Indwelling urinary catheters remain one of the most used clinically invasive devices in the UK (Loveday et al, 2014; Feneley et al, 2015). It is estimated that there are at least 90,000 people living in community settings in England currently using long-term urinary catheters (Gage et al, 2016).  

Clinical evidence demonstrates the length of time a catheter is in place can increase the risk of developing an infection and a significant number of patients with long-term catheters develop sepsis, which can lead to death (Chenoweth and Saint, 2013; Loveday et al, 2014). Furthermore, it has been estimated that around 2,100 deaths a year are directly caused by using indwelling catheters (Feneley et al, 2015). The cost of treating catheter-related urinary tract infections (CAUTIs) is estimated to be about £2,000 an episode, while the total annual cost of using indwelling catheters in the NHS is estimated to be between £1–2.5 billion (Yates, 2016).  

The impact of catheter complications is felt most by the patient who experiences significant issues relating to infection and the need for antibiotics (Chapple et al, 2016). Nursing and social care services across community and acute care departments report an increased demand on their services with catheter-related issues, leading to a reduction in capacity and ability to respond to the holistic needs of patients with indwelling catheters. This can impact on an already pressured healthcare economy across the NHS and social care sector (Tay et al, 2016; Ansell and Harari, 2017).  

There are recognised situations where the use of an indwelling urinary catheter is an acceptable option for managing bladder drainage. However, considering the evidence and risks of urinary catheters, their use must only be considered when all other options have been discounted. Appropriate management and early removal of these devices should also be a priority (National Institute for Health and Care Excellence [NICE], 2014; Davey, 2015; Yates, 2016; Simpson, 2017; Royal College of Nursing [RCN], 2019).  

WHEN SHOULD A CATHETER BE USED?


Clinical indications for the use of indwelling urinary catheters have been identified by the Royal College of Nursing (RCN, 2019) and the European Association of Urology Nurses (EAUN) (Geng et al, 2012) (Table 1).
 
• Acute or chronic retention of urine
  • • Accurate measurement of urine output in critically ill patients
  • • Neurological conditions affecting sensation or control of micturition
  • • Perioperative use for selected surgical procedures
  • • Urology/genito-urinary tract surgery
  • • Prolonged duration of surgery, intraoperative monitoring
  • • Wound healing of open sacral or perineal wounds in incontinent patients
  • • Patients requiring prolonged immobilisation, e.g. unstable thoracic or lumbar spine injuries, multiple trauma injuries
  • • Bladder irrigation/lavage
  • • To maintain skin integrity in intractable incontinence.  
Table 1: Indications for use of an indwelling urinary catheter (Geng et al, 2012; RCN, 2019).
There are significant risks associated with the introduction of a foreign body into the bladder (Table 2), not least infection, with statistics demonstrating that the longer a urinary catheter is in place, the more likely an infection is to develop (Loveday et al, 2014). Therefore, it is widely acknowledged that indwelling urinary catheters should only be used as a last resort and when all other options have been considered, tried and failed (RCN, 2019).
 
  • • Catheter-associated urinary tract infection
  • • Catheter blockage
  • • Catheter bypassing
  • • Iatrogenic trauma
  • • Bladder spasm
  • • Bladder pain  
  • • Haematuria
  • • Granulation formation
  • • Urinary extravasation
  • • Inability to remove catheter
  • • Squamous cell carcinoma (SCC)
  • • Epididymitis
Table 2: Complications associated with the use of indwelling urinary catheters (Geng et al, 2012; RCN, 2019).
 

BLADDER FUNCTION


It is important to understand the normal bladder physiology and the impact of a urinary catheter on normal bladder function to enable practitioners to promote effective and safe use of these devices.

Normal bladder


Urine can only be effectively stored in the bladder if the urethral pressure remains higher than the internal bladder pressure. A sustained substantive contraction of the pelvic floor, urethral wall and external sphincter increases and maintains a higher urethral pressure in comparison with the intravesical pressure to maintain continence (Feneley et al, 2015).

A compliant bladder is achieved when the detrusor muscle actively relaxes during the filling stage of the micturition cycle, allowing the bladder to stretch without allowing the internal pressure to increase. The parasympathetic nervous system inhibits detrusor contraction until the individual is ready to pass urine.

