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Over the nearly two years of navigating the COVID pandemic, urology practices were forced to increase their efficiency by focusing on streamlining patient visits without sacrificing care quality. However, postponed checkups were unavoidable as the public was encouraged to stay home. According to the Centers for Disease Control and Prevention (CDC), 40% of Americans in 2020 delayed or avoided medical care due to pandemic-related concerns. Although necessary, we are now facing the severe consequences of delayed diagnosis and prostate cancer seems to be leading the way.

II. Proper Techniques for Urinary Catheter Insertion

1. Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site. (Category IB) (Key Question 2D)
2. Ensure that only properly trained persons (e.g., hospital personnel, family members, or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility. (Category IB) (Key Question 1B)
3. In the acute care hospital setting, insert urinary catheters using aseptic technique and sterile equipment. (Category IB) 
   
   1. Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion. (Category IB)
   2. Routine use of antiseptic lubricants is not necessary. (Category II) (Key Question 2C)
   3. Further research is needed on the use of antiseptic solutions vs. sterile water or saline for periurethral cleaning prior to catheter insertion. (No recommendation/unresolved issue) (Key Question 2C)
4. In the non-acute care setting, clean (i.e., non-sterile) technique for intermittent catheterization is an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization.(Category IA) (Key Question 2A) 
   
   1. Further research is needed on optimal cleaning and storage methods for catheters used for clean intermittent catheterization. (No recommendation/unresolved issue) (Key Question 2C)
5. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (Category IB)
6. Unless otherwise clinically indicated, consider using the smallest bore catheter possible, consistent with good drainage, to minimize bladder neck and urethral trauma. (Category II)
7. If intermittent catheterization is used, perform it at regular intervals to prevent bladder overdistension. (Category IB) (Key Question 2A)
8. Consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions. (Category II) (Key Question 2C) 
   
   1. If ultrasound bladder scanners are used, ensure that indications for use are clearly stated, nursing staff are trained in their use, and equipment is adequately cleaned and disinfected in between patients. (Category IB)

III. Proper Techniques for Urinary Catheter Maintenance

1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. (Category IB) (Key Question 1B and 2B) 
   
   1. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. (Category IB)
   2. Consider using urinary catheter systems with preconnected, sealed catheter-tubing junctions. (Category II) (Key Question 2B)
2. Maintain unobstructed urine flow. (Category IB) (Key Questions 1B and 2D)
   1. Keep the catheter and collecting tube free from kinking. (Category IB)
   2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. (Category IB)
   3. Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container. (Category IB)
3. Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system. (Category IB)
4. Complex urinary drainage systems (utilizing mechanisms for reducing bacterial entry such as antiseptic-release cartridges in the drain port) are not necessary for routine use. (Category II) (Key Question 2B)
5. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. (Category II) (Key Question 2C)
6. Unless clinical indications exist (e.g., in patients with bacteriuria upon catheter removal post urologic surgery), do not use systemic antimicrobials routinely to prevent CAUTI in patients requiring either short or long-term catheterization. (Category IB) (Key Question 2C)
   
   1. Further research is needed on the use of urinary antiseptics (e.g., methenamine) to prevent UTI in patients requiring short-term catheterization. (No recommendation/unresolved issue) (Key Question 2C)
7. Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate. (Category IB) (Key Question 2C)
8. Unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery) bladder irrigation is not recommended. (Category II) (Key Question 2C)
   
   1. If obstruction is anticipated, closed continuous irrigation is suggested to prevent obstruction. (Category II)
9. Routine irrigation of the bladder with antimicrobials is not recommended. (Category II) (Key Question 2C)
10. Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended. (Category II) (Key Question 2C)
11. Clamping indwelling catheters prior to removal is not necessary. (Category II) (Key Question 2C)
12. Further research is needed on the use of bacterial interference (i.e., bladder inoculation with a nonpathogenic bacterial strain) to prevent UTI in patients requiring chronic urinary catheterization. (No recommendation/unresolved issue) (Key Question 2C)

Catheter Materials

1. If the CAUTI rate is not decreasing after implementing a comprehensive strategy to reduce rates of CAUTI, consider using antimicrobial/antiseptic-impregnated catheters. The comprehensive strategy should include, at a minimum, the high priority recommendations for urinary catheter use, aseptic insertion, and maintenance (see Section III. Implementation and Audit). (Category IB) (Key Question 2B)
   
