Chapter 6: Elimination
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Catheter‐associated complications
A number of complications can arise from having a urinary catheter. UTIs are one of the most common and are discussed in detail below. Other complications are outlined in Table 6.5.
Table 6.5 Complications of catheterization
| Problem | Cause | Suggested action |
|---|---|---|
| Inability to tolerate an indwelling catheter | Urethral mucosal irritation | Nurse may need to remove the catheter and seek an alternative means of urine drainage. |
| Previous trauma (e.g. sexual abuse) | Explain the need for and the functioning of the catheter and consider referral to psychological support for assessment and possible therapy. | |
|
Unstable bladder
Radiation cystitis | Pharmacological support may assist with catheter tolerance. If patient remains intolerant to indwelling catheter, refer to urology. | |
| Inadequate drainage of urine | Incorrect placement of a catheter | Resite the catheter. |
| Kinked drainage tubing | Inspect the system and straighten any kinks. | |
| Blocked tubing, e.g. from pus, urates, phosphates or blood clots | If a three‐way catheter, such as a Foley, is in place, irrigate it. If a two‐way Foley catheter is in use, milk the tubing in an attempt to dislodge the debris, then attempt a gentle bladder washout. Failing this, the catheter will need to be replaced; a three‐way catheter should be used if the obstruction is being caused by clots and associated haematuria. | |
| Fistula formation | Pressure on the penoscrotal angle | Ensure the catheter is correctly secured. |
| Penile pain on erection | Not allowing enough length of catheter to accommodate penile erection | Ensure that an adequate length is available to accommodate penile erection. |
| Formation of crusts around the urethral meatus | Increased urethral secretions collect at the meatus and form crusts, due to irritation of the urothelium by the catheter ( Fillingham and Douglas [78]) | Regular meatal cleansing using recommended technique. |
| Leakage of urine around the catheter | Incorrect catheter size | Replace with the correct size, usually 2 ch smaller. |
| Incorrect balloon size | Select a catheter with a 10 mL balloon. | |
| Use a Roberts tipped catheter. | ||
| Bladder hyperirritability | Consider pharmacological support such as anticholinergic drugs ( MacDiarmid [138]). | |
| Inability to deflate the balloon | Valve expansion or displacement | Check the non‐return valve on the inflation/deflation channel. If jammed, use a syringe and needle to aspirate the inflation channel above the valve. |
| Channel obstruction | Obstruction by a foreign body can sometimes be relieved by the introduction of a guidewire through the inflation channel (only under advice from urology). | |
| Inject 3.5 mL of 0.9% sodium chloride into the inflation arm (only under advice from urology). | ||
| Alternatively, the balloon can be punctured suprapubically using a needle under ultrasound visualization. | ||
| Following catheter removal, the balloon should be inspected to ensure it has not disintegrated, leaving fragments in the bladder. | ||
| Note: the steps above should only be attempted by or under the direction of a urologist. The patient may require cystoscopy following balloon deflation to remove any balloon fragments and to wash the bladder out. | ||
| Dysuria | Inflammation of the urethral mucosa | Encourage a fluid intake of 2–3 L per day. Advise the patient that dysuria is common but will usually be resolved once micturition has occurred at least three times. Inform medical staff if the problem persists. |
Infections
UTI is the most common healthcare‐associated infection and accounts for up to 36% of all such infections, and CAUTI accounts for up to 80% of UTIs (Parker et al. [188]). Several key areas have been identified as having a direct link with the development of a UTI:
- The risk of developing a catheter‐associated infection increases with the length of time that a catheter is in situ (Bernard et al. [21]). Therefore, assessing the need for catheterization and monitoring the length of time the catheter is in situ are essential (EAUN [71]).
- It is important to select the most appropriate type of catheter and drainage system.
- It is important to ensure that aseptic conditions are used during insertion and that a closed drainage system is maintained.
- It is important to ensure timely and appropriate catheter removal as per the HOUDINI protocol (Adams et al. [5]) (see Table 6.1).
- The person performing the procedure and those undertaking the aftercare (i.e. patients, relatives and health professionals) should be appropriately trained and competent.
- Patient education is essential in preventing catheter‐associated infections. Adequate information and teaching for patients may help to reduce infection by helping patients to take care of their catheters with good hygiene (RCN [208]).
The maintenance of a closed drainage system is central to reducing the risk of catheter‐associated infection. It is thought that micro‐organisms reach the bladder by two possible routes: from the urine in the drainage bag and via the space between the catheter and the urethral mucosa (Ostaszkiewicz and Paterson [183]). To reduce the risk of infection, it is important to keep manipulation of the closed system to a minimum; this includes unnecessary emptying, changing the drainage bags or taking samples (Ostaszkiewicz and Paterson [183]). There is now an integral catheter and drainage bag available to reduce the number of potential disconnection sites and minimize the infection risk. Before handling catheter drainage systems, hands must be decontaminated and a pair of clean non‐sterile gloves should be worn (Loveday et al. [135]). All urine samples should only be obtained via the specially designed sampling ports using an aseptic technique.
An important aspect of management for patients in whom a clear pattern of catheter history can be established is the scheduling of catheter changes prior to likely blockages (Wilde et al. [248]). In patients in whom no clear pattern emerges, or for whom frequent catheter changes are traumatic, acidic bladder washouts can be beneficial in reducing catheter encrustations (Wilson [253]). The administration of catheter maintenance solutions to eliminate catheter encrustation can also be timed to coincide with catheter bag changes (every 5–7 days) so that the catheter system is not opened more than necessary (Peate and Gill [195]).
A UTI may be introduced during catheterization because of an inadequate aseptic technique, inadequate urethral cleaning or contamination of the catheter tip. It may also be introduced via the drainage system because of faulty handling of equipment, breaking the closed system or raising the drainage bag above bladder level, causing urine reflux.
If a UTI is suspected, a catheter specimen of urine must be sent for analysis. The patient should be encouraged to have a fluid intake of 2–3 L per day. Medical staff should be informed if the problem persists so that antibiotics can be prescribed; however, all healthcare practitioners have a responsibility to adhere to the Antimicrobial Stewardship guidelines, which cover the effective use of antimicrobials and are aimed at reducing resistance (NICE [173]). Implementing good catheter care techniques helps to reduce UTI rates.
Meatal cleansing
EAUN ([71]) found no reduction in bacteriuria between routine bathing or showering when compared to antiseptic or antimicrobial solutions for meatal cleansing. However, Fasugba et al. ([76]) found that using 0.1% chlorhexidine solution (as opposed to 0.9% sodium chloride) for meatal cleansing before urethral catheterization led to a reduced rate of CAUTI. Further studies support the view that vigorous meatal cleaning is unnecessary and may compromise the integrity of the skin, thus increasing the risk of infection (Leaver [125], Panknin and Althaus [186]). Therefore, it is recommended that routine daily personal hygiene with soap and water (NICE [174]) is all that is needed to maintain meatal hygiene (Loveday et al. [135], Pomfret [200]). Nursing intervention is necessary if there is a poor standard of hygiene or a risk of contamination (Gilbert [89]); removal of a smegma ring, where the catheter meets the meatus, is important to prevent ascending infections and meatal trauma (Wilson [252]). It is imperative that the individual perfoming meatal cleansing returns the foreskin to the natural position in uncircumcised men.