Increased abdominal pressure during coughing, laughing or sneezing is equally distributed to the urethra and bladder in a healthy person to ensure that pressures are maintained, and the pelvic floor supports the bladder effectively preventing leakage.

During the filling stage of the micturition cycle, receptors within the detrusor are stimulated to send messages to the sacral cord via afferent nerve pathways. Motor efferent nerves then transmit signals back to the detrusor muscle, initiating relaxation while maintaining a contracted external sphincter. This mechanism allows stretching and filling of the bladder.
This process is controlled from the pontine micturition centre (PMC) located in the frontal lobe of the brain. The first sensation of needing to pass urine usually occurs in adults at approximately 200–300ml, but the desire to urinate can be deactivated by the PMC until a socially acceptable time and place. The sensation intensifies as the bladder fills, until the voiding phase (usually recognised at approximately 500mls in adults, although this varies individually), where the receptors at the S2–S4 level are activated, initiating sphincter relaxation and bladder contraction in synergy to expel urine. This mechanism is susceptible to muscle fatigue and cannot be sustained indefinitely. Any urine remaining when the mechanism reverses is retained in the bladder until the next time urination is initiated (Feneley et al, 2015).

Aside from normal physiology, bladder function is also affected by social and psychological factors. Learned behaviour obtained through formal toilet training popular in westernised society can adversely affect the function of a normal bladder, as it encourages a belief that toileting is a totally private function behind a closed, locked door (Holroyd, 2015; Bladder & Bowel UK [BBUK] and ERIC, 2019). Any issue affecting continence, including the need to wear an indwelling catheter, can leave a patient feeling vulnerable and dependent on another person to manage the basic function of bladder emptying, resulting in a feeling of a lack of control (Booth, 2013; Holroyd, 2018).
 

EFFECT OF INDWELLING CATHETERS ON BLADDER FUNCTION


In some cases, a patient’s bladder function will slow down over a period of weeks or months when a catheter is in situ, especially if the urine is on continuous drainage into a bag (Addison, 2001; Robinson, 2005). There is an increase in negative pressure within the bladder and catheter drainage system (when on free drainage), which can lead to the mucosal walls of the bladder being ‘sucked’ into the catheter eyelet holes, causing a disruption to the drainage of urine and resulting in blockage (Geng et al, 2012; Feneley et al, 2015). Choice of the urine drainage bag attached to the catheter, and the distance the bag is placed from the bladder, can also have a negative impact on bladder drainage resulting in pain, urine bypassing, frequent catheter blockage or slower urine drainage (Feneley et al, 2015).

Some common issues reported by patients following removal of an indwelling catheter include incontinence, incomplete bladder emptying, lack of bladder sensation, frequency and urgency of micturition, detrusor over/underactivity, reduced bladder capacity, and urinary tract infection (UTI) (Gilbert, 2006; Colley, 2015; Feneley, 2015, Holroyd, 2018).

CATHETER VALVES


As previously discussed, the bladder protects itself by regularly filling and emptying. Catheter valve devices are attached to the indwelling catheter, negating the continuous use of a free drainage system and allowing controlled filling and emptying of the bladder. This mimics normal bladder function to some extent and reduces the risk of tissue trauma on the bladder neck, mucosal lining and urethra (Woodward, 2013). Additionally, the use of a catheter valve can preserve some bladder sensation and function in some patients (Yates, 2016).

A catheter valve is usually attached direct to the urinary catheter and can remain in situ for up to seven days before requiring a complete valve change. Any valve changes should be treated as an aseptic procedure to reduce the risk of infection. Patients or carers who are responsible for changing the valve should be taught by a healthcare professional the appropriate procedure for safe and effective changes. Opening and closing of the valve by a simple lever tap allows the bladder to fill and empty at designated times. This should be managed using appropriate infection control measures, including hand hygiene, and in situations where someone other than the patient is handling the valve, an aseptic technique is advised (RCN, 2019).
To manage the daily care of a valve, current advice is to wash the entry and exit points of the valve thoroughly at least once every 24 hours (RCN, 2019). This should be a clean or aseptic technique and can be managed in the same way as the standard protocol for catheter care (refer to local policies for exact procedure relevant in your area). It is also advised that before and after each use, the valve is wiped clean using an appropriate alcohol/ antiseptic wipe (refer to local policies for relevant procedures). Patients are also advised to wash their hands before and after handling the valve. It is not necessary for the patient to wear protective gloves, although gloves would be advised if a third person was handling the valve (RCN, 2019).

