Urinary catheterization is a common healthcare intervention used to manage urinary dysfunc-

tion 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.

Case 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?

U
rinary catheters are used by home health- the bladder. Frederick Foley later redesigned this
care patients, like Edward Jones, for a catheter in 1932, and the Foley catheter remains
variety of reasons. Urinary catheterization one of the most commonly used devices for man-
allows access to the bladder for the purpose of agement of urinary dysfunction today (Bloom
draining urine. This access is gained by inserting et al., 1994; Lawrence & Turner, 2005). As the
either a catheter through the urethra into the materials and design of catheters have evolved
bladder or a suprapubic catheter through the over time, so too have the care and management
anterior abdominal wall into the bladder. The involved with catheterization. To ensure the best
practice of urinary catheterization may date back patient outcomes and minimal complications, the
to 300 AD or possibly earlier. The precursor to the home healthcare practitioner must stay informed
modern catheter, made of gum elastic, was intro- about catheter care. This article reviews current
duced in 1779, followed by the first latex cath- options for urinary catheterization and their as-
eter in the 1800s. In 1853, Jean François Reybard sociated complications and provides approaches
developed the first indwelling catheter, which to the assessment and management of catheters
utilized an inflated balloon to secure its place in in patients with urinary dysfunction.

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

342 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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

Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
including the lower risks of catheter-associated • Urethral or pelvic floor trauma
urinary tract infection (CAUTI) and complica- • Complex urethral or abdominal surgery
tions, may make it a more desirable and safer • Patients in wheelchairs or patients who want
option than indwelling catheterization. Practic- to maintain sexual relationships
ing intermittent catheterization, however, may • Patients with fecal incontinence who might
be difficult for patients with limited vision, dex- soil urethral catheters (Robinson, 2009).
terity, and mobility, although, in these cases,
family members and caregivers can be taught the Complications of Urinary
procedure (Robinson, 2009). Catheterization
Although catheterization is a common healthcare
Indwelling Urethral Catheterization practice, it presents many risks that must be
Indwelling urethral catheterization involves the taken seriously. The complications associated
insertion of a catheter through the urethra into with catheterization include
the bladder. The catheter is held in place with
a retention balloon and then connected to a • Trauma or introduction of bacteria into the
drainage bag, creating a closed urinary system. urinary system, resulting in infection and,
The indications for indwelling urethral catheters consequently, possible septicemia or death
include • Trauma to the urethra or bladder from in-
correct insertion or attempts to remove the
• Accurate monitoring of urine output in criti- catheter without deflating the balloon
cally ill patients • Accidental catheter dislodgement
• Increasing comfort in terminally or severely • Urine bypassing the bladder
ill incontinent patients and managing any • Urethral perforation
skin damage caused by incontinence, when • Blockage of the catheter
all other methods of managing urinary incon- • Encrustment
tinence have failed • Urinary stones
• Maintaining a continuous outflow of urine in • Chronic renal inflammation
preoperative patients and patients with void- • Profound effects on a patient’s social, work,
ing difficulties resulting from neurological and psychological well-being (Hart, 2008).
disorders
• Providing immediate treatment of acute uri- Particular attention must be paid to the most
nary retention (Hart, 2008). likely complication associated with catheter use:
CAUTI. CAUTI is currently one of the most com-
Suprapubic Catheterization mon infections and comprises 40% of all institu-
Suprapubic catheterization involves the inser- tionally acquired infections (National Center for
tion of a catheter midline above the symphysis Health Statistics, 2004). In the home setting, CAU-
pubis through the anterior wall of the abdomen TIs occur in 8% of patients (Getliffe & Newton,
into the bladder. Like the indwelling catheter, 2006). The daily risk of developing CAUTI ranges
the suprapubic catheter uses a balloon to hold from 3% to 7% and cumulatively increases the
its position and is connected to a drainage bag. longer the catheter remains in place (Lo et al.,
Suprapubic catheterization is performed under 2008). After 30 days of indwelling catheterization,
local or general anesthesia usually in a hospital bacteriuria, bacteria in the urine, will be present
or office setting (Robinson, 2009). Indications for in virtually 100% of patients. In addition, bacte-
using suprapubic catheters include remia, a serious and potentially life-threatening
complication, will develop in approximately 3%
• Anatomical problems in the lower urinary of all catheterized patients (Parker et al., 2009a,
tract, including the urethra 2009b). Using infection control measures, an es-
• Total urethral or prostatic obstruction or timated 17% to 69% of CAUTIs may be prevented
urethral strictures that cause difficulty when (Association for Professionals in Infection Con-
inserting a urethral catheter trol and Epidemiology [APIC], 2008).
• Weak pelvic floor muscles causing urethral The bacteria that cause CAUTI can gain entry
catheters to fall out into the bladder via two pathways: the periurethral

