Urinary catheterisation policy (adults)

Urinary catheterisation is an invasive procedure and should not be undertaken without full consideration of the benefits and risks. The presence of a catheter can be a traumatic experience for patients and have huge implications for body image, mobility, pain, and comfort. Indwelling catheters are a key source of urinary tract infections (UTI). It is essential that they are only used if clinically necessary.

The ongoing need for the urinary catheter must be reviewed at regular intervals

• Informed consent (verbal) must be obtained and recorded
• Remove catheters at earliest point to reduce risk of morbidity and mortality
• Long-term catheters should be changed at least every 12 weeks
• Incontinence is not an indication for catheterisation
• Patients should be encouraged to have fluid intake of 1.5 - 2 litres per day
• Catheterisation can increase the risk of pressure ulcer development
• Where chronic wounds are present, catheterisation presents greater risk
• Catheterisation should be avoided in agitated or cognitively impaired patients
• For male patients who are incontinent consider a trial of a urosheath first
• Do not dipstick urine for a patient who has a urinary catheter in situ
• Assessment of patients symptoms are required before antibiotics prescribed
• Balloons should be filled only with sterile water
• It is not best practice to deflate and re-inflate the balloon for troubleshooting
• Intermittent catheterisation to be considered where appropriate and practical
• When unable to change catheter bags using sterile procedure connection should be cleaned with 2% chlorhexidine in 70% isopropyl (blue clinell wipe) before disconnection.

There is no policy or legal position regarding male practitioners catheterising female patients or female practitioners catheterising male patients. Patients should be offered a chaperone or be invited to request the presence of a chaperone. Nurses and other health care professionals should consider being accompanied by a chaperone (irrespective of organisational constraints or settings in which this is carried out) when undertaking intimate examinations and procedures to avoid misunderstanding and, in rare cases, false accusations of abuse (RCN 2006)

All NHS Borders staff involved in urinary catheterisation should:

• Undertake NHS Borders Urinary Catheterisation Programme (via LearnPro)
• Complete 2 yearly peer reviews in order to demonstrate competence
• Staff joining NHS Borders must have their competency checked before
  carrying out catheter management (transferability of skills form available from
  Clinical Practice and Development (CP&D)
• Bladder scanner training should be accessed via company rep for machine
  in use

• All patients with an indwelling urethral or supra-pubic catheter must have a Urinary Catheter Care Passport completed
• There is no requirement for a passport for patients who are likely to have a catheter in-situ for less than 72 hours
• For hospital patients, keep the passport in bedside notes
• Maintenance must be checked daily and recorded weekly
• If no passport present, initiate new passport
• When a patient is discharged, the passport MUST be given to them
• Staff should show the patient/carer how to manage their passport
• When a passport is complete and no longer in use, it should be filed in the medical records
• Elective patients do not need to be issued with a catheter passport. The duration of catheterisation will be defined by the operating surgeon and documented in medical records

This is a patient held document which should remain with the patient at all times and be taken to all hospital appointments and hospital admissions

Read as a table: PDF

Urethral catheterisation

Description

Sterile procedure that facilitates direct drainage of the urinary bladder

Indications

• Acute urinary retention (Symptomatic chronic urinary retention and/ or renal impairment
• Debilitating disease involving skin ulceration
• Severe burns
• Monitoring fluid balance in severely ill patient (urosepsis policy)
• Neurological disorders
• Surgical procedures: intra-operative/ following abdominal, gynecological or urological surgery
• Unfit for urology surgery
• For comfort and dignity in end of life care
• Prolonged immobilization
• Intractable urinary incontinence when alternative non-invasive approaches are unsatisfactory or unsuccessful
• Post bladder/prostate surgery

Contraindications

• Pelvic fracture
• Severe burns
• Traumatic urethral injury
• Failed Trial Without Catheter (TWOC) following transurethral resection of Prostate (TURP) within four weeks
• Artificial urinary sphincter

Indications for hospitalisation

• Fresh haematuria
• Within 3 weeks of radical prostatectomy or bladder/ urethral reconstructive surgery, consult the Urology Department if re-catheterisation is required
• Urethral obstruction

