Urinary catheterization is a common healthcare intervention used to manage urinary dysfunction that poses serious associated risks and

complications. This article discusses methods of

urinary catheterization and their indications, catheter-associated complications, and assessment
and management strategies that home healthcare practitioners can employ to ensure best
patient outcomes and minimize complications.
Study
Edward Jones is an 82-year-old man with an indwelling urethral cath- eter for postoperative
urinary retention following colon resection sur- gery 3 weeks ago. He currently resides with his
daughter and is visited by a home healthcare nurse for catheter management and monitoring.
When his nurse arrived 3 days ago, she discovered a blockage in the urinary drainage system.
She immediately removed and replaced the catheter and collecting system. In the past 2 days,
Mr. Jones has become increasingly more confused and agitated, and his urine has a cloudy
appearance and foul odor but he remains afebrile. A dipstick urinalysis reveals the presence of
leukocytes. The nurse suspects that Mr. Jones has developed a catheter-associated urinary tract
infec- tion. She promptly contacts the healthcare practitioner managing Mr. Jones postsurgical
care for further guidance and treatment.
How did this infection occur? What catheter management and care practices could have been
used to prevent this infection? What role can the home healthcare practitioner play in reducing
the risk of such infections in their patients?
urinary catheters are used by home health-

followed by the first latex cath- eter in the

care patients, like Edward Jones, for a

1800s. In 1853, Jean Franois Reybard

variety of reasons. Urinary catheterization

developed the first indwelling catheter,

allows access to the bladder for the

purpose of draining urine. This access is

which utilized an inflated balloon to secure its

place in

gained by inserting either a catheter

through the urethra into the bladder or a
suprapubic catheter through the anterior
abdominal wall into the bladder. The
practice of urinary catheterization may date
back to 300 AD or possibly earlier. The
precursor to the modern catheter, made of
gum elastic, was intro- duced in 1779,
Copyright 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

the bladder. Frederick Foley later

redesigned this catheter in 1932, and the
Foley catheter remains one of the most
commonly used devices for man- agement
of urinary dysfunction today (Bloom et
al., 1994; Lawrence & Turner, 2005). As
the materials and design of catheters have
evolved over time, so too have the care
and management involved with
catheterization. To ensure the best patient
outcomes and minimal complications, the
home healthcare practitioner must stay
informed about catheter care. This article
reviews current options for urinary
catheterization and their as- sociated
complications and provides approaches to
the assessment and management of
catheters in patients with urinary
dysfunction.

Copyright 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Rebecca Herter, BS, and Meredith Wallace Kazer, PhD, APRN, A/GNP-BC
342

Copyright 2010 Wolters Kluwer Health | Lippincott Williams &

Wilkins
Approximately 4 million Americans un- dergo urinary catheterization annually, and more
than 500,000 of these catheter- izations involve indwelling catheters left in place for some
period (Warren, 2001). Between 15% and 25% of patients may receive indwelling catheters
during hospi- talization, and the prevalence of catheter use in residents of long-term care
facilities is estimated between 7.5% and 10% (Saint et al., 2000). One study found that of
4,010 individuals receiving home care services,
4.5% used an indwelling catheter (Sorbye et al., 2005). Although the indications for
catheterization have been extensively out- lined, reports of the inappropriate use of
catheters range from 21% to more than
50% (Hazelett et al., 2006).

Urinary Catheters
Urinary catheters are primarily used to manage urinary problems, namely urinary
incontinence and urinary retention. The cause of urinary dysfunction determines the need for
either short- or long-term catheter- ization and consequently the appropriate selection of
catheterization method (New- man, 2008). These methods of catheteriza- tion include
intermittent and indwelling catheterization. Indwelling catheterization can be either urethral
or suprapubic.

Intermittent Catheterization Intermittent catheterization involves the brief insertion of a

catheter into the blad- der through the urethra to drain urine at regular intervals. Uses for
intermittent catheterization include

Obtaining urine samples

Emptying the bladder

 Measuring residual volume

Instilling medication
Instilling contrast material into the bladder to study the bladder and ure- thra (Hart,
2008).
Intermittent catheterization is becom- ing the gold standard for the management of
bladder-emptying dysfunctions and fol- lowing surgical interventions. Certain ad- vantages
to intermittent catheterization,
vol. 28 no. 6 June 2010

