Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines
Shropshires Community Health NHS Trust
Male Acute Urinary Retention Policy - 1876-22627.doc
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Male Acute Urinary Retention in the Community Policy and Guidelines
Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
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Document Details Title Male Acute Urinary Retention and Trial Without catheter in the Community Policy and Guidelines Trust Ref No 1876-22627 Local Ref (optional) Main points the document covers Guidance and pathway for conducting a catheterisation on a Male Adult presenting with acute retention of urine in the community. Guidance and pathway for conducting trial without catheter in the community. Who is the document aimed at? Community Nurses and Doctors who are responsible for these pathways Author Andrea Davies Approval process Approved by (Committee/Director) Clinical Policy Group Approval Date 11 th November 2013 Initial Equality Impact Screening
Full Equality Impact Assessment
Lead Director Maggie Bayley Category Clinical Sub Category Continence pathway Review date November 2016 Distribution Who the policy will be distributed to Community clinicians, Community Hospitals and Shropdoc colleagues Method Electronically via managers / Datix, available to all staff via Trust Website and Key clinicians , Continence Link Nurses Document Links Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
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Required by CQC Required by NHLSA Other Pathway is supported and verified by Urgent Care Pathway Group Amendments History No Date Amendment 1 V1 August 2011 Included Continence Advisors Nicola Head and Fiona Glover, Shrewsbury and Telford Hospitals (SATH) Consultant Urologist, Urology Nurse Specialist and Shropshire and Telford GPS. Pathway taken to Urology Clinical Governance meeting at SaTH 2 V2 29 May 2012 Pathway documents presented and ratified at Urgent Care Pathway Group 3 July 2012 Adopted by Shropshire Community Health NHS Trust 4 V3 November 2013 Policy developed to support documentation pathways and reflect Shropshire Community Health Trust policy framework. Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
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Contents 1 Introduction ......................................................................................... 6 2 Purpose ............................................................................................... 6 3 Glossary/ Definition ............................................................................ 6 4 Duties .................................................................................................. 7 4.1 Director of Quality and Nursing................................................................................ 7 4.2 Director of Operations ............................................................................................. 7 4.3 Divisional Managers, Service Leads and Team Leads ............................................ 7 4.4 Continence Service ................................................................................................. 7 4.5 Staff ......................................................................................................................... 7 5 Acute Retention of Urine and Trial Without Catheter Guidance ..... 7 5.1 Causes of Acute Urinary Retention ......................................................................... 7 5.2 Assessment Process ............................................................................................... 8 6 Consultation ...................................................................................... 13 7 Dissemination and Implementation ................................................. 13 8 Monitoring Compliance .................................................................... 14 9 Associated Documents .................................................................... 14 10 References ........................................................................................ 14 11 Appendices and related forms ........................................................ 15 Appendix 1 CNT 017 Catheterisation Procedure ................................................................. 16 Appendix 2 CNT018 Example - Acute Urinary Retention in males A&E Pathway ............... 17 Appendix 3 CNT019 Pathway Initial Catheterisation of Male Patients with AUR in the Community ........................................................................................................................... 18 Appendix 4 CNT020 Example Male Acute Retention of Urine Pathway Form .................. 20 Appendix 5 CNT 024 Example - International Prostate Symptom Score (I-P-S-S)Chart ..... 24 Appendix 6 CNT027 Example - Bristol Stool Chart .............................................................. 26 Appendix 7 CNT 025 Example Notification to GP of Male Acute Urinary Retention Pathway27 Appendix 8 CNT026 Notification to Community Nurse of Male Acute Urinary Retention Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 5 Pathway 29 Appendix 9 CNT 013 Example Indwelling Urinary Catheters information for Patients and Carer leaflet ......................................................................................................................... 30 Appendix 10 CNT023 Example Bladder Diary Form ......................................................... 38 Appendix 11 CNT 021 Example Male Acute Urinary Retention and TWOC Leaflet ........... 40 Appendix 12 CNT028 Example Trial Without Catheter (TWOC) Pathway ........................... 42 Appendix 13 CNT029 Trial Without Catheter (TWOC) Pathway Algorithm .......................... 46 Appendix 14 CNT030 Example Trial Without Catheter Outcome Summary to GP Form ..... 47 Appendix 15 CNT031Example Trial Without Catheter (TWOC) Referred to Continence Advisory Service .................................................................................................................. 48
Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 6 1 Introduction Acute Retention of Urine (AUR) is considered an emergency and is associated with increasing pain and anxiety as the episode progresses. Immediate treatment is catheterisation to relieve the pain, decompress the bladder and allow the urine to drain. Urinary catheterisation and Trial Without Catheter (TWOC) is a common procedure in the community. This policy provides Community Nurses, with standardised, evidence based knowledge, skills and training to undertake AUR and TWOC. The policy has been compiled using a systemic review of literature and evidence based research in order to provide best practice in line with the Royal College of Nursing RCN guidance for nurses on catheter care. 2 Purpose To provide a patient-focused service which will diagnose, treat and manage acute urinary retention and trial without catheter in male patients in the community setting. The service will provide the opportunity to improve patient experience, reduce avoidable admissions to acute services, reduce associated risks and reduce the cost of care. 3 Glossary/ Definition Acute urinary retention is the sudden inability to pass urine and is often associated with severe abdominal pain Trial without Catheter is the term used when a catheter which has been inserted via the urethra into the bladder for drainage purposes, is removed for a trial period to determine whether the patient is able to pass urine safely and spontaneously without the need for further catheterisation.
