CATHETERISATION STANDARD OPERATING

PROCEDURE
Sop Number SOP-09-009

Author Joanne Whiteley

Consultation with Anne Cerchione

stakeholders Caroline Summers
Catherine Gibbs
Catherine Smyth
Chistina Quinn
Gwen Ruddlesdin
Janice Boucher
Joan Booth
June Watson
Mark Marshall
Linda Meeson
Pam Lumb
Sandie Bunyard
Sheena Kelly

Date approved at SOP 18.02.10

development group

Responsible Director: Robert Flack

Responsible Directorate: Kirklees Community Healthcare Services

Ratified at KCHS 03.06.10

Governance Committee

Review Date: June 2011

NICE GUIDANCE
Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their
clinical judgment. However, NICE guidance does not override the individual responsibility of health professionals to make
appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their
guardian or carer.
Version Control

Current versions of all policies can be found on NHS Kirklees internet and intranet.
If printing a document, please check internet/intranet for most up-to-date version.

Document Title: Catheterisation Procedure

Document number: 1
Author: Joanne Whiteley
Contributors: Felicity Kendall
Version: 1
Date of Production: June 2009
Review date: June 2011
Postholder responsible for Joanne Whiteley
revision:
Primary Circulation List: Kirklees CHS, HRI, HVMH
Web address:
Restrictions:
Contents

Section Page
1. Introduction 4
2. Associated Policies and Procedures 4
3. Aims and Objectives 4
4. Scope of the Procedure 5
5. Accountability 5
6. Key Principles of Procedure 5
6.1 Key Principles of Procedure 7
6.2 Indwelling Urethral Catheters 8
6.3 Types of Catheters 9
6.4 Principles of Catheterisation 11
6.5 Who should Catheterise 11
6.6 Training and education 11
6.7 Catheter Management 12
6.8 Types of Drainage System 13
6.9 Catheter Changes 14
6.10 Supra-Pubic Catheters 15
6.11 Troubleshooting 17
6.12 Removal of Indwelling Catheter 18
6.13 Catheter Maintenance Solutions 19
6.14 Intermittent Catheterisation 20
6.15 Who should teach Intermittent Catheterisation 22
6.16 Urinary Tract Infection 23
6.17 Children & Young People Catheter Management 23
7. Equality Impact Assessment 23
8. Training Needs Analysis 23
9. Monitoring Compliance with this Procedure 24
10. Audit Process 24
11. References 24
Appendices

A Key Stakeholders consulted/involved in the 25

development of the procedure
B Equality Impact Assessment Tool 26
 Procedure Statement

NHS Kirklees will ensure best practice for all patients requiring catheterisation or catheter care,
through evidence based education and policies.

1. Introduction

These guidelines have been developed to provide Health Care Professionals.

in the primary care setting with an evidence based framework on which to base clinical
decisions about the catheterisation of clients. Where evidence of practice has been
unavailable, consensus of expert opinion has been drawn upon. The policies are designed to
be used for the process of catheterisation and the care of the client regardless of whether the
catheterisation is short term, intermittent, or long term.

Primarily aimed at nursing staff; however, it is recognised that other health care professionals
who are involved in urinary catheterisation would benefit from accessing them

2. Associated policies & procedures

This procedure should be read in accordance with the following Trust policies, procedures and
guidance:

NHS Kirklees Infection Control Policy

NHS Kirklees Consent Policy
NHS Kirklees Hand Decontamination Policy
Kirklees PCT, Trial without Catheter Policy 2007
The guidelines support the National Service Framework (NSF) for older people
(DoH 2001a)
The guidance has incorporated the recommendations of the epic project (Pratt et al
2001) for developing national evidence-based guidelines for preventing healthcare
associated infections.
Records Management policy (Kirklees PCT)
Urinary Incontinence The management of urinary incontinence in women
(NICE 2006)
Epic Two Guidelines – National Evidence Based Guidelines for Preventing
Healthcare-Associated Infections in NHS Hospitals in England (updated 2007)
RCN – Catheter Care (2008)
Essential Steps to DoH (2006) safe, clean care ; reducing healthcare – associated
infections

Resource :- Marsden Manuel, 7th edition, chapter 16, pages 330-47

3. Aims and objectives

To improve the quality of care, by providing, a clear evidence base where evidence is
available. To provide a uniform process for all clients who undergo urinary catheterisation thus
reducing the risk of adverse events
 Objectives are :

Support the education of pre registration health care professionals

Support the education of post registration health care professionals
Contribute to Professional and Clinical Development of the health care professionals
involved in urinary catheterisation.
Support professionals in achieving and maintaining clinical competence
To minimize the risk of infection

4. Scope of the procedure

This procedure must be followed by all NHS Kirklees employees who are involved in the
procedure of catheterisation and/or the care of the catheterised individual.

It must be followed by all staff who work for NHS Kirklees, including those on temporary or
honorary contracts, bank staff and students.

Breaches of this procedure will lead to disciplinary action being taken against the individual.

Independent Contractors are responsible for the development and management of their own
procedural documents and for ensuring compliance with relevant legislation and best practice
guidelines. Independent Contractors are encouraged to seek advice and support as required.

5. Accountabilities and Responsibilities

Each Health Care Professional (HCP) is responsible for excellent standards of catheter care
for each catheterised patient they encounter.

It is the responsibility of each Health Care Professional to adhere to good practice guidelines
included in this procedure.

It is the responsibility of each Health Care Professional to attend catheterisation training once
every 3 years or more often if they feel their skills need updating.

