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Urinary catheterization

Urinary catheterization is a common medical procedure that involves inserting a flexible tube, called a catheter, into the bladder via the urethra or through a small abdominal incision to drain and collect urine.^[1] This technique is essential for managing urinary retention, monitoring urine output during surgery or in critically ill patients, and assisting individuals with incontinence or neurogenic bladder conditions.^[2] Performed in various clinical settings, it can be temporary or long-term, depending on the patient's needs, and requires sterile techniques to minimize infection risks.^[3] There are several types of urinary catheters, each suited to specific situations. Indwelling catheters, such as the Foley type, remain in place for extended periods and are secured by an inflatable balloon filled with sterile water, allowing continuous drainage into a collection bag.^[1] Intermittent catheters are inserted and removed multiple times a day by the patient or caregiver to empty the bladder as needed, promoting better bladder function over time.^[1] External catheters, often used for men, fit over the penis like a condom and connect to a drainage device without entering the body, providing a non-invasive option for incontinence management.^[2] Additionally, suprapubic catheters are placed directly into the bladder through the lower abdomen, bypassing the urethra for cases where urethral insertion is not feasible.^[2] The procedure is indicated for therapeutic purposes, including relieving acute urinary retention due to conditions like benign prostatic hyperplasia or spinal cord injuries, perioperative bladder management, and delivering medications such as chemotherapy agents directly to the bladder.^[2] Diagnostic applications include obtaining sterile urine samples for urinalysis or performing urodynamic studies to assess bladder function.^[2] Despite its benefits, urinary catheterization carries significant risks, primarily catheter-associated urinary tract infections (CAUTIs), which account for approximately 70% of healthcare-associated urinary tract infections and result in substantial morbidity and costs estimated at $340–450 million annually in the United States.^[4] Other complications may include bladder spasms, urethral trauma, bleeding, or catheter blockage, with infection rates rising by 3-7% per day of use and reaching nearly 100% bacteriuria after one month.^[3] To mitigate these, guidelines emphasize hand hygiene before insertion, proper peri-urethral cleaning, daily catheter site care, and prompt removal when no longer medically necessary, alongside avoiding routine urine cultures unless symptoms of infection are present.^[3] Ongoing assessment and multidisciplinary approaches, such as urology consultations for difficult placements, are crucial for safe and effective use.^[2]

Overview

Definition and purpose

Urinary catheterization is a medical procedure involving the insertion of a flexible tube, known as a catheter, into the bladder through either the urethra or a suprapubic incision in the lower abdomen to drain urine when normal voiding is impaired.^[2] This intervention is utilized for both therapeutic and diagnostic purposes, with the urethral route being the most common approach.^[2]^[5] The primary purposes of urinary catheterization include relieving acute or chronic urinary retention, where the bladder cannot empty properly due to obstruction, neurological conditions, or other factors; monitoring urine output in critically ill patients to assess renal function and fluid balance; facilitating bladder irrigation to remove blood clots, debris, or medications post-surgery; and providing temporary drainage during surgical procedures or anesthesia to prevent bladder distension.^[2]^[6] In diagnostic contexts, it enables the collection of sterile urine samples or performance of urodynamic studies to evaluate bladder function.^[2] The procedure relies on key anatomical structures: the bladder, a muscular sac that stores approximately 350-500 mL of urine before triggering voiding; the urethra, which serves as the conduit from the bladder to the external orifice; and the sphincters, including the internal urethral sphincter (involuntary smooth muscle at the bladder neck) and the external urethral sphincter (voluntary striated muscle in the proximal urethra), which regulate urine flow and must be navigated during catheter placement.^[2] In hospital settings, urinary catheterization is prevalent, affecting 15-25% of hospitalized patients, often for short-term use, though it carries risks such as catheter-associated urinary tract infections, the most common healthcare-acquired infection.^[7]

Historical context

The practice of urinary catheterization has ancient origins, with the earliest documented references appearing in ancient Egyptian texts. The Ebers Papyrus, dating to approximately 1550 BCE, describes the use of transurethral bronze tubes, reeds, and straws to treat urinary retention.^[8] In ancient Greece, Hippocrates around 400 BCE detailed the use of metal catheters, marking an early systematic approach to relieving bladder obstruction through instrumentation.^[9] During the 18th century, innovations focused on improving flexibility to reduce trauma during insertion. Benjamin Franklin, in 1752, designed a silver wire helical catheter coated with tallow for his brother, which allowed greater maneuverability compared to rigid metal predecessors.^[10] French surgeons contributed to these advancements, experimenting with elastic gum materials to create less brittle devices, though early rubber versions often softened excessively at body temperature.^[8] The 19th century marked a transition to modern materials with the vulcanization of rubber by [Charles Goodyear](/page/Charles_G Goodyear) in 1844, enabling durable yet flexible catheters. French surgeon Auguste Nélaton (1807–1873) developed a vulcanized rubber catheter featuring a solid tip and single eye, which could be secured with adhesive tape or string, facilitating safer and more reliable use.^[8] This era's adoption of rubber laid the groundwork for distinguishing indwelling designs for prolonged drainage from intermittent ones for temporary relief.^[11] In the late 19th century, the introduction of sterile techniques profoundly influenced catheterization safety. British surgeon Joseph Lister's 1867 advocacy for antiseptic principles, including carbolic acid sprays and dressings, reduced infection risks associated with bladder instrumentation, transforming it from a high-morbidity procedure to a more viable clinical tool.^[11]

