Urology Care Today

FOCUS ON INDWELLING CATHETERISATION

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Patient choice

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Length of tubing required

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Design and position of the tap

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The patient’s ability to manage

the system

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The patient’s bladder capacity.

Any drainage bag should be

adequately supported with an

appropriate device or stand to reduce

the weight exerted on the catheter

and bladder, which may otherwise

cause tissue trauma and increase the

risk of infection. Drainage bags should

be emptied frequently enough to

maintain the flow of urine and prevent

reflux, without interrupting the closed

drainage system unnecessarily, which

could increase the risk of infection

(Geng et al, 2012; RCN, 2012). It is

recommended that the bags are not

allowed to become more than three-

quarters full (Loveday et al, 2014).

Valves

Catheter valves are a popular choice,

as they allow the bladder to fill

and empty over a period of time,

mimicking the micturition cycle, which

may contribute to a more successful

trial without catheter (TWOC, see

pp.35–39

) (Woodward, 2014). As

the urinary catheter is considered a

high risk intervention, planning a

TWOC should always be considered

at the earliest opportunity in patients

who may regain effective control of

bladder filling and emptying. If a

patient is identified as always needing

assistance with bladder emptying,

consideration should be given to

the feasibility of alternative less

risky management methods, such

as intermittent catheters. However,

there are some factors that the nurse

must consider before recommending

a catheter valve, for example, the

patient’s bladder capacity, their

sensation of whether their bladder

is full (although a patient with no

sensation can be taught to safely

manage a valve system). Their ability

to understand the valve system

should also be assessed (Yates, 2016).

The risk of high pressure from a full

bladder causing renal damage, or

a history of recent surgery on the

genitourinary tract, exclude the use

of a catheter valve system (see

Table 3

for the advantages and disadvantages

of using a catheter valves).

UROLOGY AND CONTINENCE CARE TODAY

2018,Vol 1, No 1

Table 2:

Risks associated with

indwelling catheters

(Geng et al, 2012; RCN, 2012)

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Catheter-associated urinary tract infection

(CAUTI)

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Epididymitis

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Catheter blockage

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Catheter bypassing

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Iatrogenic trauma

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Bladder spasm

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Bladder pain

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Haematuria

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Granulation formation

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Urinary extravasation

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Inability to remove catheter

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Squamous cell carcinoma (SCC)

Catheter fixation devices

Catheter fixation devices have been

in use since the 1960s and a variety

of products are now available. An

unsecured catheter will move inside

the bladder causing unstable detrusor

contractions, bladder spasms, pain,

bypassing and possible expulsion

of the catheter (Geng et al, 2012).

This increases the risk of urethral,

bladder neck or suprapubic tract

trauma, which can lead to infection

(Hanchett, 2002; Spinks, 2013; Feneley

et al, 2015). Urinary bypassing also

increases the risk of skin damage,

incontinence-associated dermatitis

and secondary infections. This is

because as the skin comes into contact

with urine, the epidermis can become

overhydrated or irritated by the urine

leading to damage or secondary

infections (Holroyd, 2016).

The Wound Ostomy and

Continence Nurses Society published

best practice guidance on the benefits

of catheter fixation (WOCN, 2012).

Any assessment should aim to identify

an appropriate catheter fixation device

that will reduce the incidence of

catheter displacement, expulsion and

migration and, thereby, reduce the

risk of tissue damage and infection

(Holroyd, 2016).

CATHETER-ASSOCIATED URINARY

TRACT INFECTIONS

CAUTIs account for a large

proportion of healthcare-acquired

infections (Pellowe, 2009) and the

cost of treating a single CAUTI is

estimated at almost £2,000 (Loveday

et al, 2014), placing an enormous

burden on the healthcare economy.

Establishing the effect of a CAUTI on

a patient’s quality of life is difficult

to determine, with the risk of serious

infection rising the longer the

catheter is in place (Chang et al, 2011;

Loveday et al, 2014). Forty-five per

cent

Escherichia coli

bacteraemia are

attributed to the urinary tract and use

of catheters (Abernathy, 2017). It is

now a Public Health England policy

to reduce all healthcare-associated

Gram-negative bloodstream

infections by 50% by 2021, and all

trusts have been challenged with

ensuring a robust action plan is

in place to achieve this by closer

monitoring, robust early detection

and appropriate treatment of CAUTIs

(NHS Improvement, 2017).

ENCRUSTATION

Catheter blockage and bypassing are

common issues encountered with the

use of indwelling urinary catheters

and are usually caused by infection

and encrustation. Encrustation is

commonly caused by a build-up of

Proteus mirabilis

, a urease-producing

bacteria, which causes biofilm

formation on the catheter surface

leading to blockage of the lumen and

drainage eyelets (Stickler et al, 2003;

Feneley et al, 2015). Traditionally,

catheter maintenance solutions

have routinely been used to dissolve

the encrustation or remove debris.

However, this is a high-risk strategy

for a number of reasons (Turner and

Dickens, 2011; Davey, 2015; Feneley

et al, 2015; Gibney, 2016):

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To flush the catheter with

maintenance solutions requires

breaking the closed drainage

system, thus increasing the risk

of infection

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The acidic content of catheter

maintenance solutions can

damage the urothelial lining

of the bladder and cause an

inflammatory response

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The increased pressure under