1. Catheter Care
Jacinta Stewart Urology & Continence Nurse

2. Indications for Long Term Catheter Use
Long term urinary catheters should only be used with
Clients who cannot satisfactorily be managed with less
invasive means
For example:
Neurological disorders causing paralysis, or loss of sensation leading to voiding difficulties
Urinary retention – when ISC not an option
To manage severe incontinence - as a last resort
When incontinence poses a risk of skin breakdown, or infection to nearby surgical sites
Palliative care at end of life

3. Catheter Types Indwelling urethral catheter
Indwelling suprapubic catheter
Clean Intermittent Self Catheterisation
Intermittent catheterisation (less common)
Intermittent catheterisation would be used by someone who uses other means to manage their bladder and wants a break for a short time e.g. MS pt who does ISC

4. Catheter Types Polyvinylchloride (PVC) Latex Silicone
Nelaton catheter for ISC
large internal diameter so drains easily
inexpensive
intended for single use according to manufacturers’ instructions
Latex
Not commonly used
disadvantages due to allergies
high risk of encrustation
can only be used for short term
Silicone
Commonly used
larger lumen (uncoated), drains more easily
less inclined to become encrusted
softer, therefore comfortable
balloons tend to lose water over time through osmosis
12 weeks insitu (e.g. Releen®)

5. Catheter Types Silicone elastomer-coated Hydrogel-coated Silver-coated
latex catheter coated with silicone
behaves like a silicone catheter
unsuitable for latex sensitivities
2 to 4 weeks insitu (e.g. Bardia®)
Hydrogel-coated
very soft; coating designed to absorb fluid (hydrophilic) which forms a smooth surface, so reduces friction and urethral irritation
good choice for clients with Urethral pain
12 weeks insitu (e.g. Biocath®)
Silver-coated
manufactured using silver alloy with hydrogel
reduces and delays the incidence and onset of biofilm formation, but only for less than one week
may be useful in symptomatic UTI
available in both silicone and latex
12 weeks insitu (e.g. BARDEX® I.C.)

7. Catheter Equipment Catheter change pack Long term catheters
Sterile gloves
Cleaning solution, e.g. sterile water, chlorhexidine
Lubricant - Sterile anaesthetic lubricating gel (as per policy)
10mls sterile H2O for balloon inflation
10ml syringe
Catheter of appropriate size and length
Long term catheters
100% silicone
Biocath
Releen
Cath straps & leg bag holders
Leg bags
Different types and sizes; consider ease of use for client
Overnight drainage
Bag or bottle
Catheter Valves
Silicone
Simpla
Releen
Bardia - Silicone Elastomer coated
Biocath - Hydrogel coated
Bardex – Lubricious/silver coated
Nelaton

8. FlexiTrak Is not recommended in my experience because it doesn’t stick very well. Better to use an elastic/velco strap e.g. Cathstrap or similar

9. Tips when Inserting Urinary Catheters
Consent, reassurance and explanation for client
Aseptic technique
Male and female length catheters
What size should be used?
Lubricant gel
How far do you insert the catheter?
What do you inflate the balloon with?
How much fluid in the balloon?
Secure attachment of catheter
Aseptic technique – bladder is a sterile environment & we are introducing a foreign body into it
Rarely use female length IDC’s
Generally 14Fg for females & 16Fg for males
Lignoacaine gel
Insert until urine flow – Males – all the way to bifurcation then inflate; females insert approx 5 to 7 cm then inflate. Don’t inflate until urine flows
Only sterile H2O

10. Insertion Tips
Aseptic technique: is mandatory for all catheter insertions to prevent infection
Length:
Male length ( cm) is standard for both male & female use
Female length ( cm) not commonly used; provides discretion & comfort for long-term, ambulant client. Not appropriate for bed bound or obese clients due to high risk of urethral trauma. Must never be used for male clients
Size:
Catheters are measured in Charriere (Ch) or French gauge (Fg or Fr) which indicates the external diameter. Sizes range from Fg. There is an international colour code for catheter sizes (usually on the inflation port)
General Guide
Fg Paediatric
Fg Females
Fg Males
Fg Suprapubic
Fg Haematuria

