Internal and External Urinary Catheters: A Primer for Clinical Practice
Index: Ostomy Wound Manage. 2008;54(12):18-35
Internal and external urinary catheters are used to manage urinary incontinence and incomplete bladder emptying. Bladder dysfunction cause determines whether short- or long-term catheter use is required which, in turn, determines whether an indwelling, intermittent, or external catheter should be used. The method of catheterization is based on the underlying bladder condition, the goals of treatment, and gender appropriateness. Complications such as infection (eg, catheter-associated urinary tract infection, sepsis) and its related sequelae have been found to be directly related to length of time of catheter use (eg, women are at greater risk for catheter-associated urinary tract infection when an indwelling catheter is in place >2 weeks); thus, catheter use must be medically justified and in the case of an indwelling catheter, involve the shortest period possible to ensure patient safety and regulatory compliance. Some newer catheter systems include coatings to prevent complications; complications specific to indwelling catheter use include obstruction from encrustations, urethral trauma and erosion, bladder stones and bladder cancer, and, in men, epididymitis. Complications from external catheters may occur when skin condition is compromised. Overuse of catheters has reimbursement ramifications. Numerous guidelines reflect the need for the judicious use of urinary catheters, particularly in long-term care patients. Because evidence-based research on long-term use of these devices is lacking, clinicians should use clinical experience when caring for patients with catheters.
Urinary Catheter Use
General indications. Catheters are used primarily to manage two types of bladder dysfunction: urinary incontinence (UI) and urinary retention (UR). Urinary incontinence is the unwanted leakage of urine and may be classified as urgency UI (urine loss following urgency and accompanied by overactive bladder symptoms of urgency and frequency) or stress UI (urine leakage with activity or effort —coughing, laughing, and overflow — due to blockage or obstruction in the urethra from an enlarged prostate, stricture, or pelvic organ prolapse). Catheters may be inserted intermittently into the bladder (intermittent catheterization or IC), placed in the bladder on a more permanent basis (indwelling urethral or suprapubic catheterization), or placed externally (condom catheters for men).
Urgency incontinence in men can be managed with an external catheter (EC); incontinence due to overflow may be managed short-term with an indwelling urinary catheter (IUC) and long-term with IC (see Table 11-5).
Urinary retention may be acute or chronic. Acute UR is the sudden and complete inability to void and requires immediate and rapid bladder decompression with a short-term IUC. An IUC is the preferred short-term method for draining the bladder in persons with acute or postsurgical (urologic or gynecologic) UR. Chronic UR is the ongoing inability to void that usually develops over months. As the bladder slowly stretches, patients may unknowingly adapt to the condition. Voiding involves abdominal straining. Severe chronic UR can expand the bladder to 2 to 3 L and lead to upper tract damage and renal failure. Chronic UR is usually treated with IC. In patients with chronic UR or who undergo a urinary diversion with the formation of a catheterizable stoma, IC is preferred for long-term bladder management.6
With all urinary catheters, complications are directly related to length of use. An IUC has the greatest complication rate and specific indications have been developed for its use. Complications, specifically infection, develop when a catheter is in place longer than 30 days. To prevent complications related to long-term need, IC is the preferred method for bladder drainage and has been used by spinal cord injured patients and others with neurologic disease.7 External catheters are appropriate for men as a urine collection device. To address the increasing prevalence of patients with neurologic diseases worldwide and because bladder management can become a long-term problem, several medical and nursing guidelines have been released regarding the use of internal and external catheters.1,8-13
Classification and reimbursement. Indwelling and intermittent catheters are labeled “Class II” devices by the US Food and Drug Administration (FDA), which requires performance testing or labeling specific to the device to ensure its safety and effectiveness relevant to what is already on the market. External catheters are labeled as “Class I” devices and require general controls (ie, adequate labeling, registration, and listing) — no significant safety issues or performance issues require extensive review by the FDA, exempting manufacturers from the need to submit any information directly to the agency.2
Catheters used for bladder management usually are reimbursed by most insurers to some extent. Quantity of catheters allowed varies among insurers and often is based on medical necessity. Table 2 reviews the current Medicare allowance for internal and external urinary catheters coverage.
