This document provides information on best practices for basic care of indwelling urinary catheters. It discusses short-term versus long-term catheter use, types of catheters, insertion and securement, drainage bags, irrigation, symptoms of catheter-associated urinary tract infections, and prevention of CAUTIs. The document aims to educate continence nurses to improve patient care and health outcomes related to indwelling urinary catheter use globally.

1. Teaching Module
International Continence Society
Teaching Module
Best Practices:
Basic Care in Indwelling Urinary
Catheter Management
January 2016
Mary H. Wilde, PhD, RN
Professor, School of Nursing, University of Rochester, USA
Member of the ICS Nurses’ Committee

2. Teaching Module
Objectives
• Our purpose is to educate continence nurses to improve
patient care and health outcomes globally.
At the conclusion of this presentation, readers should be able to:
• 1. Describe best practices for basic care of people using
indwelling urinary catheters.
• 2. Understand the differences and similarities in shorter-term
care in acute settings as compared with long-term care in the
community.

3. Teaching Module
Prevalence of catheter use
Prevalence in the USA:
• Acute care, 15-25%; 5% nursing homes (Gould et al. HICPAC, 2009)
• Long term catheter users overall estimate is 153,818.
• 9% home care ;33% hospice (National Home and Hospice Study,
2007cdc.gov/pub/Health Statistics/NCHS/Datasets/NHHCS/2007)
• 34% in home care were long-term users (Wilde et al, 2010.)
• Spinal cord injury– 23% of those discharged from
rehabilitation, but some use an intermittent catheter later.
(Cameron et al., 2010)
Prevalence in England:
• England & Wales, 19 hospitals 1997 cited by Scottish Nurses
Association, 26.3% in acute care, range 12-40% depending on
specialty (Glynn et al. 1997)
• England, survey in acute care, 18%, varied by specialty, more in
ICU. HPA survey on HCAI and antimicrobial use across acute hospitals in England (2011)
• England, 0.07% community study of 827,595 over two years
(0.05% > 75 yrs old) (Kohler-Ochmore & Feneley 1996)

4. Teaching Module
Indications for short-term catheter use
 Urinary retention or bladder outlet obstruction
 Improving comfort for end-of-life care if needed
 Critically-ill and need for accurate measurements of I&O
(e.g., hourly monitoring)
 Selected surgical procedures (GU surgery/colorectal
surgery)
 Assist in healing open sacral or perineal wound in the
incontinent patient
 Intraoperative monitoring of urinary output during surgery
or large volumes of fluid or diuretics anticipated
 Prolonged immobilization (e.g., potentially unstable
thoracic or lumbar spine, multiple traumatic injuries such as
pelvic fractures)
http://nursingworld.org/CAUTI-Tool (based on USA CDC guidelines, Gould et al. 2009)

5. Teaching Module
Indications for long-term catheter use
 Intractable urinary retention for those who cannot
manage an intermittent catheter (and no caregiver to do
it)
 Bladder outlet obstruction, not surgically treated
 Improving comfort for end-of-life care if needed
 Alternatives to consider: toileting schedule (when no
retention), intermittent catheter, condom/sheath
catheter (for cooperative males without obstructed
urine or persistent retention )
(USA CDC guidelines, Gould et al. 2009)

6. Teaching Module
Short & long-term catheter use defined:
 Short term- less than 1 months’ expected use
 Can be longer, failing trial without catheter
 Long term- over 1 months use but often extends
over many years.
 “Indefinite use” would be more accurate term,
but no agreement on terminology.
 Both “catheter types” and “catheter use” for
expected time of catheterization are called short
and long-term, causing confusion. (Cottenden et al. 2013)

7. Teaching Module
Short term catheter types
 Short term use—less than 14 days’ expected use
 Latex or plastic, but caution related to latex allergy.
 Coated catheters (silver alloy, nitrofurazone or
minocycline/rifampicin) for up to two weeks
 Can decrease bacteriuria but do not prevent
symptomatic UTI & evidence is weak.
 Can be uncomfortable and are more expensive.
(Lam et al., 2014)
 Long term catheter types also can be used.
(Cottenden et al., 2013).