Types of catheters

Indwelling catheters

Indwelling urinary catheters, commonly known as Foley catheters, are designed for prolonged bladder drainage and feature a retention balloon at the distal tip that is inflated after insertion to secure the device in place. This balloon, typically filled with 5 to 30 mL of sterile water or 10% glycerine solution for silicone variants, prevents accidental expulsion while allowing continuous urine flow through a lumen connected to an external drainage bag.^[12]^[2] Catheters are sized using the French (Fr) scale, which measures outer diameter in millimeters (3 Fr = 1 mm), with common sizes ranging from 12 to 24 Fr; smaller gauges like 12-14 Fr are preferred for routine use to minimize urethral trauma, while larger 20-24 Fr accommodate thicker fluids such as in cases of hematuria.^[12]^[13] Materials for indwelling catheters vary to balance flexibility, durability, and biocompatibility, with latex offering short-term pliability but risking allergic reactions, silicone providing hypoallergenic long-term use with larger lumens to resist encrustation, and coatings such as hydrogel, polytetrafluoroethylene (PTFE), or silver-alloy enhancing surface smoothness to reduce irritation and bacterial adhesion.^[2]^[13]^[12] Placement occurs via the urethral route, which is most common and involves advancing the catheter through the urethra into the bladder, or the suprapubic route, which requires a surgical incision above the pubic bone for direct bladder access, often preferred in chronic scenarios to avoid urethral complications.^[2]^[12] To minimize risks like infection or encrustation, indwelling catheters are generally limited to 2-4 weeks for latex models and up to 12 weeks for silicone or coated variants, with regular assessment for replacement based on patient condition and manufacturer guidelines.^[12]^[13] Their primary advantages include reliable continuous drainage, which is particularly beneficial for patients with chronic urinary retention, severe immobility, or neurogenic bladder dysfunction, enabling better management without frequent interventions—though they carry a higher infection risk compared to intermittent catheterization, they simplify long-term care.^[2]^[12]

Intermittent and external catheters

Intermittent urinary catheters, also known as in-and-out or single-use catheters, are designed for periodic bladder emptying and are typically inserted by the patient or caregiver several times a day. These catheters are straight-tipped for standard urethral navigation or coudé-tipped with a curved end to facilitate passage around obstructions such as an enlarged prostate.^[14] The technique of clean intermittent catheterization (CIC), emphasizing non-sterile but clean handling to minimize infection risk, was pioneered by urologist Jack Lapides and colleagues in 1972 as a method to manage urinary tract disease effectively.^[15] Patients generally perform catheterization every 4 to 6 hours or as needed to maintain bladder volumes below 400-500 mL, using single-use devices to ensure hygiene and reduce complications.^[16] Intermittent catheters are commonly made from flexible materials like PVC or silicone, with hydrophilic coatings that activate upon contact with water or saline to create a low-friction surface for easier insertion and reduced urethral trauma.^[17] Available in French sizes ranging from 8 to 14 for most adult users, particularly suitable for intermittent applications, these catheters vary in length—typically 6 inches for females and 14-16 inches for males—to accommodate anatomical differences.^[18] External urinary catheters provide a non-invasive alternative for managing incontinence in males without urinary retention, consisting of a sheath that fits over the penis like a condom and connects to a drainage bag. Also known as condom or Texas catheters, these devices are secured using self-adhesive interiors, external straps, or tapes to prevent slippage during activity.^[19] Texas-style variants feature a softer, more flexible sheath rolled onto the glans penis, often without internal adhesive for sensitive skin, and are changed daily or as needed based on fit and leakage.^[20] Both intermittent and external catheters offer advantages over indwelling types, including potentially lower rates of urinary tract infections due to reduced continuous foreign body presence in the bladder.^[2] Additionally, intermittent catheterization supports bladder training by allowing periodic natural voiding attempts, potentially improving continence and bladder function over time, particularly in rehabilitation settings for conditions like spinal cord injury.^[21]

