Continuous Bladder Drainage / Long-Term Catheterization

Long-term (chronic) catheterisation is an indwelling catheter in place for 30 days or more; short-term is under 30 days.

Three basic types of catheter are used in incontinence management: external (condom) catheters, intermittent straight catheterisation, and chronic indwelling catheterisation (urethral or suprapubic).

Catheters should be avoided in the management of incontinence unless specific indications are present, and should never be used for convenience, because they foster dependency.

Urinary retention that is causing persistent overflow incontinence, symptomatic infection or renal dysfunction, and which cannot be corrected surgically or medically and cannot be practically managed by intermittent catheterisation.

Skin wounds, pressure injuries or irritation being contaminated by incontinent urine.

Care of terminally ill or severely impaired patients for whom bed and clothing changes are uncomfortable or disruptive.

Patient preference, where toileting or changing causes excessive discomfort.

Short-term additional indications include accurate measurement of urine output in acute illness and perioperative use for defined procedures — but the catheter must be removed as soon as the indication ends.

Maintain a sterile, closed gravity-drainage system and never break the closed system; keep the bag below bladder level and off the floor.

Secure the catheter to the upper thigh or lower abdomen to prevent perineal contamination and urethral traction injury from catheter movement.

Avoid frequent vigorous cleaning of the catheter entry site — washing with soap and water once a day is sufficient; use clean technique and hand hygiene when emptying or changing the drainage system.

Do not routinely irrigate. If bypassing occurs in the absence of obstruction, consider bladder spasm, treatable with a bladder relaxant.

If obstruction occurs frequently, increase fluid intake; catheter blockage is usually due to encrustation with struvite from urease-producing Proteus mirabilis, and the catheter change interval should be planned ahead of the predictable blockage time.

Do not use prophylactic or suppressive urinary antiseptics or antimicrobials routinely.

Do not perform surveillance cultures to guide management, because all chronically catheterised patients have bacteriuria, often polymicrobial, and the organisms change frequently.

Do not treat infection unless the patient develops symptoms; symptoms may be non-specific, so other sources of infection must be carefully excluded first.

If a patient develops frequent symptomatic infections, arrange genitourinary evaluation to exclude stones, periurethral or prostatic abscess and chronic pyelonephritis.

Chronic bacteriuria is universal; further complications include catheter-associated UTI and urosepsis, bladder and renal stones, periurethral and prostatic abscess, epididymo-orchitis, urethral trauma, erosion and false passage, catheter bypassing and blockage, haematuria, and — with long-term use — squamous cell carcinoma of the bladder.

Nursing home residents, especially men, managed by chronic catheterisation are at relatively high risk of symptomatic infection. Indwelling catheterisation remains overused in acute hospitals.

Non-infectious harms matter as much: pain, restricted mobility and rehabilitation, falls over tubing, loss of dignity, and being a “one-point restraint”.

Intermittent catheterisation (self- or carer-performed, 2–4 times daily, keeping bladder volume under about 400 mL) is preferred where feasible; the catheter should be clean but need not be sterile at home. In nursing homes, anatomical abnormalities and resistant institutional flora may make repeated straight catheterisation impractical.

External (condom) catheters should be used only for intractable incontinence in men without retention who are extremely physically dependent; they still increase the risk of symptomatic infection and skin damage.

Suprapubic catheterisation avoids urethral erosion, is more comfortable, permits sexual activity, and is easier to change — preferred when long-term drainage is genuinely unavoidable.

Plan removal actively: use a trial without catheter (TWOC) with a bladder retraining protocol; most indwelling catheters in acute hospitals and many in long-term care can be removed this way.