Catheter selection

• „Standard‟ catheter lengths (40cm) are only available within BGH
• In Primary Care, a female length catheter may be prescribed on a named patient basis
• Smaller gauge catheters minimise the risk of urethral trauma which predisposes to Urinary Tract Infections
• If recurrent blockages due to sediment, consider larger bore catheter or open-ended catheters
• Tiemenn tipped if large prostate

Catheter diameter

Use smallest gauge catheter initially. If there is a latex allergy use all silicone
catheter:
Size 12/14ch - Clear urine, no debris, no haematuria
Size 16ch - Slightly cloudy urine, light haematuria with or without small clots, mild debris
Size 18ch - Moderate to heavy debris, haematuria with moderate clots

Lubricant

The anaesthetic-based gel must be used prior to catheterisation for both male and female patients as per the manufacturer's instructions. 11ml syringe for male patients and 6ml syringe for female patients.

Supra-pubic catheterisation

Description

Surgically created connection between the urinary bladder and the anterior abdominal wall to drain urine from the bladder

Indications

• Elective abdominal or urological surgery
• Inability to pass urethral catheter due to obstruction
• Acute urinary retention or chronic retention
• Advanced neurological disease
• Disorders of the genitalia or urethral trauma
• Patient preference, particularly if sexually active or to maintain the ability to self-care
• Less urethral trauma
• Persistent expulsion of the urethral catheter
• More comfortable to wear
• Intractable incontinence, where other options have failed

Contraindications

• Known or suspected carcinoma of bladder
• Undiagnosed haematuria
• Femoral-femoral crossover vascular grafts
• Previous lower abdominal surgery
• Blood clotting disorders
• Ascites
• Suspected/diagnosed ovarian cyst
• Severe obesity

Indications for hospitalisation

• Previous problematic insertions by the clinician

Catheter selection

• Maintain size at catheter change, unless otherwise clinically indicated
• Standard length is 1st choice
• Size 16 - 18ch catheter at the initial insertion
• For ongoing catheter changes use an all silicone 16ch - 18ch catheter, unless instructed to upsize catheter for recurrent blockages (may upsize to size 20ch in total)
• First changes (after 4 weeks) may be performed within the community unless requested by the surgeon. Contact the Urology if catheter requires change within 4 weeks
• Exchange suprapubic catheter without delay (suprapubic tract can be closed within half an hour of removal of the existing catheter

Lubricant

The anaesthetic-based gel must be used prior to catheterisation for both male and female patients as per the manufacturer's instructions. 11ml syringe for male patients and 6ml syringe for female patients

Intermittent self-catheterisation

Description

Insertion of a urinary catheter to drain urine or instil solution into the bladder which is immediately removed and not left in situ

Indications

• Management of chronic urinary retention or incomplete bladder emptying
• Reduce UTI with draining residual urine
• Male or female patients who suffer from some form of neurogenic bladder dysfunction or voiding difficulty
• Management of a urinary pouch via a continent stoma
• Installation of drug therapy
• Self-dilation of urethral stricture disease

Contraindications

• ISC performed in an acute or emergency situation is a sterile procedure
• Clinically clean procedure within the home setting
• Catheters are single use only
• Dependent upon individual patient needs and based on full clinical assessment
• Patient understands how to order their supply of catheters. (GP prescription)

Catheter selection

• Size 12ch Tiemenn tipped if large prostate

Basic principles

• Balloon size of 10mls/5mls must be used
• Charrier size - choose the smallest size possible to provide adequate drainage
• Patients should have spare catheter within home setting. A catheter valve may be used as an alternative to a drainage bag

Cleansing

• Ensure the peri-urethral area is socially clean using unperfumed soap & water prior to commencing
• Use sterile saline for cleansing the meatus prior to insertion

Changing urinary drainage systems

• Leg bags or catheter valves must be changed every 5-7 days as per manufacturers guidelines. Urinary catheters should be connected to a sterile closed drainage system, incorporating a link system for overnight drainage to keep the day system intact
• Ensure patient /carer is taught how to change leg drainage bags using a clean technique. Overnight bag is a single-use item only
• Manual dexterity is extremely important when choosing the correct leg bag tap for the patient
• Short tubing leg bag (6cm) long tubing (25cm) available depending on patient requirements

