Urinary catheter

A urinary catheter such as a Foley catheter, is a hollow plastic tube which is either inserted through the urethra into your bladder or attached to a male patient’s penis, allowing your urine to drain freely. A balloon located at the end of the catheter is usually inflated with sterile water to prevent the catheter from slipping out. A urinary catheter is usually used when people have difficulty passing urine or have difficulty completely emptying their bladder. You may need a catheter for a short period, such as before or after surgery, or you may need it long term or permanently.

A urinary catheter can be fitted through your urethra (the tube that carries urine from your bladder). This is called a urethral catheter. A catheter can also be fitted through the wall of your stomach. This is called a suprapubic catheter. In both cases, a small inflated balloon keeps the catheter in place. The catheter tube is attached to a urine drainage bag (a catheter bag), where the urine can be collected. In this manner, the patient’s urine is collected and contained for various medical purposes. You can secure the day bag to your thigh or calf using straps. You can attach the bag to whichever side feels most comfortable. You should always keep the bag lower than your bladder. The drainage bag has a valve at the bottom that you open to drain the urine that’s been collected. You’ll be taught how to do this. You should empty the drainage bag every three to four hours during the day, or before the bag overfills.

Some people with urinary catheters use a catheter valve, with or without a drainage bag. When the valve is closed, it stops the urine draining from your bladder. You should open the valve every three to four hours or when your bladder feels full so the urine can drain into the toilet or a container.

At night, you’ll connect the day bag (or valve) to a larger bag called a night bag. You’ll open the valve at the bottom of the day bag to allow the urine to drain freely into the night bag. This is so you don’t have to wake up to empty your bag overnight and so you can move around when in bed.

You should place the night bag lower than your bed. Placing it in a container such as an ice cream container is a good idea in case there’s any leakage.

In the morning, you’ll close the valve at the bottom of the day bag and disconnect the night bag. You can empty the collected urine down the toilet.

Clean the night bag after each use with warm soapy water and allow it to dry thoroughly. Store the dried bag in a clean sealed plastic bag ready for the next time you use it.

The procedure of catheterization will usually be done by a clinician or continence nurse, although self-catheterization is possible as well.

Some people with urinary problems need urinary catheters permanently, but more often people need them temporarily.

Sex differences

In males, the urinary catheter tube is inserted into the urinary tract through the penis. A condom catheter can also be used. In females, the urinary catheter is inserted into the urethral meatus, after a cleansing using betadine. The procedure can be complicated in females due to varying layouts of the genitalia (due to age, obesity, Female genital cutting, childbirth, or other factors), but a good clinician should rely on anatomical landmarks and patience when dealing with such a patient.

Common indications to catheterize a patient include acute or chronic urinary retention, orthopedic procedures that may limit a patient’s movement, the need for accurate monitoring of input and output such as in an ICU, benign prostatic hypertrophy (BPH), incontinence, and the effects of various surgical interventions involving the bladder and prostate.

For many patients the insertion and removal of a urinary catheter can cause severe pain, so a topical anesthetic can be used. Catherization should be performed as a sterile medical procedure and should only be done by trained, qualified personnel, using equipment designed for this purpose.

Complications of urinary catheter use may include: urinary tract or kidney infections, blood infections (sepsis), urethral injury, skin breakdown, bladder stones, and blood in the urine (hematuria). After many years of catheter use, bladder cancer may also develop.

There can be problems with urinary catheters, such as:

• leaking – sometimes leaking occurs and you feel wet even if the catheter is still draining into the bag
• falling out – occasionally the catheter may fall out
• blockages – sometimes the catheter gets blocked and doesn’t drain properly.

Figure 1. Male and female urethra

Conditions that may require urinary catheterisation

Urinary catheterisation can be useful for people with bladder problems, such as:

• urinary retention – inability to empty the bladder, for example due to neurological conditions such as stroke and multiple sclerosis, or other factors such as faecal impaction or enlarged prostate
• bladder obstruction – for example, caused by bladder stones or narrowing of the urethra (the passage from the bladder to the outside).

It can also be useful on a temporary basis, such as:

• to help people to retrain their bladder – catheterisation can be discontinued as soon as bladder control is re-established
• after surgery to the genital area – such as prostate gland or hip surgery or a hysterectomy
• as an indwelling catheter for the first few days after major surgery or to monitor fluid output in patients receiving intravenous fluids.

