Indwelling Urinary Catheter-related Problems

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.

Hematuria is more likely to be seen in newly inserted catheters and in men, during insertion due to false passage in the prostatic urethra. Catheter blockage is more common in long-term IUC patients following the buildup of sediment in subclinical bacteriuria. A blocked catheter usually requires immediate catheter changes, often times leading to an unplanned visit by a home care nurse or a trip to the urology office or emergency room. Accidental IUC removal is more likely to be seen in residents of long-term care facilities or in home care patients than in acute care patients. Bypassing, which is when the bladder forces urine around either a transurethral or suprapubic (SP) catheter, has been reported to be as high as 79% in catheter users at home. A secondary analysis by Wilde et al (2017), of community-dwelling persons (n=193) with long-term IUCs, showed that leakage (bypassing) was reported at least once in last 12 months by 67% of patients. In this study, CAUTIs were marginally associated with catheter blockage but other catheter-related problems reported included blockage (34%), accidental dislodgment (28%), sediment (87%), bladder spasms (59%), kinks/twists (42%), and catheter pain (49%). Over 50% of patients report that an IUC is uncomfortable.

Patients who have recurring catheter-related adverse events should undergo diagnostic cystoscopy to determine the cause (e.g. stones, cancer). Patients should be screened yearly for bladder cancer if they have had an IUC for more than 10 years. Patients and caregivers should be educated about fluid intake, bowel management, hygiene and self-monitoring/management, including adverse events (Alex et al., 2020). The following table details nursing solutions for common IUC-related problems.

Problem/Signs & Symptoms	Solution
Blockage: anything that inhibits or completely stops drainage of urine from the bladder through the catheter tube
Urine is not draining or reduced urine flow and obstruction is suspected. Leakage of urine around catheter.	Ultrasound bladder scanning is a non-invasive technique to assess proper bladder emptying that confirms residual urine, blockage in catheter system. Reposition tubing, check for kinks or twisting and check bag to ensure free flow of urine Ensure bag and tubing above level of the bladder.
Recommend a bowel regimen if constipation is a problem. Impacted stool present, perform stool removal.	As catheter can be blocked from pressure from impacted stool.
Gross hematuria with clots retention (accumulation of blood clots in the bladder, blocking outflow and leading to urinary retention).	If occurring in an acute care patient, continuous or manual bladder irrigation to keep the IUC open and flowing may be indicated. The goal is to continuously wash out blood clots from the bladder. May need to insert a 3-way IUC that has an irrigation port for a closed continuous system. If gross hematuria occurs in a patient with a long-term catheter, contact primary care provider or managing provider for further instructions regarding evaluation. These patients may need referral to urology where manual irrigation in an office setting is warranted.
Encrustations and sediment seen in drainage tube and bag, as a result of biofilm-producing bacteria that form crystals. Encrustations in the catheter and/or tubing shedding into the bladder resulting in formation of stones.	Change the catheter, observe the inside catheter lumen to determine nature of the blockage and any external deposits According to a Cochrane review (Shepherd et al., 2014), irrigations (termed “washouts”) should be avoided as it is unknown if washouts convey any benefits in reducing encrustations, sediment, etc for patients with long-term IUCs. Educate patients and caregivers to increase/maintain fluid intake to maintain an output of 50–100 ml/hour Patients who form multiple encrustations that lead to an obstruction (‘blockers’) need more frequent catheter changes (i.e., weekly or twice weekly). Monitoring the time between the blockages on at least three different occasions can help determine the interval between the blockages so the catheter can be changed before the date of the expected blockage.
Stone-like material observed in urine.	Consider referral for evaluation by urology for possible diagnostic cystoscopy and stone removal. Renal ultrasound due to increased risk for development of renal and bladder calculi.
Non-silicone catheter in place.	Switching to an all-silicone (100%) catheter may reduce the risk of encrustation in long-term catheterized patients who have frequent obstruction. Silicone catheters have larger internal lumen that reduces intraluminal biofilm adherence.
Urinary tract infection	Assess patient for signs and symptoms of an infection as a blocked catheter can cause accumulation of infected urine in the bladder, and eventual reflux of infected urine to the upper urinary tract and kidneys
Urethral leakage in a patient with a SP catheter	Referral to urology for consideration of surgical closure of the urethra.
Bypassing: urine leakage around catheter
Bladder irritation, overactivity (spasms) or obstruction (drainage tube kinked).	Bladder spasms (overactivity) may be occurring due to the presence of the catheter. Ensure the catheter is draining and there is nothing obstructing urine flow. Ensure correct catheter and balloon placement (e.g. catheter is in the bladder not in the urethra). Consider antispasmodic/antimuscarinic or beta3 adrenergic agonist medication to reduce bladder overactivity.
Urinary tract infection	Assess patient for signs and symptoms of an infection as a CAUTI can also be another cause of bypassing (see Table 1).
Balloon size 30 cc.	Catheter balloon is preventing complete drainage as eyelets inadequately draining residual urine at bladder neck as depicted in this Figure. If appropriate, decrease the catheter balloon size.
Catheter size > 16 Fr.	Large size catheter diameter causing irritation to bladder muscle. Replace with standard size of 14 Fr.
Inadvertent removal (unintended or accidental IUC extraction, catheter falls out)
Identify those patients at risk (e.g. catheter tension causing catheter to fall out, confused and/or agitated patient pulls out catheter).	Every patient with an IUC who has delirium or dementia is potentially at risk of a traumatic IUC removal (e.g. patients recovering from anesthesia, procedures or sedation, head injury). Use caution during transfer or transport of the patient to prevent dislodgment of the catheter.
Check for adequate catheter securement.	Proper securement of the catheter will minimize tension on the catheter and risk of unintentional removal.
Catheter repositioned so it is not within reach of the patient. A wide ace bandage is wrapped around the patient’s thigh, completely covering the tape and IUC. A “decoy” is placed catheter within reach of patient.	These strategies will make it more difficult for patient to reach the catheter. A ‘decoy” catheter is a very simple and effective technique for protecting IUCs from even the most persistent patients who seem determined it pull it out.
Bladder spasms (overactivity) may be occurring due to the presence of the catheter. Determine recommended catheter and balloon size.	Consider overactive bladder drug therapy (antispasmodic/antimuscarinic or beta3 adrenergic agonist medication). Using the smallest size catheter and balloon that ensures adequate urine drainage may reduce bladder spasms that can lead to catheter expulsion. Larger catheter balloons may be more stimulating and increase an at-risk patient's attempts to remove the catheter.
Retention balloon deflates. Constipation with hard stool in the rectum can push catheter out, especially during straining when defecating.	Silicone catheters are prone to loss of fluid volume in the balloon. All catheters gradually lose water over time. Assess bowel function, remove any impacted stool and recommend a bowel regimen.
Pain or discomfort
Men will complain of pain at the tip of the penis which can be referred pain from the bladder or due to trauma to the meatus (e.g. catheter under tension)	Consider antispasmodic/antimuscarinic or beta3 agonist medication as discomfort and pain may be related to bladder overactivity (spasms). Evaluate for tension to catheter and address as needed.
Catheter size is too large.	Large gauge catheter may block periurethral glands leasing to discomfort and pain so decrease catheter size.
Difficult catheter removal
Balloon not deflating.	Requires careful assessment of potentially causative factors (e.g. encrustations hardening balloon, enlarged prostate, scar tissue formation after urologic surgery, malfunctioning valve, or debris in inflation channel). Attach a syringe to the inflation channel, and leave it in place for 5-10 minutes so the effect of gravity will help with the deflation process. Avoid forcefully retracting the plunger of the attached syringe as a vacuum may be created causing the balloon channel inside the catheter to collapse and seal itself. Stretch or milk the catheter in hopes of dislodging debris in the deflation channel. Instill 1-2 ml of additional sterile water into the inflation channel to dislodge debris but do not overinflate and “pop” the balloon as over-inflation of the balloon results in balloon fragmentation, patient discomfort and likely will require cystoscopy to remove the resulting residual balloon pieces in the bladder. Cutting the balloon inflation valve is usually not effective and can compromise the catheter making it more difficult to remove so it is not recommended. Invasive techniques may be warranted and will involve urologic consultation or referral.
Constipation, stool impaction	Hard and impacted stool can occlude the inflation channel necessitating stool removal and placing patient on a bowel regimen.

