In an ideal world, patients who have a problem with continence would not have to resort to an indwelling catheter to keep dry. As catheterisation is an invasive procedure, the introduction of a foreign body into the bladder puts the patient at risk of a number of complications, such as infection (Kleinpell et al, 2008; National Institute for Health and Care Excellence [NICE], 2012), encrustation or catheter blockages (European Association of Urology, 2012). It is good practice, therefore, to ensure that alternative management strategies, i.e. conservative treatment such as pelvic floor exercises (NICE, 2015), bladder retraining, intermittent or self-catheterisation (ISC), are explored before resorting to an indwelling catheter (Mercer Smith, 2003; Fenelly et al, 2015).
However, for some patients, long-term catheterisation is the only way they can be managed effectively, either by inserting a catheter into the bladder via the urethra or a suprapubic incision. Reasons for this include (Geng et al, 2012):
  • Acute or chronic urine retention
  • Neurological disorders that affect sensation or control of micturition
  • The need to accurately measure urinary output in critically ill patients
  • Perioperative use for certain surgical procedures
  • Prolonged length of surgery and intraoperative monitoring
  • To help open or sacral wounds heal in patients who are incontinent
  • Patients who need prolonged immobilisation
  • Bladder irrigation
  • To prevent skin breakdown in intractable incontinence
  • To promote comfort and dignity for patents at the end of life
  • Acute urine output monitoring
  • Detrusor failure
  • Bladder irrigation after urology surgery.
Caring for patients with long-term catheters can be challenging both to healthcare professionals and carers, and, indeed, patients themselves (Moore et al, 2009). Complications of long-term catheterisation include (Gibney, 2016):
  • Urinary tract infections (UTIs)
  • Encrustation
  • Catheter blockage
  • Bladder spasm
  • Bypassing
  • Urethral trauma
  • Bladder pain
  • Bladder stones
  • Difficult removal of the catheter.
Chronic infection may lead to kidney infections (pylonephritis) and kidney damage, and, as all patients with long-term catheters have bacteriuria (bacteria in their urine, whether symptomatic or asymptomatic), they are also at risk of septicaemia (Fenelly et al, 2015).

THE SCIENCE — COMMON BLADDER SYMPTOMS

Symptoms of bladder dysfunction include:
- A sudden urge to go to urinate or difficulty ‘holding on’ is a symptom of urgency or urge incontinence
- Needing to urinate more than eight times in a single day can be a sign of urinary frequency
- Nocturia is signalled by repeated urination through the night; nocturnal enuresis is wetting the bed at night
- Urination upon laughing, coughing, sneezing or exercise is a symptom stress urinary incontinence (SUI)
- Mixed incontinence is when an individual has symptoms of both stress and urge incontinence
- Overflow incontinence is signalled by small leakages of urine that are not noticed by the individual.
Source: Bladder and Bowel Foundation: www.bladderandbowelfoundation.org

CHOOSING THE RIGHT CATHETER

The Foley indwelling catheter is the most common design of catheter generally used for both urethral and suprapubic catheterisation. It was first described by Frederick Foley in the 1930s and since then very little has changed in the design. However, what has changed are the materials used to manufacture the catheters (Fenelly et al, 2015). These continue to evolve in the quest to find the ideal catheter, which will not cause the user problems or at least minimise them. Healthcare professionals should be aware of the different types of catheter available and make sure that they select the best catheter for each individual patient. There is a huge choice of catheters available on the market nowadays, but looking at some of the evidence available can help with making an informed choice.

Catheters are made from a number of materials such as latex, silicone, hydrogel or polytetrafluoroethylene (PTFE)-coated latex or pure silicone. A number of studies over the years have been carried out to determine the best material to reduce urethral trauma and improve bladder drainage, as well as combat UTI and subsequent encrustation and bypassing (Fenelly et al, 2015). Bacterial activity is the main cause of the problems with blockage and encrustation (Gibney, 2016). If a catheter is left in for longer than 5–7 days, all catheterised bladders show an increase in bacteria in the urine, no matter what material or coating is used, although some materials are more resistant than others. However, after 30 days, these differences disappear and all patients have bacteriuria (Lee et al, 2004; Fenelly et al, 2015). Patients may not necessarily have symptoms, so may not need treatment, but they will still carry a bacterial load.

