Placement and management of urinary bladder catheters in adults

INTRODUCTION — Bladder catheters are used for urinary drainage, or as a means to collect urine for measurement. Many clinical situations are appropriate for the placement of catheters, but too frequently they are used without proper indication or continued longer than needed. Daily evaluation of the ongoing need for the catheter is essential to reduce complications. Alternatives to indwelling urethral catheterization should be considered and include external sheath (ie, condom) catheters, suprapubic catheters, intermittent catheterization, and, in some cases, supportive management with protective garments. Our recommendations for urinary bladder catheter placement and care are generally consistent with major guidelines that focus on prevention of catheter-associated urinary tract infection [1-3].

This topic will discuss the use and management of urinary bladder catheters. Management of bacteriuria and catheter-associated urinary tract infection is discussed elsewhere. (See "Catheter-associated urinary tract infection in adults" and "Complications of urinary bladder catheters and preventive strategies".)

INDICATIONS FOR CATHETERIZATION — The single most important factor for preventing urinary catheter-related complications is limiting their use to appropriate indications (table 1) [4-6]. Urinary catheters are indicated in the following clinical situations:

●Management of urinary retention with or without bladder outlet obstruction. (See "Clinical manifestations and diagnosis of urinary tract obstruction (UTO) and hydronephrosis" and "Acute urinary retention", section on 'Bladder decompression'.)

●Hourly urine output measurement in critically ill patients.

●Daily urine output measurement for fluid management or diagnostic test.

●During surgery to assess fluid status and prevent bladder overdistention (ie, prolonged procedures, large-volume fluid infusion).

●During and following specific surgeries of the genitourinary tract or adjacent structures (ie, urologic, gynecologic, colorectal surgery).

●Management of hematuria associated with clots. (See "Etiology and evaluation of hematuria in adults" and "Blunt genitourinary trauma: Initial evaluation and management".)

●Management of immobilized patients (eg, stroke, pelvic fracture).

●Management of patients with neurogenic bladder. (See "Chronic complications of spinal cord injury and disease".)

●Management of open wounds located in the sacral or perineal regions in patients who are incontinent. (See "Clinical staging and general management of pressure-induced skin and soft tissue injury".)

●Intravesical pharmacologic therapy (eg, bladder cancer). (See "Treatment of primary non-muscle invasive urothelial bladder cancer".)

●Improved patient comfort for end-of-life care. (See "Palliative care: The last hours and days of life", section on 'Loss of sphincter control'.)

●Management of patients with urinary incontinence following failure of conservative, behavioral, pharmacologic, and surgical therapy [7]. (See "Female urinary incontinence: Treatment".)

Contraindications — The only absolute contraindication to the placement of a urethral catheter is the presence of urethral injury, which is typically associated with pelvic trauma [8]. The presence of blood at the meatus or gross hematuria associated with trauma is evaluated first with retrograde urethrogram; urologic consultation and urethroscopy may be necessary. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Retrograde urethrogram'.)

Relative contraindications to urethral catheterization include urethral stricture, recent urinary tract surgery (ie, urethra, prostate, bladder), and the presence of an artificial sphincter. For these issues, a urologist or urogynecologist should be consulted to assist with management.

If an artificial sphincter is present, it should be deactivated and catheterization limited to a short period of time. Artificial sphincters are discussed elsewhere. (See "Stress urinary incontinence in females: Persistent/recurrent symptoms after surgical treatment", section on 'Artificial urinary sphincter' and "Urinary incontinence in men", section on 'Stress urinary incontinence'.)

Inappropriate use of catheters — Unwarranted urinary catheters are placed in 21 to 50 percent of hospitalized patients [9-13]. The most common inappropriate indication for placing an indwelling urethral catheter is management of urinary incontinence [11]. While catheter use in these patients may have a short-term nursing benefit, the increased risk of complications associated with their use outweighs any benefit [7,14-16]. (See "Female urinary incontinence: Treatment".)

It is also inappropriate to use catheters to obtain urine for testing in individuals who are capable of voiding spontaneously or who can reliably collect urine for monitoring output [17]. Catheters are also often used to measure residual urinary bladder volume in hospitalized patients; however, we prefer the use of a portable ultrasound unit (eg, BladderScan). These devices correctly estimate residual volume greater than 50 mL in >90 percent of patients [18].

Other common examples include catheterizing older adults, even those who are continent, to prevent them from being toileted to reduce staff time and leaving catheters in longer than necessary in postoperative patients.

