Historically, the word ‘catheter’ derives from Greece, meaning ‘to let or send down’. Urinary catheters date back as far as 3 000 BCE, and have been used for the relief of painful urinary retention. A variety of materials were used, including papyrus, straw and even hollow tops of onions (Urotoday, 2022). Frederick Foley designed the catheter known today back in 1935 when latex rubber became available, and little modification has been made to the original design to date (Holroyd, 2017).
Long-term catheter use forms a large proportion of district nursing caseloads. In 2017, there were an estimated 90 000 people living with long-term catheters in the UK (Gage et al, 2017; Nazarko, 2019), and this number is likely to have risen further since this time. Evans et al (2000) claim that the costs of long-term catheterisation and its associated complications cost the NHS approximately £10 000 per service user, per annum, bearing in mind these figures were approximated over two decades ago. Fernley et al (2015) discovered the costs to the NHS to be between £1-2.5 billion per annum. Furthermore, they argue that catheter complications are responsible for around 2100 deaths each year. Queensland Spinal Injuries Service (2020) agrees that implications on health services, with respect to time and resources, are costly and have a large impact upon the service user's quality of life.
Catheter blockage is one of the most common complications of long-term catheter use. According to Linsenmeyer (2016), up to 30% of long-term catheter users experience blocking. However, the Health Protection Surveillance Centre (HPSC) argues that up to 50% of catheterised people experience blocking. This significantly impacts the service users' health and wellbeing, causing symptoms such as pain, bypassing, urinary tract infections, pyelonephritis, septicaemia and endotoxic shock (Stickler, 2014; Bhandari et al, 2018; MacKay et al, 2018).
A potentially life-threatening condition named autonomic dysreflexia is a sudden emergency that can affect service users with spinal cord injury, caused by increased pressure in the bladder, triggering an over-activity of the autonomic nervous system (HPSC, 2011; Wilde et al, 2016). All healthcare staff involved in the care of urinary catheters should be aware of urgency in dealing with catheter blockage (NHS England, 2018). It is also worth considering the effect of burdening already overstretched health services (McIver et al, 2015; MacKay et al, 2018). The district nurse is a specialist practitioner who is able to instil this information within community teams.
Is a long-term catheter really necessary?
When dealing with catheter-related complications, it should first be ascertained if the catheter is indeed required (Thompson and Browne, 2019). Nazarko (2019) argues that 30-50% of people with long-term catheters in place have no clear indication for its use. However, there is a clear need for many service users with long-term conditions, such as multiple sclerosis, spinal cord injuriesor urinary retention. Nevertheless, there are other options to explore; intermittent self-catheterisation is ‘gold-standard’ for long-term catheterisation (Tremayne, 2020) but this is only suitable for service users who have the required dexterity and cognitive ability to manage this independently.
Service users could be assessed and taught this procedure by the district nurse in collaboration with the community continence services. Suprapubic catheterisation is considered as an alternative to urethral catheterisation, which poses more risk of complications. It is considered to be more comfortable for service users and easier for healthcare professionals to change. Due to placement through the abdominal wall, it is considered more appropriate for people who are sexually active with the added benefit of decreased risk of contamination and infection from bowel flora (Paterson et al, 2019).
This procedure is performed in hospital under anaesthesia. However, the impact of the COVID-19 pandemic on waiting times for elective procedures could limit this option for service users at present (The King's Fund, 2021). The use of catheter valves in place of drainage bags helps simulate natural voiding and can reduce the risk of trauma to bladder and urethral tissue (Loveday et al, 2014). However, once again, this option requires the service user to have the dexterity and cognitive ability to use this device.
External catheters should be considered in service users who have an indwelling urinary catheter for issues such as immobility, incontinence or wounds, as this is a non-invasive procedure (Gage et al, 2017). The district nurse is ideally placed to assess and discuss such options with service users, thus enabling best care outcomes by reducing risks associated with indwelling urinary catheterisation.
