Urinary Catheter Management.

[Argirios Argiriou]

American Family Physician. January 15, 2000.

Urinary Catheter Management (part 1).

DAVID D. CRAVENS, M.D., M.S.P.H., and
STEVEN ZWEIG, M.D., M.S.P.H.
 
University of Missouri¬Columbia School of Medicine, Columbia, Missouri.
 
The use of urinary catheters should be avoided whenever possible. Clean intermittent catheterization, when practical, is preferable to long-term catheterization. Suprapubic catheters offer some advantages, and condom catheters may be appropriate for some men. While clean handling of catheters is important, routine perineal cleaning and catheter irrigation or changing are ineffective in eliminating bacteriuria. Bacteriuria is inevitable in patients requiring long-term catheterization, but only symptomatic infections should be treated. Infections are usually polymicrobial, and seriously ill patients require therapy with two antibiotics. Patients with spinal cord injuries and those using catheters for more than 10 years are at greater risk of bladder cancer and renal complications; periodic renal scans, urine cytology and cystoscopy may be indicated in these patients. (Am Fam Physician 2000;61:369-76.)

For centuries, the urethral catheter system consisted of a tube inserted through the urethra into the bladder and drained into an open container. The closed catheter system was developed in the 1950s and is still in use today.1
 
Urinary catheterization can cause many health problems. Alternatives to catheterization should be used whenever possible. Studies have shown that universal bacteriuria occurs within four days when open catheters are used versus approximately 30 days with closed systems.1 Complications of long-term catheterization include chronic renal inflammation, chronic pyelonephritis, nephrolithiasis, cystolithiasis, symptomatic urinary tract infection with pyelonephritis, bacteremia, sepsis and death.1-4

 
....................
 TABLE 1
Indications for Use of Urinary Catheters
________________________________________
Long-term catheterization.

Bladder outlet obstruction not correctable medically or surgically
Intractable skin breakdown caused or exacerbated by incontinence
Some patients with neurogenic bladder and retention
Palliative care for terminally ill or severely impaired incontinent patients for whom bed and clothing changes are uncomfortable
Preference of a patient who has not responded to specific incontinence treatments.

Short-term catheterization.

Urologic surgery
Surgery on contiguous structures
Critically ill patients requiring accurate measure of urinary output
Acute urinary retention

....................
 
Clinical Indications for Catheter Use

Accepted indications for urinary catheterization are listed in Table 1.4-7 An initial episode of acute urinary retention should be treated with an indwelling catheter to allow the bladder to regain its tone, with catheter removal and a voiding trial after 10 to 14 days.8 While catheters are frequently used in older patients, chronic indwelling catheterization is not a substitute for good nursing care in the management of incontinence. Because a single in-and-out catheterization may cause bacteriuria in as many as 20 percent of older people,4 catheterization is not recommended as a way of obtaining urine specimens for diagnostic testing in patients who could provide a voided specimen.5 In women undergoing total vaginal hysterectomy, even short-term use of urinary catheters has been associated with longer hospital stays, and added cost and discomfort; it also discouraged early ambulation.9

Intermittent catheterization may be preferable to chronic indwelling catheterization in certain patients with bladder-emptying dysfunction.5 It has become the standard of care in patients with spinal cord injuries.10 Following surgical repair of a hip fracture, elderly patients regained satisfactory voiding more quickly (5.1 days versus 9.4 days) on a program of intermittent catheterization every 6 to 8 hours compared with the use of indwelling catheters.11 Women undergoing total abdominal hysterectomy who had in-and-out catheterization at the time of surgery had a lower rate of bacteriuria than women with indwelling catheters.12 While there has been reluctance to use clean intermittent catheterization in the nursing home,13 some higher-functioning nursing home patients may be candidates for self-administered clean intermittent catheterization using the procedure described in Table 2.14
 
Because as many as 20 percent of older patients have bacteriuria from a single catheterization, a urine sample should be obtained from a voided specimen, if possible.
 

In patients who require long-term intermittent catheterization, no difference in colonization or infection rates has been found between those using sterile single-use catheters and those using clean intermittent catheterization.14 Bacteriuria occurs in most patients in two to three weeks.10 Regular, frequent meatal cleansing offers no advantage in preventing bacteriuria or urinary tract infections in patients performing or using clean intermittent catheterization.15

....................
TABLE 2
Steps in Performing Clean Intermittent Self-Catheterization
________________________________________
1. Wash hands and catheter with soapy water.
2. Rinse hands and catheter with tap water.
3. Self-catheterize (without gloves).
4. After use, wash reusable catheter with soapy water, rinse and store in ventilated container until dry.
5. Place in plastic zipper bag or other clean container.

