Indwelling Urethral Catheter

1. Concept and Purpose of the Procedure

  • To have free urinary drainage by indwelling Foley catheter through the urethra

2. History

  • Once the preferred method to treat the neuropathic bladder and for a long time the most common treatment in women, even into the 1990’s.
  • During and after WWII catheter complications were recognized as male patients survival improved.
  • Efforts were then made to achieve a catheter free state and “balanced bladder function” defined by the residual urine after voiding in relation to the volume that triggered the contraction. This clearly did not define risk, and catheter free states were achieved only in about 25% of patients, and not permanently.
  • It was suggested by those centers where catheter use was continued that a catheter free state had its own complications and so it did, as did chronic catheterization.
  • Only when CIC was used for long term management did the high rate of complications associated with the other treatment methods, by comparison become obvious.
  • For more information, please refer to this (link to the Tx-1.5. History of SCI Management.doc)

3. Terminology

  • Transurethral catheter indwelling

4. Indication

  • Short-term bladder drainage for initial bladder management in SCI (for example, in spinal shock phase of SCI) [Lloyd 1986].
  • A last resort of therapy for long-term bladder drainage, especially in women, when other methods fail (for example, unable to perform CIC due to limited upper limb function) or are not applicable or are not accepted by the patient.  
  • Permanent catheters are primarily appealing to women
    • But the usual reason for catheter use is to assure continence. Unfortunately 50% of patients at 5 years are incontinent despite the catheter.
    • No collecting devices (e.g., condom catheter) available for women

5. Procedure

  • Cleanse the urethral meatus (male) /perineum (female) with antiseptic solution
  • Lubricating the catheter
  • Gently inserting the catheter into the meatus using aseptic technique
  • Inserting the catheter 1 inch beyond so that enough room for balloon inflation can be ensured.
  • Fixing the catheter and the penis to the abdomen (male), or to the thigh (female)

6. Clinical Outcomes

1) Short-term use

  • A short-term ID during the acute phase is still a safe method for neuropathic patients.

Short-term Use of Indwelling Catheters

Authors (Year)

Methods

Results

Comments

Stamm WE. [Ann Intern Med. 1975]

Literature review

 

With an indwelling catheter the prevalence of infection is 100% if the catheter is used for more than 2 weeks.

Jacobs SC, Kaufman JM. [J Urol 1978]

Retrospective review of
SCI patients
 
Group 1 (25 pts): long-term catheter ID
Group 2 (25 pts): intermediate term catheter ID
Group 3 (9 pts): short term catheter (initial stage of SCI) ID

Follow-up measure: IVP, renal function

Renal complication: no difference
Bladder complication: significantly fewer in group 3
Urethral complication: significantly fewer in group 3
Epididymo-orchitis: no difference

Overall:
The least complication rate (0.11/patient/year) in group 3, compared to other groups with intermediate (0.26) and long-term (0.25) ID

Very high rate of malignant changes in patients with Foley urethral catheters and suprapubic tubes.

Lloyd LK, Kuhlemeier KV, Fine PR, Stover SL. ]J Urol 1986]

 

 

Initial bladder management in 204 SCI patients during acute and rehabilitation
phases

No significant differences in regard to fever and chill, UTI, upper
tract changes, and pyelocaliectasis between those with ID and those with IC or SC

Method of initial bladder management is relatively unimportant in determining the urological prognosis after SCI.

2) Long-term use

  • Potential complications associated with chronic indwelling of the urethral catheter are well established.
  • Permanent catheters can cause acute septic and chronic UTI, bladder and renal stones, bladder carcinoma, urethral trauma and bleeding, false passages, urethral sphincter erosion and bladder neck incompetence, urethral strictures, diverticuli and fistula of the urethra. In particular, urethral destruction and bladder cancer develop most commonly beyond after 5-10 years. [Hess 2003; West 1999]. [VIDEO]

(A) UTI

(B) Stone

(C) Bladder cancer

(D) Renal function

(E) Bladder function

i) Bladder compliance

ii) Bladder spasm

  • Catheter indwelling can cause subsequently urethral leakage of the urine around the catheter.
  • Mechanical stimulation of the catheter or the balloon provokes bladder contractions [Lindan 1987]
  • Sometimes the contractions are strong enough to expel the catheter [McGuire 1986]

iii) Risk of intravesical pressure elevation

  • Free urinary drainage by indwelling Foley catheter did not prevent VUR and thus did not protect the refluxing kidney from damage [Lamid 1988].
    • The majority of VURs developed 1-2 years post-injury, and some disappeared spontaneously without causing any damage to the urinary tract [Lamid 1988].
    • The incidence of VUR was higher in patients with complete spinal lesion. [Lamid 1988]
    • The incidence of VUR was higher in individuals with an upper motor neuron lesion. [Lamid 1988]
  • Indwelling catheters do not guarantee free drainage with a constantly low intravesical pressure:
    • Detrusor contractions causing intravesical pressure rises greater than 40cmH2O by ambulatory urodynamic study in 30 SCI patients [Jamil 1999]
    • For more information, please refer to this.