8. Teaching Module
Long term catheter types
 Can be used for 28 days and up to 12 weeks, dependent on
local policy.
 Latex coated poly-tetrafluoro-ethylene (PTFE or Teflon)
 Silicone elastomer-coated latex or 100% silicone (harder
surface but wider lumen). Balloon water can evaporate
quicker in pure silicone catheters. Take care to prevent
traction as erosion of penis has occurred with silicone.
 Hydrogel polymer-coated latex (softer which can be of
benefit) Hydrogel less likely to form suprapubic catheter
“deflation cuff”. (Parkin, 2002;Jahn et al. 2012; Cottenden et al. 2013)

9. Teaching Module
Catheter sizes
Catheter sizes (Fr= French which is the same as
Charrière or Ch) Use the smallest size that permits
flow and to prevent potential trauma to urethra and
sphincter.
• 12-16 Fr for men and 12-14 Fr for women.
• Children: 5-6 Fr for newborns ; 5-10 Fr
toddlers to children to age 12
Balloons 5-10 mL. (30mL only for postoperative
bleeding), 2.5-5mL for children
(WOCN, Indwelling Urinary Catheters, Best Practices for Clinicians, 2009; Cottenden et
al. 2013)

10. Teaching Module
Catheter insertion
 Long term catheters often
changed every 4 weeks. People
with frequent blockage can need
it every 2-3 weeks or more
often. Can extend to 6-8 weeks
if no problems.
 Observe several changes for
“catheter life pattern.” (Getliffe,
1994)
 Good lighting, and help of
another if spasticity in legs.
 Use sterile gloves.
 Lubricate catheter well,
especially for males.
• For Males:
• Insert all the way to Y
(bifurcation) to prevent
catheter being inflated
within the urethra.
• If resistance is felt,
encourage deep breaths and
distraction.
• For females: Urethra can be short,
especially in older women.
 Insert 1” further than point of
urine flow.
 Fill balloon all the way to 10mL.
(ANA CAUTI prevention, 2015
http://nursingworld.org/ANA-CAUTI-
Prevention-Tool ; Wilde & Feng, 2013)

11. Teaching Module
Catheter securement
 Nurses often recommend but not use it:
 Of 82 nurses (8 continence specialists), 98%
recommended but only 4% used it. (Siegel, 2006);
 18% secured in acute care in one day point-
prevalence study (N= 8 of 44) (Appah et al. 2015)
 Securement could prevent dislodgement and
urethral/bladder neck trauma
 Adhesive—good for those likely to dislodge but
irritating to skin
 Non-adhesive—prevent constricting circulation
(Wilde & Feng, 2013)

12. Teaching Module
Securement examples
• Non-adhering Adhering Holster

13. Teaching Module
General catheter care
 Hand hygiene before and after catheter care. In home,
teach family.
 If breaks in the closed system (e.g., disconnection,
cracked tubing), replace the catheter and tubing.
 Perform perineal hygiene at a minimum daily, per
facility protocol/procedure and as needed. Soap and
water is all that is needed most often.
 Use fecal containment device when appropriate for
fecal incontinence.
ANA CAUTI prevention, 2015 http://nursingworld.org/ANA-CAUTI-Prevention-Tool

14. Teaching Module
Drainage bags
 Closed drainage essential in acute care, short term use.
 It is the only proven method of decreasing UTI. (Kunin &
McCormack, 1966)
 Types:
 Overnight (2000-4000mL)
 Leg bags (270-1000 mL.)
 Belly bag (with normal bladder pressure) (WOCN, 2009)
 Prevent kinks/twists in tubing: Blocked urine flow can
contribute to damage to the kidneys (Feneley et al. 2015)
 Keep bag at least 12” below the level of the bladder and off the
floor to prevent suction of the catheter eyes on the bladder
mucosa. (Glahn et al. 1988)

15. Teaching Module
Care for drainage bags
 Empty the drainage bag regularly using a separate,
clean collecting container for each patient; avoid
splashing, and prevent contact of the drainage spout.
http://nursingworld.org/ANA-CAUTI-Prevention-Tool
 Empty when 1/3 to ½ full.
 For long-term catheter users, replace drainage bags
weekly.
 No evidence that connecting a catheter to a leg bag
continuously & then hooking up an overnight bag is
beneficial. (Cottenden et al. 2013)

16. Teaching Module
Cleaning & reuse of drainage bags
 Systematic review revealed need for research in this area.
 Conflicting guidelines and research virtually lacking
since 1990s. (Wilde, Fader et al. 2013)
 In a U.S. study of 202 long-term catheter users, most
switched between leg and night bag
 54% cleaned leg bags & 59% night bags. (Wilde , McDonald, et
al. 2013)
 Rehabilitation nurses have used mild bleach (1 part
household bleach to 10 parts water). (Dille & Kirchhoff, 1993;
Dille et al. 1993)
 In home care in the past: vinegar was recommended (1 part
vinegar to 4 parts water) (Wilde, 1986)

17. Teaching Module
Irrigation (also called flushing or washouts)
 Irrigation not recommended. Sometimes used in
hospitals to remove blood clots post operatively.
 In one U.S. study of 202 long term catheter users , 42%
irrigated and 18% once or more a day.
 Solutions were saline (76%) and sterile water (23%).
 Surprising, 9% used plain tap water, which could
have bacteria or other impurities in it.
 4% used Renacidin --not readily available in the US
and made fresh in a pharmacy. (Wilde, McDonald et al. 2013)

18. Teaching Module
Irrigation sachets
 Irrigation sachets (Suby G and Suby R, called catheter
maintenance solutions) are available in the United Kingdom,
and in some other countries, to dissolve encrustations if
change is not appropriate. These solutions are not available
in every country.
 Saline or sterile water is not effective in breaking up
encrustations.
 Research in Canada testing saline, no irrigation and Suby
G showed no difference in decreasing time to change
but underpowered. (Moore et al., 2009)
 There is a desperate need for irrigation solutions which
are effective, easily obtained and used, inexpensive, and
safe.

