Version July 2025
INTRODUCTION —
The first balloon catheter was designed in the 1930s by Frederic Foley; the basic catheter retains his name. Modern-day alternatives to indwelling urethral catheterization include external catheters, suprapubic catheters, intermittent catheterization, and, in some cases, supportive management with protective garments. Our recommendations for urinary 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 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 URINARY CATHETERS —
Urinary catheters are used for urinary drainage, or as a means to collect urine for measurement or access the bladder for treatment. Many clinical situations are appropriate for the placement of catheters, but too frequently they are used without proper indication or continued longer than needed. (See 'Inappropriate use of catheters' below.)
The single most important factor for preventing urinary catheter-related complications is limiting their use to appropriate indications [4-6]. Daily evaluation of the ongoing need for the catheter is essential to reduce complications. Urinary catheters are indicated in the following clinical situations (table 1):
●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'.)
●Management of patients with urinary incontinence following failure of conservative, behavioral, pharmacologic, and surgical therapy [7]. (See "Female urinary incontinence: Treatment".)
•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".)
●Urinary catheters are used to collect urine for measurement or deliver treatment to the bladder:
•Hourly urine output measurement in critically ill patients.
•Daily urine output measurement for fluid management or diagnostic tests.
•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 "Evaluation of hematuria in adults" and "Blunt genitourinary trauma: Initial evaluation and management".)
•Intravesical pharmacologic therapy (eg, bladder cancer). (See "Treatment of primary non-muscle invasive urothelial carcinoma of the bladder".)
●For patient safety, comfort, or continence:
•Management of immobilized patients (eg, stroke, pelvic fracture).
•Management of patients with neurogenic bladder from spinal cord injury. (See "Chronic complications of spinal cord injury and disease".)
•Improved patient comfort for end-of-life care. (See "Palliative care: The last hours and days of life", section on 'Loss of sphincter control'.)
Once the decision to use a urinary catheter has been made, the clinician should choose the most appropriate option based on the patient's unique needs, while also aiming to minimize the risk of catheter-associated urinary tract infections. Options include indwelling urethral catheters, external catheters, suprapubic catheters, and intermittent catheterization. A key consideration is whether the need for catheterization is acute or chronic (eg, a patient admitted with a pre-existing urinary catheter). The selection process is outlined in this algorithm (algorithm 1) and further detailed below. (See 'Choice of catheters' below.)
Inappropriate use of catheters — Unwarranted urinary catheters are placed in 21 to 50 percent of hospitalized patients [8-12].
●The most common inappropriate indication for placing an indwelling urethral catheter is management of urinary incontinence [10]. Chronic urinary incontinence should not be managed with an indwelling urethral catheter unless there is no other option (see 'Choice of catheters' below). 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 [7,13-15]. Alternatives, such as behavioral modification, drug therapies, surgery, and pads, are discussed elsewhere. (See "Female urinary incontinence: Treatment".)
●Other common examples of misuse 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.
●It is 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 [16].
●Catheters are 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 [17].
CHOICE OF CATHETERS —
The choice of catheter depends upon clinical indication and the expected duration of catheterization. Our suggestion for the initial choice of urinary catheter for various indications is presented in this algorithm (algorithm 1). Different catheters can be used during the course of care reflecting the patient's changing needs (table 1).
Indwelling urethral catheters are most commonly placed in the hospital setting for acute indications. However, they are intended for short-term use (less than three weeks) and should be changed to a suitable alternative when the indication for catheterization becomes subacute or chronic, or the expected duration of catheterization exceeds three weeks.
●For patients requiring chronic catheterization who do not have urinary retention, we suggest external catheters over urethral catheters whenever possible. (See 'External catheters' below.)
●For patients requiring chronic catheterization for bladder emptying dysfunction, we suggest intermittent catheterization over chronic indwelling catheters. (See 'Clean intermittent catheterization' below.)
Although urethral catheters are frequently used initially, substituting external catheters, intermittent catheterization, or suprapubic catheters 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 a 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) [18]. However, the initial choice of catheter may be influenced by factors other than the risk of urinary tract infection.