It is the responsibility of the Kirklees Community Healthcare Service Continence Service to

deliver evidence based catheterisation training, theoretical and practical, that fits with RCN
competencies at regular intervals and to support other HCP‟s on applying their training into
practice.

6.1 Key principles of Procedure

The client must be fully informed and give verbal consent, where able, prior to the
procedure. (DoH 2003)
The first catheterisation normally requires medical consent from Consultant, GP or
Continence Specialist Nurse. All information must be clearly documented in the
patient‟s notes stating the date, time and name of the health professional who has
gained consent alongside clinical reason for catheterisation.

Urinary catheterisation must only be performed after alternative methods of

management have been considered and evaluated.

Only Healthcare Professionals who can demonstrate they have achieved key
competencies must be allowed to practice catheterisation.
Promoting optimum client comfort during urinary catheterisation is fundamental.
A client‟s privacy and dignity must be respected at all times.

The product selected must be appropriate to the clients needs; it is recommended that
where appropriate the client is involved in product selection.

Select the smallest gauge urethral catheter that allows urinary flow

It is recommended that clients/carers are given the appropriate level of information,

written and verbal to allow them to continue to care for the urinary catheter safely, thus
reducing risk of infection and preventing hospital admission.

Reducing the infection risk is paramount, this is achieved by:

o Maintaining a sterile closed urinary drainage system.

o Ensuring that the connection is not broken without good clinical indication.

o Decontaminating hands and wearing personal protective equipment i.e. apron

and gloves before manipulating a client‟s catheter.

o Not changing catheters or urinary drainage bags unnecessarily.

o Positioning urinary drainage bags below bladder level, ensuring it does

not come in contact with the floor, with the exception of the „Belly Bag‟,
a specialist drainage bag.

o Health professionals adhering to aseptic technique when performing the

procedure of catheterisation.

o Competent health professionals performing the procedure of catheterization

o Securing the urinary drainage bag with appropriate straps and urisleeves

Catheterisation and catheter care is a key component of nursing care. Advice from
specialised professionals, usually the Continence Specialist Nurse, should be sought
when further guidance is required.

Discharge of clients with catheters from hospital to community:

 It is recommended that clear documentation is instigated so as to improve
communication between primary and secondary care. Appropriate equipment should be
provided to allow continuation of care when a client is transferred
from or to secondary care (Appendix 1)

6.2 Indwelling Urethral Catheters

Choosing the right catheter system for each client will be influenced by the results of a
comprehensive individual assessment that should include the anticipated duration of the
catheter, any history of latex allergy and the client‟s preference (Pellowe 2004)

Points to Consider

General Health – will catheterisation enhance, or cause detriment to, the client‟s quality
of life?

Bladder capacity – identify whether the client has an unstable bladder which could lead
to the catheter being expelled or complications such as bypassing – consider the
previous use of anti-muscarinics i.e. Oxybutynin, (NICE 2006)

Bowel management – assess to exclude constipation, as this could put pressure on the
lumen of the catheter, thereby affecting drainage and may cause the catheter to bypass
or be expelled.

Dexterity – Has the client got the ability to manage the catheter independently or would
additional carer involvement be required?

Comprehension – has the client got the cognitive ability to manage the catheter? Is
this an acceptable form of management for the client? e.g. consider whether the client
will remove the catheter due to lack of understanding, as to why the catheter is in situ.

Sexual activity – consideration should be given to the client‟s sexual needs. It is

necessary to inform the client/partner how sexual activity can continue with an
indwelling catheter in situ. (Getliffe & Dolman 2005) or discuss alternative
catheterisation such as intermittent or suprapubic.

Acute or Chronic Retention – discuss with the KCHS Continence Service. May need
a referral to Urology

Indications for Catheterisation

To relieve acute or chronic retention of urine including failure of trial without catheter
To preserve bladder and renal function.
Long term management of residual urine where intermittent catheterisation is
not appropriate or possible.
To irrigate the bladder.
 For the instillation of drugs.
Pre and post operatively including stricture therapy
Wound management – short term use
To obtain an accurate record of urinary output.
To manage intractable incontinence where all other methods have failed and client has
received all relevant information to make an informed choice
To assess for signs and symptoms of infection

Selection of the catheter type and system following comprehensive assessment will include the
anticipated duration of the catheter, any history of latex allergy and the client‟s preference.
(Pellowel 2004)

Consideration to be given to material; size, length, and balloon fill volume of catheter.

Make, type, length, charrier size and balloon type should be specified on the prescription.

If the original reason for Catheterisation resolves – remove the catheter. (See trial
without catheter).

6.3 Types of catheters

These determine length of time a catheter can remain in situ. However, it is the product liability
stated by manufacturer that must be followed. Some companies have different warranties
dependent on where the catheter is used e.g. urethrally or supra-pubic.

