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1 CG25 VERSION 1.0 1/20 Guideline ID CG25 Version 1.0 Title Approved by Urinary Catheterisation Clinical Effectiveness Group Date Issued 01/10/2014 Review Date 31/09/2017 Directorate Authorised Staff Medical Ambulance Care Assistant Emergency Care Assistant Student Paramedic Advanced Technician Paramedic (non-ecp) Nurse (non-ecp) ECP Doctor Clinical Publication Category Guidance (Green) - Deviation permissible; Apply clinical judgement 1. Introduction 1.1 Urinary Catheterisation is defined as the passage of a catheter into the urinary bladder. A catheter is a thin hollow flexible tube which can be inserted in the bladder either through the urethra (urethral) or suprapubic channel to drain the urine. 1.2 Catheterisation is a core skill for Emergency Care Practitioners. However, as the provision of catheterisation is normally well managed within primary care, only those ECP localities with an identified need shall be deemed to require this skill. 2. Indications 2.1 Primary catheterisation is now supported by the Trust where the individual ECP skill set and competencies allow. 2.2 Urethral re-catheterisation is indicated for those patients in acute urinary retention whose catheter is currently blocked.

2 CG25 VERSION 1.0 2/20 3. Competence 3.1 All ECPs who are required to catheterise must achieve and maintain clinical competence in urinary catheterisation. Initial training and sign off may be achieved through the use of training aids. 3.2 Competence to undertake primary catheterisation for male patients in retention should also be maintained for those ECPs who undertake catheterisation as a regular feature of their clinical workload. 4. Assessment of Acute Retention Requiring Primary Intervention 4.1 Classically, acute urinary retention affects men with prostatic hypertrophy (enlarged prostate). When obstruction occurs the patient will experience pain and may become agitated. Inserting a urinary catheter into the bladder will generally relieve the symptoms. 4.2 History taking will aid diagnosis of the type of retention: Acute retention is defined by sudden inability to void with a tender, palpable bladder. Chronic retention is long standing incomplete bladder emptying with an over-distended, non-tender bladder and very large residual, with possible renal impairment. Acute chronic retention is the sudden inability to void, with a background of chronic retention and possible overflow or night-time incontinence. 4.3 Detailed abdominal assessment must be undertaken prior to primary insertion, which must also cover: Check blood pressure as a possible indicator of renal impairment. Abdominal and genitourinary examination. Patients with significant urinary retention should have a palpable enlarged bladder, which will usually be non-tender. Check for enlargement of kidneys, via bimanual palpation. Examine external genitalia to seek evidence of urethral abnormalities causing urinary flow obstruction, e.g. urethral stricture, phimosis or meatal stenosis. Neurological examination should exclude cord compression and look for evidence of other relevant neurological conditions.

3 CG25 VERSION 1.0 3/ Where available consider onward referral and engagement with urology nurses and District Nurses for consideration of catheter care, particularly over the out of hours period. Those patients with suspected chronic or acute exacerbation of chronic retention of urine will need admission to hospital (for close fluid balance monitoring, fluid replacement and investigations). All uncomplicated patients should be referred back to their GP for determination of the cause of retention and consideration of definitive management. 4.5 If after primary catheterisation the residual volume drained initially exceeds 1200mls, then a follow up visit must be arranged in two to four hours. If at this revisit there is evidence of a urinary output of 200mls per hour or more then there is severe risk of dehydration and potentially fatal hypovolaemia. If due to service demands a revisit is impossible then a referral to another health care provider is essential i.e. GP, out of hours clinician or community nursing. If this cannot be arranged, then the patient must be referred to secondary care. A telephone call to the patient could be indicative but must not replace verification 4.6 Initial drainage of the residual volume depends on catheter size: 12ch = Approximately 1 hour 14ch = Approximately 20 minutes 16ch = Approximately 6-7 minutes 5. Catheters 5.1 When consideration is given to the type of catheter used for re-catheterisation following assessment and determination of acute urinary retention, the choice should be based on the patient s current catheter. Where possible the patient s own supplies should be used. 5.2 Silicone The silicone catheter (100% silicone) is very gentle for the tissue and is hypoallergenic. Because it is uncoated it has a relatively large lumen and has a reduced tendency for encrustation. While silicone causes less tissue irritation and potential damage, the catheter balloon has a tendency to lose fluid which increases the risk of displacement. Silicone catheters also have a greater risk for developing a cuff when deflated, which can result in uncomfortable catheter removal or urethral trauma.