(F) Erosion of the urethral sphincter/ bladder neck

  • Most literatures indicate significantly more urethral complications with urethral catheter indwelling [Larsen 1997] although there are a few reports suggesting there is little difference. [Dewire 1992].
  • Mechanism of injury: pressure necrosis
    • Pressure effect caused by improper size of the urethral catheters
    • Pressure effect caused by improper technique of securing the catheters
    • Pressure necrosis by the balloon results in progressive destruction of the entire urethra, with subsequent incontinence despite the catheter [Zimmern 1985]
  • Chronic use can ultimately cause serious urethral erosion.
    • 54% of the patients with indwelling catheter suffered urethral erosion or a totally incompetent or patulous urethra 2-4 years after ID [McGuire 1986]
    • Indwelling urethral catheterization caused severe irreversible urethral erosion with intractable incontinence despite catheterization in 18 female patients having indwelling urethral catheterization for a mean of 3.5 years [Andrews 1998]
  • Downward pressure of an indwelling urethral catheter in males causes iatrogenic hypospadias with an unacceptable appearance [Andrews 1998] or urethra meatal stricture/erosion (insertion of the Fig)
  • Urethral erosion around the urethral sphincter, once developed, is very difficult to treat to stop especially in women.
    • Urethral closure combined with urinary diversion is eventually needed in SCI/D patients to correct urethral defects [Stower 1989; Andrews 1998] and carries a high risk of reoperation [Secrest 2003]. [VIDEO]
    • Functional urethral closure with pubovaginal sling for destroyed female urethra after long-term urethral catheterization [Chancellor 1994]

(G) Catheter blockage

  • Catheter blockage leads to urinary leakage, and very high bladder pressure.
  • Urinary catheters tend to block when biofilm from urease-producing organisms build up on the catheter surface (encrustation) [Burr 1997]
  • 20 patients out of 40 patients with indwelling cathetersm had catheters that blocked frequently. [Burr 1993]
  • Patients with frequent catheter blockage had elevated urinary pH, increases in urinary calcium or magnesium excretion and inadequate or erratic fluid intake [Burr 1993]

(H) Quality of Life

  • Indwelling catheterization as a method of long-term urinary treatment should be avoided in neurologically impaired women because of poorer sexuality and quality of life [Watanabe 1996]
  • At discharge from the hospital, patients were taught to perform IC. However the percentage of women using indwelling catheter increased with advancing time post-injury [Sekar 1997]

7. Advantages

  • Effectiveness in controlling urinary incontinence: if there is no obstruction to catheter drainage or urethral erosion.
  • Quality of life or convenience of the patient: Patient, especially tetraplegic female, may feel this method of urine drainage more comfortable.  
    • No significant difference in the QOL score with regard to the type of urinary management used among 230 SCI persons [Brillhart 2004]

8. Disadvantages

  • Long-term complications described above

9. Current Significance

  • Although long term complications can be decreased with less irritating better catheter materials, using smaller size catheters and proper technique of securing the catheter and regular urological check-up, chronic urethral indwelling catheterization is not a safe method in SCI patients.
  • Removal of the urethral catheter as soon as possible and use of other methods such as CIC to decrease urethral complications is recommended.
  • After CIC became popular, indwelling catheterization was discouraged for all but desperate situations

Summary

Effectiveness

In the short term excellent. In the long term major complications develop which may be irreversible

Safety

Not safe , but problems are slow in onset

Ease of application

Very easy

Patient Comfort

Varies but usually good for a time. If sensation is preserved less so

Cost

Relatively inexpensive but leads to very costly reconstructive surgery

10. Other Comments

  • Anticholinergic drugs may be important in patients with bladder hyperreflexia to prevent the development of small contracted bladder. This is not proven though often used.

Key Points of This Section

  • Catheters are easy to place but once initiated they are difficult to remove.
  • Complications are serious, cumulative and can be life threatening.