There are some clinical situations that do not support or benefit from the use of a catheter valve. The following factors should be considered before engaging in the use of a catheter valve, and careful individual assessment is key (Yates, 2016):
  • Capacity — the capacity of an individual bladder may affect the ability to store volume of urine, leading to the risk of an overdistended bladder or pain if the valve is not drained appropriately. Bladder capacity may also be dictated by recent surgery that requires avoidance of filling the bladder to protect anastomoses (common in urogynaecology, pelvic or abdominal procedures)
  • The risk of renal damage caused by a full bladder should always negate the use of a catheter valve system
  • Sensation — most patients will rely on a feeling of bladder fullness to alert them to open the catheter valve at an appropriate time to empty the bladder. Patients with a lack of bladder sensation may be taught to use a valve system safely and effectively if bladder capacity and frequency of need to empty can be established. This can be achieved through assessment of fluid intake and urine output over a period of at least 24 hours to establish kidney function and normal urine production, and will include specialised input from appropriately trained staff, preferably supported with the use of bladder scans
  • Cognitive ability — a patient with impaired cognitive function may not be able to manage a catheter valve safely and effectively, even with support of another person. Table 3 details the potential advantages and disadvantages of using a catheter valve.

Advantages

  • • Discretion
  • • Comfort
  • • Potential for maintenance bladder function, capacity and tone
  • • Mimics normal bladder
  • • Reduces risk of trauma by lifting bladder wall tissue away from catheter tip
  • • Reduces risk of bladder neck trauma caused by drainage bag
  • • The four hourly release schedule may reduce catheter blockage
  • • Possible reduction in risk of infection

Disadvantages

  • • Limited bladder capacity
  • • Potential for detrusor overactivity
  • • Ureteric reflex — when urine is forced back up the ureter towards the kidneys leading to swelling and potential damage of both ureter and kidney
  • • Reflux/anal impairment
  • • Poor dexterity
  • • Impaired bladder sensation
  • • Immobility
Table 3: Advantages and disadvantages of using catheter valves (Simpson, 2017).
The ultimate aim of any catheter should be early and timely removal to reduce the risks previously discussed. There has been some suggestion that using a catheter valve before trial without catheter (TWOC) may improve the success and outcome of the procedure (Woodward, 2013; Yates, 2016). The author has not been able to find any clinical evidence suggesting a minimum amount of time to wear a valve before a TWOC to ensure its success. In practice, the recommended timescale to wear a valve system appears to range from 48 hours to two weeks before removing the catheter. Clinicians should follow local policy and guidelines for use of catheter valves. It should be noted that a successful TWOC is not wholly dependent on the use of catheter valves — other considerations include fluid intake and bowel activity, which are essential to achieving a successful TWOC.

Practice point


It is important to ascertain a patient’s dexterity before using a catheter valve, as they vary in how they work — some need to be pushed laterally while others require twisting of a tap-like device (Woodward, 2013).

CONCLUSION


It is clear that the clinical risks associated with urinary indwelling catheters cause concern, while use of catheters remains a viable and effective treatment option for many patients. However, establishing the cost to a patient’s quality of life is difficult to determine, with the risk of serious infection increasing the longer the catheter is in place (Chang et al, 2011; Loveday et al, 2014). Some 45% of all bacteraemia cases caused by Escherichia coli are attributed to the urinary tract and the use of catheters (Abernathy, 2017).

It is a Public Health England (PHE) focus to reduce all healthcare-associated Gram-negative bloodstream infections (GNBSI) by 50% by 2021, and all trusts have been challenged with ensuring that a robust action plan is in place to achieve this by closer monitoring, early detection and appropriate treatment of CAUTIs (NHS Improvement, 2017). However, it should be noted that this target was unlikely to have been fully achieved given the focus on the global pandemic over the past 18 months. As health care settles into some kind of post pandemic normality, the reduction of healthcareassociated GNBSI will again become a higher priority. The guidance has been updated to reflect the global challenges with a new target date of 2024/25 for achieving the 50% reduction.

Appropriate use of a catheter valve can be achieved after careful individual assessment and may improve the chance of normal bladder function resuming following removal of the catheter. A valve system offers more discretion to the patient, as it can be hidden in clothing and managed easily by many patients. Use of catheter valves should always reflect latest best practice guidance and local policy.

