How Does A Catheter Work?

A catheter drains urine from the bladder into a drainage bag which may be supported at thigh or calf level. The leg drainage bag requires changing every 5 to 7 days depending on manufacturers instructions.

A Belly Bag or a catheter valve may be recommended. Your District Nurse or Continence Advisor will advise you on which type may be appropriate for your needs.

If you do use a leg drainage bag then it requires emptying when it is half to three-quarters full. Always ensure it does not pull on the catheter.

The bags are usually of 350ml, 500ml, 750ml or 1litre capacity for daytime use (depending on manufacturer). At night an extra 2-litre bag can be fitted easily to the day leg bag to increase the available capacity. These larger night bags mean you don’t have to get up in the night to empty the bag. They should be supported on a catheter drainage bag stand.

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The Catheter in Situ

An indwelling urethral catheter is passed through the urethra (the tube through which urine passes). This is the usual method of draining urine from the bladder when short-term drainage is required (usually less than 30 days).

If you are sexually active it may be possible to be taught to remove your indwelling urethral catheter prior to intercourse and insert a new one afterwards. You may wish to discuss this with your partner. The District Nurse or Continence Advisor will advise you so don’t be embarrassed to discuss this.

Male catheter in situFemale catheter in situ

Suprapubic Catheters

In some cases when long term catheterisation is needed (longer than 30 days), the preferred method of drainage is via a suprapubic catheter. This method involves a small operation to form an artificial track directly into the bladder and the catheter is inserted through the lower abdominal wall directly below the belly button. Both men and women can have this type of catheter.

This type of catheter is generally administered when the urethral route cannot be used or if a person is still sexually active. It also reduces the risks of complications from catheter-associated urinary tract infections which are more commonly associated with urethral indwelling catheters.

Male suprapubic catheterFemale subrapubic catheter

A Suprapubic catheter is normally inserted whilst in hospital and may require an overnight stay, however, the routine changes to the catheter can be done at home. Many District Nurses and Continence Advisors are well practised in this procedure.

Some people prefer to cover the site with a dry dressing but this is only necessary for the initial few weeks after insertion or if there is leakage or exudate. The area needs to be kept clean by daily bathing or whilst showering, or by cleansing with soap and water and drying well afterwards.

Leg bags and catheter valves can be used by those assessed for suitability but some users of suprapubic catheters may find the Belly Bag more useful. These are available on prescription, see your Healthcare Professional for information.

Please see our additional resources for more information:

You can download our complete Catheter Care Guide here, or read our FAQ’s session with our very own Catheter Nurse.

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Urine Drainage Leg Bag Care

The Foley catheter is a tube that helps drain urine from the bladder. It is used by some patients who have had urological or gynecological surgery, or who have a condition that makes urination difficult.

The urinary (Foley) catheter is placed into the bladder through the urethra, the opening through which urine passes. The catheter is held in place in the bladder by a small, water-filled balloon. In order to collect the urine that drains through the catheter, the catheter is connected to a bag. It is either a regular (large bag) drainage bag or a small leg bag.

If you have a urinary (Foley) catheter, you will use the larger drainage bag at night while you are sleeping. You can use the leg bag during the day.

Attaching or removing a leg bag

The leg bag is attached to your leg and allows you to move around more easily. Because the bag is hidden under your clothes, it may also make you feel more comfortable about the catheter.

To attach or remove a leg bag, you will need the following materials:

• Clean leg bag(s).
• Leg straps or tape.
• Cotton balls and alcohol pads.
• White vinegar.
• Water and a towel.
• Regular (large) drainage bag.

To attach or remove the leg bag:

• Wash your hands with soap and water for 15 seconds.
• Empty the large drainage bag. The different types of drainage bags open in different ways: a drain spout that you remove from its sleeve, a clamp that you open to the side, or an opening that you twist. Whichever method you use, be sure to not touch the tip when you let the urine flow out of the large drainage bag into the container or toilet.
• Place a towel under the connection between the catheter and the bag.
• Pinch off the soft rubber tube (the catheter tube) so that urine doesn’t leak out.
• Disconnect the urinary (Foley) catheter tube from the current large drainage bag with a twisting motion. Keep pinching the soft rubber tube (the catheter tube) so that urine does not leak out.
• Be careful not to pull on the catheter. Place the old large drainage bag on the towel.
• Prepare to place the leg bag in the catheter tube from which you just disconnected the large drainage bag. Remove the protective coating from the tip of the leg bag drainage tube. (Save this tip to use later when you change back). Clean the tip with an alcohol pad, wiping away from the opening to avoid getting the tube dirty. Insert the tip in the catheter tube.
• Fasten the straps of the leg bag to your thigh. Secure the catheter itself to your leg with tape. Be sure to leave some slack in the catheter so that you don’t put too much pressure on the bladder, urethra, and other parts of the body. Don’t fasten the straps on the leg bag too tightly to your leg, as that may interfere with your circulation. If the leg strap gets dirty, wash it with soap and water.

Emptying the leg bag

Please note that because a leg bag is smaller than a regular drainage bag, it will have to be emptied more frequently.

• Empty the leg bag when it is half-full, or at least twice a day.
• Place a large plastic or metal container on the floor next to you. You may also empty the urine into the toilet. The nurse may give you a container to use at home.
• Wash your hands with soap and water.
• The different types of drainage bags open in different ways: a drain spout that you remove from its sleeve, a clamp that you open to the side, or an opening that you twist. Whichever method you use, be sure to not touch the tip when you let the urine flow out of the urine bag into the container or toilet.
• When the bag is empty, close the clamp or twist on the cap on the leg bag.
• Wash your hands with soap and water.
• Write down how much urine was in your bag, if your caregivers have asked you to keep a record.

It is a good idea to occasionally change your leg bag from one leg to the other. The best time to do this is right after you shower.

Cleaning the bag

• When you are ready to go to sleep, change out the leg bag and put on the drainage bag. Rinse out the leg bag with 1 part vinegar and 3 parts water. Soak the bag for 20 minutes. Rinse the bag out with warm water and hang it up to dry.
• In the morning, take off the drainage bag, put on the leg bag, and clean out the drainage bag the same way.
• Clean your leg bag every day and replace it whenever your doctor tells you to. This is usually once a month.

Other care tips

• Drink plenty of liquids. You should drink at least 8 cups of healthy liquids a day, if your health care provider approves.
• Do not pull or tug on the tubing. This can cause bleeding and hurt the area in which the water-filled balloon is located.
• Do not step on the tubing when you are walking. Hold the tubing curled in your hand, with the urine bag below your bladder when you are walking. You may also want to clip or pin the tubing to your clothing.
• Arrange the catheter tubing so that it does not twist or loop. When you are getting into bed, hang the urine bag beside the bed. You can sleep in any position as long as the bedside bag is below your bladder. Do not place the urine bag on the floor.
• Always keep your urine bag below your bladder, which is at the level of your waist. This will prevent urine from flowing back into your bladder from the tubing and urine bag, which could cause an infection. Also, do not go to bed or take a long nap while wearing the leg bag.
• When you take a shower, you can keep the larger drainage bag in place and hang it on the rail in the shower area. You can also use a plug that is inserted in the place where the catheter connects to the drainage bag. Lay the drainage bag aside with a cover over the connection piece while you shower, and reconnect when you are done. It is important to put a cap on the end of the drainage bag tubing so it does not become contaminated.
• If you dislodge the catheter, it will stop draining or it will leak. Call your doctor if this happens. Leakage can happen from many things: dislodgement, bladder spasms, or blockage. In all cases, notify your doctor.
• Check the catheter and drainage tube on a regular basis to make sure the tube isn’t squeezed or tangled.

When should you contact your healthcare provider about your urine drainage bag?

Contact your healthcare provider if you have:

• Cloudy, foul-smelling urine.
• Red or pink urine, mean that there is blood in the urine.
• A fever greater than 101 degrees Fahrenheit.
• Pain or burning in your urethra, bladder or lower back.
• Swelling, draining, or redness in your urethra (the area where the Foley catheter leaves the body).

You should also contact your healthcare provider if no urine has drained from your catheter in six to eight hours or if your catheter is leaking.

Symptoms of a urinary tract infection may include:

• A need to urinate often.
• A painful, burning feeling in the area of the bladder or urethra while you are urinating.
• Nausea or vomiting.

You may also feel bad all over — tired, shaky, washed out —and feel pain even when you are not urinating. The urine itself may look milky or cloudy or even reddish if blood is present.

3 Types of Male Catheters and Their Uses

Are you searching where to buy male catheters? If you’re not sure where to start, take a look at our handy guide to go over the 3 main types of male catheters.

Whether you’re using catheters for urinary retention, benign prostatic hyperplasia (BPH), after prostate cancer treatment, or another medical condition, you have a world of catheter options available to you at 180 Medical. Plus, many insurance companies today will cover the use of sterile intermittent catheters.

Take a look at our helpful guide to learn more about the three main types of intermittent catheters for men here!

What are Male Intermittent Catheters?

First, let’s go over the basics. After all, what exactly are intermittent catheters?

A catheter is a thin flexible tube that you insert into the urethra or through a stoma to drain urine from the bladder. The term intermittent means that the catheter doesn’t stay in the bladder, like an indwelling (Foley) catheter does. Intermittent catheters drain urine, then you withdraw them and throw them away after each use.

While in the early days of the first catheter invention, people may have used metal or glass tubes to self-cath, current catheters are very different and way more comfortable. Most catheters come in sterilized, body-safe materials such as vinyl (PVC), silicone, POBE, or red rubber latex. Additionally, as technology continues to advance, catheters continue to become more comfortable and discreet.

Male Catheter Lengths

The male anatomy typically has a longer urethra than the female anatomy. That’s why male catheters (sometimes known as unisex catheters) are usually around 16 inches long on average.

However, many options today, including pocket catheters for men, come in shorter lengths. For example, the Coloplast SpeediCath Flex Coudé Pro Pocket Catheter clocks in at around 13 inches long. Its actual package size is compact and pocket-size in a dimension of 3″ by 7 1/4″, so it’s perfect for discreet carrying in public. Plus, it offers helpful and hygienic features such as a flexible insertion tip and a unique protective dry-sleeve, so you never directly touch the catheter tube.

Male Catheter French Sizes

Male length catheters come in many different French sizes to suit a wide variety of anatomies. What are French sizes? French size measurement is the way catheter tube diameters are sized.

Most male catheters, with the exception of certain red rubber catheters, follow the universal color-coding system, which helps you easily identify the French size of your intermittent catheter.

How do you know which French size will work best for you? Your urologist or another prescribing medical professional will be the one to help you determine the right French size to fit your unique anatomy.

For instance, if you use a smaller French size than needed, you may end up with a mess on your hands as urine seeps around the sides of the tube. Also, it will drain much more slowly.

