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.7

urethral vs. suprapubic catheters

Suprapubic catheters are recommended by some physicians for short-term use when a catheter is needed for gynecologic, urologic and other surgeries.1 Theoretically, there are fewer microbes on the abdominal wall than on the perineum, creating less risk for infection. Another advantage is easier catheter changes. Suprapubic catheters can also be clamped to test for adequate voiding. Some patients might also prefer a suprapubic catheter to enhance self-image and sexual functioning. Other patients prefer its comfort and convenience.1 Disadvantages of suprapubic catheters include the risk of cellulitis, leakage, hematoma at the puncture site, prolapse through the urethra1 and the psychologic barrier of insertion through the abdominal wall.

latex vs. silastic catheters

Silastic catheters have been recommended for short-term catheterization after surgery. Compared with latex catheters, silastic catheters have a decreased incidence of urethritis and, possibly, urethral stricture.18 However, use in animal models for longer than six weeks showed no difference in inflammatory response between latex and silastic catheters.18 Because of its lower cost and similar long-term outcomes, latex is the catheter of choice for long-term catheterization. The cost differential becomes less significant in patients who do not require frequent catheter changes.6 Silastic catheters should be used in latex- allergic patients.

Catheters impregnated with various substances have not proved to be beneficial in patients with long-term catheterization. Silver- impregnated catheters, antibiotic-coated catheters and electrified catheters may diminish bacteriuria for a few days but are costly and have no role in long-term catheterization.4,19-21 In one study, silver- impregnated catheters were associated with more frequent bacteriuria and an increased risk of staphylococcal bacteriuria.21

Routine Management

catheter size

Authorities recommend choosing “the narrowest, softest tube that will serve the purpose.”22 Rarely is a catheter larger than 18 F required, and 14 or 16 F usually suffices.22,23 A size 12 F catheter was found to be successful in catheterizing men with acute urinary retention.24 In most patients, it is best to minimize bladder irritation by using a catheter with a 5 mL balloon inflated with 5 to 10 mL of fluid.22

minimizing infection

Once the decision has been made to use an indwelling urinary catheter, efforts should be made to minimize problems. The catheter should be inserted using sterile technique (Table 3).5 Once inserted, the catheter should be anchored to prevent urethral traction. In men, the penis should lie over the lower abdomen with the catheter taped to the abdomen. In women the catheter should be secured to the anteromedial thigh.6

Every attempt should be made to keep the drainage system closed. Any break in the catheter-to-collection unit may invite earlier infection. Infection in the catheterized patient is suggested by signs or symptoms of pyelonephritis6,25 (fever greater than 38.3[degree sign]C [100.9[degree sign]F] for more than one day, mental status changes, hypotension), unusually cloudy urine, more frequent blockage, and new or increased detrusor spasms.

Avoiding cross-contamination is most important in controlling nosocomial epidemics of catheter-related infections.10 Caretakers should wash hands before and after any manipulation of a patient’s catheter or collection unit. If possible, devices used for emptying collection bags should be clean and patient-specific.

Catheters should not be changed routinely. Some physicians advocate monitoring patients for time-to-obstruction of urinary catheter, with the catheter changed just before the patient would be expected to obstruct.26 With this approach, some patients required catheter changes weekly, and others did not need them for several weeks. Such a policy will lead to fewer catheter changes than scheduled changes and will result in less trauma to the urinary system and fewer symptomatic infections.6 An obstructed catheter with cessation of urine flow for four to eight hours should obviously be changed. Some physicians recommend a catheter change when an episode of symptomatic urinary infection occurs.25

Several procedures that have been used to decrease the risk of infection are of no benefit. For example, meatal disinfectants and antibacterial urethral lubricants are ineffective.6 Cleansing with soap and water during bathing suffices to remove accumulated debris.6 Prophylactic bladder irrigations using antibiotics, hydrogen peroxide or povidone-iodine are not helpful.27-29 The end result is colonization or infection with more resistant organisms.