Saint et al (2008) raise the point that catheterisation can reduce mobility due to discomfort, which then increases the risk of developing pressure-related skin damage and constipation—a known cause of catheter blockage. Urinary catheters are invasive devices that can cause health problems and affect quality of life. Therefore, they should only be considered when all other options have been exhausted (Nazarko, 2019). Furthermore, Stickler (2014) argues that catheters undermine the bladder's natural defences; the balloon prevents the bladder from fully filling and emptying, leaving a residual amount of stagnant urine below the balloon which is susceptible to bacterial invasion.
Causes of catheter blockages
Paterson et al (2019) argue that it is important that nurses are aware of the reasons why catheters block. The author agrees; if one does not understand why a catheter blocks, then it will not be possible to rectify or prevent/minimise risk recurrence. The following section will discuss the causes of catheter blockage.
Simple causes
Catheter blockage can be caused by something as simple as restrictive clothing, kinked tubing or inappropriate positioning of the drainage bag, all of which can be easily rectified (Peate, 2015; Paterson et al, 2019). MacKay et al (2018) conducted a research study of catheterised service users, in which they found there was a lack of knowledge surrounding catheter management and care among participants. In fact, they found that some practices were potentially harmful. This may suggest a general lack of standardised information and education being cascaded to service users. Bhandari et al (2018) found similar issues among participants in their study surrounding the importance of hygiene, to which Payne (2021) concurs, further adding that strict hygiene is essential in catheter management, as microorganisms are able to migrate up the catheter, causing infection.
Davey (2015) places importance on the correct positioning of drainage bags secured with devices such as leg straps and also ensuring drainage bags are emptied often to prevent pulling. Davey (2015) found that many service users were unaware of the importance of this and often used securing devices incorrectly. Once again, this highlights the significance of service user education.
Tay et al (2016) discovered that education of community healthcare staff was variable in quality, resulting in some service users requiring hospital visits to rectify catheter-related problems that could have been resolved at home. It could be suggested that education and training should be standardised across healthcare trusts, ensuring all staff are educated to the same level.
Part of the district nurse's role involves educating and supporting service users and/or their carers (National Institute for Health and Care Excellence (NICE), 2012; Queen's Nursing Institute (QNI), 2015). As autonomous senior nurses, they possess the required knowledge, skills and experience to aid service users in self-care and maintaining independence for as long and safely as practically possible. They are also able to disseminate and cascade their experience and knowledge to support and teach junior or inexperienced staff members, thus ensuring service user safety is prioritised.
Dietary and fluid intake
The diet and fluid intake of service users can impact the catheter efficacy and result in complications such as constipation, leading to blockage (Paterson et al, 2019). Increasing fluid intake helps to dilute the urine and flush out bacteria. Payne (2021) suggests 3.7 litres of fluids—preferably clear fluids, per day for males and 2.7 litres for females, whereas Yates (2016) recommends 25-35 millilitres (mls) per kilogram per day. However, neither estimation is backed up with any facts or research.
From reviewing the literature, it is clear that increasing fluid intake is beneficial to catheter function and reducing the risk of constipation (NICE 2012; Stickler 2014; Wilde et al, 2016; Maeda et al, 2017). The Queensland Spinal Cord Injuries Service (QSCIS, 2020) advocates increasing fluids but stipulates diuretics such as caffeine and alcohol should be limited. It goes on to say that eating a well-balanced diet is important, but highlights that, by reducing intake of magnesium and calcium, the formation of crystalline deposits can be decreased (this will be discussed in the next section).
There is debate around cranberries being beneficial for urinary health. Thompson and Browne (2019) claim that cranberries can be mildly effective in preventing bacterial colonisation. However, despite this claim, cranberries are high in sugar, so any of these benefits might be outweighed by implications of increased sugar intake. The district nurse should assess the dietary and fluid status of service users as part of the clinical nursing assessment. This provides further opportunity to provide support and education.