CHOICE OF CATHETER — The choice of catheter depends upon clinical indication and expected duration of catheterization. Different catheters can be used during the course of care reflecting the patient's changing needs (table 1). The best alternative to an indwelling urethral catheter should be considered.

Although urethral catheters are frequently used initially, substituting external catheters, or intermittent catheterization, can reduce complications. In a network meta-analysis of 14 randomized trials, the risk of urinary tract infection was comparable between indwelling urethral catheterization, suprapubic tube, and intermittent catheterization if catheterization duration was ≤5 days. If catheterization duration was >5 days, however, intermittent catheterization and suprapubic tube were associated with significantly decreased risk of urinary tract infection compared with indwelling urethral catheterization (odds ratio [OR] 0.173, 95% CI 0.073-0.412 and OR 0.142, 95% CI 0.073-0.276, respectively) [19]. However, the initial choice of catheter may be influenced by factors other than the risk of urinary tract infection.

External — External catheter systems are the least invasive for urine drainage and are available as penile sheath catheters (ie, condom catheters) or urinary pouches. External catheters are not appropriate for accurate urine measurement or management of urinary obstruction (table 1). (See 'External catheter systems' below.)

Male external catheter — Condom catheters are an effective mode of collecting urine in men who do not have evidence for urinary retention or urinary obstruction. A condom catheter does not facilitate bladder drainage; it only collects urine. They are widely used in chronic care facilities [20,21]. Contraindications to their use include the presence of penile ulceration or perineal dermatitis. It is important to ensure the patient has adequate manual dexterity if he is expected to place the device himself [17].

Advantages of condom catheters are minimization of urethral trauma and improved comfort and mobility compared with indwelling catheters [22]. The decreased incidence of urinary tract infection associated with condom catheters is dependent upon patient cooperation and minimization of catheter manipulation.

The main disadvantage of condom catheters is irritation if attached too tightly; penile ulceration, scarring, and penile tissue loss can result. Dislodgement and urinary spillage can also be problematic [22]. (See "Complications of urinary bladder catheters and preventive strategies".)

Female external catheter — In the past decade, several external urinary devices have been designed for the female anatomy, which have been found to reduce the use of indwelling catheters. Female external urinary devices have been associated with reduced catheter-associated urinary tract infections in some studies but not others [23].

In a study of 50 patients, an external urinary device diverted 85 percent of patients' urine into the canister [24]. In a survey of 119 patients and 204 caregivers who used a female external urinary device (PureWick), >80 percent favored the newer device to diapers despite a higher cost [25].

Some clinicians are concerned that the use of an external urinary device that relies on suction may create an additional "tether" that disincentivizes patients from getting out of bed [23]. As a result, patients may become more deconditioned and prone to falling when they do get out of bed.

Urethral — Urethral catheters are inserted through the tip of the urethra (ie, transurethrally) and are appropriate for all indications related to catheterization (table 1).

Indwelling — Indwelling urethral catheters are most commonly used in the hospital setting for short-term bladder drainage (ie, <3 weeks). They are also used for management for patients with chronic urinary retention who are refractory to, or not candidates for, other interventions (eg, transurethral resection of the prostate).

Intermittent — Intermittent catheterization, which is the removal of the catheter immediately after bladder decompression with recatheterization on a scheduled basis, is an alternative to indwelling catheterization. When intermittent catheterization is used, it must be performed at regular intervals to prevent bladder overdistention [17,26]. (See 'Clean intermittent catheterization' below.)

Intermittent urethral catheterization can be used for either short- or long-term management of urinary retention or neurogenic bladder dysfunction (eg, patients with spinal cord dysfunction, myelomeningocele, or bladder atonia) [17,27-29]. Despite its advantage of reducing complications, intermittent catheterization is not commonly used for short-term catheterization [30-39]. Isolated (single) use of intermittent catheterization can be applied to achieve isolated decompression of a distended bladder, or instillation of pharmacologic therapy.

Intermittent catheterization may not be possible for some patients due to upper extremity impairment, discomfort, obesity, or urinary obstruction (eg, enlarged prostate, urethral stricture), and others who may not be willing to perform the procedure [2].

Suprapubic — Suprapubic catheters are the most invasive catheter and require a surgical procedure for placement, usually by a urologist or urogynecologist. A suprapubic catheter is placed through the abdominal wall and into the bladder either intraoperatively in association with another surgical procedure or percutaneously.