Bag position and support

• Patient/carer understands need to keep urine bag below level of the bladder
• The leg bag is drained when 2/3 full – leave small amount of urine in bag to prevent vaccum
• The urine bag tap must not touch the floor
• All urethral catheters should be supported with a catheter retaining strap (G strap/Clinifix) or aquasleeves to minimise trauma at bladder neck, and external meatus. The leg bag strap is not a catheter retaining strap
• Suprapubic catheters should be secured by suitable device to prevent tension to catheter and site. Avoid use of care dressings to suprapubic site, as this can encourage infection

Catheter valves

• The valve should be opened every 2 to 3 hours or earlier if needed to ensure the bladder does not overdistend
• An overnight 2-liter drainage bag may be attached to the valve to promote drainage if this is the patient preference
• Catheter valves are only suitable for patients who have a good cognitive function, sufficient manual dexterity to manipulate the valve and adequate bladder capacity. It is important that catheter valves are not used with patients that have uncontrolled detrusor overactivity, ureteric reflux or renal impairment
• Catheter valves must not be used on patients following surgical procedures to the prostate or bladder,

Immobile acute patients

• Should have a standard 2 litre drainable urine bag attached to the hospital bed
• Changed every 5 to 7 days
• The patient‟s bed should be lowered to lowest possible height to enable catheter bag to be free from floor
• Where there is a requirement to lower the bed further a catheter stand should be used

Patient discharge from hospital

• The hospital is responsible for notification of patient being discharged with a urinary catheter to the district nurse, treatment room nurse and or GP where appropriate
• Before leaving the hospital, patients should be taught catheter care or if unable to self manage, a family member or carer taught
• Urinary Catheter Care Passport must be completed and given to the patient
• Patients are to be discharged with one week‟s supply of night bags, leg bag x1 and a replacement catheter of the appropriate size and information booklet
• Subsequent catheters are obtained on prescription via the GP

Responsibility of the Health Care Professional

Once the changing of catheter regime is established, the ongoing review must be assessed and agreed by the clinician

Non-registered nurse urinary catheter insertion

Non-registered staff may only undertake urinary catheterisation following formal training and specific departmental agreement. The registered Health Care Professional responsible for the patient remains accountable for all non-registered staff practice

Documentation

The Health Care Professional undertaking catheterisation must document all details within the patients‟ Catheter Passport

The District/Community/Practice/Treatment Room Nurse will be the clinician responsible for the ongoing management of the patient‟s urinary catheter and assess on an ongoing basis and prior to each catheter change and consider trial without catheter (TWOC).

Catheter maintenance solution is prescription only medication. Instilling catheter maintenance solutions breaks the closed drainage system. Only perform if evidence of encrustation. pH management is required for this.

Individuals with pH above 6.8 are more likely to experience problems with an encrusted catheter, as encrustation develops due to alkaline urine. Do not use solutions to unblock catheters, blocked catheters should always be removed and replaced.

Any catheter maintenance regime should be undertaken as infrequently as possible in order to achieve clinical improvement. Please note: best practise is to change catheter i.e. if catheter becomes blocked with encrustations at week 8, the catheter should be changed at week 7, and careful monitoring is required by the health care provider.

Test and record urine specimens from the catheter port twice a day for 7-10days. If the pH is >7 the urine is alkaline.

1 Potential signs and symptoms of urine infection

A working clinical definition for use in NHS Borders is at least 2 criteria out of the following:

• Fever (>= 38.0) and/or chills and/or rigors
• Flank and/or costovertebral and/or suprapubic, pain or tenderness
• New haematuria
• New delirium or change in cognitive state

For patients who have had a catheter removed within the previous 2 days additional symptoms would be:

• Dysuria
• Frequency

For patients with spinal cord injury additional symptoms would be:

• Increased spasticity
• Autonomic dysreflexia
• Sense of unease

2 Lab Specimens

• When obtaining a urine specimen from a catheter, change urinary catheter and send CSU from a new catheter
• It is important that an aseptic technique via the sampling port is used
• Samples must not be taken from the drainage bag

If recurrent UTI, consider changing the catheter again 72 hours after commencing antibiotics and consider increasing frequency of catheter changes. Patients may be treated empirically with an antibiotic.