Clinical indications and contraindications

Common indications

Urinary catheterization is commonly indicated for the relief of acute urinary retention, which can arise from obstructive causes such as benign prostatic hyperplasia (BPH), blood clots, urethral strictures, or tumors, as well as neurogenic factors including spinal cord injury, stroke, or multiple sclerosis.^[2] In these scenarios, catheterization provides immediate decompression of the bladder to alleviate pain, prevent renal damage, and restore urine flow, particularly when conservative measures like alpha-blockers fail.^[22] For instance, in cases of post-obstructive diuresis following relief of retention due to BPH or stones, ongoing catheterization ensures safe management of high urine volumes.^[2] Perioperative catheterization is routinely employed during surgeries involving the abdomen, pelvis, or genitourinary tract, such as urological or gynecological procedures under anesthesia, to facilitate bladder emptying and monitor urine output accurately.^[22] In intensive care settings, it is justified for critically ill patients requiring precise hourly measurement of urine output to assess fluid balance, renal function, and response to therapies like diuretics or vasopressors.^[23] This indication is especially critical in postoperative recovery or during major surgeries where immobility or anesthesia impairs natural voiding.^[2] For neurogenic bladder dysfunction, catheterization—often intermittent—is indicated in conditions like multiple sclerosis, stroke, or spinal cord injury to manage incomplete emptying, reduce infection risk, and preserve upper urinary tract integrity.^[24] Postpartum urinary retention, with reported incidences ranging from 1% to 14% after vaginal delivery due to perineal trauma or epidural analgesia, warrants catheterization to prevent overflow incontinence and bladder overdistension, with intermittent methods preferred for quicker resolution.^[25] In palliative care for end-stage diseases such as advanced cancer or severe neurological impairment, indwelling catheters provide comfort by addressing intractable incontinence or retention when other interventions are unsuitable.^[22] In pediatric patients, catheterization is indicated for congenital anomalies like posterior urethral valves or neurogenic bladder from myelomeningocele, as well as acute retention and perioperative monitoring during procedures.^[26] For geriatric populations, common applications include retention from BPH or medications, incontinence associated with dementia, and pressure ulcer prevention in immobile elderly with skin breakdown risks.^[27] Intermittent catheterization is particularly suited for neurogenic cases in both age groups to minimize infection while promoting bladder health.^[23]

Contraindications and precautions

Urinary catheterization carries specific absolute contraindications where the procedure should not be performed due to high risk of exacerbating injury or causing severe harm. These include recent urethral trauma, such as from pelvic fracture or instrumentation; and active urethritis or prostatitis, which may propagate infection or cause significant discomfort and bleeding.^[2]^[28]^[12] Relative contraindications warrant careful evaluation and often alternative approaches, as the benefits may still outweigh risks in select cases. Urethral stricture requires specialized techniques, such as guidewire assistance, or urology consultation to avoid false passage or perforation. Coagulopathy increases bleeding risk during manipulation of the urethra or bladder neck, potentially leading to hematoma formation. Latex allergy necessitates avoidance of latex-based catheters to prevent anaphylactic reactions, with silicone alternatives recommended. Undiagnosed hematuria, particularly gross or with blood at the meatus, requires urologic consultation to rule out underlying trauma or malignancy before proceeding.^[2]^[12]^[29] Precautions are essential to mitigate procedural risks and ensure patient safety. Informed consent must be obtained after explaining the procedure, potential discomfort, and alternatives, with documentation in the medical record. Allergy screening for latex, chlorhexidine, or local anesthetics like lignocaine should precede insertion to select appropriate materials and agents. For patients with urethral contraindications or chronic needs, suprapubic catheterization serves as a safer alternative, bypassing the urethra while reducing infection rates in long-term use, though it requires ultrasound guidance and assessment for bowel interposition.^[12]^[30] Risk stratification involves identifying high-risk patients to guide decision-making and monitoring. Risk assessment tools for long-term catheter management evaluate factors like duration of use, patient mobility, and comorbidities to predict catheter-associated urinary tract infection (CAUTI) likelihood, with daily risk increasing 3-7% per catheter-day. Key factors include female sex, advanced age, diabetes, and immunosuppression, prompting heightened vigilance or alternatives in vulnerable individuals. Such assessments link to elevated complication risks if contraindications are overlooked.^[12]^[31]