   1. Further research is needed on the effect of antimicrobial/antiseptic-impregnated catheters in reducing the risk of symptomatic UTI, their inclusion among the primary interventions, and the patient populations most likely to benefit from these catheters. (No recommendation/unresolved issue) (Key Question 2B)
2. Hydrophilic catheters might be preferable to standard catheters for patients requiring intermittent catheterization. (Category II) (Key Question 2B)
3. Silicone might be preferable to other catheter materials to reduce the risk of encrustation in long-term catheterized patients who have frequent obstruction. (Category II) (Key Question 3)
4. Further research is needed to clarify the benefit of catheter valves in reducing the risk of CAUTI and other urinary complications. (No recommendation/unresolved issue) (Key Question 2B)

Management of Obstruction

1. If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. (Category IB)
2. Further research is needed on the benefit of irrigating the catheter with acidifying solutions or use of oral urease inhibitors in long-term catheterized patients who have frequent catheter obstruction. (No recommendation/unresolved issue) (Key Question 3)
3. Further research is needed on the use of a portable ultrasound device to evaluate for obstruction in patients with indwelling catheters and low urine output. (No recommendation/unresolved issue) (Key Question 2C)
4. Further research is needed on the use of methenamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction. (No recommendation/unresolved issue) (Key Question 2C)

Specimen Collection

1. Obtain urine samples aseptically. (Category IB)
   
   1. If a small volume of fresh urine is needed for examination (i.e., urinalysis or culture), aspirate the urine from the needleless sampling port with a sterile syringe/cannula adapter after cleansing the port with a disinfectant. (Category IB)
   2. Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag. (Category IB

Reference:

[Guideline] Gould, C. V., C. A. Umscheid, et al. (2010). "Guideline for prevention of catheter-associated urinary tract infections 2009." Infect Control Hosp Epidemiol 31(4): 319-326.
[Guideline] Hooton, T. M., S. F. Bradley, et al. (2010). "Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines fInfectious Diseases Society of America." Clin Infect Dis 50(5) :625-663.

There are other non-infectious IUC-related adverse effects that occur the longer an indwelling urinary catheter (IUC), particularly a transurethral IUC, is used for bladder drainage. They include catheter blockage, urine bypassing, bladder spasms, accidental catheter dislodgement, and non-deflating balloons.

Overview  |  Bacteriuria  |  CAUTIs  |  Catheter-Associated Biofilms
Encrustations  |  Urosepsis  |  Urethral Damage  |  Common Urethral Complications  |  References

Catheter-Associated Complications

Catheter related problems due to an indwelling urinary catheter (IUC) have existed as long as urinary catheters have been utilized.  This section will review IUC complications: infectious complications such as (symptomatic bacterial infection, cystitis, pyelonephritis, urosepsis, and epididymitis), catheter blockage (due to calculi, biofilms, and encrustations), catheter related malignancy, hematuria, stones, urethral stricture and fistula from urethral injury, traumatic hypospadias, and periurethral urine leakage. 

Indwelling urinary catheters (IUCs) are semi-rigid, flexible tubes. They drain the bladder but block the urethra. IUCshave double lumens, or separate channels, running down it lengthwise. One of the lumen is open at both ends and allows for urine drainage by connection to a drainage bag.



The other lumen has a valve on the outside end and connects to a balloon at the tip; the balloon is inflated with sterile water when it lies inside the bladder, and allows for retention in the bladder.  These are known as two-way catheters.  

The name of the Foley catheter comes from the designer, Frederic Foley, a surgeon working in Boston, Massachusetts, in the 1930s. His original design was adopted by C. R. Bard, Inc. who manufactured the first prototypes and named them in honor of the surgeon.

Foley Catheter Sizes

Catheter sizes are colored-coded at the balloon inflation site for easy identification

The relative size of a Foley catheter is described using French units (Fr).  In general, urinary catheters range in size from 8Fr to 36Fr in diameter. 1 Fr is equivalent to 0.33 mm = .013" = 1/77" in diameter.  

The crosssectional diameter of a urinary catheter is equal to three times the diameter.

Since urethral mucosa contains elastic tissue which will close around the catheter once inserted, the catheter chosen should be the smallest catheter that will adequately drain urine.  

