When is a Foley catheter indicated?

Indications for Foley Catheter Insertion

Foley catheters should be used only when clearly indicated, with daily assessment of continued need, and removed as early as possible (within 24-48 hours when feasible) to minimize complications including catheter-associated urinary tract infections (CAUTIs) and genitourinary trauma. 1

Appropriate Indications for Foley Catheter Use

Definite Indications

• Acute urinary retention or bladder outlet obstruction that cannot be managed by other means
• Accurate measurement of urinary output in critically ill patients when fluid status cannot be assessed by other means (not just because a patient is in ICU) 2
• Perioperative use for specific surgical procedures:
  • Urologic surgery or surgery on contiguous structures of the genitourinary tract
  • Anticipated prolonged surgery (>4 hours)
  • Large-volume infusions or diuretics during surgery
  • Need for intraoperative monitoring of urinary output

Conditional Indications

• Management of incontinence in:
  • Patients with stage III-IV pressure ulcers with wounds that could be contaminated by urine 3
  • End-of-life care where comfort is the priority
• Prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries)

Inappropriate Uses of Foley Catheters

• Convenience for staff or as a substitute for nursing care in incontinent patients
• Routine use in ICU without specific indications 2
• Prolonged postoperative use without specific indications
• Substitute for adequate nursing care in patients with dementia or confusion
• Obtaining urine specimens when patient can void voluntarily
• Prolonged bed rest (use alternatives like scheduled toileting, bedside commode)

Alternatives to Consider Before Foley Catheter Insertion

• External condom catheters for cooperative male patients without urinary retention
• Intermittent straight catheterization for patients requiring periodic bladder emptying
• Scheduled toileting or bedside commodes for mobile patients
• Absorbent pads or briefs for incontinent patients without skin breakdown

Minimizing Complications When Foley Catheters Are Necessary

Infection Prevention

• Use strict aseptic technique during insertion
• Select appropriate catheter size (typically 14-16 Fr for adults)
• Secure catheter properly to prevent movement and urethral trauma 1
• Maintain a closed drainage system
• Clean the catheter exit site daily 1

Trauma Prevention

• Use adequate lubrication during insertion
• Avoid excessive balloon inflation
• Prevent catheter tugging or pulling
• Consider silver alloy-coated catheters for prolonged catheterization 1

Daily Assessment

• Document daily assessment of continued need for catheter 3
• Monitor for signs of UTI (fever, cloudy urine, change in mental status) 1
• Evaluate for catheter removal as soon as possible 3

Special Considerations

• Perform retrograde urethrography before attempting catheterization in patients with blood at the urethral meatus after pelvic trauma 1
• Consider suprapubic tube placement in cases of confirmed urethral disruption or complex bladder repairs 1
• Limit use of urinary catheters to eliminate frequent nosocomial UTIs in patients with cirrhosis/ACLF 3
• Remove Foley catheters as part of infection prevention measures in geriatric patients 3

Remember that catheter-related genitourinary trauma is as common as symptomatic UTI, with approximately 1.5% of catheter days resulting in trauma, of which 32% require interventions such as prolonged catheterization or cystoscopy 4. Early removal is the best strategy to prevent both infection and trauma complications.