Can Ureteral Stents Be Pulled Out by String in Males with a Foley Catheter?
Yes, ureteral stents with attached strings can be safely removed in male patients who also have an indwelling Foley catheter, and this approach may actually reduce complications compared to cystoscopic removal.
Evidence-Based Recommendation
The most compelling recent evidence comes from a 2025 multi-center study 1 demonstrating that early stent removal when attached to the Foley catheter significantly reduced urinary tract infections (5.7% vs. 11.9%, p=0.013) compared to later cystoscopic removal, with no differences in ureteral stricture, urine leak, or allograft failure rates. This study specifically addressed your clinical scenario—stents removed simultaneously with Foley catheters.
Key Clinical Considerations
Pain and Patient Comfort
- String-based removal causes significantly less pain than cystoscopic removal in men 2, 3
- A 2026 meta-analysis showed mean pain reduction of 2.49 points on VAS scale 2
- Men specifically experienced less urethral pain with string removal 3
Timing Strategy
The optimal approach is to remove both the ureteral stent and Foley catheter simultaneously when clinically appropriate:
- Typical timing: 3-4 days post-procedure for Foley 1
- Stent removal at same time (3.7 days) vs. traditional 21.9 days 1
- This avoids a second procedure and reduces infection risk
Risk of Stent Dislodgement
Important caveat: Males have significantly lower dislodgement rates than females:
- Male dislodgement rate: 5.3% 4
- Female dislodgement rate: 24.4% 4
- Men are fourfold less likely to experience premature dislodgement 4
When String Removal is Appropriate
Proceed with string removal if:
- Uncomplicated ureteroscopy or stone procedure 5
- No ureteral injury, stricture, or large residual stone burden 5
- Patient is not in a solitary kidney situation requiring prolonged drainage 5
- No signs of infection or obstruction
Consider cystoscopic removal instead if:
- Complicated procedure with ureteral injury 5
- Solitary kidney or renal insufficiency 5
- Large residual stone burden 5
- High risk of obstruction if premature dislodgement occurs 4
Practical Execution
- Coordinate removal timing: Plan to remove both catheters on the same day (typically POD 1-4) 1, 6
- Patient positioning: Have patient in comfortable position, typically supine
- Gentle traction: Apply steady, gentle traction on the string—do not force
- Monitor for complications: Assess for hematuria, flank pain, or fever post-removal
- Patient education: Warn about transient dysuria and hematuria, which are normal
Infection Prevention Advantage
The presence of the Foley catheter does not contraindicate string removal—in fact, removing both simultaneously reduces the overall catheter burden and UTI risk 1. Guidelines consistently emphasize early catheter removal to prevent infections 7, 8, 9, 7, 10, 8, 11.
Common Pitfalls to Avoid
- Do not leave the Foley in place longer than necessary just because a ureteral stent is present—this increases infection risk 8
- Do not assume string removal is unsafe in males—the evidence shows it's actually safer and less painful than cystoscopy 2, 3
- Do not ignore signs of stent migration—if the string appears longer or the patient reports sudden relief of stent symptoms, assess for dislodgement 4
- Do not use excessive force—if resistance is met, stop and consider cystoscopic removal 12
Bottom Line
For uncomplicated cases in male patients, removing the ureteral stent by string at the time of Foley catheter removal is the preferred approach, offering reduced pain, lower infection rates, and elimination of a second procedure 2, 1, 3. The male urethra's anatomy makes this approach particularly safe with low dislodgement risk 4.