Table 1. CDC: Catheter-Associated Urinary Tract Infection

IUC was in place for more than two days on the date of event, with day of device placement being day one, and an IUC was in place on the date of event or the day before. If an IUC was in place for more than 2 consecutive days in an inpatient location and then removed, the date of event for the UTI must be the day of device discontinuation or the next day for the UTI to be catheter-associated.
Must have at least one of the following signs or symptoms
Fever with temperature >38°◦C (if > 65 years of age, the IUC needs to be in place for more than 2 consecutive days in an inpatient location on date of “event”
Suprapubic tenderness*
Costovertebral angle pain or tenderness
Urinary urgency+
Urinary frequency+
Dysuria+
Patient has an aseptically obtained urine culture with no more than two species of organisms identified, at least one of which is a bacterium of > 10⁵CFU/ml.

Signs not directly associated with a CAUTI:

Pyuria—not a good indicator as it is common in catheterized individuals
Odor—the persistent bacteria in the urine of catheterized patients will produce odor

Possible signs in an elderly patient:

Increased restlessness or altered mental status
Change in health status not attributable to any other cause (pneumonia, medication side effects)

Treatment of CAUTI once a diagnosis is established:

If possible, remove the catheter and follow bladder management at least until the antibiotic course is completed.
If not possible to leave the catheter out, change the catheter prior to starting antibiotics so that there is the least amount of biofilm present.
Start antibiotics—typical course of antibiotics is 7 to 14 days, usually a fluoroquinolone.
Chart symptom improvement.

*With no other recognized cause
+ These symptoms cannot be used when a catheter is in place, but can be used if symptoms occur after urinary catheter removal, on the day of removal or day after removal
Adapted from CDC, Retrieved from https://www.cdc.gov/nhsn/pdfs/training/2019/cauti-508.pdf.

Published Date: October 2022

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