Indwelling Catheter Management: From Habit-based to Evidence-based Practice

JoAnn Mercer Smith, BSN, RN, CWOCN

Coude-tipped catheters should be inserted with the tip pointed upward towards the patient’s umbilicus.

Catheter Balloons

     Confusion exists among nurses regarding selecting and filling catheter balloons for routine catheterization; many use 5-cc and 30-cc balloons interchangeably. Either a 1.5-cc or 3-cc (pediatric) or 5-cc (adult) balloon should be used for routine catheterization, filled per manufacturer directions. Catheter balloons are designed to secure the catheter in the bladder, not occlude the urethra or prevent leakage. When filled, the 30-cc balloon weighs approximately 48.2 g and sits high in the bladder.20 The added pressure on the bladder neck and pelvic floor can lead to bladder spasms and leakage. Over time, this can damage the bladder neck, resulting in inability to retain a catheter. In addition, the large balloon results in stasis because the drainage eyes sit above the balloon and, therefore, above the urine.21

     Patients with long-term catheters are at significant risk for bladder stones that can puncture the retention balloon. Any patient who experiences repetitive, spontaneous balloon deflation should be evaluated by the urologist for the presence of bladder calculi.

Guidelines for Insertion

Guidelines for catheter insertion are outlined in Table 1.


     Handwashing is considered the single most important action to prevent infections.22 Patients and caregivers alike should be taught to wash their hands with antibacterial soap or alcohol-based hand cleaners before and after catheter insertion, changing drainage systems, or manipulating the catheter.

Male Catheterization

     Male catheterization can be particularly difficult due to the greater urethral length and the prostatic curve. Copious lubrication is essential. Injecting 10 cc of water-soluble lubricant directly into the urethra distends the urethra and places the lubricant high in the urethra where it is needed.23 Using lidocaine jelly 2% reduces discomfort and can prevent urethral spasm; catheter insertion should be delayed for 2 to 5 minutes in order for the anesthetic to take effect.24 The catheter should be advanced almost to the bifurcation to avoid inflation of the balloon in the urethra. Placement should be confirmed by urine return before the balloon is inflated. Lubricating jelly in the drainage eyes may delay urine return; gentle aspiration of urine can confirm placement.

Female Catheterization

     Identification of the female urethra may be difficult, as landmarks vary with each woman. In older women, the urethra may prolapse into the upper vaginal wall. The catheter should be inserted with the patient in the supine position. Insertion of a catheter from the rear, as recommended in nursing procedure manuals, may introduce fecal bacteria into the bladder and should be avoided unless the patient has limited mobility or restricted range of motion, preventing a supine position. In female patients, it is important to identify the urethra before beginning the sterile procedure. If the catheter is inadvertently placed into the vagina, it should be left temporarily as a landmark and a new catheter obtained for insertion into the bladder. Good lighting is essential, and an assistant may be needed to maintain sterile technique, especially with elderly or combative patients.

Balloon Pretesting

     Pretesting catheter balloons is commonly recommended as a way to prevent insertion of a defective catheter. Some catheter manufacturers no longer recommend pretesting because their balloons are pretested during the manufacturing process.