On the other hand, a larger French size than necessary may make catheterization feel uncomfortable or even painful.

The right French size for your anatomy will drain efficiently while keeping catheterization comfortable. So be sure to discuss your catheter size options with your healthcare professional.

Male Catheter Insertion Tips: Straight and Coudé Tips

Next, you should know a little bit about the different types of catheter insertion tips available on all types of male catheters.

On average, most people tend to use the standard straight catheter tip. This is usually slightly tapered to aid in a more comfortable insertion, but straight catheters have no curve or bend in the tip.

Coudé tip catheters, however, feature a curve in the tip. In fact, coudé is a French word for “elbow” or “bend.” Some people may refer to coudé tip catheters as bent tip catheters or curved tip catheters.

Because some men have difficulty passing straight catheters, doctors may sometimes prescribe coudé catheters. The unique curve near the insertion tip of male coudé catheters helps aid catheter-users to bypass tight places like urethral strictures, enlarged prostates, or blockages in the urethral passage.

Learn more about the basics of coudé catheters here, including the different types of coudé catheter tips.

The Three Main Types of Male Catheters

Straight Male Catheters

Straight intermittent catheters are sometimes called uncoated catheters because they need manual lubrication before insertion. Most people use single-use packets of sterile lubricating jelly. Others prefer larger tubes of catheter lubricant, which we also provide at 180 Medical.

Straight catheters, like all types of male catheters, may also be available to you as pocket catheters. Straight pocket catheters typically come in a curved or U-shaped package, which you can discreetly tuck into your pocket, bag, or briefcase for easy carrying.

Pre-lubricated and Hydrophilic Male Catheters

Hydrophilic male catheters are similar to straight catheters, except for one unique feature: their hydrophilic coating. This coating, when activated by water, becomes a sort of high-tech lubrication. In other words, it gets super slippery for a more comfortable and smoother catheterization from beginning to end.

Some types of male hydrophilic catheters require manual activation of the hydrophilic coating by an included water packet, such as the popular GentleCath Glide Male Catheter. The GentleCath Glide is also available in both straight and coudé tip.

The GentleCath Glide is available in straight tip and coudé tip.

Some hydrophilic catheters are pre-hydrated and ready to use as soon as you open the package, such as the Bard Magic3 GO Male Catheter. Just take it out of its packaging, and it’s ready to go when you are.

Just like hydrophilic catheters, pre-lubricated male catheters don’t require additional lubricating jelly. Pre-lubricated catheters come ready to use as soon as you open the packaging.

Most pre-lubricated and hydrophilic intermittent catheters offer a no-touch handling sleeve in their packaging to allow the user to more easily handle the catheter without touching the tube itself. This reduces the risk of bacterial contamination from your hands.

Benefits of Hydrophilic Catheters

• Less mess
• Easy to use
• Touchless catheterization for reduced risk of infection
• Easy carrying and traveling

Male Closed System Catheters

A closed system catheter, which is also known as a touchless or no-touch catheter, features a pre-lubricated or hydrophilic male length catheter housed in its own self-contained sterile collection bag.  This makes it great for traveling. Also, people in wheelchairs often prefer closed system catheter kits because they don’t have to transfer to a toilet or find a receptacle to drain into. With a closed system catheter, you can self-catheterize anywhere you have privacy.

One new and popular option is the Hollister VaPro Plus Touch-Free Male Catheter, which has its own integrated collection bag and a protective touch-free sleeve.

Sometimes closed system catheter kits have catheter insertion supplies such as gloves, an underpad, and an antiseptic wipe. Most closed systems also feature soft pre-lubricated introducer tips to further reduce the risk of bacterial contamination.

At 180 Medical, we specialize in intermittent catheters, and we carry all the major catheter brands and types, including pocket catheters for men (available in straight, coudé, hydrophilic, and closed system catheter options).

When you choose 180 Medical, you have the option to try free male catheter samples that might work best for you from a wide variety of brands.

Request Free Samples

Alternative Types of Male Catheters

There are two other male catheter options, depending on your condition and needs. 180 Medical provides these catheter types when prescribed in addition to intermittent catheters.

Indwelling Foley Catheters

Indwelling Foley catheters are mainly for long-term use. A doctor or nurse will handle inserting the catheter for you. To keep it from slipping out, they inflate a small balloon near the insertion tip to hold it in place in the bladder. Next, the Foley catheter allows urine to drain throughout the day into an attached collection device like a urinal, leg bag, or drain bag.

Since Foley catheters remain inside the body for long periods, the risk of urinary tract infections may increase. However, indwelling catheters may be the right choice for people who are unable to self-cath.

Male External Catheters

External catheters, also called Texas catheters or condom catheters, fit over the penis like a condom. Skin-friendly adhesive or soft straps hold external catheters in place. Drain bags or leg bags easily connect to collect urine throughout the day.

Men who use condom catheters usually wear one for no longer than a day or two at a time. Maintaining proper hygiene and changing your external catheters regularly will help minimize the possible risk of skin irritation or infections.

How to Catheterize Using a Male Catheter

We want you to feel confident and comfortable as you learn to self-cath. That’s why we provide easy online instructions for how to catheterize at www.howtocath.com.

Our helpful self-catheterization instructions include options for all of the above types of catheters, including straight intermittent male length catheters, coudé catheters, closed system catheters, and hydrophilic catheters.

In addition, we can provide step-by-step catheterization instructions like full-color brochures and DVDs in your order.

What Type of Catheter for Men is Best?

When it comes to catheters, no single type or size works for everyone. That’s why we suggest talking to your doctor about your needs. They can assess your condition and recommend what may work best for you.

Our Product Specialists are also more than happy to help you find the right intermittent catheter for you! As true experts in the catheter industry, we’re glad to be a trusted resource and support system as you determine what kind of male catheter product works best for your individual needs.

Contact us today or give us a call at 1-877-688-2729. We’d love the opportunity to discuss male catheters with you!

Urinary catheterisation – Tests & treatments

It’s possible to live a relatively normal life with a long-term urinary catheter, although it may take some getting used to at first.

Before being discharged from hospital, a specialist nurse will give you detailed advice about looking after your catheter.

Catheter equipment

You will be given a supply of equipment to take with you when leaving hospital, and told where to get further supplies in the future. In most cases, catheter equipment is available on prescription from pharmacies.

You will also be shown how to empty and change your equipment.

Self-catheterisation

If you have been taught to use intermittent catheters, you should insert them several times a day to drain urine into a toilet or bag. These catheters are usually designed to be used once and then thrown away.

How often intermittent catheters need to be used differs from person to person. You may be advised to use them at regular intervals spaced evenly throughout the day, or only when you feel you need the toilet.

Indwelling catheters

Indwelling catheters can either drain into a bag attached to your leg, which has a tap on the bottom so it can be emptied, or they can be emptied into the toilet or suitable receptacle directly using a valve.

Bags should be emptied before they become completely full (around half to three-quarters full). Valves should be used to drain urine at regular intervals throughout the day to prevent urine building up in the bladder.

Both bags and valves should be replaced and thrown away about every 5 to 7 days.

At night, you will need to attach a larger bag to your valve or regular bag. This should be placed on a stand next to your bed, near the floor, to collect urine as you sleep. Depending on the type of night bag you have, it may need to be thrown away in the morning or it may be emptied, cleaned and reused for up to a week.

The catheter itself will need to be removed and replaced at least every 3 months. This will usually be done by a doctor or nurse, although sometimes it may be possible to teach you or your carer to do it.

Preventing infections and other complications

Having a long-term urinary catheter increases your risk of developing urinary tract infections (UTIs), and can also lead to other problems, such as blockages.

You will be advised about measures to take to minimise these risks, such as:

• regularly washing your hands, body and catheter with warm water and soap – it’s particularly important to clean your hands before and after touching your equipment
• ensuring you stay well hydrated – you should aim to drink enough fluids so that your urine stays pale
• preventing constipation – staying hydrated can help with this, as can eating high-fibre foods such as fruits, vegetables and wholegrain foods
• avoiding kinks in the catheter and making sure any urine collection bags are kept below the level of your bladder at all times

Read more about the risks of urinary catheterisation.

Your regular activities

Having a urinary catheter shouldn’t stop you from doing most of your normal activities. You will be advised about when it is safe for you to go to work, exercise, go swimming, go on holidays, and have sex.

If you have an intermittent or suprapubic (inserted through your tummy) catheter, you should be able to have sex as normal.

Indwelling catheters can be more problematic, but it’s still usually possible to have sex with them in place. For example, men can fold the catheter along the base of their penis and cover them both with a condom.

In some cases, you may be taught how to remove and replace the catheter so you can have sex more easily.

When to seek medical advice

You should contact a district nurse or nurse practitioner (you may be given a phone number to call before discharge from hospital) or your GP if:

• you develop severe or persistent bladder spasms (similar to stomach cramps)
• your catheter is blocked, or urine is leaking around the edges
• you have persistent blood in your urine, or are passing large clots
• you have symptoms of a UTI, such as pain, a high temperature (fever) and chills
• your catheter falls out (if it’s indwelling and you haven’t been taught how to replace it)

If your catheter falls out and you can’t contact a doctor or nurse immediately, go to your nearest accident and emergency (A&E) department.

Support groups and further information

Living with a catheter can be a challenge and you may find it useful to seek more information and advice from support groups and other organisations.

history, current status, adverse events and research agenda

J Med Eng Technol. 2015 Nov 17; 39(8): 459–470.

Roger C. L. Feneley

^aNorth Bristol NHS Foundation Trust, Southmead Hospital, Southmead Road,
Bristol BS10 5NB,
UK

Ian B. Hopley

^bAlternative Urological Catheter Systems Ltd, Bramford House, 23 Westfield Park,
Bristol BS6 6LT,
UK

Peter N. T. Wells

^cCardiff University, School of Engineering, Queen’s Buildings,
The Parade, Cardiff CF24 3AA,
UK

^aNorth Bristol NHS Foundation Trust, Southmead Hospital, Southmead Road,
Bristol BS10 5NB,
UK

^bAlternative Urological Catheter Systems Ltd, Bramford House, 23 Westfield Park,
Bristol BS6 6LT,
UK

^cCardiff University, School of Engineering, Queen’s Buildings,
The Parade, Cardiff CF24 3AA,
UK

Received 2015 Jun 13; Revised 2015 Aug 11; Accepted 2015 Aug 18.

Copyright © 2015 The Author(s). Published by Taylor & Francis.This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/Licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.This article has been cited by other articles in PMC.

