Approximately 13% of all NHS patients are catheterised (Shackley et al, 2017), and, in England, there are 90 000 patients with long-term catheters in the community (Gage et al, 2017). Because of the high prevalence of catheterised patients on a district nurse team's caseload, catheterisation is an essential skill for all community nurses, no matter what shift patterns they work, and for many community nurses, catheter care can be a large part of their role. However, catheter management does not just have an impact on district nursing services. Ansell and Harari (2017) found that 49% of catheter patients went to the emergency department because of a blocked catheter, while O'Donohue et al (2010) found that 48% of patients with catheters visited the emergency department because of a urinary infection. These visits to the emergency department have an economic impact on the NHS, especially on emergency department services themselves, as well as the impact that this has on patients and their lives, especially when it involves a patient being discharged in the early hours of the morning. Many of these visits could be avoided with the better management of community-dwelling patients with catheters.
Can the patient manage their own catheter?
In their literature review, Waskiewicz et la (2019) found that there were four factors that affected patients' ability to manage their own catheter. These were education, knowledge, empowerment and communication. It can be argued that empowerment stems come from good education and knowledge, and they both require good communication, so the present article focuses on the information and knowledge that patients need. All the areas discussed below are aimed at reducing complications.
Hydration
It is recommended that men drink 15.5 cups (3.7 litres) of fluids and women drink 11.5 cups (2.7 litres) daily. This includes water, other drinks and fluids from food; about 20% of fluids come from foods (Mayo Clinic, 2020). Dehydration can quickly lead to strong or concentrated urine, which along with a low urine output, can be a cause of catheter blockages (Paterson et al, 2019).
Darker coloured or brightly coloured urine can indicate that a patient is becoming dehydrated (Paterson et al, 2019). Patients can use this as a ‘warning sign’ and increase their fluid intake when they observe this.
Personal hygiene
Personal hygiene is important with catheter management because microorganisms can migrate up a catheter and cause urinary infections (Jones, 2016). Therefore, patients need to be encouraged to wash their genitals and catheter daily with soap and water. The catheter should be washed in a direction away from the body to wash any microorganisms and detritus away from the urethra.
Positioning catheters
If the urine flow down the catheter is restricted or even stopped, then it can lead to the catheter becoming blocked (Paterson et al, 2019). Therefore, catheter bags should always be positioned below the bladder to aid drainage (Fraczyk et al 2003); they should never be placed on the floor, and instead a suitable stand should be used (Jones, 2016). The tubing should not become kinked or twisted, and patients should not sit on their catheter tubing, and it should not be wrapped underneath their leg. As much as possible, patients should be encouraged to ensure that their catheter and tubing are free from obstructions, and that the catheter and catheter bag are positioned so that they run down the top of the thigh and leg.
Emptying the catheter bag
A full catheter bag can put pressure on the catheter and can cause complications. It can cause urine to back flow into the bladder, risking infection and/or blockage (Paterson et al, 2019). It can also pull on the catheter and can damage a patient's urethra, both in men and women (Nazarko, 2016). Therefore, a catheter bag should be emptied at least when it is half full. Patients can often be aware of when their catheter bag is likely to fill up and know the best times to empty it, but they must be encouraged to do this regularly and certainly not wait until it is full.
Because of the risk of contamination of the catheter bag, when it is emptied, it should be done as a clean procedure. Even if patients are emptying their own bags, hands should always be washed before and after emptying. The outlet value should be cleaned before opening, and, while the catheter bag is being emptied, the outlet value should not come in contact with the receptacle for the urine, especially if it is a toilet bowl. The valve should be cleaned again after all the urine has been emptied, ensuring that it is firmly closed again (Jones, 2016).
Changing the catheter bag
Most manufacturers recommend that the catheter leg bags be changed every 7 days. Urine is an ideal medium for microorganisms to grow in, and it can easily contaminate a catheter bag (Evans et al, 2001). Leaving catheter leg bags on for longer than recommended will certainly increase the risk of contamination and can also increase the risk of microorganisms backtracking up the catheter (Evans et al, 2001). When catheter bags are changed, it should always be done as a non-touch technique to ensure against contamination.
Patients should have the ability to order new catheter bags from their GP or community suppliers, and not rely on others to do so. This may require ensuring that the correct catheter supply details are supplied to the GP or community suppliers.