EXTERNAL CATHETERS —
External catheters are the least invasive means of collecting urine in patients who do not have urinary retention or urinary obstruction. They are widely used in chronic care facilities because they avoid urethral trauma and improve patient comfort and mobility compared with indwelling catheters [19-21] (table 1). The impact of external catheters on hospital-acquired urinary tract infections is not known because external catheters are typically not included in the surveillance programs of catheter-associated urinary tract infections [22].
External catheters are available as penile sheath catheters (ie, condom catheters) for males or urinary pouches for both males and females. 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 they are expected to place the device themselves [16].
Male external catheters — External sheath catheters (eg, condom catheters) are available in latex and silicone. Removable tips are available for men who also need to perform intermittent catheterization. Condom catheters are available in many sizes, and the 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. Options for males with a small or retracted penis include catheters that adhere directly to the glans penis, and adhesive urinary pouches [22].
Most sheath catheters are pre-rolled 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.
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. 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.
The application and maintenance of external catheters, while simple in theory, can be challenging. Condom catheters can cause irritation if attached too tightly; penile ulceration, scarring, and penile tissue loss can result. Dislodgement and urinary spillage can also be problematic [21]. (See "Complications of urinary bladder catheters and preventive strategies", section on 'External catheters'.)
Female external catheters — In the past decade, several external urinary devices have been designed for the female anatomy to reduce the use of indwelling catheters. These devices are placed in the perineal area between the labia, against the urethra, and connected to low continuous suction providing a sump mechanism to divert urine into an external canister [22].
It is crucial to regularly check any external urinary device, especially after bowel movement, and to inspect the perineal and vaginal skin for any signs of breakdown or fungal infection [23]. Additionally, the suction should be set to low, following the manufacturer's recommendations, to prevent pressure injuries.
Female external urinary devices have been associated with reduced catheter-associated urinary tract infections in some studies but not others [24]. A 2024 meta-analysis reported that implementing female external urinary devices reduced urethral catheter utilization rates by 14 percent (rate ratio 0.86, 95% CI 0.76-0.97) and nonsignificantly decreased catheter-associated urinary tract infection (CAUTI) rates by up to 32 percent (incidence rate ratio [IRR] 0.68, 95% CI 0.39-1.17). In studies that included detailed implementation protocols, the incidence of indwelling CAUTIs significantly decreased by up to 54 percent (IRR 0.46, 95% CI 0.32-0.66) [25]. 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 [26].
On the other hand, 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 [24]. As a result, patients may become more deconditioned and prone to falling when they do get out of bed.
INTERNAL CATHETERS —
Internal catheters are placed into the bladder to drain urine.
Types of internal catheters — Internal catheters can be placed through either the urethra or the abdominal wall.
●Urethral catheter – Urethral catheters are inserted through the urethral orifice and are appropriate for all indications related to catheterization (table 1). Once the bladder is decompressed, the catheter can be left in place or removed and reinserted at another time:
•Indwelling urethral catheter – Indwelling urethral catheters are most commonly used in the hospital setting for short-term bladder drainage (ie, less than three weeks). They are also used in patients with chronic urinary retention who are refractory to, or not candidates for, other interventions (eg, transurethral resection of the prostate). Indwelling urethral catheters should be inserted using sterile techniques. (See 'Placement of indwelling urethral catheters' below.)
•Intermittent urethral catheterization – 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) [16,27-29]. Intermittent catheterization is not commonly used for short-term catheterization except to achieve isolated decompression of a distended bladder, or instillation of pharmacologic therapy [30-39].
It is generally accepted that a clean (nonsterile) technique for intermittent catheterization is safe, with lower complication rates compared with indwelling urethral or suprapubic catheterization [28,30-37]. However, randomized trials that compared intermittent catheterization with indwelling urethral catheterization or suprapubic catheter were inclusive of asymptomatic bacteriuria or urinary tract infection [34]. (See "Complications of urinary bladder catheters and preventive strategies".)
Both indwelling and intermittent urethral catheters are placed in a similar fashion. The catheter used for intermittent catheterization is easier to insert as it is less bulky at the tip due to the absence of a balloon. While indwelling catheter placement is always performed with a sterile technique, intermittent catheterization can be performed with either a sterile or nonsterile, clean technique. (See 'Clean intermittent catheterization' below.)