Abstract

For more than 3500 years, urinary catheters have been used to drain the bladder when it fails to empty. For people with impaired bladder function and for whom the method is feasible, clean intermittent self-catheterization is the optimal procedure. For those who require an indwelling catheter, whether short- or long-term, the self-retaining Foley catheter is invariably used, as it has been since its introduction nearly 80 years ago, despite the fact that this catheter can cause bacterial colonization, recurrent and chronic infections, bladder stones and septicaemia, damage to the kidneys, the bladder and the urethra, and contribute to the development of antibiotic resistance. In terms of medical, social and economic resources, the burden of urinary retention and incontinence, aggravated by the use of the Foley catheter, is huge. In the UK, the harm resulting from the use of the Foley catheter costs the National Health Service between £1.0–2.5 billion and accounts for ∼2100 deaths per year. Therefore, there is an urgent need for the development of an alternative indwelling catheter system. The research agenda is for the new catheter to be easy and safe to insert, either urethrally or suprapubically, to be retained reliably in the bladder and to be withdrawn easily and safely when necessary, to mimic natural physiology by filling at low pressure and emptying completely without damage to the bladder, and to have control mechanisms appropriate for all users.

Keywords: Urinary catheters, adverse events, infection, biomaterials, research agenda

1. A brief history of the development of the urinary catheter

The word catheter is derived from the ancient Greek kathiénai, which literally means “to thrust into” or “to send down”.

The main events in the chronology of the recorded development of the urinary catheter are identified in . Before the widespread introduction of the Foley catheter [14] in the 1930s, catheterization was almost exclusively for the treatment of urinary retention in the male. The early catheters (some examples are shown in ) were usually rigid and they were designed—to the extent that they were designed at all—for intermittent catheterization. shows what was involved, although most sufferers presumably would have preferred a greater degree of privacy. Urinary retention was—and is—rare in women. Urinary incontinence was not a medical emergency: it was left as a personal embarrassment for men and women alike, who generally adopted their own idiosyncratic methods of coping with the disability. The indwelling Foley catheter, however, made both short- and long-term catheterization feasible for both males and females and this opened up a new era in the management of urinary retention and incontinence. It also opened up a Pandora’s box of medical conditions and adverse events.

Tubular silver catheters devised by Ambroise Paré (1510–1590), with long gentle curves (they are known as coudé catheters) to permit easier insertion [8].

Urinary catheterization in the middle ages [17].

Table 1.

Some important events in the history of the development of the urinary catheter.

2. Bladder function and catheterization

The urinary tract system () produces, stores and excretes urine from the body. In the adult, under normal conditions of hydration and temperature, the kidneys continuously filter the blood to produce ∼1 ml of urine per minute, equivalent to ∼1500 ml per day. Urine from the kidneys is transported via the ureters to the bladder. The capacity of the bladder is variable: a healthy bladder can normally hold 350–500 ml. Three sets of muscles control the flow of urine from the bladder via the urethra. The internal sphincter is formed by the involuntary smooth muscle of the bladder wall, located at the base of the bladder where it joins the urethra. The external sphincter which surrounds the proximal part of the urethra is formed by striated muscle and is, thus, under voluntary control. Third, the pelvic floor muscles act as a sling to support the bladder and urethra and provide additional control. Urine flow is initiated by the voluntary relaxation of the external sphincter muscle which, by reflex action, triggers contraction of the bladder muscle and opening of the internal sphincter.

In the normal urinary tract, the regular flushing of the urethra as the bladder empties helps to impede the ascending infection of the tract by the bacteria that normally colonize the periurethral skin. Any bacteria that manage to migrate into the bladder are also washed out during micturition. In addition, the bladder is lined by urothelial cells coated with a glycosaminoglycan mucin, which provides a surface resistant to the adherence of bacteria. Bacterial adherence, when it does occur, initiates invasion of the urothelium. This activates microbial-sensing proteins in the superficial umbrella cells, triggering the host defences with a cascade of cellular and molecular effectors to eliminate the bacteria [18].

In people with impaired bladder function, whether retention or incontinence, a safe and reliable system is required to collect and contain the urine, whether for short- or long-term use.

In those males and females for whom the method is feasible, clean intermittent self-catheterization is the optimal procedure to manage urinary retention [19]. This mimics normal bladder function, allowing the bladder to fill and periodically to empty completely, thus minimizing the risk of infection. Although some find the procedure uncomfortable and distasteful, with practice clean intermittent self-catheterization is usually quite easy to perform. Whilst observing a high standard of cleanliness, the patient inserts a flexible catheter (typically a plastic tube, with drainage eyes adjacent to its rounded closed tip) into the urethra until urine starts to flow, drains the urine directly into a toilet bowl or into a suitable container for later disposal and withdraws the catheter when the flow ceases. The procedure needs to be repeated six or seven times a day, depending on the volume of residual urine. In the UK, catheters tend to be used only once, but randomized controlled trials are being undertaken to assess whether multiple uses of the same catheter might be acceptable. In a study of 172 adults (68 male, 104 female), seven were unable or unwilling to adopt the technique, but, for the remainder, the mean infection rate was only one per 14 patient-months [20].

In patients for whom clean intermittent self-catheterization is not possible, an indwelling catheter has to be used. Depending on the clinical indication, the duration of catheterization may be short- or long-term. A long-term urinary catheter is defined as one that is in place for more than 30 days.

For male patients with urinary incontinence, one possibility for short- or long-term use is the external or condom catheter. This consists of a sheath that fits snuggly over the penis and which has a tube at its tip to transport urine to a collection bag, which may be strapped to the leg and emptied periodically. Although this is superficially an attractive approach, it does have several significant disadvantages. Up to 40% of condom catheter users develop urinary tract infections [21], 15% suffer from inflammation, ulceration, necrosis, gangrene or constriction of the skin of the penis [22] and there is the ever-present risk of detachment of the condom and urine leakage. Moreover, the nursing time required for condom catheter care is considerable [23]. In summary, the condom catheter is far from satisfactory in the management of male urinary incontinence; it does, however, have a useful application in the non-invasive measurement of bladder pressure [24].

The eponymous indwelling balloon-retained catheter () now in worldwide use was conceived by the American urologist Frederic Foley nearly 80 years ago to provide continuous urinary drainage and to control bleeding while haemostasis occurs, following transurethral prostatectomy [14]. It soon became apparent, however, that the use of the Foley catheter was a solution to the general problems of urinary retention and incontinence. From the outset, buckets or open flasks were used for urine collection: it was not until the 1960s that a bag that could be strapped to the patient’s leg was introduced as an hygienic and more aesthetically acceptable alternative.

A typical Foley catheter. This catheter is size 16 Fr. Its overall length is ∼400 mm and the volume of the fully-inflated balloon is ∼10 ml. The catheter has two channels. When the catheter has been inserted, the retaining balloon is inflated with sterile water from a syringe via the inflation connector and one of the channels. The inflation connector incorporates a valve to prevent the sterile water from escaping when the syringe is detached. The other channel allows the free flow of urine from the drainage eye to the drainage funnel. To remove the catheter, the retaining balloon is first deflated by withdrawing the water from it with a syringe, which opens the valve in the inflation connector when it is attached.

The design of the Foley catheter is simple. As shown in , the catheter typically has two channels, the drainage channel for the passage of urine and the inflation channel, to allow the balloon at the end of the catheter to be inflated with sterile water from a syringe, to retain the catheter within the bladder. The smooth rounded tip of the catheter extends beyond the balloon and one or more eye-holes are cut in the tube adjacent to the tip to allow urine to drain. Were it not for its complications (discussed in Section 4), it would often be desirable for a Foley catheter to be able to be in place for up to ∼12 weeks before the possibility of mechanical failure of the balloon would dictate its replacement.

The principal reasons for indwelling catheterization are as follows:

1. to permit urinary drainage in patients with neurological conditions which cause bladder dysfunction;

2. to manage urinary incontinence in patients lacking cognitive function;

3. to minimize skin breakdown and pressure ulcers in paralysed, comatose or terminally ill patients;

4. to irrigate the bladder;

5. to administer chemotherapy;

6. to aid in urological surgery or other surgery on contiguous structures;

7. to obtain accurate measurements of urinary output in critically ill or post-operative patients;

8. to empty the bladder during childbirth; and

9. to undertake urodynamic studies (such as pressure measurements).

Of these, (a), (b) and (c) are likely to be for long-term catheterization.

Bladder drainage may be performed by passing a Foley catheter through the natural urethral passage (termed transurethral catheterization) or by creating an artificial track between the lower abdominal wall and the bladder (suprapubic catheterization), as shown in . Transurethral catheterization is the simpler and safer approach. The female urethra is short, being ∼40 mm in length, muscular and straight. The male urethra is ∼160 mm long, more sensitive and curved, which can give rise to complications. Passage of a catheter can be painful and, in the male, the curvature of the urethra introduces a risk that its tip may cause damage [25]. Some designs of catheters are curved (coudé and bicoudé) to minimize this risk. The main problem with suprapubic catheterization is the risk of perforating the bowel on insertion of the guidance cannula [26]. Guidelines on minimizing morbidity associated with suprapubic catheter usage have been published by the British Association of Urological Surgeons [27].

The Foley catheter, introduced (a) Urethrally and (b) Suprapubically. In both cases, the bladder is shown to be draining continuously into a urine collection bag attached to the leg: this bag can be emptied when necessary by opening a valve. Alternatively, the bladder can be drained intermittently if a catheter valve is inserted into the drainage funnel of the catheter.

Catheter size is usually expressed in French gauge (Fr or FG = circumference in mm). The normal practice is to use the smallest catheter compatible with good drainage [28]: 12–16 Fr is usually adequate and only rarely is a catheter larger than 18 Fr necessary.

3. The modern Foley catheter

Foley’s original catheter was made of latex, the mechanical properties of which are ideal for this purpose: it has a high stretch ratio, a high level of resilience and it is extremely waterproof. The main problem with latex is its cytotoxicity: for instance, in the 1980s, an epidemic of severe urethral strictures was recorded in patients as the result of using latex catheters. The cause was traced to cellular toxicity due to eluates from rubber [29]. Latex catheters are now usually coated with silicone elastomer to reduce this risk [30]. Many modern catheters are made entirely of silicone elastomer and hydrophilic coatings are used to provide a slippery surface to reduce friction [31]. Silicone catheters are not only non-allergenic, but they also have superior resistance to kinking and better flow properties in comparison with latex catheters [32].

Emphasis has also been placed on the need for a smooth surface to the catheter and the drainage eyes [33]. Rough surfaces encourage the deposition of bacterial biofilm and sharp edges to the drainage eyes can cause bleeding from the urethral lining when the catheter is introduced or withdrawn.

Some catheter research over the last few years has focused on the development of antiseptic and antimicrobial coatings, with the aim of reducing the incidence of catheter-associated urinary tract infections [34], so far with negligible success [35] (see also Section 6d). Thus, a randomized controlled trial performed to compare the ability and cost-effectiveness of an antiseptic- and antimicrobial-impregnated catheter vs a standard coated catheter to minimize the risk of catheter-associated urinary tract infection revealed no evidence of benefit [36]. Indeed, in an earlier randomized clinical trial, infection actually increased with a silver-impregnated catheter [37].