Indwelling Urinary Catheters
An indwelling (Foley) urinary catheter is a closed bladder drainage system held in the bladder with a retention balloon. These catheters are used to relieve urinary retention and in specific populations to manage long-term UI. 14 The system comprises soft, flexible tubes that have double lumens, one for urine drainage and the other for inflation and deflation of the retention balloon (see Figure 1). Once inflated, the balloon allows for retention of the catheter in the bladder.
The catheter is sized by the outer circumference and according to a metric scale known as the French (Fr) gauge (range is 6 Fr to 24 Fr), in which each French unit equals 0.33 mm in diameter. The smallest catheter size, generally 14 to 16 Fr, is preferred. The use of large-sized catheters (18 Fr or larger) is not recommended because catheters with larger diameters can increase erosion of the bladder neck and urethral mucosa, cause stricture formation, and prohibit adequate drainage of periurethral gland secretions, causing a buildup of secretions that may lead to irritation and infection.2 The catheter can be inserted either through the urethra or suprapubically.
Because of historic, inappropriate, long-term use of these devices, strict indications have been developed (see Table 1). Indwelling urinary catheters are recommended only for short-term (30-day) use is discouraged because it provides access for bacteria from a contaminated environment into a vulnerable body organ and system2 — catheter-associated urinary tract infection (CAUTI) is the most common type of infection acquired in hospitals and LTC facilities.15
Each year, IUCs are inserted in more than 5 million patients in acute care hospitals and LTC facilities. Inappropriate catheter use has been equated to a “one-point restraint,” and, as a form of restraint, catheters could be associated with discomfort, nosocomial infection, pressure ulcers, functional impairment, and death.16 In a study of hospitalized older medical patients without a specific medical indication, IUC was associated with a four-times greater risk of death during hospitalization and two times greater risk of death within 90 days of discharge. 17 Although IUCs are commonly used in most clinical settings, data suggest that more than 20% of these catheters are placed without a specific medical indication and that they often remain in place without the knowledge of the patients’ physician.18,19 Studies of IUC usage appropriateness indicate that 21% to 38% of initial urinary catheterizations are unjustified and one third to one half of days of continued catheterization are unjustified. 20 A strong surveillance program with computerized usage monitoring may help reduce catheter overuse.21,22
Use of catheters in LTCs requires medical justification (see Table 1) and is now publicly reported as a quality measure. 23 Nursing home residents who have long-term IUCs are three times more likely as similar residents without IUCs to die within a year. 24 In this setting, the use of alternatives (ie, intermittent or external catheters) is infrequent. In a retrospective chart review, Rogers et al25 found that 26
Complications. Patients with IUCs are at increased risk for catheter-related problems that range from simple obstruction (blockage) to serious infections, sepsis, and death.27 Bacteriuria usually occurs in one out of four patients who have a catheter in place for 2 to 10 days28 but symptoms may be absent or nonspecific in most patients. Catheter-associated urinary tract infection is not only the most common, but also the most severe complication and can lead to urosepsis and septicemia.29,30 A CAUTI is more likely to occur in women and in patients with IUCs in place >2 weeks. The Center for Medicare and Medicaid Services (CMS)4 has developed parameters for diagnosing a UTI in nursing home residents with an IUC (see Table 3).
Catheter biofilms that adhere to the internal catheter lumen and drainage bag also may contribute to CAUTIs. 10 A biofilm is a collection of micro-organisms that colonize the surface of a medical device such as an IUC. These bacteria are different from bacteria that float in urine (planktonic bacteria).31 Initially, IUC biofilms may be composed of single organisms; however, because the presence of the biofilm inhibits antimicrobial activity, organisms within the biofilm cannot be eradicated by antimicrobial therapy or by irrigation, which can lead to multi-organism biofilms. 2 Biofilms have occasionally been reported to become so thick as to block a catheter lumen, 32 contributing to CAUTI. 33
Additional IUC complications include obstruction from encrustations, urethral trauma, epididymitis and erosion seen primarily in men, formation of bladder stones, and development of bladder cancer. 34 Urethral trauma can be minimized by catheter securement (see Figure 2).
