Complications of urinary bladder catheters and preventive strategies
Author
Anthony J Schaeffer, MD
Section Editor
Jerome P Richie, MD, FACS
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: May 2012. | This topic last updated: Abr 27, 2012.
INTRODUCTION — Urinary bladder catheters are used for urinary drainage or as a means to
collect urine for measurement. Many clinical situations are appropriate for the placement of
indwelling urethral catheters (table 1), but too frequently they are used without proper
indication or continued longer than needed [1]. Daily evaluation of the ongoing need for the
indwelling catheters with removal when no longer indicated is essential to reduce
complications.
This topic will discuss the complications associated with urinary catheter use. The indications
for placement, types, and the management of urinary catheters are discussed in detail
elsewhere. (See "Placement and management of urinary bladder catheters".)
GENERAL COMPLICATIONS
Bacteriuria and urinary tract infection — The presence of bacteria in the urine is almost
universal in patients with catheters in place for over one week. Rates vary depending upon the
type of catheter and duration of use. The evaluation of bacteriuria and diagnosis of catheterassociated urinary tract infection is discussed in detail elsewhere. (See"Urinary tract infection
associated with urethral catheters", section on 'Asymptomatic bacteriuria' and "Urinary tract
infection associated with urethral catheters", section on 'Urinary tract infection'.)
Recurrent urinary tract infections as a result of chronic catheter use can lead to acute or
chronic pyelonephritis, or bladder cancer. (See "Epidemiology and etiology of urothelial
(transitional cell) carcinoma of the bladder" and "Nonurothelial bladder cancer".)
Epididymitis — Urethral instrumentation of any type can cause epididymitis which may rarely
disseminate to the testes as orchitis [2]. (See "Evaluation of the acute scrotum in adults".)
Retained balloon fragments — Spontaneous rupture of the urinary catheter balloon can
occur. If the catheter spontaneously falls out, the integrity of the balloon should be examined
carefully for any missing material. If balloon fragments cannot be located, cystoscopy should
be performed to identify fragments retained in the bladder as these have the potential to cause
urethral obstruction [3,4].
Balloon rupture can occur spontaneously, but also from the attempt to bluntly rupture or
overdistend a balloon that will not deflate; this practice is not advised. Sharp balloon puncture
to manage a non-deflating balloon (ie, percutaneous spinal needle) was not found to be
associated with retained balloon fragments in one experimental study [3]. (See "Placement and
management of urinary bladder catheters", section on 'Troubleshooting catheter removal'.)
Bladder fistula — The presence of air or feces in the urine of a patient with an indwelling
catheter may indicate the formation of a fistula. Fistulas can occur between the bladder and
small intestine, colon, rectum, or vagina (ie, enterovesical, colovesical, rectovesical, and
vesicovaginal). They are an uncommon complication of indwelling bladder catheters and more
likely to occur in the setting of prolonged catheterization with risk factors that include
malignancy, inflammation, radiotherapy or trauma [5].
Bladder perforation — Bladder perforation, both intraperitoneal and extraperitoneal, is rare
but has been reported with long-term indwelling catheters [6-8]. Hematuria and abdominal pain
may indicate acute perforation; free air is seen only with intraperitoneal perforation.
Bladder stone formation — Stones can form in the bladder due to the presence of a foreign
body. Bacteria that are urea-splitting (ie, Proteus mirabilis) are frequently associated with stone
formation. The type of catheter may influence stone formation; however, there are no data to
support the use of one catheter material (ie, latex, silicon) over another.
COMPLICATIONS SPECIFIC TO TYPE OF CATHETER
Condom catheters — Most complications related to condom catheter usage are due to
improper or prolonged application, and inadequate monitoring of the device when in place.
Most complications are minor and self limited; however, significant penile injury resulting in
scarring and deformity can occur.
Patients with penile skin sensory loss (ie, spinal injury patients) are at the highest risk for more
severe complications [9]. Instruction of the patient, relatives, and medical personnel on the
proper application of the condom device is essential in preventing associated complications.
(See "Placement and management of urinary bladder catheters", section on 'External catheter
placement'.)
Pressure effects — Skin depigmentation can occur but is more likely in patients with
underlying dermatologic conditions. (See "Vitiligo".)
Constrictive effects of the condom catheter's adhesive band or roller ring can lead to superficial
ulceration. Reapplication exacerbates the ulcer and can prevent healing. The condom catheter
should be temporarily discontinued and a catheter (intermittent or indwelling) used until the site
is healed.
Prolonged continuous pressure of the penis from an improperly placed condom catheter can
cause tissue ischemia which may lead to penile and/or urethral necrosis. Treatment with
surgical debridement is necessary to remove devitalized tissue, and reconstruction with skin
grafts to the penis may be required.
Urethral catheters — Mechanical catheter problems such as leakage, blockage, and catheter
rejection can frustrate and annoy both patient and clinician [10]. Knowledge of catheter
technology and routine catheter care can help reduce mechanical problems. (See "Placement
and management of urinary bladder catheters", section on 'Catheter
technology' and "Placement and management of urinary bladder catheters", section on
'Catheter care'.)
Effects of urethral trauma — Traumatic urethral catheter placement can lead to urethral
injury. The presence of pain and bleeding following attempted catheter insertion, and
subsequent inability to pass the catheter into the bladder suggests that a false urethral
passage may have been created. Such injuries usually require significant reconstructive
surgery.
Inflammation and infection of the periurethral soft tissues may create an abscess as a
consequence of the creation of a false passage [11]. If the abscess is not visible on physical
examination, diagnosis may be delayed and the infection can spread into surrounding tissues.
Urethrocutaneous fistulae may result as the infection tracks to the skin. Fournier's gangrene
has been reported as a consequence of urethral catheterization [12]. (See "Necrotizing soft
tissue infections" and "Evaluation of the acute scrotum in adults".)
