1. Bladder Irrigation of Long-Term Indwelling Urinary Catheters A-Success or
Washout?
Donna Aris RN
INTRODUCTION
BACKGROUND
REFERENCES
PURPOSE
BACKGROUND REVIEW OF LITERATURE
1. Getliffe, K., Hughes, S., Le Claire, M. (2000). The dissolution of urinary catheter encrustation BJU International,
85(1):60-4.
2. Hagen, S. (2010). Washout policies in long-term indwelling urinary catheterisation in adults. Cochrane Database Of
Systematic Reviews, (4), doi:10.1002/14651858.CD004012.pub4
3. http://www.apic.org/Resource_/EliminationGuideForm/c0790db8-2aca-4179-a7ae-676c27592de2/File/APIC-CAUTI-
Guide.pdf
4. Mayes, J., Bliss, J., & Griffiths, P. (2003). Preventing blockage of long-term indwelling catheters in adults: are citric acid
solutions effective?. British Journal Of Community Nursing, 8(4), 172-175
5. Muzzi-Bjornson, L., Macera, L., (2011) Preventing infection in elders with long-term indwelling urinary catheters, Journal
of the American Academy of Nurse Practitioners, 23(1), 127-134
6. Nicolle, L. (2014). Catheter-Related Urinary Tract Infection: Practical Management in the Elderly. Drugs & Aging, 31(1),
1-10. doi:10.1007/s40266-013-0089-5
7. Pomfret, I., Bayait, F., Mackenzie, R., Wells, M., & Winder, A. (2004). Clinical evaluation. Using bladder instillations to
manage indwelling catheters. British Journal Of Nursing, 13(5), 261.
8. http://www.cdc.gov/hicpac/pdf/cauti/cautiguideline2009final.pdf Pg8-14
9. Stickler, D. J., & Feneley, R. L. (2010). The encrustation and blockage of long-term indwelling bladder catheters: a way
forward in prevention and control. Spinal Cord, 48(11), 784-790. doi:10.1038/sc.2010.32
10.Macleod, S., Stickler, D. (2007), Species interactions in mixed-community crystalline biofilms on urinary catheters
Journal of Medical Microbiology 56, 1549–1557
11.Wilde, M. (1997). Long-term indwelling urinary catheter care: conceptualizing the research base. Journal of Advanced
Nursing, 25: 1252-1261
• Complications of LTIC- Frequent bladder irrigations and forced
instillations may cause irritation and damage to the bladder mucosa.
• Presence of a catheter and inflated balloon causes mechanical irritation.
• Opening the catheters’ closed system increases risk of infection.
• Catheter use greater than six days increases bacteriuria (bacteria in the
urine) by day 30 of catheterization.
• Bacterial Biofilm- Proteus Mirabilis the most common gram negative
urease-producing bacteria, initiates formation of biofilm on the surface of
the catheter, by generating ammonia from urea, elevating the pH (> 6.8) of
urine and cause blockage of urine flow.
• Blockage & Encrustation:
• The term “Bladder Washout” is a misnomer as it is the catheter which is
being irrigated, not the bladder.
• The risk of bacterial infection and encrustation increases with the length of
time a catheter is in situ ≥ 30 days.
• The most common cause of catheter obstruction is the formation of
crystalline biofilm, which is associated with Proteus Mirabilis, and identified
in 80% of long- term indwelling urinary catheters (LTIC’s).
• The use and effectiveness of an acidic solution to irrigate/washout the
catheter to prevent obstruction and encrustation is conflicting, and of low
quality scientific evidence, however, nurses continue to use this
intervention to manage LTIC complications.
CONCLUSION
PRACTICE RECOMMENDATIONS
RELEVANT FINDINGS
• To review existing scientific research, and evaluate the benefits of bladder
irrigation/washout with an acidic solution versus no irrigation, in decreasing
obstruction and encrustation in the long-term indwelling urinary catheter.
• Centers for Disease Control (CDC), and the National Institutes of
Health (NIH), estimates that biofilm is responsible for approximately
65%–80% of all catheter related infections.5
• Understanding biofilm formation and its physiology is essential in
formulating effective evidenced -based practice to prevent catheter
related complications.9,11
• Removal of the catheter eliminates the biofilm and encrustation but
requires repeated re-catheterization, and this increases risks of
infection.9,11
• There is evidence supporting the use of bladder irrigation/washout
with an acidic solution to extend catheter life in patients who have
frequent blockage and encrustation of their LTIC.1,2,11
• Evidence suggests, catheter changes should be based on catheter
patency, not fixed schedule changes; opening the catheter's closed
system increases risk of infection.11
• Research suggests there is a benefit of acidifying the urine to reduce
catheter encrustations and blockage in LTIC, which, if left untreated
increases the risk of bacterial infection.2
• Scientific evidence supporting the effectiveness of bladder
irrigation/washout is rated low-quality with inconsistent results.2,4
• There is no consensus in research and practice regarding the
frequency, duration, volume of solution, or success of bladder
irrigation/washout in preventing LTIC obstruction or encrustation.2
• The CDC 2009 guidelines recommends bladder irrigation of LTIC
only to prevent obstruction from encrustation of the catheter and
graded findings as (No recommendation/unresolved issue).8
• Nurses have the responsibility to deliver care based on current
research and best practices. The current research to support the
success of bladder irrigation/washout of long-term indwelling
catheters is inadequate.
• In the absence of scientific research supporting the effectiveness of
bladder irrigation/washout, clinicians will continue this intervention, as
the evidence to stop this practice is also not strong.
• Further scientific research and evidence is needed in this area of
practice, on the appropriate volume of solution per instillation,
frequency and duration of bladder irrigations/washouts required to
effectively reduce catheter obstruction and encrustation.
Figure 4: Proteus Mirabilis note the hair-like fimbria
Figure 2: Chronic inflammation within the bladder of a patient with a
long term indwelling catheter
Figure 5: Encrustation on the end of a long-term indwelling urinary catheter
Figure 3: Opening the urinary catheter closed system increases
infection risks
Figure 1: The rate of catheter encrustation by
P. mirabilis, Calcium and Magnesium
Figure 6: Medication Administration Record
Figure 7: Example of Run Chart
PRACTICE RECOMMENDATIONS
 Nurse-Driven
protocols needed to
decrease bladder
irrigation frequency
and volume
inconsistencies;
evidenced by three
current (2014)
medication
administration
records (MAR’s).
• pH increases in the
urine and catheter
biofilm.
• Calcium crystals
increases.
• Magnesium
phosphates precipitates
causes a crystalline
biofilm.
• Catheter is encrusted
and blocked.
Establish an interactive framework
to manage LTIC, using the CAUTI
surveillance format from the 2008
APIC Guide,3 e.g. run chart to:
 Track data and analyze trends.
 Evaluate the effectiveness of
interventions to drive positive
outcomes.