Some Foley catheters have a third channel, which can be used to infuse saline or other irrigating fluid into the bladder: this may be useful when there is a likelihood that blood clots may form in the bladder, perhaps as the result of post-operative bleeding. There is also a commercially-available catheter that has two balloons at the end of the catheter. The balloon at the tip is intended to reduce the risk of trauma to the urothelium; the drainage eyes perforate a short section of catheter between the two balloons, the proximal of which serves as the retention device. A possible disadvantage of the dual-balloon catheter is that it may trap more urine in the bladder at the end of drainage, thus increasing the risk of bladder infection.

4. Adverse events caused by the Foley catheter

In an editorial in the New England Journal of Medicine in 1988, the American physician, Calvin M. Kunin, published a comprehensive indictment of the Foley catheter, 51 years after its introduction into clinical practice [38]. Having acknowledged that the Foley catheter is indispensable in modern clinical practice to provide temporary relief of urinary retention, a dry environment for incontinent or comatose patients and an accurate measurement of urinary output in those who are seriously ill, his intervention added momentum to the publication of major contributions covering virtually every aspect of the subject.

An adverse event is defined as “any untoward medical occurrence, unintended disease or injury or any untoward clinical signs in subjects, users or other persons”[39]. For an adverse event to be considered to be serious, it should either: have led to a death; or have led to a serious deterioration in health that either resulted in life-threatening illness or injury or permanent impairment of a body structure or body function, or required in-patient hospitalization or prolongation of existing hospitalization or resulted in medical or surgical intervention to prevent life-threatening illness or injury or permanent impairment of a body structure or a body function; or led to foetal distress, foetal death or a congenital abnormality or birth defect [39]. The principal adverse events—some of which are serious—for which the Foley catheter is responsible are as follows:

4.1. Bacterial colonization

The flow of urine through an indwelling catheter may be continuous or intermittent. The introduction of a Foley catheter without a valve results in continuous drainage and, thereby, suppresses the normal process by which the build-up of bacteria is inhibited by periodic flushing. Periodic flushing is usually facilitated by a manually-operated pinch or rotary valve. It can also be provided by “tidal drainage”, which allows the bladder to fill and empty automatically [40]. By raising the height of the drainage tubing leading from the catheter to a few centimetres above the level of the bladder, the bladder fills to the corresponding hydrostatic pressure before a syphon is formed that empties the bladder, after which the cycle is repeated. In a series of 33 patients with neurologically-damaged bladders following spinal cord injuries, tidal drainage reduced the rate of infection from 73% to 15% [41]. Although this is a marked improvement and urethral damage can be avoided by suprapubic catheterization [42], tidal drainage is seldom used nowadays, possibly because of the level of nursing care required.

Bacteria can invade the bladder by migrating along the inside and the outside of the catheter. With short-term catheterization, the daily infection rate is ∼5% [16], so that ∼95% of catheterized patients suffer bacterial invasion after 1 month. Urinary tract infection necessitates the use of antibiotics, which are all too frequently untested against the specific bacteria and consequently often prove to be ineffective until the right one is found by a process of trial and error. This adds to the cost of clinical management, as well as being a burden for patients and carers.

4.2. Antibiotic resistance

The use of antibiotics to control catheter-induced infections contributes significantly to the development of resistant strains, about which the World Health Organization (WHO) has expressed grave concern [43]. The WHO referred in particular to seven bacteria: the first of these, Escherichia coli, is strongly associated with urinary tract infections. In five out of the six WHO regions, it was found that the antimicrobial drugs that were used failed in 50% or more of the cases investigated. The second bacterium in the list, Klebsiella pneumonia, which is also found in urinary tract infections, was similarly resistant. In view of the increasingly serious threat to global public health identified by the WHO, the present pervasive lack of interest in research aimed at finding a better alternative to the Foley catheter is both disturbing and inexcusable.

4.3. Chronic infection

The balloon of the Foley catheter occupies the base of the bladder, obstructing the internal urethral orifice, with the result that 10–100 ml of urine remains in the bladder when its flow has ceased [44]. This sump of residual urine is likely to be infected, so that uninfected urine descending from the kidneys will also rapidly become infected, resulting in chronic infection of the bladder.

4.4. Kidney and bladder damage

Invasion of the bladder by urease-producing bacteria, particularly Proteus mirabilis, results in the conversion of urea in the urine into ammonia [35]. The consequential increase in the alkalinity of the urine causes phosphates to nucleate out of solution, forming crystals of struvite (magnesium ammonium phosphate) and hydroxyapatite (an hydroxylated form of calcium phosphate in which some of the phosphate groups are replaced by carbonate). Increasing fluid intake with citrate-containing drinks increases the pH at which crystals form in the urine [45] and there is evidence [46,47] that this could be used to control the rate at which catheter encrustation occurs.

The nucleation of struvite and hydroxyapatite crystals on the biofilm on the catheter resulting from the activity of the bacterial urease causes encrustation to form around and within the catheter, blocking the drainage eyes and the lumen and preventing the flow of urine (). This is a medical emergency that not only can be excruciatingly painful for the patient, but that also and more importantly requires a rapid response (usually the replacement of the blocked catheter) if permanent damage to the bladder and the kidneys (due to ureteric reflux) caused by the high bladder pressure is to be avoided. These problems are exacerbated if associated with bladder spasm [48]. Moreover, it is apparent that some patients are more likely to block their catheters than others [49] (blockers tend to have urine that is more alkaline, which is consistent with other observations).

A section through a Foley catheter that has become blocked during use by the formation of struvite. The smaller patent lumen is the channel for the inflation and deflation of the retaining balloon. The length of the scale bar is 1 mm.

It has been reported that, in cases of Proteus mirabilis infection, the necessity for antibiotics might be avoided by adding the biocide triclosan to the sterile water used to inflate the balloon of the Foley catheter. This appears to prevent the rise in urinary pH that drives biofilm formation and catheter blockage [50], presumably by leaching into the urine. It is disappointing, however, that exposure to triclosan has also been shown to encourage the development of resistant strains of Proteus mirabilis, so this does not hold out much promise as a long-term solution [51].

4.5. Bladder stones

The crystals of struvite resulting from Proteus mirabilis infection act as nuclei for stone formation within the bladder [52]. Bladder stones entrap Proteus mirabilis bacteria and, thus, maintain the infection. Recurrent blockage of a catheter raises a high suspicion that bladder stones may be present. Endoscopic transurethral techniques are used to remove bladder stones: fragmentation by crushing (litholapaxy), shock-wave ultrasound or laser probes may be required to break them into particles small enough to be washed out of the bladder through the urethra.

4.6. Pseudopolyps

Insertion into the urethra of a hard unyielding catheter, with its balloon and its protruding tip perforated by drainage eyes, transforms the natural process of intermittent drainage. When the drainage valve at the distal end of the catheter is opened, the low viscous drag of the catheter allows the urine to flow rapidly, driven by both the collapsing bladder and the negative pressure of the hydrostatic column to the open end of the catheter. Towards the end of the drainage process, when the bladder wall comes into what is frequently traumatic contact with the tip of the catheter, the mucosal lining can be sucked into the drainage eye [53]. Patients may experience a sharp pain at this stage, sometimes accompanied by “stuttering” when the urine flow momentarily ceases as the result of the bladder wall being sucked into the drainage eye and then released. This suction can result in the formation of haemorrhagic pseudopolyps, with cumulative damage [54].

4.7. Septicaemia

The physical trauma caused by the catheter tip and the suction at the drainage eyes can damage the normally impermeable bacterial barrier provided by the urothelial lining of the bladder (see Section 4.6). This provides direct access for bacteria into the bladder wall and the bloodstream (bacteraemia), with a high risk of septicaemia. Moreover, reflux of infected urine via the ureters can lead to renal infection (pyelonephritis) and septicaemia. If inadequately treated, septicaemia can prove to be fatal [55].

4.8. Urethral trauma

The process of inserting the catheter requires skill and practice, if urethral trauma is to be avoided [56]. One of the problems with indwelling catheters with silicone balloons is that, when the water is removed from the balloon with a syringe prior to catheter withdrawal, a phenomenon known as creep may cause the balloon to fail to collapse completely. This may result in a small rim that can make it difficult or impossible to to remove the catheter [57]. (This presents a particular problem in the case of suprapubic catheters because these pass through a rigid fibrous track into the bladder, rather than through the urethra with its more elastic muscular walls.) Even more serious damage can occur if the catheter is deliberately pulled out when the balloon is still inflated, as can be done by disorientated or demented patients. In women with neurological conditions such as multiple sclerosis, the catheter can be expelled spontaneously by a sudden inappropriate contraction of the bladder. Under these circumstances, the urethra is dilated by the balloon and, if frequently repeated, the sphincter mechanism may become incompetent.

4.9. Balloon fragments

There is the risk that the catheter balloon may burst, either during insertion or withdrawal (particularly by a demented or disorientated patient) or when it is indwelling [58]. If this should happen, the fragments must be removed, usually with the aid of a cystoscope, as otherwise they can lead to stone formation or catheter blockage.

4.10. Commentary

Several of these adverse events are demonstrated in a video presentation that can be accessed via the internet [59].

It is axiomatic that the incidence of catheter-associated urinary tract infections can be reduced by reducing unnecessary catheter use. There have been numerous studies aimed at achieving this worthy objective. In reviews of these studies [60,61], two effective strategies have been identified. First, unnecessary placement of indwelling catheters should be avoided by imposing protocols including, for instance, a requirement to confirm by ultrasonic scanning that urine is being retained in the bladder [62]. There are semi-automated scanners designed for this purpose, but they are not without their shortcomings [63]. Second, there should be a system to remind the medical and nursing staff to be aware of the catheter’s existence, perhaps by means of a daily checklist, to prompt its removal when no longer necessary. This simple expedient can have a significant impact.

The achievable goal of the implementation of these two strategies is typically to reduce the rates of catheter-associated infections by 25% [60]. These strategies are already being implemented in many hospitals but, even if they were universally followed, the Foley catheter would still have to remain in widespread use.

5. The scale of the burden of urinary incontinence

5.1. Overview

Data from 2006–2007 reveal that ∼1.3 million people in England sought help for incontinence problems. The number had risen to 2.3 million in 2010–2011. Urinary incontinence increases with age from 14% in individuals aged 65–69 years to 45% in those aged 85 years or over [64]. The care of older and disabled people in an ageing population presents a major challenge: the management of bladder (and bowel) function is fundamental to the standard of care that they receive. It is difficult or impossible for those affected to maintain a reasonable quality-of-life and urinary incontinence is a major reason for sufferers to seek residential care [65].