●Suprapubic catheter – Suprapubic catheters are the most invasive type of catheter, requiring a surgical or interventional procedure to place through the abdominal wall directly into the bladder. (See 'Placement of suprapubic catheters' below.)
Compared with chronic indwelling urethral catheters, suprapubic catheters prevent urethral trauma and stricture formation. A 2015 Cochrane review of 42 trials also associated suprapubic catheters with less asymptomatic bacteriuria (risk ratio [RR] 2.25, 95% CI 1.63-3.10) and pain (RR 5.62, 95% CI 3.31-9.55), although the data on urinary tract infection were inconclusive (RR 1.01, 95% CI 0.61-1.69) [34]. Suprapubic catheterization also allows attempts at normal voiding without the need for recatheterization and interferes less with sexual activity. Patient comfort and preference usually dictate the choice.
Contraindications to urethral catheters — The only absolute contraindication to the placement of a urethral catheter is the presence of urethral injury, which is typically associated with pelvic trauma [40]. The presence of blood at the meatus or gross hematuria associated with trauma is evaluated first with a 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 males", section on 'Stress urinary incontinence'.)
Clean intermittent catheterization — In a 2017 meta-analysis of 14 randomized trials, intermittent catheterization was associated with a significantly decreased risk of urinary tract infection compared with indwelling urethral catheterization (odds ratio [OR] 0.173, 95% CI 0.073-0.412) when the duration of catheterization is longer than five days [18].
Patient populations that benefit from clean intermittent catheterization (CIC) technique are adults and children with neurogenic bladder, such as those with spinal cord injury [14,21,41,42]. For intermittent catheterization to be effective, it must be performed at regular intervals to prevent bladder overdistention [16,43].
Single- or multiple-use straight catheters without a balloon are used for intermittent catheterization. Low-friction hydrophilic catheters (eg, LoFric) do not require lubrication for insertion. In a 2023 meta-analysis of nine trials, hydrophilic catheter users had a lower risk of urinary tract infections compared with nonhydrophilic catheter users (RR 0.78, 95% CI 0.62-0.97) [44]. However, hydrophilic catheters did not reduce the rate of urinary tract infections compared with single-use nonhydrophilic catheters, and they did not reduce catheter-related sequelae of urethral problems (eg, hematuria) or improve patient satisfaction compared with standard catheters [44-46]. Hydrophilic catheters are also more expensive.
The technique for CIC is similar to that for placing an indwelling catheter, except CIC can be done using a clean technique and the catheter is removed after bladder drainage. Research indicates no differences in the incidence of asymptomatic bacteriuria or catheter-associated urinary tract infection between sterile versus clean techniques for intermittent catheterization [44,45]. Instructions for self-intermittent catheterization are as follows [47]:
●For males – 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 females – Females can choose between the standard 16-inch catheter or the shorter 6-inch catheter [46]. Assemble all equipment and wash hands with soap and water. CIC can be performed in any comfortable position; however, many females 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 fingers, 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 2 to 3 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.
Disposable catheters are discarded immediately after use. Reusable catheters 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. Research indicates no differences in the incidence of asymptomatic bacteriuria or catheter-associated urinary tract infection between coated versus uncoated catheters, or single-use versus multi-use catheters [44,45]. Compact catheters are available and may increase patient quality of life [48].
Outpatient chronic CIC can be challenging for the patient. Some individuals may not be able to perform intermittent catheterization due to upper extremity impairment, discomfort, obesity, urinary obstruction (eg, enlarged prostate, urethral stricture), or a reluctance to perform the procedure [2]. Successful CIC requires patients to have the necessary cognitive and physical abilities or access to an appropriately trained caregiver [49].
Indwelling catheter placement — Most indwelling catheters have two lumens: one for draining the catheter and one for inflating or deflating the balloon.
Catheter size should be individualized to the needs of the patient. In adults, a 14 to 16 Fr (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 females.
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 females with weak pelvic musculature if urine leakage occurs [50]. (See 'Managing leakage' below.)
