What is the protocol for a voiding trial and catheter (urinary catheter) reinsertion?

Protocol for Voiding Trials and Catheter Reinsertion

The recommended protocol for voiding trials includes removing the urinary catheter as early as possible when the patient is medically stable, performing a backfill technique for the trial, and monitoring post-void residual volume to determine success. 1, 2

Timing of Catheter Removal

• Remove indwelling urinary catheters within 24 hours after admission for acute conditions when possible 2
• For surgical patients, evaluate catheter use daily and remove as early as possible 2
• Specific timing considerations:
  • Postoperative day 1 for most patients following surgery 1
  • Immediately after cesarean delivery if strict urine output monitoring is not needed 2
  • Once the patient is medically and neurologically stable for stroke patients 2

Voiding Trial Technique

Backfill Technique (Preferred Method)

1. Fill the bladder with 300cc of sterile saline before removing the catheter 3, 4
2. Remove the catheter
3. Ask patient to void within 15 minutes
4. Measure post-void residual (PVR) volume via straight catheterization 3

Alternative: Auto-fill Technique

1. Remove the catheter
2. Allow the bladder to fill spontaneously
3. Have patient attempt to void when feeling the urge
4. Measure PVR via straight catheterization

Note: Research shows backfill technique correlates better with successful voiding trials (κ = 0.91) compared to auto-fill technique (κ = 0.56) 3

Criteria for Successful Voiding Trial

• Successful void: Patient voids at least two-thirds of total bladder volume (voided volume plus PVR) 3
• Failed void: PVR greater than half of the voided volume 5

Management Based on Voiding Trial Results

Successful Trial

• Discharge without catheter
• Provide instructions on normal voiding patterns and when to seek medical attention

Failed Trial

• Reinsert urinary catheter
• Options for management:
  1. Intermittent catheterization: Recommended every 4-6 hours to prevent bladder filling beyond 500mL 2
  2. Indwelling catheter: If intermittent catheterization is not feasible
  3. Pharmacological management: Consider alpha-blockers (e.g., alfuzosin 10mg daily) for at least 3 days before attempting another voiding trial 1

Repeat Voiding Trial Protocol

• For patients with failed initial trials, schedule repeat trial in 3-4 days 5
• Consider home catheter removal for appropriate patients (shown to be non-inferior to office removal with fewer office visits and less pain) 5
• For patients with persistent retention, consider urological consultation

Special Considerations

Stroke Patients

• Intermittent catheterization is recommended if post-void residual urine volume is >100mL 2
• Implement a bladder-training program with scheduled voiding every 2 hours during the day and every 4 hours at night 2

Post-Surgical Patients

• Active voiding trials (backfill technique) are associated with 63% reduction in UTI rates compared to passive trials 4
• Implementation of standardized voiding trial algorithms has been shown to reduce catheter use and potentially decrease CAUTI rates 6

Prevention of Complications

• Early catheter removal reduces risk of catheter-associated UTIs 2
• Encourage high fluid intake during the day and decreased fluid intake in the evening 2
• Implement behavioral techniques such as double voiding, relaxation techniques, and warm sitz baths to improve voiding success 1

By following this protocol, healthcare providers can standardize the approach to voiding trials, minimize catheter use, and reduce the risk of complications such as urinary tract infections and prolonged retention.