Types of urinary catheters

Different urinary catheters are used depending on whether they stay in your bladder or are removed once your bladder is empty.

Urinary catheters come in a large variety of sizes; materials (latex, silicone, PVC, or Teflon); and types (Foley catheter, straight catheter, or coude tip catheter). In the case of internal urinary catheters, those inserted into the urethra, the smallest size is usually recommended, although a larger size is sometimes needed to control leakage of urine around the catheter. A large size can also become necessary when the urine is thick, bloody or contains large amounts of sediment. Larger internal urinary catheters, however, are more likely to cause damage to the urethra. Some people have developed allergies or sensitivities to latex after long-term latex catheter use. In such cases, silicone or Teflon types should be used.

Proper urinary catheter use can also often be determined by the length of time for which the process is necessary: long-term (often called indwelling) or short-term use:

Short-term use urinary catheter

In some situations, incontinent patients are catheterized to reduce their cost of care. A condom catheter, which fits on the outside of the penis using adhesive, can be used for short-term cathaterization in males. However, long-term catheterization is not recommended because chronic use carries a significant risk of urinary tract infection.

Long-term use urinary catheter

A urinary 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: The first is a leg bag, a smaller drainage device that attaches by elastic bands to the leg. A leg bag is usually worn during the day, as it fits discreetly under pants or skirts, and is easily emptied into a toilet. The second type of drainage bag is a larger device called a down drain that may be used during the night. This device is usually hung on the patient’s bed or placed on the floor nearby.

During long-term use, the catheter may be left in place during the entire time, or a patient may be instructed on a procedure for placing a catheter just long enough to empty the bladder and then removing it known as clean intermittent self-catheterization. Patients undergoing major surgery are often catheterized and may remain so for some time.

Long-term catheterization can expose patients to an increased risk of infection. Long-term catheterization as a remedy for incontinence is not appropriate, as the risks outweigh the benefits.

Foley catheter

Foley catheters are flexible (usually latex) tubes that are passed through the urethra during urinary catheterization and into the bladder to drain urine. They are retained by means of a balloon at the tip which is inflated with sterile water. The balloons typically come in two different sizes: 5 ml and 30 ml.

The relative size of a Foley catheter is described using French units (F). The most common Foley catheters typically range from 10 F – 28 F. 1 F is equivalent to 0.33 mm = .013″ = 1/77″ of diameter. Thus the size in French units is roughly equal to the circumference of the catheter in millimeters.

Foley catheters come in several sub-types. Coudé (French for elbowed) catheters have a 45° bend at the tip to allow easier passage through an enlarged prostate. Council tip catheters have a small hole at the tip which allows them to be passed over a wire. 3-way catheters are used primarily after bladder, prostate cancer or prostate surgery. They have a third arm or bell that allows an irrigant to pass to the tip of the catheter through a small separate channel into the bladder. This serves to wash away blood and small clots through the primary arm that drains into a collection device. This prevents larger clots, which might plug the catheter, from forming. The second, or inflation, arm has a small plastic valve that allows for the introduction or removal of sterile water through a very small channel to inflate or deflate the retaining balloon.

Foley catheters can also be used to “ripen” the cervix, to allow the induction of labour. The catheter is inserted behind the cervical wall and inflated. The remaining length of the catheter is gently pulled and taped to the inside of the woman’s leg. The inflated balloon applies pressure to the cervix, like the baby’s head would prior to labor, causing it to dilate. Over time the catheter is adjusted and re-taped to maintain pressure on the cervix. When the cervix has dilated sufficiently, the catheter simply drops out.

Figure 2. Foley catheter

Intermittent urinary catheter

An intermittent urinary catheter is inserted into your bladder each time you need to drain urine and once your bladder is empty it’s removed. This process may be referred to as ‘clean intermittent self-catheterisation.’

Intermittent urinary catheters are inserted a few times throughout the day, as decided by your doctor or nurse. An intermittent catheter is inserted through the urethra into the bladder. You can do this yourself, or it can be done by your healthcare worker, carer, or urology nurse. Many people learn how to insert a catheter themselves.

Intermittent urinary catheter reduces the risk of infection and kidney damage by making sure your bladder is emptied adequately at regular intervals. The equipment doesn’t interfere with a normal sexual relationship.