Stricture associated with urethral catheterization occurs almost exclusively in male patients
[11]. Repeated urethral trauma from intermittent catheterization can cause urethral stricture
formation, which in turn increases the likelihood of traumatic catheterization. The incidence of
urethral stricture increases with duration of chronic catheterization; most have developed
following at least five years of intermittent catheterization (IC) [13,14].
A retrospective review found urethral stricture in 3.7 percent of 230 men with a history of
indwelling catheter usage; chronic changes of the urethra were documented in nearly one-third
of the patients [15].
Incontinence — Incontinence can occur due to catheterization and is also related to urethral
sphincter dysfunction. (See "Clinical presentation and diagnosis of urinary incontinence".)
Suprapubic catheters — When performed properly, complications from suprapubic catheter
placement are uncommon. Complications associated with initial placement include cutaneous
or bladder bleeding and bowel injury, which is more common if suprapubic catheter placement
is attempted when the bladder is not fully distended [16].
Long-term complications include skin erosion and problems with chronic leakage.
PREVENTION OF COMPLICATIONS — Appropriate urinary catheter implementation and
management can reduce the incidence of complications. The most effective strategies to
reduce infectious complications of urinary catheters are avoidance of unnecessary
catheterization, and catheter removal when the catheter is no longer indicated. Adherence to a
protocol for indwelling catheter placement, care, and removal can reduce the incidence of
urinary tract infection and other complications [1,17].
Measures which help prevent complications associated with urinary catheters include:



Use of urinary catheters only for appropriate indications (table 1). (See "Placement and
management of urinary bladder catheters", section on 'Indications for catheterization'.)
Considering alternatives to indwelling urethral catheters. (See "Placement and
management of urinary bladder catheters", section on 'Choice of catheter'.)
Provision of adequate training to medical staff, patients, and other caregivers on
catheter placement and management. (See "Placement and management of urinary
bladder catheters".)


Removal of catheters when no longer indicated. (See "Placement and management of
urinary bladder catheters", section on 'Catheter care'.)
Not routinely replacing urethral catheters. (See "Placement and management of urinary
bladder catheters", section on 'Catheter care'.)
Specific measures to prevent catheter-associated urinary tract infection include:


Using a continuously closed drainage system. (See "Placement and management of
urinary bladder catheters", section on 'Catheter technology'.)
Not routinely irrigating catheters; catheters are irrigated only under select
circumstances. (See "Placement and management of urinary bladder catheters",
section on 'Catheter care'.)
SUMMARY AND RECOMMENDATIONS






The most effective strategy to reduce complications of urinary bladder catheters is the
avoidance of unnecessary catheterization. When urinary bladder catheters are
required, adequate training of the patient, hospital personnel, and caregivers is
essential to avoid complications related to placement, ensure proper care, and to
promptly recognize and treat complications expeditiously when they do occur.
(See 'Prevention of complications' above.)
The most common complication of urinary bladder catheters is catheter-associated
urinary tract infection. In males, urinary infection can lead to epididymitis or orchitis.
Other rare complications of indwelling catheters include urinary tract obstruction from
retained balloon fragments, bladder fistula, bladder perforation, or bladder stone
formation. (See 'General complications' above.)
Improper or prolonged application of condom catheters can cause pressure-related
complications including skin depigmentation, ulceration, or penile necrosis. These
complications are more frequent in patients with penile sensory loss and can be
prevented with proper application of the device and frequent patient monitoring.
(See 'Condom catheters' above.)
The traumatic insertion of urethral catheters can create a false passage which may, if
infected, lead to periurethral abscess. This complication is more frequent in patients
with prior urethral stricture and can result in significant soft tissue infection.
(See 'Effects of urethral trauma' above.)
Long-term complications associated with chronic urethral catheters (indwelling or
intermittent) include urethral stricture and incontinence (see 'Urethral catheters' above).
When properly placed, complications from the placement of suprapubic catheters are
uncommon. Inadvertent bowel injury can occur during percutaneous suprapubic
catheter placement if the bladder is not fully distended, or the needle is not visualized
with cystoscopy when performing the procedure in patients with prior pelvic surgery.
(See 'Suprapubic catheters' above.)
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REFERENCES
1. Hooten, TM, Bradley, SF, Cardenas, DD, et al. Diagnosis, prevention and Treatment of
Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice
Guidelines from the Infectious Diseases Society. Clinical Infectious Diseases 2010; 50:625.
2. Igawa Y, Wyndaele JJ, Nishizawa O. Catheterization: possible complications and their
prevention and treatment. Int J Urol 2008; 15:481.
3. Gülmez I, Ekmekcioglu O, Karacagil M. A comparison of various methods to burst Foley
catheter balloons and the risk of free-fragment formation. Br J Urol 1996; 77:716.
4. Daneshmand S, Youssefzadeh D, Skinner EC. Review of techniques to remove a Foley
catheter when the balloon does not deflate. Urology 2002; 59:127.
5. Hawary, A, Clarke, L, Taylor, A, et al. Enterovesical fistula: a rare complication of urethral
catheterization. Adv Urol 2009; 59:1204.
6. Merguerian PA, Erturk E, Hulbert WC Jr, et al. Peritonitis and abdominal free air due to
intraperitoneal bladder perforation associated with indwelling urethral catheter drainage. J Urol
1985; 134:747.
7. Farraye MJ, Seaberg D. Indwelling foley catheter causing extraperitoneal bladder perforation.
Am J Emerg Med 2000; 18:497.
8. Spees EK, O'Mara C, Murphy JB, et al. Unsuspected intraperitoneal perforation of the urinary
bladder as an iatrogenic disorder. Surgery 1981; 89:224.
