The use of an artificial hollow tube to drain bladder contents dates back to the time of the ancient Egyptians (Nazarko, 2012). Despite advances in medical technology, the Foley indwelling catheter has changed little in its design and concept since it was initially popularised in the 1930s by an American Urologist (Feneley et al, 2015). The risks of indwelling urinary catheters have been well publicised (Chenoweth and Saint, 2013), with evidence suggesting the incidence of catheter-associated urinary tract infection (CaUTI) accounts for 20% of all healthcare acquired infections (HCAIs). These impact significantly on the health economy, with the cost of treating one single episode of CaUTI at almost £2,000 (Loveday et al, 2014).
 

'Clinical indication for catheter use should be clearly identified and documented within patient records, and challenged every time the catheter is changed to ensure it is still the safest option for managing an individual’s bladder drainage.'


 Use of indwelling urinary catheters should be a last resort and must adhere to the best practice guidance available, which is designed to reduce risk/harm to patients (National Institute for Health and Care Excellence [NICE], 2014; Davey, 2015; Yates, 2016; Simpson 2017, Royal College of Nursing [RCN], 2019).

Despite the evidence, there are still estimated to be over a million catheters inserted across the NHS every year, equating to almost a quarter of all hospitalised patients using a urinary catheter during their inpatient stay (Health Protection Scotland, 2012; Feneley et al, 2015). The statistics relating to community care usage vary greatly, and may in some areas be as high as 40% (Royal College of Physicians [RCP], 2005; Loveday et al, 2014).

WHEN TO USE AN INDWELLING CATHETER

The RCN best practice guidelines relating to catheterisation were revised and re-published earlier this year (RCN, 2019). These guidelines are aimed at any healthcare professional responsible for safe and effective catheterisation techniques, and should be readily available and widely evidenced in everyday practice across the various health and social care environments. NHS Improvement also recently updated national clinical documentation to support the safe and effective use of urinary catheters (NHS Improvement, 2019).

Any situation where the bladder cannot effectively empty or drain needs careful assessment and consideration of how best to be managed. This can only be achieved with an individual assessment of clinical symptoms and need (Feneley et al, 2015; Yates, 2016). While it is recognised that an indwelling catheter is a last resort, there are several reasons for their legitimate use (Geng et al, 2012; RCN, 2019) (Table 1).

Assessment should include risk assessments of contraindications before insertion (RCN, 2019), as well as consideration of the type of product and drainage system used to ensure safe and effective drainage of the bladder (Leaver, 2017).
Table 1
 H  haematuria
 O  obstructed
 U  urologic surgery
 D  decubitus ulcers, open sacral or perineal sore in an incontinent patient
 I  input/output monitoring
 N  not for resuscitating/end-of-life care/comfort
 I  immobility due to physical restraints.
 
Clinical indication for catheter use should be JCN 2019, Vol 33, No 5 41 clearly identified and documented within patient records, and challenged every time the catheter is changed to ensure it is still the safest option for managing an individual’s bladder drainage. When a patient has an indwelling catheter, its presence should be challenged regularly to ensure it is only worn for the shortest amount of time possible. Use of the HOUDINI acronym is widely incorporated in many acute trusts and catheters are challenged every 24 hours.

In community settings, it can be more difficult to challenge catheters on a regular basis due to caseload management and actual physical contact with patients.

WHICH CATHETER TO CHOOSE?

Catheter and balloon sizes
The material, size, length and duration of a urinary catheter should be carefully considered before insertion. The charrière (CH) size of the catheter should be small enough to reduce tissue damage and trauma, but large enough for effective and timely drainage. The European Association of Urology Nurses (EAUN) evidence-based guidelines (Geng et al, 2012) recommend a 12–14CH in adult males and females for urethral catheterisation, and a size 16CH or larger for suprapubic catheters. Smaller CH catheters can be adversely affected by abdominal pressure on the catheter material, whereas too large a CH can increase tissue trauma.

Catheter length in the UK is available in three different choices:
  • Paediatric length, which is 30cm and available up to a size 10CH
  • Female length, which is 23–26cm, and available in sizes 10–26CH
  • Standard or male length, which is 40–44cm, and available in sizes 10–26CH.
A standard length catheter must always be used in adult males aged 16 and above, as insertion of a shorter length may result in balloon inflation within the urethra leading to haematuria, swelling, retention, and significant trauma to the prostatic urethra (National Patient Safety Agency [NPSA], 2009). Standard length catheters are also useful in females who are larger, obese or taller, as the extra length offers more comfort and drainage connection is further away from the genitalia. Standard length catheters should also be the only choice in female transgender patients who have undergone significant urethral reconstruction.