4 CG25 VERSION 1.0 4/ A Cochrane review from 2007 did not find sufficient evidence to determine the best type of indwelling urinary catheter for long-term bladder drainage in adults. However, silicone catheters might be preferable to other catheter materials to reduce the risk of encrustation in long-term catheterised patients. 5.3 Hydrogel-coated Hydrogel coated catheters are soft and highly biocompatible. Because they are hydrophilic, they absorb fluid to form a soft cushion around the catheter, and reduce friction and urethral irritations. 5.4 Silicone-coated/Silicone Elastomer-coated Silicone elastomer coated catheters are latex catheters coated inside and out with silicone. The catheter has the strength and flexibility of latex and the durability and reduced encrustation typical of 100% silicone catheters. 5.5 Silver-coated Catheter One type of coating combines a thin layer of silver alloy with hydrogel which is antiseptic. Silver-hydrogel coated catheters are available in latex and silicone. Silver alloy coated catheters significantly reduce the incidence of asymptomatic bacteriuria, but only for less than a week. There is some evidence of reduced risk in the case of symptomatic UTIs. Therefore, they may be useful in some settings. Another type, silver oxide coated catheters are not associated with a statistically significant reduction in bacteriuria. 5.6 PTFE (Polytetrafluoroethylene) PTFE-coated latex catheters or Teflon has been developed to protect the urethra against latex. The absorption of water is reduced due to the Teflon coating. It is smoother than plain latex, which helps to prevent encrustation and irritation. Do not use this catheter for patients who are sensitive to latex. 5.7 Latex Latex, made from natural rubber is a flexible material but it has some disadvantages. Because of the potential discomfort due to high surface friction, vulnerability to rapid encrustation by mineral deposits from the urine and the implication of latex allergic reactions in the development of urethritis and urethral stricture or anaphylaxis, the use of latex catheters is restricted to short-term indwelling catheterisation and should be avoided if possible.

5 CG25 VERSION 1.0 5/ Catheter Gauge Foley catheters are sized in Charrieres, also known as French Grade (FG): 1 Ch = 1/3 mm diameter. Selection of the right catheter size will increase patient comfort and allow adequate drainage (a 12 Ch catheter has a drainage capacity of 100 litres in 24 hours) The smallest size of catheter allowing drainage should be used, as larger gauges are more likely to cause trauma and mucosal irritation. However, where there is infection or postoperative bleeding, a larger bore minimises the risk of obstruction Catheters sizes are labelled using the colour code below. The following provides an approximate guide to which size of catheter to insert in specific circumstances: Catheterisation (female), with clear urine, containing no grit (encrustation), debris or haematuria Ch/3.3-4mm. Catheterisation (male), with clear urine, containing no grit, debris or haematuria Ch/4-4.7mm. Male and female with debris or mild haematuria 16 ch/5.3mm Length The standard male catheter length of cm can be used for males and females, but a shorter female length of 25 cm can be more comfortable and discrete for some women. However, a female catheter can be too short if the woman is severely obese and then a male size is preferred. The female length catheter must not be used for males as inflation of the balloon within the urethra can result in severe trauma.

