How do you assess a patient's ability to urinate before removing a urinary catheter?

Assessment of Urinary Function Before Catheter Removal

Before removing a urinary catheter, assess the patient's ability to void by performing a bladder scan or straight catheterization to measure post-void residual volume, with intermittent catheterization recommended if post-void residual volume is >100 mL. 1, 2

Pre-Removal Assessment

• Evaluate the patient's medical stability and neurological status before attempting catheter removal 1
• Consider administering a non-titratable alpha blocker (e.g., tamsulosin or alfuzosin) prior to catheter removal to improve chances of successful voiding, especially in patients with BPH 1, 2, 3
• Remove the catheter as soon as the patient is medically and neurologically stable to reduce infection risk 1
• Avoid prolonged catheterization as UTIs occur in approximately 15-60% of stroke patients and independently predict poor outcomes 1

Voiding Trial Techniques

Back Fill Method (Preferred)

• Fill the bladder with 300 cc saline before removing the Foley catheter 4
• This technique shows better correlation with successful voiding trials compared to auto fill (spontaneous filling) 4

Auto Fill Method

• Remove the catheter and allow the bladder to fill spontaneously 4
• Less predictive of adequate postoperative bladder emptying compared to back fill technique 4

Post-Removal Monitoring

• Measure post-void residual volume within 15 minutes after voiding using a bladder scanner or straight catheterization 1, 2, 4
• Consider a successful void when the patient empties at least two-thirds of the total bladder volume (voided volume plus post-void residual) 4
• Implement intermittent catheterization if post-void residual volume exceeds 100 mL 1
• Monitor for signs of urinary retention such as bladder distention, discomfort, and inability to void 1, 2

Special Considerations

• For patients with stroke, assess for neurogenic bladder, hyperreflexia with urge incontinence, and urinary retention with or without overflow incontinence 1
• In patients with BPH, a voiding trial is more likely to be successful if the underlying retention was precipitated by temporary factors (e.g., anesthesia or medications) 1, 2
• For patients with refractory retention who fail at least one attempt at catheter removal, surgical intervention may be necessary 1, 2
• For patients who cannot undergo surgery, treatment with intermittent catheterization, an indwelling catheter, or stent is recommended 1, 2

Bladder Training Program

• Initiate a bladder-training program to decrease incontinent episodes 1
• Offer the patient a commode, bedpan, or urinal every 2 hours during waking hours and every 4 hours at night 1
• Encourage high fluid intake during the day and decreased fluid intake in the evening 1
• Use prompted voiding techniques for patients with urinary incontinence 1, 2

Common Pitfalls and Caveats

• Bladder training by catheter clamping before removal offers no advantage over free drainage removal and is not indicated 5
• Avoid delaying surgical intervention in patients with refractory retention as this can lead to bladder decompensation and chronic retention 2
• Be aware that patients with prostatism under medication have significantly higher odds of requiring re-catheterization (odds ratio 26.42) 5
• Remember that indwelling catheters should be avoided if possible, with alternatives including external catheters, incontinence pants, and intermittent catheterization 1