The Foley catheter was first designed by Frederick Foley in 1936 (Foley, 1937), and is the most widely used medical appliance in the world (Allegranzi et al, 2011), and as such, poses a considerable burden to both healthcare professionals and patients. The National Catheter Education Programme is taking part in educational and quality improvement work to identify and address the issues facing clinicians, nursing staff and patients, surrounding catheter care.


THE SCALE OF THE PROBLEM

It has long been established that the longer a catheter is in place, the greater the problems it can cause. For example, a study of patients who had been catheterised for more than two years, reported that more than three-quarters of those patients required some kind of professional intervention or help, at least once within an eight-month period. For some patients, this amounted to more than 10 call-outs in that eight-month time frame (Wilde et al, 2010).

Twenty percent of all hospitalised patients are catheterised (Ansell et al, 2017). As a crude estimate, there are approximately 28,500 catheterised patients in acute NHS hospital beds, in the UK every day (Ewbank et al, 2017). It can be estimated that approximately onethird of those patients have been admitted from the community with a catheter already in situ (ranges of 17–41% have been reported) (Ansell et al, 2017).

Published community prescribing data estimates that there are 90,000 catheterised patients living outside of hospitals — approximately 0.07% of the population (Kohler-Ockmore and Feneley, 1996; Gage et al, 2017). It is also estimated that between 9–32% of all care home residents have catheters in place (Kohler-Ockmore and Feneley, 1996; McNulty et al, 2003; Wagg et al, 2008).

WHAT PROBLEMS ARE ASSOCIATED WITH CATHETERS?

There are many different catheterrelated problems encountered in clinical practice, all of which can cause considerable morbidity (Kunln et al, 1992; Getliffe, 1994; Getliffe et al, 2006; Wilde et al, 2010; Chapple et al, 2016). Often patients who are catheterised are either unwell or have other compromises to their health or mobility.

Catheters can cause discomfort, sensitivity reactions, can block, cause bladder spasms, bypass urine, cause external trauma and result in pressure ulcers. For men, there can be additional problems, including penile cleavage and impediment to semen flow (Andrews et al, 1998; Cottenden et al, 2013; Saint. et al, 2018).

As clinical conditions change et al, 2013; Ansell et al, 2017; Ansell and Harari, 2017). over time, the need for a catheter may require re-evaluation. However, identifying the individual responsible for deciding on a patient’s catheter needs is difficult, as they ofen have multiple care providers. This can lead to disjointed care and, indeed, ‘fragmentation’ of care is a frequently cited shortcoming of overall catheter care (Getliffe and Newton, 2006; Wagg et al, 2008; Wilde et al, 2010; Hunter


Managing catheterrelated problems?

When problems with catheters arise in the community setting, patients and their carers have three options:
  1. To access a specialist nursing service in their home environment.
  2. To call or attend dedicated continence clinics or urology departments where there is an open-access service.
  3. To attend an A&E department.
For the first option, it is noted that home visits for catheterrelated problems comprise 5% of community nurse workload (Getliffe, 1994). However, this represents only a portion of the scale of the problem, as a recent audit of patients attending an A&E department found that only one-third presenting with a catheter problem were known to the district nursing services (Tay et al, 2016).
Where available, dedicated catheter, continence or rapid access urology clinics are an effective solution, as they have been shown to markedly reduce complications and catheter-related events that often result in hospital admissions (Khan et al, 2007). However, a national survey concluded that integrated continence services were available for less than half of all catheterised patients being cared for in the community (Wagg et al, 2008).

The third option is that patients attend an A&E department. Data from one of the A&E departments in the Health Innovation Network (HIN PSC) has reported that about two-thirds of patients with catheterrelated problems are brought to hospital by ambulance (Ansell and Harari, 2017). However, to date, catheter care has been given little consideration by the ambulance service in their training programmes.
 