Insertion procedures

Preparation and techniques

Preparation for urinary catheterization begins with thorough pre-insertion steps to ensure patient safety and minimize infection risk. The patient is positioned supine with legs extended and slightly separated to provide access to the perineal area, while maintaining privacy with drapes and a waterproof pad under the buttocks. Healthcare providers must perform hand hygiene immediately before and after the procedure, using soap and water or alcohol-based sanitizer, and don sterile gloves to maintain asepsis. A sterile catheter insertion kit is assembled, including a catheter of appropriate size (typically 14-16 French for adults), lubricant, antiseptic solution (such as chlorhexidine or povidone-iodine), drapes, and sterile water for balloon inflation if using an indwelling catheter. Lubrication with a sterile, water-soluble jelly is applied to the catheter tip to reduce friction during insertion.^[32]^[33]^[28] The urethral insertion technique is the most common method and requires strict aseptic practices. The perineal area is cleansed starting from the meatus and moving outward in a circular motion using antiseptic-soaked swabs, discarding each swab after a single use to avoid recontamination. For females, the labia are gently separated to expose the urethral meatus, and the lubricated catheter is advanced at a 30-degree angle toward the umbilicus for approximately 5-7 cm until urine return is observed. In males, the penis is held upright with gentle traction to straighten the urethra, and the catheter is inserted steadily for 15-20 cm in adults, navigating the penile urethra and prostatic curve; if resistance is encountered due to anatomical obstructions like an enlarged prostate, a coudé-tipped catheter may be used with the curve oriented upward. Once urine flows, confirming bladder placement, the catheter is advanced an additional 2-5 cm, and for indwelling types, the balloon is inflated with 10 mL of sterile water. Variations account for anatomical differences: in females, the shorter urethra necessitates careful separation of labia to avoid vaginal insertion, while in males, retraction of the foreskin (if uncircumcised) prevents contamination.^[32]^[33]^[28]^[22] Suprapubic catheterization is an alternative for cases where urethral access is contraindicated, involving percutaneous insertion through the lower abdominal wall under local anesthesia. The patient is positioned in a supine or slight Trendelenburg tilt, and the bladder is confirmed full via ultrasound to avoid bowel injury. After prepping the suprapubic area with antiseptic and administering local anesthetic (e.g., lidocaine) along the insertion tract approximately 2 cm above the pubic symphysis, a needle is inserted midline until urine aspirates, followed by guidewire placement using the Seldinger technique. The tract is dilated, and the catheter is advanced over the wire into the bladder, with the balloon inflated to secure it. Ultrasound guidance is recommended throughout to visualize bladder position and confirm placement.^[34] Pediatric catheterization requires sizing adjustments based on age and weight to prevent trauma, using smaller French sizes such as 6-8 Fr for infants up to 1 year and 10-12 Fr for older children, with silicone preferred for longer-term use. Positioning mirrors adult supine placement but with knees flexed in females and gentle foreskin retraction in males; local anesthetic gel (e.g., lidocaine 2%) may be applied for boys over 3 years. The aseptic technique is identical, but insertion depth is reduced (e.g., 3-5 cm in neonates), and no balloon is used in children under 6 months to avoid bladder neck injury; instead, the catheter is secured with tape or straps.^[35]

Post-insertion assessment

Following insertion of a urinary catheter, immediate verification of proper placement is essential to confirm functionality and minimize risks. This involves observing for immediate urine drainage from the catheter, which indicates correct positioning in the bladder, and noting the color and clarity of the urine to establish a baseline for output assessment.^[2] The balloon of an indwelling catheter, such as a Foley type, should then be inflated with the manufacturer-recommended volume of sterile water (typically 10 mL for standard sizes), followed by a gentle tug on the catheter to ensure the balloon seats securely against the bladder neck without resistance or patient discomfort.^[12] To verify balloon integrity, a syringe can be reattached to gently aspirate and confirm the water volume remains stable, preventing deflation-related complications.^[2] The catheter must be securely anchored post-insertion to prevent movement, traction, or dislodgement, which could cause urethral trauma. For most patients, this is achieved by taping or using a stabilization device to affix the catheter tubing to the upper thigh (in women) or abdomen (in men), ensuring no tension on the insertion site while allowing slack in the tubing to accommodate leg movement.^[36] Initial patient monitoring focuses on assessing for pain at the insertion site, gross hematuria (visible bleeding in urine), or bladder spasms, which may manifest as discomfort or leakage; analgesics or antispasmodics can be administered if needed.^[12] Urine output should be documented hourly in the first few hours post-insertion, particularly in critically ill patients, aiming for at least 30 mL per hour to confirm adequate renal perfusion and catheter patency.^[35] Troubleshooting begins if issues arise during this initial phase. For instance, absence of urine flow may indicate kinking of the tubing, which requires inspection and straightening while ensuring the collection bag remains below bladder level; if unresolved, gentle flushing with sterile saline may be attempted before considering replacement.^[2] Suspected false passage, evidenced by resistance during the final advancement or minimal output, warrants prompt repositioning or re-insertion by a skilled practitioner, potentially under urological guidance to avoid further trauma.^[12] Early signs of complications, such as persistent bleeding or severe pain, should prompt immediate evaluation but are addressed in detail elsewhere.^[22] Comprehensive documentation is critical immediately after insertion to support ongoing care and legal standards. This includes recording the catheter type and size, exact time and date of insertion, patient tolerance (e.g., any discomfort during procedure), initial urine output volume and characteristics, balloon inflation details, and securement method used.^[2] Baseline assessments, such as vital signs and any pre-existing urinary symptoms, should also be charted to facilitate comparison in subsequent monitoring.^[12]