The female length catheter should only be used in females and may offer more discretion to the wearer as it is easily concealed, and there is less movement in and out of the urethra (Yarde, 2015). There may be rare cases where a female length catheter is useful in a male patient, for example, a very slender build gentleman with a demonstrably short urethra or suprapubic tract, whereby the use of a longer length catheter would increase the risk of migration and tissue trauma. However, these situations should always be overseen by a competent urologist or clinical nurse specialist.

Balloon size of the catheter is an important consideration when choosing which catheter to use. Manufacturers produce Foley catheters for use in adults with balloon sizes ranging from 5mls to 30mls. The larger balloons can increase the risk of trauma and infection within the bladder neck, sphincter or suprapubic entry site, and leave a higher residual volume of urine within the bladder, thereby increasing the risk of infection from the static urine (Garcia et al, 2007; Feneley et al, 2015). Larger balloons may also increase the incidence of urine bypassing, bladder spasms, pain and discomfort (Simpson, 2017).

When inflating the balloon of a catheter, manufacturers’ advice should be followed and the balloon should never be overinflated beyond its maximum capacity. It may in some situations be acceptable to catheter occurs. In an underinflated balloon, this can increase the risk of self-expulsion; the catheter simply drops out with the balloon still inflated. This osmosis effect may be reduced by using glycerine solutions to inflate the balloon (Simpson, 2017). Saline should never be used to inflate a catheter balloon, as it leads to crystallisation and may cause pain, discomfort or increased risk of infection. underinflate the balloon, for example, to ease discomfort or pressure. 
However, it should be noted that due to the osmosis that occurs with sterile water-filled balloons, a loss of volume within the balloon over the life of a catheter occurs. In an underinflated balloon, this can increase the risk of self-expulsion; the catheter simply drops out with the balloon still inflated. This osmosis effect may be reduced by using glycerine solutions to inflate the balloon (Simpson, 2017). Saline should never be used to inflate a catheter balloon, as it leads to crystallisation and may cause pain, discomfort or increased risk of infection.
Catheter materials
Many different types of materials are used in the manufacture of indwelling urinary catheters. Healthcare professionals should consider the use of latex, siliconecoated or composite materials (Elvy and Colville, 2009), and choose the appropriate material with the least risk to the individual.

Latex is made from natural rubber and has been a popular choice for catheters due to the flexibility. The surface, however, does have a tendency to stick due to friction and is associated with increased catheter encrustation (Yates, 2016; Feneley et al, 2015). Healthcare professionals also need to consider the risk of latex sensitivity or allergy (Health and Safety Executive, 2011; NICE, 2012).

Coated latex catheters (polytetrafluroethylene [PTFE]) have a smoother outer layer and can reduce encrustation-related issues. However, they still contain a high level of latex and therefore should only be used in patients where there is no known sensitivity or allergy to latex.

Silicone is a popular alternative to latex products. There is a wider internal lumen due to the composition of silicone and thus it can offer a more effective drainage than an alternate material of the same CH size. One hundred percent silicone catheters are hypoallergenic for the majority of the population (Loveday et al, 2014), however, some individuals are sensitive to silicone and may suffer skin reactions. As silicone is slightly more rigid than latex, the catheters can be more prone to cuffing or ridging when the balloon is deflated. This, in turn, can increase tissue trauma as the catheter adheres to the urethral or suprapubic tract (Geng et al, 2012; Feneley et al, 2015). In the author’s experience, this issue can be reduced by completely deflating the catheter balloon and then inserting 1ml of sterile water to smooth out the edges before removing the catheter from the entry site.

Hydrogel-coated catheters are soft, hydrophilic and biocompatible and may reduce friction and irritation for the wearer (Geng et al, 2012).

Silver-coated catheters have been widely used in the past to reduce the risk of infection due to the natural antimicrobial properties (Hayes, 2009; Pellowe, 2009; Pickard et al, 2012). The most recent clinical evidence now disputes the long-term efficacy of the natural antimicrobial and therefore silver-coated catheters are only thought to be of benefit in this way for a maximum of 28 days (Tenke et al, 2008; Beattie and Taylor, 2011; Geng et al, 2012; Loveday et al, 2014; RCN, 2019). Silver-coated catheters should only be used when clinically indicated, for example, in someone with a significant history of colonisation or infection.