IMPROVING MANAGEMENT OF CATHETER-RELATED PROBLEMS

A recent development at Ashford and St Peter’s Hospitals NHS Foundation Trust has been the inception of the National Catheter Education Programme. This multiprofessional educational project is linked to a systems-change goal. It aims to improve clinical care, patient safety, patient experience, and integrate systems-working. The project centres on an educational programme that is combined with a specialist team who provide supportive care to all catheterised patients, both in hospital and community settings.

The project is closely aligned to the Five Year Forward View (NHS England, 2014); one of the main goals of which was to improve out-of-hospital care by designing services responsive to patient needs. This was to be built on a framework of ‘redesigned services that are fit for-the-purpose of modern-day healthcare needs’ (NHS England, 2014).


‘A national survey in the UK concluded that integrated continence services were available for less than half of all catheterised patients being cared for in the community.’

 

THE SECRET LIFE OF CATHETERS

Table 1This 11-module programme consists of short, animated lectures delivered in three to four-hour sessions. Six modules deal with core anatomical themes, the fundamentals of material science and the biology of catheter life. The five further sequential modules cover clinical dimensions of catheter care. The aim of the programme is to ‘iron out’ many of the confusions, myths and misunderstandings that surround catheter care.

All sessions include interactive feedback and self-assessment to help consolidate knowledge gained. In a multiprofessional group setting, training sessions conclude with structured case studies, which are designed to enable reflective learning and sharing experiences across interdisciplinary boundaries.


Course overview

It is beyond the scope of this article to cover all the content, however, what follows is a taster of some key aspects of the course.

Module one is an introduction to the course and introduces the three overarching principles of catheter care (Table 1). For those clinicians trained in catheter insertion, the course focuses on eight golden rules (Table 2).
Table 2
Figure 1. Development of a false passage at the bulbar urethra. Figure 1.
Development of a false passage at the bulbar urethra.

KEY PRINCIPLES OF CATHETER CARE

There are four main reasons for using a catheter, namely:
  • To help manage urinary incontinence
  • To monitor urine output
  • To relieve retention of urine
  • To wash clot and debris from the bladder.
Alternatives to urethral catheters for urinary retention are individual to each patient, but can include intermittent self-catheterisation and suprapubic catheters. If voiding adequately, alternatives include convenes or incontinence pads (Cottenden et al, 2013). There are many reasons to place a catheter, each with their own relative merits. However, clinical situations do change, and so it is vital to reassess patients to ensure that the need does still exist.
 

EIGHT GOLDEN RULES OF CATHETERISATION

 

1. Be gentle and never force a catheter

The narrowest part of the male urethra is the penile opening; the external meatus. Most catheters should fit through the meatus but it is often a snug fit.

The male urethra has two bends. The first is at the peno-scrotal junction and the second, known as the bulbar urethra, is close to the external sphincter and the prostate. The bend at the penoscrotal junction can be straightened by lifting the penis away from the anterior abdominal wall, a catheter tube then has a straight run through this bend. The second bend in the bulbar urethra is fixed and cannot be changed. A well lubricated catheter will usually glide and follow around this natural curved path, passing through the external sphincter and prostate into the bladder.

The curvature of the bulbar urethra, makes it the most common site for the formation of a false passage. Sometimes, the catheter will dig a small hole and follow a straight-line path. Trying to force a catheter around the bulbar urethral bend risks the formation of a false passage (Figure 1). This explains why the number one golden rule of this programme is to be gentle and never force a catheter.
 

2. Have a go, but only one

The second golden rule logically follows the first. Have only one go at passing a catheter. The catheter will always preferentially go in a straight line, thus, once a false passage is created, each further attempt to pass a catheter will simply compound the problem and worsen the false passage. Pushing a catheter harder will never help it round this bend.

3. Never use an introducer

There are three ways to insert a catheter round the bulbar urethral bend once a false passage has been created. The first and safest option is to negotiate the defect using direct vision with a flexible cystoscope and a guidewire, this is undertaken by a urologist.

