University of Missouri-Columbia School of Medicine, Columbia, Missouri

The use of urinary catheters should be avoided whenever possible. Clean intermittent catheterization, when practical, is preferable to long- term catheterization. Suprapubic catheters offer some advantages, and condom catheters may be appropriate for some men. While clean handling of catheters is important, routine perineal cleaning and catheter irrigation or changing are ineffective in eliminating bacteriuria. Bacteriuria is inevitable in patients requiring long-term catheterization, but only symptomatic infections should be treated. Infections are usually polymicrobial, and seriously ill patients require therapy with two antibiotics. Patients with spinal cord injuries and those using catheters for more than 10 years are at greater risk of bladder cancer and renal complications; periodic renal scans, urine cytology and cystoscopy may be indicated in these patients. (Am Fam Physician 2000;61:369-76.)

For centuries, the urethral catheter system consisted of a tube inserted through the urethra into the bladder and drained into an open container. The closed catheter system was developed in the 1950s and is still in use today.1

Urinary catheterization can cause many health problems. Alternatives to catheterization should be used whenever possible. Studies have shown that universal bacteriuria occurs within four days when open catheters are used versus approximately 30 days with closed systems.1 Complications of long-term catheterization include chronic renal inflammation, chronic pyelonephritis, nephrolithiasis, cystolithiasis, symptomatic urinary tract infection with pyelonephritis, bacteremia, sepsis and death.1-4

Clinical Indications for Catheter Use

Accepted indications for urinary catheterization are listed in Table 1.4-7 An initial episode of acute urinary retention should be treated with an indwelling catheter to allow the bladder to regain its tone, with catheter removal and a voiding trial after 10 to 14 days.8 While catheters are frequently used in older patients, chronic indwelling catheterization is not a substitute for good nursing care in the management of incontinence. Because a single in-and-out catheterization may cause bacteriuria in as many as 20 percent of older people,4 catheterization is not recommended as a way of obtaining urine specimens for diagnostic testing in patients who could provide a voided specimen.5 In women undergoing total vaginal hysterectomy, even short- term use of urinary catheters has been associated with longer hospital stays, and added cost and discomfort; it also discouraged early ambulation.9

Intermittent catheterization may be preferable to chronic indwelling catheterization in certain patients with bladder-emptying dysfunction.5 It has become the standard of care in patients with spinal cord injuries.10 Following surgical repair of a hip fracture, elderly patients regained satisfactory voiding more quickly (5.1 days versus 9.4 days) on a program of intermittent catheterization every 6 to 8 hours compared with the use of indwelling catheters.11 Women undergoing total abdominal hysterectomy who had in-and-out catheterization at the time of surgery had a lower rate of bacteriuria than women with indwelling catheters.12 While there has been reluctance to use clean intermittent catheterization in the nursing home,13 some higher- functioning nursing home patients may be candidates for self- administered clean intermittent catheterization using the procedure described in Table 2.14

In patients who require long-term intermittent catheterization, no difference in colonization or infection rates has been found between those using sterile single-use catheters and those using clean intermittent catheterization.14 Bacteriuria occurs in most patients in two to three weeks.10 Regular, frequent meatal cleansing offers no advantage in preventing bacteriuria or urinary tract infections in patients performing or using clean intermittent catheterization.15

Catheter Choices

external catheters

Use of a condom catheter should be considered in incontinent men without urinary retention who have severe functional disabilities.16 In this setting, condom catheters are more comfortable and have a lower incidence of bacteriuria than indwelling catheters.1 Skin breakdown is common, whereas urethral diverticuli and penile ischemia occur only occasionally.6 To minimize sleep disruption and limit bacteriuria and other complications, condom catheters can be used only at night.16 External catheters have also been developed for female patients,17 but their safety and effectiveness have not been determined in nursing home patients.  Medical Supplies.