11. Insertion Tips
Lubricant gel: Minimises pain & urethral trauma. Must be water soluble. Local anaesthetic gel is preferable for all catheterisations
Males: Use Lignocaine gel. Apply a small amount to the then instill the remainder of lubricant syringe contents into the urethra. Warn the client that the gel may sting. Hold urethral meatus closed with thumb & forefinger to prevent gel from escaping from urethra. Aim is to get lubricant to bladder neck, to reduce discomfort
Females: Apply a generous amount of lubricant to the catheter prior to insertion
How far to insert Catheter?
Males: Urethra is approx 15 – 25cm long. Insert the entire length of catheter, to the Y bifurcation at the inflation port. Don’t inflate balloon until urine flows, stop if client has pain. This will ensure IDC correctly placed and not in the prostatic urethra or bladder neck
Females: Urethra is approx 4cm long, so insert catheter about 7cm. Insert another 2 to 3 cm further, then inflate balloon once urine flows

12. Insertion Tips What to inflate balloon with:
Use only sterile water. Never use normal saline; balloons can lose fluid due to osmosis, leaving salt crystals in balloon making deflation & removal difficult and traumatic
How much fluid in the balloon:
Inflate to size indicated on inflation port (5ml to 10 ml)
No need to check balloon prior to insertion by inflating - can cause balloon ridging, therefore trauma (quality tested at manufacture)
If client requires less in balloon, inflate to full size then remove required amount

13. Correct Inflation of the Balloon

14. Catheter Securement
Remember, a catheter is not a bungee….

15. Catheter Securement
IDC’s should be well secured for Client comfort and in order to prevent bladder neck and urethral trauma, bladder spasm, traumatic dislodgment or haematuria
There are several devices available to provide securement. Use the device which suits your Client best
The device will only work to secure the IDC if it is correctly fitted and checked regularly. Ensure the Client or Client’s family and Carers know how to adjust it appropriately

16. Catheter Securement: Cathstrap

17. Catheter Securement: Cathstrap & Holder

18. Catheter Securement: Flip-Flo Valve

19. Complications Associated with Long Term Catheters
Infection - CAUTI
Bladder spasm
Haematuria – cause?... Infection, trauma…
Leakage, bypassing
Paraphimosis
Urethral trauma
Balloon inflation within the urethra
False passage
Un-prescribed removal – usually traumatic
Obstruction due to encrustation
Alternate strapping to prevent pressure ulcers. Clean around foreskins, replace foreskins

20. Complications Associated with Long Term Catheters
Stones (bladder)
Periurethral abscess
Pain – bladder, urethral, penile tip
Urethral erosion
Fistula formation
Epididymitis, epidiymal orchitis
Urethritis, blepharitis

21. Encrustation & Blocking
Results from bacteria in urine, commonly Proteus
Produces an enzyme called urease which splits urinary urea into carbon dioxide & ammonia
This makes urine more alkaline, an ideal environment for crystals to develop around catheter eyelets, balloons and internal lumens, leading to encrustation
Debris:
urothelial cells from the bladder
blood from infection
tumour cells
urological surgery
or from mucous
‘Blockers’ are usually less active than ‘non blockers’
An alkaline pH has a strong association with catheter encrustation
Urine normally acidic – between pH 5 and pH 6
Blockers have high urinary pH, plus high ammonia and calcium concentrations compared to non-blockers
Establish a pattern of catheter dwell time and change IDC accordingly

22. So Basically…
Don’t give Clients Ural or similar (it makes urine alkaline)
Make sure Clients are drinking enough – spread fluids evenly throughout the day
Make sure their bowels are working
Change IDC’s at regular intervals, before blocking occurs

23. Examples of Encrustation

24. An option for difficult cases…

25. Suprapubic Catheters
Indicated in wheelchair bound or immobile clients e.g. MS, spinal cord injury
Thought to have lower infection rates, increased acceptance and ease of self care
Contraindicated in clients with chronically unstable bladders
UTI’s, leakage, bladder spasm and difficult removal may occur
36% of people with a suprapubic for over 10years will develop stones (Nomura et al 2000)
People with long term IDC using ditropan decrease the incidence of kidney disease i.e. 3% compared to 23% in Pt not taking ditropan