344 Home Healthcare Nurse www.homehealthcarenurseonline.com

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 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. Bacteria Urinary Catheterization Assessment

following the periurethral route move into the A practitioner’s assessment of the catheterized
bladder between the outside of the catheter patient is an essential part of catheter care. Be-
and the inner side of the urethral wall. Bacteria cause the incidence of complications rises the
following the intraluminal route, likely the most longer the catheter remains in place, the need
common route, move upward inside the catheter for the continued usage of an indwelling catheter
drainage system after contamination of the drain- must be assessed during every visit (Healthcare
age bag through the outflow tap or disconnection Infection Control Practices Advisory Committee
of the catheter (Madeo & Roodhouse, 2009). The [HICPAC], 2009). In cases of indwelling cath-
bacteria associated with CAUTI are particularly eterization, the practitioner should determine
problematic because they attach to the surface whether the catheter is functioning properly.
of the catheter and produce a biofilm. Biofilm is This means looking to see whether the catheter
a densely adherent polysaccharide structure that system is draining effectively by comparing the
protects bacteria from the body’s natural defense urine output with the patient’s fluid intake. A
mechanisms, allowing for bacterial growth and discrepancy in intake and output volumes may
reproduction (Trautner & Darouiche, 2004). After indicate a mechanical problem with the catheter.
a biofilm has formed on the inside or outside The practitioner should also inspect the catheter
surface of a catheter, the risk of CAUTI can only to ensure that it is properly anchored and posi-
be eliminated by removing the catheter (APIC, tioned, as catheter stabilization may be a factor
2008). in decreasing the risk of complications especially
As catheterization poses serious risks, this infection (Gray, 2008). A thorough physical assess-
method of bladder drainage should not be con- ment of the patient upon each visit should focus
sidered until all other interventions have been on the presence of any drainage and excoriation of
assessed as inappropriate or deemed unsuc- the urethral orifice, which may indicate leakage or
cessful. When patients require catheterization, irritation from the catheter (Nazarko, 2009).
intermittent catheters should be considered first, The practitioner can guard against the threat
and indwelling catheters should be left in place of CAUTI using risk assessment and detection
for as short a time as possible (Healthcare In- strategies. Patients identified as being at high
fection Control Practices Advisory Committee, risk for these infections should be carefully moni-
2009). To minimize the complications associated tored. Risk factors for developing CAUTI include
with catheterization, healthcare interventions female sex, older age, prolonged catheterization,
supported by best practice evidence should be impaired immunity, and lack of antimicrobial
implemented by all practitioners involved in exposure (HICPAC, 2009). Practitioners should
catheter care. With proper assessment and man- monitor all catheterized patients for signs and
agement of catheters, the benefits of catheteriza- symptoms of CAUTIs. The APIC criteria for symp-
tion outweigh the risks. tomatic catheter infection (2008) include