CATHETER MATERIALS AND BIOFILMS

The uneven surfaces of catheters allow bacteria in the urine to colonise catheters and form biofilms on both the internal and external catheter surface (Tunney and Gorman, 2002; Stickler et al, 2003). Studies have shown that silicone catheters are the smoothest when examined under electron microscopes. However, all catheters, including silicone ones, have cracks and uneven surfaces, which is down to the manufacturing process and the bonding of the catheter coatings to the latex base (Lawrence and Turner, 2006a). Bacteria attach themselves in these areas and rapidly multiply forming a thick matrix known as a biofilm. Once within the biofilm, bacteria are protected and very resistant to antibiotics or catheter maintenance solutions (Gibney, 2016).

Thus, even if treated, the bacteria may then reseed and infect the urine again (Ford et al, 2017). Ultimately, the bacterial activity results in a change in the pH of urine, making it more alkaline. Research has shown that urea-splitting bacteria such as Proteus mirabilis result in more alkaline urine (Stickler and Morgan, 2008). This alkalinity allows crystallisation of salts in the urine, which congregate around the area of the catheter tip and eventually build up to form encrustation which, in turn, leads to blockage of the ‘eyes’, i.e. the drainage holes at the catheter tip, resulting in urine bypassing and/or retention of urine (Gibney, 2016). A good flow of urine has been shown to prevent or delay encrustation. Silicone catheters usually have a larger lumen and kink less and so allow better drainage (Lawrence and Turner, 2006b), and consequently formation of biofilms and encrustation occurs later than on other catheter material (Morris et al, 1997; Tunney and Gorman, 2002; Verma et al, 2016).

However, on the negative side, when deflating the balloon to remove or replace the catheter, there can be more ‘cuff’ formation around the bottom end of the deflated balloon where it is attached to the catheter tip because of ‘creeping’ of the material. This cuff means that the catheter tip is no longer smooth and the ridge formed by the cuff can catch internally and hinder removal. While all types of catheters result in cuffing, silicone catheters are usually the most difficult to remove, especially suprapubically (Parkin et al, 2002). Removal may need more force than a softer latex catheter, resulting in pain and trauma for the patient (Robinson, 2003a; Evans et al, 2001; Lawrence and Turner, 2006b).
 

Innovation

Innovation in catheter manufacturing focuses on tackling these universal problems, with new products becoming available on the market for healthcare professionals to try. One example are those by LINC Medical, with their Unibal® technology where the balloon is integral to the catheter itself with no bonded parts, promising a smoother insertion and removal and thus less trauma to the urethra (see p. 47). There are also catheters on the market which have coatings bonded to their surface specifically to try to minimise or delay urinary tract infection. Other innovations are the use of antimicrobial coatings on Foley catheters, such as impregnation with antibiotics or antimicrobial agents, with the aim of reducing infection and consequently encrustation and blockage (Stickler and Morgan, 2008).

It is important to note, however, that most studies have shown that these latter types of catheters mainly work in patients in the short term (Johnson et al, 2006).

SUPRAPUBIC CATHETERS

For some patients, long-term suprapubic catheterisation may be the preferable option. It is seen as having fewer complications than urethral catheterisation and allows the patient more dignity, comfort and convenience when it comes to caring and changing the catheter (NHS, 2009). However, as previously said, they are not problem-free and complications such as UTIs, urine leakage around the abdominal catheter site or from the urethra, and bladder spasms are common (Addison and Mould, 2002). They are also prone to infection around the catheter site and granulation of tissue in this area, which can lead to pain and difficulty with catheter removal. This is not helped by catheter balloon cuffing.

Long-term complications for suprapubic catheters are identical to those of urethral catheters and there is the increased risk of stone formation. Patients who have suprapubic catheters long term have also been found to have thick debris and metaplastic changes in the bladder and there is some debate as to whether they should have regular cystoscopic surveillance, especially as all patients with urinary catheters in place are ultimately also at high risk of bladder cancer with long-term use (El Masri et al, 2014). Healthcare professionals need to be aware of this and anticipate problems. If patients are allergic to latex, the use of silicone catheters is the only option, and hopefully, newer products such as Uni-Flo® (LINC Medical), will make this a less traumatic experience for the patient.
 