9. Jayachandran S, Mooppan UM, Kim H. Complications from external (condom) urinary drainage
devices. Urology 1985; 25:31.
10. Belfield PW. Urinary catheters. Br Med J (Clin Res Ed) 1988; 296:836.
11. Pannek J, Göcking K, Bersch U. Perineal abscess formation as a complication of intermittent
self-catheterization. Spinal Cord 2008; 46:527.
12. Conn IG, Lewi HJ. Fournier's gangrene of the scrotum following traumatic urethral
catheterisation. J R Coll Surg Edinb 1987; 32:182.
13. Wyndaele JJ, Maes D. Clean intermittent self-catheterization: a 12-year followup. J Urol 1990;
143:906.
14. Perrouin-Verbe B, Labat JJ, Richard I, et al. Clean intermittent catheterisation from the acute
period in spinal cord injury patients. Long term evaluation of urethral and genital tolerance.
Paraplegia 1995; 33:619.
15. Gunther, M, Lochne, ED, Kramer, G, Stohrer, M. Intermittent catheterization in male
neurogenics: No harm to the urethra. Abstract poster 93 presented during Annual Scientific
Meeting of IMSOP, Sydney, Australia 2000. Abstract book p. 112.
16. Farina LA, Palou J. Re: Suprapubic catheterisation and bowel injury. Br J Urol 1993; 72:394.
17. Stéphan F, Sax H, Wachsmuth M, et al. Reduction of urinary tract infection and antibiotic use
after surgery: a controlled, prospective, before-after intervention study. Clin Infect Dis 2006;
42:1544.
Topic 8095 Version 5.0
GRAPHICS
Indications for urinary bladder catheters
Type of catheter
Indications
Indwelling
urethral
Intermittent
urethral
Suprapubic
Condom
Urinary retention
Y
Y
Y
N
Urine output monitoring in critically ill
patient
Y
Y
Y
N
• Patients undergoing prolonged duration
of surgery
Y
N
Y
N
• Patients requiring large volume
infusions or diuretics
Y
N
Y
N
• Patients requiring intraoperative
monitoring of urinary output
Y
N
Y
N
• Patients with urinary incontinence
Y
N
Y
Y
Post-prostate, bladder or gynecologic
surgery
Y
Y
Y
N
Hematuria with clots
Y
N
Y
N
Prolonged immobilization
Y
Y
Y
Y
Urinary incontinence in patients who fail
behavioral and pharmacological therapy and
incontinence pads
Y
N
N
Y
Neurogenic bladder/spinal cord patients
Y
Y
Y
Y
Assist in healing of open sacral or perineal
wounds in incontinent patients
Y
Y
Y
Y
Improve comfort for end of life care
Y
Y
Y
Y
Intra- and post-operative monitoring:
Data from: Gould, CV, Umscheid, CA, Agarwal, RK, et al. Guideline for the prevention of catheterassociated urinary tract infections 2008. Department of Health and Human Services. Centers for
Disease Control and Prevention.
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Licensed to: UpToDate Individual Web - FABIO SOUZA |Support Tag: [ecapp1003p.utd.com-177.146.71.2512C53CE97-6.14-178097067]
Placement and management of urinary bladder catheters
Author
Anthony J Schaeffer, MD
Section Editor
Jerome P Richie, MD, FACS
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: May 2012. | This topic last updated: Out 7, 2010.
INTRODUCTION — Bladder catheters are used for urinary drainage, or as a means to collect
urine for measurement. Many clinical situations are appropriate for the placement of catheters,
but too frequently they are used without proper indication or continued longer than needed.
Daily evaluation of the ongoing need for the catheter is essential to reduce complications.
Alternatives to indwelling urethral catheterization should be considered and include external
sheath (ie, condom) catheters, suprapubic catheters, intermittent catheterization, and in some
cases, supportive management with protective garments.
This topic will discuss the use and management of urinary bladder catheters. Management of
bacteriuria and catheter-associated urinary tract infection is discussed elsewhere. (See"Urinary
tract infection associated with urethral catheters" and "Complications of urinary bladder
catheters and preventive strategies".)
INDICATIONS FOR CATHETERIZATION — The single most important factor for preventing
urinary catheter-related complications is limiting their use to appropriate indications (table
1) [1,2]. Urinary catheters are indicated in the following clinical situations:






Management of acute urinary retention or bladder outlet obstruction. (See "Acute
urinary retention", section on 'Initial management' and "Diagnosis of urinary tract
obstruction and hydronephrosis".)
Urine output measurement in critically ill patients.
During surgery to assess fluid status (ie, prolonged procedures, large volume fluid
infusion).
During and following specific surgeries of the genitourinary tract or adjacent structures
(ie, urologic, gynecologic, colorectal surgery).
Management of hematuria associated with clots. (See "Etiology and evaluation of
hematuria in adults" and "Blunt genitourinary trauma".)
Management of immobilized patients (eg, stroke, pelvic fracture).





Management of patients with neurogenic bladder. (See "Chronic complications of
spinal cord injury".)
Management of open wounds located in the sacral or perineal regions in patients who
are incontinent. (See "Treatment of pressure ulcers".)
Intravesical pharmacologic therapy (eg, bladder cancer). (See "Treatment of nonmuscle-invasive bladder cancer".)
Improved patient comfort for end of life care. (See "Palliative care: Issues specific to
geriatric patients".)
Management of patients with urinary incontinence following failure of conservative,
behavioral, pharmacologic and surgical therapy [3]. (See "Treatment of urinary
incontinence".)
Contraindications — The only absolute contraindication to the placement of a urethral
catheter is the presence of urethral injury which is typically associated with pelvic trauma [4].
The presence of blood at the meatus or gross hematuria associated with trauma is evaluated
first with retrograde urethrogram; urologic consultation and urethroscopy may be necessary.