Suprapubic catheterization prevents urethral trauma and stricture formation, reduces the incidence of catheter-associated bacteriuria (at least temporarily), and may be associated with increased patient satisfaction compared with chronic indwelling urethral catheters. Suprapubic catheterization allows attempts at normal voiding without the need for recatheterization and interferes less with sexual activity. Patient comfort and preference usually dictate the choice.

Various types of suprapubic tubes are available, including balloon (eg, Foley, Rutner) and mushroom (eg, Malecot) catheters with a single lumen in sizes ranging from 10 to 18 F. No benefit has been shown for any particular catheter [2].

CATHETER TECHNOLOGY — Most catheters have dual-lumen tubes with one lumen draining the catheter and the other delivering water to the balloon. The first balloon catheter was designed in the 1930s by a surgeon, Frederic Foley; the basic catheter retains his name.

For most adults requiring urethral catheterization, a standard Foley catheter (ie, double-lumen latex) is appropriate. Single- or multiple-use straight catheters without a balloon are used for intermittent catheterization.

Sizing — Catheter size should be individualized to the needs of the patient. In adults, a 14 to 16 French (Fr/3 = diameter in millimeters) catheter is typically chosen for short-term indwelling catheterization. Larger catheters, 20 to 24 Fr, are used to provide an adequate bore for the drainage of hematuria or clots. Sizing charts are available to determine the proper diameter for children.

Both short (21 cm) and longer (40 to 45 cm) catheter lengths are available. Shorter catheters may be more appropriate for women.

Two balloon volumes are available, 5 mL and 20 to 30 mL. For most patients, a 5 mL balloon is adequate. A larger balloon volume may be desirable in some postoperative patients or women with weak pelvic musculature if urine leakage occurs [40]. (See 'Managing leakage' below.)

External sheath catheters (ie, condom catheters) are available in many sizes, and use of a measurement or sizing guide is recommended. Penile circumferential measurement is taken at the mid shaft of the nonerect penis as it is gently extended away from the body. Size is adjusted as needed.

Materials — Catheters are manufactured from latex, silicone, plastic, or Teflon [41-43]. Latex catheters are inexpensive and the most commonly used. However, latex is associated with urethral inflammation, which may be due to protein and salt encrustation on the surface of the catheter. Chronic inflammation from prolonged catheter use can lead to urethral stricture. For this reason and the potential for latex allergy, silicone catheters may be preferable when more prolonged catheterization is required [17]. (See "Complications of urinary bladder catheters and preventive strategies", section on 'Urethral catheters'.)

External catheter systems

Male external catheter — Condom catheters are available in latex and silicone. Removable tips are available for men who also need to perform intermittent catheterization.

Most sheath catheters are prerolled and incorporate a self-adhesive vertical strip that provides penile fixation. Self-adhesive sheaths have fewer complications compared with those that require separate adhesive strips or other fixating devices. These are often circumferentially placed and can cause undue tissue compression. (See "Complications of urinary bladder catheters and preventive strategies", section on 'External catheters'.)

Options for males with a small or retracted penis include catheters that adhere directly to the glans penis, and adhesive urinary pouches. Adhesive urinary pouches are also available for women.

Female external catheter — These devices are placed in the perineal area between the labia, against the urethra, conforming to the female anatomy, and connected to low continuous suction providing a sump mechanism to divert urine into an external canister.

It is essential that any external urinary device is regularly changed (and as needed with any bowel movement) and the perineal and vaginal skin integrity checked to avoid skin breakdown or fungal infection [44]. The suction should be set on low per manufacturer’s recommendation to avoid pressure injury.

Specialized catheters — Specialized catheters are available for use as the need arises and include coudé and hydrophilic catheters to facilitate catheter placement, triple-lumen catheters for irrigation, and antimicrobial catheters and other strategies for preventing urinary tract infection.

To facilitate insertion

●Coudé (ie, bent) catheters have a curved tip that facilitates catheter placement in males, especially those with obstructive uropathy due to benign prostatic hyperplasia.

●Low-friction hydrophilic catheters (eg, LoFric) do not require lubrication for insertion and may be useful when intermittent catheterization is needed. In observational studies, hydrophilic catheters reduce urethral inflammation and are associated with improved patient satisfaction in some, but not all, studies [45-47]. Catheter-related bacteriuria, urinary tract infection, or sequelae of urethral problems in patients managed with intermittent catheterization are not significantly reduced compared with standard catheters [47]. These catheters are also more expensive.

