Managing complications associated with the use of indwelling urinary catheters
Intended for healthcare professionals
Evidence and practice    

Managing complications associated with the use of indwelling urinary catheters

Penny Tremayne Senior Lecturer, Faculty of Health and Life Sciences, De Montfort University, Leicester, England

Why you should read this article:
  • To understand the clinical indications for urinary catheterisation

  • To familiarise yourself with the main complications associated with indwelling urinary catheterisation

  • To increase your knowledge of how to reduce the incidence of catheter-associated complications

The insertion of an indwelling urethral urinary catheter is an invasive procedure that is commonly undertaken in healthcare settings. However, there are several risks and potential complications associated with these devices, so their use should be avoided where possible. It is important that nurses are equipped with the necessary knowledge and skills not only to assess if a patient requires a catheter, but also to minimise the risk of associated complications and to understand how these can be managed. This article discusses some of the common complications that can occur with the use of indwelling urinary catheters, including: catheter-associated urinary tract infections; catheter blockages; encrustation; negative pressure; bladder spasm and trauma; and, in men, paraphimosis. It also explains the steps that nurses can take to reduce the risk of these complications and how to manage them effectively.

Nursing Standard. doi: 10.7748/ns.2020.e11599

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

ptremay@dmu.ac.uk

Conflict of interest

None declared

Tremayne P (2020) Managing complications associated with the use of indwelling urinary catheters. Nursing Standard. doi: 10.7748/ns.2020.e11599

Published online: 19 October 2020

Catheterisation is a relatively common procedure undertaken in hospital and community settings, with more than one million indwelling urinary catheters used in NHS patients every year in the UK (Holdroyd 2019). Urinary catheters are inserted for a variety of reasons in men and women of all ages. However, one UK study of the presence of a catheter at a given time point (point prevalence) in NHS patients noted that catheter use was highest in hospital settings, notably in critical care, and that men were more likely to have a catheter in place than women (Shackley et al 2017). Furthermore, the study identified that catheters are more common in patients aged over 70 years in hospital and hospice settings, but are more common in those under 70 years in the community setting (Shackley et al 2017).

In England, around 900,000 adults live in the community with an indwelling catheter, often as a result of being catheterised when in hospital (Nazarko 2020). Therefore, nurses will often encounter patients with complications associated with indwelling catheter use, the management of which remains central to the nursing role. This article discusses some of the common complications that these patients may experience, including: catheter-associated urinary tract infections (CAUTIs); catheter blockages; encrustation; negative pressure; bladder spasm and trauma; and, in men, paraphimosis (entrapment of retracted foreskin behind the corona of the glans penis). It also explains how these complications can be managed and the steps that nurses can take to reduce the risk of their occurrence. This article focuses on the complications of indwelling urethral catheters, and it is beyond its scope to discuss the complications associated with suprapubic and intermittent catheterisation.

Key points

  • Catheterisation is a relatively common procedure undertaken in hospital and community settings

  • Nurses will commonly encounter patients with complications associated with indwelling urinary catheter use, such as urinary tract infections, catheter blockages, encrustation, bladder spasm and trauma

  • Measures that can be taken to reduce the risk of complications include: using an aseptic technique during the catheterisation procedure; performing meatal cleansing daily; using a catheter stand or leg straps to support the drainage bag; and using appropriate devices to secure the catheter

  • Nurses need to carefully assess whether indwelling catheterisation is required and, unless clinically indicated, the catheter should be removed at the earliest opportunity

Use of urinary catheters

A urinary catheter is a hollow tube that drains urine from the bladder, and is usually inserted via the urethra. An indwelling catheter remains in place for a few days or weeks and is secured in the bladder by a balloon inflated with fluid (Hill and Mitchell 2018). The length of time the catheter remains in place is informed by clinical indications and the presence of any complications, and the device should be changed in accordance with the manufacturer’s recommendations. In long-term catheters, this length of time generally does not exceed 12 weeks.

Patients who have an indwelling catheter typically tend to be older and have co-morbidities (Smith et al 2019), so experiencing complications such as CAUTIs can have significant health implications, and catheterisation should be avoided wherever possible (Buckley et al 2015). National Institute for Health and Care Excellence (NICE) (2020) guidelines recommend that intermittent catheterisation should be used in preference to an indwelling catheter if it is clinically appropriate and practical for the patient. Nurses need to maintain a proactive and positive approach towards supporting patients in their need to pass urine, and it is essential that they carefully assess whether catheterisation is required. Box 1 details the clinical indications for urinary catheterisation.