....................

Catheter Choices.
 
External Catheters

Use of a condom catheter should be considered in incontinent men without urinary retention who have severe functional disabilities.  16 In this setting, condom catheters are more comfortable and have a lower incidence of bacteriuria than indwelling catheters.1 Skin breakdown is common, whereas urethral diverticuli and penile ischemia occur only occasionally.6 To minimize sleep disruption and limit bacteriuria and other complications, condom catheters can be used only at night.16 External catheters have also been developed for female patients,17 but their safety and effectiveness have not been determined in nursing home patients.7
 

Urethral vs. Suprapubic Catheters.

Suprapubic catheters are recommended by some physicians for short-term use when a catheter is needed for gynecologic, urologic and other surgeries.1 Theoretically, there are fewer microbes on the abdominal wall than on the perineum, creating less risk for infection. Another advantage is easier catheter changes. Suprapubic catheters can also be clamped to test for adequate voiding. Some patients might also prefer a suprapubic catheter to enhance self-image and sexual functioning. Other patients prefer its comfort and convenience.1 Disadvantages of suprapubic catheters include the risk of cellulitis, leakage, hematoma at the puncture site, prolapse through the urethra1 and the psychologic barrier of insertion through the abdominal wall.

Latex vs. Silastic Catheters

Silastic catheters have been recommended for short-term catheterization after surgery. Compared with latex catheters, silastic catheters have a decreased incidence of urethritis and, possibly, urethral stricture.18 However, use in animal models for longer than six weeks showed no difference in inflammatory response between latex and silastic catheters.18 Because of its lower cost and similar long-term outcomes, latex is the catheter of choice for long-term catheterization. The cost differential becomes less significant in patients who do not require frequent catheter changes.6 Silastic catheters should be used in latex-allergic patients.
Catheters impregnated with various substances have not proved to be beneficial in patients with long-term catheterization. Silver-impregnated catheters, antibiotic-coated catheters and electrified catheters may diminish bacteriuria for a few days but are costly and have no role in long-term catheterization.4,19-21 In one study, silver-impregnated catheters were associated with more frequent bacteriuria and an increased risk of staphylococcal bacteriuria.21

 
Routine Management

Catheter Size

Authorities recommend choosing "the narrowest, softest tube that will serve the purpose."22 Rarely is a catheter larger than 18 F required, and 14 or 16 F usually suffices.22,23 A size 12 F catheter was found to be successful in catheterizing men with acute urinary retention.24 In most patients, it is best to minimize bladder irritation by using a catheter with a 5 mL balloon inflated with 5 to 10 mL of fluid.22
 
Minimizing Infection

Once the decision has been made to use an indwelling urinary catheter, efforts should be made to minimize problems. The catheter should be inserted using sterile technique (Table 3).5 Once inserted, the catheter should be anchored to prevent urethral traction. In men, the penis should lie over the lower abdomen with the catheter taped to the abdomen. In women the catheter should be secured to the anteromedial thigh.6
 
Infection in catheterized patients is suggested by fever, unusually cloudy urine, more frequent blockage or detrusor spasms.
 

Every attempt should be made to keep the drainage system closed. Any break in the catheter-to-collection unit may invite earlier infection. Infection in the catheterized patient is suggested by signs or symptoms of pyelonephritis 6,25 (fever greater than 38.3°C [100.9°F] for more than one day, mental status changes, hypotension), unusually cloudy urine, more frequent blockage, and new or increased detrusor spasms.
Avoiding cross-contamination is most important in controlling nosocomial epidemics of catheter-related infections.10 Caretakers should wash hands before and after any manipulation of a patient's catheter or collection unit. If possible, devices used for emptying collection bags should be clean and patient-specific.
....................
TABLE 3
CDC Guidelines for Prevention of Catheter-Associated UTI
________________________________________
Category I. Strongly recommended.