If you develop recurrent urine infections while doing clean intermittent self-catheterisation, see your nurse for a review.

Indwelling urinary catheter

An indwelling urinary catheter is inserted into your bladder but, unlike an intermittent catheter, it is not removed when your bladder is empty. It is held in place by a small, water-filled balloon that is connected to the catheter. The catheter is attached to a drainage bag outside your body that can be secured to your leg or rest on the floor.

Indwelling catheters remain in place continuously and are changed regularly, as required (for example every eight weeks), by a nurse.

Some indwelling urinary catheters continuously drain urine from your bladder while others have a valve that is opened every few hours to drain your bladder when it feels full.

Indwelling urinary catheters are inserted into the bladder either through the urethra (urethral catheter) or the wall of the stomach above the pubic bone (supra-pubic catheter).

A urethral catheter is the most commonly used type of indwelling catheter, but is also associated with the highest risk of infection. Both types of indwelling catheters are held in the bladder by a water-filled balloon.

Indwelling catheters may be drained:

• continuously via a tube into a drainage bag – for example the supra-pubic catheter, which is the preferred choice for people with cervical spinal cord injury or other conditions that limit hand dexterity and where clean intermittent self-catheterisation is not an option
• intermittently via a catheter valve – which can be opened, when required, to allow urine to drain into a toilet, then closed to allow the bladder to refill. This avoids the need for a permanently attached drainage bag and allows the bladder to fill and empty intermittently ,helping maintain good bladder shape . The valve must be released regularly to prevent over filling of your bladder. It is usually connected to a larger bag for drainage at night. A catheter valve is discreet and comfortable and can provide greater independence. It also reduces the possibility of trauma and infection in your bladder.

There is a variety of urine drainage bags to suit different situations. Your nurse will help you select the bags that best suit your needs.

If you are unable to walk and need to use a collection bag, there are collection bags that can hold up to two litres of urine. They can be hung on your bed, your wheel chair or on a stand.

If you are able to walk, there are collection bags that can be placed discreetly on your leg or belly, held by elasticised straps. These are usually worn during the day as they fit discreetly under trousers or skirts, and are easily emptied. The length of the tube can be customised to suit where you want to wear it.

Larger bags can be used at night time. They are usually hung on the bed or placed on a stand on the floor.

Suprapubic urinary catheter

A suprapubic urinary catheter is a tube that is inserted through your abdominal wall into your bladder. Urine is drained from your bladder into a drainage bag outside your body. A small stitch in your abdomen helps to keep a suprapubic catheter in place. Suprapubic catheters are used when the urethra is damaged or a catheter is unable to be inserted through your urethra or when someone is unable to use an intermittent catheter.

Rather than being inserted through your urethra, a suprapubic catheter is inserted through a hole in your abdomen and then directly into your bladder. This procedure can be carried out under general anesthetic, epidural anesthetic or local anesthetic.

The catheter may be secured to the side of your body and attached to a collection bag strapped to your leg. Alternatively, a valve can be attached that opens to allow urine to be drained into a toilet, and closes to allow the bladder to fill with urine until drainage is convenient.

This type of catheter is usually changed every 6 to 8 weeks.

What are the possible complications of using a urinary catheter?

The most common complication of urinary catheter use is a urinary tract infection (UTI). See your doctor if you have any of the following symptoms:

• pain or burning during or immediately after passing urine
• fever, tiredness or shakiness
• an urge to urinate (go to the toilet) more often
• passing small amounts of urine more frequently
• pressure in your lower belly
• urine that smells bad or looks cloudy or reddish.

Kidney infections, called pyelonephritis, are less common but are still a risk, and can be caused by an untreated or undiagnosed urinary tract infection.

Other risks and side effects

Bladder spasms, which feel like stomach cramps, are also quite common when you have a catheter in your bladder. The pain is caused by the bladder trying to squeeze out the balloon. You may need medication to reduce the frequency and intensity of the spasms.

Leakage around the catheter is another problem associated with indwelling catheters. This can happen as a result of bladder spasms or when you open your bowels. Leakage can also be a sign that the catheter is blocked, so it’s essential to check that it’s draining.

Blood or debris in the catheter tube is also fairly common with an indwelling catheter. This could become a problem if the catheter drainage system becomes blocked

Get medical advice as soon as possible if you think your catheter may be blocked, or if you’re passing large pieces of debris or blood clots.