References

  • Andrews HO, Nauth-Misir R, Shah PJ. Iatrogenic hypospadias--a preventable injury? Spinal Cord. 1998 Mar;36(3):177-80.
  • Andrews HO, Shah PJ. Surgical management of urethral damage in neurologically impaired female patients with chronic indwelling catheters. Br J Urol. 1998 Dec;82(6):820-4.
  • Brillhart B. Studying the quality of life and life satisfaction among persons with spinal cord injury undergoing urinary management. Rehabil Nurs. 2004 Jul-Aug;29(4):122-6.
  • Burr RG, Nuseibeh IM. Blockage of indwelling urinary catheters: the roles of urinary composition, the catheter, medication and diet. Paraplegia. 1993 Apr;31(4):234-41.
  • Burr RG, Nuseibeh IM. Urinary catheter blockage depends on urine pH, calcium and rate of flow. Spinal Cord. 1997 Aug;35(8):521-5.
  • Chancellor MB, Erhard MJ, Kiilholma PJ, Karasick S, Rivas DA. Functional urethral closure with pubovaginal sling for destroyed female urethra after long-term urethral catheterization. Urology. 1994 Apr;43(4):499-505.
  • Dewire DM, Owens RS, Anderson GA, Gottlieb MS, Lepor H. A comparison of the urological complications associated with long-term management of quadriplegics with and without chronic indwelling urinary catheters. J Urol. 1992 Apr;147(4):1069-71.
  • Hess MJ, Zhan EH, Foo DK, Yalla SV. Bladder cancer in patients with spinal cord injury. J Spinal Cord Med. 2003 Winter;26(4):335-8.
  • Jacobs SC, Kaufman JM. Complications of permanent bladder catheter drainage in spinal cord injury patients. J Urol. 1978 Jun;119(6):740-1.
  • Jamil F, Williamson M, Ahmed YS, Harrison SC. Natural-fill urodynamics in chronically catheterized patients with spinal-cord injury. BJU Int. 1999 Mar;83(4):396-9.
  • Lamid S. Long-term follow-up of spinal cord injury patients with vesicoureteral reflux. Paraplegia. 1988 Feb;26(1):27-34.
  • Larsen LD, Chamberlin DA, Khonsari F, Ahlering TE. Retrospective analysis of urologic complications in male patients with spinal cord injury managed with and without indwelling urinary catheters. Urology. 1997 Sep;50(3):418-22.
  • Lindan R, Leffler EJ, Bodner D. Urological problems in the management of quadriplegic women. Paraplegia. 1987 Oct;25(5):381-5.
  • Lloyd LK, Kuhlemeier KV, Fine PR, Stover SL. Initial bladder management in spinal cord injury: does it make a difference? J Urol. 1986 Mar;135(3):523-7.
  • McGuire EJ, Savastano J. Comparative urological outcome in women with spinal cord injury. J Urol. 1986 Apr;135(4):730-1.
  • Secrest CL, Madjar S, Sharma AK, Covington-Nichols C. Urethral reconstruction in spinal cord injury patients. J Urol. 2003 Oct;170(4 Pt 1):1217-21.
  • Sekar P, Wallace DD, Waites KB, DeVivo MJ, Lloyd LK, Stover SL, Dubovsky EV. Comparison of long-term renal function after spinal cord injury using different urinary management methods. Arch Phys Med Rehabil. 1997 Sep;78(9):992-7.
  • Stamm WE. Guidelines for prevention of catheter-associated urinary tract infections. Ann Intern Med. 1975 Mar;82(3):386-90.
  • Stower MJ, Massey JA, Feneley RC. Urethral closure in management of urinary incontinence. Urology. 1989 Nov;34(5):246-8.
  • Watanabe T, Rivas DA, Smith R, Staas WE Jr, Chancellor MB. The effect of urinary tract reconstruction on neurologically impaired women previously treated with an indwelling urethral catheter. J Urol. 1996 Dec;156(6):1926-8.
  • Weld KJ, Graney MJ, Dmochowski RR. Differences in bladder compliance with time and associations of bladder management with compliance in spinal cord injured patients. J Urol. 2000 Apr;163(4):1228-33.
  • West DA, Cummings JM, Longo WE, Virgo KS, Johnson FE, Parra RO. Role of chronic catheterization in the development of bladder cancer in patients with spinal cord injury. Urology. 1999 Feb;53(2):292-7. 
  • Zimmern PE, Hadley HR, Leach GE, Raz S. Transvaginal closure of the bladder neck and placement of a suprapubic catheter for destroyed urethra after long-term indwelling catheterization. J Urol. 1985 Sep;134(3):554-7.

 

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