To irrigate the bladder

●Triple-lumen catheters are used for bladder irrigation and are available in larger diameters (20 to 24 Fr) to aid removal of clot. Irrigation fluid is instilled into the bladder through the irrigation port and drained through the catheter. Intermittent or continuous irrigation can be used depending upon the indication for irrigation.

To prevent urinary tract infection

●Antimicrobial catheters are coated with antimicrobial agents (eg, nitrofurazone, minocycline, or rifampin) or silver. While silver alloy catheters appear to reduce the incidence of bacteriuria [41], these more costly catheters have not been shown to consistently reduce the incidence of catheter-associated urinary tract infection [1,17,41-43,48-57].

Catheter drainage systems — Because between 10 to 25 percent of patients who develop catheter-associated bacteriuria will develop a symptomatic urinary tract infection, catheter drainage systems have been designed to limit the development of bacteriuria [58]. Based primarily upon a prospective study of 676 patients, the use of closed catheter urinary drainage system is the standard of care [59,60]. In this prospective trial, the incidence of bacteriuria in patients managed with continuously closed urinary drainage was 23 percent compared with a reported historic incidence of 95 percent for open urinary drainage. The pathogenesis of urinary tract infection in the presence of urinary catheters is discussed separately. (See "Catheter-associated urinary tract infection in adults", section on 'Epidemiology'.)

For patients who develop bacteriuria, the drainage bag represents a large reservoir of pathogens, many of which are resistant to antimicrobials [61-67]. Cross-contamination of bacteria from one patient to another is possible, and outbreaks of urinary tract infection with highly resistant organisms have occurred. As such, gloves should be worn whenever the catheter and drainage system are manipulated. (See 'Meatal care' below.)

Preconnected systems (catheter is preattached to the tubing of a closed drainage bag) may reduce bacteriuria, but there are insufficient data to support a reduction in the incidence of catheter-associated urinary tract infection [68]. The application of tape at the catheter-drainage tubing junction does not reduce the incidence of bacteriuria [2,69]. Randomized trials evaluating more complex drainage systems, including those that release antiseptic solutions into the drainage bag, have not demonstrated a reduction in the incidence of urinary tract infection [17,57,58,70-73].

We prefer to use a sterile, continuously closed drainage system with a needle aspiration port and antireflux device to prevent urine backflow. We replace the drainage unit for any disruption in the urine collection system (ie, catheter disconnect). (See 'Catheter care' below.)

EXTERNAL CATHETER PLACEMENT — The application and maintenance of external catheters (eg, condom catheter), while simple in theory, can be challenging. Nonsterile gloves should be used when applying or handling the device. The prior device is removed gently with careful removal of any adhesive; adhesive remover can also be used. Devices are placed per manufacturer's instructions.

For self-adhesive penile condom catheters, the penis is cleansed with soap and water and dried prior to application of the new device. The condom catheter is applied to the tip of the penis and rolled up the length of the penis, gently pressing the self-adhesive strip into place. It is important to unroll as completely as possible to minimize any residual roller ring, which can produce tissue compression. (See "Complications of urinary bladder catheters and preventive strategies", section on 'External catheters'.)

TRANSURETHRAL CATHETER PLACEMENT — Both indwelling and intermittent urethral catheters are placed in a similar fashion. The catheter used for intermittent catheterization is easier to insert; it is less bulky at the tip because there is no balloon. While indwelling catheter placement is always performed with sterile technique, intermittent catheterization can be performed with either sterile or nonsterile, clean technique. (See 'Clean intermittent catheterization' below.)

A typical urethral catheterization kit includes sterile gloves, drapes, antiseptic solution and sponges for periurethral cleansing, a single-use lubricant gel packet, urinary catheter, prefilled syringe for balloon inflation, and urine drainage system. Several trials have found no significant differences in the rates of bacteriuria or urinary tract infection for obstetric patients prepared with water compared with antiseptic solution prior to catheter placement [74-76]; another trial found that meatal cleaning with 0.1% chlorhexidine solution, as opposed to normal saline, before catheter insertion decreased the incidence of catheter-associated asymptomatic bacteriuria and urinary tract infection [77]. We prefer to use the antiseptic agent already provided in the kit.