Some physicians recommend diluted acetic acid irrigations in patients with frequent catheter obstructions who have had no response to increased fluid intake or acidification of urine.7 Pharmaceuticals, including systemic antibiotics, methenamine (Hiprex) and acidifying agents have also not proved to be beneficial in minimizing bacteriuria or infection. Agents added to collection bags have also not proved effective.6 Table 35 provides the guidelines from the Centers for Disease Control and Prevention for preventing catheter-associated infections.

Management of Complications

obstruction

The material that obstructs urinary catheters consists of bacteria, glycocalyx, protein and precipitated crystals.1 Patients who tend to develop blocked catheters excrete more calcium, protein and mucin, and have a higher urine pH level than patients with infrequent blockage.26 Proteus mirabilis bacteriuria may also be associated with catheter obstruction. Its potent urease splits ammonia, causing alkaline urine, which in turn precipitates crystals of struvite and apatite in the catheter lumen.6,10 Methenamine preparations may be beneficial in reducing episodes of obstruction.30 Irrigation may prevent repeated obstructions that are not responsive to increased fluid intake and urine acidification.7,31 However, obstructed catheters must be removed.

leakage

Bladder spasms are not uncommon in patients with long-term catheterization. The force generated by spasms commonly overwhelms the drainage capacity of the catheter, creating leakage around the catheter. This type of leakage should not be corrected by using a larger diameter catheter. Infection or catheter obstruction, if present, should be treated. Antispasmodics, such as oxybutynin (Ditropan) and flavoxate (Urispas), can be effective in alleviating spasm due to detrusor instability (Table 4).

colonization vs. infection

Virtually every patient with chronic catheterization is colonized with bacteriuria within six weeks. Bacteriuria also occurs within a few months in the majority of patients using clean intermittent catheterization. Asymptomatic bacteriuria does not require treatment.32 Antibiotic prophylaxis simply promotes emergence of antibiotic- resistant microbes.32,33 Slight pyrexia is not uncommon in patients with chronic indwelling urinary catheters and often lasts only a day. An isolated incident should not prompt initiation of antibiotic therapy.1 In the noncatheterized population, no evidence has been shown of a causal relationship between asymptomatic bacteriuria and mortality.4

Asymptomatic bacteriuria occurs frequently after the removal of a short-term-use indwelling catheter.34 It is currently not clear what the proper treatment should be. Some physicians recommend treatment of asymptomatic bacteriuria, but it may be more reasonable to treat only symptomatic episodes. If treatment is chosen, a single dose of trimethoprim-sulfamethoxazole (Bactrim, Septra) is effective in asymptomatic younger women and those with lower urinary tract symptoms. Duration of antibiotic treatment should probably be at least 10 days in women 65 years and older.34 While no studies have addressed this issue in men, it seems reasonable to use this approach in men with short-term catheterization. Only symptomatic infection should be treated in patients undergoing long-term catheterization.10 Periodic urine cultures in chronically catheterized patients are not warranted. The bacterial flora changes over time, and serial cultures offer no benefit in determining correct antibiotic choice for future acute infection episodes.33

When a patient undergoing long-term catheterization develops fever, a source of infection should be sought. When urinary infection is suspected, culture should be obtained to guide therapy. Some physicians recommend inserting a new catheter and collecting a fresh urine sample for culture, to more accurately determine the source of bladder infection,4,25 although no data support this practice. Blood cultures may be helpful if bacteremia is suspected. Infections are usually polymicrobial and may include bacteria such as Pseudomonas, Proteus, Providencia, Enterobacteriaceae, Morganella and Enterococci.4,10

The usual duration of therapy is five to 14 days or longer.4 When multidrug-resistant pathogens are not likely and the patient is not critically ill, trimethoprim-sulfamethoxazole or a second-generation cephalosporin will generally suffice.4,25 Seriously ill or septic patients require a two-drug combination of ampicillin plus a third- generation cephalosporin such as ceftriaxone (Rocephin), aztreonam (Azactam), an aminoglycoside or a quinolone.4,25 A urinary Gram stain may guide empiric therapy while culture results are pending; one organism per oil field is approximately 90 percent sensitive in indicating 105 bacteria per mL on urine culture.25 Enterococcus is more frequently isolated from men.4 Treatment recommendations for catheter- associated urinary tract infections are summarized in Table 5.4-7,25