The second solution is to use a wire introducer. This has an angled tip and resembles the appearance of a coat hanger. A catheter is back fed over the wire, and introduced into the male urethra. However, introducers can cause significant damage if used by those who have not been trained. Therefore, the Secret Life of Catheters programme teaches that an introducer should only be used in practice by urologists.

The principle of using a tool that is angled to safely navigate a problematic bulbar urethra leads logically onto the third solution; a Tiemann tip catheter. The specifically designed Tiemann tip catheter has a built-in anterior-shaped curve, that can often direct the catheter round the bend. It is reasonable for the clinician to have one gentle attempt at passing this catheter before seeking help. The salient point from this golden rule is never to use an introducer, but rather a Tiemann tip.
Figure 2. There are four main types of catheters. Figure 2.
There are four main types of catheters.
Figure 3. Cross-section through a coated latex catheter. Figure 3.
Cross-section through a coated latex catheter.
Figure 4. Cross-section through an all-silicone catheter.Figure 4.
Cross-section through an all-silicone catheter.

4. Use the smallest catheter to do the job

Red flagThe two natural urethral bends in the male urethra are also the most common sites for urethral strictures to occur, as the catheter may rub resulting in trauma. Trauma within the urethral lumen can result in inflammation. As this heals, there is resultant scar tissue leading to contraction and a tighter, more rigid, passage. This is known as a urethral stricture and markedly reduces the lumen size of the urethra. Therefore, the smallest catheter suitable should always be used, thus minimising disruption to the urethral wall and the risk of future development of urethral strictures.

There are several principles that underpin the concept of an ideal catheter, e.g:
  • It should have a good lumen-toexternal diameter ratio to enable maximum drainage
  • It should have a low coefficient of friction to minimise trauma to the urethra
  • It should be soft and flexible enough not to cause discomfort to the patient and to avoid trauma at pressure points, yet sufficiently strong for the lumen not to be collapsible.
Catheters are commonly made from either silicone or latex that has been coated in an inert material. Different materials result in the varying properties and lifespan of different catheter types. There are three types of coated latex catheters in common clinical use and one allsilicone catheter (Figure 2).

There is only one type of ‘short-term’ catheter, which is constructed from latex coated in polytetrafluoroethylene (PTFE), commonly known as Teflon. With time, degradation of the outer Teflon coating leads to the development of micro-cracks. This catheters should therefore be changed every 28 days.

There are three other commonly used catheter types, which are all considered ‘long-term’ catheters and should be changed every 12 weeks. Hydrogel-coated latex catheters have hydrophilic properties, giving them an exceptionally low coefficient of friction, reducing trauma to the urethra. Secondly, there are silastic catheters, which are made from latex coated in silicone elastomer. These have a hydrophobic surface, which results in a smooth and atraumatic catheter surface. These are the most flexible, but, as a result, have the most collapsible lumen. Finally, there are catheters that are all silicone and so are safe for anyone with a known latex sensitivity. They are less collapsible, but this also renders them to be less flexible. They have a larger drainage lumen when compared to a latex catheter (Figures 3 and 4).

 


'The two natural urethral bends in the male urethra are also the most common sites for urethral strictures to occur. They are the sites where the catheter may rub the most, resulting in trauma.'

 

5. Avoid antibiotics in catheterised patients

Practice pointPerhaps the biggest controversy that confuses healthcare professionals is the role of antibiotics in catheter care. The presence of a catheter in the human urinary tract effectively creates a dynamic biological ecosystem. When a catheter is inserted, a muco-protein film begins to develop on its surface — produced by the bladder urothelium. At the same time, bacteria ascend along the catheter and start to colonise the urinary system. Within 24 hours, all catheterised bladders are colonised with bacteria. Therefore, any patient who has had a catheter in place for more than one day will have a positive dipstick test of urine to leucocytes and nitrites. This is not infection, but rather normal colonisation due to the presence of a catheter. It is therefore essential to avoid doing a dipstick on urine from an existing catheter. Antibiotics will never eradicate this bacterial fauna, indeed, the exposure of antimicrobials to this ecosystem will simply clone out antibiotic resistance in a system where microbial colonisation is normal and unchangeable. The course, thus provides guidance on how antibiotic administration should be both limited and used effectively. Messages which are in keeping with the teaching of both the World Health Organization (WHO) and Health Education England (HEE, 2015).