The patient is placed in a supine position. In women, the lower extremities are frog-legged to maximize exposure of the periurethral region. Adequate lighting is essential. Sterile gloves are donned and the catheterization kit is inspected to ensure its contents are complete and free of defects. If an indwelling catheter is chosen, the balloon can be inflated briefly to check its integrity, but this is generally not necessary. For silicone catheters, checking the balloon should not be performed, because the region of the balloon can become wrinkled, making placement more difficult. The end of the catheter, if not preattached, can be attached to the drainage system before or after catheter placement.

Drapes are placed and the periurethral region cleansed. In men, the penis is grasped firmly with the nondominant hand and tension directed toward the ceiling, straightening the urethra. A viscous lidocaine solution can be instilled into the urethra prior to catheter insertion at the clinician's discretion. In women, the nondominant hand is used to spread the labia to facilitate cleansing the periurethral region and viewing the urethral meatus.

The gloved dominant hand is used to place the lubricated catheter tip into the urethral meatus and steady gentle pressure used to advance the catheter. When a coudé catheter is used, the curved tip of the catheter should be oriented toward the dorsal surface of the penis (figure 1). When the catheter tip approaches the external sphincter in men, resistance will be felt. It is often helpful to pause momentarily to let the sphincter relax before continuing insertion.

The catheter should be inserted to the flared portion of the catheter (ie, hub). The balloon is inflated only after the flow of urine is seen. Air should not be used to inflate the balloon because of the risk of balloon deflation and catheter falling out. There is no consensus on whether it is better to use water or saline to inflate the balloon [78-80]; we recommend using the fluid at the specified volume in the prefilled syringe that comes with the kit. (See 'Troubleshooting catheter removal' below.)

Once the balloon is inflated, the catheter is withdrawn until slight resistance is felt. The urine collection system is connected and the drainage tubing anchored to the leg with tape to prevent traction of the catheter on the urethral meatus [38].

Troubleshooting urethral catheter placement — If no urine is obtained, an assistant can be asked to apply gentle pressure to the suprapubic region, which may initiate urine flow. In women, the insertion site of the catheter is examined; vaginal catheterization may have occurred. If this is the case, the catheter is removed and a new sterile catheter used.

If the catheter has passed easily to its hub, suprapubic pressure has been applied, and urine is still not observed, the patient may be dehydrated or may have voided recently. Gentle irrigation through the end of the catheter using 10 to 20 mL sterile saline can be performed and should return the saline mixed with urine. If the saline is not returned or any resistance to catheterization was encountered, underlying pathology may be present and urologic consultation should be obtained.

If the patient complains of pain during catheter insertion, the catheter should be removed. If blood appears at the meatus or on the tip of the catheter, a urethral injury may have occurred. The procedure is abandoned and a urologic consultation is obtained. (See "Complications of urinary bladder catheters and preventive strategies", section on 'Effects of urethral trauma'.)

Clean intermittent catheterization — Patient populations that benefit from clean intermittent catheterization (CIC) technique are adults and children with neurogenic bladder, including patients with spinal cord injury [15,22,81,82]. Clean (nonsterile) technique for intermittent catheterization is safe with lower complication rates compared with indwelling urethral or suprapubic catheterization [28,30-37]. (See "Complications of urinary bladder catheters and preventive strategies".)

No differences in the incidence of asymptomatic bacteriuria or catheter-associated urinary tract infection have been found between sterile versus clean technique for intermittent catheterization, coated versus uncoated catheters, or single-use versus multi-use catheters [83,84]. Compact catheters are available for use and may increase patient quality of life [85]. (See "Catheter-associated urinary tract infection in adults".)

The technique for CIC is generally the same as for indwelling catheter placement except for the option for clean technique and the removal of the catheter following bladder drainage. If the catheter is disposable, it is discarded immediately after use. Reusable catheters are also available and can be used for up to four weeks. Following catheterization, the reusable catheter is washed with soap, rinsed with water, dried, and stored in a clean, dry location.

Outpatient chronic CIC can be challenging for the patient. The patient must have appropriate cognitive and physical abilities to self-catheterize [86] or an appropriately trained caregiver. Instructions to assist performing self-intermittent catheterization are as follows [87]:

●For men – Once all equipment (ie, catheter, lubricant, drainage receptacle) is assembled and the hands are washed thoroughly with soap and water, clean the urethral meatus with soap and water. Lubricate the catheter and gently insert into the urethra with the penis positioned perpendicular to the body. As resistance is felt at the level of the prostate, relax and breathe deeply, then continue to advance the catheter. Once the urine starts to flow, continue to advance the catheter another inch. Hold the catheter in place until the urine flow stops and the bladder is empty. Remove the catheter slowly to allow complete drainage of the bladder.