Catheter bags should also suit the patient and their lifestyle. In their study, Fraczyk et al (2003) found that 89% of participants wanted their catheter bag to be concealed. There are a wide range of bags available, so the one that suits that patient's life and wishes should be selected. Bags with short tubes can be secured to the thigh and be hidden by shorts and skirts, while bags with longer tubes are secured around the lower leg and are only hidden by trousers or long skirts (Nazarko, 2016).
Can patients recognise the signs of complications?
Having a urinary catheter is the main factor that puts a patient at risk of having a urinary tract infection (UTI) (Evans et al, 2001). Identifying a catheter-associated UTI (CAUTI) means it can be treated as soon as possible, and the risk of any complications can be reduced. The symptoms include (Tremayne, 2020):
- Malodorous/badly smelling urine
- Dark and/or cloudy urine
- Lower abdominal pain
- Flank or over-the-kidney tenderness
- Pelvic discomfort.
If a patient has any of these symptoms, they need to seek advice as soon as possible. Patients need to know how to identify that their catheter is blocked and what to do if it is. They also need to be aware that a leaking catheter should not be ignored, because it can be a symptom of a blockage or a functional problem with the catheter, and appropriate help should be sought; if their catheter becomes blocked, they should know how to seek help in a timely way. It is important that patients know where to seek appropriate help and how to appropriately contact the district nurse team.
Blocked catheters
The risk of catheter blockage among patients in the community has been found to be between 20% to 70% (Paterson et al, 2019). Frequent and unplanned catheter changes put pressures on healthcare resources and time. Blocked catheters can be caused by the following factors (Paterson et al, 2019):
- Urinary infection
- Low urine output, often caused by poor fluid intake
- Kinked/twisted catheter tubing, restricting urine flow
- Incorrect positioning of catheter bag, where it is positioned higher than the bladder
- Catheter straps being too tight and not allowing urine to flow into bag
- Full catheter bag causing urine to backflow
- Constipation causing pressure on the bladder
- Blood clots blocking a catheter
- Encrusting at the catheter tip.
The first six risk factors can be relieved by the care strategies outlined in the above section on patient self-care. If the patient is constipated, lifestyle factors should be examined first: are they drinking enough fluids or eating a diet low in fibre? Laxatives may be needed, but this should be discussed with the patient's GP or non-medical prescriber. If the patient is having blood clots in their bladder/urine, these should not be ignored, and they need an urgent urology referral for further investigations.
Encrusting occurs when a crystalline biofilm forms around the tip of the catheter and blocks the catheter's eyelets (the holes in the tip that allow the urine to drain down the catheter) (Tremayne, 2020). The biofilm around the tip of the catheter causes the formation of urease, which breaks down in the urinary urea to release ammonia; this turns into urine alkaline, which crystalises in the urine, and these attach to the catheter, blocking the eyelets and then the catheter itself (Tremayne, 2020). Catheter maintenance solutions can help prevent encrusting by dissolving the crystals, helping prevent blockages, and this can extend the catheter's life (Tremayne, 2020).
Evans et al's (2001) research found that problems with catheters occur within 1–8 weeks of the catheter being inserted, with a median of 4 weeks for all-silicone catheters (Evans et al, 2001). If a patient's catheter is regularly becoming blocked before it is due to be changed, the interval between catheter changes should be reduced. This can mitigate the risks of catheter blockage and will improve a patient's quality of life, as they will not have to endure the complications of a blocked catheter on a regular basis.
Appropriate catheter changing
Catheterisation and re-catheterisation is an invasive medical procedure that does carry risks for a patient. Therefore, it should only be undertaken by practitioners who are suitably trained and competent in it, as well as competent in the appropriate type of catheterisation required, whether it is female urethral, male urethral or suprapubic (National Institute for Health and Care Excellence (NICE), 2017). Additionally, because the catheter is inserted directly into a patient's bladder, it should always be performed as an aseptic technique (Royal College of Nursing (RCN), 2019).
When changing a catheter, suitable catheter insertion gels should always be used; these are important for reducing risks and should be used with both men and women (Wilson, 2013). Women may have shorter urethras than men, but this does not mean they are not at risk of damage during catheter change. Simple lubricants, such as KY Jelly, are not a suitable substitute (Kyle, 2011). Designated catheter insertion gels are purposefully designed for lubrication during catheterisation, and they often contain a local anaesthetic and an antiseptic to ease the catheter's entry and to reduce pain and trauma.