Home

Healthcare Nurse 343

including the lower risks of catheter-

Increasing comfort in terminally or

associated urinary tract infection (CAUTI)

severely ill incontinent patients and

and complica- tions, may make it a more

managing any skin damage caused by

desirable and safer option than indwelling

incontinence, when

catheterization. Practic- ing intermittent

catheterization, however, may be difficult
for patients with limited vision, dex- terity,

all other methods of managing urinary incontinence have failed

and mobility, although, in these cases,

Maintaining a continuous outflow of urine

family members and caregivers can be

in preoperative patients and patients with

taught the procedure (Robinson, 2009).

void- ing difficulties resulting from

neurological disorders

Indwelling Urethral Catheterization

Indwelling urethral catheterization involves

Providing immediate treatment of acute

uri- nary retention (Hart, 2008).

the insertion of a catheter through the

urethra into the bladder. The catheter is
held in place with a retention balloon and

Suprapubic Catheterization

then connected to a drainage bag,

Suprapubic catheterization involves the

creating a closed urinary system. The

inser- tion of a catheter midline above the

indications for indwelling urethral catheters

symphysis pubis through the anterior wall of

include

the abdomen into the bladder. Like the

indwelling catheter, the suprapubic catheter
uses a balloon to hold its position and is

Accurate monitoring of urine output in

connected to a drainage bag. Suprapubic

criti- cally ill patients

catheterization is performed under local or

general anesthesia usually in a hospital or

office setting (Robinson, 2009). Indications
for using suprapubic catheters include

Urethral or pelvic floor trauma

Complex urethral or abdominal surgery
Patients in wheelchairs or patients who
want to maintain sexual relationships

Anatomical problems in the lower urinary

tract, including the urethra

Patients with fecal incontinence who might

soil urethral catheters (Robinson, 2009).

Total urethral or prostatic obstruction or

urethral strictures that cause difficulty when
inserting a urethral catheter

Complications of Urinary

Weak pelvic floor muscles causing

Catheterization

urethral catheters to fall out

Although catheterization is a common

healthcare practice, it presents many risks
that must be taken seriously. The
complications associated with catheterization
include

Trauma or introduction of bacteria into the

urinary system, resulting in infection and,
consequently, possible septicemia or death
Trauma to the urethra or bladder from incorrect insertion or attempts to remove the
catheter without deflating the balloon
Accidental catheter dislodgement
Urine bypassing the bladder
Urethral perforation
Blockage of the catheter
Encrustment
Urinary stones
Chronic renal inflammation

 Profound effects on a patients social,

2008). After 30 days of indwelling

work, and psychological well-being (Hart,

catheterization, bacteriuria, bacteria in the

2008).

urine, will be present in virtually 100% of

patients. In addition, bacte- remia, a serious
and potentially life-threatening

Particular attention must be paid to the

complication, will develop in approximately

most likely complication associated with

3% of all catheterized patients (Parker et al.,

catheter use: CAUTI. CAUTI is currently

2009a,

one of the most com- mon infections and

comprises 40% of all institu- tionally
acquired infections (National Center for
Health Statistics, 2004). In the home setting,
CAU- TIs occur in 8% of patients (Getliffe
& Newton,
2006). The daily risk of developing CAUTI
ranges from 3% to 7% and cumulatively
increases the longer the catheter remains in
place (Lo et al.,

344 Home Healthcare Nurse

www.homehealthcarenurseonline.com

2009b). Using infection control measures,

an es- timated 17% to 69% of CAUTIs may
be prevented (Association for Professionals
in Infection Con- trol and Epidemiology
[APIC], 2008).
The bacteria that cause CAUTI can gain
entry into the bladder via two pathways: the
periurethral

Approximately 4 million Americans undergo urinary catheterization annually, and more than
500,000
of these catheterizations involve indwelling catheters left in place
for some period of time.
pathway and the intraluminal pathway.

catheters should be left in place for as

Bacteria following the periurethral route

short a time as possible (Healthcare In-

move into the bladder between the

fection Control Practices Advisory

outside of the catheter and the inner side

Committee,

of the urethral wall. Bacteria following the

intraluminal route, likely the most common
route, move upward inside the catheter
drainage system after contamination of the
drain- age bag through the outflow tap or
disconnection of the catheter (Madeo &
Roodhouse, 2009). The bacteria associated
with CAUTI are particularly problematic
because they attach to the surface of the
catheter and produce a biofilm. Biofilm is a
densely adherent polysaccharide structure
that protects bacteria from the bodys natural
defense mechanisms, allowing for bacterial
growth and reproduction (Trautner &
Darouiche, 2004). After a biofilm has
formed on the inside or outside surface of
a catheter, the risk of CAUTI can only be
eliminated by removing the catheter (APIC,
2008).
As catheterization poses serious risks, this
method of bladder drainage should not be
con- sidered until all other interventions
have been assessed as inappropriate or
deemed unsuc- cessful. When patients
require catheterization, intermittent catheters
should be considered first, and indwelling

