Routine Irrigation of Chronic Foley Catheters in Paraplegics
Routine scheduled irrigation of chronic indwelling Foley catheters is not recommended for clot prevention in paraplegic patients. Instead, irrigation should only be performed when catheter obstruction occurs or is imminent.
Evidence Against Routine Irrigation
The available evidence does not support prophylactic scheduled irrigation:
A prospective study of 1,000 catheter-days found that routine irrigation with sterile solution had no effect on clinical outcomes except reducing catheter plugging episodes, but was costly and time-consuming. 1
Routine irrigation increases the risk of introducing bacteria into a closed drainage system, which accelerates biofilm formation and infection risk. 2
All chronic indwelling catheters become colonized with bacteria and develop biofilm regardless of irrigation practices. 2
When to Irrigate: Therapeutic Rather Than Prophylactic
Irrigation should be reserved for specific clinical situations:
Irrigate only when catheter obstruction occurs or when decreased flow/increased resistance is detected. 3
Use saline as the first-line irrigation solution when obstruction develops, applying forceful manual irrigation to restore patency. 4
If saline irrigation fails to restore flow and blood clots are suspected, fibrinolytic agents (urokinase or alteplase) should be instilled with a dwell time of at least 30 minutes. 4
Optimal Catheter Management to Prevent Clots
Rather than scheduled irrigation, focus on these evidence-based strategies:
Change the indwelling catheter every 5 days maximum, as bacteria can cause encrustation and blockage within 24 hours in some cases. 5
Maintain a closed drainage system at all times—avoid breaking the system for irrigation unless obstruction occurs. 2
Ensure adequate hydration with 2-3 liters of fluid daily unless contraindicated, as concentrated urine increases crystal formation and clot risk. 4
Monitor for signs of catheter dysfunction including decreased urine output, bypassing around the catheter, bladder distention, or suprapubic discomfort. 4
Special Considerations for Paraplegic Patients
Intermittent catheterization every 4-6 hours is strongly preferred over chronic indwelling catheters when feasible, as it significantly reduces infection and complication rates. 4, 6
If an indwelling catheter is medically necessary, consider suprapubic catheterization rather than urethral, especially in males, as it reduces periurethral complications and discomfort. 2
For paraplegic patients with neurogenic bladder, anticholinergic medications may be needed if detrusor overactivity is present on urodynamic studies. 7
Critical Pitfalls to Avoid
Do not establish a routine irrigation schedule (e.g., "irrigate every 8 hours")—this increases infection risk without proven benefit. 1
Do not use the catheter for blood sampling or medication administration, as this introduces bacteria and increases occlusion risk. 4
Do not ignore early signs of obstruction—partial obstruction can rapidly progress to complete blockage, bladder distention, and autonomic dysreflexia in paraplegic patients. 5
Do not assume all decreased flow is due to clots—mechanical kinking, external compression, or catheter malposition are common causes that irrigation will not resolve. 4
When Continuous Bladder Irrigation Is Indicated
Continuous bladder irrigation (CBI) through a three-way catheter is indicated only when active bleeding with clot formation is present, such as after urologic surgery or trauma. 3, 8
For CBI, use 22F or 24F three-way catheters, which provide optimal irrigation and drainage flow rates. 8
CBI should be discontinued once urine clears and is not maintained as chronic prophylaxis. 3