Catheterize only when necessary.
Educate personnel in correct techniques of catheter insertion and care.
Emphasize handwashing.
Insert catheter using aseptic technique and sterile equipment.
Secure catheter properly.
Maintain closed sterile drainage.
Obtain urine specimens aseptically.
Maintain unobstructed urine flow.

Category II. Moderately recommended

Periodically re-educate personnel in catheter care.
Use smallest suitable catheter bore.
Avoid irrigation unless needed to prevent or relieve obstruction.
Refrain from daily meatal care.
Do not change catheters at arbitrary intervals.
________________________________________
CDC = Centers for Disease Control and Prevention; UTI = urinary tract infection.
Information from Wong ES. Guideline for prevention of catheter-associated urinary tract infections. February 1981. Retrieved December 1999 from: Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος

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Catheters should not be changed routinely. Some physicians advocate monitoring patients for time-to-obstruction of urinary catheter, with the catheter changed just before the patient would be expected to obstruct.26 With this approach, some patients required catheter changes weekly, and others did not need them for several weeks. Such a policy will lead to fewer catheter changes than scheduled changes and will result in less trauma to the urinary system and fewer symptomatic infections.6 An obstructed catheter with cessation of urine flow for four to eight hours should obviously be changed. Some physicians recommend a catheter change when an episode of symptomatic urinary infection occurs.25
 
Several procedures that have been used to decrease the risk of infection are of no benefit. For example, meatal disinfectants and antibacterial urethral lubricants are ineffective.6 Cleansing with soap and water during bathing suffices to remove accumulated debris.6 Prophylactic bladder irrigations using antibiotics, hydrogen peroxide or povidone-iodine are not helpful.27-29 The end result is colonization or infection with more resistant organisms.

Some physicians recommend diluted acetic acid irrigations in patients with frequent catheter obstructions who have had no response to increased fluid intake or acidification of urine.7 Pharmaceuticals, including systemic antibiotics, methenamine (Hiprex) and acidifying agents have also not proved to be beneficial in minimizing bacteriuria or infection. Agents added to collection bags have also not proved effective. 6 Table 3 5 provides the guidelines from the Centers for Disease Control and Prevention for preventing catheter-associated infections.

End of part 1. To be continued..

Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος

[Argirios Argiriou]

American Family Physician. January 15, 2000.

Urinary Catheter Management (part 2).

DAVID D. CRAVENS, M.D., M.S.P.H., and
STEVEN ZWEIG, M.D., M.S.P.H.
 
University of Missouri¬Columbia School of Medicine, Columbia, Missouri.


Management of Complications.

Obstruction

The material that obstructs urinary catheters consists of bacteria, glycocalyx, protein and precipitated crystals.1 Patients who tend to develop blocked catheters excrete more calcium, protein and mucin, and have a higher urine pH level than patients with infrequent blockage.26 Proteus mirabilis bacteriuria may also be associated with catheter obstruction. Its potent urease splits ammonia, causing alkaline urine, which in turn precipitates crystals of struvite and apatite in the catheter lumen.6,10 Methenamine preparations may be beneficial in reducing episodes of obstruction.30 Irrigation may prevent repeated obstructions that are not responsive to increased fluid intake and urine acidification.7,31 However, obstructed catheters must be removed.
 
....................

TABLE 4
Anticholinergics For Treatment of Bladder Spasm
________________________________________
Medication
________________________________________   Dosage
________________________________________   Comments
________________________________________
Oxybutynin (Ditropan)    2.5 to 5 mg four times daily    May have central anticholinergic effects
Flavoxate (Urispas)    100 to 200 mg four times daily    May have central anticholinergic effects
Dicyclomine (Bentyl)    10 to 20 mg four times daily    Unapproved for bladder spasticity
Hyoscyamine sulfate (Cystospaz)    0.125 to 0.5 mg four times daily    May have central anticholinergic effects
Tolterodine (Detrol)    1 to 2 mg twice daily                    Better tolerated but may be less effective

....................

Leakage

Bladder spasms are not uncommon in patients with long-term catheterization. The force generated by spasms commonly overwhelms the drainage capacity of the catheter, creating leakage around the catheter. This type of leakage should not be corrected by using a larger diameter catheter. Infection or catheter obstruction, if present, should be treated. Antispasmodics, such as oxybutynin (Ditropan) and flavoxate (Urispas), can be effective in alleviating spasm due to detrusor instability (Table 4).
 
Colonization vs. Infection.

