Clinical indications for the use of indwelling urinary catheters have been identified by the Royal College of Nursing (RCN, 2012) and also the European Association of Urology Nurses (EAUN) (Geng et al, 2012) (Table 1). There are significant risks associated with the introduction of a foreign body into the bladder (Table 2), not least infection, with statistics demonstrating that the longer a urinary catheter is in place, the more likely an infection is to develop (Loveday et al, 2014). It is widely acknowledged, therefore, that indwelling urinary catheters should only be used as a last resort and when all other options have been considered, tried and failed (National Institute for Health and Care Excellence [NICE], 2014; Davey, 2015; Yates, 2016; Simpson, 2017).

An indwelling urinary catheter can be inserted through the urethra or via the suprapubic (abdominal) route using a self-retaining balloon catheter, which can be used over a short-term (less than 28 days) or long-term (up to 12 weeks) period (RCN, 2012).

Inserting a new, or changing an existing urinary catheter should only be undertaken following a thorough individual assessment (Feneley et al, 2015; Yates, 2016). This must include a risk assessment of any contraindications before insertion (RCN, 2012), such as an inability to care for it, no carer support, or cognitive impairment where there is a high risk of deliberate self-expulsion/removal, and also consideration of the type of drainage system used to ensure safe and effective drainage of the bladder (Leaver, 2017). The clinical indication for the use of the catheter should be clearly identified and documented in the patient notes and reviewed every time the catheter is changed to ensure it is still the best option for managing the individual’s bladder drainage.

CHOOSING THE CORRECT CATHETER

There are many different types of indwelling urinary catheters available. The nurse should consider the use of latex, silicone, coated or composite materials, and pay attention to any patient history of sensitivity or allergy (Elvy and Colville, 2009).
 

Latex catheters

Latex catheters are the most common type of catheter available. They are made from natural rubber and have been traditionally popular due to their flexibility. However, the high surface friction associated with latex can increase the risk of catheter encrustation, particularly around the catheter tip, which can increase pain and discomfort for the patient (Feneley et al, 2015; Yates, 2016). Sensitivity and allergy to latex is common and the initial assessment of each patient needs to consider the risks associated with the use of latex materials (Health and Safety Executive [HSE], 2011; NICE, 2017).
 

Silicone catheters

Practice pointSilicone catheters have a wider internal lumen due to the composition, i.e. thinner walls than latex or coated catheters, and those made of 100% silicone are hypoallergenic for the majority of the population (Loveday et al, 2014). Silicone is slightly more rigid than latex and has a tendency to cause ‘cuffing’ or ‘ridging’ around the deflated balloon, which may in turn become attached to the urethral or suprapubic tract on removal, causing trauma (Geng et al, 2012; Feneley et al, 2015). In the author’s experience, this issue can be managed by completely deflating the catheter balloon and then inserting 1ml of sterile water to smooth out the edges of the balloon, which helps prevent the catheter from sticking to the urethral or abdominal tract tissues on removal. This, in turn, will reduce potential trauma.
 

Polytetrafluoroethylenecoated catheters

These are latex catheters coated in polytetrafluoroethylene [PTFE], which is smoother than latex and can be useful in reducing encrustation and discomfort for the wearer. There is still the risk of latex allergy and, therefore, PTFE-coated catheters must be avoided in patients with a known allergy or sensitivity.

Hydrogel-coated catheters

Hydrogel-coated catheters can reduce friction and irritation, as they are soft,hydrophilic and biocompatible (Geng et al, 2012). They are typically a latex catheter with an integral hydrogel coating that offers a smooth catheter surface aimed at reducing friction and trauma on insertion.
 

Silver-coated catheters

Practice pointSilver-coated catheters were introduced in the 1980s and are manufactured either as silicone, hydrogel or latex catheters with a thin layer silver alloy coating. Silver has long been recognised for its natural antimicrobial properties (Hayes, 2009), and these catheters were initially thought to significantly reduce the incidence of catheterassociated urinary tract infections (CAUTIs) (Pellowe, 2009; Stickler and Feneley, 2010; Pickard et al, 2012). However, it has since been acknowledged that the antimicrobial effect is short-lived and lasts no longer than 28 days (Tenke et al, 2008; Hayes, 2009; Beattie and Taylor, 2011; Geng et al, 2012; Loveday et al, 2014; Feneley et al, 2015). This means that the catheter has no added benefit in reducing infections after the 28 days and, therefore, would need changing to ensure optimum antimicrobial effect is continued. This will have cost implications, as these types of catheters are more expensive.
 

Nitrofurazone catheters

Nitrofurazone catheters are antibioticimpregnated catheters that may reduce asymptomatic bacteriuria when used as a short-term measure. However, the clinical evidence does not demonstrate a significant reduction in the incidence of symptomatic infection and, therefore, the use of this particular type of catheter is not widely recommended (Geng et al, 2012; Feneley et al, 2015).