Box 1.

Clinical indications for urinary catheterisation

  • To manage acute or chronic urinary retention

  • To monitor renal function in an acutely unwell patient

  • To monitor, record or drain residual urine volumes

  • To enable bladder irrigation

  • To enable the instillation of medicines, for example chemotherapy

  • To bypass an obstruction or address voiding difficulties

  • To enable bladder function tests

  • To support continence and maintain skin integrity, when all other methods have been unsuccessful

  • To obtain a sterile urine specimen

  • During and after surgery

(Royal College of Nursing 2019)

Nurses need to ensure they maintain the knowledge and skills required for safe and effective practice (Nursing and Midwifery Council (NMC) 2018), and therefore are required to ensure they are competent in urinary catheterisation and have the necessary underpinning theoretical knowledge and practical skills (NMC 2018, Royal College of Nursing (RCN) 2019). In addition, the patient must give consent before the catheterisation procedure or catheter care is undertaken. If the patient is unable to give consent, there must be a clear rationale for using a catheter and it must be in the patient’s best interests (RCN 2019).

Unless clinically indicated, the catheter should be removed at the earliest opportunity, so it is important to undertake regular reviews and develop an appropriate plan for removal. This plan can include an estimated removal date documented on insertion, as well as simply asking colleagues ‘Why does this patient have a catheter?’ during handovers. Zurmehly (2018) found that an evidence-based urinary catheter protocol and associated online education reduced the number of catheter days by 10%. Many of the complications associated with catheter use, such as CAUTIs, blockages, bypass (leakage of urine around the catheter), bladder spasm and encrustation are often interlinked, so identifying the primary causative factor can be challenging for the nursing team.

Complications associated with indwelling urinary catheter use

Catheter-associated urinary tract infections

Indwelling urinary catheters rapidly become colonised by bacteria, with almost 100% of catheters colonised after 28 days (Morris et al 1997). However, bacterial colonisation is not the same as a CAUTI. Bacteria in the urine and without symptoms is known as asymptomatic bacteriuria, and is not usually treated with antibiotics (Belfield et al 2019). Bacterial colonisation occurs as a consequence of the urethral catheter interfering with the natural flushing action of urine that usually eliminates bacterial microorganisms from the bladder (NICE 2018).

In a CAUTI, bacteria enter the bladder leading to clinical symptoms such as malodorous, dark and/or cloudy urine, lower abdominal pain, flank or costovertebral angle tenderness, and pelvic discomfort (Gould 2015). Older people with a CAUTI may present with restlessness, disorientation or confusion. In accordance with local guidelines, a catheter specimen of urine should be obtained from the sampling port for culture and susceptibility testing to ensure that an early diagnosis can be made and an appropriate antibiotic can be prescribed (Gould 2015). However, antibiotics should only be used to treat a CAUTI if the patient has clinical symptoms (Nazarko 2020). It is important to consider the risk of antimicrobial resistance and note the patient’s previous antibiotic use, since this may have led to the development of resistant bacteria (NICE 2018).

The complications of a CAUTI are significant and are outlined in Box 2. Individuals who are at increased risk of developing complications of a CAUTI are detailed in Box 3.

Box 2.

Complications of a catheter-associated urinary tract infection

  • Sepsis

  • Pyelonephritis

  • Sacral breakdown, as a result of a lack of movement

  • Cross-contamination with the bladder from a wound

  • Cystitis

  • Gram-negative bacteraemia

  • Endocarditis

  • Vertebral osteomyelitis

  • Septic arthritis

  • Endophthalmitis

  • Meningitis

  • Prosthetic joint infections

  • In men, prostatitis, epididymitis and orchitis

(Buckley et al 2015, Gould 2015, Clayton 2017)

Box 3.