Maintenance and removal

Daily care protocols

Daily care protocols for indwelling urinary catheters emphasize maintaining hygiene, ensuring patency, and promoting patient comfort to minimize risks during prolonged use. These practices focus on routine upkeep rather than initial insertion or endpoint procedures, drawing from established guidelines by health authorities. Hygiene practices are essential to prevent contamination around the catheter site. The perineal area should be cleaned twice daily using mild soap and warm water, gently wiping from front to back to avoid introducing bacteria; antiseptics are not recommended for routine meatal cleaning as they offer no additional benefit and may cause irritation. Powders or lotions should be avoided near the catheter to prevent residue buildup that could obstruct drainage. The drainage bag must be emptied regularly when it reaches approximately two-thirds full, using a clean, separate container for each patient to avoid cross-contamination, and the spigot should not touch any surface. Hand hygiene with soap and water or alcohol-based sanitizer is required before and after any manipulation of the catheter or bag. Irrigation is not a routine procedure but may be ordered for suspected blockages to restore flow. When indicated, sterile technique is mandatory: use a 30- to 60-mL syringe filled with 0.9% sterile saline to gently flush the catheter, allowing the solution to drain before reconnecting the system. This should only be performed by trained healthcare providers, avoiding forceful instillation to prevent trauma. To support mobility and prevent sediment accumulation, the catheter should be secured to the upper thigh or lower abdomen using a soft strap, tape, or dedicated securement device, ensuring no tension on the urethra during movement. Patients are encouraged to ambulate as tolerated, with the drainage bag positioned below bladder level but off the floor to facilitate gravity drainage and reduce stagnation. Monitoring involves regular assessment of urine output and characteristics to detect early issues. Output should be tracked hourly or shift-wise, noting volume (normal adult range approximately 0.5–1 mL/kg/hour, or 30–70 mL/hour for an average adult) and color/clarity; low output below 0.5 mL/kg/hour may signal obstruction from sediment or kinking and requires prompt evaluation.^[37] Changes in urine appearance, such as cloudiness, could indicate potential infection precursors, warranting hygiene reinforcement.

Removal procedures

The removal of an indwelling urinary catheter is performed to discontinue bladder drainage once the underlying indication has resolved, minimizing risks associated with prolonged use such as infection. Guidelines emphasize prompt removal as soon as the catheter is no longer clinically necessary to reduce complications.^[36] For short-term catheters placed for postoperative monitoring, a trial of voiding is often initiated 24 to 48 hours after insertion. For acute urinary retention, longer durations such as 3 to 7 days or more may be appropriate depending on resolution.^[38] In cases of long-term catheterization, exceeding several weeks, removal requires evaluation by a urology specialist to assess bladder function and potential underlying issues like outlet obstruction.^[39] The standard technique for removing a Foley-style indwelling catheter involves first deflating the retention balloon completely to prevent urethral trauma. This is achieved by attaching a 5- to 10-mL syringe to the balloon inflation port and aspirating all instilled fluid (typically 5 to 30 mL of sterile water), confirming deflation by gentle tugging on the catheter without resistance. The catheter is then withdrawn slowly and steadily, ideally while the patient attempts to void to facilitate passage and reduce discomfort; lubrication with water-soluble gel may be applied externally if needed.^[40] The procedure should be conducted under aseptic conditions, with the patient in a comfortable position such as supine or seated, and all equipment disposed of as biohazardous waste afterward.^[22] Following removal, patients are monitored for urinary retention, which occurs in up to 20-30% of cases depending on duration of catheterization and patient factors. A bladder scan or ultrasound is performed if the patient fails to void within 6 to 8 hours, with volumes exceeding 300-500 mL indicating need for re-catheterization.^[41] Dysuria or discomfort is common and managed with oral analgesics such as acetaminophen or nonsteroidal anti-inflammatory drugs, resolving in most cases within 24-48 hours.^[22] If retention persists, brief re-insertion may be required pending further evaluation. Complications specific to the removal process include urethral trauma, such as mucosal tears or bleeding, particularly if the balloon is not fully deflated or after prolonged catheterization when encrustations may form.^[41] Risks increase with catheter dwell times beyond 7-10 days, potentially leading to strictures.^[39] Late-night removal (e.g., 10 PM to midnight) may slightly lower the risk of immediate recatheterization compared to morning removal, based on moderate evidence from randomized trials.^[41]