Nice guidelines state: - For urethral and supra-pubic catheters, the choice of catheter material
and gauge will depend on an assessment of the patient‟s individual characteristics and
predisposition to blockage (NICE 2003)

Catheter materials

o Plastic/PVC – used for residual urine and bladder irrigation, the catheter is quite rigid
and may be uncomfortable it may be left in situ for up to seven days.

o PTFE (Polytetrafluroethylene) bonded latex catheter, used for up to twenty- eight

days, smoother than plain latex, therefore more resistant to encrustation.

o Silicone elastomer coated latex combines the advantages of silicone and latex and
has a bonded surface. It is smooth and therefore less likely to lead to encrustation and
may be left in situ for up to twelve weeks.

o Hydrogel coated latex – more compatible with human tissue, comfortable and easier to
insert, it is also more resistant to encrustation and bacterial colonisation, and may be left
in situ for up to twelve weeks.
o All silicone catheters – more rigid, have a larger internal lumen and therefore
minimises encrustation and tissue irritation. (Ryan-Wooley 1987) These catheters are
essential for use with clients who have a latex allergy and can be left in situ for up to
twelve weeks.

o Silver Alloy coating catheters (should not be left longer than 28 days). Inhibits
bacterial growth. Reduces incidence of urinary tract infections within acute care settings
(Saint 1999). Anti bacterial properties are demonstrated for up to 28 days. (Bard 2005).
See Appendix 4. Not generally used in Primary Care. Used in Acute Secondary care
settings to prevent health care Associated infections. If an individual is considered for a
silver catheter, consultation must take place with the Continence Service, infection
control and microbiology.

Expiry Date

Take note of the expiry date on the catheter to be used; will it cover the length of time the
catheter is to be in situ?

Sizes

The external diameter of a catheter is measured in charriere (Ch) – one ch equals

⅓ mm, therefore 12Ch equals 4 mm. The smallest size should be chosen to provide adequate
drainage. Larger sizes can cause irritation and bypassing of urine around the catheter. The
larger sizes are usually reserved for clot drainage (post operatively) and stricture dilatation. In
any other situation their use should be questioned. The range of sizes that are acceptable to
use are:

Paediatric – 6 – 10ch
Female – 10 – 14ch – good practice – 12ch
Male – 12 – 16ch – good practice – 12ch

Dependent on why the catheter needs to be in situ the following guide maybe useful:
12ch for clear urine.
16ch for persistently significantly cloudy urine with debris present.
16ch+ for haematuria, clots and irrigation – under the supervision of
a Consultant Urologist

Suprapubic catheters must be replaced with the same size charriere catheter of original
catheterisation NORMAL RANGE 14-18ch

Length

Available in paediatric, female, and standard lengths (for male and supra-pubic use). A female
length should always be used in women; however consideration should be given to client‟s
lifestyle, ie, wheelchair user, as standard can be used for male and female.

Balloon Size

Routine 10 ml
 Post-prostatic surgery 30 ml (under the supervision of a consultant urologist) not to be
changed in community
Paediatric 5 ml

Catheter balloons must be filled as specified by the manufacturer. They must never be over or
under filled as this can lead to a mis-shaping of the balloon that could interfere with urine
drainage. The balloon is not designed to occlude the internal urethral meatus to prevent
leakage – this is prevented by the bladder neck and sphincters gripping the catheter lumen –
but merely to gently retain the catheter in the bladder to prevent it from falling out. Few
catheters need more than 10 ml of fluid for this purpose.

30 ml balloons MUST only be used in specific circumstances such as post prostatic surgery
and only under the supervision of a consultant urologist, but their use should always be
questioned.

The heavier weight and larger balloon may cause bladder spasm, bypassing and irritation of
the trigone.

The balloon must always be filled with sterile water, never:

air, as the balloon would float above the urine, preventing drainage
tap water as it contains soluble salts that may precipitate out of the solution and block the
inflation channel.
saline as crystals of salt may form in the inflation channel preventing deflation of the
balloon at a later stage. (Getliffe & Dolman 2005)

6.4 Principle of Catheterisation

All catheterisations performed by a health care professional must be aseptic procedures,

although it is not necessary to use aseptic preparations to clean the urethral meatus prior to
catheter insertion. The use of a sterile single use lubricant or anaesthetic gel will minimise
trauma and discomfort. (DeCourcy–Ireland 1993). It is therefore essential that anaesthetic gel
is used. Instillagel is recommended; it is essential that 6mls is used for females and 11mls for
males. (Essential Steps 2006)

6.5 Who should catheterise?

Any Registered Nurse who deems themselves competent and confident to undertake the
procedure. Consideration should be given to their professional accountability and code of
practice. Acquisition of competence will be by observation and supervision within the clinical
setting. (Essential Steps 2006, RCN 2008)

Male/female urethral and supra-pubic catheterisation can be undertaken by any Registered

Nurse who deems themselves competent and confident to undertake the procedure following
the relevant training – All Aspects of Catheterisation Theoretical and Practical Course (KCHS)

Where appropriate a carer or relative may undertake re-catheterisation. The Registered Nurse
responsible for the client ensures knowledge and competence of carer/ relatives. This should
 involve observation of procedure. Written management guidelines will also be provided to
ensure that a carer undertakes the procedure in line with PCT procedure.

6.6 Training and Education

Many Health Professionals are employed in positions where urinary catheterisation

management is part of their role. To ensure high quality care for the patients undergoing
urinary catheterisation it is imperative that all staff undertaking this procedure are educated to
the same level to protect the interests of the patients. The Registered Practitioner is
accountable for the patient care provided. It is the responsibility of the Health Professional to
ensure they have current knowledge and skills to allow them to practice the role expected of
them (NMC 2009).

Catheterisation training to be provided by KCHS Continence Team.

Responsibility: The Team Leaders are to ensure the key competencies are obtained.
It is recommended that Health Professionals attend updates every three years, This must be
documented by team leaders.
Catheter care training is offered to Social services and independent sector carers to ensure
individuals receive excellent standards of care and adverse effects kept as low as possible.