It is important to remember that when a catheter is draining the bladder, semen from the prostate will also often leak alongside the tube, as there is no other escape for it. A common misconception is that this represents pus, and while it may be, this would be in the context of an acutely unwell patient. Semen often dries out causing an irregular encrustation along the catheter surface. Thus, in an asymptomatic, clinically well male patient, who notices encrusting or fluid around the catheter at the urethral meatus, this does not equate to infection and the need for antibiotics. A suprapubic catheter should be considered for patients with longterm catheters, as it has the benefit of not impeding semen flow.

Constant awareness of the fifth of these golden rules will help to reduce antibiotic resistance and improve clinical practice.
 

6. Do not overinflate the balloon

Catheter balloons are designed to keep the catheter safely in position, reducing the likelihood of it slipping into the prostate and/or falling out. Usually the balloon is filled to 10ml. Most Foley balloons can manage a volume in excess of 90ml before they burst. However, a larger volume can cause significant trouble for the bladder, as irritation from a catheter balloon can result in detrusor instability, causing bladder spasms and urine bypassing along the outside of the catheter.
A volume of 40ml is equivalent in size to that of a small tomato. Imagining an object of this size sitting at the bladder neck can help clinicians to understand why overinflating the balloon can result in symptoms of strangury. Strangury is the intense desire to void but being unable to pass more than a few dribbles, much the same as symptoms described by men with bladder stones. For this reason, it is important not to overinflate the catheter balloon.


7. Replace the foreskin

For patients who are not circumcised, before catheterisation the foreskin is withdrawn and the glans of the penis cleaned. This cleansing ensures that there is no superficial smegma, which may be swept up along the urethra with the advancing catheter.

Having inserted the catheter, seen urine drain, inflated the balloon and attached the catheter bag, remember to replace the foreskin. The foreskin should be pulled back forward over the glans into its normal position. A not infrequent complication arises due to a slight natural tightness of the foreskin proximal to the coronal sulcus. If very tight, this can be a phimotic band. If the distal foreskin hooks behind this band, the tissue can become oedematous and result in a paraphimosis.

Reducing a paraphimosis can be uncomfortable for the patient and challenging for the clinician. It is, therefore, best avoided by remembering the seventh golden rule, to always replace the foreskin.
 

8. Measure volume drained, describe and dipstick test

Before inserting any catheter, it is essential to record whether the patient is comfortable or not, and whether their bladder is palpable. This will help to determine if there is urinary retention and if it is acute or chronic.

Accurate record keeping is also essential, e.g. noting the patient’s heart rate, temperature and blood pressure gives vital information about their overall physical condition.

Recording the volume of urine drained is mandatory as it guides future clinical decisions. On first insertion of a catheter, urine should be dipstick-tested, for presence of nitrites, leucocytes or red blood cells. If these are present, the urine should be sent for microscopy, culture and sensitivity (MC&S).


'Accurate record keeping is essential. Making a note of the patient’s observations, their heart rate, temperature and blood pressure gives vital information for the overall physical state of the patient.'

 

KEY POINTS

- There are many different catheter-related problems encountered in clinical practice.
- Problems with catheters can cause considerable morbidity.
- An educational programme has been developed to improve catheter care across primary and seconday care settings.
- Key areas of catheter care include use of antibiotics, insertion and catheter size.
- Feedback has highlighted new emerging concerns and misconceptions around catheter care.
 


More information

TAKE-HOME MESSAGE

In the authors’ clinical opinion, there is scope for improvement to reduce controversy and variations in practice around catheter use and management. One programme, the Secret Life of Catheters, has been specifically designed to enhance the care and experience of patients by providing education to improve both the confidence of healthcare professionals and continence care provision.

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