What are the guidelines for discontinuing a Foley catheter and initiating a voiding trial?

From the Guidelines

Foley catheters should be discontinued as soon as clinically appropriate, typically when the original indication has resolved, and a voiding trial should be initiated to assess the patient's ability to void spontaneously. To initiate a voiding trial, first ensure the patient is medically stable and able to recognize bladder fullness 1. The catheter should be removed in the morning to allow for monitoring throughout the day. After removal, instruct the patient to drink 1-2 liters of fluid over the next 6-8 hours and to void when feeling the urge. Document the time and volume of each void. Successful trials typically require the patient to void at least 200 mL within 6 hours of catheter removal, with post-void residual volumes less than 100-150 mL (measured by bladder scanner or in-and-out catheterization) 1.

Some key considerations before initiating a voiding trial include:

• Assessing the patient's ability to recognize bladder fullness and respond to the urge to void
• Evaluating the patient's medical stability and ability to tolerate potential complications
• Considering the use of alpha-blockers, such as tamsulosin or alfuzosin, prior to catheter removal in patients with urinary retention, as recommended by the American Urological Association 1
• Monitoring for signs of urinary retention, such as bladder distention or significant post-void residual volumes, and reinserting the catheter if necessary

Patients with neurological conditions, prolonged catheterization (>2 weeks), or previous urinary retention may require a more gradual approach with intermittent catheterization 1. Early mobilization, proper positioning during voiding, and privacy can improve success rates. The physiological basis for these guidelines is that normal bladder function requires coordinated detrusor muscle contraction and urethral sphincter relaxation, which may be temporarily impaired after catheterization due to decreased bladder tone and altered neurological signaling.

It is also important to note that the use of silver alloy-coated urinary catheters may help reduce the risk of urinary tract infections, as recommended by the American Heart Association 1. Additionally, a bladder-training program should be implemented in patients who are incontinent of urine, including timed and prompted toileting on a consistent schedule 1.

From the Research

Guidelines for Discontinuation of Foley Catheter and Initiation of Voiding Trial

• The decision to discontinue a Foley catheter and initiate a voiding trial should be based on individual patient factors and medical history, as there is no one-size-fits-all approach 2, 3.
• A study published in 2010 found that the back fill technique, where the bladder is filled with 300 cc saline before the Foley catheter is removed, correlated better with a successful voiding trial than the auto fill technique 2.
• Another study published in 2020 implemented a standardized postoperative voiding management protocol that included removing the Foley catheter at six hours postoperatively, performing a universal bladder scan after the first void, and limiting re-catheterization to patients with bladder scan volumes >150 ml 3.
• The protocol reduced the rate of unnecessary re-catheterization by 90% and facilitated early hospital discharge, without overlooking true urinary retention 3.
• A 2022 study compared voiding assessment based on a minimum spontaneous voided volume of 150 mL with the standard retrograde fill approach in women after urogynecologic procedures, and found no significant difference in voiding trial failure rate between the two groups 4.
• Risk factors associated with urinary retention include older age, use of medications with anticholinergic properties, and preexisting urinary dysfunction 3.
• The use of alpha-blockers such as tamsulosin and alfuzosin may be effective in patients with acute urinary retention secondary to benign prostatic hyperplasia, but the effectiveness of these drugs may be overestimated due to the lack of objective criteria in the definition of successful micturition 5.
• A multidisciplinary approach to standardize catheter care with a trial of void algorithm is feasible and effective in reducing catheter use and decreasing the risk of catheter-associated urinary tract infections 6.