1) Urinary catheters have been used for thousands of years to treat urinary retention, but Foley catheters introduced in the 1920s opened up new medical issues. 2) Indwelling catheters are used when clean intermittent catheterization is not possible, for reasons like neurological conditions, incontinence, surgery, or intensive care. 3) Long term catheter use can lead to complications like infection, bladder and kidney damage, stones, and trauma due to bacterial biofilm buildup. Future research aims to develop catheters that better mimic natural physiology and prevent these issues.

1. Urinary catheters:
history, current status,
adverse events and
research
agenda
Dr. Oğuz Kızılkaya
Trakya University Pediatric Surgery Clinic
oguz@fikrikumbara.com

3. Catheter Kathie´nai to thrust into

4. • Treatment of urinary retention in the male
• Designed for intermittent catheterization
• Urinary incontinence was not a medical emergency
• It was left as a personal embarrassment for men and women
• Foley catheterization opened up a new era
• Also opened up a Pandora’s box of medical conditions and adverse events

5. 1500 BC - Ebers papyrus, relieving retention by transurethral bronze
tubes, reeds, straws and curled-up palm leaves

6. • 400 BC - References in Hippocratic writings about malleable lead tubes
• 79 AD - S-shaped silver tube in Pompei
• 900s - Malleable silver tube with numerous side holes by Ebu'l Kasım Halef
ibn Abbas ez - Zehravi

7. • 1500s - Fabricius of Acquapendente wax-impregnated cloth catheter moulded on silver
sound
• 1564 - Ambroise Paré silver tube with a long gentle curve for easier insertion

8. • 1600s - Jan-Baptiste van Helmont chamois skin catheter impregnated with white lead
and linseed oil, inserted over a whalebone stylet. Later, wound silver wire
was used to prevent collapse, with external grooves filled with wax, tallow or
bound with fine gut
• 1836 - Louis Auguste Mercier invented the coudé and bi-coudé catheter

9. 1929 - Rubber balloon was attached with fine silk and waterproof cement
close to the tip of a rubber catheter with a longitudinal groove which
accommodated a fine tube to inflate the balloon with water

11. • In people with impaired bladder function, whether retention or incontinence, a
safe and reliable system is required to collect and contain the urine, whether
for short- or longterm use
• In those males and females for whom the method is feasible, clean intermittent self-
catheterization is the optimal procedure to manage urinary retention
• In patients for whom clean intermittent self-catheterization is not possible, an
indwelling catheter has to be used.

13. The principal reasons for indwelling
catheterization are as follows:
(a) to permit urinary drainage in patients
with neurological conditions which cause
bladder dysfunction;
(b) to manage urinary incontinence in
patients lacking cognitive function;
(c) to minimize skin breakdown and
pressure ulcers in paralysed, comatose or
terminally ill patients;
(d) to irrigate the bladder;
(e) to administer chemotherapy;
(f) to aid in urological surgery or other surgery
on contiguous structures;
(g) to obtain accurate measurements of urinary
output in critically ill or post-operative patients;
(h) to empty the bladder during childbirth; and
(i) to undertake urodynamic studies (such as
pressure measurements).

15. • Foley’s original catheter was made of latex
• High stretch ratio
• high level of resilience
• Extremely waterproof
• Main problem with latex is its cytotoxicity
• 1980s, an epidemic of severe urethral strictures
• Now coated with silicone elastomer
• Silicone catheters
• non-allergenic
• superior resistance to kinking
• better flow properties in comparison with latex
• Rough surfaces encourage the deposition of bacterial biofilm
• Sharp edges to the drainage eyes can cause bleeding from the urethral lining when the catheter
is introduced or withdrawn.

16. Bacterial colonization
• Foley catheter without a valve results in continuous drainage and, thereby, suppresses the
normal process by which the build-up of bacteria is inhibited by periodic flushing.
• Provided by ‘‘tidal drainage’’, which allows the bladder to fill and empty automatically
• Series of 33 patients with neurologically-damaged bladders tidal drainage reduced the rate of
infection from 73% to 15%
• In short-term catheterization, the daily infection rate is 5%
Chronic infection
• The balloon of the Foley catheter occupies the base of the bladder, obstructing the internal urethral
orifice, with the result that 10–100 ml of urine remains in the bladder when its flow has ceased
• Rapidly become infected, resulting in chronic infection of the bladder

17. Kidney and bladder damage and Bladder stones
• Invasion of the bladder by urease-producing bacteria,
• Particularly Proteus mirabilis
• Conversion of urea into ammonia
• Consequential increase in the alkalinity of the urine causes crystals of struvite and
hydroxyapatite
• Nucleation of struvite and hydroxyapatite crystals on the biofilm on the catheter
resulting from the activity of the bacterial urease causes encrustation to form around
and within the catheter, blocking the drainage eyes and the lumen and preventing the
flow of urine

20. Pseudopolyps and Septicaemia
• Towards the end of the drainage process, when the bladder wall comes into what is
frequently traumatic contact with the tip of the catheter, the mucosal lining can be sucked
into the drainage eye
• This suction can result in the formation of haemorrhagic pseudopolyps and mucosal damage
Urethral trauma
• When the water is removed from the balloon with a syringe prior to catheter withdrawal, a
phenomenon known as creep may cause the balloon to fail to collapse completely.
Balloon fragments
• If burst happens, the fragments must be removed, otherwise they can lead to stone
formation or catheter blockage.

23. Research agenda
• Catheter should be flexible and experience minimal friction with the urethra with durable,
lubricious, antibacterial and hydrophilic coating
• The balloon of the Foley catheter provides a retention force between 9–41 N, depending on
the balloon inflation volüme but associated with incomplete urinary drainage, bladder and
urethral damage), so a novel approach is essential
• The catheter should mimick the natural physiology and without damage to the urothelial lining
of the bladder or the urethra.
• Catheter should be resistant to encrustation by crystalline bacterial biofilm.
• There should be an deskillized method for the safe insertion of the catheter by the suprapubic
route.