Term / abbreviation Explanation / Definition AUR Acute Urinary Retention CCC Care Co-ordination Centre CSU Catheter Specimen of Urine DRE Digital Rectal Examination IPSS International Prostate Symptom Score SATH Shropshire and Telford Hospitals TURP Trans Urethral Resection of the Prostate TWOC Trial Without Catheter
Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 7 4 Duties 4.1 Director of Quality and Nursing Has overall responsibility for this clinical policy, ensuring that it is fully implemented across the Trust as best practice. 4.2 Director of Operations Must ensure that all relevant staff access this policy. 4.3 Divisional Managers, Service Leads and Team Leads Managers and Service Leads need to ensure that: This policy is implemented into clinical practice Relevant staff are supported to attend AUR and TWOC Training. 4.4 Continence Service Continence Team are responsible for providing the specialist advice and training in accordance with this policy, supporting staff in its implementation. 4.5 Staff All nurses are accountable for their own actions; therefore it is important that the nurse acquires the relevant skills and competencies to ensure safe practice. This includes accessing the relevant training and supervision in accordance with the Nursing and Midwifery Council (NMC) 5 Acute Retention of Urine and Trial Without Catheter Guidance 5.1 Causes of Acute Urinary Retention
Resistance To Flow Benign prostatic hypertrophy Prostate Cancer Urethral stricture Clot retention Infection Calculus Inappropriate Innervation Trauma Neurological disorders (e.g. Cerebral Vascular Accident (CVA) multiple sclerosis, spinal cord injury) Diabetes mellitus Drugs Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 8 Over Distension Post general anaesthetic Alcohol Constipation Prescription drugs and non-prescription drugs Chronic Urinary Retention Over the counter medication
5.2 Assessment Process 5.2.1 Contra-indications to catheterisation for AUR in the community Patients who present with AUR to the GP must be referred to Secondary Care via CCC in the following circumstances: Post radical prostatectomy within the last three months Transurethral resection of the prostate open or endoscopic prostatectomy, bladder neck incision and optical urethrotomy, recurrent episodes of Acute Urinary Retention within the last eight weeks Undiagnosed haematuria Clot retention Systemically unwell See Catheterisation procedure Appendix 1 (CNT 017) and pathway form for: Acute Urinary Retention in Males Accident and Emergency (A&E) pathway Appendix 2 (CNT 018) 5.2.2 Limitations to Catheterisation for AUR in the Community Healthcare professionals should be cautious when performing catheterisation in the following circumstances and should seek medical advice prior to the intervention. Significant cognitive dysfunction where the patients ability to manage a catheter is significantly compromised. Trans-urethral resection of the prostate (T.U.R.P), bladder neck incision, optical urethrotomy, open or endoscopic prostatectomy more than eight weeks ago. Known history of urethral stricture Previous urethral trauma of fractured pelvis. Previous difficult catheterisation. Post radical prostatectomy undertaken more than three months ago. Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
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5.2.3 Initial Assessment and Examination 5.2.4 Day 1 Urinary Retention Pathway The initial catheterisation of male patients with Urinary Retention in the community Appendix 3 (CNT 020) History Document time of arrival at patients home and assess presenting clinical symptoms, including: Inability to pass urine Lower abdominal pain of acute onset Desire to void Timing and speed of onset Pain intensity and sensation Examination Observe for visual abdominal distension. The bladder is tender in AUR and bladder scanning may result in an urge to void or severe pain. Observe the external genitalia for evidence of trauma, phimosis or blood at the external urethral meatus. If evident, contact GP or CCC to arrange admission to Secondary Care. Carry out a bladder scan prior to catheterisation to estimate the volume of urine present
5.2.5 See Appendix 4 for Male Acute Retention of Urine pathway (CNT 020)
5.2.6 Secondary Assessment A more detailed history is obtained following catheterisation to include Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