(See "Blunt genitourinary trauma", section on 'Retrograde urethrogram'.)
Relative contraindications to urethral catheterization include urethral stricture, recent urinary
tract surgery (ie, urethra, bladder), and the presence of an artificial sphincter. For these issues,
a urologist or urogynecologist should be consulted to assist with management.
If an artificial sphincter is present, it should be de-activated and catheterization limited to a
short period of time. Artificial sphincters are discussed elsewhere. (See "Urinary incontinence
in men", section on 'Artificial urinary sphincter' and "Stress urinary incontinence in women:
Persistent/recurrent symptoms after surgical treatment", section on 'Artificial urinary sphincter'.)
Inappropriate use of catheters — Unwarranted urinary catheters are placed in 21 to 50
percent of hospitalized patients [5-7]. The most common inappropriate indication for placing an
indwelling urethral catheter is management of urinary incontinence [5]. While catheter use in
these patients may have a short-term nursing benefit, the increased risk of complications
associated with their use outweighs any benefit [3,8,9]. (See "Treatment of urinary
incontinence".)
It is also inappropriate to use catheters to obtain urine for testing in individuals who are capable
of voiding spontaneously or who can reliably collect urine for monitoring output [1]. Catheters
are also often used to measure residual urinary bladder volume in hospitalized patients;
however, we prefer the use of a portable ultrasound unit (eg, BladderScan™). These devices
correctly estimate residual volume greater than 50 mL in >90 percent of patients [10].
CHOICE OF CATHETER — The choice of catheter depends upon clinical indication and
expected duration of catheterization. Different catheters can be used during the course of care
reflecting the patient's changing needs (table 1). The best alternative to an indwelling urethral
catheter should be considered. Although urethral catheters are frequently used initially,
substituting external catheters, or intermittent catheterization can reduce complications.
External — External catheter systems are the least invasive for urine drainage and are
available as penile sheath catheters (ie, condom catheters) for men or urinary pouches for men
or women. External catheters are not appropriate for accurate urine measurement or
management of urinary obstruction (table 1). (See 'External catheter systems' below.)
Condom catheters are an effective mode of bladder drainage in men who do not have
evidence for urinary retention or urinary obstruction. They are widely used in chronic care
facilities [11,12]. Contraindications to their use include the presence of penile ulceration or
perineal dermatitis. It is important to ensure the patient has adequate manual dexterity if he is
expected to place the device himself [1].
Advantages of condom catheters are minimization of urethral trauma and improved comfort
and mobility compared with indwelling catheters [13]. The decreased incidence of urinary tract
infection associated with condom catheters is dependent upon patient cooperation and
minimization of catheter manipulation.
The main disadvantage of condom catheters is irritation if attached too tightly; penile
ulceration, scarring, and penile tissue loss can result. Dislodgement and urinary spillage can
also be problematic [13]. (See "Complications of urinary bladder catheters and preventive
strategies".)
Urethral — Urethral catheters are inserted through the tip of the urethra (ie, transurethrally)
and are appropriate for all indications related to catheterization (table 1).
Indwelling — Indwelling urethral catheters are most commonly used in the hospital setting for
short-term bladder drainage (ie, <3 weeks). They are also used for management for patients
with chronic urinary retention who are refractory to, or not candidates for, other interventions
(eg, transurethral resection of the prostate).
Intermittent — Intermittent catheterization, which is the removal of the catheter immediately
after bladder decompression with recatheterization on a scheduled basis, is an alternative to
indwelling catheterization. When intermittent catheterization is used, it must be performed at
regular intervals to prevent bladder overdistention [1]. (See 'Clean intermittent
catheterization' below.)
Intermittent urethral catheterization can be used for either short- or long-term management of
urinary retention or neurogenic bladder dysfunction (eg, patients with spinal cord dysfunction,
myelomeningocele, or bladder atonia) [1,14,15]. Despite its advantage of reducing
complications, intermittent catheterization is not commonly used for short-term catheterization
[16-24].
Intermittent catheterization may not be possible for some patients due to upper-extremity
impairment, discomfort, obesity, or urinary obstruction (eg, enlarged prostate, urethral stricture)
and others who may not be willing to perform the procedure [25].
Suprapubic — Suprapubic catheters are the most invasive catheter and require a surgical
procedure for placement, usually by a urologist or urogynecologist. A suprapubic catheter is
placed through the abdominal wall and into the bladder either intraoperatively in association
with another surgical procedure or percutaneously.
Suprapubic catheterization prevents urethral trauma and stricture formation, reduces the
incidence of catheter-associated bacteriuria (at least temporarily), and may be associated with
increased patient satisfaction compared with chronic indwelling urethral catheters. Suprapubic
catheterization allows attempts at normal voiding without the need for recatheterization and
interferes less with sexual activity. Patient comfort and preference usually dictate the choice.
Various types of suprapubic tubes are available including balloon (eg, Foley, Rutner) and
mushroom (eg, Malecot) catheters with a single lumen in sizes ranging from 10 to 18 F. No
benefit has been shown for any particular catheter [25].
CATHETER TECHNOLOGY — Most catheters have dual lumen tubes with one lumen draining
the catheter and the other delivering water to the balloon. The first balloon catheter was
designed in the 1930s by a surgeon, Frederic Foley; the basic catheter retains his name.
For most adults requiring urethral catheterization, a standard Foley catheter (ie, double-lumen
latex) is appropriate. Single or multiple-use straight catheters without a balloon are used for
intermittent catheterization.
Sizing — Catheter size should be individualized to the needs of the patient. In adults, a 14 to
16 French (Fr/3 = diameter in millimeters) catheter is typically chosen for short-term indwelling
catheterization. Larger catheters, 20 to 24 F, are used to provide an adequate bore for the
drainage of hematuria or clots. Sizing charts are available to determine the proper diameter for
children.