Because of these numerous reported complications, catheters should be removed as soon as medically possible. Additionally, any patient whose bladder is managed with an IUC should be under the care of an urologist and undergo cystoscopy on a yearly basis. Good nursing practices are essential to prevent complications in patients who need an IUC for either short- or long-term bladder management (see Table 4).
Specific types of IUCs. The most commonly used catheter is a straight-tipped catheter. However, in men with an enlarged prostate gland or urethral stricture gland, a Coudé-tipped catheter or Tiemann catheter, which is angled upward at the tip, may be preferred because it facilitates easier passage (see Figure 1). A wide range of catheter materials is available; material choice should be based on 1) catheter placement duration, 2) comfort, 3) presence of latex sensitivity, 4) ease of insertion and removal, and 5) ability to reduce the likelihood of complications such as urethral and bladder tissue damage, colonization of the catheter system by micro-organisms, and encrustation.3 Catheter types by material include: silicone-coated latex catheters, which have a chemically bonded coating of silicone elastomer or Teflon® that prevents urethral contact with the latex; Teflon®-coated catheters, which are thought to reduce the rate of absorption of water; 100% silicone catheters, which are thin-walled, more rigid, and have a larger diameter drainage lumen that may prevent the formation of biofilms and encrustations; hydrogel-coated latex catheters, which absorb water to produce a slippery outside surface; and catheters coated with silver alloy or antibiotics.
Intermittent Use of Catheters
Intermittent catheters are inserted into the bladder via the urethra or via a catheterizable stoma in patients who have undergone urinary diversion.6 In a hospital or nursing home, insertion is performed aseptically using sterile equipment. Clean intermittent catheterization (CIC) has been used in the bladder management of patients with urinary retention and other voiding dysfunction for the past 20 years. 40,41 Woodbury et al42 conducted a national survey in Canada of IC practices in community-dwelling persons living with spinal cord injury (SCI) and found that 73% used “clean” technique — ie, cleansed reusable catheters, handwashing with soap and water, and cleansing the perineum daily or more often only in the presence of fecal or other wastes. Clean intermittent catheterization has been proven the most effective and practical means of attaining a catheter-free state in persons with SCI and chronic intractable urinary retention. 43 However, Veterans Administration (VA) and the CMS guidelines recently changed to promoting single-use catheters for each catheterization12 (see Table 2).
Woodbury et al42 noted the mean frequency of self-reported UTIs in persons with SCI was 2.6 occurrences in the 12-month reporting period and that individuals who catheterized only once per day had the highest number of infections (38% of patients had five or more UTIs per year), most likely related to higher volumes of urine in the bladder at time of catheterization. Women had a higher incidence of UTIs than men and patients who self-catheterized had fewer UTIs. Interestingly, most UTIs (78%) were managed by family physicians — only 13% were managed by urologists. This is usually not the case in the US where SCI patients are usually managed by urologists. 2 Woodbury’s42 study also showed that the use of prophylactic agents such as cranberry juice, vitamin C supplements, and increased fluid intake decreased UTI rate in this community-based SCI population.
Complications. Bacteriuria occurs in 50% of IC users but rarely leads to symptomatic UTIs and should not be treated with antibiotics.15 Symptomatic UTIs occur in 10% to 15% of patients using IC and, as mentioned, are more prevalent in those who have higher residual urine volumes at the time of catheterization. 2 The catheterization schedule should be based on urine volume. As a general rule, bladder volume should not exceed 400 mL. Chronic pyelonephritis rarely develops in patients performing IC so prophylactic antibiotics should not be routinely prescribed. 44 Urethral damage can occur in male patients performing IC and urethral complications are similar to what is seen in patients with a long-term IUC but do not occur as frequently.
Another urethral complication is the formation of a stricture, indicated when the catheter does not pass easily. Creation of a false passage can occur, primarily in men with persisting urethral strictures, and may occur at the site of the external sphincter just distal to the prostate. Bladder stones may occur in patients who perform IC over the long term. Stones have been shown to grow around introduced pubic hairs. 2
Types of catheters used for IC. The size and tips of catheters used intermittently are similar to those described for IUCs. Catheters range from 6 Fr to 12 Fr for children and from 14 Fr to 22 Fr for adults. The funnel end of the catheter is usually color-coded to identify French size easily. Intermittent catheters have different lengths. Men use catheters with lengths of about 12 inches (about 40 cm) and women and children ideally should use shorter lengths of 6 to 12 inches (20 cm to 40 cm) because of their shorter urethral length. 10 This allows more efficient drainage by reducing the risk of looping, kinking, and upward gradient drainage of the tube.
