IDCs can cause significant morbidity, prolong hospital stay and increase healthcare costs. Infection and traumatic insertion are common complications; advances in catheter design have helped to limit these complications. Most complications are avoidable, do not require specialist input and can be managed by community nurses or GPs.
Reviewing indications, adopting proper technique for insertion and defining management strategies can limit complications. Indwelling urethral catheterisation short term and long term Short-term IDCs are commonly used in hospital for management of acute urinary retention AUR , urine measurements, bladder irrigations, diversion and drainage of urine after surgery, or for patients requiring epidural anaesthesia. Suprapubic catheterisation In hospital, short-term suprapubic catheterisation is used for AUR management when other methods have failed or for lower urinary tract diversion after surgery or trauma.
Contraindications for catheterisation IDCs are contraindicated in patients with abnormalities of the urethra, including false passages, severe strictures, injury or tumour. Types of catheters All Australian catheters must conform to Australian safety standards. The correct size is determined by patient characteristics, type of fluid drained and indication for insertion. Catheter obstruction Accumulation of blood clots, crystals, tissue and biofilms can cause obstruction.
Catheter bypass Urine bypassing a catheter occurs for various reasons. Conclusion Appropriate knowledge and experience of catheter management and associated complications by general practitioners reduces the impact on acute-care facilities. Key points Use the least invasive method when a urinary catheter is clinically indicated.
IDCs come in various shapes, lengths, diameters and materials. Catheter-associated urinary tract infections are the most common nosocomial infection worldwide. Most catheter-related complications can be adequately managed in the community. Provenance and peer review: Not commissioned, externally peer reviewed. Create Quick log. Self-reported competence of urethral catheterization in interns. ANZ J Surg ;81 9 — Impact of the lack of community urinary catheter care services on the Emergency Department.
BJU Int ; 2 — Indwelling urinary catheters: Pattern of use in a public tertiary-level Australian hospital. Urol Nurs ;34 2 — Catheterisation clinical guidelines. A prospective, randomized trial comparing continuous bladder drainage with catheterization at abdominal hysterectomy. Br J Urol ;80 4 — British Association of Urological Surgeons' suprapubic catheter practice guidelines. BJU Int ; 1 — Search PubMed Yates A. The risks and benefits of suprapubic catheters.
Nurs Times ; 6—7 — Caring for and changing your suprapubic catheter SPC. Medical devices — Polymer urethral catheters for general medical use. Single-blind, randomised, parallel group study of the Bard Biocath catheter and a silicone elastomer coated catheter.
Br J Urol ;68 4 — A preliminary evaluation of ovine bladder mucosal damage associated with 2 different indwelling urinary catheters. Urology ;— Types of indwelling urethral catheters for short-term catheterisation in hospitalised adults.
A decade of prevalence surveys in a tertiary-care center: Trends in nosocomial infection rates, device utilization, and patient acuity.
Infect Control Hosp Epidemiol ;20 8 — Preventing catheter-related bacteriuria: Should we? Can we? Arch Intern Med ; 8 — Urinary catheters: History, current status, adverse events and research agenda. J Med Eng Technol ;39 8 — Search PubMed Patients with chronic urinary retention without bladder outlet obstruction such as neurogenic bladders are often best managed by non-indwelling methods such as intermittent straight catheterization.
Accurate measurement of urinary output in critically ill patients —Indwelling urinary catheters are the only method to measure hourly urine output when needed to manage critical illness such as hemodynamic instability, frequent titration of life-supportive therapy such as intravenous drips requiring close titration e.
However, routine use of catheters in the intensive care unit ICU without indication is inappropriate. ICU patients who are hemodynamically stable often do not require urinary catheters and are appropriate candidates for alternate means of collecting or measuring urine output see Consider Alternatives to Indwelling Urinary Catheters subsection below.
Perioperative use in selected surgeries —According to the HICPAC guideline, urinary catheters are indicated perioperatively for selected surgical procedures.
Catheters are indicated when a surgery is expected to be prolonged, when a patient will require large-volume infusions or diuretics during surgery, or when there is a need for intraoperative urinary output monitoring. Catheters also are indicated for urologic surgeries or other surgeries on contiguous structures of the genitourinary tract. Catheters placed for surgery duration should be removed in the post-anesthesia care unit. Urinary catheters should not be used routinely for patients receiving epidural anesthesia or analgesia.