Complications of urinary tract infections may occur. Increasing renal dysfunction and recalcitrant or recurring bacteremia should prompt a search for urinary stones or other causes of obstruction.1 Men may develop urethritis, urethral fistula, epididymitis, scrotal abscess, prostatitis and prostatic abscess.1,4

special circumstances

Renal calculi are common in patients with spinal cord injury and affect at least 8 percent of patients.6 Renal failure is the cause of death in 20 to 68 percent of these patients. Thirty-nine percent of those who died from renal failure had urolithiasis at autopsy compared with 18 percent of those who died from nonrenal causes.6 Secondary prevention measures include annual urinary tract evaluation with creatinine clearance and a renal sonogram with urologic evaluation every three years, or more frequently if indicated.35

Periodic surveillance for urolithiasis and removal of stones is recommended to maintain renal function.35 Patients who have had an indwelling catheter for longer than 10 years have an increased risk of bladder cancer. In these people, annual cytology or cystoscopy is recommended as a secondary prevention strategy.6 However, none of these strategies has been systematically evaluated in a clinical trial.

REFERENCES

1.Warren JW. Catheter-associated bacteriuria. Clin Geriatr Med 1992;8:805-19.

2.Warren JW, Muncie HL Jr, Hebel JR, Hall-Craggs M. Long-term urethral catheterization increases risk of chronic pyelonephritis and renal inflammation. J Am Geriatr Soc 1994;42:1286-90.

3.Kunin CM, Douthitt S, Dancing J, Anderson J, Moeschberger M. The association between the use of urinary catheters and morbidity and mortality among elderly patients in nursing homes. Am J Epidemiol 1992;135:291-301.

4.Yoshikawa TT, Nicolle LE, Norman DC. Management of complicated urinary tract infection in older patients. J Am Geriatr Soc 1996;44:1235-41.

5.Wong ES. Guideline for prevention of catheter-associated urinary tract infections. Feb 1981. Retrieved September 27, 1999, from the World Wide Web: http://aepo-xdv-www.epo.cdc.gov/ wonder/prevguid/p0000416/entire.htm

6.Wood DR, Bender BS. Long-term urinary tract catheterization. Med Clin North Am 1989;73: 1441-54.

7.Besdine RW, Rubenstein LZ, Snyder L, eds. Medical care of the nursing home resident: what physicians need to know. Philadelphia: American College of Physicians, 1996.

8.Ferri FF, Fretwell MD. Practical guide to the care of the geriatric patient. St. Louis: Mosby-Yearbook, 1992.

9.Meeks GR. Discussion. In: Summitt RL Jr, Stovall TG, Bran DF. Prospective comparison of indwelling bladder catheter drainage versus no catheter after vaginal hysterectomy. Am J Obstet Gynecol 1994; 170:1818-21.

10.Warren JW. Catheter-associated urinary tract infections. Infect Dis Clin North Am 1997;11:609-22.

11.Skelly JM, Guyatt GH, Kalbfleisch R, Singer J, Winter L. Management of urinary retention after surgical repair of hip fracture. Can Med Assoc J 1992; 146:1185-9.

12.Dobbs SP, Jackson SR, Wilson AM, Maplethorpe RP, Hammond RH. A prospective, randomized trial comparing continuous bladder drainage with catheterization at abdominal hysterectomy. Br J Urol 1997;80:554- 6.

13.Sadowski A, Duffy L. A survey of clean intermittent catheterization in long-term care. Urol Nurs 1988; 9(1):15-7.

14.Moore KN, Kelm M, Sinclair O, Cadrain G. Bacteriuria in intermittent catheterization users: the effect of sterile versus clean reused catheters. Rehabil Nurs 1993;18(3):306-9.

15.Bakke A, Vollset SE. Risk factors for bacteriuria and clinical urinary tract infection in patients treated with clean intermittent catheterization. J Urol 1993;149:527-31.