Complications

Immediate and short-term risks

Immediate and short-term risks of urinary catheterization primarily arise during or shortly after insertion, encompassing trauma to the urinary tract, discomfort from spasms, mechanical obstructions, and the onset of bacterial colonization. These complications can occur within hours to a few days and are more prevalent in males due to anatomical differences in the urethra. Proper technique, including lubrication and aseptic methods, can mitigate many of these risks.^[2] Trauma-related complications, such as urethral injury, bleeding, or creation of a false passage, are among the most direct risks during catheter insertion. Urethral injury often results from forceful advancement or multiple attempts, particularly in males with prostatic enlargement or strictures, leading to mucosal tears, hematuria, or inadvertent perforation into surrounding tissues. The incidence of such iatrogenic urethral injuries in males is approximately 3-13 per 1,000 catheterizations, with higher rates in those with pre-existing urologic conditions. Bleeding typically manifests as gross hematuria immediately post-insertion and usually resolves spontaneously, though severe cases may require intervention. False passages, where the catheter enters a non-anatomic tract, can cause persistent pain or obstruction and are reported in up to 1% of difficult insertions.^[2]^[42]^[43]^[44] Pain and urethral spasms are common immediate responses to catheterization, affecting patient comfort and potentially complicating the procedure. Urethral discomfort arises from mechanical irritation during insertion, with up to 48% of patients reporting moderate to severe pain and 42% describing it as uncomfortable enough to limit activities. Bladder spasms, triggered by the catheter balloon or irritation, cause cramping, urgency, and urine leakage around the catheter in the first 24-48 hours. These spasms occur in a significant proportion of cases and are managed with topical lubrication, cooling gels, or antispasmodic medications like oxybutynin to reduce irritation and promote tolerance.^[44]^[2]^[29] Mechanical issues, including catheter kinking or blockage, can emerge within 24-72 hours and disrupt urine drainage. Kinking often results from improper positioning or patient movement, leading to acute retention and abdominal pain. Blockage by sediment, blood clots, or crystalline deposits is more frequent in dehydrated patients or those with hematuria, potentially causing distension if not addressed promptly through flushing or replacement. These complications affect 25-65% of cases involving urine leakage due to obstruction, emphasizing the need for regular monitoring post-insertion.^[2]^[29]^[44] Early infection risks manifest as bacteriuria, which begins shortly after catheterization due to bacterial ascension along the catheter. The daily incidence of bacteriuria is 3-10% without preventive measures, reaching 10-30% in short-term use (2-4 days), primarily from extraluminal contamination during insertion. Common pathogens include Escherichia coli and Klebsiella pneumoniae, often leading to asymptomatic colonization that can progress to symptomatic urinary tract infection if untreated. Aseptic insertion techniques substantially reduce this early onset.^[44]^[3]^[2]

Long-term complications

Long-term indwelling urinary catheterization is associated with a high incidence of chronic urinary tract infections (UTIs), primarily due to biofilm formation on the catheter surface, which serves as a reservoir for persistent bacterial colonization. Bacteriuria develops in 3–7% of patients per catheter-day, approaching nearly 100% after four weeks of continuous use.^[45] Patients with long-term indwelling catheters are at high risk of recurrent symptomatic UTIs, often leading to ascending infections such as pyelonephritis.^[46] The risk of chronic pyelonephritis is notably elevated, with a prevalence of 10% among patients catheterized for over 90 days compared to 0% in non-catheterized controls.^[46] Prolonged catheter presence can cause significant bladder and urethral damage through mechanical irritation and crystalline encrustation. Encrustation, involving the deposition of struvite and calcium phosphate crystals facilitated by urease-producing bacteria, affects up to 50% of patients with long-term catheters, frequently resulting in blockage and requiring catheter replacement every 1–3 months.^[47] Chronic irritation may lead to urethral strictures or rare fistula formation between the urethra and surrounding tissues.^[48] Functional impairments often persist after catheter removal, including bladder atony due to detrusor muscle disuse and overdistension, which can manifest as urinary retention. Post-removal incontinence affects approximately 20% of patients, with recovery times varying from days to months depending on duration and patient factors.^[49] In vulnerable populations such as the elderly, systemic complications like sepsis and renal failure are critical risks stemming from untreated chronic infections. Catheter-associated UTIs contribute to urosepsis in 1–4% of long-term users, with elderly patients facing a 2–3-fold higher mortality risk from resultant bacteremia and acute kidney injury.^[44] Renal failure may develop progressively from recurrent pyelonephritis, exacerbating chronic kidney disease.^[50]