Virtually every patient with chronic catheterization is colonized with bacteriuria within six weeks. Bacteriuria also occurs within a few months in the majority of patients using clean intermittent catheterization. Asymptomatic bacteriuria does not require treatment.32 Antibiotic prophylaxis simply promotes emergence of antibiotic-resistant microbes.32,33 Slight pyrexia is not uncommon in patients with chronic indwelling urinary catheters and often lasts only a day. An isolated incident should not prompt initiation of antibiotic therapy.1 In the noncatheterized population, no evidence has been shown of a causal relationship between asymptomatic bacteriuria and mortality.4
Asymptomatic bacteriuria occurs frequently after the removal of a short-term¬use indwelling catheter.34 It is currently not clear what the proper treatment should be. Some physicians recommend treatment of asymptomatic bacteriuria, but it may be more reasonable to treat only symptomatic episodes. If treatment is chosen, a single dose of trimethoprim-sulfamethoxazole (Bactrim, Septra) is effective in asymptomatic younger women and those with lower urinary tract symptoms. Duration of antibiotic treatment should probably be at least 10 days in women 65 years and older.34 While no studies have addressed this issue in men, it seems reasonable to use this approach in men with short-term catheterization. Only symptomatic infection should be treated in patients undergoing long-term catheterization.10 Periodic urine cultures in chronically catheterized patients are not warranted. The bacterial flora changes over time, and serial cultures offer no benefit in determining correct antibiotic choice for future acute infection episodes.33
When a patient undergoing long-term catheterization develops fever, a source of infection should be sought. When urinary infection is suspected, culture should be obtained to guide therapy. Some physicians recommend inserting a new catheter and collecting a fresh urine sample for culture, to more accurately determine the source of bladder infection,4,25 although no data support this practice. Blood cultures may be helpful if bacteremia is suspected. Infections are usually polymicrobial and may include bacteria such as Pseudomonas, Proteus, Providencia, Enterobacteriaceae, Morganella and Enterococci.4,10
The usual duration of therapy is five to 14 days or longer.4 When multidrug-resistant pathogens are not likely and the patient is not critically ill, trimethoprim-sulfamethoxazole or a second-generation cephalosporin will generally suffice.4,25 Seriously ill or septic patients require a two-drug combination of ampicillin plus a third-generation cephalosporin such as ceftriaxone (Rocephin), aztreonam (Azactam), an aminoglycoside or a quinolone.4,25 A urinary Gram stain may guide empiric therapy while culture results are pending; one organism per oil field is approximately 90 percent sensitive in indicating 105 bacteria per mL on urine culture.25 Enterococcus is more frequently isolated from men.4 Treatment recommendations for catheter-associated urinary tract infections are summarized in Table 5.4-7,25
 
....................

TABLE 5
Treatment Recommendations for Catheter-Associated UTI
________________________________________
Catheterization period    Infection                   Treatment
________________________________________
Short-term    Single organism    TMP-SMZ (Bactrim, Septra)
                                                                 or
                                                                 Quinolone
                                                                 or
                                                                 Nitrofurantoin (Furadantin, Macrobid)
Long-term                   Usually polymicrobial     Noncritical illness:
                                                                 TMP-SMZ
                                                                  or
                                                                  Second-generation cephalosporin (e.g., Cefuroxime)
                                                                  Critical illness:
                                                                  Ampicillin plus one of the following:
                                                                  Ceftriaxone (Rocephin), cefprozil (Cefzil) or ceftazidime (Fortaz)
                                                                  or
                                                                  Aztreonam (Azactam)
                                                                  or
                                                                  Aminoglycoside or quinolone
________________________________________

UTI = urinary tract infection; TMP-SMZ = trimethoprim-sulfamethoxazole.
Information from references 4 through 7, and 25.

....................
 

Complications of urinary tract infections may occur. Increasing renal dysfunction and recalcitrant or recurring bacteremia should prompt a search for urinary stones or other causes of obstruction.1 Men may develop urethritis, urethral fistula, epididymitis, scrotal abscess, prostatitis and prostatic abscess.1,4
 
Special Circumstances.