2009). To minimize the complications

associated with catheterization, healthcare
interventions supported by best practice
evidence should be implemented by all
practitioners involved in catheter care. With
proper assessment and man- agement of
catheters, the benefits of catheteriza- tion
outweigh the risks.

Urinary Catheterization Assessment

A practitioners assessment of the
catheterized patient is an essential part of
catheter care. Be- cause the incidence of
complications rises the longer the catheter
remains in place, the need for the
continued usage of an indwelling catheter
must be assessed during every visit

catheter stabilization may be a factor in

decreasing the risk of complications
especially infection (Gray, 2008). A thorough
physical assess- ment of the patient upon
each visit should focus on the presence of
any drainage and excoriation of the urethral
orifice, which may indicate leakage or
irritation from the catheter (Nazarko, 2009).

(Healthcare Infection Control Practices

The practitioner can guard against the

Advisory Committee [HICPAC], 2009). In

threat of CAUTI using risk assessment

cases of indwelling cath- eterization, the

and detection strategies. Patients identified

practitioner should determine whether the

as being at high risk for these infections

catheter is functioning properly. This

should be carefully moni- tored. Risk factors

means looking to see whether the catheter

for developing CAUTI include female sex,

system is draining effectively by comparing

older age, prolonged catheterization,

the urine output with the patients fluid

impaired immunity, and lack of

intake. A discrepancy in intake and output

antimicrobial exposure (HICPAC, 2009).

volumes may indicate a mechanical problem

Practitioners should monitor all catheterized

with the catheter. The practitioner should

patients for signs and symptoms of

also inspect the catheter to ensure that it is

CAUTIs. The APIC criteria for symp-

properly anchored and posi- tioned, as

tomatic catheter infection (2008) include

vol. 28 no. 6 June 2010

Healthcare Nurse 345

Home

1. Urgency, frequency, dysuria, or other

supra- pubic tenderness
2. Fever (>104F or 38C)
3. Color or character changes in the urine
indicative of infection, hematuria, or positive culture.

Urinary Catheterization Management Over

the past several years, catheter management interventions have been evaluated to
pro- duce evidence-based best practice
guidelines for providing effective catheter
care at home and minimizing the risks of
catheter-associated infections and

Older patients with indwelling catheters

may not present with the typical signs and
symptoms of infection. Change in mental
status, particularly in older adults, may be
symptomatic of CAUTI (Parker et al.,
2009b). Consequently, any subtle change in

complications (Emr & Ryan, 2004). These

guidelines, presented in the following sections, cover proper techniques for insertion
and management of catheters as well as
information that should be included in
patient/caregiver training and education.

physical condition or behavior should lead

practitioners to consider the possibility of
infection and quickly investigate, as sepsis

Insertion

may develop before diagnosis of the

To minimize the potential for introduction

infection (Siegel,

of microorganisms into the bladder, urinary

2008).

cath- eters should only be inserted by

properly trained individuals. Hand hygiene

After noting signs and symptoms of

is the most important means of preventing

infection in catheterized patients,

infection and should be performed

practitioners should obtain a urine sample

immediately before and after inser- tion

from a freshly inserted catheter or

or any manipulation of the catheter device

collection port of an indwelling cath- eter for

or site (Emr & Ryan, 2004). Indwelling

urine culture and sensitivity testing and

catheters should be inserted using aseptic

perform a dipstick urinalysis. Diagnosis of

technique and sterile equipment. The

CAUTI is only made when signs and

equipment needed for

symptoms of CAUTI coexist with

microbiologic evidence of bacteri- uria and
elevated white blood cell count upon
urinalysis (Parker et al., 2009b).

insertion includes sterile gloves, drape,

secre- tions. The use of 30 mL balloons is

sponges, an appropriate antiseptic or sterile

not recom- mended. The buildup of these

solution for periurethral cleansing, and a

secretions may result in infection or

single-use packet of lubricant jelly

irritation (Newman, 2008). The indwelling

(HICPAC, 2009). Chronic inter- mittent

catheter should be secured to the thigh or

catheterization in the nonacute setting can

abdomen after insertion to prevent

be practiced using clean technique.