It should always be ensured that the right catheter size for the patient is used. A larger Ch size catheter should only be used if there is a clinically justified reason. A larger Ch size catheter can distend the walls of the urethra, leading to damage and risk of infection (Wilson, 2008). Guidelines recommend that 12Ch–14Ch catheters are used to catheterise both men and women (RCN, 2019). Catheters also come in different lengths (standard or male and female). Because of the different average length of the urethra, standard/male catheters are longer than female catheters. Female-length catheters should never be used for men (Wakefield, 2021). It can cause the valve end of the catheter to be close to or press on the meatus/entrance to the urethra, which can cause damage to the meatus and even the urethra, or the catheter balloon can be inflated in the urethra because of its shorter length.
Once the catheter is changed, a securement device should be considered. This is a device that holds the catheter directly to a patient's skin, usually on the thigh. It prevents the catheter from moving and transfers any forces placed on the catheter—from a full catheter bag or the catheter being pulled—directly to the thigh, thereby stopping the catheter from being pulled and causing trauma to the urethra (Nazarko, 2016). One study reported that some 54% of patients who had an indwelling catheter for 2–4 years had experienced urethral injuries (Nazarko, 2016).
The RCN guidelines state that documentation should ‘include the planned date of review and catheter change date’ (RCN, 2019). In the community, more information than this is often required to prevent complications. Notes should include the size and type of the catheter used, the amount of water used to inflate the balloon, the catheter insertion gel used and the date when the next change is due. This should ensure that the right catheter, in terms of size and type, is used at the next change.
Catheter Passports (RCN, 2019) are becoming more frequently used. They contain the relevant information about a patient's catheter—that is, the reason for catheterisation, catheter type, size, insertion information, catheter-related equipment and next planned catheter change. A patient can take it with them, and, if they are admitted to hospital or have to be seen in the emergency department, they will have the relevant information to hand. Patients with Catheter Passports need to be informed of the importance of these documents, and they should be encouraged to carry it with them at all times; nurses involved in their care should ensure that these records are kept up to date.
Once the catheter is changed, the nurse should ensure there are enough catheter supplies in the patient's home for the next catheter change. Catheters often become blocked out of hours, so it is very important that patients have adequate supplies in their home to manage this. It is not acceptable that a patient has to visit the emergency department because they have not got a new catheter in their home.
Catheter-related pain
O'Donohue et al (2010) found that almost one-third (32%) of patients complained of pain from their catheter more than once. Unfortunately, pain from catheters can be caused by several different factors, and different methods are needed to manage these factors. If there is any concern about how to manage a patient's catheter pain, the district nursing team's local bladder and bowel service should be contacted for advice and support.
Infection can cause pain, either at the meatus or in the lower abdomen (Tremayne, 2020). Treating the infection should relieve this pain, but patients may need analgesia when the infection is active.
The patient may find that the type of catheter used is uncomfortable (Wilson, 2008). Hydrogel-coated catheters absorb a small amount of body fluids, which decreases the friction from the catheter. However, if the patient has a latex allergy, even though the catheter is coated, they could still react to the catheter. All-silicone catheters are porous, because of the nature of silicone, and the balloon may deflate prematurely due to osmosis. This may cause the partially deflated balloon to enter the urethra and cause pain (Wilson, 2008). A change in the type of catheter may relieve this; alternatively, reducing the time between catheter changes, especially if the patient is experiencing pain, might help.
If the Ch size is too large, this can distend the walls of the urethra, leading to damage and pain (Wilson, 2008). Switching to a smaller Ch catheter might help solve this problem. Using a female-length catheter for a man can also cause discomfort or pain (Wakefield, 2021), and the catheter should be changed to a male/standard-length catheter as soon as possible.
If a catheter bag is allowed to become full, it pulls and drags on the catheter and can cause pain (Wilson, 2008), especially if it is allowed to occur frequently. Regular emptying of the bag before it becomes full will prevent this, but the use of a catheter securement device should also be considered. If a patient relies on others to empty their catheter bag, a catheter securement device will help prevent the catheter being pulled or put under traction, even when it is full.