Debris and encrustation bacteria develop rapidly in long-term catheter use and, if not treated effectively, can develop into bacteraemia. Maeda et al (2017) and Paterson et al (2019) allege that bacteriuria occurs in all urinary catheters at 30+ days. Andersen et al (2020) argue that only 30% of people actually become symptomatic, further adding that there is a higher incidence in community; possibly due to lack of asepsis and education of service users/carers. Stickler (2014) argues that district nurses should be aware of this and obtain a catheter specimen of urine for analysis when a catheter has been in place for 4 weeks.
Some 40-50% of people with a long-term catheter experience lumen blockage due to debris or encrustation (European Association of Urology Nurses, 2012). Bahndari et al (2018) and Nazarko (2019) claim this figure to be at the higher end of this estimation at 50%. Furthermore, Thompson and Browne (2019) suggest that 90% of long-term catheter users have bacterial colonisation, that is, presence of bacteria to the catheter itself. Debris is caused by urothelial cells from the bladder, tumours, blood from infection or trauma or mucus (European Association of Urology Nurses, 2012; Wilson, 2016).
Proteus mirabilis is the most common bacteria found to be associated with catheter complications. Often found in bowel flora, it is the main cause of blocking and encrustation (Stickler and Fernley, 2010). It is an especially active urease producing bacteria that converts urea into ammonia, damaging cells that protect against infection and raising potential of hydrogen (pH), thus making the urine alkaline. Alkaline urine provides the perfect conditions for the formation of crystalline deposits. The normal pH of urine is 6.0; the QSCIS (2020) highlights that, when pH reaches 6.7 or above, considerable encrustation develops and also increases the likelihood of bladder stone formation. Proteus mirabilis colonises the catheter forming extensive biofilm; this biofilm protects the bacteria and renders antibiotic therapies ineffective (Holroyd, 2019; Thompson and Browne, 2019). Therefore, it is essential that it is identified early on for any treatments to be effective.
Treatment
The evidence surrounding effective treatments for this common complication is diverse and largely contradictory, yet it appears that there is a lack of availability of good quality research, leaving nursing staff confused about suitable treatment options.
The district nurse must first perform a full, holistic nursing assessment to establish rationale for catheter use and to rule out any obvious issues as discussed above. Previously, in the case where the blockage could not be resolved, the usual practice in the NHS Trust where the author is currently based was to remove the problematic catheter and replace it using triclosan (Farco-fill®) to inflate the balloon rather than sterile water; however, Farco-fill is no longer available in the UK market. Furthermore, there are no alternative triclosan products for catheter care that the author is aware of. Wilde et al (2016) agree that changing the catheter is a priority.
Pannek and Vestweber (2011), Holroyd (2017), Nazarko (2019) and Jordan et al (2015) have all performed studies in the use of triclosan. All of the research studies had positive results. Pannek and Vestweber (2011) found that triclosan is able to diffuse through the catheter balloon, which significantly reduced harmful bacteria and colonisation. All authors found that triclosan reduced encrustation and aided catheter removal. Jordan et al (2015) identified that triclosan is highly effective against proteus mirabilis. Nazarko (2019) states that triclosan is only licensed for 4-weekly use, but this statement is not supported with any further reasons, and it is possible that triclosan loses its effectiveness after this period of time. Burns et al (2021) have also expressed concerns regarding bacteria building resistance to triclosan. Similarly, Davey (2015) found that the use of antimicrobials such as triclosan is increasing throughout Europe and North America; however, there is a possibility of bacteria forming resistance to this product. Therefore, further studies are required to support its use, and it should be used with caution.
Bhandari et al (2018) suggest intermittent balloon deflation and reinflation as a possible solution for blocked catheters but offer no explanation or evidence to support this theory, nor was any further evidence found during the research for this article. Nazarko (2019) disagrees with Bhandari et al (2018) and states that balloons are designed for single inflation only. As with any product, the manufacturer's instructions must always be followed to ensure patient safety is prioritised, minimising risk of potentially life-threatening complications and litigation.