Size Considerations

• The routine use of large-size catheters diameters can cause more erosion of the bladder neck and urethral mucosa, can cause stricture formation, and do not allow adequate drainage of peri-urethral gland secretions, causing a buildup of secretions that may lead to irritation and infection. 
• Larger Fr sizes (e.g., 20-24 Fr) are most commonly used for drainage of blood clots.  
• The most commonly utilized indwelling transurethral and suprapubic catheters range from 14 to 16Fr in both adult females and males. 
• A 14 or 16 Fr is also the standard catheter in most commercially available IUC insertion kits or trays.
• In adolescents, catheter size 14 Fr is often used but for younger children, pediatric catheter sizes of 6-12 Fr are preferred.  

Shape and Design Variations

The distal end of most urinary catheters contains two ports (lumen or channel or dual lumen).  One is a funnel shaped drainage channel to allow efflux of urine once the catheter is placed and the other is the inflation/deflation channel for infusion of water into the retention balloon.  The infusion port for the balloon is usually labeled with the size of the balloon (5cc or 30 cc) and the size of the catheter.

 
Three-way catheters are available with a third channel to facilitate continuous bladder irrigation or for instillation of medication.  This catheter is primarily used following urological surgery or in case of bleeding from a bladder or prostate tumor and the bladder may need continuous or intermittent irrigation to clear blood clots or debris. 

The catheter should have a smooth surface with two drainage eyes at the tip that allow for urine drainage.

Drainage eyes are placed either laterally or opposed. Opposing drainage eyes generally facilitate better drainage.

Catheter products have changed significantly in their composition, texture, and durability since the 1990s.

The challenge is to produce a catheter that matches as closely as possible to the normal physiological and mechanical characteristics of the voiding system, specifically the urethra and bladder. Foley catheters come in several subtypes, which are described in the area designs. 

References

1. Jahn P, Beutner K, Langer G. Types of indwelling urinary catheters for long-term bladder drainage in adults. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD004997. DOI: 10.1002/14651858.CD004997.pub3.Newman DK, Cumbee RP, Rovner ES. Indwelling (transurethral and suprapubic) catheters. In: Newman DK, Rovner ES, Wein AJ, editors. Clinical Application of Urologic Catheters and Products.  Switzerland: Springer International Publishing;2018,  47-77.
2. Newman DK. Devices, products, catheters, and catheter-associated urinary tract infections. In: Newman DK, Wyman JF, Welch VW, editors. Core Curriculum for Urologic Nursing. 1^st ed. Pitman (NJ): Society of Urologic Nurses and Associates, Inc; 2017, 439-66.
3. Newman DK. The indwelling urinary catheter: Principles for best practice. JWOCN. 2007;34:655-61 DOI: 10.1097/01.WON.0000299816.82983.4a
4. Newman DK, & Wein AJ. Managing and Treating Urinary Incontinence, Second Edition.  Baltimore: Health Professions Press;2009a;445-458.

Overview  |  Executive Summary
Summary of Recommendations  |  Appropriate Urinary Catheter Use
Proper Techniques for Urinary Catheter Insertion  |  Proper Techniques for Urinary Catheter Maintenance
Quality Improvement Programs  |  Administrative Infrastructure  |  Surveillance  |  Download  |  References

CAUTI Prevention:

The 2009 Centers for Disease Control and Prevention (CDC) guidelines for the prevention of catheter-associated urinary tract infections (UTIs) recommends catheter use only for appropriate indications. Catheter use and duration should be minimized in all patients, especially those at higher risk for catheter-associated UTIs (e.g., women, elderly persons, and patients with impaired immunity).

Background

Use of Indwelling Urinary Catheters  |  Acute Care Catheter Use  |  Indications for indwelling urinary catheter use
Selected peri-operative needs  |  LTC Catheter Use  |  References

Each year, urinary catheters are inserted in more than 5 million patients in acute care hospitals and long-term care (LTC) facilities. Historically, indwelling urinary catheters (IUC) have been used in the chronically, medically compromised older adults. 

The settings in which the prevalence of long-term IUCs usage is the greatest are: 1) skilled nursing facilities, where they are used in residents with UI, and 2) homes where the person requires skilled nursing visits.

