What are the guidelines for urinary catheterization?

Guidelines for Urinary Catheterization

Indications for Catheter Use

Indwelling urinary catheters should only be inserted for specific clinical indications and never for staff convenience. 1, 2, 3

Appropriate Indications:

• Acute urinary retention or bladder outlet obstruction requiring continuous drainage 2, 3
• Perioperative use for specific surgical procedures (urologic surgeries, procedures requiring precise urine output monitoring) 2, 3
• Wound healing in sacral, perineal, or buttock areas where urine contact would impair healing 2, 3
• Prolonged immobilization in critically ill or severely injured patients 2, 3
• Palliative care for terminally ill patients when comfort is prioritized 3
• Accurate urine output measurement in hemodynamically unstable patients 2

Inappropriate Indications (Never Use For):

• Staff or caregiver convenience 3
• Routine incontinence management 3
• Obtaining urine cultures from patients who can void 3
• Incontinence-related dermatitis alone 3

Catheter Selection Hierarchy

Intermittent catheterization should be strongly preferred over indwelling catheters whenever feasible, as it significantly reduces urinary tract infections, urethral trauma, bladder stones, and improves quality of life. 2

Decision Algorithm:

1. First Choice: Intermittent Catheterization

   • Use for acute or chronic urinary retention (postvoid residual >300 mL) without bladder outlet obstruction 2, 3
   • Significantly lower infection rates compared to indwelling catheters 2
   • Best quality of life outcomes 2
   • Can use clean technique in hospitalized patients (not sterile required) 4

2. Second Choice: External Condom Catheters (for men)

   • For male patients with incontinence and postvoid residual <300 mL 3
   • Reduces CAUTI risk 5-fold compared to indwelling urethral catheters (hazard ratio 4.84) 5
   • Not appropriate for patients with dementia 5

3. Third Choice: Suprapubic Catheterization

   • When long-term catheterization is required (>2 weeks) 2
   • Lower risk of bacteriuria than urethral catheters (2.60 times lower risk) 2
   • Reduced urethral trauma and stricture risk 2
   • Allows attempts at normal voiding without recatheterization 2

4. Last Resort: Indwelling Urethral Catheterization

   • Only when above options are not feasible 2
   • Remove as soon as clinically indicated 1, 5

Insertion Technique Requirements

Use strict aseptic technique with sterile equipment for all catheter insertions. 5

Key Steps:

• Clean meatal area with chlorhexidine before insertion 5
• Use sterile gloves and sterile catheter for insertion 5
• Secure catheter adequately to prevent movement and urethral traction 5
• Establish closed drainage system immediately upon insertion 1, 5

Contraindications to Urethral Catheterization:

• Urethral trauma or suspected urethral injury 2
• Acute prostatitis 2
• Urethral stricture 2

Essential Maintenance Practices

Always maintain a closed catheter drainage system with the collection bag below bladder level—this is the single most important infection prevention measure. 1, 5

Daily Management:

• Keep drainage bag below bladder level at all times to prevent bacterial reflux 1, 5
• Minimize disconnection of catheter junction 1
• Use preconnected systems (catheter preattached to drainage bag) when possible 1
• Implement mandatory daily evaluation of catheter necessity with automatic stop orders 5
• Ensure adequate hydration to maintain good urine flow 2
• Perform routine perineal hygiene (but NOT daily meatal cleansing with antiseptics) 1, 2

What NOT to Do:

• Do NOT perform routine catheter irrigation with saline or antimicrobials 1, 5
• Do NOT add antimicrobials or antiseptics to drainage bags 1
• Do NOT raise drainage bag above bladder level 1
• Do NOT use daily meatal cleansing with antiseptic solutions 1

Infection Prevention and Management

Do NOT screen for or treat asymptomatic bacteriuria in catheterized patients, as treatment does not improve outcomes and promotes antimicrobial resistance. 1

Exceptions (When to Treat Asymptomatic Bacteriuria):

• Before urologic procedures involving mucosal trauma (give 1-2 doses of targeted antimicrobials 30-60 minutes preoperatively) 1, 5
• Pregnant women 5

Diagnosing Symptomatic CAUTI:

Diagnose based on clinical symptoms, not bacteriuria alone 1:

• New onset fever without another identified cause 1
• Suprapubic tenderness 1
• Costovertebral angle pain or tenderness 1
• Acute hematuria 1
• New onset delirium (especially elderly) 1

Treatment of Symptomatic CAUTI:

• Obtain urine culture before starting antimicrobials 1
• Remove or change catheter if in place >2 weeks 1
• Select antimicrobials based on local resistance patterns and culture results 1

Catheter Removal Timing

Remove catheters as soon as they are no longer clinically indicated—duration of catheterization is the single most important modifiable risk factor (5% increased infection risk per day). 1, 5

At Time of Removal:

• For patients with risk factors (noninfectious urinary tract disease, post-urologic surgery): consider single-dose or 3-day antimicrobial prophylaxis 6
• For low-risk patients: no antimicrobial prophylaxis needed 6
• Alternative approach: obtain urine culture and give culture-directed treatment only if positive 6

Special Catheter Types

Antimicrobial-Coated Catheters:

• May consider for short-term catheterization (<14 days) to delay bacteriuria onset 1, 5
• Use only in settings with persistently high CAUTI rates despite implementing all prevention strategies 5
• Insufficient evidence for preventing symptomatic CAUTI 5

Common Pitfalls to Avoid

• Never use catheters solely for staff convenience or routine incontinence 3
• Never treat asymptomatic bacteriuria (except pre-urologic procedures or pregnancy) 1, 5
• Never use prophylactic systemic antimicrobials for catheterized patients 5
• Never forget daily assessment of continued catheter necessity 5
• Avoid indwelling catheters in stroke patients when possible—they independently predict worse outcomes and should be removed as soon as medically and neurologically stable 6