The difference between catheters inserted intermittently and those that are indwelling involves surface properties. The type of surface may influence associated problems of IC, such as urethral complications and UTIs, as well as user satisfaction and preference. 2 Catheters used for IC can be made of rubber that contains latex (called a “red rubber catheter”). They are more flexible and often are recommended for patients who are performing IC on a short-term basis (eg, following stricture dilation). Polyvinyl catheters (PVC), the most commonly used catheter for IC, are firmer and feature a larger internal diameter. Both of these catheters require lubrication for insertion in both men and women. An increasingly popular type of catheters is hydrophilic-coated45,46 (see Figure 3 and Figure 10). These catheters have a layer of polymer coating that is bound to the catheter surface. The catheter surface consists of polyvinyl pyrrolidone (PVP) and salt. This outer layer becomes smoother when hydrated. When soaked in water, the PVP attracts the water and the biocompatible salt coating binds the water to the surface of the catheter, creating an outer layer mainly consisting of water. 47 This thick, slippery, smooth layerof water stays on the catheter, ensuring lubrication of the urethra in its entire length during catheter insertion and withdrawal. Designed for ease of insertion and minimizing discomfort and friction between the urethra and the catheter during IC, 48 these catheters may help decrease the risk of urethral trauma and other complications such as stricture formation. 46,49-51
“Closed” or self-contained systems include all the equipment needed to perform IC and feature a sterile, prelubricated catheter in a drainage bag. Some systems contain gloves, antiseptic swabs, and a waterproof underpad. Using a sterile system may decrease UTI risk. The need for a sterile IC system should be based on incidence of UTIs. These systems often are referred to as “no-touch” because they enable the catheter to be gripped through the sleeve, avoiding the need to touch the catheter2,52 (see Figure 4). Some have a special guide mechanism (called a protective or introducer tip) at the top of the pocket (see Figure 9). Hydrophilic-coated, no-touch catheter systems are also available.
External catheters are condom-type sheaths applied (usually rolled) over the penis and connected to a drainage bag. They are used primarily for urine collection in men who experience urinary incontinence. The most popular ECs are disposable and must be changed every 24 to 48 hours. Reusable ECs are removed, washed, and reapplied. Although ECs can be an appropriate urine containment option for men, scant research has rendered the role of ECs in hospitalized patients or LTC residents unclear. Most available research53 has involved men in VA medical centers (VAMC) who report that an EC is more comfortable, less painful, and less restrictive on their activities than other devices such as an IUC. This research also indicated that nurses preferred ECs to IUCs. Saint et al53 compared IUCs with ECs in male inpatients in a VAMC. Seventy-five subjects were randomized to receive either an IUC (n = 41) or a condom catheter (n = 34). The incidence of adverse outcomes was 131 per 1,000 patient-days with an IUC and 70 per 1,000 patient-days with a condom catheter. The median time to an adverse event was 7 days in the indwelling and 11 days in the condom group. Adverse outcomes including bacteriuria, symptomatic UTI, or death were lower in men using ECs, particularly in men who did not have dementia. When patient satisfaction with the urinary device was assessed, the patients with an EC were more likely than patients with an IUC to report their device to be comfortable and not painful.
Complications. Complications related to ECs primarily involve external penile shaft (skin) problems and include contact dermatitis, maceration of the penis shaft or glans, ischemia, penile edema, and penile obstruction. External use CAUTIs can occur but are less common because there is no invasive instrumentation of the urethra. Most adverse effects seen are the result of improper and prolonged EC use and are more pronounced in men who have decreased penile and scrotal sensation. 54 Skin breakdown (eg, dermatitis, minor skin erosions) occurs because of penile shaft occlusion. The use of silicone ECs allows visualization of the skin without removing the catheter and their water and oxygen vapor transmission properties prevent maceration2 (see Figure 11). Causes of skin breakdown include: a tight-fitting EC, EC removal that tears the skin, possible latex allergy, UTIs, and friction. In men at-risk for developing EC-related skin issues, a skin barrier product should be applied before catheter use (see Figure 5).