In the home-care setting, the prevalence of IUCs is growing with the increasing number of older adults. The median time of indwelling catheter use in home care is reported as 3 to 4 years.  However, the number of “home-bound” patients who use a catheter indefinitely to manage UI or because of urinary retention has not been well documented in medical or nursing research. 

Indications for Indwelling Catheter (medical necessity)

Indwelling catheter overuse occurs when a device is in place without an appropriate indication. There are two ways of reducing IUC use: 1) by minimizing the initial placement of IUCs and 2) by reducing the duration of each catheterization.  Urinary catheters have various medical indications but the most common is short term drainage of the urinary bladder.    For some patients with upper tract deterioration due to elevated bladder storage pressures (e.g. poor compliance from prior radiation therapy, neurogenic disease, etc.), an IUC may have a role.  The catheter permits low pressure, unimpeded drainage of urine from the upper urinary tract through the bladder and then directly into a collection receptacle.  The following are indications for IUC use.

- Short term for acute urinary retention: 

•  Sudden and complete inability to void
•  Need for immediate and rapid bladder decompression
•  Monitoring of intake and output

- Temporary relief of bladder outlet obstruction secondary to:

• Enlarged prostate gland in men
• Urethral stricture
• Obstructing pelvic organ prolapse in women

- Chronic urethral obstruction or urinary retention and surgical interventions, or the use of intermittent catheterization, has failed or is not feasible, or both
- Short term following a urological or gynecological surgical procedure
- Irreversible medical conditions are present (e.g., metastatic terminal disease, coma, end stages, of other conditions)
- Presence of stage III or IV pressure ulcers that are not healing because of continual urine leakage
- Instances in which a caregiver is not present to provide incontinence care 

 Use of Indwelling Urinary Catheters 

Although indwelling urinary catheters are commonly used in most clinical settings, data suggest that more than 20% of these catheters are placed without a specific medical indication and that they often remain in place without the knowledge of the patient’s physician. Studies of the appropriateness of use of urinary catheters indicate that 21 to 38% of initial urinary catheterizations are unjustified, and one-third to one-half of days of continued catheterization are unjustified. The current challenges are to develop effective methods to sensitize the minds of clinicians to avoid the routine use of indwelling catheters, remove catheters when they are no longer needed, develop alternative methods for care of urinary incontinence (UI), employ noninvasive methods to measure bladder function and urine output, and improve urine drainage systems.

Catheter Use in Acute Care Setting (Hospitals, Acute Rehabilitation)

In acute care hospital settings, approximately 12-16% of adult patients and up to 25% of all hospitalized patients usually for surgery, urine output measurement, urinary retention, or UI. Their use is greater in high acuity patient units, with critical care and intensive care units having the highest.  At least 8%-23% of patients admitted through the emergency room have an IUC.  Nearly 50% of surgical patients remain catheterized beyond 48 hours postoperatively; approximately 50% of medical patients do not have a clear indication for an IUC.   

Hospitals use IUCs more than any other medical device. Because the most important risk factor for catheter-associated bacteriuria is duration of catheterization, most catheters in hospitalized patients are placed for only 2 to 4 days.

Extended indwelling catheter use in older adult patients sustaining hip fracture who are discharged to skilled nursing facilities with a catheter in place have been associated with poorer outcomes because these individuals are at higher risk of rehospitalization for CAUTIs and sepsis. Increased mortality at 30 days is seen in these individuals when compared to patients whose catheter was removed prior to discharge. In hospitalized older medical patients with UI, without a specific indication, an IUC has been associated with a greater risk of death - four times as great during hospitalization and two times as great within 90 days after discharge.

The risk of infection is associated with the method and duration of catheterization, the quality of catheter care, and host susceptibility. Around 50% of hospitalized patients catheterized longer than 7 to 10 days contract bacteriuria.

Although frequently asymptomatic, 20 to 30% of individuals with catheter-associated bacteriuria will develop symptoms of CAUTI. Many of these infections are serious and lead to significant morbidity and mortality. 

Catheter Use in a Nursing Home

The prevalence of indwelling urinary catheter use in nursing homes has been established as 5-7%.
It may be greater in facilities that have poor success with toileting programs because the catheter is used as a means to maintain resident dryness.  
At least 40% of all infections seen in nursing homes are in the urinary tract. Of these infections, 80% are due to urinary tract catheterization and instrumentation.  
CAUTI is of major importance because of its effect on outcomes and treatment costs. The major reason for use of an indwelling catheter in LTC is incontinence or for healing a pressure injury.  

