We are all too aware of the dreaded indwelling Foley catheter and the complications it invites. We know that its smooth, plastic surface becomes the perfect nidus for biofilms: impermeable matrices of low-lying, slowly reproducing bacteria safely encased in their own secreted polymers, providing extra virulence against even the most bactericidal of antibiotics (1). In medical school we are taught the canonical wisdom of how to safely use Foleys: utilize them only for appropriate indications; consider alternatives; adequately train relevant individuals in catheter insertion, replacement, and care; remove catheters when no longer indicated; and question every catheter placement (2).
Although we are aware of the associated risks, we tolerate indwelling Foley catheters in the hospital for their indisputable benefits in voiding assistance for acute urinary retention, urinary diversion away from open or healing wounds, and urine output monitoring in critical care settings (3). But when it’s time for discharge and the patient hasn’t passed a trial of void, providers must consider responsible long-term options. Although there is ample literature supporting clean intermittent self-catheterization (CISC) as the preferred method of long-term voiding assistance, scant data exists to help providers appropriately identify good candidates.
Catheter-associated complications adversely affect patient quality of life and drive up costs for the health care system (4). In fact, catheter-associated urinary tract infection (CAUTI) was the first iatrogenic condition chosen by Medicare and Medicaid for denial of hospital reimbursements (5). Therefore, it is imperative that providers do their best to set patients up for success in unknown home and social environments by selecting appropriate bladder management strategies. In the hospital, we are constantly exposed to cases of outpatient catheterization gone wrong. One such case is the patient who presents with florid urosepsis from an indwelling Foley, with no one able to speak to the indication, how long it is been in place, or when it was last changed and why. Another is the patient prescribed CISC who presents with post-obstructive nephropathy and uremia after neglecting the need to self-catheterize.
The Infectious Diseases Society of America (IDSA) guidelines support the use of CISC over indwelling Foley catheters as incidence of bacteriuria and UTI is much lower in patients who use CISC (6). Mechanical and urological complications – including formation of urethral strictures, bladder stones, bladder fistulas, and false lumens – also occurred at markedly lower rates (7). One retrospective analysis comparing complication rates of CISC, indwelling catheters, spontaneous voiding and suprapubic catheters in patients with spinal cord injury noted that those who utilized CISC had the lowest complications rates at 27.2%, versus 53.5% for indwelling catheter and 44.4% for suprapubic catheterization (5).
Non-infectious complications of CISC include urethral stricture formation or erosion, bladder stone formation, bladder fistula formation and creation of a false lumen (8). The majority of strictures develop in males, typically after five or more years of intermittent catheterization (9). Unfortunately, intermittent hematuria typically develops in one-third of individuals using CISC (10). Similar complications are noted in patients with indwelling Foleys, although the risk of UTI and urosepsis is higher. Bladder stone formation occurs frequently in patients with long-term indwelling Foleys, which confers an increased risk of uroepithelial malignancy (5).
For individuals with chronic urinary retention, appropriate voiding management is essential for preventing acute complications such as UTI, but also long-term complications, like urothelial malignancy and renal failure (5). In general, good measures that prevent UTI development while using CISC include maintaining a low residual volume, preventing bladder overdistension, and utilizing appropriate, clean (but not necessarily sterile) technique (6). In a study comparing habits of male veterans utilizing CISC, UTI development was associated with a higher median number of daily catheterizations. More UTIs developed among those for whom catheter training had not been documented (6).
Although appropriately selected patients typically understand the risks associated with neglecting catheter care, barriers to adherence abound. Patients frequently cite busy lifestyles and lack of access to clean public spaces with hygienic surfaces as a barrier to adhering to their physician’s recommended protocol (10). Underlying disease factors such as the presence of sensory alteration, lack of motor coordination, compromised visual acuity, spasticity, cognitive decline, and psychological disorders greatly limited patients’ ability to succeed with catheterization (11).