References

Abernathy J, Guy R, Sheridan EA, et al (2017) Epidemiology of Escherichia coli bacteraemia in England, Results of an enhanced sentinel surveillance programme. J Hosp Infect 95(4): 365–75  

Addison R (2001) Trial removal of a catheter. Nurs Times 97(4): 45–6  

Ansell T, Harari D (2017) Urinary catheter-related visits to the emergency department and implications for community services. Br J Nurs 26(9)Suppl: S4–11  

Bladder and Bowel UK and ERIC (2019) Managing bladder and bowel issues in nurseries, schools and colleges. Available online: www.bbuk.org.uk/schools-resources/   

Booth J (2013) Continence care is every nurses’ business. Urol News 18(1): 17–19  

Chang R, Todd GM, Chenoweth CE (2011) Epidemiology of hospital acquired urinary tract related bloodstream infection at a university hospital. Infect Contr Hosp Epidemiol 32(11): 1127–9  

Chapple A, Prinjha S, Feneley R, et al (2016) Drawing on accounts of long-term urinary catheter use: design for the ‘seemingly mundane’. Qual Health Res 26(2): 154–63  

Chenoweth C, Saint S (2013) Preventing catheter-associated urinary tract infections in the intensive care unit. Crit Care Clin 29(1): 19–32  

Colley W (2015) Use of frequency volume charts and voiding diaries. Nurs Times 111(5): 12–15  

Davey G (2015) Troubleshooting indwelling catheter problems in the community. J Community Nurs 29(4): 67–74  

Feneley R, Hopley I, Wells P (2015) Urinary catheters history: current status, adverse events and research agenda. J Med Eng Technol 39(8): 459–70  

Gage H, Avery M, Flannery C, Williams P, Fader M (2016) Community prevalence of long-term urinary catheter use in England. Neurourol Urodyns 36(2): 293–6  

Geng V, Cobussen-Boekhorst H, Farrell J (2012) Catheterisation: Indwelling in Adults. European Association of Urology Nurses (EAUN), Holland  

Gilbert R (2006) Procedure to undertake a trial without catheter. Nurs Times 102(42): 48–50  

Holroyd S (2015) What can we do to improve the patient experience of continence care? J Community Nurs 29(2): 66–73  

Holroyd S (2018) Best practice for trial without catheter. Urology and Continence Care Today 1(1): 35–9 

Holroyd S (2018) Best practice in the use of indwelling catheterisation. Urology and Continence Care Today 1(1): 28–34  

Loveday HP, Wilson JA, Pratt RJ, et al (2014) epic3: national evidence-based guidelines for preventing healthcare associated infections in NHS hospitals in England. J Hosp Infect 86(Suppl 1): S1-70  

NHS England (2017) Preventing healthcare associated Gram-negative bloodstream infections (GNBSI). Updated 2019. Available online: https://www.england.nhs.uk/patient-safety/preventing-gram-negative-bloodstream-infections/  

National Institute for Health and Care Excellence (2014) Long Term Urinary Catheters: Prevention and Control of Healthcare-associated Infections in Primary and Community Care. NICE, London  

Robinson J (2005) Removing indwelling catheters: trial without catheter in the community. Br J Community Nurs 10(12): 553–7  

Royal College of Nursing (2019) Catheter care: RCN guidance for healthcare professionals. Last updated 2021. Available online: www.rcn.org.uk/professional-development/publications/catheter-care-guidance-for-health-care-professionals-uk-pub-009-915   

Simpson P (2017) Long-term urethral catheterisation: guidelines for community nurses. Br J Nurs 26(9): S22–S26  

Tay LJ, Lyons H, Karrouze I, et al (2016) Impact of the lack of community catheter care services on the emergency department. BJU Int 118(2): 327–34  

Woodward S (2013) Catheter valves: a welcome alternative to leg bags. Br J Nurs 22(11): 650–4  

Yates A (2016) Indwelling urinary catheterisation: what is best practice? Br J Nurs 25(9 Suppl): S4–12 
 
This piece was first published in the Journal of Community Nursing. To cite this article use: Holroyd S (2021) Catheter valves: appropriate use and reduction of risk to bladder. J Community Nurs 35(5): 52-56 


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