Placement of indwelling urethral catheters — All indwelling urethral catheters should be placed using sterile techniques. For most adults requiring urethral catheterization, a standard Foley catheter (ie, double-lumen latex) is appropriate unless the patient has a latex allergy [51].
A typical urethral catheterization kit includes sterile gloves, drapes, antiseptic solution and sponges for periurethral cleansing, a single-use lubricant gel packet, urinary catheter, a prefilled syringe for balloon inflation, and a urine drainage system.
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.
Patients are positioned supine. Female patients are frog-legged to expose the perineum. Drapes are placed and the periurethral region is cleansed. The agent used to clean the meatus prior to catheter placement can vary and includes water [52-54], saline, soap, and antiseptics such as chlorhexidine or povidone-iodine. We prefer to use the antiseptic agent already provided in the kit. A systematic review and meta-analysis of 18 studies (15 trials) indicated a potential benefit of antiseptics in reducing the risk of bacteriuria or urinary tract infection (pooled OR 0.84, 95% CI 0.70-1.01), with 13 out of 18 studies favoring antiseptics [55]. In particular, a trial included in the meta-analysis found that meatal cleaning with 0.1% chlorhexidine solution, instead of normal saline, before catheter insertion reduced the incidence of catheter-associated asymptomatic bacteriuria by 74 percent and urinary tract infection by 94 percent [56].
●In male patients, the penis is grasped firmly with the provider's nondominant hand and tension is 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. The provider's dominant hand is used to place the lubricated catheter tip into the urethral meatus and steady gentle pressure is 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 males, 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.
●In female patients, the provider's nondominant hand is used to spread the labia to facilitate cleansing the periurethral region and viewing the urethral meatus. The dominant hand is used to place the lubricated catheter tip into the urethral meatus and steady, gentle pressure is used to advance the catheter until the flow of urine is seen.
Once urine flow is verified, we inflate the catheter balloon with the prefilled syringe provided in the kit. Catheters with water- and saline-filled balloons have similar failure rates [57,58]. However, air-filled balloons have a higher rate of balloon deflation and the catheter falling out. (See 'Difficult 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 is anchored to the leg with tape to prevent traction of the catheter on the urethral meatus [38]. (See 'Catheter drainage systems' below.)
Difficult urethral catheter placement — If no urine is obtained despite advancing the catheter to the hub, an assistant can apply gentle pressure to the patient's suprapubic region, which compresses the bladder and may initiate urine flow.
Additionally, in females, the insertion site of the catheter should be re-examined to see if vaginal catheterization may have occurred. If this is the case, the catheter is removed and a new sterile catheter is used to cannulate the urethra.
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. The catheter can be gently irrigated with 10 to 20 mL of sterile saline and should return the saline mixed with urine. If the saline is not returned or any resistance to catheterization is encountered, urethra/bladder pathology should be suspected and urologic consultation obtained.
In patients with an enlarged prostate, there is frequently proximal urethral angulation which requires either a larger (16 to 18 Fr) catheter or one with a coudé tip to access the bladder. By contrast, a urethral stricture may require a smaller catheter (eg, 12 Fr) to pass. Additionally, a coudé catheter may be helpful to access a retracted urethra in both males and females with obesity.
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 should be aborted, and a urologic consultation obtained. (See "Complications of urinary bladder catheters and preventive strategies", section on 'Effects of urethral trauma'.)
Specialized catheters — Besides standard latex Foley catheters, specialized catheters are available for the following clinical scenarios:
●Prolonged catheterization – Catheters are manufactured from latex, silicone, plastic, or Teflon [59-61]. 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 [16].
●Difficult 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.
●Bladder irrigation – Triple-lumen catheters are used for bladder irrigation and are available in larger diameters (20 to 24 Fr) to aid clot removal. 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.
●Infection prevention – 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 [59], these more costly catheters have not been shown to consistently reduce the incidence of catheter-associated urinary tract infection [1,16,59-71].
Placement of suprapubic catheters — Suprapubic catheters are the most invasive urinary catheter. They are placed into the bladder directly through the abdominal wall either surgically or percutaneously.
●Surgical suprapubic catheter is usually placed in association with other surgeries (eg, prostate, bladder trauma repair) by a urologist or urogynecologist. A 12 to 14 Fr catheter is generally selected.