6.7 Catheter Management

When in situ, how a catheter is managed will have an effect on the health and wellbeing of the
client. However, every client with a long term indwelling catheter (urethral/supra-pubic) will
develop bacterium, but this is usually asymptomatic. infection can easily occur but the risks
can be minimised by:

Limiting the use of catheters – changing only when clinically indicated or required by
Manufacturers‟ guidelines.
Maintaining a closed drainage system.
Hand washing and use of gloves to reduce the risk of cross infection. (NICE 2003).
Practitioners must follow aseptic technique at all times (Essential Steps 2006)
The meatus should be washed daily with soap and water. (NICE 2003)

If a client does become ill the infection will have to be treated. Symptoms may include fever,
rigors, loin pain, significant haematuria, and, in the elderly, the onset of sudden unexplained
confusion. The catheter may have to be removed or changed for treatment to be successful –
the length of time the catheter is out may vary, consider the reason for catheterisation i.e.
retention and presenting symptoms Antibiotics will not kill micro-organisms in the bio-film.

Obtaining urine sample from a urinary catheter:

Urine samples must be obtained from a sampling port using an aseptic technique (N.I.C.E.
2003). In most cases this can be done without using a needle. Samples can be obtained from
the sample port with just a syringe.The risk of infection when taking a urine sample can be
minimised by choosing a drainage system with a self-sealing sample port (Godfrey and Evans
2001). Urine samples should only be taken if an individual shows symptoms of infection.
Routine samples are NOT necessary and may increase the risk of infection (Essential Steps
2006).
 Fluid intake:

It is recommended that the client be encouraged to drink 1.5 – 2 litres of fluid per day this
maintains the flow of urine through the bladder and helps prevent constipation.
Medical reasons or current physiological conditions may lead to a restriction of fluids.

Cranberry juice:

Often recommended for the prevention and treatment of urinary tract infections as it may
prevent the adherence of bacteria to the bladder wall. However, there is no evidence
regarding dosage (Averon 1994). It has been suggested that 300 ml daily may be beneficial.
Cranberry juice should be avoided by clients taking Warfarin due to possibility of
interaction (Suvarna et al, 2003). Cranberry capsules may be more suitable for diabetics.

6.8 Types of Drainage System

The choice of drainage equipment is particularly important for the promotion of client
independence and self-care, and it is a nursing responsibility to match choice with the
individual client (Getliffe & Dolman 2005).

A wide range of products are available and wherever possible clients should have the
opportunity to trial different systems.

Catheter valves – consideration should be given to the use of catheter valve in preference to a
catheter bag. This is viewed as good practice as it assists in maintaining bladder tone and
allows more independence.

An individual requiring the valve will need to meet the following criteria (Addison 1999)
have appropriate:
Manual dexterity
Mental awareness
Bladder sensation

The benefits to the client of using a valve are:

Maintains bladder tone

Greater independence
More discreet
More natural voiding process
Minimises bladder trauma (less weight)
Bladder capacity
Creates a flushing effect

Problems that the client may experience:

Bypassing – consider use of antimuscarinics

Urgency – unstable bladder
Frequent emptying – may indicate small capacity bladder
Catheter bags

Should be positioned below the level of the bladder with the exception of the Belly Bag,
specialist product by Rusch (which is worn on the abdomen). Suction can be created if the bag
is positioned too low, causing damage to the bladder mucosa.

Bag emptying

It is important that the client should be instructed and encouraged to empty their own bag when
possible, in order to maintain their dignity and independence. If the client is unable to empty
their own drainage bag, single use powder free gloves, an apron followed by strict hand
washing (Gibbs1986) should be worn by the nurse or carer to minimise the risk of cross
infection. Hands must be washed before and after emptying the bag. Ensure the drainage tap
is off the floor at all times. Bags should be emptied when they are approximately three quarters
full to avoid accidental trauma due to the weight of the bag. Consider the use of a sleeve or
other fixation devises to assist management.

Changing the bag

The bag should be changed in accordance with manufacturer‟s recommendations and

Department of Health Guidelines i.e. 5 – 7 days or earlier if the bag is damaged (Drugs Tariff,
Oct 2004), the Rusch belly bag 28 days. However, frequent changes will break the closed
drainage system, presenting an increased risk of infection. It has to be noted that most
products are single use only therefore if the closed drainage system is broken at any time the
products used should not be reconnected in any circumstances.
It is important that the bag is emptied appropriately to avoid it becoming too heavy, and it is
adequately supported so it cannot pull on the catheter and cause urethral trauma.

Overnight Drainage

Single use catheter bags (2 litres) must be used for all individuals who receive care from formal
care organisations, i.e. Social Services/NHS or who reside in care homes.
Individuals who manage their own catheter care and empty their own bag can use a drainable
catheter bag. This includes individuals who receive assistance from informal carers e.g.
spouse

Principles to consider:

Clients should be encouraged to have a catheter valve if they meet the appropriate
criteria

Consider the use of a 500 ml leg bag if the bladder capacity is known
to be small or the client is cognitively impaired.

Clients, who require some assistance with Activities of Daily Living, should be encouraged
to use a catheter valve where possible.

Clients who are managed in bed could have a two-litre drainage bag attached directly to
the catheter and this must be well supported on a catheter stand.
 Liaison with the Continence Service should take place if further guidance is needed.

Link Systems

Clients who require a higher capacity drainage bag overnight should not disconnect the leg bag
from the catheter, but attach the two litre non-drainable bag to the catheter valve or the leg
bag. It is recommended that a catheter stand or hanger be used.

6.9 Catheter Changes

Should always be planned following an assessment of client‟s history, circumstances and

need. All changes should be clearly documented in the client‟s notes.
(Appendix 1). Frequent catheter changes may increase trauma and infection.