6 CG25 VERSION 1.0 6/ Closed Drainage System When the catheter has been inserted using aseptic technique, it is directly connected to the sterile bag, because an aseptic closed drainage system minimises the risk of catheter associated urinary tract infections (CAUTI). Unnecessary disconnection of a closed drainage system should be avoided, but if it occurs the catheter and collecting system have to be replaced using aseptic technique and sterile equipment. There are several different bags available. Selection of the bag depends on whether it is for short-term drainage or for long-term use, taking into consideration the patient s mobility, cognitive function, daily life routine. Leg bags can be used for 5-7 days before needing changing, unless single use only, night bags used in the community should be single use only Leg Bag/Body Worn Bag If the patient is mobile a leg bag can be preferable. The leg bags allow maximum freedom and movement and can be concealed beneath the clothes. Leg bags are available in different sizes, designs and qualities and it is important to select a bag according to the patient s preference, mobility and the intended duration The following factors must be considered when selecting a bag: Capacity: Ranges from 120 to 800 ml and the size depends on how often the bag has to be emptied according to the patient s daily routines. Chamber: Bags are available with a single or several chambers. Several chambers flatten the bags profile and are therefore more discreet. Materials: Bags are produced in different materials with different backings for comfort. Some of the bags are PVC-free as well. Tube: Range from about 4 cm to 45 cm. Some can be cut to length. In addition some tubes are kinking-free, which reduces the risk for obstruction. Suspension System: Leg bags can be attached to the leg with straps (elasticated), nets, bags/pocket of cotton, etc Overnight Bedside Bag Patients normally require a 2 litre drainage bag that is connected to the leg bag at night or if they are immobile or bedbound. The outlet tap on the leg bag is left open so that the urine collects in the larger bag without breaking the closed drainage system. The night bag requires a stand for support, to reduce the risk of dislodging the link system and is available in different designs and materials.

7 CG25 VERSION 1.0 7/ Catheter Valves Valves are small devices connected to the catheter outlet instead of a bag and are available in a variety of designs. These are only suitable for patients with the dexterity and cognitive ability to open the valve 5 6 times/day; they are not suitable for patients with chronic retention or renal impairment. 6. Preparation 6.1 Consent Catheterisation is an invasive procedure that can cause embarrassment, physical and psychological discomfort and impact on the patient s self-image. To ensure the patient is fully prepared for catheterisation it is the responsibility of the clinician to inform the patient of the reasons and necessity for the procedure, and obtain the patient s permission. It is a necessity that verbal consent and agreement is reached and the relevant information is recorded in the patient s clinical records. Informed consent requires the patient to understand the reason for catheterisation, possible complications and what is required to manage the catheter. 6.2 Information and Support Explaining the procedure to the patient can help reduce patient anxiety and embarrassment and help the patient to report any problems that may occur while the catheter is in-situ. Relaxing the patient by offering reassurance and support will help for smoother insertion of the catheter and assist in avoiding unnecessary discomfort and the potential of urethral trauma during the insertion. 6.3 Equipment and Preparation The clinician should take a brief medical patient history, especially about urological conditions before the procedure. Catheterisation is a sterile procedure as it involves instrumentation of a sterile tract. It is imperative that the clinician has a good understanding of the principles of the aseptic procedure as this will help to reduce the risk of UTI.

8 CG25 VERSION 1.0 8/ Lubricating Gel Catheterisation can be painful in both males and females. The use of anaesthetic lubricating gels is well recognised for male catheterisation. An appropriate sterile single-use syringe with lubricant should be used before catheter insertion of a non-lubricated catheter to minimise urethral trauma, discomfort and infection. However, it is essential to ask the patient if they have any sensitivity to lignocaine/lidocaine, chlorhexidine or latex before commencing the procedure. There have been reported cases of anaphylaxis attributed to the chlorhexidine component in lubricating gel. Ten to fifteen ml of the gel is instilled directly into the urethra, until this volume reaches the sphincter/bladder neck region. Blandy and Colley recommend a 3 to 5 minute gap before starting the catheterisation after instilling the gel, but it is important to follow manufacturer s guidance A maximised anaesthetic effect will help the patient to relax and the insertion of the catheter should be easier if the lubricant contains lignocaine/lidocaine or chlorhexidine. Care should be taken if the patient has an open wound, severe damaged mucous membranes or infections in the regions where the lubricant will be used. Caution is advised in patients with severe disorders of the impulse conduction system or epilepsy as well as women in the first three months of pregnancy or breast feeding, prior using a lignocaine/lidocaine containing lubricant. 7. Procedures 7.1 Removal of a Urethral Catheter Equipment Checklist: Non-sterile Disposable gloves. Syringe for deflating balloon. Disposable pad (to protect bed). Plastic disposable apron or protective clothing. Gauze swabs disposable wipes.