Bladder irrigation solutions
According to the Trust policy, catheter maintenance solutions are not recommended for prevention of catheter–associated urinary tract infections but may be useful for certain service users to minimise encrustation and blocking. NICE (2012) state that installations must not be used to prevent infection. Evidence surrounding the use of such solutions vary.
It is worth noting that bladder instillations are contraindicated in people with spinal cord injury due to the risk of autonomic dysreflexia (HPSC, 2011). There is much debate surrounding the use and effectiveness of bladder irrigation solutions. Gibney (2016) argues that the catheter tubing holds approximately 4ml of fluid, while bladder solutions are usually supplied in pre-filled bags or bottles of 50-100ml. Gibney (2016) suggests that only a small amount of solution is required to bathe the tip, any remainder enters the bladder itself and can cause irritation and tissue damage, a point agreed by Holroyd (2019).
There are different solution preparations to consider. For example, 0.9% saline is commonly used for service users who experience frequent catheter blockages due to debris, in order to reduce incidence. Nazarko (2019) claims this is an ineffective procedure for preventing encrustation, with QSCIS (2020) concurring, adding that this procedure can cause bladder spasms and mucosal irritation. Tremayne (2020) counterargues that this can indeed help prevent blocking, whereas Paterson et al (2019) claim this is useful for prevention but not removing existing deposits.
Citric acid solutions are available in two strengths: 3.23% and 6%. The Royal College of Nursing (RCS, 2021) recommends the 6% solution for use prior to catheter removal to dissolve deposits and the 3.23% solution for weekly use (5-10ml) as a preventative measure against encrustation. They go on to add that sequential smaller volumes are more effective than single dose larger volumes; this may conflict with the suggestion proposed by Gibney (2016). Bandhari et al (2018) and QSCIS (2020) concur that this could be helpful in reducing encrustation. However, Hagen et al (2010), Stickler and Fernley (2010) and the European Association of Urology Nurses (2012) disagree due to the lack of evidence from poorly reported trials.
Peate (2015) and Thompson and Browne (2019) argue that breaching of the closed system for bladder irrigation poses risks to the service user by raising the possibility for introduction of bacteria, which could potentially lead to bacteria resistance. It is further claimed that bladder irrigation cannot penetrate biofilm if this is present. The HPSC (2011) claims that citric solutions can prolong the life of a catheter and that the risk of infection could be outweighed by reducing frequency of catheterisation.
Andersen et al (2020) performed a 5-week study using Uro-Tainer polyhexanide 0.02%. It revealed significant reduction in bacteria colonisation compared to saline, although no other studies were identified that have used this solution, so further research over longer periods may be required to validate its use. Peate (2015) suggests using bladder irrigation products and checking the pH of urine could be carried out during weekly leg bag changes while the closed-system is already being breached, allowing for timely treatment. Furthermore, Peate (2015) recommends using chlorhexidine swabs to clean the catheter tubing to reduce the bacterial risk. This, again, may induce bacterial resistance if used frequently. Stickler (2014) argues that good standard of hygiene and strict asepsis is sufficient to prevent introduction of bacteria.
Oral citrate
Increasing citrate orally has been implied as beneficial to long-term catheter users in reducing crystallisation (QCSIS, 2020). While Thompson and Browne (2019) negate this theory, advising that large doses would be required to make even the smallest impact upon pH values, they do, however, support use of oral methanamide and/or acetohydroxamic acid for blocking urease activity, although no additional evidence was found to support this claim.