It should be recognised that some clients have problems with their catheter blocking.
It is advisable to monitor these clients, to establish a pattern, to allow proactive management to
take place.

‘Blockers’ – defined as those clients who consistently and repeatedly develop

extensive encrustation of their urinary catheters within a few days to a few weeks,
resulting in shorter catheter life because of diminished flow and leakage.

‘Non-blockers’ – defined as those clients who do not form encrustations even when the
catheter is left in place for weeks to months (Kunin et al 1987).

A problem that occurs during re-catheterisation should be documented and

appropriate advice sought from a GP/Urologist/Continence Specialist Nurse.

6.10 Supra-pubic Catheters

A urinary catheter that is inserted, through an artificial tract in the abdominal wall, just above
the pubic bone, and into the dome of the bladder. The initial insertion of a supra-pubic catheter
is performed by a Urologist under local anaesthetic, in a hospital setting, as an aseptic
technique.

Advantages:

Reducing the risk of urethral trauma

Reducing the risk of necrosis to the bladder neck and urethra
Reducing catheter induced urethritis
Reduced urinary infection rates in comparison to urethral catheters
Does not interfere with client‟s sexual activities
More comfortable for individuals who are chair bound

Supra-pubic catheterisation is suitable for the following clients:

Chronic retention with renal impairment

 Unable/unwilling to perform intermittent self catheterisation (I.S.C.)
Persistent expulsion of urethral catheter
Client comfort and sexual expression
Anatomically difficult to catheterise urethrally
Greater comfort for clients who are chair bound
Intractable incontinence
Gentlemen with prostatic and stricture problems

Supra-pubic catheterisation is contra indicated for clients who have:

A history of a bladder tumour

Blood clotting disorders
Ascites
Severe obesity
Suspicion of ovarian cyst

Types of supra-pubic catheter

A long term catheter that is licensed for use (see manufacturer‟s guidelines). A Hydrogel
catheter should be used in preference to an all silicone catheter however for clients with a latex
allergy an all silicone catheter must be used.

Sizes

Generally size 14ch to 18ch for adult management but consideration should be given to
smaller sizes for children. Do not change the size of catheter from the size used at initial
insertion.

Length

The length used is mostly dependant on client preference, standard length is the most usual,
but a female length is acceptable providing the person using the catheter has sufficient length
to connect to a bag or valve.(Addison & Mould, 2000). Consider:

Obesity
Mobility
Clothing

A 10 ml balloon should be used at all times.

Supra-pubic Catheter Management

The entry site should be checked by the client/carer on at least a daily basis and cleansed with
mild soap and water, this may require more frequent cleansing if there is any
leakage/discharge. Always wash away from the entry site and dry thoroughly.
In some clients there may be over-granulation of the insertion site, this can be improved by
altering the direction of the lay of the catheter and treating the over-granulation with Allevyn
foam dressing, well secured It is the pressure that reduces the over-granulation. Management
 is otherwise the same as for urethral catheters. If unsure please consult with Tissue Viability
Nurse Specialist.

Changing the catheter

Any Registered Nurse competent in undertaking the procedure may change a supra-pubic
catheter whether it is the first change or not – as the abdominal channel becomes established
at about four weeks. Relevant training should have been attended.
After four weeks there is no rationale for the first change to be done in the hospital setting, this
change can be done in the clients own home or clinic setting. A newly inserted catheter is
usually changed at 4 – 6 weeks and then at intervals between 4-10 weeks, or as
recommended by manufactures (Getliffe & Dolman 2003). This guidance is for scheduled
changes only, not for catheters that have become blocked or have been inadvertently
removed. If this occurs before four weeks, please refer to urology consultant for advice or the
urology ward from which the patient has been discharged.

If a problem occurs during re-catheterisation, liaise with the General Practitioner or

Continence Specialist Nurse re: future management.

Points to remember

Obtain clients consent

It is useful to observe how much of the catheter was in the abdominal cavity upon
removal, to use as a guide for re-insertion.
A small amount of blood may be apparent at supra-pubic catheter changes this
should stop within 24 hours.

6.11 Troubleshooting

Urethral/Supra-pubic Catheterisation

Encrustation – recurrent catheter blockage caused by encrustation affects around 50% of

long term catheterised clients. It can be distressing to clients and carers and costly to Health
Services, in terms of time and resources. A pattern of catheter life can be identified for many
clients and changes can be planned accordingly; in some circumstances this may be as
frequent as a weekly change, - use the catheter management record to obtain this information.

Catheter encrustation is caused by magnesium ammonium phosphate and calcium phosphate

(struvite) which precipitate from the urine in alkaline conditions.

If indicated, the use of a catheter maintenance solution could be considered. This may not be a
suitable form of management for all clients.

By-passing
Check that the drainage tube is not kinked
Check that the client is not constipated
Check fluid intake is adequate
Check for systemic symptoms of infection
 Consider anti-cholinergic medication
Review and if necessary change the catheter, checking for encrustation and blockage
Replace the catheter with a smaller charriere size, with appropriate 10 ml balloon as
larger sizes can cause by-passing

Expulsion of catheter

If the catheter is frequently expelled, consider whether it is the most appropriate form of
management for the client.

Haematuria

Trauma or infection may produce small amounts of blood loss seen in urine; if severe seek
medical help urgently.

Cramping pain

Common when catheter is first inserted; pain should subside within 24 hours, if this persists
there may be bladder spasm and anti-cholinergic medication should be considered.