9 CG25 VERSION 1.0 9/ Procedure Action 1. Explain procedure to patient. 2. Check volume of water in balloon (refer to patient documentation if available). 3. Attach the syringe to catheter valve to deflate the balloon. Do not use suction on the syringe but allow the solution to come back spontaneously. 4. Ask patient to breathe in and then out: as patient exhales, gently remove the catheter. Male patients should be warned of discomfort as the deflated balloon passes through the prostatic urethra. 5. Clean meatus using gauze / disposable wipe, clear away equipment, and make the patient comfortable. 6. Used equipment should be placed in a clinical waste bag and disposed of in line with Trust policy. 7.2 Male Urethral Catheterisation Equipment Checklist: Sterile catheterisation pack containing gallipots, receiver, low-linting swabs, disposable towels. Disposable pad for bed protection. 2 pairs of sterile gloves, in order to maintain asepsis. Selection of appropriate catheters; it is advisable to take a spare catheter in addition to the one you want, and one of a different/smaller size. Sterile anaesthetic lubricating jelly (1-2 tubes). Universal specimen container, if required. Cleansing solution. Bactericidal alcohol hand disinfection. 10ml sterile water (inflation of balloon) or as recommended by the manufacturer. Syringe and needle to draw up sterile water and inflate balloon Disposable plastic apron/protective clothing. A closed urinary drainage system, e.g. a night bag, leg bag or catheter valve. A catheter drainage bag stand, if required Procedure Action and Rationale 1. Check patient file/history for past problems, allergies etc. 2. Before the procedure explain the process to the patient, to ensure that they are able to give informed consent. 3. Undertake procedure on the patient s bed or in clinical treatment area using screens/curtains to promote and maintain dignity.

10 CG25 VERSION /20 4. Assist the patient to get into the supine position to ensure the penis is accessible. Do not expose the patient at this stage of the procedure. 5. Wash hands using soap and water or bactericidal alcohol hand rub to reduce risk of infection. 6. Place all equipment required on a clean working surface. 7. Open the outer cover of the catheterisation pack then open the sterile field, handling the outer corners only. Using aseptic non-touch technique open/place all other equipment onto sterile field. 8. Remove cover that is maintaining the patient s privacy and position a disposable pad under the patient s buttocks and thighs, to ensure urine does not leak onto bed. 9. Clean hands again with a bactericidal alcohol hand rub, as they may have become contaminated by handling the outer packs. Put on first pair sterile gloves. 10. Using an aseptic technique, connect the bag to the catheter at this stage. 11. Place dressing/protective towel across the patient s thighs and under penis. To create a protective sterile field. 12. Lift the penis and if present, retract the foreskin, using a gauze swab. Clean the glans penis with the solution. Beginning with the foreskin, the glans and urethral meatus at the end, using a new swab for each part. 13. Still with the first pair of sterile gloves on, hold the penis in an upright position (to straighten out the penile urethra and facilitate catheterisation). Slowly instill ml of the (anaesthetic) lubricating gel into the urethra holding firmly below the glans with thumb and fingers and with the tip of the syringe firmly in the meatus to prevent the gel from leaking out. Adequate lubrication helps to prevent urethral trauma. Use of a local anaesthetic minimises the discomfort experienced by the patient and can aid success of the procedure. 14. Remove the syringe tip from the urethra and keep the urethra closed. 15. Wait as recommended by the manufacturer (normally 3 to 5 minutes) to maximise the anaesthetic effect. 16. Now remove gloves, decontaminate hands and put on second sterile pair 17. Insert the catheter into meatus and advance the catheter gently to the bifurcation. Hold the penis all the time in the upright position, with traction of the other hand. If no urine drains gently apply pressure over the symphysis pubis area or ask the patient to cough. Advancing the catheter ensures that it is correctly positioned in the bladder. 18. Slowly inflate the balloon according to the manufacturer s instructions, having ensured that the catheter is draining urine beforehand. Inadvertent inflation of the balloon in the urethra causes pain and urethral trauma.