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Assessment Medical, surgical and urological history. Urinary symptoms prior to the AUR episode using the International Prostate Symptom Score (I-P-S-S) chart Appendix 5 (CNT 024) Any previous episodes of AUR Medication Bowel status using the Bristol Stool Chart- form Appendix 6 (CNT 027)
Examination and observations Identify other possible causes of the acute urinary retention episode and plan the appropriate interventions e.g. constipation, urinary tract infection Take blood pressure (lying and standing) and pulse to establish a baseline reading Bloods are taken for urea and electrolytes on day one or two and should reach the GP surgery or laboratory within three hours for spinning
Advice and medication Advise patient to make an appointment with GP for digital rectal examination, medication review and review of blood results, as this will facilitate future management of their AUR episode A prescription for alpha-blockers, if appropriate should be obtained by the patient from the GP and commenced 48 hours prior to the proposed Trial without Catheter Fax notification form to GP and community nurse (if appropriate) Appendix 7 (CNT 025) and or Appendix 8 (CNT 026) and Appendix 9 (CNT 013) indwelling catheter patient leaflet
5.2.7 Follow up visit Day 1 The patient is reviewed 4 hours post catheterisation: Examination and observations Blood pressure (lying and sitting) and pulse should be recorded. Observe fluid balance and urinary drainage Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 11 Advice If there are any signs of excessive post catheterisation diuresis i.e. >200mls of urine per hour, postural hypotension or the patient feels systemically unwell contact GP/C.C.C to arrange possible admission to secondary care. If the observations are normal, continue with the AUR care pathway and arrange a visit for the following day.
5.2.8 Follow up Day Two
Examination and observations Check fluid balance and record on pathway. If the fluid balance is normal continue AUR pathway. Appendix 10 (CNT 023) If negative fluid balance and excessive diuresis noted contact GP/CCC to discuss possible admission to Secondary Care. Advice patient for, and carry out a T.W.O.C, 7 -10 days post catheterisation
5.2.9 Trial Without Catheterisation TWOC Patients who may be suitable for TWOC in the community include those who have undergone: Catheterisation for Acute urinary Retention Post Trans-urethral Resection of the prostate Laser Prostate Surgery 5.2.10 Contra-indications for TWOC in the community: Radical prostatectomy within the last 3 months Urethral stricture Transurethral resection of prostate(TURP), bladder neck incision, optical urethrotomy, endoscopic or open prostatectomy in the last six weeks Patients spelling error who have a history of difficulty in catheterisation Patients who withhold consent Patient who are unable to concord with treatment regime Patients, families or carers who are unable to alert the community nurse of any difficulties when undergoing a TWOC Patients who are constipated with no bowel movement for 3 days or more Confirmed Urinary Tract Infection or recurrent urinary Tract infections Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
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5.2.11 Trial without Catheter This should be conducted 7-10 days following acute catheterisation, or as requested by the referring Consultant / Doctor, as this may be longer. Prior to the visit ensure the following:
Advice Ensure that the patient has been taking the prescribed Alpha- blocker (if appropriate) for at least 48 hours before TWOC is undertaken. Check that patients taking diuretics are aware of the need to take medication on the morning of the procedure. Discuss potential risks, particularly the need for re- catheterisation if TWOC should be unsuccessful and provide patient leaflet Acute Retention of Urine and Trial Without Catheter Patient Leaflet Appendix11 (CNT 021) Ensure patient has receptacle for measuring urine and explain the need to monitor fluid intake and output Ensure catheterisation equipment is available including documentation pathways. Ensure patient has Team/ Nurse contact details 5.2.12 Day of the Trial Without Catheter
Assessment Ensure patient has normal bowel movement. If patient has not had bowels opened for three days you may need to postpone until constipation is sorted, particularly if constipation was the key reason for acute retention of urine.