Infection prevention strategies

Hygiene and guideline adherence

Hygiene and guideline adherence are fundamental to minimizing infection risks associated with urinary catheterization, emphasizing procedural protocols that prioritize sterility and timely use. Major health organizations, including the Centers for Disease Control and Prevention (CDC) and the Society for Healthcare Epidemiology of America (SHEA) in collaboration with the Infectious Diseases Society of America (IDSA), provide evidence-based recommendations to standardize practices and reduce catheter-associated urinary tract infections (CAUTIs). These guidelines stress training for healthcare workers to ensure consistent application, as improper techniques can significantly elevate infection rates.^[36]^[51] Hand hygiene serves as the cornerstone of infection prevention, performed immediately before and after catheter insertion or any manipulation of the device or site. The World Health Organization (WHO) outlines five key moments for hand hygiene in healthcare settings: before touching a patient, before performing a clean or aseptic procedure (such as catheterization), after the risk of body fluid exposure, after touching a patient, and after touching patient surroundings. For urinary catheterization, these moments are critical during periurethral cleaning, insertion, and handling of the drainage system to prevent microbial transmission. Adherence to alcohol-based hand rubs or soap-and-water washing, depending on visible soiling, aligns with WHO protocols and CDC category IB recommendations (2009, updated 2019), which classify them as strongly supported by well-designed experimental or epidemiologic studies.^[36] Aseptic insertion techniques further mitigate contamination risks by employing sterile equipment throughout the process. According to CDC guidelines (2009, updated 2019), insertion requires sterile gloves, a sterile drape, sponges, an appropriate antiseptic solution for periurethral cleaning, and a single-use packet of lubricant jelly to avoid introducing pathogens. SHEA/IDSA basic practices (2023 update) reinforce this by mandating sterile barriers and antiseptic application, performed only by trained personnel to maintain sterility. These measures, categorized as essential by both organizations, prevent breaks in technique that could lead to immediate bacterial entry into the urinary tract.^[36]^[51] Appropriate catheter selection optimizes patient safety by balancing drainage efficacy with reduced trauma and infection potential. Guidelines recommend using the smallest bore catheter possible—typically 14 to 16 French—that ensures adequate drainage, thereby minimizing urethral and bladder neck irritation. Silver-alloy coated catheters may be considered for short-term use in select high-risk patients only if CAUTI rates remain elevated despite adherence to basic prevention strategies, per CDC category IB evidence (2009, updated 2019) and SHEA/IDSA guidelines (2023 update), as they may reduce CAUTI risk by 10-20% through antimicrobial properties on the surface. This selection aligns with CDC category IB evidence and SHEA/IDSA special approaches for targeted use in acute settings.^[36]^[51] Minimizing the duration of catheterization is a primary strategy to lower cumulative infection exposure, with protocols urging prompt removal once the indication resolves. The CDC specifies removing catheters as soon as possible postoperatively, ideally within 24 hours after surgery or 48 hours after urologic procedures unless clinically necessary, to limit biofilm formation and bacterial ascension. SHEA/IDSA echoes this with daily assessments for necessity and automatic stop orders, emphasizing that prolonged use exponentially increases CAUTI risk. These practices, supported by high-quality evidence, promote interdisciplinary review to avoid unnecessary prolongation.^[36]^[51]

Antimicrobial approaches

Antimicrobial approaches to urinary catheterization primarily involve incorporating agents directly into catheter materials or using targeted pharmacological interventions to inhibit microbial adhesion, biofilm formation, and subsequent infections such as catheter-associated urinary tract infections (CAUTIs). Antibiotic-impregnated catheters, such as those coated with minocycline and rifampin, have demonstrated efficacy in reducing bacteriuria rates by providing sustained release of antimicrobials that target both Gram-positive and Gram-negative pathogens on the catheter surface.^[52] Similarly, nitrofurazone-impregnated catheters delay the onset of catheter-associated bacterial biofilms and reduce the need for systemic antibiotic treatment in short-term use, though large-scale trials indicate only modest reductions in symptomatic UTIs (approximately 2% absolute risk reduction) compared to standard catheters.^[53] Silver alloy-hydrogel coated catheters represent another key material-based strategy, leveraging the oligodynamic effect of silver ions to disrupt bacterial cell membranes and prevent biofilm development. Clinical trials have shown these coatings achieve up to a 57% reduction in CAUTI rates (from 6.13 to 2.62 per 1000 catheter-days) in intensive care settings, with no emergence of silver-resistant strains observed in tested isolates.^[54] These coatings are particularly effective against common uropathogens like Escherichia coli and Pseudomonas aeruginosa, offering broad-spectrum activity without promoting resistance, though their cost-effectiveness depends on institutional UTI treatment expenses (yielding net savings of $5,811 to $535,452 annually in modeled scenarios).^[54] Prophylactic systemic antibiotics are not recommended for routine use in catheterized patients due to the risk of fostering antimicrobial resistance and lack of benefit in asymptomatic cases, per CDC and IDSA guidelines; however, targeted short-term applications, such as nitrofurazone coatings for durations under 14 days, may be considered in high-risk scenarios like postoperative care to minimize bacteriuria without broad-spectrum exposure.^[36] Bladder instillation of antiseptics like chlorhexidine gluconate (0.05-0.2%) is reserved for select cases, such as patients with chronic suprapubic catheters or spinal cord injuries, where intermittent irrigation has reduced bacteriuria incidence by up to 70% in controlled studies, though routine use is discouraged to avoid mucosal irritation or resistance.^[55]^[56] These methods complement basic hygiene practices by directly addressing microbial colonization at the catheter interface.^[36] Emerging technologies as of 2025 focus on advanced coatings to enhance durability and responsiveness, including nanotechnology-based silver nanoparticles embedded in hydrogels, which sustain antimicrobial release for over 10 days in preclinical models while inhibiting E. coli biofilms with minimal cytotoxicity (less than 5% cell viability loss in fibroblasts).^[57] Bacteria-responsive coatings, such as pH- or enzyme-triggered systems (e.g., polyacrylic acid/chitosan layers releasing ciprofloxacin upon urease detection), extend catheter patency by over 30 hours against Proteus mirabilis-induced encrustation in vitro and porcine models.^[58] Antimicrobial lock solutions, adapted from vascular applications, are conceptually under investigation for urinary use but lack specific clinical data as of 2025.^[57] These innovations aim for technology readiness levels of 3-5, prioritizing multi-layered designs for broad-spectrum, resistance-minimizing protection in long-term catheterization.^[57]