Both short (21 cm) and longer (40 to 45 cm) catheter lengths are available. Shorter catheters
may be more appropriate for women.
Two balloon volumes are available, 5 mL and 20 to 30 mL. For most patients, a 5 mL balloon is
adequate. A larger balloon volume may be desirable in some postoperative patients or women
with weak pelvic musculature if urine leakage occurs [26]. (See 'Managing leakage' below.)
External sheath catheters (ie, condom catheters) are available in many sizes and use of a
measurement or sizing guide is recommended. Penile circumferential measurement is taken at
the mid shaft of the non-erect penis as it is gently extended away from the body. Size is
adjusted as needed.
Materials — Catheters are manufactured from latex, silicone, plastic, or Teflon®. Latex
catheters are inexpensive and the most commonly used. However, latex is associated urethral
inflammation which may be due to protein and salt encrustation on the surface of the catheter.
Chronic inflammation from prolonged catheter use can lead to urethral stricture. [27,28]. For
this reason and the potential for latex allergy, silicone catheters may be preferable when more
prolonged catheterization is required [1]. (See "Complications of urinary bladder catheters and
preventive strategies", section on 'Urethral catheters'.)
External catheter systems — Condom catheters are available in latex and silicone.
Removable tips are available for men who also need to perform intermittent catheterization.
Most sheath catheters are pre-rolled and incorporate a self-adhesive vertical strip which
provides penile fixation. Self-adhesive sheaths have fewer complications compared with those
that require separate adhesive strips or other fixating devices. These are often circumferentially
placed and can cause undue tissue compression. (See "Complications of urinary bladder
catheters and preventive strategies", section on 'Condom catheters'.)
Options for males with a small or retracted penis include catheters that adhere directly to the
glans penis, and adhesive urinary pouches. Adhesive urinary pouches are also available for
women.
Specialized catheters — Specialized catheters are available for use as the need arises and
include coudé, triple lumen, antibiotic-coated, and hydrophilic catheters.




Coudé (ie, bent) catheters have a curved tip that facilitates catheter placement in
males, especially those with obstructive uropathy due to benign prostatic hyperplasia.
Triple-lumen catheters are used for bladder irrigation and are available in larger
diameters (20 to 24 F) to aid removal of clot. Irrigation fluid is instilled into the bladder
through the irrigation port and drained through the catheter. Intermittent or continuous
irrigation can be used depending upon the indication for irrigation.
Antimicrobial catheters are coated with antimicrobial agents (eg,
nitrofurazone, minocycline, or rifampin) or silver alloy. While these catheters reduce the
incidence of bacteriuria, they have not been shown to consistently reduce the incidence
of catheter-associated urinary tract infection [27-38]. These catheters are also more
costly [1].
Low friction hydrophilic catheters (eg, LoFric®) do not require lubrication for insertion
and may be useful when intermittent catheterization is needed. In observational
studies, hydrophilic catheters reduce urethral inflammation and are associated with
improved patient satisfaction in some, but not all, studies [39-41]. Catheter-related
bacteriuria, urinary tract infection, or sequelae of urethral problems in patients
managed with intermittent catheterization are not significantly reduced compared with
standard catheters [39]. These catheters are also more expensive.
Catheter drainage systems — Because between 10 to 25 percent of patients who develop
catheter-associated bacteriuria will develop a symptomatic urinary tract infection, catheter
drainage systems have been designed to limit the development of bacteriuria [42]. Based
primarily upon a prospective study of 676 patients, the use of closed catheter urinary drainage
system is the standard of care [43]. In this prospective trial, the incidence of bacteriuria in
patients managed with continuously closed urinary drainage was 23 percent compared with a
reported historic incidence of 95 percent for open urinary drainage. The pathogenesis of
urinary tract infection in the presence of urinary catheters is discussed separately.
(See "Urinary tract infection associated with urethral catheters", section on 'Epidemiology and
pathogenesis'.)
For patients who develop bacteriuria, the drainage bag represents a large reservoir of
pathogens, many of which are resistant to antimicrobials [44-49]. Cross-contamination of
bacteria from one patient to another is possible, and outbreaks of urinary tract infection with
highly resistant organisms have occurred. As such, gloves should be worn whenever the
catheter and drainage system are manipulated. (See 'Hygiene' below.)
Pre-connected systems (catheter is pre-attached to the tubing of a closed drainage bag) may
reduce bacteriuria, but there are insufficient data to support a reduction in the incidence of
catheter-associated urinary tract infection [50]. The application of tape at the catheter-drainage
tubing junction does not reduce the incidence of bacteriuria [25,51]. Randomized trials
evaluating more complex drainage systems, including those that release antiseptic solutions
into the drainage bag, have not demonstrated a reduction in the incidence of urinary tract
infection [1,38,42,52-55].
We prefer to use a sterile, continuously closed drainage system with a needle aspiration port,
and antireflux device to prevent urine backflow. We replace the drainage unit for any disruption
in the urine collection system (ie, catheter disconnect). (See 'Catheter care' below.)
EXTERNAL CATHETER PLACEMENT — The application and maintenance of external
catheters (eg, condom catheter), while simple in theory, can be challenging. Nonsterile gloves
should be used when applying or handling the device. The prior device is removed gently with
careful removal of any adhesive; adhesive remover can also be used. Devices are placed per
manufacturer’s instructions.
For self adhesive penile condom catheters, the penis is cleansed with soap and water and
dried prior to application of the new device. The condom catheter is applied to the tip of the
penis and rolled up the length of the penis, gently pressing the self-adhesive strip into place. It
is important to unroll as completely as possible to minimize any residual roller ring which can
produce tissue compression. (See "Complications of urinary bladder catheters and preventive
strategies", section on 'Condom catheters'.)