In a study of 430 new admissions to nursing homes in the US, 39% of patients aged 65 years or over suffered from daytime urinary incontinence [66]. In this setting, catheterization is only recommended as a last resort, because of its high incidence of urinary tract infections. Elderly patients are managed by using incontinence pads, but immobile patients lying on wet pads develop pressure sores. Choosing the lesser of two evils, the development of a pressure sore is accepted as an indication for catheterization.

In England, Wales and Northern Ireland (and there is no reason to suppose that the situation is significantly different in Scotland), indwelling Foley catheters are used by 3% of people living in the community and 13% of care home residents [67].

5.2. Incidence of adverse events

It is a profoundly disturbing statistic that healthcare-associated urinary tract infections are estimated to have caused 13 088 deaths in hospitals in the US in 2002 [68]. Assuming that 80% of these were due to catheter-induced infections [16], that equates to 10 470 deaths. The population of the US is 4.98-times that of the UK, so the corresponding annual number of deaths in the UK is probably at least 2100.

In a postal survey to determine the incidence and morbidity of long-term catheterization in a typical National Health Service setting [69], there were 506 referrals from a cohort of 457 patients over a 6-months period. From these referrals, 54 patients were selected for detailed study: 48% experienced catheter blockage, 37% reported urine by-passing the catheter and 30% noted haematuria.

Catheter-associated urinary tract infections not only place heavy demands on healthcare resources, but their treatment also raises profound concern regarding the development of antimicrobial resistance and they cause immense distress and social problems for the sufferers, their carers and their communities.

5.3. Economic implications

A rigorous analysis of economic costs of urinary retention, incontinence and catheterization is beyond the scope of this review. It may be helpful, however, to give some insight into the orders of magnitude involved, as follows:

In 2008, the world market for urinary continence care devices of all kinds (mainly catheters and pads) was estimated to be US$1.8 billion per year, growing at ∼7% per year; of this, Foley catheters accounted for ∼US$380 million in 2007 [70]. The costs of the relevant devices are, however, small in relation to those of the clinical and societal consequences of incontinence and retention and its management by long-term catheterization. In the US in 2002, urinary tract infections were responsible for over 7 million physician visits; they accounted for more than 100 000 hospital admissions, mostly for pyelonephritis; and the direct and indirect costs associated with community-acquired urinary tract infections exceeded an estimated US$1.6 billion [71]. In 1997, ∼15% of all community-prescribed antibiotics in Germany were dispensed for urinary tract infections, at an estimated cost of over US$1 billion [72]. In 1991, it was estimated that an episode of nosocomial bacteriuria added US$500–1000 to the direct cost of acute-care hospitalization [73].

The use of incontinence pads could be greatly reduced if there were a satisfactory alternative to the Foley catheter. In addition to the fact that the use of pads is difficult or impossible to conceal, thus tending to make sufferers socially reclusive, there is the further problem of progressive deterioration of the condition of their skin. Unless pads are changed so frequently that the skin is kept dry, it tends to become macerated, leading to pressure sores and, with repeated drenching, the problem becomes chronic and unmanageable. The cost of pads to the NHS in England increased from £77 million in 2006/2007 to £121 million in 2010/2011, so that their use has begun to be restricted. Until 2013, the allocation was based on clinical need. Now it is often based on financial considerations and, as a result, the allowance per patient can be as few as four disposable continence products in 24 h [64]. This rationing perversely ignores the downstream costs of treating the resulting increase in the incidence of pressure ulcers, many of which are due to the use of pads and which, in the UK, was already between £1.4–£2.1 billion annually in 2004, accounting for 4% of total NHS expenditure [74].

Clearly it is impossible to make a simple and accurate calculation of the financial cost attributable to catheter-associated urinary tract infections. According to hospital episode statistics, there were 281 296 finished consultant episodes of serious adverse events related to urinary tract infections in National Health Service hospitals (and private hospitals undertaking work for the NHS) in England and Wales in 2012–2013 [75]. It is reasonable to assume that 80% of these episodes (225,036) were due to catheter-induced infections [16]. Data for 2001 show that infected patients, on average, incurred UK hospital costs 2.9-times higher than uninfected patients, at that time equal to an additional £3154 per patient [76]. Between 2001–2014, the UK consumer price index increased by a factor of 1.48 [77]. Admittedly this may not be a very good index of healthcare cost inflation, but no better measure seems to be available. Thus, the additional UK National Health Service cost of each catheter-associated urinary tract infection must be in the order of £4600 so, by this calculation, the total annual cost of all episodes must be at least £1.0 billion.

Data for Scotland in 1999 [78] gave an estimated £125 million as the additional annual cost of treating catheter-associated urinary tract infections. Scotland accounts for ∼8% of the UK population and financial inflation from 1999 to 2015 was ∼55%. This calculation indicates that the total current UK cost of catheter-associated urinary tract infections is ∼£2.5 billion per year.

Thus, it can be concluded that the annual total additional UK cost of catheter-associated urinary tract infections probably now lies somewhere between £1.0–£2.5 billion.

For the US, it was recently estimated that healthcare-acquired infections account for nearly US$45 billion per year in direct hospital costs [79]. Assuming that 80% were due to catheter-induced infections [16], the total annual cost must be ∼US$36 billion.

Prior to 1 October 2008, hospitals in the US were able to recover additional payment to compensate for the extra cost of treatment of catheter-associated urinary tract infections. Then the Medicare rule was changed and reimbursement for this was stopped [80]. Whether or not this was justified, the rationale was that catheter-associated urinary tract infection could reasonably be prevented through the application of evidence-based guidelines. Whatever the other effects of this change in the rule have been, however, it is perhaps surprising that it does not seem yet to have been seen as an incentive to develop a better catheter.

Of course, the availability of a better catheter would not completely eliminate catheter-associated urinary tract infections but, even if only 50% of its potential could be achieved, the annual savings would be in the order of £500 million in the UK and US$18 billion in the US. Furthermore, over 1000 deaths would probably be avoided each year in the UK and over 5000 in the US.

6. Research agenda

It has rightly been said to be healthcare’s hidden scandal of neglect that the Foley catheter, a device originated in the 1930s and which is directly responsible for tremendous morbidity and significant mortality is still in routine long-term clinical use today [81].

In order to meet this challenge, an alternative indwelling catheter system must be developed. Taking into account the data presented in this review, as well as other analyses [82–84], the following research agenda can be proposed:

1. The catheter should be easy to insert and withdraw. This means that the catheter should be flexible and experience minimal friction with the urethra, possibly by the application of durable, lubricious, antibacterial and hydrophilic coating [85].

2. The catheter should be retained within the bladder. The mechanism of retention is arguably the pivotal aspect of design development. The balloon of the Foley catheter provides a retention force between 9–41 N, depending on the balloon inflation volume [86], which normally provides satisfactory retention, but it is associated with many problems (mainly incomplete urinary drainage, bladder and urethral damage), so a novel approach is essential.

3. The catheter should allow the bladder to fill at low pressure and to empty completely, mimicking the natural physiology and without damage to the urothelial lining of the bladder or the urethra. This “bioinspired” approach, based on the evidence of normal biological function, would surely minimize the occurrence of infection. For instance, an alternative to the balloon of the Foley catheter as a retention device should minimize the retained volume of urine. A catheter with numerous drainage eyes, extending from a suprapubic port to the urethral opening, could be retained suprapubically, with negligible volume within the bladder. A collapsible section in the catheter close to the end of the urethra or the suprapubic port could serve to restrict the rate of flow towards the end of drainage and, thus, to reduce the suction which otherwise could lead to pseudopolyps and other complications at the drainage eyes of the catheter. The catheter system should be able to minimize any increase in bladder pressure (such as that due to muscle spasm), to avoid damage to the kidneys. One possibility might be to provide an external reservoir to compensate for the reduction in the functional capacity of the bladder when it contracts during a spasm, with the urine flowing back into the bladder as it subsequently relaxes. Such a reservoir could also compensate for the reduction in the structural capacity of the bladder due to long-standing inflammation.

4. Catheter blockage is primarily the result of urinary infection and so the catheter should be resistant to encrustation by crystalline bacterial biofilm. Attempts to prevent catheter encrustation by impregnating the catheter surface with antimicrobial agents such as silver (see Section 3) have failed because of a lack of understanding of the encrustation process. Thus, it has been shown that, in patients infected with Proteus mirabilis, crystals generated in the alkaline urine rapidly cover the silver surface, protected from the underlying antibacterial agent [87,88]. The lesson here is clear: if antimicrobials are to be incorporated into catheters to prevent encrustation, they must diffuse from the catheter into the urine and, thus, prevent the bacteria from elevating the urinary pH. As a precautionary measure, a sensor might be used to predict imminent encrustation. Such a sensor already exists: strips of cellulose-acetate/bromothymol-blue polymer change their colour from yellow to dark blue when the pH of the urine increases due to the presence of Proteus mirabilis and this colour change has been shown reliably to occur some 12 days before catheter blockage [89]. Moreover, the incidence and severity of catheter encrustation and blockage could be expected to be reduced if the normal periodic drainage of the bladder were to be restored.

5. There should be an effective method for the safe insertion of the catheter by the suprapubic route. Ultrasonic guidance is satisfactory, but only when used by a trained practitioner [90], so this needs to be deskilled. An alternative is to construct a permanent continent suprapubic port by the Mitrofanoff [91] procedure, which involves the transplantation of the vermiform appendix and major surgery. In this context, there has been an attempt to use a plastic gastrostomy button as an alternative port [92]. Neither of these approaches is completely satisfactory; research into biomaterials with tissue-integrating surfaces or scaffolds must be worth exploring, aimed at developing a prosthetic suprapubic port suitable for intermittent or indwelling catheterization.

6. The catheter should have control mechanisms appropriate for all users, including those with loss of manual or cognitive abilities. A valve is needed to mimic the normal cyclical filling and emptying of the bladder. For users with manual dexterity and cognitive ability, this valve can be a simple tap, although a pinch valve is preferable because it eliminates the possibility of bacterial ingress. For people who cannot use a manual valve, an electrically-actuated valve is necessary, with pre-set timing for those for whom that is required: a prototype device already exists [93].

7. The intellectual property in the design of the catheter should be protected, as this will be the catalyst for its commercial manufacture, without which it cannot be introduced into clinical practice. The performance of the catheter will need to be tested in clinical trials and it will need to be shown to comply with the relevant medical device regulations. Rigorous cost-benefit analysis will also be needed to generate the data to justify the inevitably higher cost than that of the Foley catheter.

illustrates how some of these concepts, several of which are the subjects of patent applications [94–96], could be incorporated in a catheter system designed to meet the specifications of the research agenda.