Urethral/meatal discomfort can be caused by changes in the urethra from having a catheter in situ or from changes in the body. In men, because the man is no longer passing urine down their urethra, mucus produced by the glands at the head of the penis (paraurethral glands) is not washed away and can be encrusted around the meatus. This can irritate and damage the sensitive tissue there (Wilson, 2008). Daily cleansing of the head of the penis should ease and relieve this, but reducing the catheter's Ch size should also be considered. After menopause, a woman may find a catheter uncomfortable. The urethra and the neck of the bladder (the trigone) is formed of similar tissue as the vagina. As oestrogen levels fall after menopause, these areas can become thin and dry, and even inflamed (Wilson, 2008). If this occurs, then the local bladder and bowel service should be consulted and the patient's GP informed.
If the catheter is on free drainage, then the bladder walls will collapse down around the catheter's tip. This can irritate the bladder walls and be uncomfortable for the patient (Wilson, 2008). If the catheter bag is replaced with a catheter valve, this will allow the bladder to fill up with urine, lifting the bladder walls off the catheter lip and releasing the discomfort.
If the pain/discomfort continues after a care strategy has been tried with the patient, then they should be referred to the local urology service. Pain, even from a catheter, should never be ignored.
Does the catheter still need to stay in?
Tremayne (2020) recommended that a catheter should be removed as soon as it is no longer needed, and, if it is still clinically needed, then it should be regularly reviewed for its clinical need.
If the catheter is not needed, then a trial without catheter should be arranged as soon as possible. A trial without catheter may be awkward and often involves a considerable amount of time spent in a hospital clinic, but the complications from having a catheter far outweigh this, and a patient's life can be improved with the removal of the catheter.
If the patient needs a long-term catheter, it must be assessed carefully whether it needs to be a urethral catheter. Intermittent self-catheterisation and supra-pubic catheters are a better alternative to urethral catheterisation because they carry fewer complications.
Intermittent self-catheterisation (ISC) is the gold standard for long-term catheterisation (RCN, 2019). They can reduce the risk of CAUTIs and trauma to the urethra and can also help maintain renal function and bladder tone, allowing a patient to have sexual relationships and giving them back control of when they empty their bladder (Cassani, 2014). Unfortunately, these do not come without their disadvantages (Cassani, 2014):
- Patients must be dexterous enough and have the cognitive ability to perform ISC
- Carrying out an ISC outside the home environment maybe a challenge and will certainly need planning
- Patients can still get a urinary tract infection while performing ISC
- Some patients find it uncomfortable
- Some find it socially unacceptable.
Supra-pubic catheters can also reduce the risk from a long-term catheter. When compared with urethral catheters, supra-pubic catheters reduce the risk of urethral trauma and damage, can be more comfortable, especially for patients who use wheelchairs, are easier to change, can carry a reduced risk of contamination from bowel flora and allow patients to be sexually active (RCN, 2019). However, they also have some disadvantages—for example, patients may have problems accepting a catheter coming out of their abdomen, the site can become swollen, overgranulated or infected (cellulitis), they can bypass urine via the stoma and/or the patient's urethra, especially if it is blocked, catheter removal can be uncomfortable, especially if the catheter tip is encrusted, and bladder stones can be more common with patients with a supra-pubic catheter (RCN, 2019).
Before switching a patient from a urethral catheter to intermittent self-catheterisation or a supra-pubic catheter, patients will need to be referred to and assessed by the local bladder and bowel or urology services. However, this should not put district nursing teams off the notion, as either of these changes can improve the patient's quality of life.
Conclusion
Catheters do carry many risks and can impact a patient's life, but many of these complications can be managed in the community. A patient's catheter should not be dismissed as just one that ‘blocks’ or ‘bypasses’ all the time. An investigation into the underlying causes can ease pressure on a district nursing team and improve the patient's quality of life.
The patient is the person who spends most of their time with their catheter, so it is very important to involve them and/or their relatives carers in the care of their catheter. Urinary catheters will remain a large part of a district nursing team's caseload, but with assessment and patient education regarding self-care strategies, many associated complications can be reduced.
KEY POINTS
- Urinary catheters can have serious complications, and involving patients in catheter management is very important to reduce complications, so that they can seek help as early as possible
- Catheter-related pain should never be ignored
- Catheters should always be changed appropriately, and the need for a catheter should be regularly assessed (and the catheter removed if not needed)
- All community nurses should be competent in catheter management
CPD REFLECTIVE QUESTIONS
- How would a patient identify that they are becoming dehydrated?
- How could a nurse prevent a patient having to attend the emergency department for a catheter change?
- What complications could an over-full catheter bag cause?