What is the recommended order for removing an epidural and a Foley (urinary) catheter?

Epidural and Foley Catheter Removal Order

Remove the epidural catheter first, then remove the Foley catheter after the epidural has been discontinued. This sequence significantly reduces the risk of urinary retention requiring recatheterization.

Evidence-Based Removal Sequence

The Foley catheter should remain in place until after epidural analgesia has been discontinued to minimize urinary retention risk. 1 Patients who have their urinary catheter removed before epidural discontinuation are nearly 4 times more likely to develop urinary retention requiring recatheterization (OR 3.8,95% CI 1.5-9.7). 1

Step-by-Step Protocol

1. Discontinue the epidural infusion first 1

   • Allow adequate time for epidural effects to wear off (typically 4-6 hours after discontinuation) 1

2. Remove the epidural catheter 2

   • Standard practice is removal on postoperative day 2 in most surgical patients 2
   • Ensure appropriate coagulation status before removal if patient is on anticoagulation 3

3. Remove the Foley catheter only after epidural discontinuation 1

   • Wait until the patient has regained normal bladder sensation 1
   • This timing dramatically reduces urinary retention rates from 15% to 4.7% 1

Clinical Rationale

Epidural analgesia significantly impairs bladder function through sympathetic and parasympathetic blockade, preventing normal detrusor muscle contraction and sphincter relaxation. 4, 5 The urinary retention rate with epidurals in place is substantially elevated:

• 55% retention rate with epidural and early Foley removal 5
• 26.7% retention rate even after early catheter removal with epidural 4
• Only 4.7% retention rate when Foley is removed after epidural discontinuation 1

Removing the Foley before the epidural is discontinued leaves patients unable to void effectively while simultaneously removing their bladder drainage system, creating a high-risk situation for acute urinary retention. 1

Important Timing Considerations

For patients on anticoagulation or with coagulopathy, epidural catheter removal requires specific timing relative to anticoagulant dosing:

• Remove catheter ≥12 hours after last LMWH dose 3
• Ensure platelet count >75,000 and normal coagulation before removal 3
• Next anticoagulant dose should be delayed ≥12 hours after catheter removal 3

Cost and Morbidity Impact

Urinary retention from premature Foley removal incurs significant additional costs averaging $15,000 per patient who requires recatheterization. 1 Beyond financial impact, recatheterization increases:

• Patient discomfort and anxiety 1
• Urinary tract infection risk 4
• Hospital length of stay 1

Common Pitfalls to Avoid

Never remove the Foley catheter while the epidural is still running or within 4-6 hours of discontinuation, as this is the highest-risk period for urinary retention. 1 The temptation to remove both catheters simultaneously on postoperative day 2 should be resisted—stagger the removals by several hours minimum. 2, 1

Do not assume younger patients or those without urinary history are at low risk—the epidural effect on bladder function is universal and age-independent. 5, 1

Avoid early Foley removal protocols in epidural patients despite pressure to minimize catheter-associated UTI risk, as the urinary retention risk far outweighs the modest infection benefit. 4, 1