Catheter Use in Home Care

In the community, the prevalence of IUC is difficult to determine as many of the long-term IUC patients are lost to urologic follow-up and are managed by home care nurses or allied clinicians.  A National Home and Hospice Care Survey in 2007 reported catheter prevalence in home care (excluding hospice) at 9% (n = 4683) or 135,000 people with catheters of the 1.5 million home care patients in 2007. (http://www.cdc.gov/nchs/fastats/homehealthcare.htm).

 Alternatives to indwelling urinary catheter use

1. Before placing an indwelling catheter, please consider if these alternatives would be more appropriate:

• Bedside commode, urinal, or continence garments: to manage incontinence.
• Bladder management through the use of a bladder scanner: to assess and confirm urinary retention, prior to placing catheter to release urine.
• Straight catheterization: for one-time, intermittent, or chronic voiding needs.
• External “condom” catheter: appropriate for cooperative men without urinary retention or obstruction.

2. Before placing an indwelling catheter, does the patient have one of the following appropriate indications* for placing indwelling urinary catheters?

• Acute urinary retention: e.g., due to medication (anesthesia, opioids, paralytics), or nerve injury
• Acute bladder outlet obstruction: e.g., due to severe prostate enlargement, blood clots, or urethral compression
• Need for accurate measurements of urinary output in the critically ill
• To assist in healing of open sacral or perineal wounds in incontinent patients
• To improve comfort for end of life, if needed
• Patient requires strict prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fracture)

Selected peri-operative needs:

• Urologic surgery or other surgery on contiguous (adjacent) structures of the genitourinary tract
• Anticipated prolonged duration of surgery (Note: catheters placed for this reason should be removed in PACU)
• Large volume infusions or diuretics anticipated during surgery
• Need for intraoperative monitoring of urinary output

                  

References
1. Centers for Medicare & Medicaid Services. Nursing Home Data Compendium. 2013. http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc /downloads/nursinghomedatacompendium_508.pdf.
2. Fakih MG, Heavens M, Ratcliffe CJ, Hendrich A. First step to reducing infection risk as a system: evaluation of infection prevention processes for 71 hospitals. Am J Infect Control. 2013;41:950-54. doi:10.1016/j.ajic.2013.04.019
3. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, HICPAC. Guideline for prevention of catheter associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31:319-26. doi: 10.1086/651091.
4. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter‐associated urinary tract infections 2009. Infect Control Hosp Epidemiol;31:319‐26.
5. Holroyd-Leduc JM, Sen S, Bertenthal D, Sands LP, Palmer RM, Kresevic DM, ………. Landefeld CS. The relationship of indwelling urinary catheters to death, length of hospital stay, functional decline, and nursing home admission in hospitalized older medical patients. Journal of the American Geriatrics Society, 2007;55;227–233.
6. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control. 2000;28(1):68-75.
7. Saint S, Wiese J, Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109(6):476-480.
8. Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital‐acquired urinary tract infection in the United States: a national study. Clin Infect Dis 2008;46:243‐50.  
9. Saint S, Kaufman SR, Rogers MA, Baker PD, Ossenkop K, Lipsky BA. Condom versus indwelling urinary catheters: a randomized trial. J Am Geriatr Soc. 2006;54:1055‐61.  
10. Schuur JD, Chambers JG, Hou PC. Urinary catheter use and appropriateness in U.S. emergency departments, 1995-2010. Acad Emerg Med. 2014 Mar;21(3):292-300. doi: 10.1111/acem.12334Urinary catheter use and appropriateness in U.S. emergency departments, 1995-2010. Acad Emerg Med. 2014 Mar;21(3):292-300. doi: 10.1111/acem.12334