Clinical evidence does not demonstrate a significant reduction in the incidence of symptomatic infection when using an antibioticimpregnated catheter, and thus the use of this particular type of catheter is not widely recommended (Geng et al, 2012; Feneley, 2015; RCN, 2019).


CLEANSING SOLUTIONS

Indwelling urinary catheterisation is performed using aseptic no touch technique (ANTT) (Rowley, 2010; NICE, 2017). The use of sterile normal saline or sterile water for skin cleansing before insertion of the catheter has been the standard for several years (Healthcare Infection Control Practices Advisory Committee [HICPAC], 2009; Loveday et al, 2014). NICE (2012) recommends that practitioners use local policy and guidance for meatal cleansing before urethral catheterisation without any specific reference to the type of cleansing solution.

In individual situations, there may be an argument for the use of an antimicrobial cleansing agent to reduce the risk of CaUTI (Sandle, 2013; Levers, 2014). This may be of particular benefit within a community setting, as own home environments are less easily controlled and present more challenges than a hospital or healthcare environment. However, the studies supporting this are small and limited and more research is required in this area before a definitive recommendation can be made on the advantages or disadvantages of introducing antimicrobial cleansing as a standard approach in urethral catheterisation techniques. The recommendation for best practice of managing hygiene of the catheter on a daily basis is still the use of soap and water during the individual’s normal personal hygiene routine (NICE, 2017).
 

WHICH LUBRICANT?

An appropriate lubricant to minimise trauma, discomfort and the risk of infection is a necessity when inserting an indwelling urinary catheter (Loveday et al, 2014). Long-term practice across the UK has been to use antiseptic agents (chlorhexidine), anaesthetic (lidocaine), or a combination of both in catheter lubricant gels. More recently, there has been an increase in the report of adverse reactions, sensitivities and allergic reactions to chlorhexidine (Moka et al, 2015). This is thought to be linked to the inclusion of the active ingredient in many household cleaning products (Marinho et al, 2013; Wilson, 2016). As the clinical evidence suggesting the use of chlorhexidine to effectively reduce the incidence of CaUTIs is limited and inconclusive (Wilson, 2016), many areas are choosing to use antiseptic-free gels (Williams, 2017). Several studies have, however, agreed that the use of an anaesthetic gel is beneficial in reducing pain on insertion of catheters (Ramakrishnan and Mold, 2004; Kyle, 2009; Tzortzis et al, 2009).

The conclusion to the latest research is that it is the individual healthcare professional’s duty and responsibility during assessment before catheterisation to identify any contraindications, sensitivities or allergies to active ingredients used in lubricating gels, and to use the assessment to choose an appropriate product for the individual patient that will offer a safe, effective and comfortable experience. Healthcare professionals should refer to their local policy for guidance on best practice.
 

CATHETER FIXATION

An unsecured catheter will move inside the bladder causing unstable detrusor contractions, bladder spasms, pain, bypassing and selfexpulsion of the catheter (Geng et al, 2012). This increases the risk of urethral, bladder neck or suprapubic tract trauma leading to the incidence of infection (Hanchett, 2002; Spinks, 2013; Feneley et al, 2015). Urine bypassing a catheter also increases the risk of skin damage, incontinence-associated dermatitis (IAD) and secondary infections (Holroyd, 2016). Catheter fixation devices have been in use since the 1960s and a variety of products are now available.

A fixation device is designed to minimise the movement of the catheter itself, rather than any drainage device stabilisation (Health Improvement Scotland, 2004; Geng et al, 2012; Wound, Ostomy and Continence Nurses Association [WOCN], 2012; Yarde, 2015). It should secure the catheter to the thigh or abdomen minimising any tugging or stretching of the catheter, thereby reducing the traction on the urethra or abdominal site (WOCN, 2012). There are a variety of commercially available fixation devices that may be adhesive or nonadhesive. It is recommended that an individual assessment should identify an appropriate catheter fixation device to reduce the incidence of catheter displacement, expulsion and migration, thus reducing the risk of tissue damage and infection (Holroyd, 2016).


DRAINAGE EQUIPMENT

Choice of drainage bags for use with urinary catheters are multiple and varied, ranging from 250mls to 3000mls capacity. The bags may be single use or drainable, and must be sterile, maintaining a closed system to reduce the risk of infection. The drainable bags are generally changed every 5–7 days in line with manufacturers’ instructions. Choice of bag will depend on the reason for the catheter, patient choice, length of tubing required, design and position of the tap, manual dexterity and ability to manage the system, and bladder capacity (Yates, 2016).