Paraphimosis in uncircumsized men prevents retraction of the foreskin over the glans, which can cause constriction or strangulation of the penis if a double-sided adhesive strap to secure the EC is used.
Types of ECs. Most external catheters are “condom-like” in appearance and are either disposable or reusable. Devices that can adhere to the glans of the penis or the perineum like an ostomy pouch may be more appropriate for a man with a retracted penis (lacks penile shaft length to support a “rolled-on” EC). “Retracted” penis pouches are available for men and female pouches for women. Once applied, the EC is attached to an extension tube and drainage bag for urine collection.
External catheter materials include latex rubber, PVC, or silicone. 55 The EC may be secured to the penile shaft using adhesive material or a latex or foam strap that encircles the penis. Self-adhesive one-piece ECs are the most popular and easiest to apply. They are rolled over the shaft of the penis and pressed so the adhesive sticks to the skin. 2 Two-piece systems include a double-sided adhesive hydrocolloid strap. The strap is wrapped around the circumference of the penis and the EC is rolled up and over the straps; pressure and warmth ensure adherence. The strap should not be too tight around the shaft; men who use this type of EC should have penile sensation and understand the application process. For men with adequate erectile function, a barrier strap that stretches and has the capacity to return to its original size and shape is appropriate. Because foam straps are not elastic, they will not stretch and should be used with caution. 10 Nonadhesive, reusable ECs also are available and feature an inflatable retention ring or a Velcro® strap to secure the catheter. The latter can be wrapped around the sheath once the sheath is applied2 (see Figure 6). Another product for men who have a retracted penis facilitates attachment to the glans penis with adhesive (see Figure 7). It is important to size the condom properly to prevent rolling or wrinkling. Everyone involved with the use of ECs should receive training on their use and monitor the device frequently to avoid adverse events.
Application. The actual application of ECs can be challenging for nurses, patients, and caregivers. Pemberton et al56 compared commonly used ECs and found that ease of use and application with gloves were important criteria. The first step in successful application is to ensure patient hand dexterity; adequate penis width, length, and skin condition; and that erectile function is not compromised — otherwise, application and removal will be difficult. 2 One EC includes a patient/caregiver-friendly applicator and a removable tip for men with UI who also must also perform IC to ensure bladder emptying (see Figure 8). The condition of the genitalia — specifically the penis and scrotum — also must be assessed. In men with UI, the presence of erythema (redness), open areas, and perineal dermatitis (bacteria and yeast rashes) may be contraindications for the use of an EC. Men at risk for skin breakdown should use a barrier film skin product. 2 These devices come in many sizes and a measurement or sizing guide is recommended. The penis is measured halfway down the shaft and the measurement should be preformed when the penis is non-erect, extended, and gently pulled forward away from the body. If the man has nocturnal erections and uses an EC while asleep, the size should be adjusted.
New Regulations and New Catheter Technology that are Influencing Clinical Care
“Single-use” intermittent catheters. In late 2007, the VA57 issued guidance to clinicians on the re-use of urinary catheters for patients using IC for bladder management. This guideline noted that the FDA considers urinary catheters to be single-use devices and that manufacturers of catheters specifically identify them as such. The VA recommends that until manufacturers specifically change labeling for urinary catheters, no policy interpretation allows the re-use of urinary catheters; therefore, clinicians who practice in the VA system “should follow the manufacturer’s instructions for catheter use. Catheters identified as single-use devices should not be re-used in any setting.” 57
In the spring of 2008, the CMS4 noted an increase in monthly coverage to 200 coated or uncoated catheters used for IC (formerly four catheters per month). The evidence for decreased UTIs in patients using single-use catheters versus clean technique is still evolving. 58
Nonpayment for CAUTIs. The CMS recently has reshaped reimbursement regulations for acute care facilities, holding acute-care hospitals accountable for failing to avert preventable harm resulting from medical care and withholding additional payments to hospitals for “serious preventable events.” 59 Payment can be denied for eight costly and sometimes deadly preventable hospital-acquired conditions, one of which is CAUTIs, 60 placing a high priority on reducing CAUTIs viewed as unacceptable harm resulting from medical care. Hospitals will be at risk for financial losses (nonpayment for additional costs) if CAUTIs occur.