Introduction

Depression and Anxiety

Broader Mental Health Considerations

Suicide

Future Endeavors

Conclusions

• Document in the patient’s medical record all procedures involving the catheter or drainage system.
• Also practice hand hygiene prior to performing catheter care.
• Remove catheter as soon as possible to reduce the risk of CAUTIs. Insert the catheter using an aseptic technique.
• Use the smallest size catheter possible.
• Cleanse the catheter insertion site daily with soap and water or with a perineal cleanser.
• Use of an antiseptic or meatal care is unnecessary, use soap and water.
• Avoid routine or arbitrary catheter changing schedules in the absence of infection.
• Maintain a uniform and adequate daily fluid intake to continuously flush the urinary drainage system.
• Clamping the catheter prior to removal is unnecessary.
• Routine catheter and bladder irrigations and/or instillations are not recommended.
• Avoid routine urine cultures in the absence of infection.
• Avoid inappropriate use of antibiotics and antimicrobials.
• Maintain the acidification of urine.
• Patients and caregivers should be educated about their role in preventing CAUTIs.
• Acute and long-term care staff should be educated through quality improvement programs about the selection, insertion, and management of indwelling catheters to reduce UTI incidence.
• Patients with indwelling urinary catheters should be reevaluated periodically to determine whether an alternative method of bladder drainage can be used instead.
• Patients should undergo bladder training after catheter removal to successfully regain bladder function.
• Health-care workers and clinicians in institutions should observe their facility’s protocols for care of catheters and drainage bags. Daily catheter care should include:
  • Labeling on bag insertion date, time and place (e.g. OR, ER).
  • Maintain a closed urinary drainage system to prevent introduction of bacteria into the urinary tract.
  • Adequately secure and anchor the catheter to prevent urethral and bladder-neck tension.
  • Ensure that urine drainage is unobstructed and continuous by avoiding dependent loops, ensuring no kinks in tubing and bag is positioned below the bladder but not on the floor.
  • Scan the bladder if no urine is draining to determine if system is obstructed.
  • Use needleless sampling port for urine specimen collection
  • Anchor and secure catheter
  • Empty bag if > 400 mls to prevent tension on catheter and to prevent the migration of bacteria ascending from bag to catheter.

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What is an Indwelling Catheter?

An indwelling urinary catheter (IUC), generally referred to as a “Foley” catheter, is a closed sterile system with a catheter and retention balloon that is inserted either through the urethra or suprapubically to allow for bladder drainage. External collecting devices (e.g. drainage tubing and bag) are connected to the catheter for urine collection 

Indwelling urinary catheters are recommended only for short-term use, defined as less than 30 days (EAUN recommends no longer than 14 days.) The catheter is inserted for continuous drainage of the bladder for two common bladder dysfunction: urinary incontinence (UI) and urinary retention.

Catheters are semi-rigid but flexible tubes. They drain the bladder but block the urethra.

The challenge is to produce a catheter that matches as closely as possible to the normal physiological and mechanical characteristics of the voiding system.

This requires construction of a thin-walled, continuously lubricated, collapsible (conformable) catheter to protect the integrity of the urethra; a system to hold the catheter in place without a balloon; and a design to imitate the intermittent washing of the bladder with urine.

Catheter products have changed significantly in their composition, texture, and durability since the 1990s.

The catheter should have a smooth surface with two drainage eyes at the tip that allow for urine drainage.

Drainage eyes are placed either laterally or opposed. Opposing drainage eyes generally facilitate better drainage.

Catheter Tips

The most commonly used catheter is a straight-tipped catheter.

A Coudé-tipped catheter, or Tiemann catheter, is angled upward at the tip to assist in negotiating the upward bend in the male urethra.  

This feature facilitates passage through the bladder neck in the presence of obstruction from a slightly enlarged prostate gland (e.g., in benign prostatic hyperplasia) or through a narrowed stricture in the urethra.

The Carson catheter is a slightly larger bulb to assist in negation of restrictions. 

The Council catheter features a reinforced hole at the tip of the catheter.

A whistle-tipped catheter is open at the end and allows drainage of large amounts of debris (e.g., blood clots).

Catheter Size and Length 

Each catheter is sized by the outer circumference and according to a metric scale known as the French (Fr) gauge (range is 6 to 18 Fr), in which each French unit equals 0.33 mm in diameter.

The golden rule is to use the smallest catheter size (termed bore), generally 14 to 16 Fr, that allows for adequate drainage.

The use of large-size catheters (e.g., 18 Fr or larger) is not recommended because catheters with larger diameters can cause more erosion of the bladder neck and urethral mucosa, can cause stricture formation, and do not allow adequate drainage of periurethral gland secretions, causing a buildup of secretions that may lead to irritation and infection. Also, large size catheters can cause pain and discomfort.  