TRANSURETHRAL CATHETER PLACEMENT — Both indwelling and intermittent urethral
catheters are placed in a similar fashion. The catheter used for intermittent catheterization is
easier to insert; it is less bulky at the tip because there is no balloon. While indwelling catheter
placement is always performed with sterile technique, intermittent catheterization can be
performed with either sterile or nonsterile, clean technique. (See 'Clean intermittent
catheterization' below.)
A typical urethral catheterization kit includes sterile gloves, drapes, antiseptic solution and
sponges for periurethral cleansing, a single-use lubricant gel packet, urinary catheter, 5 mL
syringe filled with sterile water for balloon inflation, and urine drainage system.
The patient is placed in a supine position. In women, the lower extremities are frog-legged to
maximize exposure of the periurethral region. Adequate lighting is essential. Sterile gloves are
donned and the catheterization kit is inspected to ensure its contents are complete and free of
defects. If an indwelling catheter is chosen, the balloon is inflated briefly to check its integrity.
The end of the catheter, if not pre-attached, can be attached to the drainage system before or
after catheter placement.
Drapes are placed and the periurethral region cleansed. In men, the penis is grasped firmly
with the nondominant hand and tension directed toward the ceiling straightening the urethra. In
women, the nondominant hand is used to spread the labia to facilitate cleansing the
periurethral region and viewing the urethral meatus.
The gloved dominant hand is used to place the catheter into the urethral meatus and steady
gentle pressure used to advance the catheter. When a coude catheter is used, the curved tip of
the catheter should point caudally. When the catheter tip approaches the external sphincter in
men, resistance will be felt. It is often helpful to pause momentarily to let the sphincter relax
before continuing insertion.
The catheter should be inserted to the flared portion of the catheter (ie, hub). The balloon is
inflated with sterile water only after the flow of urine is seen. Saline should not be used to
inflate the balloon because crystal formation may obstruct the balloon channel and prevent
balloon deflation [56]. (See 'Troubleshooting catheter removal' below.)
Once the balloon is inflated, the catheter is withdrawn until slight resistance is felt. The urine
collection system is connected and the drainage tubing anchored to the leg with tape to
prevent traction of the catheter on the urethral meatus [24].
Troubleshooting urethral catheter placement — If no urine is obtained, an assistant can be
asked to apply gentle pressure to the suprapubic region which may initiate urine flow. In
women the insertion site of the catheter is examined; vaginal catheterization may have
occurred. If this is the case, the catheter is removed and a new sterile catheter used.
If the catheter has passed easily to its hub, suprapubic pressure has been applied, and urine is
still not observed, the patient may be dehydrated or may have voided recently. Gentle irrigation
through the end of the catheter using 10 to 20 mL sterile saline can be performed and should
return the saline mixed with urine. If the saline is not returned or any resistance to
catheterization was encountered, underlying pathology may be present and urologic
consultation should be obtained.
If the patient complains of pain during catheter insertion, the catheter should be removed. If
blood appears at the meatus or on the tip of the catheter, a urethral injury may have occurred.
The procedure is abandoned and a urologic consultation is obtained. (See "Complications of
urinary bladder catheters and preventive strategies", section on 'Effects of urethral trauma'.)
Clean intermittent catheterization — Patient populations that benefit from clean intermittent
catheterization (CIC) technique are adults and children with neurogenic bladder, including
patients with spinal cord injury [9,13,57]. Clean (non-sterile) technique for intermittent
catheterization is safe with lower complication rates compared with indwelling urethral or
suprapubic catheterization [14,16-23]. (See "Complications of urinary bladder catheters and
preventive strategies".)
No differences in the incidence of asymptomatic bacteriuria or catheter-associated urinary tract
infection have been found in randomized trials comparing sterile to clean technique for
intermittent catheterization [29,39], or single use compared with multi-use catheters [25].
(See "Urinary tract infection associated with urethral catheters".)
The technique for clean intermittent catheterization is generally the same as indwelling catheter
placement except the option for clean technique, and the removal of the catheter following
bladder drainage. If the catheter is disposable, it is discarded immediately after use. Reusable
catheters are also available and can be used for up to four weeks. Following catheterization,
the reusable catheter is washed with soap, rinsed with water, dried, and stored in a clean, dry
location.
Outpatient, chronic CIC can be challenging for the patient. Instructions to assist performing
intermittent catheterization are as follows [58]:


For men — Once all equipment (ie, catheter, lubricant, drainage receptacle) is
assembled and the hands are washed thoroughly with soap and water, clean the
urethral meatus with soap and water. Lubricate the catheter and gently insert into the
urethra with the penis positioned perpendicular to the body. As resistance is felt at the
level of the prostate, relax and breathe deeply then continue to advance the catheter.
Once the urine starts to flow, continue to advance the catheter another inch. Hold the
catheter in place until the urine flow stops and the bladder is empty. Remove the
catheter slowly to allow complete drainage of the bladder.
For women — Assemble all equipment and wash the hands with soap and water.
Clean intermittent catheterization can be performed in any comfortable position;
however, many women find it easiest to stand with one foot on the toilet. Clean the
vulva with soap and water. With the nondominant hand, spread the labia with the
second and fourth finger, using the middle finger to locate the urethral opening, which
is below the clitoris and above the vagina. Gently insert the catheter into the opening
with the dominant hand. Guide the catheter toward the umbilicus (ie, belly button).
Urine will begin to flow when the catheter has been inserted two to three inches.
Advance the catheter another inch and hold it in place until the urine flow stops and the
bladder is empty. Remove the catheter slowly to allow complete drainage of the
bladder.
