Does bladder training help before attempting urinary catheter removal?

From the Guidelines

Bladder training before removing a urinary catheter is recommended for patients who are incontinent of urine, as it can help improve outcomes and reduce complications. The evidence suggests that a bladder-training program should be implemented in patients who are incontinent of urine, including timed and prompted toileting on a consistent schedule 1. This approach can help assess the patient's ability to void normally and reduce the risk of urinary retention or urinary tract infections. In fact, the use of a bladder-training program is supported by evidence level C, which recommends implementing such a program in patients who are incontinent of urine 1. Additionally, the evidence suggests that prompted voiding can lead to short-term improvement in incontinence symptoms, although the quality of the evidence is medium and may not be generalizable to all stroke patients 1. However, it is essential to weigh the benefits of bladder training against the potential risks, such as increased infection risk associated with prolonged catheter time. After catheter removal, healthcare providers should monitor for successful voiding within 4-6 hours, measuring post-void residual volumes if needed. Some key points to consider when implementing a bladder-training program include:

• Assessing the patient's ability to void normally and identifying any underlying urological issues
• Implementing a timed and prompted toileting schedule on a consistent basis
• Monitoring for successful voiding and measuring post-void residual volumes as needed
• Weighing the benefits of bladder training against the potential risks, such as increased infection risk.

From the Research

Bladder Training Before Urinary Catheter Removal

• The effectiveness of bladder training before removing a urinary catheter has been studied in various clinical trials 2, 3, 4, 5, 6.
• A randomized controlled trial published in the International Journal of Nursing Studies found that bladder training by catheter clamping offers no advantage over free draining removal of short-term urinary catheters in patients with total hip and knee arthroplasty 2.
• Another study published in the Scandinavian Journal of Urology found that bladder training before urinary catheter removal did not increase the chance of trial without catheter (TWOC) success significantly in spontaneous acute urinary retention (AUR) patients with benign prostatic hyperplasia (BPH) 3.
• A systematic review and meta-analysis published in BMJ Open found that bladder training by clamping indwelling urinary catheters increases the incidence of urinary tract infection and lengthens the hours to first void in patients with indwelling urinary catheters use durations of ≤7 days compared with the free drainage 6.

Outcomes of Bladder Training

• The outcomes of bladder training have been evaluated in terms of urinary tract infection incidence, hours to first voiding, incidence of urinary retention and recatheterisation, and residual urine volume 6.
• A Cochrane systematic review found that the limited evidence available suggests that bladder training may be helpful for the treatment of urinary incontinence, but this conclusion can only be tentative as the trials were of variable quality and of small size with wide confidence intervals around the point estimates of effect 5.
• A metastudy of four Cochrane systematic reviews on bladder training and voiding programmes found that frequency of incontinence was the most common and constant outcome measure of effectiveness in the reviews, but limited data were available on other health outcomes, change in dependency status, quality of life, and cost-effectiveness 4.

Clinical Implications

• The findings of these studies suggest that bladder training may not be necessary before removing a urinary catheter in all patients, and that the decision to use bladder training should be based on individual patient needs and circumstances 2, 3, 6.
• Healthcare providers should monitor patients' urination after removal of the catheter to detect any potential complications, such as urinary retention or urinary tract infection 2, 6.