1. Dobson C, Naidu S, Johnson M. Nurses’ perceptions of urinary catheter selection and management. Urology Nursing. 1996;16:140–144.
2. Evans E. Indwelling catheter care: dispelling the misconceptions. Geriatric Nursing. 1999;20(2):85–89.
3. Maki DG, Tambyah PA. Engineering out the risk of infection with urinary catheters. Emerg Infect Dis. 2001;7(2)342–347.
4. Wilde M. Meanings and practical knowledge of people with long-term urinary catheters. Journal of Wound Ostomy Continence Nursing. 2003;30(1):33–39.
5. Saint S, Veenstra DL, Sullivan SD, et al. The potential clinical and economic benefits of silver alloy urinary catheters in preventing urinary tract infection. Arch Intern Med. 2000;160(17):2670–2675.
6. Cravens DD, Zweig S. Urinary catheter management. Am Fam Physician. 2000;61(2):369–376.
7. Fanti JA, Newman DK, Colling J, et al. Clinical Practice Guidelines, No. 2, 1996 Update: Urinary Incontinence in Adults. Acute and Chronic Management. Rockville, Md. US Department of Health and Human Services. Public Services Agency for Health Care Policy and Research; March 1996. AHCPR Publication No.96-0682.
8. Wong ES, Hooten TM. Guideline for prevention of catheter-associated urinary tract infection. Center for Disease Control and Prevention. 1981;Feb. [serial online]. Available at: Accessed September 8, 2003.
9. Addison R, Mould C. Risk assessment in suprapubic catheterization. Nursing Standard. 2002;14(36):43–46.
10. Robinson J. Deflation of a foley catheter balloon. Nursing Standard. 2003;17(27):33–38.
11. Mitsui T, Minami K, Furuno T, et al. Is suprapubic cystostomy an optimal urinary management in high quadriplegics? A comparative study of suprapubic cystostomy and clean intermittent catheterization. Eur Urol. 2000; 38(4):434–438.
12. Nomura S. Ishido T, Teranishi J, Makiyama K. Long-term analysis of supra-pubic cyctostomy drainage in patients with neurogenic bladders. Urologia Internationalis. 2000;65(4):185–189.
13. Parkin J, Scanlan J, Woolley M, et al. Urinary catheter “deflation cuff” formation: clinical audit and quantitative in vitro analysis. British Journal of Urology. 2002;90(7):666–671.
14. Liss GM, Sussman GL. Latex sensitization: occupational versus general prevalence rates. Am J Ind Med. 1999;35(2):196–200.
15. Vila L, Sanchez G, Ano M, et al. Risk factors for latex sensitization among health care workers. J Investig Allergol Clin Immunol. 1999;9(6):356–360.
16. Department of Health and Human Services. FDA. Federal Register: Natural Rubber-Containing Medical Devices; User Labeling, Federal Register 1997;62(189):51021–51030.
17. Tullock AGS. Ferguson AF. Catheter-induced urethritis: a comparison between latex and silicone catheters in a prospective clinical trial. British Journal of Urology. 1985;57(3):325–328.
18. Studder UE, Bishop MC, Zingg EJ. How to fill silicone catheter balloons. Urology. 1983;22(3):300–302.
19. Salgado CD, Karchmer TB, Farr BM. Prevention of catheter-associated urinary tract infections. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections, 4th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2003;297–311.
20. Robinson J. Urethral catheter selection. Nursing Standard. 2001;15(25):39–42.
21. Newman DK. Managing indwelling urethral catheters. Ostomy/Wound Management. 1998;44(12):26–35.
22. Chinnes L, Dillion A, Fauerbach L. Home Care Handbook of Infection Control 2002. Washington, DC: Association of Professionals in Infection Control and Epidemiology (APIC);2002.
23. Gerard L, Sueppel C. Lubrication technique for male catheterization. Urology Nursing. 1997;17(4):156–158.
24. Cancio LC, Sabanegh ES JR, Thompson IM. Managing the foley catheter. Am Fam Physician. 1993;48(5):829–836.
25. Wilde M. Long-term indwelling urinary catheter care:conceptualizing the research base. J Adv Nurs. 1997;25(6):1252–1261.
26. Hanchett M. Techniques for stabilizing urinary catheters. Am J Nurs. 2002;102(3):44–48.
27. Getliffe K. Managing recurrent urinary catheter blockage: problems, promises and practicalities. Wound Ostomy Continence. 2003;30(3):146–151.
28. Dille C, Kirchhoff K. Increasing the wearing time of vinyl urinary drainage bags with bleach. Rehabilitation Nursing. 1993;18(5):292–295.
29. Rutala WA, Barbee SL, Aquiar NC, et al. Antimicrobial activity of home disinfectants and natural products against potential human pathogens. Infect Control Hosp Epidemiol. 2000;21(1):33–38.
30. Daifuku R. Stann WE. Association of rectal urethral colonization with urinary tract infection in patients with indwelling catheters. JAMA. 1984;252(15)2028–20230.
31. Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents. 2001;17(4):299–303.
32. Maki DG, Knasinski V, Halvorson K, Tambyah PA. Risk factors for catheter-associated urinary tract infection: a prospective study showing the minimal effect of catheter care violations on the risk of CAUTI (abstract). Infect Control Hosp Epidemiol. 2000;21:165.
33. Stickler DJ. Bacterial biofilms and encrustations of urethral catheters. Biofouling. 1996;94:293–305.
34. Donlan RM. Biofilms and device-associated infections. Emerg Infect Dis CDC. 2001;(7)2:277–281.
35. Kunin CM, Chin QF, Chambers S. Formation of encrustations on indwelling urinary catheters in the elderly: a comparison of different types of catheter materials in “blocker” and “nonblocker”. J Urol. 1987;138(4):899–902.
36. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic; a prospective study of 1,497 catheterized patients. Arch Intern Med. 2000;160(5):678–682.
37. Gammack JK. Use and management of chronic urinary catheters in long-term care: much controversy, little consensus. Journal of the American Medical Directors Association. 2002;3(3):162–168.
38. McGeer A, Campbell B, Emori TG, et al. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control. 1991;19(1):1–7.
39. Switters DM. Assessing leakage from around the urethral catheter. Urological Nursing. 1989;9(3):8–10.
40. Bhatia NN, Bergman A. Cystometry: unstable bladder and urinary tract infection. Brit J Urol. 1986;58(2):134–137.
41. Ziemann LK, Lastauskas NM, Ambrosini G. Incidence of leakage from indwelling urinary catheters in home-bound patient. Home Healthcare Nurse. 1984;2(5):22–26.
42. Stickler DJ. Hewitt P. Activity of antiseptics against biofilms of mixed bacterial species growing on silicone surfaces. Eur J Clin Microbiol Infect Dis. 1991;10:416–421.
43. Morris NS, Stickler DJ. Does drinking cranberry juice produce urine inhibitory to the development of crystalline, catheter-blocking Proteus mirabilis biofilms? BJU Int. 2001;88(3):192–197.

Anonymoussays: January 10.2010 at 23:59 pm

Hi there, thanks for this wonderful article. have gotten quite a bit of insight on evidence-based practice on the care of IDC.

Reply to this comment »
Anonymoussays: October 2.2009 at 19:47 pm

Excellent article. I work in a facility where they are filling 30 ml balloons with 10 ml and wondering constantly why they are leaking . Foleys are being changed on a continual basis because of lack of knowledge. All we have is 14 & 16 fr 30- ml . Of course orders are always for 14 , 16 10 ml. And the story goes on and on . i printed this article and I am going to leave in the DON's desk. Directions are right on the foleys by the way , " fill 30 ml only with 30 ml " Yet they still fill the balloons with 10 ml , and the foleys fall out. I left a note to order 14 and 16 fr 5 ml . Hopefully this article will do some good

Reply to this comment »

Post new comment

  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
  • Use to create page breaks.

More information about formatting options

Enter the characters shown in the image.