EDUCATING THE PATIENT

Besides choosing the best catheter for the job, healthcare professionals should also educate the patient and carers on catheter care and personal hygiene and the importance of good fluid intake to ensure steady flow of urine through the catheters. Good flow has been shown to reduce infection and consequently encrustation and blockage. Catheter maintenance solutions may be used to irrigate the catheter and dissolve the encrustation, which may help prolong the life of the catheter. Some healthcare professionals advocate regular washouts with chemical solutions (e.g. Opitflo® G [Bard]), or normal saline (Gibney, 2016). However, Moore et al (2009) found no significant difference between carrying out regular washouts or not on patients with long-term catheters, and the reality is that their efficacy may differ from patient to patient (Moore et al, 2009).

It is well known that certain patients are often labelled as ‘blockers’, while others are ‘nonblockers’ (Gibney, 2016). This refers to the fact that despite all precautions and regular washouts, some patients will regularly have catheter blockages. In these cases, the only strategy would be to change the catheter routinely to pre-empt blockage (Moore et al, 2009). Encouraging the patient to consume lemon/citricbased drinks may also help reduce the alkalinity of urine, and thus lower the pH. Patients could also be advised to trial an open-tipped catheter, such as Supra-Flo® or Opti-Tip® catheters (LINC Medical), as they promote more drainage compared to standard catheters. Eating a healthy diet and drinking more fluids will prevent constipation, which may also impact on the flow of urine (Gibney, 2016). Gibney (2016) also advises monitoring when a patient’s catheter is prone to blockage and advocates proactive catheter changes to avoid crisis blockages.

EDUCATING OTHER HEALTHCARE PROFESSIONALS

Gibney (2016) states that nurses are in an ideal position to improve catheter management. She recommends standardising practice and disseminating evidence to healthcare professionals to ensure that all who look after catheters are aware of the importance of regularly reviewing patients with catheters in place, monitoring urine pH, monitoring the patient’s fluid intake and encouraging citric drinks, as well as assessing the need and efficacy of using catheter maintenance solutions. Choosing the right catheter and maintenance products should also be part of the strategy to reduce complications and less crisis management and distress for patients and carers.


CONCLUSION

Caring for patients with long-term catheters can be challenging for community nurses. Long-term catheterisation leads to inevitable problems, requiring nurses to have the knowledge and skills to be proactive in care as well as being able to offer effective solutions for problems when they arise. Understanding the causes of these problems is key, as is keeping up to date with new research and innovations in catheter manufacture in order to minimise complications and improve the quality of patients’ day-to-day life.

References

Addison R, Mould C (2002) Risk assessment in suprapubic catheterisation. Nurs Standard 14(36): 43–6

All Party Parliamentary Group for Continence Care (2013) Continence Services. England. Survey Report. Available online: www.appgcontinence.org.uk/pdfs/Continence%20Care%20Services%20England%20Report%202013.pdf

Bard (2004) Speciality Foley catheters, sales tarining reference guide. Interventional Urology

Charous BL, Blanco C, Tarlo S, et al (2002) Natural rubber latex allergy after 12 years: Recommendations and perspectives. J Allergy Clin Immunol 109(1): 31–4

El Masri WS, Patil S, Prasanna KV, Chowdhury JR (2014) To cystoscope or not to cystoscope patients with traumatic spinal cord injuries managed with indwelling urethral or suprapubic catheters? That is the question! Spinal Cord 52: 49–53

European Association Urology (2012) Catheterisation: indwelling catheters in adults. Available online: www.nursing.nl/PageFiles/11870/001_1391694991387.pdf

Evans A, Godfrey H, Fraczyk L (2001) An audit of problems associated with urinary catheter withdrawal. Br J Community Nurs 6(10): 511–19

Fenelly RCL, Hopely IB, Wells NT (2015) Urinary catheters: history, current status, adverse events and research agenda. J Med Engineering Technol 39(8): 459–70