Assistance with healing of stage III or IV perineal and sacral wounds in incontinent patients —This is a relative indication for urinary catheter use when there is concern that urinary incontinence is leading to worsening skin integrity in areas where skin breakdown already exists. For example, indwelling urinary catheters can be appropriate for stage III, IV, or unstageable pressure ulcers or similarly severe wounds that cannot be kept clear of urinary incontinence despite wound care and other urinary management strategies.
Urinary catheters should not be used as a substitute for the use of skin care, skin barriers, and other methods to manage incontinence and limit skin breakdown. A catheter may be needed when nurses do not have resources such as lift teams and mechanical lifts to help turn a heavy patient frequently to provide the necessary skin care. However, be aware that all indwelling urinary catheters can cause discomfort during placement and use, and not all patients or families desire urinary catheters.
Required immobilization for trauma or surgery —Indwelling urinary catheters may be used when patients require strict prolonged immobilization following specific types of trauma or surgery. Examples include instability in the thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures, and acute hip fracture when there is risk of displacement with movement prior to surgical repair. Other appropriate indications, based on the Ann Arbor Criteria, include the following: Single hour urine sample for diagnostic testing that cannot be obtained by other urine collection strategies, such as urinal, bedside commode, bedpan, external catheter, or intermittent straight catheter.
Indwelling urinary catheters may be appropriate to reduce the need for movement in the patient with acute severe pain when other urine management strategies are difficult, such as an acute, unrepaired hip fracture; however, catheter use should be reconsidered once acute pain is better controlled. Clinical conditions for which intermittent straight catheters or external catheters would be appropriate, but placement by an experienced nurse or physician is difficult.
In a patient for whom bladder emptying was inadequate with non-indwelling strategies. Inappropriate Indications Urinary catheters should not be placed in the following situations: Urine output monitoring that can be obtained by means other than an indwelling urinary catheter —Many patients currently receive urinary catheters to monitor urine output as part of routine care when admitted for certain conditions such as heart failure or renal failure.
When urine output monitoring is needed to provide care but hourly measurement is not required, alternatives to indwelling catheters should be prioritized. For patients with congestive heart failure, consider involving the patients and family members. Providing patients and family members with educational materials on how to document the urine output and daily weight may assist in this process and may be useful information for assessing urine output after discharge home Exceptions: The benefits of urinary catheters may outweigh potential harms in cases where hourly measurement of urine volume is required to provide treatment such as management of hemodynamic instability, severe electrolyte imbalance, or hourly titration of fluids, drips, or life-supportive therapy that occurs outside the ICU.
Catheters also may be used when daily measurement of urine volume is required to provide treatment and cannot be assessed by other strategies. Incontinence without a sacral or perineal pressure sore —Urinary catheters should not be routinely placed for management of urinary incontinence in patients for whom skin care can be provided. Remember that patients with preexisting incontinence managed their incontinence prior to admission. Nursing homes rarely use urinary catheters to manage urinary incontinence even though this is a common comorbidity for nursing home residents.
Mechanisms to keep the skin intact need to be instituted on admission. Some potential solutions for the management of incontinence include use of skin barrier creams for skin protection, high-absorbency briefs or pads that wick moisture away from the skin, and scheduled voiding by use of a bedpan, or frequent assistance to the bedside commode.
Check for any wet bed linen, and change linens if they are wet when the patient is being turned in bed. Exceptions: Use of an indwelling urinary catheter may be appropriate to manage incontinence in patients with morbid obesity or severe edema for whom available resources are inadequate for standard turning protocols. Prolonged postoperative use —Urinary catheters should be promptly discontinued within 24 hours or less after surgery unless there is an appropriate indication for continued postoperative catheter use e.
Other potentially inappropriate uses of urinary catheters include the following: Patients who are being transferred within or from an acute care facility —Any handoff transition when a patient moves from one unit to another is an opportunity for the offgoing and oncoming staff to review together whether the patient has an indication for continued use of an indwelling urinary catheter.
In particular, transfer from the ICU or emergency department to an acute-care setting frequently triggers an opportunity to remove a urinary catheter. Morbid obesity or immobility —Morbid obesity or immobility alone is not an appropriate indication for urinary catheter placement. Patients who are morbidly obese have functioned without a urinary catheter prior to admission.
The combination of immobility and morbid obesity may lead to inappropriate urinary catheter use. Confusion or dementia —Confusion or dementia is not an appropriate indication for urinary catheter placement. Patient and or family request —Patient and or family request is not a sufficient reason for placement of a urinary catheter. Explain to the patient and family the risk of infection, trauma, and immobility related to the use of the urinary catheter, and consider providing them with educational materials on the risks of CAUTI.