Examination and observations Ensure perineum is washed prior to catheter removal Remove catheter, if no signs of infection, using clean technique (see indwelling catheter policy) Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 13 Advice and Further Action Ask patient to record fluid intake and urine output on bladder diary Explain that the first void may sting and there may be a small amount blood in the urine, due to the trauma of removing the catheter. Advise on fluid intake 1 litre in 4 hours initially Provide urgent contact number in case of any problems. Visit patient in 4 hours - see Trial without catheter pathway and algorithm Appendix 12 (CNT 028) Appendix 13 (CNT 029) Complete the TWOC pathway and inform GP and refer to continence advisors if required Appendix 14 (CNT 030) Appendix 15 (CNT 031) If TWOC is unsuccessful and the patient needs to re- catheterised consider whether the patient would be suitable for Intermittent Self Catheterisation (ISC).
6 Consultation The policy was developed by The Continence Team leader in association with SaTH Consultant Urologists, Clinical Commissioning Groups. It has been circulated widely by consultation with the following people: Urgent Care Work steam- led by Dr Bill Gowans Infection Prevention Protection and Control Team-Led by Rachael Allan Community Nurses Georgina English Nurse Consultant Cath Molineux Community Hospital Lead- Gilly Scott Clinical leads and Divisional Managers- Lynda Randle , Hayley Butler Director of Infection Prevention Protection and Control Maggie Bayley Safe care CAUTI work stream members led by Tanya Kidson 7 Dissemination and Implementation This policy and guidelines will be disseminated to staff by the following methods: Deputy Director cascading to Divisional Managers Disseminated to all relevant staff by Datix Inform article Published to Web Site Raising awareness through specialist groups e.g. Link Nurse Meetings Implementation will be via a rolling programme of training delivered by the Continence Specialist Nursing Service in association with the Organisation and development service. This Training must be secondary to the primary catheterisation training. All training will be Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 14 logged via Electronic Staff Record to demonstrate competance For advice and guidance on this policy or training information contact the Specialist Continence Nursing Service. 8 Monitoring Compliance Compliance will be monitored through the audit programme. 9 Associated Documents This policy must be read in conjunction with following policies: Community Antibiotic Policy for Shropshire and Powys Primary Care, Shropshire And Telford Hospital Shropshire Community Health NHS Trust Clinical Records Keeping Policy Shropshire Community Health NHS Trust Indwelling Urinary catheter Policy Shropshire Community Health NHS Trust Infection Prevention and Control Policies Shropshire Community Health NHS Trust Consent to Examination and Treatment Policy Shropshire Community Health NHS Trust Records Management Policy Shropshire County NHS Primary Care Trust and Telford and Wrekin NHS Primary Care Trust Waste Management policy.
10 References Anderson B, Khadra A (2006) Acute Urinary Retention: developing an A & E management pathway. British Journal of Nursing 15, 8, 434-438. Choong S, Emberton M (2000) Acute Urinary Retention. British Journal of Urology International 85, 2, 180-201. Cathcart P, Van der Meulen J . Armitage J, Emberton M (2006) Incidence of primary and recurrent acute urinary retention between 1998 and 2003 in England Journal of Urology 176.200-4 Catheter Care RCN for Nurses (2012) Royal College of Nurses, London Department of Health (DH) The Mental Capacity Act Code of Practice London: DH Emberton M, Anson K (1999) Acute urinary retention in men: an age old problem. British Medical Journal, 318, 7188, 921-925. Macdonald V (2007) Community Catheterisation for Adult urinary retention clinical practice development - Continence UK Volume 1, No: 1 MacDonald V (2008) How to deal with acute urine retention Continence Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 15 Essentials Vol 1; 66-69. National Institute of Clinical Excellence (NICE) 2003 Infection Control Prevention of Healthcare associated infections in primary and secondary care. National Institute for Clinical Excellence, London. NICE National Institute of Clinical Excellence (NICE) 2010 The management of lower urinary tract symptoms in men. London NICE Nursing and Midwifery Council (NMC) (2008) The Code - standards if conduct, performance and ethics for nurses and midwives. London Staffordshire/Shropshire Urology Continence Formulary (2010) Thomas K, Oades G, Taylor-Hay C, Kirby RS (2005) Acute urinary retention: what is the impact on patients quality of life? British Journal of Urology International 95,1, 72-76 Warrilow, M. Williams, D. and Guest, J. (2004) The Introduction of a trial without catheter in community nursing. British Journal of Community nursing.Vol10,no12 