CHARRIÈRE AND LENGTH

The Charrière (Ch) size of the catheter should be small enough to reduce tissue damage and trauma, yet large enough for effective and timely drainage. The EAUN guidelines for best practice (Geng et al, 2012) recommend a 12–14 Ch catheter be used in adult male and females for urethral catheterisation, and a size 16 Ch or larger for suprapubic catheters, as catheters with a smaller Ch can be become blocked through abdominal pressure. Catheter lengths in the UK are categorised as:
  • Paediatric catheter: 30cm in length and available up to a size 10 Ch
  • Female catheter: 23–26cm in length
  • Standard- or male-length catheter: 40–44cm in length (maximum size is 26 Ch for male and female).
A standard-length catheter must always be used in adult males aged 16 years and above as insertion of a shorter catheter may result in the balloon being inflated within the urethra leading to haematuria, swelling, retention, and significant trauma to the prostatic urethra (National Patient Safety Agency, 2009).

Female catheters provide discretion for the wearer, as they are easily concealed; similarly, there is less movement in and out of the urethra (Yarde, 2015). However, standard length catheters can also be used in females who are larger, obese or taller, as the extra length provides more comfort and the drainage connection is further away from the genitalia, thereby reducing the risk of infection. Female transgender patients who have undergone significant urethral reconstruction should only use standard-length catheters.
Table 1 - Indications for indwelling catheter use

BALLOON SIZE

BypassingThe balloon size of the catheter needs to be considered when choosing a product. Manufacturers produce Foley catheters with balloon sizes ranging from 5mls to 30mls. The larger balloons can increase the trauma and infection risk at the bladder neck, sphincter or suprapubic entry site, and leave a higher residual volume of urine within the bladder, thereby increasing the risk of infection from static urine (Garcia et al, 2007; Feneley et al, 2015). Larger balloons may also increase the incidence of urine bypassing, bladder spasms, pain and discomfort (Simpson, 2017). Larger balloon size catheters are commonest in urology when the Ch size is much larger, and the catheter is three-way rather than the standard two-way product to enable irrigation and effective drainage postoperatively. As the larger balloon size can cause trauma and increase the risk of infection, their use should be short term. A clinical indication for the choice of catheter should always be documented and the least risky option used.

Consideration should also be given to the loss of liquid volume that occurs over the catheter life of a sterile water-filled balloon, due to osmosis. While this is believed to be less of an issue when using glycerine solutions to inflate the balloon (Simpson, 2017), nurses should always follow the manufacturer’s advice when inflating a catheter balloon with water, and the balloon should never be overinflated.
 

CLEANSING SOLUTIONS

Indwelling urinary catheterisation is undertaken using an aseptic no-touch technique (ANTT) (Rowley et al, 2010; NICE, 2017). The use of sterile normal saline or sterile water to cleanse the meatal or abdominal skin is normally recommended before inserting the catheter (Healthcare Infection Control Practice Advisory Committee [HICPAC], 2009; Loveday et al, 2014). However, NICE (2017) has recommended that nurses use local policy and guidance for meatal cleansing before urethral catheterisation, without any specific reference to the type of cleansing solution.

There have been some small studies reviewing the benefits of using an antimicrobial solution for meatal cleansing to reduce CAUTIs (Sandle, 2013; Levers, 2014). These have suggested that the use of such solutions may be beneficial, particularly in a community setting as the patient’s home environment can be more challenging from an infection control point of view, than a hospital setting. However, more work is required in this area before a definitive recommendation can be made on the advantages or disadvantages of introducing antimicrobial cleansing as a standard approach in urethral catheterisation. Until then, the best practice recommendation for managing catheter hygiene on a daily basis remains the use of soap and water in the individual’s normal personal hygiene routine (NICE, 2017).


LUBRICATION

Insertion of a urinary catheter, both suprapubic and urethral, requires the use of an appropriate lubricant so that trauma, discomfort and the risk of infection can be minimised (Loveday et al, 2014). Standard practice across the UK has been to use catheter lubricant gels that contain chlorhexidine (an antiseptic) or lidocaine (an anaesthetic), or a combination of both. However, in recent years there has been an increase in reports of adverse reactions, sensitivities and allergic reactions to chlorhexidine, possibly because of the inclusion of the active ingredient in many everyday household products (Marinho et al, 2013; Wilson, 2016).

The clinical evidence suggesting that the use of chlorhexidine effectively reduces the incidence of CAUTIs is also limited and inconclusive (Wilson, 2016), with many countries switching to antiseptic-free gels (Williams, 2017). Several studies have outlined the benefits of anaesthetic gels in reducing pain on catheter insertion (Ramakrishnan and Mold, 2004; Kyle, 2009; Tzortzis et al, 2009).

