Is a sterile normal saline (NS) bag sufficient for bladder irrigation through a 3-way Foley catheter?

Is Sterile Normal Saline Sufficient for Bladder Irrigation Through a 3-Way Foley Catheter?

Yes, sterile normal saline from a standard IV bag is the appropriate and recommended solution for continuous bladder irrigation through a 3-way Foley catheter. 1

Standard of Care for Bladder Irrigation

Sterile normal saline is explicitly recommended by the Infectious Diseases Society of America as the standard irrigation solution for continuous bladder irrigation (CBI) through 3-way Foley catheters. 1 This applies across clinical settings, from acute post-operative care to skilled nursing facilities.

Primary Indication: Active Hematuria Management

• Use CBI with normal saline when there is active hematuria to prevent catheter obstruction from blood clots, particularly following urological procedures such as TURP, TURB, or open prostatectomy. 1, 2
• Continue irrigation as long as there is persistent visible hematuria in the drainage bag. 2
• The goal is clot prevention and maintaining catheter patency, not infection prevention. 3

Temperature Considerations

• Use room temperature or body temperature saline rather than cold water for patient comfort, though cold water is equally effective mechanically. 1
• Body temperature saline significantly improves patient tolerance without compromising efficacy. 1

What NOT to Do: Critical Pitfalls

Do NOT Add Antimicrobials or Antiseptics Routinely

• The Infectious Diseases Society of America explicitly recommends against routine addition of antimicrobials or antiseptics to the drainage bag (Grade A-I recommendation). 3
• Randomized trials of chlorhexidine, hydrogen peroxide, povidone-iodine, and silver ions added to drainage bags showed no benefit in reducing catheter-associated bacteriuria or UTI. 3
• In a study of 668 catheterized patients, hydrogen peroxide in the drainage bag showed no difference in bacteriuria rates compared to controls. 3

Do NOT Irrigate to Prevent Infection in Long-Term Catheterization

• Bladder irrigation with normal saline does not reduce catheter-associated bacteriuria or UTI in patients with long-term catheterization. 1, 4
• A randomized crossover trial of 32 women with long-term catheters showed that 10 weeks of daily normal saline irrigation versus no irrigation resulted in similar rates of bacteriuria, catheter obstructions, and febrile episodes. 3
• A double-blind study of 89 community-residing persons with neurogenic bladders found no effect on bacteriuria levels from twice-daily irrigation with neomycin-polymyxin, acetic acid, or sterile saline. 3, 5

Do NOT Treat Asymptomatic Bacteriuria

• Asymptomatic bacteriuria in catheterized patients should not be treated with antibiotics or irrigation. 1, 4

Limited Exception: Perioperative Antiseptic Irrigation

Antiseptic bladder irrigation (chlorhexidine or povidone-iodine) may reduce postoperative bacteriuria only in the immediate perioperative period for patients undergoing transurethral operations, but this is a weak recommendation limited to surgical contexts. 3, 1

• In 89 men undergoing transurethral operations, postoperative chlorhexidine irrigation reduced bacteriuria to 12.8% versus 36.7% in saline controls (P < 0.02). 3
• In 156 patients undergoing open prostatectomy, preoperative povidone-iodine washing reduced postoperative bacteriuria to 22.5% versus 100% in controls (P < 0.001). 3
• However, this does NOT apply to routine long-term catheter management in non-surgical settings. 1

Special Circumstance: Fungal Cystitis

• For fluconazole-resistant fungal cystitis, Amphotericin B deoxycholate bladder irrigation (50 mg/L sterile water daily for 5 days) may be used. 1
• This is the only scenario where an alternative to normal saline is recommended. 1

Practical Setup and Monitoring

Equipment Setup

• Suspend the normal saline bag 80 cm above the indwelling 3-way Foley catheter. 6
• Connect the drainage tube to the irrigant port of the catheter. 6
• Maintain a closed drainage system at all times to minimize infection risk. 3, 4

When to Continue CBI

• Persistent visible hematuria in drainage bag 2
• Presence of urease-producing organisms (particularly Proteus mirabilis) causing catheter blockage 1, 2

When to Discontinue CBI

• Resolution of hematuria with clear urine output 2
• Stabilization of bleeding parameters 2

Catheter Selection Matters

• For optimal continuous bladder irrigation, Bardex 22F to 26F catheters demonstrated superior irrigation and drainage flow compared to Dover catheters in laboratory testing. 7
• The Bardex 22F and 24F catheters showed maximal manual irrigation flow rates of 8.9-9.5 mL/s through the irrigation port. 7