11 Appendices and related forms 1. CNT 017 Catheterisation procedure 2. CNT 018 Acute Urinary Retention in males A&E Pathway 3. CNT019 The initial catheterisation of male patients with Urinary Retention in the community 4. CNT020 Male Acute Retention of Urine Pathway form 5. CNT024 International Prostate Symptom Score (I-P-S-S) chart 6. CNT027 Bristol Stool Chart 7. CNT025 Notification to GP of Male Acute Urinary Retention Pathway 8. CNT026 Notification to Community Nurse of Male Acute Urinary Retention Pathway 9. CNT013 Indwelling Urinary Catheters information for patients and carers leaflet 10. CNT023 Bladder Diary form 11. CNT021 Male Acute retention of Urine and Trial Without Catheter Leaflet Form 12. CNT028 Trial Without Catheter (TWOC) Pathway
Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 16 Appendix 1 CNT 017 Catheterisation Procedure Consider allergy i.e. to latex or lidocaine/chlorohexidine gel. Use a 100% silicone catheter and simple lubricating gel, Cathejell Mono if allergy is known or suspected. Catheters use an all silicone catheter size 16ch standard length. (refer to Staffordshire/Shropshire Urology Continence Formulary 2010 for catheters and drainage bag systems) Catheterise the patient following the Male Catheterisation procedure guidelines. Use a closed-link catheter drainage bag system. (Refer to Shropshire Community Health NHS Trust Indwelling Catheter policy for full guidance) A catheter valve is not appropriate for the management of AUR. Record the initial volume of urine drained. Routinely undertake urinalysis, if leucocytes/nitrite or symptoms of urinary tract infection present send a Catheter Specimen of Urine (CSU) and inform the GP. The person taking the CSU is responsible for following up the results If no urine drains or following initial inflation of the balloon or symptoms persist, refer to GP or CCC for referral to secondary care. Provide the patient with the Shropshire Community NHS Trust approved Indwelling Urinary Catheters information for patients and carers leaflet CNT013 and ensure that all aspects of catheter care are understood by the patient/carer/relative as appropriate. Particular attention should be paid to: Hand washing, before and after manipulating the catheter and drainage system Maintaining a close drainage system Maintaining a non-obstructed downhill flow of urine Provide patient with the Shropshire Community NHS Trust approved Male Acute Urinary Retention and Trial Withoutt Catheter leaflet form CNT021. Commence a bladder diary to record intake and on-going urinary drainage, as this guides future clinical management form CNT023.
Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 17 Appendix 2 CNT018 Example - Acute Urinary Retention in males A&E Pathway
Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 18 Appendix 3 CNT019 Pathway Initial Catheterisation of Male Patients with AUR in the Community
Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
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Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 20 Appendix 4 CNT020 Example Male Acute Retention of Urine Pathway Form
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Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
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Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
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Appendix 5 CNT 024 Example - International Prostate Symptom Score (I-P-S-S)Chart
Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
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Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 26 Appendix 6 CNT027 Example - Bristol Stool Chart
Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
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Appendix 7 CNT 025 Example Notification to GP of Male Acute Urinary Retention Pathway
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Appendix 8 CNT026 Notification to Community Nurse of Male Acute Urinary Retention Pathway
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Appendix 9 CNT 013 Example Indwelling Urinary Catheters information for Patients and Carer leaflet
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Appendix 10 CNT023 Example Bladder Diary Form
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Page 40 Appendix 11 CNT 021 Example Male Acute Urinary Retention and TWOC Leaflet
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Page 42 Appendix 12 CNT028 Example Trial Without Catheter (TWOC) Pathway
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Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 47 Appendix 14 CNT030 Example Trial Without Catheter Outcome Summary to GP Form
Male Acute Urinary Retention and Trial Without Catheter in the Community Policy and Guidelines Shropshires Community Health NHS Trust Male Acute Urinary Retention Policy - 1876-22627.doc
Page 48 Appendix 15 CNT031Example Trial Without Catheter (TWOC) Referred to Continence Advisory Service