vol. 28 • no. 6 • June 2010 Home Healthcare Nurse 345

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 1. Urgency, frequency, dysuria, or other supra- insertion includes sterile gloves, drape, sponges,
pubic tenderness an appropriate antiseptic or sterile solution for
2. Fever (>104°F or 38°C) periurethral cleansing, and a single-use packet
3. Color or character changes in the urine of lubricant jelly (HICPAC, 2009). Chronic inter-
indicative of infection, hematuria, or posi- mittent catheterization in the nonacute setting
tive culture. can be practiced using clean technique. Clean
technique involves the use of cleansed reusable
Older patients with indwelling catheters may catheters, washing hands with soap and water,
not present with the typical signs and symptoms and daily cleansing of the perineum or more
of infection. Change in mental status, particularly often only when fecal or other wastes are pres-
in older adults, may be symptomatic of CAUTI ent (Newman, 2008). Cleansing the perineal area
(Parker et al., 2009b). Consequently, any subtle to decrease bacteria in the surrounding area is
change in physical condition or behavior should highly recommended.
lead practitioners to consider the possibility of During the catheterization procedure, efforts
infection and quickly investigate, as sepsis may should also be made to minimize pain and
develop before diagnosis of the infection (Siegel, trauma. These efforts include using an appropri-
2008). ate-size catheter, lubricating the catheter thor-
After noting signs and symptoms of infection oughly, and inserting the catheter far enough into
in catheterized patients, practitioners should the bladder to prevent trauma to the urethral tis-
obtain a urine sample from a freshly inserted sues with the inflation of the retention balloon
catheter or collection port of an indwelling cath- (Hart, 2008). Select the smallest bore catheter
eter for urine culture and sensitivity testing and possible that will allow for adequate drainage.
perform a dipstick urinalysis. Diagnosis of CAUTI Large-size catheters (18 Fr or larger) can increase
is only made when signs and symptoms of CAUTI erosion of the bladder neck and urethral mucosa,
coexist with microbiologic evidence of bacteri- cause the formation of strictures, and impede
uria and elevated white blood cell count upon adequate drainage of periurethral gland secre-
urinalysis (Parker et al., 2009b). tions. The use of 30 mL balloons is not recom-
mended. The buildup of these secretions may
Urinary Catheterization Management result in infection or irritation (Newman, 2008).
Over the past several years, catheter manage- The indwelling catheter should be secured to
ment interventions have been evaluated to pro- the thigh or abdomen after insertion to prevent
duce evidence-based best practice guidelines movement and the exertion of excessive force on
for providing effective catheter care at home the bladder neck or urethra (Gray, 2008). Unse-
and minimizing the risks of catheter-associated cured and displaced catheters can also cause
infections and complications (Emr & Ryan, 2004). pressure ulcers on the perineum and buttock
These guidelines, presented in the following sec- (Siegel, 2008).
tions, cover proper techniques for insertion and
management of catheters as well as information Management
that should be included in patient/caregiver Once an indwelling catheter has been inserted
training and education. using aseptic technique, all possible measures
should be employed to maintain a closed drainage
Insertion system. If breaks in aseptic technique, discon-
To minimize the potential for introduction of nection, or leakage occur, use aseptic technique
microorganisms into the bladder, urinary cath- and sterile equipment to replace the catheter and
eters should only be inserted by properly trained collecting system. The use of urinary catheter sys-
individuals. Hand hygiene is the most important tems with preconnected, sealed catheter-tubing
means of preventing infection and should be junctions may reduce the occurrence of disconnec-
performed immediately before and after inser- tions (HICPAC, 2009). Extensive measures should
tion or any manipulation of the catheter device also be taken to maintain unobstructed urine flow.
or site (Emr & Ryan, 2004). Indwelling catheters To prevent obstruction, the catheter and collect-
should be inserted using aseptic technique and ing tube should be kept free from kinking, the col-
sterile equipment. The equipment needed for lecting bag should be positioned below the level

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Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Intermittent catheterization is becoming the gold standard for the
management of bladder-emptying 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 on the vinegar and 3% hydrogen peroxide irrigation of
floor. The collecting bag should be emptied regu- catheter bags in a sample of 20 patients. The
larly using a clean collecting container (HICPAC, study showed that patients whose bags were
2009). In ambulatory patients, collecting bags may irrigated with vinegar showed a significant reduc-
be disguised in bags and pouches. tion of bacteriuria compared with patients whose
Patients practicing intermittent catheteriza- bags were irrigated with the hydrogen peroxide
tion should pay close attention to the catheteriza- solutions (Washington, 2001). Authors concluded
tion schedule and avoid bladder overdistension that more research is needed on the self-cleaning
and unnecessary catheterizations. As CAUTIs are of Foley bags.
more prevalent for intermittent catheterization in Additional strategies can also be employed
patients with high residual urine volumes at the to reduce the risk of CAUTI and other complica-
time of catheterization, urine volume should de- tions.
termine the catheterization schedule. In general,
bladder volume should not exceed 400 mL (New- • Choose catheter materials appropriate for
man, 2008). Intermittent catheterization should each patient.
be performed at regular intervals to prevent – For patients requiring intermittent cath-
bladder distension. Portable ultrasound devices eterization, consider hydrophilic catheters
have also been recommended as a means of as- over standard catheters (HICPAC, 2009).
sessing urine volume and consequently minimiz- – The short-term use of silver alloy cath-
ing unnecessary catheter insertions (HICPAC, eters may reduce the incidence of CAUTI
2009). It should be noted that in May 2008, Medi- and bacteriuria.
care coverage was extended from 4 to 200 single- – Silicone or hydrogel catheters are recom-
use, disposable catheters per month for many mended for patients using catheters longer
patients undertaking intermittent catheterization than 14 days (Parker et al., 2009a).
(Muller, 2009). In patients with long-term indwell- • Change indwelling catheters and drainage
ing catheters, self- or family management of the bags according to clinical indications such
system requires infection control methods that as infection, obstruction, or when the closed
are both economical and effective. Nash (2003) system is compromised rather than at rou-
conducted a recent review of the literature on tine, fixed intervals.
self-cleaning of catheter training bags. She rec- • Obtain urine samples aseptically and only
ommends adhering to the findings of a clinical from newly placed catheters (≤7 days). After
trial by Dille and Kirchhoff (1993) in which the cleansing the needleless sampling port with
daily cleansing of both nighttime and leg drain- a disinfectant, aspirate the urine with a ster-
age bags with 1:10 household bleach solution ile syringe.
extended the use of the urinary drainage bags • Avoid irrigation unless needed to prevent or
from 1 week to 1 month without any significant relieve obstructions.
increase in urine or drainage bag colonization • Practice routine meatal care while a catheter
or increase in rate of urinary tract infection. One is in place, including cleansing with soap and
study was found that compared distilled white water during daily showers. Avoid vigorous