19. Teaching Module
Symptoms CAUTI- short term catheter users
• In acute care diagnosis of CAUTI, catheter in place 2> days:
• 1. At least one symptom below with no other recognized cause:
• fever (>38.0°C) • suprapubic tenderness • costovertebral
angle pain or tenderness • urinary urgency • urinary
frequency • dysuria
2. AND urine culture with no more than two microorganism ≥105
CFU/m
• http://www.cdc.gov/nhsn/pdfs/pscManual/7pscCAUTIcurre
nt.pdf
• Differential diagnosis not simple to identify source of infection
• Fever-- without other possible source, comorbidities
confound
• Bacteriuria (Lo et al., 2014)

20. Teaching Module
Symptoms CAUTI--long term catheters
• Urine Changes:
• Color – Discolored,
cloudy, dark, blood
stained
• Odor – Foul smelling,
change in smell from
usual
• Sediment (grit) –
Increased amount
Temperature – Fever, chills
Pain and/or pressure in bladder
area or back (Burning possible,
not common)
Early, mild symptoms of
autonomic dysreflexia (e.g.,
goosebumps, headaches,
sweats) mainly in people with
spinal cord injury
General Symptoms Blahs!,
feeling sick
• Functioning or mental
changes – weakness,
spasticity, change in
the level of alertness
(Wilde, McDonald et al., 2013)

21. Teaching Module
CAUTI prevention
 Do not insert indwelling catheter if bladder management is
possible any other way, e.g., condom catheter (sheath, external)
or intermittent catheter (including caregiver performing or
assisting).
 Remove catheter as soon as possible.
 Track CAUTI rate systematically:
Events of symptomatic UTI X 1000
Catheter days’ use (number of persons X days catheter used)
 Encourage staff and celebrate when CAUTI rate & usage of
catheters decreases.
 In acute care, a daily order for catheter continued use is
recommended.
 In community, assess regularly whether indwelling is still
needed.
 Check out this important document from the USA, American Nurses’
Association: ANA CAUTI prevention, 2015 http://nursingworld.org/ANA-CAUTI-
Prevention-Tool

22. Teaching Module
References
• Appah, Y., Hunter, K. F., & Moore, K. N. (2015). Securement of the
indwelling urinary catheter: A prevalence study. Journal of Wound,
Ostomy, and Continence Nursing doi:10.1097/WON.0000000000000176
• Cameron AP, Wallner LP, Tate DG, Sarma AV, Rodriguez GM, Clemens
JQ. Bladder management after spinal cord injury in the United States
1972 to 2005. J Urol. 2010 Jul;184(1):213-7. doi:
10.1016/j.juro.2010.03.008.
• Cottenden, A., Bliss, D., Buckley, B., Fader, M., Gartley, C., Hayer, D ,
Ostaszkiewicz, J., Pieters, R., & Wilde, M.H (2013). Management using
continence products. In P. Abrams, L. Cardozo, S. Khoury, & A. Wein A,
Eds., Incontinence: 5th international consultation on incontinence (pp.
1651-1786). Arnheim, The Netherlands: ICUD-EAU Publishers
• Dille, C. A., Kirchhoff, K. T., Sullivan, J. J., & Larson, E. (1993). Increasing
the wearing time of vinyl urinary drainage bags by decontamination
with bleach. Arch Phys Med Rehabil, 74(4), 431-7.

23. Teaching Module
• Dille, C. M., & Kirchhoff, K. T. (1993). Decontamination of vinyl
urinary drainage bags with bleach. Rehabil Nurs, 18(5), 292-5.
doi:10.1002/14651858.CD004013.pub4
• Fisher, E., Gillies, K., & MacLennan, S. (2014). Types of indwelling
urethral catheters for short-term catheterisation in hospitalised
adults. The Cochrane Database of Systematic Reviews, 9, CD004013.
• Feneley, R. C., Hopley, I. B., & Wells, P. N. (2015). Urinary catheters:
History, current status, adverse events and research agenda. Journal
of Medical Engineering & Technology, 1-12.
• Getliffe, K. A. (1994). The characteristics and management of
patients with recurrent blockage of long-term urinary catheters. J
Adv Nurs, 20(1), 140-9.
• Glahn, B. E., Braendstrup, O., & Olesen, H. P. (1988). Influence of
drainage conditions on mucosal bladder damage by indwelling
catheters. II. histological study. Scand J Urol Nephrol, 22(2), 93-9.