For example, if a patient is on diuretics and does not want to move out of bed multiple times, a catheter should not be used as a substitute for urine collection otherwise available by urinal, bedpan, or toilet. Education is key! Explain to the patient the increased risks associated with use of a urinary catheter and the resulting immobility: urine infection, skin breakdown pressure ulcers , and deep venous thrombosis.
An exception would be for patients who are receiving end-of-life or palliative care and in whom a catheter would facilitate meeting quality-of-life goals appropriate indication 5 described above. Before placing an indwelling catheter, consider if these alternatives would be more appropriate: Bedside commode, urinal, incontinence garments for both sexes and external condom catheter for males —Use these tools to manage incontinence.
Additional planning and personnel resources may be required to ensure that patients are regularly prompted and assisted with voiding or assessed for incontinence. Portable bladder scanners use ultrasound, a noninvasive way to determine the volume of urine remaining in the bladder after voiding i.
For example, portable bladder ultrasounds are useful on medical, surgical, or rehabilitation units to determine whether a patient has sufficient urinary retention to justify catheterization. Intermittent catheterization is most often used in patients with neurogenic bladder or spinal cord injury, and lessens the risk of urinary tract infection compared to chronic indwelling urinary catheters.
Intermittent catheterization is a preferable treatment method to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. When the patient returns to the community, intermittent catheterization enhances patient privacy and dignity and facilitates return to activities of daily living.
It is important to perform intermittent catheterization at regular scheduled intervals to avoid overdistending the bladder. Among hospitalized patients, one-time or intermittent catheterization is often used in combination with a portable bladder scanner ultrasound.
External catheters are useful especially for management of incontinence in cooperative elderly male patients with dementia but remain underutilized.
Engage the input of frontline staff to determine which products to add to the hospital and unit Central Supply stock. Proper Catheter Insertion and Maintenance Properly Trained Clinicians Ensure that only staff members trained in aseptic technique for catheter insertion are given responsibility for catheter placement. Aseptic Insertion Techniques for catheterization of female and male patients vary.
Make sure urinary flow is not obstructed. Ensure the catheter tubing is not kinked. Urine in drainage bags should be emptied at least once each shift and before any transfer off the unit e. Care must be taken to keep the outlet valve from becoming contaminated.
Follow standard precautions by using gloves and performing proper hand hygiene before and after handling the drainage device. Consider changing the urinary system in the event of infection, obstruction, or a break or leak of the closed system.
Do not remove any seals between the catheter and the drainage tubing or disconnect the closed system. Avoid irrigation. If catheter obstruction is determined and the catheter remains indicated, replace the catheter and drainage system.
When obtaining a sample of urine from the system, disinfect the sampling port and allow the disinfectant to dry before accessing the port. Frequently washing the meatus with povidone-iodine or soap is not associated with lower infection risk. The CDC recommends routine perineal hygiene using soap and water during daily bathing. Unit team leaders can take steps to encourage use of a nurse-driven protocol for catheter removal through the following: Early engagement of the physician champion Presentation of data before implementation Approval of the protocol by physician and nursing leadership prior to implementation Recognition that physicians and nurses must continue to discuss unusual cases Education of nursing staff Involvement of staff on matters related to reducing catheter use Use of bedside catheter rounds to provide one-on-one coaching about when to remove catheters Assurance that staff are fully supported in removing unnecessary urinary catheters Sharing and celebration of results with frontline staff Having physician champions engaged in the development of the protocol and process is key.
In women the catheter should be secured to the anteromedial thigh. Information from Wong ES. Guideline for prevention of catheter-associated urinary tract infections. February Every attempt should be made to keep the drainage system closed. Any break in the catheter-to-collection unit may invite earlier infection. Infection in the catheterized patient is suggested by signs or symptoms of pyelonephritis 6 , 25 fever greater than Avoiding cross-contamination is most important in controlling nosocomial epidemics of catheter-related infections.
If possible, devices used for emptying collection bags should be clean and patient-specific. Catheters should not be changed routinely. Some physicians advocate monitoring patients for time-to-obstruction of urinary catheter, with the catheter changed just before the patient would be expected to obstruct. Such a policy will lead to fewer catheter changes than scheduled changes and will result in less trauma to the urinary system and fewer symptomatic infections.