●Alternatively, suprapubic catheters can also be placed percutaneously by an interventional radiologist. This procedure is typically performed under local anesthesia with possible intravenous sedation. Ultrasound is used to verify full bladder distension and identify any overlying loops of bowel prior to the procedure [72]. The catheter can be placed via either a direct puncture or the Seldinger technique (figure 2). If the patient has a history of prior lower abdominal surgery, percutaneous suprapubic catheters should not be attempted without simultaneous cystoscopy.
After percutaneous suprapubic catheter placement, the initial 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 regular Foley catheter, which may be more comfortable for the patient and less likely to dislodge due to the presence of a retention balloon [73,74].
Various types of suprapubic tubes are available, including balloon (eg, Foley, Rutner) and mushroom (eg, Malecot) catheters with lumen sizes ranging from 10 to 18 Fr. No benefit has been shown for any particular catheter [2].
Indwelling catheter care — Ideal catheter care is easy to prescribe but difficult to achieve [75,76]. 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 [77].
No routine 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 [78-84]. Antimicrobial therapy promotes the development of resistant bacterial strains. (See "Catheter-associated urinary tract infection in adults", section on 'Prevention'.)
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 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) [81]. 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 [81,82].
Similarly, a 2016 Cochrane review of three trials found it inconclusive whether prophylactic antibiotics are beneficial for catheter exchange [85]. The NICE guidelines do not recommend routine antibiotic prophylaxis for catheter exchange [86].
Meatal care — Cleansing with soap and water around the catheter (periurethral, suprapubic) during daily bathing is adequate for ongoing maintenance [87]. For urethral catheters, we do not use meatal disinfectants or antibacterial urethral lubricants because they do not prevent infection and may lead to the development of resistant bacteria at the meatus [88-91].
Managing leakage — If leakage occurs around a urethral catheter or established suprapubic catheter (more than six weeks after placement), the catheter can be replaced with a new catheter that is larger by 2 to 4 Fr.
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 recently placed (less than six weeks), a urologist or urogynecologist should be consulted.
Catheter drainage systems — 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 'Indwelling catheter care' above.)
Compared with open urinary drainage systems, closed catheter drainage systems restrict the development of bacteriuria [92]. In a prospective study of 676 patients with an indwelling urethral catheter, the incidence of bacteriuria in those managed with continuously closed urinary drainage was 23 percent, which was much lower than the reported historic incidence of 95 percent for open urinary drainage [93]. Based primarily on this study, the use of closed catheter urinary drainage systems became the standard of care [87,93].
It is worth noting that between 10 to 25 percent of patients who develop catheter-associated bacteriuria will develop a symptomatic urinary tract infection. 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 [94-100]. 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, the staff should wear gloves when they manipulate urinary catheters or drainage systems for any reason. When emptying the collection bag, the drainage spigot should not touch the collecting container [16,76]. Separate collecting containers should be used for each patient.
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 [101]. The application of tape at the catheter-drainage tubing junction does not reduce the incidence of bacteriuria [2,102]. 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 [16,71,92,103-106].
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 removal of the catheter. The collection system must stay below the level of the bladder at all times. For ambulatory use, there are urinary collection bags ("leg bags") designed to be strapped to the thigh.
Urine specimen collection — Microbiology specimens should not be obtained from the drainage bag. Urine specimens required for other analysis (eg, creatinine clearance) may be obtained aseptically from the drainage bag [16,107,108]. Procedures for obtaining urine samples for microbiologic analysis are discussed separately. (See "Catheter-associated urinary tract infection in adults", section on 'Diagnostic evaluation'.)
Bladder irrigation — Bladder irrigation is usually performed for specific purposes (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 [16]. If this is not effective, the catheter should be replaced. If there is a suspicion that the latex 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 of infection [109-111]. One randomized trial of 200 catheterized patients found no significant difference in the incidence of urinary tract infection for patients treated with neomycin-polymyxin bladder irrigation compared with no irrigation [109]. Patients who received bladder irrigation were found to have more resistant organisms.
Other approaches to reducing 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 [112].