Renal calculi are common in patients with spinal cord injury and affect at least 8 percent of patients.6 Renal failure is the cause of death in 20 to 68 percent of these patients. Thirty-nine percent of those who died from renal failure had urolithiasis at autopsy compared with 18 percent of those who died from nonrenal causes.6 Secondary prevention measures include annual urinary tract evaluation with creatinine clearance and a renal sonogram with urologic evaluation every three years, or more frequently if indicated.35
Periodic surveillance for urolithiasis and removal of stones is recommended to maintain renal function.35 Patients who have had an indwelling catheter for longer than 10 years have an increased risk of bladder cancer. In these people, annual cytology or cystoscopy is recommended as a secondary prevention strategy.6 However, none of these strategies has been systematically evaluated in a clinical trial.
Members of various medical faculties develop articles for "Practical Therapeutics." This article is one in a series coordinated by the Department of Family and Community at the University of Missouri¬Columbia School of Medicine, Columbia, Mo. Guest editor of the series is Robert L. Blake, Jr., M.D.
________________________________________
The Authors

DAVID D. CRAVENS, M.D., M.S.P.H.,
is an academic fellow in geriatrics and clinical instructor in the Department of Family and Community Medicine at the University of Missouri¬Columbia School of Medicine. After completing medical school and a family practice residency at the University of Missouri¬Columbia School of Medicine, Dr. Cravens practiced medicine in rural Missouri for 15 years.
 
STEVEN ZWEIG, M.D., M.S.P.H.,
is a professor in the Department of Family and Community Medicine and director of senior health care at the University of Missouri¬ Columbia School of Medicine. He attended medical school, completed a family practice residency and a Robert Wood Johnson Foundation¬sponsored fellowship in academic family practice at the University of Missouri¬Columbia School of Medicine.
Address correspondence to David D. Cravens, M.D., M.S.P.H., Department of Family and Community Medicine, University of Missouri¬Columbia School of Medicine, MA303 Health Sciences Center; DC032.00, Columbia, MO 65212. E-mail: cravensd@health.missouri.edu. Reprints are not available from the authors.