A catheter incorporating some of the concepts in the research agenda. The catheter is retained by wings which spring open after insertion through the suprapubic tract to the bladder: this traps less urine than the balloon of a Foley catheter and the catheter can be withdrawn transurethrally after cutting through it at the external suprapubic port. Multiple drainage eyes in the section of the catheter within the bladder minimize the risk of the formation of pseudopolyps, and this risk is further reduced by a collapsible section (shown stippled) of the catheter situated close to the external meatus of the urethra. The elastic reservoir at the suprapubic end of the catheter and strapped to the abdominal wall expands to accommodate urine from the bladder during spasmodic bladder contraction and returns it to the bladder when it relaxes after the spasm, thus minimizing the possibility of kidney damage. Periodic drainage of the bladder into a leg bag is actuated by a pinch valve beyond the collapsible section of the catheter, under manual or timed automatic control.

7. Conclusions

Whilst it is true that the huge clinical, social and economic costs of the use of the Foley catheter for long-term urinary drainage have come into sharper focus since the publication of Kunin’s seminal paper in 1988 [38], it is regrettably also true that the scientific community, the relevant commercial companies and the regulatory authorities have largely failed to seek a solution. Perhaps the scientific community has not realized that there are significant interdisciplinary research challenges to be solved. The commercial companies probably see no reason to upset their business models with disruptive new technologies. The regulatory authorities apparently complacently neglect their responsibility to encourage innovation where existing devices are clearly inadequate.

This review ends with a research agenda for the achievement of safe long-term catheterization. The way forward is clear: now is the time for the research funders, the healthcare providers and the regulators to stimulate the scientific, engineering, commercial and clinical communities to meet the challenge.

Declaration of interest

R. C. L. Feneley is Emeritus Consultant Urologist at North Bristol NHS Foundation Trust; he and I. B. Hopley are Directors of Alternative Urological Catheter Systems Limited. P. N. T. Wells is Distinguished Research Professor at Cardiff University: he has no conflicts of interest to report.

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Tips From Other Journals – American Family Physician

Tips from Other Journals

Am Fam Physician. 2000 Sep 15;62(6):1397-1398.

Approximately 10 to 15 percent of patients admitted to the hospital receive a Foley catheter. Complications associated with the use of urinary catheters include infection, bladder spasms, catheter encrustations and retained catheters. The latter problem is rather common and presents a challenging problem for the family physician. Shapiro and colleagues present a case illustrating this problem and provide a review of the literature about managing retained Foley catheters caused by balloons that will not deflate.

The primary reason for the catheter balloon not deflating is malfunction of the inflation valve caused by external clamping, crushing or kinking of the inflation channel. The valve can also become obstructed by crystallization when nonsterile fluid is used to fill the balloon.

The first step in managing the nondeflating Foley balloon is to advance the catheter to ensure that it is actually in the bladder. If this does not work, the balloon port should be cut proximal to the inflation valve. This removes the valve and should allow the water to spontaneously drain. If this does not work, the area of obstruction is likely to be along the length of the catheter or at the entrance to the balloon.

The next maneuver is to pass a lubricated fine-gauge guidewire through the inflation channel. The guidewire or stylet should allow fluid to drain along the wire itself. If this does not work, a 22-gauge central venous catheter can be passed over the guidewire. When the catheter tip is into the balloon, the wire can be removed, and the balloon should drain.

If the above techniques are unsuccessful, the authors advise against hyperinflation with air or saline. This step may cause severe pain and could cause bladder rupture. Instead, it is recommended that the balloon be dissolved chemically. The literature cites the use of ether, chloroform, acetone and mineral oil as possible options. However, only mineral oil is recommended because the other compounds are potentially toxic to the bladder epithelium. About 10 mL of mineral oil may be injected through the inflation port and will dissolve the balloon within 15 minutes. If this does not occur, an additional 10 mL can be instilled. Overall, this technique has a reported 85 to 90 percent success rate.

The final methods described involve active rupture of the Foley balloon with a sharp instrument. In women, a transurethral approach can be used that involves applying continuous, steady pressure on the catheter that might cause part of it to show through the urethral meatus, followed by piercing the balloon with a lumbar needle. This technique is not recommended for use in men. Other approaches include transabdominal, transvaginal, transperineal and transrectal puncture of the catheter balloon. The authors recommend the transrectal approach in men, preferably with the use of transrectal sonography (see the accompanying figure).

View/Print Figure

Nondeflating urethral catheter balloon

FIGURE

Management algorithm for the nondeflating urethral catheter balloon.

Reprinted with permission from Shapiro AJ, Soderdahl DW, Stack RS, North JH Jr. Managing the nondeflating urethral catheter. J Am Board Fam Pract 2000;13:117.

Nondeflating urethral catheter balloon

FIGURE

Management algorithm for the nondeflating urethral catheter balloon.

Reprinted with permission from Shapiro AJ, Soderdahl DW, Stack RS, North JH Jr. Managing the nondeflating urethral catheter. J Am Board Fam Pract 2000;13:117.

If all of the above techniques fail, urology consultation for an endoscopic balloon puncture is recommended. The catheter can be cut at the meatus and pushed into the bladder. This is followed by cystoscopic puncture with a needle and subsequent retrieval with the scope. Urologic consultation is also recommended for any case of suspected balloon rupture because cystoscopy will need to be performed to remove any possible retained balloon fragments.

Indwelling Catheter Types

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.

Published Date: January 2013

Foley catheters: types and features of use

Latex or silicone, three- and two-way balloon catheters for long-term catheterization of the bladder.

What are Foley catheters used for?

Pomerantsev-Foley catheters have a very wide range of applications:

• stimulation of labor by dilating the cervix,
• urinary problems caused by trauma, medication or diseases of the urinary system,
• preparation for surgery,
• diagnostics of infectious and other urological diseases.

The use of Foley catheters for urinary retention is very effective: the outflow of urine begins already at the time of insertion.

Catheters of this type are most often recommended for installation in patients who need long-term catheterization (from 5-7 to 30 days)

Material of manufacture and design of Foley catheter

According to the material of manufacture, catheters are divided into 3 types:

• Latex – they are highly durable, very resistant to urine, while elastic and flexible: for some patients, the introduction of a latex catheter is much more comfortable than a silicone one.However, latex can cause allergies, and therefore such catheters are often coated with silicone

• Silicone – a material that has been used in medicine for over 60 years, has established itself as biocompatible, resistant to heat treatment and does not allow salts to be deposited on the inner surface of the catheter. Does not cause allergies

• Silver plated silicone – have antibacterial properties, i.e. eliminate pathogenic microflora and reduce the risk of developing infections during long-term catheterization

However, in addition to material, Foley catheters differ in design and are of 2 types:

• 2-way – are considered classic: they have one common channel and two strokes: one serves to drain urine, and through the second the balloon is filled to fix the catheter in the bladder.Such a system allows you to maintain sterility and minimize the development of side effects

• 3-way – unlike the previous one, it is equipped with an additional channel, which is used for the administration of drugs. It is a more modern and multifunctional model and has a wider range of applications

Types of Foley catheters

Catheters for long-term catheterization of the urinary bladder are divided into 3 types:

1. Male Foley catheter – its main feature is the length (40 cm), i.e.because the male urinary tract is longer than the female,
2. Female Foley catheter – it is shorter than male (26 cm), which is due to the shorter length of the female canal,
3. The Pediatric Foley catheter is 28 cm long and comes complete with a stylet to facilitate insertion into the baby’s urethra.

Foley Catheter Size Chart:

How to choose a Foley catheter?

If we talk about which Foley catheter is better, then it is important to be guided by the indications and recommendations of the doctor.First of all, it depends on the duration of the catheterization (periodic, temporary or lifelong, in which the patient always needs help to urinate). Also, when selecting, 3 aspects are taken into account:

1. purpose of catheter use,
2. patient’s age,
3. product size.

The attending physician can determine the size required for a particular patient. It is not recommended to do it yourself, because the diameter of the tube is selected based on the size of the urethra and urethral canal.For example, its outer diameter can be 2.7 mm, with an inner diameter of 1.7 mm, or it can reach 8.7 mm, then the inner diameter will be 6.9 mm.

Urinary Catheter Care (Foley®)

This information will help you learn about caring for your urinary catheter (Foley) at home.

You have a urinary catheter (thin, flexible tube) inserted to drain urine from your bladder. It is held inside the bladder with a balloon filled with water. The parts of the catheter outside your body are shown in Figure 1.

Figure 1. Components of the Foley catheter

to come back to the beginning

Catheter care

• You need to clean the catheter daily, change urine bags and flush them.
• Traces of blood or urine may appear around where the catheter is inserted into the body, especially when you are walking or having a bowel movement. It is normal for urine to continue to drain into the drainage bag.If not, contact your healthcare provider.
• While you are using the catheter, drink 1-2 glasses of fluid every 2 hours while you are awake.

to come back to the beginning

Taking a shower

• You can shower when you have a catheter in place. Do not take a bath until it is removed. Taking a bath with a Foley catheter in place puts you at risk of infection.
• Always shower with a night bag.Do not shower with a leg bag. You may find it easier to shower in the morning.

to come back to the beginning

Catheter cleaning

You can clean the catheter while you shower.

You will need the following:

1. Prepare everything you need. You will need:
   • Mild soap such as Dove ^®
   • Water
   • 1 plaster Cath-Secure ^®
2. Wash hands with soap and water for at least 20 seconds.
3. Wash the genital area with mild soap and water.
   • If necessary, men should pull back the foreskin and wash this area, including the penis.
   • Women should open the labia and wash the perineum, moving from front to back.
4. Flush the urethra (urinary opening) – the place where the catheter enters the body.
5. When cleaning the catheter, move from the point of insertion into the body and down from the catheter.Hold the catheter at the site of its insertion into the body so that it is not pulled over.
6. Rinse the perineum well and blot gently dry.
7. If you have removed your old Cath-Secure patch, use the new Cath-Secure patch to anchor the catheter at your leg.

to come back to the beginning

Replacement of urine bag

You must change the bag 2 times a day.

• In the morning after showering, replace the night bag with a leg bag.
• At night, before going to bed, replace the leg bag with a night bag.

You will need the following:

• A clean washcloth (not used for showering) or gauze, 4 “x 4” (10 x 10 cm)
• Night bag or leg bag (depending on which bag needs to be connected instead of the previous one)
• 2 alcohol wipes

1. Wash your hands with warm water and soap for at least 20 seconds.
2. Empty the drainage bag into the toilet. Make sure the neck of the drainage bag does not touch the toilet wall or waste container being used.
3. Place a clean cloth or cheesecloth under the joint to collect any spills.
4. Use your fingers to squeeze the catheter and disconnect the used bag.
5. Wipe the end of the catheter with an alcohol wipe.
6. Wipe the connection of the new drainage bag with a second alcohol wipe.
7. Attach a clean bag to the catheter and release your fingers.
8. Check all connections. Straighten any kinks and kinks in the tube.