Urethral bypassing

This usually occurs when the urethral and closing pressure is less than any bladder contraction
(spasm). In female clients this may be resolved by surgical occlusion of the urethra (Addison &
Mould 2000).

6.12 Removal of Indwelling Catheter

Removal of an indwelling catheter needs to be done with caution, ensuring the balloon is fully
deflated to prevent trauma. Personal protective equipment must be used and aseptic technique
followed.

Antibiotic prophylaxis when changing catheters should only be used for patients with a history
of catheter associated urinary tract infection following catheter change, or for patients who
have a heart valve lesion, septal defect, patent ductus prosthetic valve.

Following removal of a catheter by a Healthcare professional trained in the procedure, it is

important to document the time of the first void, the volume and colour of urine passed, and if
pain was experienced on micturition.

Time of removal

There is limited research about the optimum time of indwelling catheter removal in the
community setting. In hospital, generally they are removed following instruction from
the medical staff and the times vary from one speciality to the other.
 Recent evidence (Kelleher 2002) suggests that removal of an IDC at midnight:

Reduces anxiety about need to void, invariably the patient continues to sleep.
The bladder is more compliant when filling slowly overnight and allows for larger first
void.
There is an earlier resumption of normal voiding patterns

The removal of an IDC at midnight is also supported by Noble et al (1990), Chillington (1992),
Crowe et al (1993) and Downey et al (1997).

Removal of all silicone catheters

Due to „cuff‟ formation on deflation of the balloon, this may cause pain, trauma and bleeding on
removal. To reduce “cuff” formation leaving the syringe attached to the inflation port for a few
minutes may allow the water to drain spontaneously.
All silicone catheters seem to „stick‟ within the tract requiring more traction to remove them. A
hydrogel-coated catheter may be preferable where there is no identified latex allergy.

Client Information Leaflets

Information leaflets are available from the PCT regarding urinary catheters and drainage
systems,that assist patients with their own catheter care and management.

Leaflets can be accessed via:

The Continence Service, 01924 351568, or 01484 347764

6.13 Catheter Maintenance Solutions

Use of catheter maintenance solutions continues to be a subject for discussion. Regular use of
catheter maintenance solutions can have a detrimental effect on the bladder urothelium. It has
been shown to increase shedding of urothelial cells with no significant reduction in crystal
formation or encrustation (Kennedy et al 1992). Use of a catheter maintenance solution is to
bathe the lumen of the catheter not irrigate the bladder.

Their use is a matter for professional assessment of the needs of the individual client. If the
client is newly catheterised, it is wise to monitor how long the first catheter remains in situ
before showing signs of blockage without the interference of prophylactic „washouts‟ (B.J.N
1999,).

N.B. The breaking of the circuit may lead to an increased risk of infection.
Assessment

A full client assessment needs to be carried out to determine whether a catheter maintenance
solution is required – catheters block for a variety of reasons:-

Constipation
Client‟s position
Bladder spasm
Kinked drainage system
Drainage system above the level of the bladder
Poor fluid intake

pH Levels

Check the pH of the urine normal, - pH is 6 – 7 (slightly acidic) if the pH is alkaline,

encrustation is the most likely cause of the catheter blocking. In these cases a
maintenance solution would be recommended. Best practice indicates that with problem
catheters, urine should be tested weekly to monitor the pH, record and chart the pH of urine in
care plan (see section 12i for obtaining urine sample) (Kholer – Ockmore & Feneley 1996).

Guidance for using Catheter Maintenance Solutions

1. A maintenance solution can be used daily on a heavily encrusted catheter when there
are heavy deposits of encrustation present. Once an acute episode of blocking has
subsided, a weekly maintenance with the chosen solution is acceptable. (For further
advice on individual regimes, contact the Continence Service)

2. It must be remembered that regular opening of the closed drainage system is

likely to cause infections; therefore, the closed drainage system must be changed
after every treatment to ensure that each new system is both sterile and
acceptable to the client. There is a clear correlation between the number of times
the drainage system is disconnected and the rate of infection . (Getliffe & Dolman
2003).

3. Daily use of catheter maintenance solutions should only be used for a limited period of
time, e.g. between one to two weeks. After this there should be a decrease in the
frequency of use as the encrustation will have dissolved. The aim is to decrease the
frequency of use to maintain the catheter life.

4. Some clients may only have an acute episode of catheter blockage and in these clients
it may be possible to discontinue the use of catheter maintenance solutions.

5. If weekly use of catheter maintenance solution is required then these need to be co-
ordinated to coincide with the changing of the catheter valve/ drainage system.
Remember the majority of clients should not require the use of catheter
maintenance solutions Catheter maintenance solutions may prolong catheter life,
but can cause trauma (mechanical or chemical )to the bladder mucosa
(Bregenzer et al 1997)
 6. Where catheter maintenance regimes appear to be ineffective then regular or more
frequent catheter changes should be considered.

7. Always warm the solution prior to instillation. This is to prevent the bladder going into
spasm if the solution is too cold.

8. Ensure correct non-touch technique when undertaking catheter maintenance. This

includes washing hands correctly using liquid soap before and after insertion. Clean
examination gloves should be used when carrying out the technique to prevent cross
contamination. A plastic apron should be used to prevent cross-infection and
contamination of clothes.

9. Clients who are managed with a catheter bag as opposed to a catheter valve, will have
a decreased bladder capacity. It is advisable to use a smaller volume of catheter
maintenance solution, using as little as 15 ml to gently bathe the lumen and the tip of the
catheter. Smaller amounts also given sequentially, give a Better dissolution than one
larger volume of solution, (Getliffe & Dolman 2003).