Balloon Size

A retention balloon prevents the catheter from being expelled. The preferred balloon size may be labeled either 5 mL or 10 mL, and both are instilled with 10 mL of sterile water for inflation per manufacturer’s instructions. Larger balloons (30 cc – 60 cc) are generally used to facilitate drainage or provide hemostasis when necessary, especially in the postoperative period. The balloon of the catheter usually sits at the base of the bladder, obstructing the internal urethral orifice. 

A fully inflated balloon allows the catheter tip to be located symmetrically. If a 5 mL balloon is inflated with more than 10 mL of water, irritation may occur unilaterally on the bladder wall from increased pressure of the balloon.

The specified amount of inflation ensures a symmetrical shape and allows for the catheter to maintain position in the bladder while minimizing patient discomfort   Underfilling or overfilling may interfere with the correct positioning of the catheter tip, which may lead to irritation and trauma of the bladder wall.

A balloon with a fill size greater than 10 mL, such as a 30 mL balloon, is not recommended because the 10 mL size keeps residual urine minimal, thus reducing the risk of infections and irritation.

The catheterized bladder is in a collapsed state as a result of constant urine drainage. However, a 30 mL balloon will allow persistence of a small pool of undrained urine, so the bladder emptying is not complete and the undrained urine can leak around the catheter (referred to as “catheter bypassing”)..

The use of a larger balloon size is mistakenly believed by many nurses to be a solution to catheter leakage or urine bypassing around the catheter. However, a large balloon increases the chance of contact between the balloon or catheter tip and the bladder wall, leading to bladder spasms that may cause urine to be forced out around the catheter.

A 30 mL balloon is used primarily to facilitate traction on the prostate gland to stop bleeding in men after prostate surgery or to stop bleeding in women after pelvic surgery.

Routine use of larger capacity balloons (30 mL) should be avoided for long-term use as they can lead to bladder neck and urethral erosion.

Several catheter materials have been found to lose water from the inflated balloon over time in the bladder with 100% silicone catheters losing as much as 50% of their volume within 3 weeks.

In men, the catheter should be passed initially to the bifurcation (the “Y” junction where the balloon arm and catheter meet) to ensure that the balloon will not be inflated in the urethra. 

Catheter Materials

A wide range of catheter materials are available, and the material selected should be chosen by: 

1. how long the catheter will remain in place,
2. comfort,
3. the presence of latex sensitivity,
4. ease of insertion and removal, and
5. ability to reduce the likelihood of complications such as urethral and bladder tissue damage, colonization of the catheter system by microorganisms, and encrustation

Note: Prior to insertion, all indwelling catheters should be visually inspected for any imperfections or surface deterioration.

1. Latex Catheter: The possibility of a latex allergy is an important consideration as many urinary catheters are constructed from latex or a related material. 

There are reported increases in allergies and reactions in patients with long-term use of all urinary latex and rubber catheters. Patients who have asthma and other allergies are at increased risk for these allergies. Latex allergy can result in symptoms such as skin irritation, rashes, and blisters. Urethritis and urethral strictures can also result from latex allergies.  Coatings such as silicone and polytetrafluoroethylene (PTFE) are used to coat latex catheters.

2. Hydrogel coating, which remains intact when used, has demonstrated the ability to reduce the high level of cytotoxicity associated with latex catheters. However, coated latex catheters do not protect against an allergic reaction to the underlying latex because the coating wears off.

Bonded hydrogel-coated latex catheters may be longer lasting than silicone catheters because their hydrogel coating prevents bacterial adherence and reduces mucosal friction. Hydrogels or polymers coat the catheter, absorbing water to produce a slippery outside surface. This results in the formation of a thin film of water on the contacting surface, thus improving its smoothness and lubricity. These properties might act as potential barriers to bacterial infection and reduce the adhesion of both gram-positive and gram-negative bacteria to catheters. 

3. Silicone- and hydrogel-coated catheters usually last longer than PTFE-coated catheters. If the person is latex sensitive, silicone catheters should be used. Avoiding latex catheters may also decrease the incidence of encrustation. All-silicone (100%) catheters are biocompatible and are believed to have encrustation-resistant properties.  Silicone catheters are thin-walled, rigid catheters with a larger diameter drainage lumen. 

