flight, if it took her an hour to use the bathroom every time she went? With our knowledge, teaching and compassion her life has changed, and she’s taking that trip at last. There’s so much to cope with, but with professional support, good supplies, caring follow-through, and time, people can conquer it.
I really care about how my patients get on, and want to help and support people in this very intimate part of their life. I know it can be daunting and overwhelming, and it is going to get personal – I’m going to be right up in your business! But my patients are OK with that, as they know I’m trying to help.
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