3 Antibiotics and Treatment

• Where the patient is asymptomatic, antibiotics should be avoided in order to prevent the selection of resistant strains of colonising organisms. Almost all patients with a long term indwelling catheter will develop bacteriuria
• Routine antibiotic therapy for patients with bacteriuria is not recommended unless the patient has symptoms of a urinary tract infection
• Seek microbiological advice where specific clinical concern exists
• “Routine use of antimicrobial prophylaxis during catheter change should be avoided” (SIGN 88)
• Assess the clinical need for antibiotic prophylaxis for a patient with a UTI and pyrexia who requires catheterisation
• If episodes of sepsis are related to changes of the catheter or the history of; consider antibiotic therapy in accordance with local guidelines and previous results
• Treatment of CAUTI must follow SIGN guidelines and NHS Borders Prescribing Formulary and NHS Borders Hospital Antimicrobial Prescribing Guidelines for Adults

4 Immunosuppression

Patients with conditions resulting in a low white cell count or who are undergoing chemotherapy or are on other immunosuppressant medication may require a course of antibiotics following catheterisation. Seek advice from the Microbiologist

The catheter must be removed as soon as clinically possible following insertion. Any delay in removal creates a significant risk of serious infection. Please use the Nurse-Led Catheter Removal Tool (appendix 2) to assist and encourage early removal.

For all routinely catheterised patients, medical approval is NOT required prior to removal by the Health Care Professional, subject to following this policy and indication for removal by assessment.

Where a medical or nursing concern exists, the discussion should be held with the multidisciplinary team prior to catheter removal.

Any patient with a catheter must be reviewed regularly and a planned TWOC must take place when an assessment indicates that it can be removed.

A TWOC procedure can be undertaken either in a clinical or home environment.

• Remove the catheter early morning, depending on clinical circumstances, to ensure that the patient receives full support and monitoring during the day and that the voided urine can be measured
• Encourage a good fluid intake (approx 6 cups of fluid in the morning)
• If the catheter is removed within the patient‟s home, the health care professional must provide contact numbers in case problems occur and a follow-up visit within 4-6 hours may be planned with the patient to evaluate the trial
• Document TWOC in Catheter Care Passport

Bladder scanning is a useful tool; if this is not possible, patient assessment should include fluid input/output and patient symptoms. If TWOC unsuccessful, reinsert urethral catheter and document urine volume over 15 minutes (retention volume). Note any resistance during catheterisation and whether the patient felt „relief‟ after the catheter was inserted, implying the patient has bladder sensation. If required arrange/discuss appropriate follow up with Urology.

For males catheterised for chronic/acute urinary retention, consider the use of Tamsulosin (400mcg od) prior to TWOC, for approximately 2 weeks (unless contraindicated). This will need to be initiated as a long term prescription if TWOC successful (there is good evidence that alpha-blockers increase the success of TWOCs).

• If performing a suprapubic TWOC, please attach a catheter valve for 24 – 48 hours before removing suprapubic catheter
• Patient voids per urethra and measures the volume, followed by immediately opening the catheter valve and measures the urine volume via the catheter. If volumes drained via the valve are below 100mls, please remove the catheter

This image as a PDF

The nurse-led catheter removal tool PDF

Blocked catheter

• Do not flush – change the catheter
• Check for kinks
• Consitpation
• Recurrent blockages - Consider changing catheter more frequently and upsizing to a larger diameter catheter or an „open-ended‟ catheter

Debris present

Encourage good fluid intake

Encrustations

During removal: Examine catheter and eyelets and roll catheter between fingers to feel the presence of „grit‟ in the lumen of the catheter. Encourage citric fluids as this may acidify the urine

Observe when catheter becomes blocked and arrange to change the catheter on a more regular basis

Catheter maintenance solutions are recommended, however, a catheter can be changed more frequently to avoid the use of solutions if considered appropriate

Mucosal occlusion

This occurs when the bladder mucosa blocks the eyes of the catheter. It is very important to identify this cause as the treatment is very different from encrustation. The best way to determine the cause of the blockage is to examine the catheter visually on removal both internally and externally. If there is no visible evidence of encrustation, and the catheter, when rolled between fingers does not feel gritty, then it is safe to assume that mucosal occlusion has taken place. It may be beneficial where appropriate to use a catheter valve for patients suffering from repeated mucosal occlusion. The presence of the urine in the bladder may prevent the mucosa from entering the eyes of the catheter.