SUPRAPUBIC CATHETER PLACEMENT — Suprapubic tube insertion is performed by a
surgeon, usually a urologist or urogynecologist, with either a percutaneous or open surgical
technique. Open suprapubic catheter placement is usually in association with other surgeries
(eg, prostate, bladder trauma repair). A 12 to 14 F catheter is generally selected. If the patient
has a history of prior lower abdominal surgery, percutaneous suprapubic catheters should not
be attempted without simultaneous cystoscopy.
The percutaneous procedure is performed using sterile technique with local anesthesia, and
sedation if needed. Ultrasound is used to verify full bladder distension prior to the procedure.
The catheter can be place via either a direct puncture or Seldinger technique (figure 1).
CATHETER CARE — Ideal catheter care is easy to prescribe but difficult to achieve [59]. A
Danish study using questionnaires to assess knowledge of and adherence to optimal catheter
management protocols in hospitals and nursing homes showed moderate familiarity with
written guidelines but frequent irregularities in practice [60].
Hygiene — Cleansing with soap and water around the catheter (periurethral, suprapubic)
during bathing is adequate for ongoing maintenance. For urethral catheters, we do not use
meatal disinfectants or antibacterial urethral lubricants because they do not prevent infection,
and may lead to development of resistant bacteria at the meatus [61-63].
When the catheter or drainage system is manipulated for any reason, nonsterile gloves should
be used and then immediately discarded to limit transfer of pathogens from patient to patient.
The bag should be emptied regularly, avoiding contact of the drainage spigot with the collecting
container [1,59]. Separate collecting containers should be used for each patient.
Managing leakage — If leakage occurs around an established suprapubic catheter (>6 weeks
after placement) or transurethral catheter, the catheter can be replaced with a new catheter
that is larger by 2 to 4 F.
Leakage can be due to detrusor overactivity/uninhibited bladder contractions, particularly in
some patients with neurologic conditions (eg, multiple sclerosis). In this setting, other
approaches including partially deflating the balloon, or treatment with antimuscarinic
medications may be effective.
If leakage persists or the suprapubic catheter has been more recently placed, a urologist or
urogynecologist should be consulted.
Monitoring for obstruction/preventing backflow — The catheter and collecting tubing
should be free from kinking and fixed to the patient’s leg by a strap or tape to prevent tugging
or inadvertent traumatic removal. The collection system must be positioned below the level of
the bladder at all times. Leg urinary collection bags that are strapped to the thigh are available
for ambulatory use. If the catheter or drainage system is manipulated to relieve an obstruction,
gloves (nonsterile) should be used.
Urine specimen collection — Specimens should not be obtained from the drainage bag when
collecting urine for gram stain or culture. If specimens are required for other analysis (eg,
creatinine clearance) they can be obtained aseptically from the drainage bag [1,64,65].
Procedures for obtaining urine samples for microbiologic analysis are discussed separately.
(See "Urinary tract infection associated with urethral catheters", section on 'Diagnosis'.)
Changing the catheter — Indwelling catheters as a rule should not be replaced routinely; they
should not be changed if flow appears adequate [66]. Although there is a brief reduction in the
density of bacteria found in the urine following catheter replacement, this is a short-lived
phenomenon of uncertain benefit [67]. However, catheters with mechanical problems (poor
drainage, encrusted) need to be replaced.
Suprapubic catheters are generally managed by the operating surgeon and are not changed
until a tract between the bladder and abdominal wall is established, which usually requires four
to six weeks. If the catheter is accidentally pulled out within six weeks of its placement, the
operating surgeon should be notified.
Bladder irrigation — Bladder irrigation is reserved for selected patients (eg, postoperative,
pharmacologic therapy) or for the management of hematuria. However, if a catheter is not
draining properly, it can be irrigated once with sterile saline [1]. If this is not effective, the
catheter should be replaced. If there is a suspicion that the latex catheter material contributed
to the obstruction, the catheter should be changed to a silicone catheter to reduce future
encrustation.
Antimicrobial irrigation of the bladder does not appear to prevent or delay urinary tract
infection; rather, this practice may lead to infection with more resistant organisms [68-70]. One
randomized trial of 200 catheterized patients found no significant difference in the incidence of
urinary tract infection for patients treated with a neomycin-polymyxin bladder irrigant compared
with no irrigation [68]. Patients who received bladder irrigation were found to have more
resistant organisms.
Catheter removal — The simplest strategy for preventing catheter-related urinary tract
infection is catheter removal when the indication for insertion is no longer met. Removing an
indwelling urethral catheter is usually a matter of aspirating the balloon port with an empty
syringe which deflates the balloon; the catheter should then slip out. Suprapubic catheters are
typically removed by the operating surgeon once the indication for catheter placement has
resolved.
Following surgery, catheters should be removed as soon as possible (ideally in the recovery
room) to reduce the incidence of urinary tract infection [71,72]. A meta-analysis of 7
randomized trials found fewer urinary tract infections when urinary catheters were removed
within one day postoperatively compared with three days (relative risk 0.50, 95% CI, 0.29-0.87)
[72].
On occasion, clinicians may be unaware that their patient has a urinary catheter, especially if it
had been replaced after initial removal [73]. Reminders from nursing staff and implementation
of automatic stop orders reduce the duration of catheterization and incidence of catheterassociated urinary tract infection [74,75]. A systematic review and meta-analysis of 14 studies
that evaluated reminder systems found a 52 percent reduction in the rate (episodes per 1000
catheter-days) of catheter-associated urinary tract infection with the use of a reminder or stop
order (rate ratio [RR] 0.48, 95% CI 0.28-0.69). The duration of catheterization was decreased
by 37 percent [75].
Troubleshooting catheter removal — The balloon of a urinary catheter may fail to deflate
properly due to a faulty valve mechanism or obstructed balloon channel. Obstruction is
uncommon and is typically due to the formation of crystals when saline rather than water is
used to inflate the balloon, and the catheter has been in place for a prolonged period of time.