Product selection
Urinary catheters are graded by the Charriere scale, which refers to the outer circumference. The smallest size should be used to minimise the risks of trauma, bladder spasm and leakage (Nazarko, 2019). There have been a number of debates surrounding different catheter types and materials. From reviewing the literature, silicone appears to be the material of choice for catheters. Maeda et al (2017), Bhandari et al (2018) and QCSIS (2020) suggest that silicone catheters are more resistant to catheter encrustation. This is most likely due to this catheter type having a wider lumen (European Association of Urology Nurses, 2012). Nazarko (2019) agrees, although male users found all silicone catheters to be uncomfortable due to the rigidity of the material.
Silver–coated catheters are thought to be resistant to bacterial infection (Bier, 2011); however, Paterson et al (2019) argue that studies on this catheter type are poor, and Thompson and Browne (2019) and Shaw and Wagg (2019) concur that there is little valid evidence to support the use. Wang et al (2012) conducted a study of silver-coated catheters and found that bacteria was only resisted for 6 days. Alternately, Simpson (2017) recommends the use of silver–coated catheters for users who have recurrent infections; however, it is stated that these catheters can only be used for a duration of 4 weeks. Stickler (2014) suggests that all catheters, regardless of material, are susceptible to bacteria.
Simpson (2017) suggests using curved tip catheters for service users with known prostate enlargement or strictures, and open tipped catheters for those who experience frequent blocking due to sediment or debris, or have a history of bladder spasms or bypassing. Therefore, when removing catheters, the district nurse should inspect the tip and dissect the tubing to check for evidence of encrustation (Gibney, 2016; Thompson and Browne, 2019; Shaw and Wagg, 2019); this allows for selection of appropriate treatment.
QSCIS (2020) recommend 4-6-weekly catheter changes to prevent colonisation. Subsequently, with the evidence reviewed surrounding bacterial colonisation and longevity of products, this recommendation appears to hold validity. Frequency of catheter changing should always be led by the individual service user according to their catheter history. Where a service user has recurrent catheter issues, they should be reviewed by urology to rule out any underlying genitourinary cause.
Documentation
It is vital that district nurses document episodes of catheter care, including any infections, blockages, bypassing, bladder spasms, changes in products used and lifespan of catheters being removed (Wilde et al, 2016; Simpson 2017; Thompson and Browne 2019; Paterson et al, 2019). Furthermore, the use of a catheter diary to be completed by the service user encompasses collaborative working (Gibney, 2016; Wilde et al, 2016); this will assist in establishing any patterns for anticipatory care planning.
Conclusion
District nurses have a pivotal role in the management of service users with long-term catheters in the community. Their enhanced skills, knowledge and experience are fundamental to ensuring that safe and appropriate care is delivered in a timely manner. Working in collaboration with the service user, their carers and relevant members of the multidisciplinary team, they are able to assess, plan, coordinate, deliver and evaluate individualised care to prevent unnecessary hospital admissions. It is crucial that care is evidence–based and the district nurse must keep their skills and knowledge current to enable optimal service user outcomes.
An urgent commitment from healthcare employers is required to facilitate high-quality training in catheter management and care to ensure all practitioners have a solid evidence base to optimise care delivery. District nurses play a key role in supporting and educating patients and carers to minimise risks associated with poor or self-taught practices. Doing this not only promotes independence and self-care, but also potentially reduces healthcare costs and resources. Current practice varies across healthcare settings and requires standardisation and regular updating.
There is an urgent need for more up to date research in the area of catheter blockage and its appropriate management and treatment. It is intended that this article raises awareness of current knowledge among district nursing teams and other community healthcare providers caring for service users with an indwelling urinary catheter.
Key points
- Catheter blockage is a medical emergency which requires immediate intervention
- District nurses are pivotal in managing service users with long-term catheters. They are key specialists trained to fully assess, diagnose and treat problems in collaboration with service users, carers and other members of the healthcare team
- Patient education regarding catheter care and management is essential to minimise risks from poor/self-taught practices
- An investment in high–quality training for all staff working with people who have a long-term catheter is urgently required
- Managing and minimising episodes of catheter blockage is complex, and all service users must have an individualised plan of care.