During any assessment for catheterisation, it is the individual nurse’s responsibility to identify any contraindications, sensitivities or allergies that the patient may have to the active ingredients used in lubricating gels. Similarly, the nurse should use the assessment to choose an appropriate catheter for the patient that will ensure that the experience of catheterisation is as safe, effective and comfortable as possible.

DRAINAGE BAGS, VALVES AND FIXATION DEVICES

Drainage bags

There are a variety of options available to the nurse when choosing a drainage bag to accompany the urinary catheter, both suprapubic and urethral, ranging in capacity from 350mls to 3,000mls. Drainage bags can be single-use or drainable and must be sterile and maintain a closed system to reduce the risk of infection. Drainage bags are generally changed every 5–7 days in line with the manufacturer’s instructions.

The nurse’s choice of drainage bag will depend on (Yates, 2016):
  • Rationale for catheter use — this could be influenced by many factors, such as patient mobility, manual dexterity or eyesight
  • Patient choice
  • Length of tubing required
  • Design and position of the tap
  • The patient’s ability to manage the system
  • The patient’s bladder capacity.
Any drainage bag should be adequately supported with an appropriate device or stand to reduce the weight exerted on the catheter and bladder, which may otherwise cause tissue trauma and increase the risk of infection. Drainage bags should be emptied frequently enough to maintain the flow of urine and prevent reflux, without interrupting the closed drainage system unnecessarily, which could increase the risk of infection (Geng et al, 2012; RCN, 2012). It is recommended that the bags are not allowed to become more than threequarters full (Loveday et al, 2014).

Valves

Catheter valves are a popular choice, as they allow the bladder to fill and empty over a period of time, mimicking the micturition cycle, which may contribute to a more successful trial without catheter (TWOC, see pp.35–39) (Woodward, 2014). As the urinary catheter is considered a high risk intervention, planning a TWOC should always be considered at the earliest opportunity in patients who may regain effective control of bladder filling and emptying. If a patient is identified as always needing assistance with bladder emptying, consideration should be given to the feasibility of alternative less risky management methods, such as intermittent catheters. However, there are some factors that the nurse must consider before recommending a catheter valve, for example, the patient’s bladder capacity, their sensation of whether their bladder is full (although a patient with no sensation can be taught to safely manage a valve system). Their ability to understand the valve system should also be assessed (Yates, 2016). The risk of high pressure from a full bladder causing renal damage, or a history of recent surgery on the genitourinary tract, exclude the use of a catheter valve system (see Table 3 for the advantages and disadvantages of using a catheter valves).
 

Catheter fixation devices

Catheter fixation devices have been in use since the 1960s and a variety of products are now available. An unsecured catheter will move inside the bladder causing unstable detrusor contractions, bladder spasms, pain, bypassing and possible expulsion of the catheter (Geng et al, 2012). This increases the risk of urethral, bladder neck or suprapubic tract trauma, which can lead to infection (Hanchett, 2002; Spinks, 2013; Feneley et al, 2015). Urinary bypassing also increases the risk of skin damage, incontinence-associated dermatitis and secondary infections. This is because as the skin comes into contact with urine, the epidermis can become overhydrated or irritated by the urine leading to damage or secondary infections (Holroyd, 2016).

The Wound Ostomy and Continence Nurses Society published best practice guidance on the benefits of catheter fixation (WOCN, 2012). Any assessment should aim to identify an appropriate catheter fixation device that will reduce the incidence of catheter displacement, expulsion and migration and, thereby, reduce the risk of tissue damage and infection (Holroyd, 2016).

CATHETER-ASSOCIATED URINARY TRACT INFECTIONS

CAUTIs account for a large proportion of healthcare-acquired infections (Pellowe, 2009) and the cost of treating a single CAUTI is estimated at almost £2,000 (Loveday et al, 2014), placing an enormous burden on the healthcare economy. Establishing the effect of a CAUTI on a patient’s quality of life is difficult to determine, with the risk of serious infection rising the longer the catheter is in place (Chang et al, 2011; Loveday et al, 2014). Forty-five per cent Escherichia coli bacteraemia are attributed to the urinary tract and use of catheters (Abernathy, 2017). It is now a Public Health England policy to reduce all healthcare-associated Gram-negative bloodstream infections by 50% by 2021, and all trusts have been challenged with ensuring a robust action plan is in place to achieve this by closer monitoring, robust early detection and appropriate treatment of CAUTIs (NHS Improvement, 2017).
 