Ford J, Hughes G, Phillips P (2017) Literature review of silver-coated urinary catheters. Medidex Medical Device Index. Available online: www.medidex.com/research/856-silver-catheter-review-2016-update.html (accessed 11 October, 2017)

Geng V, Cobussen-Boekhorst H, Farrell J, et al (2012) Catheterisation: indwelling catheters in adults. European Association of Urology Nurses, The Netherlands

Gibney LE (2016) Blocked urinary catheters: can they be better managed? Br J Nurs 25(15): 828–33

Johnson JR, Kuskowski MA, Wilt TJ (2006) Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients. Ann Intern Med 144(2): 116–26

Kleinpell RM, Munro CL, Giuliano KK (2008) Targeting health care–associated infections: evidence-based strategies. In: Hughes RG, ed. Patient Safety and Quality: an evidence-based handbook for nurses. Agency for Healthcare Research and Quality, Rockville, USA: Chap 42

Lawrence EL, Turner I G (2006a) Characterisation of the internal and external surfaces of four types of Foley catheter using SEM and profilometry. J Mater Sci: Mater Med 17: 1421–31

Lawrence EL, Turner IG (2006b) Kink, flow and retention properties of urinary catheters part 1: Conventional foley catheters. J Materials Sci: Materials in Medicine 17: 147–52

Lee S, Kim AW, Cho Y, et al (2004) A comparative multicentre study on the incidence of catheter-associated urinary tract infection between nitrofurazonecoated and silicone catheters. Int J Antimicrob Agents 24S: S65–S69

Mercer Smith J (2003) Indwelling catheter management: from habit-based to evidence-based practice. Ostomy Wound Management 49(12): 34–45

Moore K N, Hunter K F, McGinnis R, et al (2009) Do catheter washouts extend patency time in long-term indwelling urethral catheters? A randomised controlled trial of acidic washout solution, normal saline washout, or standard care. J Wound, Ostomy Continence Nurs 36(1): 82–90

Morris NS, Stickler DJ, Winters C (1997) Which indwelling urethral catheters resist encrustation by Proteus mirabilis biofilms? Br J Urol 80: 58–63

National Institute for Health and Care Excellence (2012) Healthcare-associated infections: prevention and control in primary and community care. NICE, London. Available online: www.nice.org.uk/guidance/cg139

National Institute for Health and Care Excellence (2015) Urinary incontinence: the management of urinary incontinence in women. NICE, London. Available online: www.nice.org.uk/guidance/qs77

NHS (2009) Rapid Response Report: Minimising risks of suprapubic catheter insertion (adults only). National Patient Safety Agency. Available online: www.nrls.npsa.nhs.uk/resources/patient-safetytopics/medical-device-equipment/?entryi d45=61917&q=0%c2%acsuprapubic+cath eter%c2%ac

Parkin J, Scanlan J, Woolley M, Grover D, Evans A and Fenely RCL (2002) Urinary catheter ‘deflation cuff’ formation: clinical audit and quantitiative in vitro analysis. BJU International 90: 666–71

Pratt RJ, Pellowe CM, Wilson JA, et al (2007) epic2: National evidence-based guideline for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 65 Suppl 1: S1–64

Robinson J (2003a) Suprapubic catheter removal: the cuffing effect of deflated catheter balloons. Br J Community Nurs 8(5): 205–8

Robinson J (2003b) Deflation of a Foley catheter balloon. Nurs Standard 17(27): 33–8

Stickler D, Young R, Jones G, Sabbuba N, Morris N (2003) Why are Foley catheters so vulnerable to encrustation and blockage by crystalline bacterial biofilm? Urol Res 31(5): 306–11

Stickler DJ, Morgan SD (2008) Observations on the development of the crystalline bacterial biofilms that encrust and block Foley catheters. J Hosp Infect 69: 350–60

Tunney MM, Gorman SP (2002) Evaluation of a poly(vinyl pyrollidone)-coated biomaterial for urological use. Biomaterials 23: 4601–08

Verma A, Bhani D, Tomar V, Bacchiwal R, Yadav S (2016) Differences in bacterial colonization and biofilm formation property of uropathogens between the two most commonly used indwelling urinary catheters. J Clin Diagn Res 10(6): PCO1–PCO3


Back to journal