Applying infection control-based practices may enhance safety. Other practices that may decrease CAUTIs include: using indwelling catheters only when necessary and removing them when no longer needed via the use of various reminder systems, using antimicrobial catheters in patients at high risk of infection, using portable ultrasound bladder volume technology (eg, BladderScan®, Verathon, Bothell, WA) to detect post void residual urine amounts, maintaining proper insertion technique, and using alternatives to IUCs, such as external devices or intermittent catheterization. 61 Table 5 outlines a nursing protocol for patient care following catheter removal. This protocol was developed by Robyn Strauss, MSN, ACNS-BC, CVN, WCC, in collaboration with this author, for use at the Hospital of the University of Pennsylvania, Philadelphia, PA.
Use of an introducer tip when performing self-catheterization. The first portion (1.5 cm) of the distal urethra harbors perineal bacteria, particularly Escherichia coli. An introducer tip (sometimes referred to as a guide and part of most closed IC systems) allows the catheter to bypass the colonized area, preventing migration of these bacteria into the bladder (see Figure 9.) Bennett et al62 found that using an introducer tip catheter reduced UTI in hospitalized spinal cord injured patients performing IC. The introducer tip also keeps the catheter straight as it is advanced, and, when squeezed, prevents it from slipping during insertion. 35
Advancements. Manufacturers have designed internal and external catheters that are compact and easy to use. Two recently introduced products include the “SpeediCath” (Coloplast Corp, Minneapolis, MN) for men and women. The one for woman can fit easily in a small purse or bag (see Figure 10). An EC with tabs to aid in rolling the self-adhesive, silicone EC over the shaft of the penis can be folded neatly in a compact that can fit in a man’s pocket (see Figure 11).
Silver alloy-coated catheters. Hospitals are considering using silver alloy-coated catheters to prevent or reduce CAUTIs. Silver alloy-coated catheters are believed to reduce the risk of inflammation and infection because they reduce microbacterial adherence and migration of bacteria to the bladder. 2 Silver alloy-coated catheters may provide more benefits than standard latex catheters for short-term catheterization in some populations because they may reduce the risk of asymptomatic bacteriuria. 63-65 A Cochrane review66 noted that the effect of silver alloy catheters compared to latex catheters is more pronounced when used in patients catheterized
There is very little evidence-based research to direct clinical nursing practice on the use of internal and external catheters. Newman et al3 advocated an integrated collaboration among industry, clinicians, and researchers to determine and prioritize questions to be investigated; have input into the design, procedures, and outcome measures; allow joint ownership of findings in a transparent and traceable manner; interpret results with the benefit of multiple perspectives; and be assured results would be disseminated.
The goal for use of an internal and/or external catheter is either for the person to remain as dry as possible or to ensure complete bladder drainage. Although catheters are an integral part of the nursing care of patients with bladder dysfunction, there is little to no research in the United States on their long-term use. Nurses play a major role in bladder management of their patients; as such, they should acquire the knowledge necessary to provide care that demonstrates clinical, regulatory, and financial awareness of prudent catheter use.
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4. Centers for Medicare and Medicaid Services. State Operations Manual, Appendix PP—Guidance to Surveyors for Long-Term Care Facilities, Tag F315, §483.25(d) Urinary Incontinence. Available at: www.cms.hhs.gov/transmittals/downloads/R8SOM.pdf. Accessed November 11, 2007.
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Ms. Newman is Co-Director, Penn Center for Continence and Pelvic Health, Division of Urology, University of Pennsylvania Health System, Philadelphia, PA. Please address correspondence to: Diane K. Newman, RNC, MSN, CRNP, FAAN, Penn Center for Continence and Pelvic Health, University of Pennsylvania Health System, Division of Urology, 9 Penn Tower, 34th and Civic Center Boulevard, Philadelphia, PA 19104; email: email@example.com.