Hydrostatic suction results from the vacuum effect of urine in the drainage tubing. There is suction of the mucosa into the eyes of the catheter and prevents drainage. This is most often found in drainage bags that are positioned more than 30 cm below the bladder and a slight temporary rising
of the catheter and bag will often help.

Occlusion will also occur when the bladder mucosa closes around the catheter due to bladder spasm. This may be due to detrusor spasm or the catheter itself may irritate the bladder lining and trigger a spasm. Anticholinergic medication may help but patients should be made aware of the side effects in order to help with compliance. It should be discontinued if no positive effect is found. It is also possible that the spasm may occur as a reaction to the catheter material: a different catheter type should be trialled in the first instance.

Bypassing

Change catheter and inspect for encrustation
Kinked tube/constipation and increase fluids
Leakage of urine around the catheter may be caused by a blocked catheter or bladder spasm. The sensitive trigone area of the bladder may be stimulated by the balloon, which in turn increases the spasm.
A smaller catheter may overcome this problem. Ensure no more than 10 ml of water is used in the balloon. N.B. A larger catheter or over-inflated balloon may exacerbate the problem. Also, consider anticholinergic medication.

No urine flow

Check there is no kink in the catheter or drainage conduit. Ensure patient is drinking enough fluid.

Constipation is a common cause of blocked catheters. Encourage good fluid intake of 1.5 to 2 litres per day.

The tubing of the catheter may be kinked or flattened, particularly if the patient is obese.

Recurrent UTI

Encourage an increase in fluid intake and increase the frequency of catheter changes.

Cramping pain

It is fairly common for some patients to experience abdominal cramps when a catheter is first inserted/changed. These will usually subside after 24/48 hours. If insufficient water was introduced into the balloon, then it is possible that the catheter can become dislodged causing pain. Persistent detrusor
muscle contractions can also cause pain and may respond to antimuscarinic drugs but these drugs should be used with caution in the over 65‟s; due to antimuscarinic overload discuss with GP. It is also possible that the tip of the catheter could be irritating the bladder wall. A catheter valve may solve this
problem.

Urethral discomfort

This may be caused by distension of the urethra by too large a catheter, or occlusion of the paraurethral glands. This may lead to infection, urethritis and an offensive discharge around the catheter. Ensure appropriate catheter selection, ? smaller catheter, ensure adequate support with catheter strap and leg bag straps. Ensure the catheter is within the bladder.

Catheter expulsion

If a patient‟s catheters are being expelled frequently with balloon intact, consider the addition of anticholinergic medication as this may be related to bladder spasms. The option of a suprapubic catheter may be considered: refer to Urology or email Urology Mailbox.

Recurrent catheter expulsion with ruptured balloons may be due to the presence of bladder calcification; discuss with GP/Urology or email Urology Mailbox.

Haematuria

Small amounts of blood are quite commonly found in the urine of catheterised patients as a result of trauma or infection. Encourage good fluid intake (1.5 to 2 litres). If severe seek medical help.

Purple bag syndrome

Older patients who are immobile may develop purple urinary bag syndrome. This condition is harmless and is brought about by the bacterial decomposition of tryptophan, an essential amino acid that can turn the colour of the bag purple. Some patients may be suffering from constipation - encourage good fluid intake

• Associate Director of Nursing Primary & Community Health Service/Chief Nurse Health &
  Social Care Partnership (Chair)
• Infection Control Manager (Deputy Chair)
• Consultant Microbiologist
• Senior Infection Prevention & Control Nurse or Infection Prevention & Control Nurse
• Infection Control Development Facilitator
• Urology Nurse Specialist
• Senior Charge Nurse DME
• Clinical Nurse Manager
• Consultant Physician Representative
• Senior Physiotherapist
• Senior Charge Nurse or Clinical Nurse Manager for Community Hospitals
• Clinical Nurse Manager, Primary & Community Services
• Home First Team Leader
• BECS Nurse Manager
• District Nurse Representative or Clinical Nurse Manager
• Lead Nurse for Care Homes
• Clinical Governance & Quality Representative (as required)
• Clinical Practice Education Facilitator