11 CG25 VERSION / Withdraw the catheter slightly to ensure that the balloon sits at the bladder base ensuring optimal urine drainage. 20. Secure the catheter using a support strap. Ensure that the catheter does not become taut when patient is mobilising, to maintain patient comfort and to reduce the risk of urethral and bladder neck trauma. 21. Ensure that the glans penis is cleansed after the procedure and reposition the foreskin if present. Retraction and constriction of the foreskin behind the glans penis resulting in paraphimosis may occur if this is not done. 22. Help the patient into a comfortable position. Ensure that the patient s skin and the bed are both dry. If the area is left wet or moist, secondary infection and skin irritation may occur. 23. Measure the amount of urine. Be aware of bladder capacity for patients with previous episodes of urinary retention and to assess for chronic retention. 24. Consider taking a urine specimen for examination, if required. 25. Dispose of equipment in a plastic clinical waste bag and seal the bag. 7.3 Female Urethral Catheterisation Procedure 1. Check patient file for past problems, allergies etc. 2. Prior to the procedure explain the process to the patient, ensure that they are able to give informed consent. 3. Undertake procedure on the patient s bed or in clinical treatment area using screens/curtains to promote and maintain dignity. 4. Assist the patient to get into the supine position. Do not expose the patient at this stage of the procedure. 5. Wash hands using soap and water or bactericidal alcohol hand rub to reduce risk of infection. 6. Prepare all equipment required on a clean working surface. 7. Open the outer cover of the catheterisation pack then open the sterile field, handling the outer corners only. Using aseptic non-touch technique open/place all other equipment onto sterile field. 8. Using an aseptic technique, connect the bag to the catheter. 9. Remove cover that is maintaining the patient s privacy and position a disposable pad under the patient s buttocks and thighs. To ensure urine does not leak onto bed. 10. Clean hands with a bactericidal alcohol hand rub, as hands may have become contaminated by handling the outer packs. 11. Put on non-sterile gloves. 12. Place dressing / protective towel across the patient s thighs, to create a protective sterile field.

12 CG25 VERSION / Clean the meatus: labia majora, labia minor and finally the urethral meatus. One swab one wipe anterior to posterior, to avoid wiping any bacteria from the perineum and anus forwards towards the urethra. 14. Replace existing gloves with a sterile pair. 15. Separate the labia with one hand and give traction upwards. In order to have a good view on the meatus and to minimise the risk of contamination of the urethra. 16. Apply a little lubrication to the meatus and then insert the conus of the syringe with (anaesthetic) lubrication in the meatus and slowly instill 6ml of the gel into the urethra. Remove the nozzle from the urethra. Adequate lubrication helps to prevent urethral trauma. Use of a local anaesthetic minimises the discomfort experienced by the patient and can add to the success of the procedure. 17. Pick up the catheter with the hand with the sterile glove. Insert the catheter in the meatus and gently advance the catheter along the urethra until it reaches the bladder and urine flows out. Then insert the catheter 2cm deeper, to confirm that the balloon is in the bladder. Inadvertent inflation of the balloon in the urethra causes pain and urethral trauma. 18. Withdraw the catheter slightly to ensure that the balloon sits at the bladder base ensuring optimal urine drainage. 19. If the patient wishes, secure the catheter using a support strap. Ensure that the catheter does not become taut when patient is mobilising. To maintain patient comfort and to reduce the risk of urethral and bladder neck trauma. 20. Ensure that the labia are cleaned after the procedure to avoid skin irritation. 21. Help the patient into a comfortable position. Ensure that the patient s skin and the bed are both dry. If the area is left wet or moist, secondary infection and skin irritation may occur. 22. Measure the amount of urine. Be aware of bladder capacity for patients with previous occurrences of urinary retention. To monitor renal function and fluid balance. 23. Consider taking a urine specimen for examination, if required. 24. Dispose of equipment in a plastic clinical waste bag and seal the bag. 25. Record information in relevant documents, as detailed in section 7.8.