Historical development

Ancient and early modern methods

The earliest documented use of urinary catheterization dates to ancient Egypt around 1550 BCE, as described in the Ebers Papyrus, where treatments for urinary retention involved inserting transurethral bronze tubes, reeds, or straws to relieve obstruction.^[8] These rudimentary instruments, often rigid and sourced from natural materials, were employed to address conditions like bladder stones or retention, reflecting an early recognition of the need for mechanical intervention in urological disorders. However, the lack of sterile techniques in this era frequently led to infections and complications, underscoring the limitations of pre-modern medical practices.^[8] In ancient India, around 600 BCE, the surgeon Sushruta detailed advanced catheterization methods in the Sushruta Samhita, including the use of metal sounds and catheters crafted from gold, silver, iron, or wood, lubricated with substances like butter or lard to facilitate insertion.66317-3)^[59] These tools were integral to urological surgery, such as for managing strictures or stones, and emphasized gradual dilation techniques to minimize trauma, marking a significant step in systematic urological instrumentation.^[60] During the medieval Islamic Golden Age, in the 10th century, the physician and surgeon Al-Zahrawi (also known as Albucasis, 936–1013 CE) advanced catheter design in his encyclopedic work Al-Tasrif, describing malleable silver tubes with side holes and a funnel end for improved drainage and irrigation in cases of urinary retention.^[8]^[61] These innovations allowed for greater flexibility and adaptability to anatomical curves, enhancing safety during insertion compared to earlier rigid metals.^[62] In the Renaissance period, French surgeon Ambroise Paré (1510–1590) contributed to trauma-related catheterization by introducing curved silver tubes, known as coudé catheters, and employing whalebone stylets to guide flexible catheters in wounded soldiers suffering from urethral injuries or retention.^[8]^[10] This approach prioritized ease of navigation through the male urethra, reducing iatrogenic damage in battlefield settings. By the 18th and 19th centuries, material advancements culminated in the introduction of gum-elastic catheters following Charles Goodyear's 1839 discovery of vulcanization, which stabilized natural rubber for more durable, flexible, and biocompatible urinary drainage devices.^[11]^[63]

20th-century innovations and regulations

The 20th century marked significant advancements in urinary catheterization materials and techniques, beginning with the development of the Foley balloon catheter in the 1930s. In 1935, American urologist Frederic E. B. Foley introduced a self-retaining indwelling catheter made from latex rubber, featuring an inflatable balloon to secure it in the bladder and facilitate hemostasis during procedures like prostatectomy. Foley obtained a patent for this design in 1936, which revolutionized bladder drainage by allowing prolonged, stable placement without reliance on external fixation.^[8] Material innovations continued with the introduction of silicone elastomer catheters in the late 1960s, addressing limitations of earlier rubber and latex options such as tissue irritation and encrustation. These silicone-based devices offered improved biocompatibility, flexibility, and reduced rates of urethritis and infection due to their inert properties and lower adherence of bacterial biofilms.^[64] Sterility practices evolved substantially in the 20th century, building on Joseph Lister's 1867 principles of antisepsis, which made bladder catheterization safer by minimizing infection risks through chemical disinfection. By the early 1900s, aseptic techniques—emphasizing sterile equipment, hand hygiene, and no-touch insertion—became standard in surgical and urologic settings, drastically reducing post-procedure complications like urinary tract infections.^[11] The U.S. Centers for Disease Control and Prevention (CDC) further codified these safety measures in its 2009 Guideline for Prevention of Catheter-Associated Urinary Tract Infections (CAUTI), which outlined evidence-based bundles including aseptic insertion, daily review of necessity, and prompt removal to curb hospital-acquired infections; this guideline remains the cornerstone reference, with updates to implementation tools as recent as 2024.^[65] Regulatory oversight intensified in the late 20th century to enhance device safety and efficacy. The U.S. Food and Drug Administration (FDA) issued guidance in 1994 for premarket notifications of antimicrobial Foley catheters, enabling approvals for silver-alloy and antibiotic-impregnated models in the 1990s that aimed to inhibit bacterial colonization and lower CAUTI incidence.^[66] The World Health Organization (WHO) complemented these efforts with its 2016 guidelines on core components of infection prevention and control, promoting rational catheter use through antimicrobial stewardship and alternatives to indwelling devices where feasible. Addressing persistent gaps in catheter reliance, post-2000 innovations emphasized non-invasive alternatives like sacral neuromodulation (SNM), approved by the FDA in 1997 and expanded for refractory urinary retention and overactive bladder. SNM involves implanting a device to stimulate sacral nerves, restoring bladder function and reducing the need for long-term catheterization in select patients, with studies showing sustained symptom relief in up to 70% of cases over five years.^[67]

References

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