vol. 28 • no. 6 • June 2010 Home Healthcare Nurse 347

Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 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- leakage, bladder spasms, encrustment, and bal-
fection (HICPAC, 2009). loon malfunction, should be included (Nazarko,
• Although there is insufficient clinical evi- 2009). Patients and caregivers should be edu-
dence to support it, increasing fluid intake in cated about symptoms of CAUTI and other cath-
patients with urinary catheters is a common eter-related complications and when to contact a
practice and may result in decreased encrus- healthcare practitioner.
tation and other benefits (Siegel, 2008).
Conclusion
Recent information has also been released Urinary catheterization is a common interven-
regarding catheter management practices that tion used by home healthcare patients to manage
have no support from clinical research. These urinary problems such as urinary retention and
practices include instilling antibiotics or other urinary incontinence. The common use of this
additives to the drainage bag, applying antisep- intervention does not, however, imply that cath-
tic compounds to the meatus, and using specific eterization is without serious complication or is
agents for meatal cleansing. In addition, sys- always used appropriately. Catheterization
temic antibiotics should not be used routinely should only be undertaken when all other meth-
to prevent CAUTI in patients requiring short- or ods of urinary system management have been
long-term catheterization. And, although cran- deemed inappropriate or have failed. If indwell-
berry juice may be beneficial for preventing uri- ing catheterization is required, the catheter
nary tract infections in noncatheterized patients, should be removed as soon as possible to reduce
there is no evidence to suggest that cranberry the risk of complications. By adhering to the rec-
juice reduces the risk of CAUTI (Parker et al., ommendations and guidelines outlined above,
2009a). home healthcare practitioners can participate in
the nationwide effort to provide effective care
Education and Training and prevent catheter-associated complications
Education and training of catheterized patients in all settings where catheterization is under-
and their caregivers should play an integral role taken.
in the practitioner’s efforts to ensure best patient
outcomes and reduce the likelihood of complica- Rebecca Herter, BS, is an Adult/Geriatric Nurse
tions. Practitioners should train patients and Practitioner Student at Yale University School of
caregivers in the correct techniques for cath- Nursing, New Haven, Connecticut.
eter insertion and care. Education should focus Meredith Wallace Kazer, PhD, APRN,
on the importance of catheter hygiene and the A/GNP-BC, is an Associate Professor at Fairfield
avoidance of catheter-related problems. Trouble- University School of Nursing, Fairfield, Connecticut.
shooting advice on common problems occurring The authors of this article have no significant
with urinary catheters, including obstruction, ties, financial or otherwise, to any company that

348 Home Healthcare Nurse www.homehealthcarenurseonline.com

Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
might have an interest in the publication of this Muller, N. (2009). Medicare coverage of catheters. Ostomy
educational activity. Wound Management, 55(3), 10.
Address for correspondence: Meredith Wallace Nash, M. A. (October, 2003). Best practice for patient self-
Kazer, PhD, APRN, A/GNP-BC, Associate Professor, cleaning of urinary drainage bags. Urologic Nursing,
23(5), 334, 339.
Fairfield University School of Nursing, Fairfield, Con-
National Center for Health Statistics, Centers for Dis-
necticut (e-mail: [email protected]).
ease Control and Prevention, US Department of
Health and Human Services. (2004). Urinary tract
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For nine additional continuing nursing education articles on

genitourinary topics, go to nursingcenter.com/ce.

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