Individuals who are at increased risk of developing complications of a catheter-associated urinary tract infection

  • Pregnant women

  • People aged over 65 years

  • Those with diabetes mellitus

  • People who are immunocompromised

  • Those with underlying renal tract abnormalities or only one functioning kidney

  • People with an artificial heart valve or heart defect

  • Those who have had organ transplants

  • People with a history of repeated urine infection or at least one urinary tract infection since using a catheter

  • People who are taking more than six medicines

  • Those who have had chemotherapy within the past six months

  • People who are taking corticosteroids

  • Those with chronic wounds that require dressings, due to the risk of cross infection

  • People with suboptimal bowel control or diarrhoea

  • Those who have been in hospital in the past 12 months

  • Those who have taken antibiotics in the past six months

(Gould 2015, Royal College of Nursing 2019)

The initial risk for CAUTI is the catheterisation procedure itself. The use of an aseptic technique and adequate preparation are essential to reduce the risk of contamination. As part of this preparation, it is important to ensure the necessary equipment is readily available. Cartwright (2018) reported on how Nottingham University Hospitals NHS Trust introduced an ‘all-in-one’ catheter insertion tray, which includes all of the necessary equipment, thus preventing interruptions to the procedure that could occur due to items of equipment being forgotten. As a result of the introduction of the tray, there was an 80% reduction in the CAUTI rate alongside an annual saving of nearly £160,000 (Cartwright 2018).

The contents of the catheter insertion tray include a pre-connected drainage system comprising a urethral catheter attached to a drainage bag. This means that the drainage system can remain in place for up to 14 days, compared with seven days with the equipment previously used (Cartwright 2018). This is beneficial because breaking the integrity of a urinary drainage system should be minimised to reduce the access of microorganisms (Mavin and Mills 2015, Powers 2016). The author recommends that this pre-connected system is used in all catheterisations, replacing the previous system where the catheter would often lie in urine inside the bladder until the drainage bag was attached.

It is essential to clean around the urethral meatus (external urethral orifice) before the insertion of the catheter, and 0.9% sodium chloride solution has traditionally been used for this task. However, Fasugba et al (2019) found that using chlorhexidine solution reduced the risk of CAUTIs and Mitchell et al (2019) subsequently identified that this was cost-effective. Meatal cleansing should also be performed daily using soap and water once the catheter is in place (Gould 2015, Mavin and Mills 2015).

As part of ongoing catheter care, it is important to ensure that the drainage bag is well secured and not in contact with the floor. Furthermore, the drainage of urine from the bag should be undertaken using an aseptic technique (Gould 2015).

Catheter blockages

Catheter blockages can be caused by anything that inhibits or completely stops the drainage of urine from the bladder via the catheter tube (Paterson et al 2019). It is important that blockages are managed promptly, to prevent complications and promote patient comfort.

It is essential to identify the reason for the blockage so that appropriate interventions can be undertaken. An initial check may be advisable to ensure that the patient is not sitting on the tubing to the drainage bag and there are no kinks in this tubing. Therefore, safe and appropriate securement of the catheter and drainage bag is essential, as is confirming whether the catheter remains in place. The patient’s bowel function may also need to be assessed, since constipation can lead to an obstruction in the flow of urine. To prevent and manage constipation, it is important to promote a healthy diet and adequate hydration (Gould 2015, Gibney 2016, NICE 2019).

Before any examination of the catheter device itself, it is essential for the nurse to decontaminate their hands and avoid touching areas where microorganisms may enter the system, such as connections and ports. It is important to ensure that the drainage bag is positioned below the level of the patient’s bladder, to support urinary drainage and prevent backflow (Gould 2015). Visual observation of the appearance of the urine is also useful because this can identify the presence of debris or a blood clot, which may be contributing to the blockage.

Encrustation

Encrustation occurs when a catheter acquires a crystalline biofilm as a result of the presence of urease-producing bacteria, most commonly from Proteus mirabilis, but also potentially involving Pseudomonas aeruginosa, Staphylococcus aureus, Klebsiella, Serratia, Morganella morganii, Providencia and Enterobacter (Feneley et al 2012, Gibney 2016, Paterson et al 2019). A biofilm can form on the lumen of the catheter, the catheter eyelets and on the balloon, and may lead to blockages, urinary retention and bypass (Yates 2018a, 2018b). The process of encrustation is as follows (Gibney 2016, Holdroyd 2017, 2019, Yates 2018a):

  • A bacterial biofilm develops on the interior or exterior of the catheter lumen.

  • This leads to the formation of a urease, which breaks down urinary urea to release ammonia.

  • Ammonia turns the urine alkaline.

  • The alkalinity of the urine causes the formation of apatite (a hydroxylated form of calcium phosphate) and struvite (magnesium ammonium phosphate) (Stickler 2014). These are ‘gritty’ crystals that attach to the lumen of the catheter and block the drainage eyelets. On removal of the catheter, these crystals can be shed into the bladder, which may result in the formation of bladder stones (Feneley et al 2015).