10. For some clients who experience blockage on an intermittent basis it may be beneficial
to use a catheter maintenance solution as a prophylactic measure. This must be
monitored on an individual basis by each practitioner and documented accordingly.

6.14 Intermittent Catheterisation

Definition

A catheter is passed intermittently into the bladder to assist in the drainage of urine where
normal voiding is not possible.

This is an aseptic technique if undertaken by a health professional but can be a clinically clean
technique if undertaken by a client.

This technique can also be undertaken by a relative or carer following full consent from the
client and relative/carer education.

Intermittent Self-catheterisation

Intermittent Self Catheterisation (I.S.C) is performed by a client and should be used in

preference to an indwelling catheter if it is clinically appropriate and a practical option for the
client (N.I.C.E. 2003). The aim of intermittent catheterisation is to drain the residual urine
before the bladder is over distended and before incontinence occurs. Whilst the advantages of
this „clean‟ technique are self-evident, the client must find the procedure acceptable, have
sufficient cognitive abilities to understand instructions and sufficient dexterity to carry out the
procedure.

In younger clients residual volume is usually nil immediately after micturition, although a
volume of up to 50 mls is generally accepted, as not being significant. In the older population
(over 75 yrs) up to 100 mls is considered to be within normal limits. Clients with greater
volumes should be investigated for a voiding problem (Norton 2001).
A bladder scan should be requested if it appears that a client is not emptying the bladder fully.
Reasons for Intermittent Catheterisation

Neurogenic bladder – An abnormality of the nerve supply to the bladder, preventing bladder
from emptying completely. This may be due to a number of causes:

Obstetric trauma/childbirth
Constipation and straining at stool
Congenital abnormality
Abdominal surgery or trauma
Anal surgery or injury
Spinal/Head injury
Degenerative/neurological conditions

Outflow Obstruction

More commonly found in males and is often associated with prostatic enlargement or urethral
stricture.

Urethral Stricture & Prostatic enlargement

More commonly found in males but a urethral stricture can occur in females. This is
a narrowing of the urethra resulting from scar tissue following an infection or trauma. (Following
dilation or surgical intervention for stricture clients may have to use intermittent catheterisation
to retain urethral patency).

Detrusor Hypoactivity

The bladder is unable to sustain or provide an adequate contraction; this results in a failure to
empty completely. The sensation of the bladder filling may be absent or reduced and often the
bladder has an enormous capacity. Large residuals may present as overflow incontinence, with
or without frequency. This condition is usually the result of some nerve damage and can be
mostly found in those whose primary condition is diabetes, pelvic floor injury, multiple sclerosis,
(Fowler 1996) and prostate surgery (Guttmann and Frankel 1966).

Reflex Incontinence

Reflex incontinence occurs when there is spinal cord damage, the normal impulses do not
pass between the sacral reflex arc level and the brain (the sacral reflex arc controls
micturition).

Surgical Procedure

Surgical procedures particularly colpo-suspension may necessitate clients to perform I.S.C.

However those with a high risk of bladder dysfunction post-operatively are generally taught the
procedure prior to surgery. Similarly, any major surgical bladder reconstruction e.g. clam
cystoplasty may also require I.S.C. as part of a long-term management plan, or insertion of
Tension Free Vaginal Tape (T.V.T.) or Botox injections for overactive bladders
6.15 Who should teach Intermittent Catheterisation?

Following individualised assessment, guidance should be sought before I.S.C. is initiated.

Consideration should be given to the practicalities within the home environment. Any
registered Nurse has attended Kirklees CHS All Aspects of Catheterisation Course and who
deems themselves competent and confident to undertake the procedure can teach the
client/carer Intermittent Catheterisation.

Specific areas need to be considered including giving of information, role of consent

and especially child/adult protection issues, whether physical, psychological or sexual.
The nurse needs to be both supportive and skilled, stressing the positive values of I.S.C.
Intermittent Catheterisation is an intimate technique and the nurse should consider the client
psychosexual awareness, verbal and non-verbal behaviour and adopt a sympathetic approach
at all times.

Consideration should be given to mental/dexterity ability to where catheterisation is to be

performed i.e. work place, leading to which catheter should be used.

Frequency of Intermittent Self-catheterisation

The frequency of intermittent self-catheterisation is determined by the client‟s individual needs.

A useful guide is based upon the measurement of voided volume and residual volume.
Residual volumes that exceed 250 mls can potentially lead to recurrent Urinary Tract Infections
(UTI.‟s).

If the client is wet between catheterisations they may require more frequent catheterisations. If
the client experiences symptoms of urgency they may require I.S.C and anticholenergic
therapy.

It is advisable to complete a Continence Bladder Diary for two weeks to ensure that
the correct management plan has been implemented and to establish that the client is drinking
the recommended amount of fluid per twenty-four hours e.g. 1½ - 2 litres.

Types of Intermittent Catheters

Hydrophilic
PVC (single client use/used with a lubricant)

There are a number of self-lubricating hydrophilic coated catheters available, which have been
shown to be safe and comfortable for client use (MDA 2000). The catheters are single use
only. There is less trauma to the urethra using low friction catheters than pvc catheters
(Hellstrom et al 1991). When the client is proficient in the technique, it is important that they
choose their own brand of catheter, as the differences may seem
a small but not insignificant, this can be a determining factor for the user regarding comfort and
compliance. Choice of catheter should be guided by the available literature and research.
6.16 Urinary Tract Infection

Research (Lindenhall et al 1994) has shown that there is a reduction in the incidence of urinary
tract infections associated with intermittent self-catheterisation. Bacteria may be present
however in most instances, the client is asymptomatic. Treatment with antibiotics is not
recommended.