13 7.4 Removal of a Suprapubic Catheter Equipment Checklist: Non-sterile disposable gloves. Syringe for deflating balloon. Disposable pad (to protect bed). Plastic disposable apron or protective clothing. Gauze swabs / disposable wipes. Sterile absorbing dressing and tape. CG25 VERSION / Procedure 1. Maintain patient dignity. 2. Prior to the procedure explain the process to the patient, to ensure that they are able to give informed consent. 3. Decontaminate hands and put on non-sterile gloves. 4. Check volume of water in balloon (refer to patient documentation), then attach the syringe to catheter valve to deflate the balloon. Do not use suction on the syringe but allow the solution to come back spontaneously. 5. Ask patient to breathe in and then out; as patient exhales, gently remove the catheter. 6. Clean suprapubic fistula using gauze/disposable wipe, clear away equipment, put on an occlusive absorbent dressing and make the patient comfortable. 7. Used equipment should be placed in clinical waste bag and disposed of in line with local Trust policy. 8. Document procedure and note any difficulties / problems experienced as detailed in section Insertion of a Suprapubic Balloon Catheter Any clinician who undertakes suprapubic re-catheterisation must have undergone a programme of training and clinical supervision and be assessed as competent to undertake this procedure. 7.6 Changing a Suprapubic Catheter Checklist equipment: Sterile catheterisation pack. Disposable pad for bed protection. Two pairs of gloves, one of which must be sterile for handling new catheter. Appropriate catheter; it is advisable to take a spare catheter in addition to the one you want. Sterile anaesthetic lubricating gel (5-6mls).

14 CG25 VERSION /20 Universal specimen container, if required. Cleansing solution (sodium chloride 0.9% is sufficient). Bactericidal alcohol hand rub. 10ml sterile water (inflation of balloon) or as recommended by manufacturer. Syringe and drawing up needle to draw up sterile water and inflate balloon, 10ml syringe to deflate existing balloon. Disposable plastic apron/protective clothing. A closed urinary drainage system, e.g. a night bag, leg bag or catheter valve. A catheter drainage bag stand, if required. Dressing and wound care set (supplementary pack) Procedure 1. Check patient file for past problems, allergies etc. 2. Prior to the procedure explain the process to the patient, to ensure that they are able to give informed consent. 3. Undertake procedure on the patient s bed or in clinical treatment area using screens/curtains to promote and maintain dignity. Assist the patient to get into a comfortable supine position to ensure the suprapubic tract is accessible. Do not expose the patient at this stage of the procedure. 4. Wash hands using soap and water or bactericidal alcohol hand rub. 5. Put on a disposable plastic apron or protective clothing. 6. Prepare all equipment required. Assemble all of the necessary equipment. The catheter size and amount of water instilled in the balloon should be the same as the existing suprapubic catheter. 7. Open the outer cover of the catheterisation pack then open the sterile field, handling the outer corners only using an aseptic non-touch technique, open the supplementary packs. 8. Using an aseptic technique, connect the bag to the catheter at this stage. 9. Remove cover that is maintaining the patient s privacy and position a disposable pad under the patient s buttocks and thighs, to ensure urine does not leak onto bed. 10. Clean hands with an bactericidal alcohol hand rub. 11. Put on sterile gloves. 12. Observe the current suprapubic site for the lie of the catheter, angle of insertion and mark the existing catheter with tape at the point of entry to the skin. This will act as a guide for the insertion length and angle for the new catheter. 13. Place dressing/protective towel across the patient s abdomen.

