Management of Patients with Long-Term Indwelling Urinary Catheters: A Review of Guidelines

Urinary bladder catheters are medical devices commonly used for urinary drainage or as a method of collecting urine for measurement.^1–3 For the purposes of urinary drainage, the choice of catheter type depends on the clinical indication and the expected duration of catheter use.²TYPES OF CATHETERS: Urinary catheters can be external, urethral (i.e., indwelling, intermittent) or suprapubic.² External catheters are considered the least invasive since the device remains outside of the body in the form of a urinary pouch (available anyone) or a penile sheath catheter.² External catheters are an effective way to collect urine but are not indicated for management of urinary obstruction.² Urethral catheters are more invasive because the device is inserted transurethrally. Indwelling urethral catheters can be used for short-term bladder drainage or for the management of patients with chronic urinary retention.² Indwelling urethral catheters are the most common type of catheter used in the hospital setting.² Intermittent catheterization involves removing the catheter immediately after the bladder is decompressed and subsequent catheterizations on a scheduled basis.² This method can be used for short- and long-term management, depending on the condition being treated.² Some patients may not be candidates for intermittent catheterization due to discomfort, obesity, urinary obstruction or an upper-extremity impairment (for self-catheterization candidates).² Suprapubic catheters are the most invasive catheter type because they require a surgical procedure for the suprapubic catheter to be placed through the abdominal wall and into the bladder.² This mode allows for attempts at normal voiding without the requirement of re-catheterization and may prevent urethral trauma and stricture formation.² INDICATIONS FOR CATHETER USE (AND MISUSE): There are several clinical scenarios that are appropriately indicated for catheter use. For example, urinary catheters may be appropriately indicated for the management of urinary retention with or without bladder outlet obstruction, management of immobilized patients (e.g., pelvic fracture), hourly urine output measurement in critically ill patients, and improved patient comfort for end of life care.^2,4 Some evidence shows that catheters are used too frequently without meeting indications for appropriate use or may be used longer than required.² Findings from Canadian and international studies indicate that 21 to 50 percent of hospitalized patients receive an unwarranted urinary catheter.^2,5–9 In addition, one Ontario hospital reported that 18% of its hospitalized patients were catheterized, 69% of whom lacked an appropriate guideline-based reason.¹⁰ The most common inappropriate indication is management of urinary incontinence via an indwelling catheter.^2,7,10 The misuse of catheters puts patients at risk, including an increased risk of urinary tract infections (UTIs).² Approximately 80% of health care-associated UTIs are related to the use of indwelling urinary catheters;¹¹ catheter-associated UTIs have been associated with increased morbidity, mortality, length of stay, and hospital costs.¹¹ EXPECTED DURATION OF CATHETER USE: The duration of catheter use is another key contributor to the type of catheter used and risks associated with their use.² Generally, short-term catheterization is considered less than a month and long-term catheterization is catheterization for one month or longer (i.e., 28 days or four weeks).^2,4,12 Long-term catheterization is considered when other methods are not effective or practical,² as long-term use can result in bacteriuria, UTI, blockage and bypassing (leakage around the catheter).⁴ In particular, the two main indications for long-term indwelling catheters are urinary retention and urinary incontinence.⁴ GAPS IN THE EVIDENCE: MANAGEMENT OF PATIENTS WITH LONG-TERM INDWELLING URINARY CATHETERS: Providing evidence-based care on catheter use is important to improving patients’ outcomes and preventing urinary catheter-related complications.^2,13–15 Despite long-term indwelling catheter use being a common treatment plan to manage urinary retention and urinary incontinence, there is a lack of clarity on how to manage patients with long-term indwelling urinary catheters, including policies for replacing long-term urinary catheters. Thus, this report aims to summarize the evidence-based guidelines regarding the management of patients with long-term indwelling urinary catheters.