The presence of bacteria in the urine may be the result of poor technique and /or an increase
in the residual urine volumes. Cranberry juice has been shown to be of benefit to clients
undertaking intermittent self-catheterisation by preventing certain types of E-coli bacteria from
adhering to the bladder wall.

Always reinforce the need for good standards of hygiene and cleansing of the meatus.

6.17 Children & Young People Catheter Management

There is a small though not significant number of children who require regular catheterisation
during the course of the day, per urethra or via an artificial channel i.e. mitrofanoff
(Mitrofanoff/continence urinary diversion

7. Equality Impact Assessment

All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set
out arrangements to assess and consult on how their policies and functions impact on race
equality.” This obligation has been increased to include equality and human rights with regard
to disability age and gender. The Trust aims to design and implement services, policies and
measures that meet the diverse needs of our service, population and workforce, ensuring that
none are placed at a disadvantage over others.

In order to meet these requirements, a single equality impact assessment is used to assess all
its policies/guidelines and practices. This Procedure was found to be compliant with this
philosophy.

8. Training Needs Analysis

In order to ensure that policies, guidelines and protocols are introduced and work effectively,
there is a need to provide adequate training and instruction. As a result, the author(s) of this
document have carried out a training needs analysis which has identified the staff who require
training, the methodology of training delivery and the frequency that the training will be
provided. The procedure author must ensure that the details of this training is passed to the
Training and Education Team and where necessary, this will then be included in the Trust
Training Prospectus.

Responsibility: The Team Leaders are to ensure the key competencies are obtained.
It is recommended that Health Professionals attend updates every three years. This is
monitored through the eKSF process in conjunction with the training department.
Catheter care training is offered to Social services and independent sector carers to ensure
individuals receive excellent standards of care and adverse effects including infections are kept
as low as possible.
9. Monitoring Compliance with this procedure

In adhering to this procedure the expected outcomes will be:-

Continence problems will be identified by a continence assessment not a pad assessment.

Continence will be improved by the implementation of an effective continence management
plan.

Continence will be promoted wherever possible. Treatment and management will be instigated
as appropriate. The health professional responsible for completing the continence
assessment will be responsible for monitoring compliance by annual review.

Continence aids will be supplied to individuals in the community, if clinically required, to ensure
good management of incontinence when true continence is not achievable.

10. Audit Process

It is the responsibility of the individual nurse / assessor to ensure these guidelines are followed,
to maintain a high standard of continence assessment and management of incontinence.

The essential steps audit for catheter care should be completed by all team members every
three years, and preventing the spread of infection essential steps audit tool must be
completed annually by all team members. This is a statutory DoH requirement and endorsed
by KCHS infection control team.

11. References

Norton C (1996) Nursing for Continence Beaconsfield Publications Ltd

Roy S (1997) The Cost of Continence Royal College of Nursing Publishing Company
Continence Foundation, Association of Continence Advice, Royal College of Nursing
Continence Forum (1995) Charter for Continence
SIGN (2004) . Scottish Intercollegiate Guidelines Network Management of urinary
incontinence in primary care Dec 2004
DoH 2000 Good practice in Continence Services
Essential Steps to DoH (2006) safe, clean care: reducing healthcare – associated infections
RCN (2008) – catheter care
The Journal of Hospital Infection (2007) epic2: National Evidence –Based Guidelines for
Preventing Healthcare-Associated Infections in NHS Hospitals in England. Volume 65,
Supplement 1, February 2007.
Department of Health (2007) Essential steps to safe, clean care. Crown: London
12. Appendices

A. Key stakeholders consulted/involved in the development of the

procedure/procedure

Key Feedback Feedback

Stakeholders name and designation Participant requested accepted
Yes/No Yes/No Yes/No
Elaine Sergeant, Locality Manager
Yes Yes Yes
Margaret Farmer, District Nursing Sister
Yes Yes
Trevor Kenworthy, Locality Manager
Yes Yes
Jackie Hadfield, District Nursing Sister
Yes Yes Yes
 B. Equality Impact Assessment Tool

To be completed and attached to any procedural document when submitted to the appropriate
committee for consideration and approval.

Insert Name of Procedure / Procedure

Yes/No Comments

1. Does the procedure/guidance affect one group

less or more favourably than another on the
basis of:
Race NO

Ethnic origins (including gypsies and travellers) NO

Nationality NO

Gender NO

Culture NO

Religion or belief NO

Sexual orientation including lesbian, gay and NO

bisexual people

Age NO

Disability - learning disabilities, physical MENTAL HEALTH

disability, sensory impairment and mental health
problems

2. Is there any evidence that some groups are YES Guidance taken from RCN
affected differently? Guidelines on Catheter Care
3. If you have identified potential discrimination, YES Difficulties may arise in mental
are any exceptions valid, legal and/or justifiable? health care where consent
difficult to obtain
4. Is the impact of the procedure/guidance likely to NO
be negative?
5. If so can the impact be avoided?

6. What alternatives are there to achieving the

procedure/guidance without the impact?
7. Can we reduce the impact by taking different
action?

If you have identified a potential discriminatory impact of this procedural document, please refer it to
Joanne Whiteley, Continence service Manager 01484 347764, together with any suggestions as to
the action required to avoid/reduce this impact.
For advice in respect of answering the above questions, please contact Joanne Whiteley, Continence
service Manager, 01484 347764