4. Antimicrobial-coating: A major problem with Foley catheters is that they have a tendency to contribute to urinary tract infections (UTI). This occurs because bacteria can travel up the catheters to the bladder where the urine can become infected. In an attempt to prevent bacterial colonization, catheters have been coated with silver alloy or nitrofurazone, a nitrofurantoin-like drug.

This has been helpful, but it has not completely solved this major problem. An additional problem is that Foley catheters tend to become coated over time with a biofilm that can obstruct the drainage. This increases the amount of stagnant urine left in the bladder, which further contributes to the problem of urinary tract infections. When a Foley catheter becomes clogged, it must be flushed or replaced.

Both nitrofurazone-coated and silver alloy-coated catheters seem to reduce the development of asymptomatic bacteriuria during short-term (< 30 days) use.
Despite their unit cost, there is a suggestion that these devices might be a cost-effective option if overall numbers of infections are significantly reduced through their use.

• Antibiotic-coated catheters were found in a meta-analysis to prevent or delay bacteriuria in short-term catheterized, hospitalized patients.  However, in 2012, nitrofurazone impregnated catheters were taken off the market.  
• Silver is an antiseptic that inhibits growth of gram-positive and gram-negative bacteria. Silver alloy-coated catheters are thought to cause less inflammation and have a bacteriostatic effect because they reduce microbacterial adherence and migration of bacteria to the bladder.
  Because they prevent bacterial adherence, these catheters also minimize biofilm formation through their release of silver ions that prevent bacteria from settling on the surface.  
  There appear to be few adverse effects, and microbial resistance to the active agent is unlikely. 

Drainage bags and an anchor for the drainage tube are parts of the design of an indwelling urinary catheter system.  These may include a: leg drainage bag, overnight drainage bag, and a spare leg strap or a device to secure the catheter tubing to the leg.  Drainage bags that cannot be worn and concealed are commonly referred to as “nighttime or overnight bags,” or “large capacity bags,” or “bedside bags”. Drainage bags that can be worn and concealed are commonly referred to as “leg bags” or abdominal bags, commonly referred to as “belly bags.”  Leg bags generally hold 300- 900 cc whereas an overnight bag can hold up to 2000cc.  It is recommended that reusable drainage bag be replaced every 30 days.   

References: 
1. Brosnahan J, A. Jull, et al. Types of urethral catheters for management of short-term voiding problems in hospitalized patients. Cochrane Database of Systematic Reviews, 2004, (1): CD004013.
2. Gray M. Does the construction material affect outcomes in long-term catheterization? JWOCN, 2006, 33: 116-121.
3. Lawrence EL. and IG. Turner. Materials for urinary catheters: A review of their history and development in the UK. Med Engineering Phys, 2005, 27: 443-453.
4. Leuck AM, Johnson JR, Hunt MA, Dhody K, Kazempour K, Ferrieri P, et al. Safety and efficacy of a novel silver-impregnated urinary catheter system for preventing catheter-associated bacteriuria: a pilot randomized clinical trial. Am J Infect Control. 2015;43:260-5. DOI: 10.1016/j.ajic.2014.11.021.
5. Newman D. The indwelling urinary catheter: Principles for best practice. JWOCN, 2007, 24: 655-661.
6. Pickard R, Lam T, MacLennan G, Starr K, Kilonzo M, McPherson G, et al. Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial. Lancet. 2012;380:1927-35. DOI: 10.1016/S0140-6736(12)61380-4. 
7. Politano AD, Campbell KT, Rosenberger LH, Sawyer RG. Use of silver in the prevention and treatment of infections: silver review. Surg Infect (Larchmt). 2013;14:8-20. DOI: 10.1089/sur.2011.097.
8. Weissbart SJ, Kaschak CB, Newman DK. Urinary drainage bags. In: Newman DK, Rovner ES, Wein AJ, editors. Clinical Application of Urologic Catheters and Products.  Switzerland: Springer International Publishing; 2018, 133-147.
9. Zugail AS, Pinar U, Irani J. Evaluation of pain and catheter-related bladder discomfort relative to balloon volumes of indwelling urinary catheters: A prospective study.  Investig Clin Urol. 2019 Jan;60(1):35-39. doi: 10.4111/icu.2019.60.1.35. Epub 2018 Dec 6.