Watching the video below on how to change drainage bags can help you.

to come back to the beginning

Care of the urine bag

Care for the leg bag

• The tube on the leg bag should reach the lower leg with the leg slightly bent.If the tube is too long, you will need to cut it. Your nurse will show you how to do this.
• The leg bag should be secured below the knee. This will help urine flow into it.
• Be sure to secure the leg bag to your lower leg using the Velcro straps ^® provided by your nurse. Using the retaining strap, attach the tubing to your thigh.
• If the straps leave marks on your leg, then they are tight and should be loosened.Tight straps can obstruct circulation and lead to blood clots.
• Empty the leg bag into the toilet through the spout on the bottom every 2-4 hours as needed. Do not fill the bag to the very top.
• Do not lie down for more than 2 hours while using the leg bag.

Maintenance of the night bag

• The night bag should always be below the level of the bladder.
• To hang the night bag while you sleep, place a clean plastic bag in the waste basket. Hang the night bag on the inside of the waste basket.

Cleaning urine bags

You will need the following:

• white vinegar;
• cold water.

1. Wash your hands with warm water and soap for at least 20 seconds.
2. Rinse the bag with cold water. Do not use hot water as it can damage plastic accessories.
3. To reduce odor, fill the bag halfway with a mixture of one part white vinegar and three parts water. Shake the bag and soak it in this mixture for 15 minutes.
4. Rinse the bag with cold water and hang it up to dry.

to come back to the beginning

Prevention of the development of infections

If you have a catheter in place, follow the guidelines below to help prevent infection.

• The urine collection bag should always be positioned below the bladder without touching the floor.
• The catheter must be securely attached to the thigh so that it does not move.
• Do not lie on the catheter or obstruct the flow of urine in the tube.
• Shower daily to keep your catheter clean.
• Wash your hands before and after touching the catheter or drainage bag.

to come back to the beginning

When to contact your healthcare provider

Call your healthcare professional immediately if you experience any of the following:

• your catheter fell out; do not try to put it back in place yourself;
• you have a body temperature of 101 ° F (38.3 ° C) or higher;
• you urinate less than usual;
• urine has a strong unpleasant odor;
• bright red blood or large blood clots appear in the urine;
• you have severe pain in your abdomen (belly) and no urine flows into the drainage bag.

to come back to the beginning

90,000 Placement, replacement and care of the Foley catheter.

The structure of the bladder

Placement of the Foley catheter.

Before inserting the catheter, it is necessary to carry out hygienic procedures.

The specialist should wash the patient’s hands and perineum with soap, disinfect with an antiseptic and wear sterile gloves. Prepare the catheter (take with sterile tweezers, lubricate if necessary).

Female catheter insertion procedure:

Lying on your back, bend and spread your legs.

Having parted the labia and finding the opening of the urethra, the catheter is inserted with careful movements. As soon as urine flows through the catheter, you should stop.

After that, through one of the passages at the outer end of the catheter, inject sterile water with a syringe in a volume sufficient to inflate the balloon. Then attach a urine collection bag to the outer end.It is necessary to ensure that the bag is always below the level of the waist to avoid backflow of urine through the catheter.

Catheter insertion procedure for men:

In men, insertion of the catheter is more difficult. Since the urinary canal is longer and has physiological narrowing. The patient needs to lie on his back and slightly bend his knees, relax, the catheter is inserted into the urethra slowly and smoothly, with rotational movements, clamping the catheter with 5 and 4 fingers of the right hand, and first the penis must be held vertically, and then tilted down.Advance the catheter carefully. The presence of urine indicates that the catheter is installed correctly.

For children:

When inserting a catheter, it is necessary to provide psychological comfort to the child.

Disinfect genital areas twice and wrap with sterile tissue. Lubricate the end of the catheter with petroleum jelly, for example.

Do not forcefully insert the catheter if an obstruction is felt – this can damage the urethra.

The procedure for inserting the catheter is similar to that for adults, but the insertion depth is shallower, since the urethra is shorter.

Urinary Catheter Care:

Wash the area around the catheter with soap and water several times a day to avoid irritating the infection. Be sure to do this after each bowel movement. Women are washed from front to back.

Drain the bag in time, keep it below the level of the bladder to avoid urine back into the catheter.

Replacing the catheter:

With a normal outflow of urine, the replacement of the catheter is performed according to the doctor’s recommendation and instructions for the use of the catheter.

Silicone have a term of use up to 30 days, latex up to 7 days, silicone with silver up to 90 days.

Never pull on the catheter. Disconnect the catheter only to flush or replace it, or empty the drainage bag.

When you need to see a doctor:

– Abdominal pain, flakes and blood in the urine appear.

– Urine leaks from under the catheter.

– The outflow of urine has ceased to be carried out.

Reasons why urine may leak:

catheter too thin, balloon not inflated enough, catheter or urine collection tube kinked, catheter blockage.

Reasons why urine stops coming out:

kinked catheter or urine collection tube,

insufficient intake of fluid in the body (increase the amount of fluid consumed),

the urine bag is fixed too high (lower it below the level of the bladder),

catheter blockade,

impaired renal function (anuria) with deterioration of the patient’s condition.

Urinary catheters are flushed according to the doctor’s recommendation:

A warm saline solution is used for rinsing. When sediment or flakes appear in the urine, the catheter is washed with a solution of furacilin, as well as miramistin or a solution of chlorhexidine. For washing, use a syringe to Jeanne.

Foley catheter

90,000 Management of long-term urinary catheter replacement in adults

Relevance

A urinary catheter is a tube that is inserted into the bladder through the urethra [urethra] to drain urine from the bladder.Typically, the use of a urinary catheter is required for only a few days, for example after surgery. However, in some conditions, it is necessary to ensure a long-term outflow of urine from the bladder. There are many different ways to care for your long-term urinary catheter. In this review, we refer to these escape routes as “tactics.” Examples of tactics associated with long-term urinary catheter replacement include: the time between catheter changes, antibiotics when changing a catheter, using cleaning solutions or lubricants [lubricants] when changing a catheter, and the personnel, environment, and methods used to replace the catheter.The aim of this review was to find out which tactics during long-term catheter replacement are most effective in improving patient care.

Main results of the survey

This review found that there is currently insufficient high-quality evidence on the effectiveness of different strategies for long-term urinary catheter replacement. Only three randomized clinical trials with 107 participants met the eligibility criteria and were included in this review.

These clinical trials evaluated: (i) different time intervals for catheter change, (ii) antibiotic use to prevent infection, and (iii) use of different cleansing solutions. There was insufficient evidence to suggest that monthly catheter changes in addition to clinically needed catheter changes reduce urinary bacterial counts compared to clinically needed catheter changes. In addition, there was insufficient evidence to say that antibiotic use during catheter change to prevent infection was effective, and that using water for treatment / cleaning during catheter change was as effective as using antibacterial wash solution.

Adverse effects

None of the clinical trials reported any adverse effects associated with the studied catheter replacement tactics.

Limitations of this review

All three trials included in this review were small and had methodological weaknesses. Therefore, new clinical trials are needed to definitively answer the research question.The evidence in this review is current to May 19, 2016.

Questions and Answers

When and why is intermittent catheterization recommended?

Intermittent catheterization is an effective and safe method of urine diversion that offers patients independence and significantly improves quality of life. In recent years, periodic catheterization has become the preferred method for the management of patients with neurogenic bladder dysfunction, paraplegia, diseases such as spina bifida or multiple sclerosis.

The choice of the method of intermittent catheterization is carried out only after this technique is recommended by the doctor in each case. Catheterization is performed by emptying the bladder at regular intervals with disposable catheters.

How is intermittent catheterization performed in children?

Children with neurogenic bladder dysfunction can be catheterized by a parent or healthcare professional, always aseptically.Parents should ask their doctor or healthcare professional who will explain and demonstrate the correct catheterization procedure. Only with careful preparation can you be sure that you are performing the catheterization procedure correctly.

For infants and young children, the following sizes are generally used: 2.0–2.7 mm (Ch06 – Ch08).

How many times a day should the bladder be catheterized?

The normal frequency of emptying the bladder is approximately 5-6 times a day.The frequency of catheterization depends on individual characteristics and factors such as the volume of fluid you drink, medication intake, etc. Your doctor may recommend how often you need to catheterize your bladder. You can decide for yourself when and how it will be best for you to perform catheterization.

How much liquid should you drink every day?

This can vary depending on how active you are. You should aim to drink about 1.5–2 liters of fluid a day.Try to avoid drinks that contain caffeine, such as tea or coffee.

What if I have difficulty inserting the catheter?

Get into a comfortable position, try to relax and wait a while before performing the catheterization procedure. If you are unable to insert the catheter yourself, see your healthcare professional.

What if I have difficulty removing the catheter?

Try not to worry and wait a while before trying again.A cough can sometimes help insert or remove a catheter.

Are there any signs or symptoms I should be aware of?

Do not wait until your bladder becomes full. The following symptoms may indicate that your bladder is too full:

• tight and distended lower abdomen,
• headache,
• Feeling hot and sweating.

What to do if urine does not come out of the catheter?

If urine does not come out through the catheter, remove it and try a new one.Make sure the catheter is inserted into the bladder. If you feel like your bladder is still full, check with your doctor.

Possible complications of intermittent catheterization

One of the most common complications of catheterization is urinary tract infection. There may also be blood in the urine, bleeding from the urethra, or difficulty in inserting a catheter. If you have any of these signs, see your doctor.

Other tips

Below is a list of symptoms that may indicate a urinary tract infection:

• burning,
• high temperature,
• fever,
• unpleasant odor of urine.

If you have any of these signs, see your doctor.

90,000 Replacement of the urological catheter Pezzer and Foley at the price of 2590 rubles in Moscow – Clinic “Doctor near”

Bladder catheterization (MP) is a procedure aimed at inserting a catheter, which is a hollow tube that allows urine to be forced out of it in a number of pathological conditions or during postoperative recovery. For these purposes, a Foley or Pezzer urological catheter is used, which are designed to be worn for a long time and require replacement after certain periods of time.

Replacement of the Foley and Pezzer catheter is one of the services that can be ordered in the Doctor Nearby network of clinics. We employ experienced specialists who will carry out the procedure carefully and provide the patient with all the necessary data regarding the care and operation of the product.

What is the difference between Foley and Pezzer catheters?

Foley and Pezzer urethral catheters are epicystomas. This means that they are designed to remove urine from the body and can be used for a long time.They are rubber tubes that are inserted through an incision in the suprapubic region in situations where natural excretion of urine is not possible.

Installation of an epicystoma is carried out for a long period: from 30 days to 6 months. In some clinical cases, it is required for life. It is important for the patient to ensure proper care and use of the product and to change it in a timely manner.

Thus, each type of catheter has a shelf life for which it is designed – and in order to eliminate the risk of developing inflammatory pathologies, the replacement of products must be carried out in a timely manner. Pezzer is suitable for short-term use even when patients are taking antiseptic drugs, but Foley has a special coating that allows you to wear it many times longer.

