What are the guidelines for performing a bladder wash?

Guidelines for Performing a Bladder Wash

Bladder irrigation should not be routinely performed as it has not been shown to effectively reduce catheter-associated bacteriuria or catheter-associated urinary tract infections (CA-UTIs) in patients with indwelling catheters. 1

Indications for Bladder Irrigation

• Bladder irrigation is primarily indicated to restore or maintain the patency of an indwelling urinary catheter, not as a routine preventive measure 2
• Bladder irrigation with antiseptics may be beneficial in specific surgical scenarios:
  • For patients undergoing transurethral operations, where chlorhexidine irrigation has shown to reduce postoperative CA-bacteriuria 1
  • For orthopedic patients undergoing single or short-term intermittent urethral catheterization, where povidone-iodine irrigation after each catheterization reduced CA-bacteriuria 1
  • For patients undergoing open prostatectomy, where preoperative bladder washing with povidone-iodine reduced postoperative CA-bacteriuria 1

Contraindications

• Routine bladder irrigation with antimicrobials or antiseptics should not be used to reduce CA-bacteriuria or CA-UTI in general catheterized patients 1
• Do not apply topical antiseptics or antimicrobials to the catheter, urethra, or meatus 1
• Avoid bladder irrigation in patients with long-term indwelling catheters as it has shown no benefit in reducing bacteriuria, pyuria, catheter obstructions, or febrile episodes 1

Procedure for Necessary Bladder Irrigation

When bladder irrigation is clinically indicated (such as before urologic procedures with mucosal trauma):

1. Obtain a urine culture prior to the procedure to guide targeted antimicrobial therapy 1
2. For surgical procedures with mucosal trauma, treat catheter-associated asymptomatic bacteriuria before the procedure 1
3. If performing irrigation:
   • Use sterile technique throughout the procedure 2
   • Consider using normal saline solution rather than antimicrobial solutions, as studies show no advantage of neomycin-polymyxin or acetic acid over saline 3
   • For pre-surgical irrigation, administer the solution 30-60 minutes before the procedure 1

Special Considerations

• For patients undergoing endoscopic urologic procedures associated with mucosal trauma:

  • Screen for and treat asymptomatic bacteriuria prior to surgery 1
  • Use a short course (1 or 2 doses) rather than prolonged antimicrobial therapy 1
  • Initiate antimicrobial therapy 30-60 minutes before the procedure 1

• For patients with indwelling catheters:

  • Replace or remove the indwelling catheter before starting antimicrobial therapy for symptomatic CA-UTI 1
  • Minimize the duration of catheterization to reduce infection risk 1
  • Use hydrophilic coated catheters to reduce CA-UTI 1

Evidence Against Routine Bladder Irrigation

• Studies involving patients with neurogenic bladders and indwelling catheters showed that twice-daily bladder irrigation with neomycin-polymyxin, acetic acid, or saline had no effect on CA-bacteriuria compared to no irrigation 1
• In a randomized cross-over trial of women with long-term catheterization, once-daily normal saline irrigation for 10 weeks showed no difference in bacteriuria prevalence, catheter obstructions, or febrile episodes compared to no irrigation 1
• For patients with neurogenic bladder, an 8-week study comparing saline, acetic acid, and neomycin-polymyxin solutions found no advantages of any solution in reducing urinary bacterial load or inflammation 3

Important Pitfalls to Avoid

• Do not use bladder irrigation as a means of preventing CA-UTI in general catheterized patients 1
• Avoid routine addition of antimicrobials or antiseptics to drainage bags, as this has not been shown to reduce CA-bacteriuria or CA-UTI 1
• Do not rely on bladder irrigation to treat bacteriuria in patients with neurogenic bladder 3
• Cleaning must always precede high-level disinfection and sterilization of any equipment used 4