Indwelling catheter exchange or removal
Timing of catheter removal — Indwelling urinary catheters should be removed as soon as it is no longer needed. A 2021 Cochrane review of 99 trials reported that earlier catheter removal can reduce the incidence of both symptomatic catheter-associated urinary tract infection (relative risk [RR] 0.52, 95% CI 0.45-0.61) and dysuria (RR 0.42, 95% CI 0.20-0.88), although the risk of recatheterization is increased compared with later removal (RR 1.81, 95% 1.35-2.41) [113].
Beyond catheter-associated urinary tract infection and dysuria, 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) [114]. 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 [115,116]. 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 (RR 0.50, 95% CI 0.29-0.87) [116]. 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 one versus day three, 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) [117].
On occasion, clinicians may be unaware that their patient has a urinary catheter, especially if it had been replaced after initial removal [118]. Reminders from nursing staff and the implementation of automatic stop orders reduce the duration of catheterization and the incidence of catheter-associated urinary tract infections [15,119,120]. 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 infections with the use of a reminder or stop order (RR 0.48, 95% CI 0.28-0.69). The duration of catheterization was decreased by 37 percent [119].
Catheter exchange — Indwelling catheters as a rule should not be replaced routinely; they should not be changed if flow appears adequate [121]. Changing an indwelling catheter at routine, fixed intervals is not recommended by the Centers for Disease Control and Prevention [6] and the Infectious Disease Society of America [2], and there is insufficient evidence to make a recommendation on long-term catheters (based on a 2016 Cochrane review of three trials) [85]. 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 [78]. However, catheters with mechanical problems (poor drainage, encrusted) need to be replaced. Additionally, NICE guidelines recommend removing or at least exchanging a catheter that has been in place for more than seven days if the patient develops a urinary tract infection [84].
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.
Catheter removal — 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.
A meta-analysis of 10 trials found catheter removal late at night may slightly reduce the risk of recatheterization compared with early morning (RR 0.71, 95% CI 0.53-0.96) [113].
According to the same Cochrane review, routine alpha-blocker prior to catheter removal did not reduce the need for recatheterization (RR 1.18, 95% CI 0.58-2.42) [113].
Difficult 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 [122]. 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 catheter 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.
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 5th to 6th 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 10th to 12th 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 topics (see "Patient education: How to use a catheter to empty the bladder in males (The Basics)" and "Patient education: How to use a catheter to empty the bladder in females (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Indications for urinary catheterization – Urinary catheters are generally placed for one of the following categories of reasons (table 1) (see 'Indications for urinary catheters' above):
•To treat urinary retention or obstruction
•To treat urinary incontinence
•To collect urinary for measurement or deliver treatment to the bladder
•For patient safety or comfort
Catheters are not indicated for determining the residual volume of urine or in the management of most patients with urinary incontinence. Limiting use to appropriate indications is important in minimizing catheter-related complications. (See 'Inappropriate use of catheters' above.)
●Choice of urinary catheters – Catheters available for urinary drainage include external (eg, condom, pouch), urethral (indwelling, intermittent), and suprapubic. Our suggestion for the initial choice of urinary catheter for various indications is presented in this algorithm (algorithm 1). (See 'Choice of catheters' above.)
•Indwelling urethral catheters are most commonly placed in the hospital setting for acute indications. However, they are intended for short-term use (less than three weeks) and should be changed to a suitable alternative when the indication for catheterization becomes subacute or chronic, or the expected duration of catheterization exceeds three weeks.
•For patients requiring chronic catheterization without urinary retention, we suggest external catheters over urethral catheters whenever possible (Grade 2C). (See 'External catheters' above.)
•For patients requiring chronic catheterization for bladder emptying dysfunction, we suggest intermittent catheterization over chronic indwelling catheters (Grade 2B). Clean technique is an acceptable and practical alternative to sterile technique. (See '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 'Indwelling catheter care' above.)
•All indwelling urethral catheters should be placed using sterile techniques. (See 'Indwelling catheter placement' 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 'Indwelling catheter care' above.)
•Bladder irrigation is usually only performed for specific purposes (eg, postoperative pharmacologic therapy) or for the management of hematuria. (See 'Indwelling catheter care' above.)
