From the Guidelines
When a Foley catheter is contraindicated due to infection risk, clean intermittent catheterization (CIC) is the preferred first-line approach for managing urinary retention or incontinence. This method involves inserting a single-use catheter 4-6 times daily to drain the bladder completely, which reduces infection risk compared to indwelling catheters 1.
Alternative Management Options
Other alternative management options include:
- External collection devices, such as condom catheters for men (changed daily) and external female urinary collection devices
- Pharmacological management, including alpha-blockers like tamsulosin (0.4mg daily) for retention due to prostatic obstruction, or anticholinergics such as oxybutynin (5mg 2-3 times daily) for urge incontinence
- Behavioral interventions, like timed voiding every 2-3 hours, pelvic floor exercises, and fluid management to help manage incontinence
- Absorbent products for temporary management while addressing underlying causes
Severe Cases
For severe cases unresponsive to these measures, suprapubic catheterization may be considered, involving surgical placement of a catheter through the abdominal wall directly into the bladder, which carries lower infection rates than urethral catheters 1. The choice of management should be individualized based on the patient's specific condition, cause of retention or incontinence, and overall health status. It is essential to weigh the potential benefits and risks of each option, considering the patient's unique needs and circumstances, as highlighted in the 2024 guideline on the diagnosis and treatment of idiopathic overactive bladder 1.
From the Research
Alternative Management Options
If a Foley catheter cannot be placed due to the risk of infection, there are alternative management options for urinary retention or incontinence. These include:
- External urinary devices, which are indicated for urinary incontinence (postvoid residual less than 300 mL) 2
- Clean intermittent catheterization, which is an alternative to indwelling urinary catheterization for acute or chronic urinary retention (postvoid residual greater than 300 mL) without bladder outlet obstruction 2
- Suprapubic catheter placement, which is considered when long-term catheterization is needed or urethral catheterization is not feasible 2
Comparison of Catheterization Routes
Studies have compared different routes of catheterization, including indwelling urethral, suprapubic, and intermittent catheterization. The evidence suggests that:
- Suprapubic catheterization may reduce the number of participants with asymptomatic bacteriuria, recatheterization, and pain compared to indwelling urethral catheterization 3
- Intermittent catheterization may be associated with a lower risk of asymptomatic bacteriuria and symptomatic urinary tract infection compared to indwelling urethral catheterization, but the evidence is inconclusive 3
Complications of Urinary Tract Infections
Urinary tract infections associated with devices used for long-term bladder management can lead to significant complications, including:
- Catheter obstruction, fever, bacteremia, urinary tract stones, and death 4, 5
- Polymicrobial bacteriuria, which can be difficult to treat 5
Prevention of Catheter-Associated Urinary Tract Infections
Several studies have investigated methods to prevent catheter-associated urinary tract infections, including:
- Once-daily irrigation of long-term urethral catheters with normal saline, which was found to have no benefit 5
- Intermittent drainage bag instillation of hydrogen peroxide, which was found to reduce contamination of the drainage bag but not catheter-associated bacteriuria or symptomatic urinary tract infection 6