movement and the exertion of excessive

Clean technique involves the use of

force on the bladder neck or urethra (Gray,

cleansed reusable catheters, washing hands

2008). Unse- cured and displaced catheters

with soap and water, and daily cleansing

can also cause pressure ulcers on the

of the perineum or more often only

perineum and buttock (Siegel, 2008).

when fecal or other wastes are pres- ent

(Newman, 2008). Cleansing the perineal
area to decrease bacteria in the surrounding
area is highly recommended.

Management
Once an indwelling catheter has been

During the catheterization procedure,

inserted using aseptic technique, all

efforts should also be made to minimize

possible measures should be employed to

pain and trauma. These efforts include

maintain a closed drainage system. If breaks

using an appropri- ate-size catheter,

in aseptic technique, discon- nection, or

lubricating the catheter thor- oughly, and

leakage occur, use aseptic technique and

inserting the catheter far enough into the

sterile equipment to replace the catheter and

bladder to prevent trauma to the urethral tis-

collecting system. The use of urinary

sues with the inflation of the retention

catheter sys- tems with preconnected, sealed

balloon (Hart, 2008). Select the smallest

catheter-tubing junctions may reduce the

bore catheter possible that will allow for

occurrence of disconnec- tions (HICPAC,

adequate drainage. Large-size catheters (18

2009). Extensive measures should also be

Fr or larger) can increase erosion of the

taken to maintain unobstructed urine flow.

bladder neck and urethral mucosa, cause the

To prevent obstruction, the catheter and

formation of strictures, and impede

collect- ing tube should be kept free from

adequate drainage of periurethral gland

kinking, the col- lecting bag should be

positioned below the level

346 Home Healthcare Nurse

www.homehealthcarenurseonline.com

Intermittent catheterization is becoming the gold standard for the management of bladderemptying dysfunctions and following surgical interventions. Certain advantages to
intermittent catheterization, including the lower associated risks of catheter-associated
urinary tract infection and complications, may make it a more desirable and safer
option than indwelling catheterization.
of the bladder at all times and never placed

bladder distension. Portable ultrasound

on the floor. The collecting bag should be

devices have also been recommended as a

emptied regu- larly using a clean collecting

means of as- sessing urine volume and

container (HICPAC,

consequently minimiz- ing unnecessary

2009). In ambulatory patients, collecting

catheter insertions (HICPAC,

bags may be disguised in bags and

2009). It should be noted that in May 2008,

pouches.

Medi- care coverage was extended from 4 to

Patients practicing intermittent catheterization should pay close attention to the

catheteriza- tion schedule and avoid
bladder overdistension and unnecessary
catheterizations. As CAUTIs are more
prevalent for intermittent catheterization in
patients with high residual urine volumes at
the time of catheterization, urine volume
should de- termine the catheterization
schedule. In general, bladder volume should
not exceed 400 mL (New- man, 2008).
Intermittent catheterization should be
performed at regular intervals to prevent

200 single- use, disposable catheters per

month for many patients undertaking
intermittent catheterization (Muller, 2009).
In patients with long-term indwell- ing
catheters, self- or family management of
the system requires infection control
methods that are both economical and
effective. Nash (2003) conducted a recent
review of the literature on self-cleaning of
catheter training bags. She rec- ommends
adhering to the findings of a clinical trial
by Dille and Kirchhoff (1993) in which the
daily cleansing of both nighttime and leg
drain- age bags with 1:10 household

bleach solution extended the use of the

vinegar and 3% hydrogen peroxide

urinary drainage bags from 1 week to 1

irrigation of catheter bags in a sample of

month without any significant increase in

20 patients. The study showed that

urine or drainage bag colonization or

patients whose bags were irrigated with

increase in rate of urinary tract infection.

vinegar showed a significant reduc- tion of

One study was found that compared

bacteriuria compared with patients whose

distilled white

bags were irrigated with the hydrogen

peroxide solutions (Washington, 2001).
Authors concluded that more research is
needed on the self-cleaning of Foley bags.
Additional strategies can also be
employed to reduce the risk of CAUTI and
other complica- tions.