27. Suprapubic Catheters Initial insertion
As Inpatient
Wound care until cystostomy heals – simple gauze and Betadine dressing
Routine changes – schedule according to need
First change is often done in Urologist’s Rooms
Subsequent changes by DNS or RN/EN in Residential facility. Normally uncomplicated
Dislodged SPC must be reinserted very promptly (within ½ hr)
Difficulty in removing catheter
Check deflation of balloon; balloon memory/ridging
Encrustation issues?
Releen & Bard 16Fg are recommended to avoid
these issues
Localised pain related to skin tags, securement issues

28. Suprapubic Catheters
If unsecured may cause enlargement and erosion of SPC tract, therefore leakage
Urethral bypassing can still occur
Use of anti-cholinergic (Ditropan) in Clients with long term indwelling catheters can significantly reduced the incidence of bladder spasm and kidney damage (hydronephrosis). Be aware of side effects

29. SPC Securement Secure with Cathstrap to thighOr
Abdominal Cathstrap is an option:
Technically, this Pt has a continent stoma rather than a SPC, but it illustrates the abdo cathstrap

30. Looking after IDC’s
Luckily it’s not……
….Rocket science

31. IDC’s - General Care Maintain Closed drainage system Hand Hygiene
Good meatal hygiene – soap and water or cleansing wipes; avoid talc & creams around IDC
Adequate fluid intake, including in the evening prior to bed and during the night if awake
Empty leg bags when ½ to 2/3 full

32. IDC’s - General Care +/-Cranberry Juice Preventing Constipation
Preventing trauma and traction on catheter
Remember, there should never be tension on the IDC
Good practice is to alternate legs for securement, which reduces incidence of penile or labial erosions
Regular IDC & bag changes as per Policy & Manufacturers’ guidelines
Generally for Community clients:
IDC’s 12 weeks
Leg bags weekly
Night bags weekly. Wash out between uses

33. Urethral trauma due to poor securement

34. Keeping Track – Documentation
Recording IDC insertion and changes should be simple and easy
Use a sticker placed in Client’s Record or an approved MR Form that travels with the Client

35. Keeping Track – Documentation

36. IDC’s - Troubleshooting
Sediment in the urine
Increase fluid intake
Blood in the urine
Small amounts of blood can make urine quite red
Check securement
Increase fluids
Investigate if it doesn’t clear
Bladder spasm or cramps
Can be common with new catheter
Constipation?
May need an anticholinergic if very troublesome

37. IDC’s - Troubleshooting
Leaking and Bypassing
Common issue
IDC’s do not form a watertight seal
May be due to bladder spasm
Ensure well secured!
Rule out constipation
Tubing kinked or blocked?
IDC may need changing more frequently e.g. 6 to 8 weeks (blocking)

38. IDC’s - Troubleshooting
No urine drainage
Kinked or blocked tubing
Not drinking enough, dehydration
Constipation?
Bag below bladder level?
Bag connected incorrectly,
particularly leg bag to night bag

39. IDC’s - Troubleshooting
Expelling IDC’s
May be due to bladder spasm
+/- constipation
Balloon too large? Try deflating by 2-3mls with next IDC
Seek advice from Continence Nurse
May need anticholinergic
Client may have bladder stones – if balloon is broken, this may be the culprit!
Check balloon inflation, especially if IDC has been in for a few weeks. May have lost fluid (osmosis)
Check securement
Can your Client manage without the IDC?

40. IDC’s - Troubleshooting
Unable to deflate Balloon
Manipulate the valve with a different syringe. Can take time to deflate
Insert an 18g needle into the inflation channel and aspirate the fluid
Don’t cut the inflation port or the catheter
May need to be removed with U/S guidance

41. Catheter Flushing
Contentious issue; evidence is thin whether it’s of value, BUT practice suggests it’s helpful in the Clinical setting for blockers
Advice of Doctor/Urologist required
No prescribed regime of what to use, how much to use or how often to do
Some use Normal Saline; others a weak acetic acid solution (vinegar and water 1:5 or 1:10) up to 50mls. Commercial products available. Instil at varying intervals depending on frequency of blockages
Can assist in removing debris, mucous
Doesn’t remove crystal trapped in biofilm on catheter
Can cause inflammation and damage to bladder lining (urothelium)
Requires the closed drainage system to be broken – increased risk of infection

42. Thanks for Your Attention 
My Puppy, Ellie

43. References