24. Teaching Module
• Glynn A, Ward V, Wilson J, et al. 1997. Hospital Acquired
Infection: Surveillance Policies and Practice. A Report of a Study of
the Control of Hospital Acquired Infection in 19 Hospitals in
England and Wales. London: Public Health Laboratory Service.
• Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D.
A., & and the Healthcare Infection Control Practices Advisory
Committee (HICPAC). (2009). Guideline for prevention of catheter-
associated urinary tract infections 2009. Atlanta, GA: Centers for
Disease Control and Prevention.
• Jahn, P., Beutner, K., & Langer, G. (2012). Types of indwelling
urinary catheters for long-term bladder drainage in adults. The
Cochrane Database of Systematic Reviews, 10, CD004997.
doi:10.1002/14651858.CD004997.pub3 [doi]
• Kunin, C. M., & McCormack, R. C. (1966). Prevention of catheter-
induced urinary-tract infections by sterile closed drainage. The
New England Journal of Medicine, 274(21), 1155-1161.
doi:10.1056/NEJM196605262742101

25. Teaching Module
• Lo, E., Nicolle, L. E., Coffin, S. E., Gould, C., Maragakis, L. L.,
Meddings, J., . . . Yokoe, D. S. (2014). Strategies to prevent
catheter-associated urinary tract infections in acute care
hospitals: 2014 update. Infection Control and Hospital
Epidemiology, 35 Suppl 2, S32-47.
• Lam, T. B., Omar, M. I., Fisher, E., Gillies, K., & MacLennan, S.
(2014). Types of indwelling urethral catheters for short-term
catheterisation in hospitalised adults. The Cochrane Database
of Systematic Reviews, 9, CD004013.
doi:10.1002/14651858.CD004013.pub4 [doi]
• Moore, K.N., Hunter, K.F., McGinnis, R., Puttagunta, L,
Chobanak, J., Bascu, C., Fader M., & Voaklander, D. (2009). Do
catheter washouts extend patency time in long term urethral
catheters? A randomized controlled trial of acidic washout
solution, normal saline washout, or standard care. Journal of
Wound, Ostomy and Continence Nursing, 36, 82-90.

26. Teaching Module
• Parkin, J., Scanlan, J., Woolley, M., Grover, D., Evans, A., & Feneley, R.
C. (2002). Urinary catheter 'deflation cuff' formation: Clinical audit
and quantitative in vitro analysis. BJU Int, 90(7), 666-71.
• Siegel, T. J. (2006). Do registered nurses perceive the anchoring of
indwelling urinary catheters as a necessary aspect of nursing care?: A
pilot study. J Wound Ostomy Continence Nurs, 33(2), 140-4.
• Wilde, M. H. (1986). Living with a Foley. American Journal of Nursing ,
86(10), 1121-3.
• Wilde, M. H., Brasch, J., Getliffe, K., Brown, K. A., McMahon, J. M.,
Smith, J. A., . . . Tu, X. (2010). Study on the use of long-term urinary
catheters in community-dwelling individuals. Journal of Wound,
Ostomy, and Continence Nursing, 37(3), 301-310.
doi:10.1097/WON.0b013e3181d73ac4
• Wilde, M. H., Fader, M., Ostaszkiewicz, J., Prieto, J., & Moore, K.
(2013). Urinary bag decontamination for long-term use: A systematic
review. Journal of Wound, Ostomy, and Continence Nursing, 40(3),
299-308. doi:10.1097/WON.0b013e3182800305 [doi]

27. Teaching Module
• Wilde, M. H., McDonald, M. V., Brasch, J., McMahon, J. M.,
Fairbanks, E., Shah, S., . . . Scheid, E. (2013). Long‐term urinary
catheter users self‐care practices and problems. Journal of
Clinical Nursing, 22(3-4), 356-367.
• Wilde, M. H., & Zhang, F. (2013). Best practices in managing the
indwelling urinary catheter for the homecare patient.
Perspectives, 10, 1-7-12.
• Wilde, M. H., Zhang, F., Fairbanks, E., Shah, S., McDonald, M. V.,
& Brasch, J., (2013). Perceived value of a urinary catheter self-
management program in the home. Home Healthcare Nurse, 31
(9), 465-473. doi: 10.1097/NHH.0b013e3182a89791
• WOCN Society Clinical Practice Continence subcommittee.
(2009). Indwelling urinary catheters: Best practice for clinicians
Wound Ostomy and Continence Nursing Society.