15 CG25 VERSION / Using a gauze swab clean the cystostomy site. 15. Remove existing gloves, decontaminate hands and put on sterile pair of gloves and place new sterile towel at the cystostomy site. 16. Deflate balloon (without suction) of existing catheter and remove catheter. Ensure you have sterile gauze at hand, to put on the Supra Pubic Catheter insertion site to prevent leakage. 17. Insert 5ml to 10ml of water-soluble lubricant or local anaesthetic gel into the suprapubic tract. 18. Remove gloves decontaminate hands with bactericidal alcohol hand rub and put on sterile pair. 19. Insert the catheter and advance the same length as the previous one. Ensure urine draining. Apply gentle pressure over symphysis pubis area if no urine draining. 20. Slowly inflate the balloon according to the manufacturer s instructions. 21. Withdraw the catheter slightly; the catheter should be able to slide up and down the cystostomy slightly. 22. Secure the catheter using a support strap, ensure that the catheter does not become taut when patient mobilises. 23. Help the patient into a comfortable position to ensure that the patient s skin and the bed are both dry. 24. Measure and document the amount of urine. 25. Take a urine specimen for laboratory examination, if required. 26. Dispose of equipment in a plastic clinical waste bag and seal the bag. 27. Record information in relevant documents, as detailed in section Obtaining a Urine Sample From an Indwelling Catheter 1. Prior to the procedure explain the process to the patient, to ensure that they are able to give informed consent. 2. Wash your hands with soap and water and put on an apron. Clean hands with bactericidal alcohol hand rub and put on sterile gloves. 3. If there is no urine visible in the catheter tubing then a clamp may be placed a few centimetres distal to the sampling port. 4. Once there is sufficient urine visible in the drainage tube above the clamp, then wipe the sampling port with a 2% Chlorhexidine in 70% alcohol swab and allow to dry. 5. Insert a sterile syringe into the needle-free sampling port. Aspirate the required amount of urine. 6. Remove the syringe and transfer specimen into sterile specimen pot. 7. Wipe the sampling port with a 2% Chlorhexidine in 70% alcohol swab and allow to dry. 8. Unclamp the drainage tubing.

16 CG25 VERSION /20 9. Dispose of all waste materials as clinical waste according to Trust policy. 10. Wash hands with soap and water or bactericidal alcohol hand rub. 11. Complete documentation as detailed in section Documentation It is important that all aspects of catheter management are documented thoroughly, including: Reasons for catheterisation. Date and time of catheterisation. Catheter type, length and size. Amount of water instilled into the balloon. Batch number and manufacturer (catheter packaging may have include stickers for this purpose which can be peeled off and placed on clinical record). Drainage system used. Problems negotiated during the procedure. Follow up arrangements as required.

17 CG25 VERSION /20 8. Complications 8.1 Catheter Bypassing Catheter bypassing occurs in up to 40% of patients with indwelling catheters, and may occur as a consequence of various aetiologies including catheter blockage, bladder spasm, constipation, pulling on the catheter or a too large diameter of the catheter. In itself, catheter bypassing is not a diagnosis but rather a symptom; treatment of which should be aimed at the underlying cause. 8.2 Iatrogenic Trauma Iatrogenic trauma during urethral catheterisation may result in either the formation of a false passage, usually at the level of the prostate or bladder neck, urethral stricture disease or traumatic cleaving in the male, with sphincteric disruption in the female. Such trauma is rare, with an overall incidence of 0.3%. Paraphimosis may occur when an uncircumcised male is catheterised and the prepuce is not replaced. Care and continued patient and carer education will reduce the incidence of such a complication. 11% of urethral strictures requiring urethroplasty arise following urethral catheterisation Suprapubic catheterisation is associated with a potential for visceral injury which although difficult to reliably quantify due to under-reporting, is in the region of 2-3% for bowel perforation, carrying a 30-day mortality rate in the region of 2%. Visceral trauma is more common amongst patients with previous lower abdominal surgery and in those with neurological disease. The patient should always be observed for persistence or worsening of lower abdominal pain, pain spreading away from cystostomy, change in bowel habit, poor or no urine output or becoming unexpectedly unwell all signs of visceral bowel injury requiring urgent admission to hospital The incidence of visceral trauma during SPC insertion may be reduced by ensuring the existing catheter is marked with tape at point of entry to skin (to act as a guide for length of re-insertion) or there is some urine (300 ml) in the bladder and that the new catheter is draining freely.