Other, less common, potential problems include:

• injury to the urethra (the tube that carries urine out of the body) when the catheter is inserted
• narrowing of the urethra because of scar tissue caused by repeated catheter use
• injury to the bladder or rectum (back passage) caused by incorrectly inserting the catheter
• bladder stones (although these usually only develop after years of using a catheter)

Your doctor or nurse can give you advice and problem-solving tips.

Urinary catheter care

Generally, people who use urinary catheters need to drink more fluid each day, unless advised otherwise by a doctor as this will help flush the catheter and keep the bladder healthy. Usually the amount of fluid will depend on the person you are caring for and their circumstances.

Careful attention must be given to personal hygiene. This is best done with daily washing around the catheter. If the person has faecal incontinence then careful attention must also be paid to washing after each bowel action. Do not use talcum powder if there is a catheter.

For people living with an intermittent or indwelling urinary catheter, attention must be given to keeping the bladder and bowel healthy and avoiding constipation.

See a continence nurse adviser or doctor if there is a problem.

Looking after yourself

If you’re using a catheter long-term, your doctor or nurse will show you how to look after it, including what to do if you have a problem, and tips for managing day to day. They will also give you information on how to clean your drainage bags and how to order equipment and supplies.

Although urinary tract infections are common with catheter use, there are ways to minimize your risk.

Here is some useful self-care information for urinary catheter care.

Urinary catheter has fallen out

If your urinary catheter has fallen out, it will need to be replaced. Try not to worry as it will not cause any immediate problems. You should follow the advice you have already been given.

Urinary catheter is leaking or not draining

Have a look to make sure that your catheter is not twisted or trapped anywhere or accidentally closed off, causing the urine to stop draining.

If that is not the problem, then it may need to be examined to see why it is leaking or not draining. It may have to be replaced. Use clean towels or pads to keep yourself dry while you wait to see a healthcare professional.

Sexual activity

Sexual activity may continue with an indwelling urinary catheter in place. You may prefer to discuss with your doctor the use of a suprapubic catheter.

It is important to wash around the catheter prior to sexual intercourse.

Men should fold the catheter along the side of the erect penis and hold in place with a condom.

Women should tape the catheter up onto the stomach.

Only water based lubricants should be used to assist with sexual intercourse. Other lubricants may damage the catheter.

General urinary catheter care

• Keep the area where the catheter is inserted clean. You should wash it gently using mild soap. Rinse well and dry thoroughly afterwards. Women should make sure they wash from front-to-back, ie, wash from your urethra towards your back passage.
• Always wash your hands before and after touching the area where the catheter is inserted.
• Maintain good personal hygiene by washing yourself daily with soap and water.
• Avoid the use of talcum powder or creams around the catheter as this may irritate your skin, unless your doctor has prescribed them.
• Try to make sure that the catheter and the tubing is not under tension, for example, being pulled by clothing or getting caught on chairs or beds or when you are moving around.
• Make sure the drainage bag is well supported and attached securely so that, as it fills, its weight does not pull on the catheter.
• Most intermittent catheters are single-use only, meaning you throw the catheter away once you have used it to drain your bladder. Your doctor or nurse will advise you what equipment you can wash and reuse.
• Drink plenty of water as it will help to flush bacteria from your bladder and urinary tract, unless you have a medical condition which means this is not possible.

Keeping your catheter working properly

• Avoid getting constipated as this can affect your urine flow.
• Avoid having kinks in your catheter tubing.
• Make sure you have a spare catheter and related equipment ready for the next change.

Looking after your indwelling catheter

• If you have an indwelling catheter it’s important to make sure your drainage bag is kept lower than your bladder, and make sure there are no kinks in the tubing – this makes sure urine flows from your bladder into the drainage bag and not back up your urethra into your bladder. It’s a good idea to empty your drainage bag regularly during the day so the weight of a full bag doesn’t pull on the tube.
• Most people will be supplied with a bag to use during the day and a different one at night. Catheter bags can be cleaned each day and reused. Your health professional will let you know how often you need to use a new bag (often once a week) and will show you how to properly clean and dry the bags. It’s important to follow the advice of your doctor or nurse to minimise your risk of infection.
• Indwelling catheters are usually changed every 6–12 weeks by your doctor or nurse.