REFERENCES

1.   Warren JW. Catheter-associated bacteriuria. Clin Geriatr Med 1992;8:805-19.
2.   Warren JW, Muncie HL Jr, Hebel JR, Hall-Craggs M. Long-term urethral catheterization increases risk of chronic pyelonephritis and renal inflammation. J Am Geriatr Soc 1994;42:1286-90.
3.   Kunin CM, Douthitt S, Dancing J, Anderson J, Moeschberger M. The association between the use of urinary catheters and morbidity and mortality among elderly patients in nursing homes. Am J Epidemiol 1992;135:291-301.
4.   Yoshikawa TT, Nicolle LE, Norman DC. Management of complicated urinary tract infection in older patients. J Am Geriatr Soc 1996;44:1235-41.
5.   Wong ES. Guideline for prevention of catheter-associated urinary tract infections. Feb 1981. Retrieved September 27, 1999, from the World Wide Web: Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος wonder/prevguid/p0000416/entire.htm
6.   Wood DR, Bender BS. Long-term urinary tract catheterization. Med Clin North Am 1989;73: 1441-54.
7.   Besdine RW, Rubenstein LZ, Snyder L, eds. Medical care of the nursing home resident: what physicians need to know. Philadelphia: American College of Physicians, 1996.
8.   Ferri FF, Fretwell MD. Practical guide to the care of the geriatric patient. St. Louis: Mosby-Yearbook, 1992.
9.   Meeks GR. Discussion. In: Summitt RL Jr, Stovall TG, Bran DF. Prospective comparison of indwelling bladder catheter drainage versus no catheter after vaginal hysterectomy. Am J Obstet Gynecol 1994; 170:1818-21.
10.   Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am 1997;11:609-22.
11.   Skelly JM, Guyatt GH, Kalbfleisch R, Singer J, Winter L. Management of urinary retention after surgical repair of hip fracture. Can Med Assoc J 1992; 146:1185-9.
12.   Dobbs SP, Jackson SR, Wilson AM, Maplethorpe RP, Hammond RH. A prospective, randomized trial comparing continuous bladder drainage with catheterization at abdominal hysterectomy. Br J Urol 1997;80:554-6.
13.   Sadowski A, Duffy L. A survey of clean intermittent catheterization in long-term care. Urol Nurs 1988; 9(1):15-7.
14.   Moore KN, Kelm M, Sinclair O, Cadrain G. Bacteriuria in intermittent catheterization users: the effect of sterile versus clean reused catheters. Rehabil Nurs 1993;18(3):306-9.
15.   Bakke A, Vollset SE. Risk factors for bacteriuria and clinical urinary tract infection in patients treated with clean intermittent catheterization. J Urol 1993;149:527-31.
16.   Ouslander JG, Greengold B, Chen S. External catheter use and urinary tract infections among incontinent male nursing home patients. J Am Geriatr Soc 1987;35:1063-70.
17.   Pieper B, Cleland V. An external urine-collection device for women: a clinical trial. J ET Nurs 1993; 20(2):51-5.
18.   Nacey JN, Tulloch AG, Ferguson AF. Catheter-induced urethritis: a comparison between latex and silicone catheters in a prospective clinical trial. Br J Urol 1985;57:325-8.
19.   Shafik A. The electrified catheter. Role in sterilizing urine and decreasing bacteriuria. World J Urol 1993;11(3):183-5.
20.   Liedberg H, Lundeberg T, Ekman P. Refinements in the coating of urethral catheters reduce the incidence of catheter-associated bacteriuria. Eur Urol 1990;17:236-40.
21.   Riley DK, Classen DC, Stevens LE, Burke JP. A large randomized clinical trial of a silver-impregnated urinary catheter: lack of efficacy and staphylococcal superinfection. Am J Med 1995;98:349-56.
22.   McGill S. Catheter management: it's the size that's important. Nurs Mirror 1982;154(14):48-9.
23.   Pomfret IJ. Catheters: design, selection and management. Br J Nurs 1996;5(4):245-51.
24.   Allardice JT, Standfield NJ, Wyatt AP. Acute urinary retention: which catheter? Ann R Coll Surg Engl 1988;70(6):366-8.
25.   Wood CA, Abrutyn E. Urinary tract infection in older adults. Clin Geriatr Med 1998;14:267-83.
26.   Kunin CM, Chin QF, Chambers S. Indwelling urinary catheters in the elderly. Am J Med 1987; 82:405-11.
27.   Warren JW, Platt R, Thomas RJ, Rosner B, Kass EH. Antibiotic irrigation and catheter-associated urinary-tract infections. N Engl J Med 1978;299:570-3.
28.   Schneeberger PM, Vreede RW, Bogdanowicz JF, van Dijk WC. A randomized study on the effect of bladder irrigation with povidone-iodine before removal of an indwelling catheter. J Hosp Infect 1992;21:223-9.
29.   Sweet DE, Goodpasture HC, Holl K, Smart S, Alexander H, Hedari A. Evaluation of H2O2 prophylaxis of bacteriuria in patients with long-term indwelling Foley catheters: a randomized controlled study. Infect Control 1985;6(7):263-6.
30.   Norberg A, Norberg B, Parkhede U, Gippert H, Lundbeck K. Randomized double-blind study of prophylactic methenamine hippurate treatment of patients with indwelling catheters. Eur J Clin Pharmacol 1980;18:497-500.
31.   Ruwaldt M. Irrigation of indwelling urinary catheters. Urology 1983;21(2):127-9.
32.   Warren JW, Anthony WC, Hoopes JM, Muncie HL Jr. Cephalexin for susceptible bacteriuria in afebrile, long-term catheterized patients. JAMA 1982;248: 454-8.
33.   Breitenbucher RB. Bacterial changes in the urine samples of patients with long-term indwelling catheters. Arch Intern Med 1984;144:1585-8.
34.   Harding GK, Nicolle LE, Ronald AR, Preiksaitis JK, Forward KR, Low DE, et al. How long should catheter-acquired urinary tract infection in women be treated? A randomized controlled study. Ann Intern Med 1991;114:713-8.
35.   Binard JE. Care and treatment of spinal cord injury patients. J Am Paraplegia Soc 1992;15:235-49.
Copyright © 2000 by the American Academy of Family Physicians.
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Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος

[Argirios Argiriou]

From MedLinePlus ( authoritative information from NLM, the National Institutes of Health (NIH), U.S.A.)

Urinary catheters
 
Contents of this page:
Alternative Names
Definition
 Information
References
 

Alternative Names    

How to insert a catheter; Suprapubic catheters; How to remove a catheter; Foley catheter
Definition    Return to top

A urinary catheter is any tube system placed in the body to drain and collect urine from the bladder.