●For women – Assemble all equipment and wash the hands with soap and water. Clean intermittent catheterization can be performed in any comfortable position; however, many women find it easiest to stand with one foot on the toilet. Clean the vulva with soap and water. With the nondominant hand, spread the labia with the second and fourth finger, using the middle finger to locate the urethral opening, which is below the clitoris and above the vagina. Gently insert the catheter into the opening with the dominant hand. Guide the catheter toward the umbilicus (ie, belly button). Urine will begin to flow when the catheter has been inserted two to three inches. Advance the catheter another inch and hold it in place until the urine flow stops and the bladder is empty. Remove the catheter slowly to allow complete drainage of the bladder.

SUPRAPUBIC CATHETER PLACEMENT — Suprapubic tube insertion is performed by an interventional radiologist with a percutaneous technique, or a urologist or urogynecologist with an open surgical technique.

●Open suprapubic catheter placement is usually in association with other surgeries (eg, prostate, bladder trauma repair). A 12 to 14 Fr catheter is generally selected. If the patient has a history of prior lower abdominal surgery, percutaneous suprapubic catheters should not be attempted without simultaneous cystoscopy.

●The percutaneous procedure is performed using sterile technique with local anesthesia, and sedation if needed. Ultrasound is used to verify full bladder distension and identify any overlying loops of bowel prior to the procedure [88]. The catheter can be placed via either a direct puncture or Seldinger technique (figure 2). The catheter should remain in place for at least four to six weeks to allow for tract maturation, after which it can be changed to a urethral catheter, which may be more comfortable for the patient and less likely to dislodge due to the presence of a retention balloon [89,90].

CATHETER CARE — Ideal catheter care is easy to prescribe but difficult to achieve [91,92]. A Danish study using questionnaires to assess knowledge of and adherence to optimal catheter management protocols in hospitals and nursing homes showed moderate familiarity with written guidelines but frequent irregularities in practice [93].

Meatal care — Cleansing with soap and water around the catheter (periurethral, suprapubic) during daily bathing is adequate for ongoing maintenance [59]. For urethral catheters, we do not use meatal disinfectants or antibacterial urethral lubricants, because they do not prevent infection and may lead to development of resistant bacteria at the meatus [94-97].

When the catheter or drainage system is manipulated for any reason, nonsterile gloves should be used and then immediately discarded to limit transfer of pathogens from patient to patient. The bag should be emptied regularly, avoiding contact of the drainage spigot with the collecting container [17,92]. Separate collecting containers should be used for each patient.

Managing leakage — If leakage occurs around an established suprapubic catheter (>6 weeks after placement) or transurethral catheter, the catheter can be replaced with a new catheter that is larger by 2 to 4 F.

Leakage can be due to detrusor overactivity/uninhibited bladder contractions, particularly in some patients with neurologic conditions (eg, multiple sclerosis). In this setting, other approaches including partially deflating the balloon or treatment with antimuscarinic medications may be effective.

If leakage persists or the suprapubic catheter has been more recently placed, a urologist or urogynecologist should be consulted.

Monitoring for obstruction/preventing backflow — The catheter and collecting tubing should be free from kinking and fixed to the patient's leg by a strap or tape to prevent tugging or inadvertent traumatic removal. The collection system must be positioned below the level of the bladder at all times. Leg urinary collection bags that are strapped to the thigh are available for ambulatory use. If the catheter or drainage system is manipulated to relieve an obstruction, gloves (nonsterile) should be used.

Urine specimen collection — Specimens should not be obtained from the drainage bag when collecting urine for gram stain or culture. If specimens are required for other analysis (eg, creatinine clearance), they can be obtained aseptically from the drainage bag [17,98,99]. Procedures for obtaining urine samples for microbiologic analysis are discussed separately. (See "Catheter-associated urinary tract infection in adults", section on 'Diagnosis'.)