The first line of action if the fluid within the balloon cannot be aspirated is to cut the valve (ie,
balloon port) from the catheter at its junction. This should result in immediate flow of water from
the balloon. To minimize the potential for urethral trauma, allow some time for the balloon to
drain before withdrawing the catheter. Rupturing the balloon by overinflation should not be
attempted since balloon fragmentation will result about 80 percent of the time requiring
cystoscopy for retrieval [76]. If cutting the valve fails to deflate the balloon, a urologist or
urogynecologist should be consulted. He or she will typically first try to maneuver a ureteric
stylet through the inflation channel to dislodge the obstruction. If this fails, the patient will need
to be sedated and the balloon punctured sharply with a spinal needle, using a transabdominal,
transurethral, or transvaginal approach.
Prophylactic antibiotics — Systemic antimicrobial agents should not be administered to
patients who do not have a proven urinary tract infection in either a short- or long-term
catheterization setting [67,77,78]. Antimicrobial therapy promotes the development of resistant
bacterial strains. (See "Urinary tract infection associated with urethral catheters", section on
'Asymptomatic bacteriuria' and "Urinary tract infection associated with urethral catheters",
section on 'Urinary tract infection'.)
COMPLICATIONS — The complications of urinary catheter placement are discussed in detail
elsewhere. (See "Complications of urinary bladder catheters and preventive strategies".)
SUMMARY AND RECOMMENDATIONS









Catheters available for urinary drainage include external (eg, condom), urethral
(indwelling, intermittent), and suprapubic catheters. (See 'Choice of catheter' above.)
There are many indications for using bladder catheters (table 1). Limiting use to
appropriate indications is important in minimizing catheter-related complications.
Catheters are not indicated for determining the residual volume of urine, or in the
management of most patients with urinary incontinence (see 'Inappropriate use of
catheters' above).
Urinary catheters are used selectively for operative patients based upon the nature (ie,
pelvic surgery) and duration of the procedure, or need for perioperative fluid
monitoring. Catheters should be removed as soon as possible, preferably in the
recovery area, if feasible. (See 'Indications for catheterization' above and 'Catheter
removal' above.)
For male patients who do not have evidence of urinary retention or bladder outlet
obstruction, we suggest external catheters over urethral catheters whenever possible
(Grade 2C). (See 'Choice of catheter' above.)
For patients with bladder emptying dysfunction, we suggest intermittent catheterization
over chronic indwelling catheters (Grade 2C). Clean technique is an acceptable and
practical alternative to sterile technique. (See 'Choice of catheter' above and 'Clean
intermittent catheterization' above.)
Following aseptic placement of indwelling catheters, we recommend a closed drainage
system (Grade 1C). Breaks in the integrity of the closed system should prompt
replacement of the drainage system. (See 'Catheter drainage systems' above.)
Routine maintenance of urinary catheters includes proper hygiene of the pericatheter
region, maintenance of unobstructed urine flow, frequent and proper emptying of the
closed catheter drainage system, and proper specimen collection. (See 'Catheter
care' above.)
Indwelling urethral catheters and drainage systems are changed only for a specific
clinical indication such as infection, obstruction, or compromise of closed system
integrity. (See 'Catheter care' above.)
For patients who do not have gross hematuria associated with clots, we suggest not
irrigating urinary catheters (Grade 2C). (See 'Catheter care' above.)
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Topic 8090 Version 6.0
GRAPHICS
Indications for urinary bladder catheters
Type of catheter
Indications
Indwelling
urethral
Intermittent
urethral
Suprapubic
Condom
Urinary retention
Y
Y
Y
N
Urine output monitoring in critically ill
patient
Y
Y
Y
N
• Patients undergoing prolonged duration
of surgery
Y
N
Y
N
• Patients requiring large volume
infusions or diuretics
Y
N
Y
N
• Patients requiring intraoperative
monitoring of urinary output
Y
N
Y
N
• Patients with urinary incontinence
Y
N
Y
Y
Post-prostate, bladder or gynecologic
surgery
Y
Y
Y
N
Hematuria with clots
Y
N
Y
N
Prolonged immobilization
Y
Y
Y
Y
Urinary incontinence in patients who fail
behavioral and pharmacological therapy and
incontinence pads
Y
N
N
Y
Neurogenic bladder/spinal cord patients
Y
Y
Y
Y
Assist in healing of open sacral or perineal
wounds in incontinent patients
Y
Y
Y
Y
Improve comfort for end of life care
Y
Y
Y
Y
Intra- and post-operative monitoring:
Data from: Gould, CV, Umscheid, CA, Agarwal, RK, et al. Guideline for the prevention of catheterassociated urinary tract infections 2008. Department of Health and Human Services. Centers for
Disease Control and Prevention.
Percutaneous suprapubic catheter placement
Percutaneous suprapubic catheters are placed using sterile technique with local
anesthesia, and sedation if needed. Ultrasound is used to verify full bladder distension
prior to the procedure. The lower abdominal skin is prepared and lidocaine is injected
in the midline, 2 centimeters above the symphysis pubis. The catheter is placed
through a small skin incision into the bladder either with a direct puncture or Seldinger
technique. For the direct puncture technique, a mushroom catheter is straightened
with a stylet and advanced into the bladder. Once the catheter is confirmed within the
bladder, the stylet is removed. For the Seldinger technique, a needle is inserted until
urine is aspirated. A guidewire is placed through the needle into the bladder and the
needle is removed. A dilator is advanced over the wire enlarging the tract. The dilator
is then replaced with a sheath, the guidewire removed, and the catheter placed
through the sheath which is then peeled away. The catheter balloon is inflated and the
catheter gently withdrawn until slight tension is felt. The catheter is then connected to
the catheter drainage system and secured to the patient.
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