18 CG25 VERSION / Bladder Spasm/Bladder Pain Bladder spasm is common in patients with indwelling catheters, causing pain and by-passing. It usually settles spontaneously. Chronic constipation may cause bladder spasm. Maintaining regular bowel function with a highfibre and high-fluid intake helps prevent constipation. Sometimes a different catheter (smaller lumen and balloon size) can also reduce the spasm caused by constipation. Hydrogel catheters are more biocompatible and may reduce bladder spasm. Persistent bladder spasm pain and symptoms can be relieved with antimuscarinic medication. 8.4 Haematuria Haematuria may occur following catheterisation and is usually self limiting. During urethral catheterisation, prostatic trauma may be the underlying cause, although decompression of high pressure chronic retention may also result in haematuria. The patient should be reassured and oral fluids encouraged. Hospitalisation is not necessary unless frank haematuria or clots are present or the patient is haemodynamically unstable. 8.5 Inability to Remove Catheter Catheters may occasionally prove impossible to remove via balloon deflation. This may be as a consequence of balloon calcific encrustation or a faulty deflation mechanism. 8.6 Catheter Washout People requiring long-term bladder draining with an indwelling catheter can often experience catheter blockage. As there are quite a few causes of catheter blockage (e.g. kinks in a tube, constipation, catheter against bladder wall, encrustation, debris) it is important to diagnose the exact reason for the blockage in order to decide on the correct course of treatment. Whilst catheter maintenance solutions exist, these should be used to maintain the catheter in situ i.e. prevent blockage and should not be used to try to unblock a catheter that is already blocked. Using maintenance solution to unblock a catheter is then an incorrect use of the product and product licence. If a catheter is blocked it needs to be changed, any form of washout or catheter manipulation must not be used.

19 CG25 VERSION /20 9. Patient Wellbeing 9.1 Fluid intake Drinking sufficient fluid dilutes the urine and helps reduce the risk of catheter encrustation and blockage. A good fluid intake also ensures a constant downward drainage and flushing effect. There is no standard amount of advised fluid intake and the type of fluid consumed appears to be insignificant as long as the volume is sufficient to prevent concentration of urine. The amount of fluid needed varies and depends on patient s size (25-35 ml/kg/day), amount of fluid loss, patient s food intake and patients circulatory and renal status. Regular fluid intake maintains the urinary flow and reduces the risk of infection and catheter blockage As a general rule, patients with indwelling catheters should not be given prophylactic antibacterial therapy and the treatment of bacteriuria with antibiotics should be carefully considered. Misuse of antibacterial therapy is likely to produce antibiotic resistance. The bowel and the bladder then become a reservoir for antibiotic resistant organisms. To avoid this complication, antibiotics should not be given in an attempt to prevent bacteriuria in long term catheterisation but rather reserved for treatment of acute episodes of clinical infection indicated by fever > 38 C, pus in urine, suprapubic or loin pain or sudden onset of confusion.

20 CG25 VERSION /20 References Harrison. C.W., et al. (2010). British Association of Urological Surgeons (BAUS), Suprapubic catheter practice guidelines. BJUI available online at baus.org.uk. The Health and Social Care Act Code of Practice on the prevention and control of infections and related guidance. London: Department of Health. Belfield P, (1988). Urinary catheters. British Medical Journal. 296, 6625, pp Blandy J et al, (1989). Catheters and catheterisation. In Blandy J et al (Eds). Urology for Nurses. First Edition. Oxford, Blackwell Scientific Publications Ltd. Britton R et al, (1990). Catheters: making an informed choice. Professional Nurse. 5, 4, pp Department of Health (2006) Essential steps to safe, clean care. Reducing healthcareassociated infections in Primary Care Trusts; Mental health trusts; Learning disability organisations; Independent healthcare; Care Homes; Hospices: GP practices and Ambulance Services. DoH, London. Getliffe K, (1993). Care of urinary catheters. Nursing Standard. 7, 44, pp Horgan A et al, (1992). Acute urinary retention: comparison of suprapubic and urethral catheterisation. British Journal of Urology. 70, 2, pp McGill S, (1982). Catheter management: it s the size that s important. Nursing Mirror. 154, April 7, pp Norton C, (1986). Catheterisation. In Norton C (Ed). Nursing for Continence. Beaconsfield Publishers, Beaconsfield. Pomfret I, (2000). Catheter care in the community. Nursing Standard. 14, 27, pp The Royal Marsden NHS Trust (2001) Manual and Clinical Nursing Procedures, London: Blackwell Science. Winn C, (1998). Complications with urinary catheters. Professional Nurse. 13, 5 (Suppl), pp7-10. Woodward S, (1997). Complications of allergies to latex urinary catheters. British Journal of Nursing. 6, 14, pp