Some physicians recommend a catheter change when an episode of symptomatic urinary infection occurs. Several procedures that have been used to decrease the risk of infection are of no benefit. For example, meatal disinfectants and antibacterial urethral lubricants are ineffective. Some physicians recommend diluted acetic acid irrigations in patients with frequent catheter obstructions who have had no response to increased fluid intake or acidification of urine.
Agents added to collection bags have also not proved effective. The material that obstructs urinary catheters consists of bacteria, glycocalyx, protein and precipitated crystals. Its potent urease splits ammonia, causing alkaline urine, which in turn precipitates crystals of struvite and apatite in the catheter lumen. Bladder spasms are not uncommon in patients with long-term catheterization. The force generated by spasms commonly overwhelms the drainage capacity of the catheter, creating leakage around the catheter.
This type of leakage should not be corrected by using a larger diameter catheter. Infection or catheter obstruction, if present, should be treated. Antispasmodics, such as oxybutynin Ditropan and flavoxate Urispas , can be effective in alleviating spasm due to detrusor instability Table 4. Virtually every patient with chronic catheterization is colonized with bacteriuria within six weeks.
Bacteriuria also occurs within a few months in the majority of patients using clean intermittent catheterization. Asymptomatic bacteriuria does not require treatment. An isolated incident should not prompt initiation of antibiotic therapy. Asymptomatic bacteriuria occurs frequently after the removal of a short-term—use indwelling catheter.
Some physicians recommend treatment of asymptomatic bacteriuria, but it may be more reasonable to treat only symptomatic episodes. If treatment is chosen, a single dose of trimethoprim-sulfamethoxazole Bactrim, Septra is effective in asymptomatic younger women and those with lower urinary tract symptoms.
Duration of antibiotic treatment should probably be at least 10 days in women 65 years and older. Only symptomatic infection should be treated in patients undergoing long-term catheterization. The bacterial flora changes over time, and serial cultures offer no benefit in determining correct antibiotic choice for future acute infection episodes.
When a patient undergoing long-term catheterization develops fever, a source of infection should be sought. When urinary infection is suspected, culture should be obtained to guide therapy.
Some physicians recommend inserting a new catheter and collecting a fresh urine sample for culture, to more accurately determine the source of bladder infection, 4 , 25 although no data support this practice. Blood cultures may be helpful if bacteremia is suspected. Infections are usually polymicrobial and may include bacteria such as Pseudomonas, Proteus, Providencia, Enterobacteriaceae, Morganella and Enterococci. The usual duration of therapy is five to 14 days or longer. Second-generation cephalosporin e.
Ampicillin plus one of the following:. Ceftriaxone Rocephin , cefprozil Cefzil or ceftazidime Fortaz. Aztreonam Azactam. Aminoglycoside or quinolone. Information from references 4 through 7 , and Complications of urinary tract infections may occur.
Increasing renal dysfunction and recalcitrant or recurring bacteremia should prompt a search for urinary stones or other causes of obstruction. Renal calculi are common in patients with spinal cord injury and affect at least 8 percent of patients. Thirty-nine percent of those who died from renal failure had urolithiasis at autopsy compared with 18 percent of those who died from non-renal causes. Periodic surveillance for urolithiasis and removal of stones is recommended to maintain renal function.
In these people, annual cytology or cystoscopy is recommended as a secondary prevention strategy. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. After completing medical school and a family practice residency at the University of Missouri—Columbia School of Medicine, Dr.
Cravens practiced medicine in rural Missouri for 15 years. He attended medical school, completed a family practice residency and a Robert Wood Johnson Foundation—sponsored fellowship in academic family practice at the University of Missouri—Columbia School of Medicine. Address correspondence to David D. Cravens, M.
E-mail: cravensd health. Reprints are not available from the authors. Warren JW. Catheter-associated bacteriuria. Clin Geriatr Med. Long-term urethral catheterization increases risk of chronic pyelonephritis and renal inflammation.
J Am Geriatr Soc. The association between the use of urinary catheters and morbidity and mortality among elderly patients in nursing homes. Am J Epidemiol. Management of complicated urinary tract infection in older patients. Wong ES. Guideline for prevention of catheterassociated urinary tract infections. Feb Long-term urinary tract catheterization. Med Clin North Am. Medical care of the nursing home resident: what physiciansneed to know.
Philadelphia: American College of Physicians, Practical guide to the care of the geriatric patient. Louis: Mosby-Yearbook, Meeks GR.
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