Changing the catheter — Indwelling catheters as a rule should not be replaced routinely; they should not be changed if flow appears adequate [100]. Changing an indwelling catheter at routine, fixed intervals is not recommended by the Centers for Disease Control and Prevention (CDC) [6] and the Infectious Disease Society of America, and there is insufficient evidence to make a recommendation on long-term catheters [2]. Although there is a brief reduction in the density of bacteria found in the urine following catheter replacement, this is a short-lived phenomenon of uncertain benefit [101]. However, catheters with mechanical problems (poor drainage, encrusted) need to be replaced.

Suprapubic catheters are generally managed by the operating surgeon and are not changed until a tract between the bladder and abdominal wall is established, which usually requires four to six weeks. If the catheter is accidentally pulled out within six weeks of its placement, the operating surgeon should be notified.

Bladder irrigation — Bladder irrigation is reserved for selected patients (eg, postoperative, pharmacologic therapy) or for the management of hematuria. However, if a catheter is not draining properly, it can be irrigated once with sterile saline [17]. If this is not effective, the catheter should be replaced. If there is a suspicion that the latex catheter material contributed to the obstruction, the catheter should be changed to a silicone catheter to reduce future encrustation.

Antimicrobial irrigation of the bladder does not appear to prevent or delay urinary tract infection; rather, this practice may increase the risk for infection [102-104]. One randomized trial of 200 catheterized patients found no significant difference in the incidence of urinary tract infection for patients treated with a neomycin-polymyxin bladder irrigant compared with no irrigation [102]. Patients who received bladder irrigation were found to have more resistant organisms.

Other approaches to reduce the incidence of urinary tract infection associated with bladder catheters include bacterial interference (purposeful inoculation of the bladder with nonpathogenic bacteria). Further investigation is required to determine whether these are appropriate for routine use [105].

Catheter removal — The simplest strategy for preventing catheter-related urinary tract infection is catheter removal when the indication for insertion is no longer met. Removing an indwelling urethral catheter is usually a matter of aspirating the balloon port with an empty syringe, which deflates the balloon; the catheter should then slip out. Suprapubic catheters are typically removed by the operating surgeon once the indication for catheter placement has resolved. Beyond association with urinary tract infection and the attendant complications, inappropriate use of indwelling catheters has been associated with increased mortality, further highlighting the importance of catheter removal when it is no longer needed. In a prospective study of 535 hospitalized older adults who had no medical indication for catheterization, death within 90 days of hospital discharge was more likely among the 75 patients who received a catheter (25 versus 10 percent among those without a catheter) [106]. The association remained despite adjustment for usual predictors of early mortality, suggesting that catheters are hazardous in this setting, or more likely, there is a poorly defined but clear preference for using catheters in patients who are likely to have a poor prognosis.

Following surgery not in the urinary tract, catheters should be removed as soon as possible (ideally in the recovery room) to reduce the incidence of urinary tract infection [107,108]. If a catheter was inserted for surgery on the urinary tract, it should only be removed by, or with prior approval of, the surgeon (urologist).

A meta-analysis of seven randomized trials found fewer urinary tract infections when urinary catheters were removed within one day postoperatively compared with three days (relative risk 0.50, 95% CI 0.29-0.87) [108]. A subsequent trial demonstrated that even after major pelvic colorectal surgery, early catheter removal is feasible and advantageous. In that trial of 142 patients with mostly ileal pouch anal anastomosis and low anterior resection, removing the urinary catheter on day 1 versus day 3, coupled with an alpha-antagonist (prazosin 1 mg orally), did not increase the rate of retention (8.5 versus 9.9 percent) but reduced the rate of infection (0 versus 11 percent) and length of stay (four versus five days) [109].

On occasion, clinicians may be unaware that their patient has a urinary catheter, especially if it had been replaced after initial removal [110]. Reminders from nursing staff and implementation of automatic stop orders reduce the duration of catheterization and incidence of catheter-associated urinary tract infection [16,111,112]. A systematic review and meta-analysis of 14 studies that evaluated reminder systems found a 52 percent reduction in the rate (episodes per 1000 catheter-days) of catheter-associated urinary tract infection with the use of a reminder or stop order (rate ratio [RR] 0.48, 95% CI 0.28-0.69). The duration of catheterization was decreased by 37 percent [111].

Troubleshooting catheter removal — The balloon of a urinary catheter may fail to deflate properly due to a faulty valve mechanism or obstructed balloon channel. Obstruction is uncommon and is typically due to the formation of crystals when saline rather than water is used to inflate the balloon and the catheter has been in place for a prolonged period of time.