Choose catheter materials appropriate for

each patient.
For patients requiring intermittent catheterization, consider hydrophilic catheters
over standard catheters (HICPAC, 2009).
The short-term use of silver alloy catheters may reduce the incidence of CAUTI
and bacteriuria.
Silicone or hydrogel catheters are recommended for patients using catheters longer
than 14 days (Parker et al., 2009a).
Change indwelling catheters and drainage
bags according to clinical indications such
as infection, obstruction, or when the
closed system is compromised rather than at
rou- tine, fixed intervals.
Obtain urine samples aseptically and only
from newly placed catheters (7 days).

After cleansing the needleless sampling port

with a disinfectant, aspirate the urine with a
ster- ile syringe.
Avoid irrigation unless needed to prevent
or relieve obstructions.
Practice routine meatal care while a
catheter is in place, including cleansing with
soap and water during daily showers. Avoid
vigorous

vol. 28 no. 6 June 2010

Home

Healthcare Nurse 347

Particular attention must be paid to the most likely complication associated with catheter
use: catheter-associated urinary tract infection (CAUTI). CAUTI is currently one of the most
common infections and comprises 40% of all
institutionally acquired infections.
cleansing, which may increase the risk of
in- fection (HICPAC, 2009).

train patients and caregivers in the correct

Although there is insufficient clinical evi-

techniques for cath- eter insertion and care.

dence to support it, increasing fluid intake in

Education should focus on the importance

patients with urinary catheters is a common

of catheter hygiene and the avoidance of

practice and may result in decreased encrus-

catheter-related problems. Trouble- shooting

tation and other benefits (Siegel, 2008).

advice on common problems Education and

Training

Recent information has also been released

regarding catheter management practices
that have no support from clinical
research. These practices include instilling
antibiotics or other additives to the
drainage bag, applying antisep- tic
compounds to the meatus, and using
specific agents for meatal cleansing. In
addition, sys- temic antibiotics should not
be used routinely to prevent CAUTI in
patients requiring short- or long-term
catheterization. And, although cran- berry
juice may be beneficial for preventing urinary tract infections in noncatheterized
patients, there is no evidence to suggest
that cranberry juice reduces the risk of
CAUTI (Parker et al.,
2009a).

Education and training of catheterized

patients and their caregivers should play an
integral role in the practitioners efforts to
ensure best patient outcomes and reduce the
likelihood of complica- tions. Practitioners
should occurring with urinary catheters,
including obstruction,

leakage, bladder spasms, encrustment, and

the catheter should be removed as soon as

bal- loon malfunction, should be included

possible to reduce the risk of complications.

(Nazarko,

By adhering to the rec- ommendations and

2009). Patients and caregivers should be

edu- cated about symptoms of CAUTI and
other cath- eter-related complications and
when to contact a healthcare practitioner.

guidelines outlined above, home healthcare

practitioners can participate in the
nationwide effort to provide effective care
and prevent catheter-associated
complications in all settings where
catheterization is under- taken.

Conclusion
Urinary catheterization is a common

Rebecca Herter, BS, is an Adult/Geriatric

interven- tion used by home healthcare

Nurse Practitioner Student at Yale University

patients to manage urinary problems such as

School of Nursing, New Haven,

urinary retention and urinary incontinence.

Connecticut.

The common use of this intervention does

not, however, imply that cath- eterization is
without serious complication or is always
used appropriately. Catheterization should
only be undertaken when all other meth-

Meredith Wallace Kazer, PhD, APRN,

A/GNP-BC, is an Associate Professor at
Fairfield University School of Nursing,
Fairfield, Connecticut.

ods of urinary system management have

The authors of this article have no

been deemed inappropriate or have failed.

significant ties, financial or otherwise, to

If indwell- ing catheterization is required,

any company that

348 Home Healthcare Nurse

www.homehealthcarenurseonline.com

might have an interest in the publication

Getliffe, K., & Newton, T. (2006).

of this educational activity.

Catheter-associated urinary tract infection in

Address for correspondence: Meredith

Wallace Kazer, PhD, APRN, A/GNP-BC,

primary and community health care. Age

and Ageing, 35(5), 477-481.

Associate Professor, Fairfield University

Gray, M. L. (2008). Securing the

School of Nursing, Fairfield, Con- necticut

indwelling catheter.

(e-mail: MKazer@Fairfield.edu).

American Journal of Nursing, 108(12), 4450.

Hart, S. (2008). Urinary

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For nine additional continuing nursing education articles on genitourinary topics, go to

nursingcenter.com/ce.

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