ENCRUSTATION

Catheter blockage and bypassing are common issues encountered with the use of indwelling urinary catheters and are usually caused by infection and encrustation. Encrustation is commonly caused by a build-up of Proteus mirabilis, a urease-producing bacteria, which causes biofilm formation on the catheter surface leading to blockage of the lumen and drainage eyelets (Stickler et al, 2003; Feneley et al, 2015). Traditionally, catheter maintenance solutions have routinely been used to dissolve the encrustation or remove debris. However, this is a high-risk strategy for a number of reasons (Turner and Dickens, 2011; Davey, 2015; Feneley et al, 2015; Gibney, 2016):
  • To flush the catheter with maintenance solutions requires breaking the closed drainage system, thus increasing the risk of infection
  • The acidic content of catheter maintenance solutions can damage the urothelial lining of the bladder and cause an inflammatory response
  • The increased pressure under which they can be administered, can also contribute to significant damage and increased infection risk. Thus, pre-filled catheter maintainence solutions should be gravity fed/administered. Any squeezing of the container/bag will create pressure within the catheter and bladder which can cause trauma and tissue damage. Catheter maintenance solutions should be used with caution, and only after a thorough assessment of risk and the formulation of a clear clinical rationale, which must be documented in the patient’s records.

Antibiotics and antiseptics are ineffective in reducing catheter encrustation; however, antimicrobials used in the ballooninflation solution may be effective in reducing harmful bacteria including P. mirabilis (Pannek and Vesweber, 2011; Sperling et al, 2014; NICE, 2017).
 
Table 3 - Advantages and disadvantages of catheter valve usage
Table 2 - Risks associated with indwelling catheters

Detrursor overactivity

PATIENT SCENARIO

Patient A is a middle-aged male in his late forties. He has multiple medical conditions, including a significant head injury that has affected his ability to effectively manage bladder drainage, resulting in the need for a catheter. His bladder is unable to store urine volumes at a safe pressure and in the past this has caused significant renal damage. Therefore, he requires the catheter to be on free drainage, which causes an internal suction effect that increases the risk of bladder spasms and pain. His head injury also causes behavioural issues and he struggles to cope with any pain, discomfort or interventions involving his catheter, often pulling at the device causing trauma and increasing the risk of infection.

The indwelling free-drainage catheter using a bag system is managed by his family and a team of community carers. The patient finds the catheter uncomfortable and painful, reporting bypassing of urine on a frequent basis. The catheter blocks frequently, resulting in several emergency calls to the district nursing team each week. There is documented evidence of encrustation around the catheter tip when it is changed and the patient is at high risk of infection and sepsis every time the closed drainage system is compromised.

A comprehensive and individualised assessment by the author investigated the rationale for the use of the catheter system and decided that a change in catheter material may reduce some of the symptoms. The patient had been using a latex catheter. Evidence demonstrates that encrustation is common in these types of catheters, so a decision was made to try a silicone catheter, as these have been shown to have reduced encrustation as previously discussed. An alternative catheter-fixation device was introduced to minimise any migration of the catheter and potential trauma. The patient had been using an elasticated strap version of a catheter fixation device, which caused issues with lower limb circulation due to peripheral neuropathy and oedema. This caused discomfort for the patient and some superficial skin damage, which resulted in the patient removing the device. An alternative hydrocolloid plaster version fixation device was used to minimise catheter migration and improve patient comfort and compliance. Fixation devices need to be appropriate for use and should be chosen after an individual assessment of the patient, including any contraindications or cautions.

Bladder washouts had been routinely performed with little effect and were stopped due to the significant risk of infection. A catheter valve was contraindicated due to patient A’s renal damage and high-pressure bladder, i.e. a bladder that is unable to store urine safely without causing high intravesical pressures leading to significant renal damage. A review of patient A’s bowel habit and fluid intake was undertaken to ensure that this was not a contributory factor. The catheter balloon size was reduced from 10ml to 30ml, and a different balloon-inflation solution containing an antimicrobial agent (triclosan 0.3%) was introduced. The rationale for a smaller balloon size was to reduce the irritation on the bladder neck and sphincter commonly seen in larger balloon sizes (Geng et al, 2012). The catheter life was extended and the amount of calls from the patient to the district nursing team reduced significantly. The change in catheter system improved the patient’s quality of life and reduced the excess workload on the carers and community nursing teams.

The trust involved in this case have now developed a quick reference guide for managing patients with problematic urinary catheters to assist staff in identifying potential issues and treating them appropriately with the lowest risk (see Figure 1).
 

CONCLUSION

Indwelling urinary catheters involve a certain amount of risk, primarily through infection, encrustation over time and leakage. However, their use is unavoidable in some patients who require a reliable bladder management option. Nurses should ensure that all patients undergo an individualised risk assessment before the insertion of a catheter to determine the clinical rationale for use, including the type of catheter, size, length and drainage options.

Best practice guidelines provide advice on managing risk appropriately and should be embedded into local policy and clinical practice to ensure patients are offered the right treatment, at the right time, with the lowest risk.

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