The first line of action if the fluid within the balloon cannot be aspirated is to cut the valve (ie, balloon port) from the catheter at its junction. This should result in immediate flow of water from the balloon. To minimize the potential for urethral trauma, allow some time for the balloon to drain before withdrawing the catheter. Rupturing the balloon by overinflation should not be attempted, since balloon fragmentation will result about 80 percent of the time in requiring cystoscopy for retrieval [113]. If cutting the valve fails to deflate the balloon, a urologist or urogynecologist may be able to maneuver a ureteric stylet through the inflation channel to dislodge the obstruction. If this fails, the patient will need to be sedated and the balloon punctured sharply with a spinal needle, using a transabdominal, transurethral, or transvaginal approach.

Accidental or traumatic removal — If an indwelling urinary catheter is accidentally removed (often by the patient), it can be gently replaced if there is no blood at the meatus. However, if there is blood at the meatus or if there is resistance upon reinserting the catheter, the reinsertion attempt should be aborted and urologic consultation requested.

Prophylactic antibiotics — Systemic antimicrobial agents should not be administered to patients who do not have a proven urinary tract infection in either a short- or long-term catheterization setting [101,114-118]. Antimicrobial therapy promotes the development of resistant bacterial strains. (See "Catheter-associated urinary tract infection in adults", section on 'Prevention' and "Catheter-associated urinary tract infection in adults", section on 'Asymptomatic bacteriuria'.)

Whether or not specific subpopulations with urinary catheters might benefit from prophylactic antimicrobials is unclear. In a meta-analysis that included six randomized and one nonrandomized study performed in mostly surgical patients, many of whom had undergone a urologic procedure, antimicrobials given around the time of catheter removal reduced the absolute risk of subsequent symptomatic urinary tract infection (UTI) by 5.8 percent (31 infections among 665 patients who received antimicrobials compared with 90 of 855 patients in the control groups, relative risk 0.45, 95% CI 0.28-0.72) [116]. These results cannot be generalized to patients catheterized for other reasons. It is important to note that the nonrandomized study contributed the greatest proportion of patients [116,117].

COMPLICATIONS — The complications of urinary catheter placement are discussed in detail elsewhere. (See "Complications of urinary bladder catheters and preventive strategies".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Urinary catheters".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: How to use a catheter to empty the bladder (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Indications for urinary bladder catheter – There are many indications for using bladder catheters (table 1). Limiting use to appropriate indications is important in minimizing catheter-related complications. Catheters are not indicated for determining the residual volume of urine or in the management of most patients with urinary incontinence. (See 'Inappropriate use of catheters' above.)

Urinary catheters are used selectively for operative patients based upon the nature (ie, pelvic surgery) and duration of the procedure or need for perioperative fluid monitoring. Catheters should be removed as soon as possible, preferably in the recovery area, if feasible (see 'Indications for catheterization' above and 'Catheter removal' above). However, catheters inserted for surgery on the urinary tract should only be removed by, or with prior approval of, the surgeon (urologist).

●Choice of urinary bladder catheter – Catheters available for urinary drainage include external (eg, condom), urethral (indwelling, intermittent), and suprapubic catheters. (See 'Choice of catheter' above.)

•For male patients who do not have evidence of urinary retention or bladder outlet obstruction, we suggest external catheters over urethral catheters whenever possible (Grade 2C). (See 'Choice of catheter' above.)

•For patients with bladder emptying dysfunction, we suggest intermittent catheterization over chronic indwelling catheters (Grade 2C). Clean technique is an acceptable and practical alternative to sterile technique. (See 'Choice of catheter' above and 'Clean intermittent catheterization' above.)

●Catheter maintenance – Routine maintenance of urinary catheters includes proper hygiene of the pericatheter region, maintenance of unobstructed urine flow, frequent and proper emptying of the closed catheter drainage system, and proper specimen collection. (See 'Catheter care' above.)

•Following aseptic placement of indwelling catheters, the standard is to use a closed drainage system. Breaks in the integrity of the closed system should prompt replacement of the drainage system. (See 'Catheter drainage systems' above.)

•Indwelling urethral catheters and drainage systems are changed only for a specific clinical indication such as infection, obstruction, or compromise of closed system integrity. (See 'Catheter care' above.)

•For patients who do not have gross hematuria associated with clots, we suggest not irrigating urinary catheters (Grade 2C). (See 'Catheter care' above.)