16.Ouslander JG, Greengold B, Chen S. External catheter use and urinary tract infections among incontinent male nursing home patients. J Am Geriatr Soc 1987;35:1063-70.

17.Pieper B, Cleland V. An external urine-collection device for women: a clinical trial. J ET Nurs 1993; 20(2):51-5.

18.Nacey JN, Tulloch AG, Ferguson AF. Catheter-induced urethritis: a comparison between latex and silicone catheters in a prospective clinical trial. Br J Urol 1985;57:325-8.

19.Shafik A. The electrified catheter. Role in sterilizing urine and decreasing bacteriuria. World J Urol 1993;11(3):183-5.

20.Liedberg H, Lundeberg T, Ekman P. Refinements in the coating of urethral catheters reduce the incidence of catheter-associated bacteriuria. Eur Urol 1990;17:236-40.

21.Riley DK, Classen DC, Stevens LE, Burke JP. A large randomized clinical trial of a silver-impregnated urinary catheter: lack of efficacy and staphylococcal superinfection. Am J Med 1995;98:349-56.

22.McGill S. Catheter management: it’s the size that’s important. Nurs Mirror 1982;154(14):48-9.

23.Pomfret IJ. Catheters: design, selection and management. Br J Nurs 1996;5(4):245-51.

24.Allardice JT, Standfield NJ, Wyatt AP. Acute urinary retention: which catheter? Ann R Coll Surg Engl 1988;70(6):366-8.

25.Wood CA, Abrutyn E. Urinary tract infection in older adults. Clin Geriatr Med 1998;14:267-83.

26.Kunin CM, Chin QF, Chambers S. Indwelling urinary catheters in the elderly. Am J Med 1987; 82:405-11.

27.Warren JW, Platt R, Thomas RJ, Rosner B, Kass EH. Antibiotic irrigation and catheter-associated urinary-tract infections. N Engl J Med 1978;299:570-3.

28.Schneeberger PM, Vreede RW, Bogdanowicz JF, van Dijk WC. A randomized study on the effect of bladder irrigation with povidone- iodine before removal of an indwelling catheter. J Hosp Infect 1992;21:223-9.

29.Sweet DE, Goodpasture HC, Holl K, Smart S, Alexander H, Hedari A. Evaluation of H2O2 prophylaxis of bacteriuria in patients with long- term indwelling Foley catheters: a randomized controlled study. Infect Control 1985;6(7):263-6.

30.Norberg A, Norberg B, Parkhede U, Gippert H, Lundbeck K. Randomized double-blind study of prophylactic methenamine hippurate treatment of patients with indwelling catheters. Eur J Clin Pharmacol 1980;18:497- 500.

31.Ruwaldt M. Irrigation of indwelling urinary catheters. Urology 1983;21(2):127-9.

32.Warren JW, Anthony WC, Hoopes JM, Muncie HL Jr. Cephalexin for susceptible bacteriuria in afebrile, long-term catheterized patients. JAMA 1982;248: 454-8.

33.Breitenbucher RB. Bacterial changes in the urine samples of patients with long-term indwelling catheters. Arch Intern Med 1984;144:1585-8.

34.Harding GK, Nicolle LE, Ronald AR, Preiksaitis JK, Forward KR, Low DE, et al. How long should catheter-acquired urinary tract infection in women be treated? A randomized controlled study. Ann Intern Med 1991;114:713-8.

35.Binard JE. Care and treatment of spinal cord injury patients. J Am Paraplegia Soc 1992;15:235-49.

Members of various medical faculties develop articles for “Practical Therapeutics.” This article is one in a series coordinated by the Department of Family and Community at the University of Missouri- Columbia School of Medicine, Columbia, Mo. Guest editor of the series is Robert L. Blake, Jr., M.D.