Peculiarities of care for Pezzer and Foley catheters

In order to exclude the development of complications and ensure comfortable operation of the catheter, the patient needs to adhere to a number of rules – namely:

• Provide regular maintenance of the area around the fistula with antiseptic drugs and dressing around the catheter;
• When planning an operation to restore natural urination, use the catheter only during the first ten days of the postoperative period, and then close it and open it only if there is a feeling of a full MP.This approach will eliminate the loss of its volume by the organ and will ensure the normalization of blood circulation in its walls;
• To rinse the catheter using antiseptics only when absolutely necessary, since the pathogenic microorganisms inhabiting it very quickly adapt to the means used. As a result, the procedure can provide the opposite effect, causing an infection in the MP and the development of complications. Flushing can be done if bleeding has opened and the catheter is clogged with blood clots.However, the procedure must be performed by medical personnel.
• It is forbidden to take a bath, you can wash only in the shower;
• A patient with a catheter needs to consume enough fluid to ensure that there is enough urine to pass through the catheter. This will eliminate the risk of calculus formation, the development of inflammatory processes and the adhesion of salt deposits.

The most important point is timely replacement with an epicist.During operation, they can become clogged, which makes it difficult to drain urine and increases the risk of infection. You can avoid it if you regularly change the product.

How are Folley and Pezzer catheters changed?

The procedure does not require any special training from the patient. It is enough for him to come to the urologist’s office, who must have all the necessary instruments and the catheter itself for replacement. The doctor removes the old catheter and replaces it with a new one, always observing all the rules of sterility and treating the skin around the fistula with antiseptic agents.If the procedure is performed for the first time, a conductor-string is used during the replacement process, which makes the process much easier for both the doctor and the patient.

If you want to be sure that the procedure will be carried out correctly and painlessly, contact the specialists of the Doctor near clinic. You can pre-make an appointment with them at a convenient time for you by calling: +7 (495) 153-01-77.

10 key principles of urinary catheter care

print version

The 10 core “principles of good practice” reflect the current scientific understanding of one of the most common invasive procedures in a hospital setting.Carol Pellowe, EdD, MA Ed, BA, RNT, RN – Deputy Director of the Richard Wells Research Center, Department of Health and Human Sciences, Thames Valley University, Brentford, England.

Reducing the risk of infection with inserted urinary catheter
Ten Key Principles of Urinary Catheter Care
17 September 2009

Urethral catheters are one of the most common invasive interventions in emergency care and, therefore, one of the most common causes of nosocomial infections.

This article describes 10 basic principles to consider when caring for patients with urinary catheters inserted for a relatively short time – within 30 days.

The article was reviewed by 2 independent experts before publication

Preamble

Urinary catheters are one of the most common invasive devices used in emergencies. Urinary catheters are a common cause of iatrogenic nosocomial infections.Catheter associated urinary tract infection (CAUTI) causes additional suffering for patients and significantly delays recovery. Proper care of the urinary catheter is a key principle in preventing CSIMP (DH, 2007). Adherence to evidence-based nursing practices can significantly reduce the risk of infection.

How necessary is urinary catheter placement?

The main reasons requiring the placement of urinary catheters in an emergency setting are:

• Acute and chronic urinary retention;
• Accurate diuresis control;
• Control of urinary excretion during surgery;
• Study of the urinary tract;
• Irrigation of the bladder;
• Administration of medicinal substances directly into the bladder cavity.

Urinary catheters should never be used unless absolutely necessary for the convenience of staff only. When assessing the need for a urinary catheter, the risk of developing urinary tract infections must be taken into account.

Inserting a catheter into the bladder, in violation of the body’s normal defense mechanisms, allows microorganisms to migrate along the outer surface of the catheter into the bladder (Curran and Murdoch, 2009).

Once the catheter is in place, bacteria accumulate in the drainage bag and at the junction points of the system form a stable biofilm that may be a precursor to CSIMP (Barford and Coates, 2009).

The daily risk of developing bacteriuria in a catheterized patient is 3–6% and the risk increases over time (Pratt et al, 2007). Thus, about 50% of hospitalized patients with urinary catheters placed for more than 7-10 days will have bacteriuria (Pratt et al, 2007).

Although bacteriuria is often asymptomatic, 20-30% of patients will develop CSIMP (Pratt et al, 2007).
The development of a urinary tract infection significantly increases morbidity and mortality rates.There are numerous other options available and should be considered prior to inserting a urinary catheter.

Good Practice Principle. Use an indwelling urinary catheter only when absolutely necessary and when all other options have been considered and rejected.

Which catheter is best?

There are many types of catheters, the choice in each case depends on the patient’s expectations, the reason for the catheterization and the expected time of insertion.The most commonly used latex Foley catheter has been around since the 1920s. However, many patients are sensitive to latex and therefore require other materials. (Elvy and Colville, 2009). There is evidence that silver-coated catheters are clinically effective in reducing the incidence of CSIMP, although the question of its cost-effectiveness remains open. (Brosnahan et al, 2008; Schumm and Lam, 2008). Antibiotic-impregnated catheters also reduce bacteriuria in catheterized inpatient adults, extending the time to onset by an average of a week.(Schumm and Lam, 2008).

Based on research, it has been shown that regardless of the type of catheter chosen, the smallest size should be used to ensure free flow of urine, and the volume of the inflated cuff should not exceed 10 ml. These measures help to minimize trauma to the urethra, irritation of the mucous membranes and the amount of residual urine, which are factors that contribute to the development of CSIMP (Pratt et al, 2007).

Good Practice Principle. Use the appropriate type of catheter for the patient and use the smallest diameter possible.

Catheterization technique

As noted, a catheter inserted into the bladder is potentially a risk factor for microorganisms to enter the bladder (Barford and Coates, 2009). To minimize the risk, catheterization should be performed under aseptic conditions only by qualified, specially trained personnel. (Pratt et al, 2007).

Expert reports indicate that there is no advantage to treating the urethra with an aseptic solution prior to catheter insertion and the use of sterile saline is sufficient (Dunn et al, 2000; Kunin, 1997).

Trauma and discomfort can be minimized by using appropriate sterile and anesthetic gels. (Pratt et al, 2007).

Good Practice Principle. Urethral catheterization should be performed under aseptic conditions by qualified and competent personnel.

Documenting

Once the cause of the catheterization has been established, the procedure, type and serial number of the catheter should be recorded in the medical history.Once the catheter has been placed, the need for catheterization should be assessed daily so that the catheter is removed as soon as possible. There is some evidence to suggest that computerized (algorithmic) workflow systems improve control and thus shorten catheterization times. (Cornia et al, 2003).

Good Practice Principle. Documenting and assessing the need for catheterisation on a daily basis will minimize catheter standing time.

Maintaining the tightness of the system

One of the main ways to minimize the risk of CSIMP is to maintain the tightness of the system, which means that access to the catheter and cases of rupture of the system should be minimized. The design of modern systems allows the cleaning of urine bags using special valves without disassembling the system for a long time. The instructions for the use of drainage bags have been revised recently, recommending a longer period of use.A systematic review has shown that the use of sealed systems (where the catheter and drainage bag are supplied together in their original packaging) helps prevent bacteriuria (Dunn et al, 2000). This was confirmed by a recent UK study that showed a 41% reduction in CSIMPs when using hermetically sealed systems. (Madeo et al, 2009).

Good Practice Principle. The tightness of the system reduces the risk of KSIMP.

Catheter Care

Because reflux and urinary stasis significantly increase the risk of CSIMP, the drainage bag should always be below the bladder and secured to a support to avoid contamination (Pratt et al, 2007). The principle of locating the urine bag below the bladder must also be observed when moving the patient (for example, when transferring from bed to chair), in order to prevent backflow of urine. The use of special urethral dilation devices reduces urethral damage, especially in men, in whom urethral dilation is often difficult and reduces the risk of infection.The existing evidence base does not indicate any benefits for postcatheterization of the external urethra with antiseptic solutions versus usual hygiene (bath or shower) (Webster et al, 2001; Dunn et al, 2000).

Good Practice Principle. Attach the bag below the level of the bladder to avoid backflow of urine. Encourage daily bathing or showering to maintain external urethral hygiene.

Irrigation, instillation and flushing

A systematic review has shown that the addition of antimicrobial drugs to the drainage bag does not reduce the incidence of CSIMP (Saint and Lipsky, 1999).In addition, there is no evidence to support the use of antimicrobial or antiseptic irrigation, instillation, or bladder flushing in preventing CSIMP (Muncie et al, 1989; Saint and Lipsky, 1999; Kennedy et al, 1992).

Evidence from EBN confirms that such procedures not only pose a threat by depressurizing the system, but can also cause local toxic tissue damage, as well as contribute to the emergence of resistant forms of microorganisms (Kunin, 1997).However, continuous or intermittent bladder irrigation may be prescribed during urologic surgery or catheter obstruction.

Good Practice Principle. Avoid irrigation, instillation, and bladder flushing unless clinically indicated.

Hand hygiene

Although it is stated that only a sealed system fully complies with the principles of good practice, there are times when the integrity of the circuit must be violated, for example, when emptying a urine bag or taking a urine sample.In these situations, nurses should treat their hands with an antiseptic and wear non-sterile gloves before using the system (Pratt et al, 2007; WHO, 2006). In some cases, an additional plastic apron may be required to protect the uniform. Once the procedure is complete, gloves should be discarded and hands handled according to regulations (Pratt et al, 2007; WHO, 2006).

Good Practice Principle. Use of non-sterile gloves and hand decontamination when handling the catheter.

Education and training

Given the incidence of bladder catheterization in the hospital and the associated risk of urinary tract infection, it is important that patients, families and healthcare professionals responsible for inserting and caring for the catheter have sufficient knowledge of preventing infection. Training of staff on prevention of infection is provided for (in England – translator’s note) by a special act that came into force on April 1, 2009 (DH, 2008).Electronic training module. A resource dedicated to this subject is available free of charge to all healthcare professionals in England. It is available at www.infectioncontrol.nhs.uk (Pellowe, 2009).

Good Practice Principle. All staff should receive specific training in the prevention of CSIMP.

High importance of care in the complex of medical care

Nursing interventions were developed by the Institute of Health Improvement and are listed as essential interventions by the Department of Health (DH, 2007).Comprehensive care is a collection of methods that, when done consistently, improve patient outcomes. In addition to rigorous adherence to evidence-based care principles, a rigorous protocol of interventions is required, reflecting adherence to an established protocol. A thorough audit reveals weaknesses in the care organization and demonstrates the organization’s commitment to quality care.

Good Practice Principle. In all departments where short-term urinary catheter placement is used, professionals should assess their performance using established care protocols.

Conclusion

KSIMP is a frequent complication of urinary tract catheterization, which leads to additional suffering for the patient and a delay in recovery.