Any drainage bag should be adequately supported with an appropriate device or stand to reduce the weight pulling on the catheter and bladder, which may otherwise cause tissue trauma and increase the risk of infection. Drainage bags should be emptied frequently enough to maintain the flow of urine and prevent reflux, without interrupting the closed drainage system unnecessarily, which again may increase the risk of infection (Geng et al, 2012; RCN, 2019). It is recommended that the bags are not allowed to fill by more than threequarters (Loveday et al, 2014).
 
Catheter valves
An alternative to standard drainage bags is a valve system. Catheter valves are a popular choice, as they allow the bladder to fill and empty over a period of time, mimicking the micturition cycle which may contribute to a more successful trial without catheter (TWOC) (Woodward, 2014). However, there are some considerations before engaging the use of a catheter valve, namely bladder capacity, sensation, and an individual’s cognitive ability to manage a valve system must be established/assessed (Yates, 2016). The risk of high pressure from a full bladder causing renal damage or any recent surgery on the genitourinary tract will exclude the use of a catheter valve system. Table 2 outlines the advantages and disadvantages of valves.


CAUTIS

Catheter-associated urinary tract infections account for a significant proportion of healthcare acquired infections (Pellowe, 2009), with treatment costs placing an enormous burden on the healthcare economy (Loveday et al, 2014). Establishing the cost to a patient’s quality of life is difficult to determine, with the risk of serious infection rising the longer the catheter is in place (Chang et al, 2011; Loveday et al, 2014). Forty-five percent of Escherichia coli bacteraemia are attributed to the urinary tract and use of catheters (Abernathy, 2017). It is now a Public Health England focus to reduce all healthcare-associated Gramnegative bloodstream infections by 50% by 2021, and trusts have been challenged with ensuring a robust action plan is in place to achieve this by closer monitoring, early detection, and appropriate treatment of CaUTIs (NHS Improvement, 2019).

Table 2


CATHETER BLOCKAGE

Catheter blockage and bypassing are common problems encountered with the use of indwelling catheters and are sometimes caused by infection and encrustation. Encrustation is commonly caused by a build-up of Proteus mirabilis, a urease producing bacteria that creates biofilm formation on the catheter surface, leading to blockage of the lumen and drainage eyelets (Stickler and Feneley, 2010; Feneley et al, 2015).

Catheter maintenance solutions have routinely been used over the years to dissolve the encrustation or remove debris. However, these are now considered high risk interventions as they break the closed drainage system, thus increasing the risk of infection. Some of the astringent solutions may damage the urothelial lining of the bladder and cause an inflammatory response, and the increased pressure under which they may be administered can contribute to significant damage and increased infection risk (Turner and Dickens, 2011; Davey, 2015; Feneley et al, 2015; Gibney, 2016).

It is therefore recommended that these interventions are used with caution, and only after a thorough assessment of risk with a clear clinical rationale for use which is documented each time in the patient’s records (Davey, 2015; Feneley et al, 2015; Gibney, 2016; RCN, 2019).

The RCN guidelines (2019) published a quick reference guide to the common causes of blockage and bypassing, with a clinical rationale for the use of washout solutions. Many washout solutions are in prefilled packaging designed to be administered using gravity rather than pressure. The use of a syringe to administer washouts is still a common procedure within specialist areas and can be essential in maintaining patency and drainage, especially after surgery or in cases of high levels of mucus build up. One option for reducing the risk introduced by the disruption of the sterile closed drainage system would be to use a bladder infusion kit. This simple device allows administration of a washout solution via the needlefree sample port of the catheter bag, without disruption to the sterile closed drainage. It should be noted that needle-free ports are not on standard catheter valves or nondrainable bags.

Antibiotics and antiseptics have been shown to be ineffective in reducing encrustation on catheters (Pannek and Wesweber, 2011; Sperling et al, 2014; NICE, 2017). Antimicrobials used in the balloon inflation solution have been used across mainland Europe for several decades. These solutions were introduced to the UK a couple of years ago and may be effective in reducing harmful bacteria, including P. mirabilis (Pannek and Wesweber, 2011; Sperling et al, 2014; NICE, 2017).
 

CONCLUSION

Indwelling urinary catheters involve a high level of risk, primarily through infection and tissue trauma. However, their use is unavoidable in some patients who require a reliable bladder management option. Healthcare professionals should ensure that all patients undergo an individualised risk assessment before the insertion of a catheter to determine the clinical rationale for use, including the key points. Best practice guidelines provide advice on managing risk appropriately and should be embedded into local policy and clinical practice to ensure that clinicians are clinically competent at all elements of catheterisation.

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