To identify if encrustation is a risk, it may be useful to test the pH of urine at regular intervals to establish a baseline, with increasingly alkaline urine indicating an increased risk of encrustation. However, according to Gibney (2016), this is not always a reliable indicator of this risk.

Some catheter materials, such as silver-alloy catheters, have antimicrobial properties, while others that are impregnated with antibiotics have similar effects (Belfield et al 2019). In addition, including antimicrobials such as triclosan in the fluid used to inflate catheter balloons has been shown to improve the patency of the catheter and the patient experience (Holdroyd 2017, RCN 2019). Open-ended catheters have also been shown to be beneficial in severe encrustation (Yates 2018a).

Catheter maintenance solutions, also known as catheter patency solutions, can be prescribed to dissolve struvite, prevent blockages and extend the life and patency of the catheter (NICE 2017, Yates 2018a, Paterson et al 2019). There are several catheter maintenance solutions available, including (Yates 2012):

  • 0.9% sodium chloride solution (neutral pH) – used to manage pus, blood and debris.

  • Solution G (acidic) – 3.23% citric acid that dissolves encrustation. It also contains magnesium oxide, which prevents bladder irritation.

  • Solution R (acidic) – 6% citric acid used in severe encrustation if solution G has been ineffective.

In addition, Yates (2018a) stated that a broad-spectrum antimicrobial irrigation solution, 0.02% polyhexanide, could prevent bacteria from adhering to the catheter.

The contraindications and potential side effects of catheter maintenance solutions should be considered because these solutions can cause hypersensitivity and chemical irritation of the bladder mucosa, alongside the risk of introducing microorganisms due to a breakage in the closed drainage system (Gibney 2016).

Negative pressure

Negative pressure occurs when the drainage bag is placed too low and more than 30cm in distance from the bladder (RCN 2019). This leads to the mucosal walls of the bladder being sucked into the catheter eyelets, resulting in catheter blockage (Holdroyd 2019). According to Feneley et al (2015), a quick solution is to raise the bag above the level of the bladder for a few seconds, which will counter the negative pressure. It is essential that the drainage bag is well supported and emptied once it is three-quarters full, which will reduce the weight on the catheter tubing and on the neck of the bladder (Holdroyd 2019). The tubing should also be less than 30cm from the bladder.

Bladder spasm and trauma

Bladder spasm and trauma are not uncommon complications (Darbyshire et al 2016, Wilde et al 2016) that are painful and can affect an individual’s quality of life (Nazarko 2014). The presence of a catheter keeps the urethra unnaturally open, and the urethral lining is delicate and highly vascularised; therefore, local trauma – from a rigid catheter, for example – can result in bleeding and other associated risks (Gould 2015).

Wilde et al (2016) noted that bladder spasm is a frequent complication encountered in those with a long-term urinary catheter in place and can cause pain and discomfort. This complication may occur because the catheter is unstable inside the bladder, causing it to migrate (Yates 2018b). Bladder spasms may also occur as a result of a neurogenic bladder (dysfunction that results from interference with the nerve pathways associated with urination), an irritable bladder resulting from a recent UTI, inadequate urinary flow, or if a latex catheter has been used and the patient is allergic to this material (Wilde et al 2016). Solutions to bladder spasms include using the smallest size catheter to avoid irritation (Gould 2015) and replacing a latex catheter with one made from an alternative material such as silicone.

The catheter balloon, particularly if it is larger than 10mL, may be in direct contact with the walls of the bladder and this can also cause spasm (Gould 2015). The bladder may simply need to adjust to the presence of the catheter, in which case this issue may resolve within 24 hours. However, if it does not resolve, one solution may be to reduce the volume of the balloon by using a syringe to withdraw some of the fluid used to inflate the balloon, making sure to document the amount of fluid withdrawn in the patient’s notes. Anticholinergic medicines may also be prescribed to relax the bladder (Yates 2018a). If these methods are not effective, botulinum toxin can be used over the course of several months to reduce bladder spasms (Nazarko 2014).