A 2011 study of patients utilizing CISC for over a year found that an age less than 40 years old, being female, and having a neurogenic cause of urinary retention were positive risk factors associated with CISC adherence. Patients with higher rates of adherence also had higher WHO-validated quality of life scores in the psychosocial sections. Marital status, bladder capacity and perceived pain scores did not correlate with adherence (12). Another study by Amarenco et al. assessed the use of a brief manual dexterity test to determine whether or not patients would be capable of performing CISC (11). Patients completed a four-minute “pencil and paper test” in which they performed hand gestures mimicking those needed to self-catheterize. High performance on the test was correlated positively with subsequent ability to successfully learn the catheterization technique (11). In patients who lack the coordination to perform CISC independently, there is limited data available for patients who rely upon family members to assist them with catheterization, and no clear data elucidating adherence rates in nursing homes, in which many patients with urinary retention reside.
Most of the studies reviewed above were conducted in patients who were able to catheterize themselves, which is not necessarily descriptive of the average patient. Indwelling Foley catheters may be a more realistic management option for patients with impaired upper extremity dexterity, multiple medical comorbidities limiting overall functional capacity, and limited social support. Patients with purely neurogenic causes of urinary retention, such as individuals with spinal cord injury – rather than patients with extensive functional decline secondary to medical conditions – are likely to be good candidates for CISC. Given the benefits of CISC over indwelling Foley placement, efforts should be made to select appropriate patients and empower them for success with appropriate training.
Dr. Scarlett Murphy is a resident physician at NYU Langone Health
Peer reviewed by Bobby Najari, MD, Assistant Professor, Department of Urology
Image courtesy of PublicDomainPictures.Net
- Lee K, Lee KM, Kim D, Yoon SS. Molecular determinants of the matrix thickening of a dual-species Pseudomonas aeruginosa and Enterococcus faecalis biofilm. Appl Environ Microbiol. 2017 Aug 25. pii: AEM.01182-17. doi:.1128/AEM.01182-17. https://www.ncbi.nlm.nih.gov/pubmed/?term=Lee%20K%5BAuthor%5D&cauthor=true&cauthor_uid=28842537
- Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases. 2010:50(1):635-663. https://www.ncbi.nlm.nih.gov/pubmed/20175247
- Meddings J, Saint S, Fowler KE, Gaies E, Hickner A, Krein SL, Bernstein SJ The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method. Ann Intern Med. 2015 May;162(9 Suppl):S1-S34. https://www.ncbi.nlm.nih.gov/pubmed/25938928
- Weld KJ, Dmochowksy RR. Effect of Bladder Management on Urological Complications in Spinal Cord Injured Patients. The Journal of Urology. 2000: 163(3): 772. https://www.ncbi.nlm.nih.gov/pubmed/10687973
- Saint S, Greene MT, Krein SL, Rogers MA, Ratz D, Fowler KE, Edson BS, Watson SR, Meyer-Lucas B, Masuga M, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 201;374(22):2111–9. https://www.ncbi.nlm.nih.gov/pubmed/27248619
- Kannankeril AJ, Lam HT, Reyes EB, McCartney J. Urinary tract infection rates associated with re-use of catheters in clean intermittent catheterization of male veterans. Urol Nurs. 2011;31(1):41-48.
- Di Benedetto P1. Clean intermittent self-catheterization in neuro-urology. Eur J Phys Rehabil Med. 2011 Dec;47(4):651-9.
- Perrouin-Verbe B, Labat JJ, Richard I, et al. Clean intermittent catheterisation from the acute period in spinal cord injury patients. Long term evaluation of urethral and genital tolerance. Paraplegia. 1995; 33:619. https://www.nature.com/articles/sc1995131
- Pannek J, Göcking K, Bersch U. Perineal abscess formation as a complication of intermittent self-catheterization. Spinal Cord. 2008 Jul;46(7):527-9. Epub 2007 Nov 13. DOI: 10.1038/sj.sc.3102142
- Newman DK, Wilson MH. Review of intermittent catheterization and current best practices. Urol Nurs. 2011;31(1):12-28. https://www.ncbi.nlm.nih.gov/pubmed/21542441
- Amarenco G, Guinet A, Jousse M, Verollet D, Ismael SS Pencil and paper test: a new tool to predict the ability of neurological patients to practice clean intermittent self-catheterization. J Urol. 2011 Feb;185(2):578-82. Epub 2010 Dec 18.
- Girotti ME, MacCornick S, PerisséH, Batezini NS, Almeida FG. Determining the variables associated to clean intermittent self-catheterization adherence rate: one-year follow-up study. Int Braz J Urol. 2011 Nov;37(6):766-72.