Table 1

Indications for Use of Urinary Catheters

Long-term catheterization

Bladder outlet obstruction not correctable medically or surgically

Intractable skin breakdown caused or exacerbated by incontinence

Some patients with neurogenic bladder and retention

Palliative care for terminally ill or severely impaired incontinent patients for whom bed and clothing changes are uncomfortable

Preference of a patient who has not responded to specific incontinence treatments

Short-term catheterization

Urologic surgery

Surgery on contiguous structures

Critically ill patients requiring accurate measure of urinary output

Acute urinary retention

Table 2

Steps in Performing Clean Intermittent Self-Catheterization

1. Wash hands and catheter with soapy water.
2. Rinse hands and catheter with tap water.
3. Self-catheterize (without gloves).
4. After use, wash reusable catheter with soapy water, rinse and
store in ventilated container until dry.
5. Place in plastic zipper bag or other clean container.

Table 3

CDC Guidelines for Prevention of Catheter-Associated UTI

Category I. Strongly recommended

Catheterize only when necessary.

Educate personnel in correct techniques of catheter insertion and care.

Emphasize handwashing.

Insert catheter using aseptic technique and sterile equipment.

Secure catheter properly.

Maintain closed sterile drainage.

Obtain urine specimens aseptically.

Maintain unobstructed urine flow.

Category II. Moderately recommended

Periodically re-educate personnel in catheter care.

Use smallest suitable catheter bore.

Avoid irrigation unless needed to prevent or relieve obstruction.

Refrain from daily meatal care.

Do not change catheters at arbitrary intervals.

CDC = Centers for Disease Control and Prevention; UTI = urinary tract infection.

Information from Wong ES. Guideline for prevention of catheter- associated urinary tract infections. February 1981. Retrieved December 1999 from: http://aepo-xdv- www.epo.cdc.gov/wonder/prevguid/p0000416/entire.htm

Table 4

Anticholinergics For Treatment of Bladder Spasm

Medication Dosage Comments

Oxybutynin (Ditropan) 2.5 to 5 mg four times daily May have central
anticholinergic effects
Flavoxate (Urispas) 100 to 200 mg four times daily May have
central anticholinergic effects
Dicyclomine (Bentyl) 10 to 20 mg four times daily Unapproved for
bladder spasticity
Hyoscyamine sulfate 0.125 to 0.5 mg four times daily May have
central anticholinergic effects
(Cystospaz)
Tolterodine (Detrol) 1 to 2 mg twice daily Better tolerated but
may be less effective
Table 5

Treatment Recommendations for Catheter-Associated UTI

Catheterization
period Infection Treatment
Short-term Single organism TMP-SMZ (Bactrim, Septra)
or
Quinolone
or
Nitrofurantoin (Furadantin, Macrobid)
Long-term Usually polymicrobial Noncritical illness:
TMP-SMZ
or
Second-generation cephalosporin (e.g., Cefuroxime)
Critical illness:
Ampicillin plus one of the following:
Ceftriaxone (Rocephin), cefprozil (Cefzil) or
ceftazidime (Fortaz)
or
Aztreonam (Azactam)
or
Aminoglycoside or quinolone

UTI = urinary tract infection; TMP-SMZ = trimethoprim-sulfamethoxazole.

Information from references 4 through 7, and 25.

The Authors

DAVID D. CRAVENS, m.d., m.s.p.h., is an academic fellow in geriatrics and clinical instructor in the Department of Family and Community Medicine at the University of Missouri-Columbia School of Medicine. After completing medical school and a family practice residency at the University of Missouri-Columbia School of Medicine, Dr. Cravens practiced medicine in rural Missouri for 15 years.

STEVEN ZWEIG, m.d., m.s.p.h., is a professor in the Department of Family and Community Medicine and director of senior health care at the University of Missouri- Columbia School of Medicine. He attended medical school, completed a family practice residency and a Robert Wood Johnson Foundation-sponsored fellowship in academic family practice at the University of Missouri-Columbia School of Medicine.

Address correspondence to David D. Cravens, M.D., M.S.P.H., Department of Family and Community Medicine, University of Missouri-Columbia School of Medicine, MA303 Health Sciences Center; DC032.00, Columbia, MO 65212. E-mail: cravensd@health.missouri.edu. Reprints are not available from the authors.

David D. Cravens

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

COPYRIGHT 2000 American Academy of Family Physicians
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