The long-term traction and friction involved in having a urinary catheter in place can cause significant trauma. This can be considered the equivalent of a pressure ulcer affecting the urinary structures, in which a form of cleavage develops along the shaft of the penis (Woodward 2014) or the labia. Urethral erosion and inflammation can occur, either at the neck of the bladder or the urethral meatus (Wilson 2013, Woodward 2014, RCN 2019), and may lead to bypass of the catheter. This trauma can be painful, and relief can be provided by taking measures to support the drainage bag and using catheter securement devices (Nazarko 2014).

Measures to support the drainage bag

One measure that can be used to support the drainage bag is a catheter stand, which the bag can be secured to so that it does not touch the floor. Alternatively, straps can be used to secure the bag to the patient’s leg. One leg strap should be placed at the top of the bag and the other should be placed at the bottom to ensure even distribution of the weight from the bag. To prevent back flow, the leg bag should be positioned below the level of the bladder, usually on the thigh or calf. The nurse should ensure that the straps are not too tight or loose. Care should be taken in patients with compromised circulation or cellulitis because they may have impaired feeling, and if the straps are too tight this could lead to trauma (Yates 2018b).

Wilson (2015) also discussed the use of catheter sleeves, which are elasticated mesh leg bags that have an opening for the drainage tap and a pocket in which the drainage bag can be inserted.

Catheter securement devices

Catheter securement devices, such as straps and adhesive devices, are increasingly used in clinical practice to support stabilisation. Adhesive devices are applied to the skin and have the appearance of a plaster that has a Velcro flap for the fixation of the catheter, or they may have a swivel retainer in the middle of the adhesive plaster, which will secure the catheter and provide some rotation.

The nurse will need to ensure that the device is compatible with the catheter and change the adhesive device every seven days, if it has not become detached. These devices should not be used in patients with fragile, damaged skin or in those who are allergic to any of the device materials (Ansell 2016, Yates 2018b). The nurse also needs to consider the risk of compromising the patient’s circulation if straps are to be used.

If appropriate, a catheter valve may be used to reduce the weight of the drainage bag and therefore reduce any urethral erosion (Wilson 2015). A catheter valve is a tap-like device that is fitted directly onto the catheter and enables an individual to retain the normal function and capacity of the bladder and therefore mimic the voiding of urine, emptying straight into a toilet or drainage bag (Holdroyd 2019). The use of a catheter valve can retrain the bladder, promote patient comfort and improve quality of life. It can also improve the outcomes of a trial without catheter, thus avoiding prolonged catheter use (Carr 2019). However, before using a catheter valve, the patient’s cognitive function and manual dexterity should be assessed carefully and any contraindications identified, for example if they have an overactive bladder (Woodward 2013).

Paraphimosis

Paraphimosis is a urological emergency that can occur in men who are uncircumcised. It occurs when the foreskin cannot be returned to its normal anatomical state after being retracted for the catheterisation procedure (RCN 2019). The entrapped and swollen tissue of the foreskin causes constriction of blood and lymphatic flow to the glans penis and foreskin (Hunter 2012).

Paraphimosis can be resolved through manual manipulation of the foreskin. This can be achieved by applying a lubricant, a cold compression or local anaesthetic to the penis, and compressing the glans while moving the foreskin to the normal position. If this does not resolve the issue, surgical intervention may be required (RCN 2019).

Reducing the risk of complications

Recommendations for optimising catheter use and reducing the risk of catheter-associated complications include:

  • Avoid indwelling urinary catheterisation whenever possible.

  • Remove an indwelling catheter as soon as possible.

  • Select the necessary equipment carefully before catheterisation.

  • Use appropriate devices to secure the catheter.

  • Implement the use of catheter passports to ensure consistency in the care provided to patients (NHS 2020). These should include information such as: the reason for catheterisation; the size, length and material of the catheter; the date it was inserted; and the onward plan of care, for example if a trial without catheter will be undertaken to determine whether the catheter remains necessary.

  • Ensure continuing professional development among healthcare professionals in relation to indwelling urethral catheterisation.

  • Educate patients and their family and/or carers about the potential for complications and what actions to take should these arise.

Conclusion

Indwelling urinary catheterisation is associated with a range of complications, and therefore should only be undertaken where there is a sound clinical rationale. These complications can have significant health effects for patients, as well as economic costs for healthcare providers. Therefore, the use of catheters should be avoided where possible and alternative approaches considered. It is essential that nurses have the knowledge and skills to provide effective catheter care and understand how to reduce the risk of complications. In addition, where complications occur, they should be able to manage these in an informed, proactive manner, ensuring that their practice is based on the latest clinical evidence.

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