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Intermittent self catheterisation with hydrophilic, gel reservoir, and non-coated catheters: a systematic review and cost effectiveness analysis

BMJ 2013; 346 doi: (Published 09 January 2013) Cite this as: BMJ 2013;346:e8639
  1. Sarah L Bermingham, senior health economist1,
  2. Sarah Hodgkinson, senior research fellow and project manager1,
  3. Sue Wright, team leader infection prevention and control2,
  4. Ellie Hayter, professional lead nursing3,
  5. Julian Spinks, general practitioner4,
  6. Carol Pellowe, senior lecturer infection control5
  1. 1Royal College of Physicians, National Clinical Guideline Centre, London NW1 4LE, UK
  2. 2Peninsula Community Health, Sedgemoor Centre, St Austell PL25 5AS, UK
  3. 3Sussex Community NHS Trust, Horsham Hospital, Horsham RH12 2DR, UK
  4. 4Court View Surgery, Strood ME2 2HA, UK
  5. 5Department of Adult Nursing, Florence Nightingale School of Nursing and Midwifery, King’s College London, London SE1 8WA
  1. Correspondence to: S L Bermingham s.l.bermingham{at}
  • Accepted 10 December 2012


Objective To determine the most effective and cost effective type of catheter for patients performing intermittent self catheterisation in the community.

Design Systematic review and meta-analysis. Results were incorporated into a probabilistic Markov model to compare lifetime costs and quality adjusted life years (QALYs).

Data sources We searched Medline, Embase, and Cochrane and Cinahl databases from 2002 to 18 April 2011 to identify studies comparing hydrophilic, gel reservoir, and non-coated intermittent catheters. Earlier guidelines were used to identify papers published before 2002. To capture studies comparing clean and sterile non-coated intermittent self catheterisation, each database was searched from its date of inception to 18 April 2011.

Main outcome measures Clinical outcomes included symptomatic urinary tract infection (UTI), bacteraemia, mortality, patient preference or comfort, and number of catheters used. The economic model included downstream complications of UTI and cost effectiveness was calculated as incremental cost per QALY gained.

Results Eight studies were included in the systematic review. Most were conducted in patients with spinal cord injuries, and most of the included patients were men. People using gel reservoir and hydrophilic catheters were significantly less likely to report one or more UTIs compared with sterile non-coated catheters (absolute effect for gel reservoir = 149 fewer per 1000 (95% confidence interval −7 to 198), P=0.04; absolute effect for hydrophilic = 153 fewer per 1000 (−8 to 268), P=0.04). However, there was no difference between hydrophilic and sterile non-coated catheters when outcomes were measured as mean monthly UTIs (mean difference = 0.01 (−0.11 to 0.09), P=0.84) or total UTIs at 1 year (mean difference = 0.18 (−0.50 to 0.86), P=0.60). There was little difference in the incidence of one or more UTIs for people using clean versus sterile non-coated catheters (absolute effect = 12 fewer per 1000 (−134 to 146), P=0.86). Although the most effective, gel reservoir catheters cost >£54 350 per QALY gained and are therefore not cost effective compared with clean non-coated self catheterisation.

Conclusion The type of catheter used for intermittent self catheterisation seems to make little difference to the risk of symptomatic UTI. Given large differences in resource use, clean non-coated catheters are most cost effective. However, because of limitations and gaps in the evidence base and the designation of non-coated catheters as single use devices, we recommend a precautionary principle should be adopted and that patients should be offered a choice between hydrophilic and gel reservoir catheters.


  • We thank Kathy Zebracki, Lawrence Vogel, Caroline Anderson, and Kathleen Chlan for providing us with access to SF-12 data collected from their research cohort. We thank Joanna Ashe for designing the search strategy and generating the bibliography and David Wonderling for his comments on the manuscript.

  • Contributors: All authors contributed to the protocol for this work. SH systematically reviewed, appraised, and analysed the included clinical studies, while SLB designed, built, and analysed the cost effectiveness model. SW, EH, and CP critically appraised all included clinical evidence and contributed to the design and interpretation of the cost effectiveness analysis. SLB wrote the first draft of the manuscript, which was subsequently edited by all authors, who have approved the final version. All authors had full access to the data (including statistical results and tables) and take responsibility for the integrity of the data and accuracy of the analysis. CP will act as guarantor.

  • Funding: This work was undertaken by the National Clinical Guideline Centre (SLB and SH), which received funding from the National Institute for Health and Clinical Excellence (NICE). The views expressed in this publication are those of the authors and not necessarily those of the institute.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required as the study used only publicly available data sources.

  • Data sharing: Technical appendix available at

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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