Information    Return to top

Urinary catheters are sometimes recommended as a way to manage urinary incontinence and urinary retention in both men and women. There are several different types of catheters. They may be used for a variety of different reasons.

URINARY CATHETERS

Urinary catheters may be used to drain the bladder. This is often a last resort because of the possible complications from long-term catheter usage. Complications of catheter use may include:

Bladder stones
Blood infections (septicemia)
Blood in the urine (hematuria)
Skin breakdown
Urethral injury
Urinary tract or kidney infections
After many years of catheter use, bladder cancer may also develop.

Your health care provider may recommend a catheter for short-term or long-term use. Long-term use catheters are called indwelling catheters.

Catheters come in a large variety of sizes, materials (latex, silicone, Teflon), and types (Foley catheter, straight catheter, coude tip catheter). For example, a Foley catheter is a soft plastic or rubber tube that is inserted into the bladder to drain the urine.

Experts recommend that the smallest possible catheter be used. Some people may need larger catheters to control urine leakage around the catheter or if the urine is thick and bloody or contains large amounts of sediment.

Be aware that larger catheters are more likely to damage the urethra. Some people have developed allergies or sensitivity to latex after long-term latex catheter use. These people should use the silicone or Teflon catheters.

LONG-TERM (INDWELLING) URETHRAL CATHETERS

A catheter that is left in place for a period of time may be attached to a drainage bag to collect the urine. There are two types of drainage bags.

One type is a leg bag. It is a smaller drainage device that attaches by elastic bands to the leg. A leg bag is usually worn during the day, because it fits discreetly under pants or skirts. It is easily emptied into the toilet.

The other type of drainage bag is a larger drainage device (down drain). It may be used during the night. This device is usually hung on the bed or placed on the floor.

HOW TO CARE FOR YOUR CATHETER

If the catheter is clogged, painful, or infected it may need to be replaced immediately.

To care for the indwelling catheter, cleanse the urethral area (where the catheter exits the body) and the catheter itself with soap and water every day. Also thoroughly cleanse the area after all bowel movements to prevent infection. Experts no longer recommend using antimicrobial ointments around the catheter, because they have not been shown to actually reduce infections.

Increase your fluid intake to reduce the risk of developing complications (unless you have a medical condition that prohibits large amounts of fluid intake). Discuss this issue with your health care provider.

The drainage bag must always stay lower than the bladder to prevent urine from flowing back up into the bladder. Empty the drainage device at least every 8 hours, or when it is full.

Take care to keep the outlet valve from becoming infected. Wash your hands before and after handling the drainage device. Do not allow the outlet valve to touch anything. If the outlet becomes obviously dirty, clean it with soap and water.

HOW TO CLEAN YOUR DRAINAGE BAG

Some experts recommend cleaning the drainage bag periodically. Remove the drainage bag from the catheter (attach the catheter to a second drainage device during the cleaning).

Cleanse and deodorize the drainage bag by filling the bag with two parts vinegar and three parts water. You can substitute chlorine bleach for the vinegar and water mixture. Let this solution soak for 20 minutes. Hang the bag with the outlet valve open to drain and dry the bag.

WHAT TO DO FOR A LEAKING CATHETER

Some people have occasional leakage of urine around the catheter. This may be caused by a catheter that is too small, improper balloon size, or bladder spasms.

If bladder spasms occur, check to see that the catheter is draining properly. If there is no urine in the drainage bag, the catheter may be blocked by blood or thick sediment. Or, there may be a kink in the catheter or drainage tubing.

If you have been instructed on an irrigation (flushing the catheter) procedure, try to irrigate the catheter and see if this helps. If you have not been instructed on irrigation and urine is not flowing into your collection device, contact your health care provider immediately.

Other causes of urine leakage around the catheter include:

Constipation or impacted stool
Urinary tract infections
POTENTIAL COMPLICATIONS

Contact your health care provider if you develop any of the following:

Bleeding into or around the catheter
Catheter draining little or no urine despite enough fluid intake
Fever, chills
Leakage of large amounts of urine around the catheter
Urine with a strong smell or becomes thick or cloudy
Urethral swelling around the catheter
SUPRAPUBIC CATHETERS

A suprapubic catheter is basically an indwelling catheter that is placed directly into the bladder through the abdomen. The catheter is inserted above the pubic bone. This catheter must be placed by a urologist during an outpatient surgery or office procedure. The insertion site (opening on the abdomen) and the tube must be cleansed daily with soap and water and covered with a dry gauze.

These catheters usually are changed by qualified medical personnel. The catheter may be attached to the standard drainage bags described above. A suprapubic catheter may be recommended:

After some gynecological surgeries
In people who need long-term catheterization
In people with urethral injury or obstruction
Complications of suprapubic catheter use may include:

Bladder stones
Blood infections (septicemia)
Blood in the urine (hematuria)
Skin breakdown
Urine leakage around the catheter
Urinary tract or kidney infections
After many years of catheter use, bladder cancer may also develop.

HOW TO INSERT A CATHETER (MEN)

Assemble all equipment: catheter, lubricant, sterile gloves, cleaning supplies, syringe with water to inflate the balloon, drainage receptacle.
Wash your hands. Use betadine or similar cleansing product (unless instructed otherwise) to clean the opening of the urethra.
Apply the sterile gloves. Make sure you do not touch the outside of the gloves with your hands.
Lubricate the catheter.
Hold the penis on the sides, perpendicular to the body. Stretch the penis away from the body.
Begin to gently insert and advance the catheter.
You will meet resistance when you reach the level of the external sphincter. Try to relax by deep breathing, and continue to advance the catheter.
Once the urine flow starts, continue to advance the catheter to the level of the "Y" connector. Hold the catheter in place while you inflate the balloon. Some men have developed urethral injuries due to the balloon being inflated in the urethra. Take care to ensure the catheter is in the bladder. You may try to irrigate the catheter with a few ounces of sterile water. If the solution does not easily return, you may not have the catheter far enough in the bladder.
Secure the catheter, and attach the drainage bag.

HOW TO INSERT A CATHETER (WOMEN)

Assemble all equipment: catheter, lubricant, sterile gloves, cleaning supplies, syringe with water to inflate the balloon, drainage receptacle.
Wash your hands. Use betadine or a cleansing product to clean the urethral opening. In women clean the labia and urethra opening using downward strokes. Avoid the anal area.
Apply the sterile gloves. Make sure you do not touch the outside of the gloves with your hands.
Lubricate the catheter.
Spread the labia and locate the opening below the clitoris and above the vagina.
Slowly insert the catheter into the opening.
Begin to gently advance the catheter.
Once the urine flow starts, advance the catheter another 2 inches. Hold the catheter in place while you inflate the balloon. Take care to ensure the catheter is in the bladder. If you feel pain while inflating the balloon, stop. Deflate the balloon, advance the catheter another 2 inches, and attempt to inflate the balloon again.
Secure the catheter, and attach the drainage bag.
 
HOW TO REMOVE A CATHETER

Indwelling catheters may be removed in two ways. One method is to attach a small syringe to the inflation port on the side of the catheter. Draw out all the fluid until you are unable to withdraw any more fluid. Slowly pull the catheter out until it is completely removed.

Note: Never remove your own catheter unless you have been trained by your health care provider. Only remove it when your doctor says you can.

Some health care providers instruct their patients to cut the inflation port tubing before it reaches the main tubing of the catheter. After all the water has drained out, slowly pull out the catheter until it is completely removed. Be careful not to cut the catheter anywhere else.

If you cannot remove the catheter with only slight pulling, notify your health care provider immediately.

Notify your health care provider if you are unable to urinate within 8 hours after catheter removal, or if your abdomen becomes distended and painful.

SHORT-TERM (INTERMITTENT) CATHETERS

Some people may only need catheterization on an occasional basis. These people can be taught to catheterize themselves to drain the bladder when needed. They don't have to constantly wear an external device.

People who may benefit from intermittent catheterization include:

Anyone who is unable to properly empty the bladder
Men with large prostates
People with nervous system (neurological) disorders
Women after certain gynecological surgeries
The process is similar to the procedures described above. However, the balloon inflation is not performed, and the catheter is removed after the flow of urine has stopped.

See also: Clean intermittent self-catheterization

References    Return to top

Moore KN, Fader M, Getliffe K. Long-term bladder management by intermittent catheterisation in adults and children. Cochrane Database Syst Rev. 2007;(4):CD006008.


Update Date: 5/22/2008

Updated by: Scott M. Gilbert, MD, Department of Urology, Columbia-Presbyterian Medical Center, New York, NY. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.


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[Argirios Argiriou]

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