“For more than 3500 years, urinary catheters have been used to drain the bladder when it fails to empty. For people with impaired bladder function and for whom the method is feasible, clean intermittent self-catheterization is the optimal procedure. For those who require an indwelling catheter, whether short- or long-term, the self-retaining Foley catheter is invariably used, as it has been since its introduction nearly 80 years ago, despite the fact that this catheter can cause bacterial colonization, recurrent and chronic infections, bladder stones and septicemia, damage to the kidneys, the bladder and the urethra, and contribute to the development of antibiotic resistance. In terms of medical, social and economic resources, the burden of urinary retention and incontinence, aggravated by the use of the Foley catheter, is huge”.1
“The insertion of biomedical devices into the body, such as intravascular and urinary catheters, represents an indispensable component of modern medical care, especially for hospitalized patients. Nevertheless, the use of these medical devices is associated with a substantial risk of bacterial infections, with catheter-associated urinary tract infections (CAUTIs) and catheter-related bloodstream infections (CRBSIs) representing significant medical problems. Specifically, Foley catheters, the most widely utilized indwelling urinary catheters, play a critical role in the relief of urinary retention, alleviation of urinary incontinence, and patient management during and after surgical procedures.”2
In the past, mainly acute and chronically ill patients in all types of medical setups had Foley urinary catheters inserted. Today, long-term use of Foley catheters has increasingly become more common in patients’ homes with aid from a health professional, and also in a number of medical facilities with high elderly populations.
“Before the widespread introduction of the Foley catheter in the 1930s, catheterization was almost exclusively for the treatment of urinary retention in the male. The early catheters were usually rigid and they were designed—to the extent that they were designed at all—for intermittent catheterization.”3
The aging of baby boomers has led perhaps to too many Foley catheters being placed at home. Although there should be solid reasons justifying Foley catheterizations, there seem seems to be countless instances where a less compromising alternative should have been the option.
The number of those using Foley catheters because of urinary incontinence and urinary retention is not clear, but the unwarranted use to deal with incontinence is on the rise.
As many as 1 in 5 cases of urinary catheter use in health facilities have no clear medical indication, and, in most instances, the primary physician doesn’t know about them. Currently, there is an effort to educate clinicians on the need to use urinary catheters when absolutely necessary and for the shortest time possible. This includes adopting other non-invasive ways of assessing bladder functionality.
“Female catheterization: The female urethra is short compared to the male urethra. It is located above the vagina in the pelvis. The insertion of the catheter is facilitated by having the patient lie down on his or her back with the buttocks at the edge of the examination table. Adequate exposure of the urethra is obtained by elevating and supporting the legs by stirrups or placing them in a frog-legged position. Finally, the labia are separated to expose the urethra.
Male catheterization: The male urethra is long compared to the female urethra. A catheter is placed while lying down or in the frog-legged position. If there is a foreskin, it is retracted to its maximal limit.”4
Reasons to use a Foley catheter
Only consider using Foley Catheters To be considered after other alternatives of urinary retention or incontinence management have been evaluated and found inappropriate
“Foley’s original catheter was made of latex, the mechanical properties of which are ideal for this purpose: it has a high stretch ratio, a high level of resilience and it is extremely waterproof. The main problem with latex is its cytotoxicity: for instance, in the 1980s, an epidemic of severe urethral strictures was recorded in patients as the result of using latex catheters. The cause was traced to cellular toxicity due to eluates from rubber. Latex catheters are now usually coated with silicone elastomer to reduce this risk. Many modern catheters are made entirely of silicone elastomer and hydrophilic coatings are used to provide a slippery surface to reduce friction. Silicone catheters are not only non-allergenic, but they also have superior resistance to kinking and better flow properties in comparison with latex catheters.”5
“The Foley catheter is inserted into the urethra, the tube that carries urine out of the body. It is gently pushed up the urethra until it reaches the bladder. A hole in the bladder end of the tube allows urine to flow out of the bladder, through the urethra and out of the body into the collection bag. Once the top of the foley tubing reaches the bladder, a balloon is inflated with sterile water to keep the tube in place.”6
Catheter insertion should only be done when there is proof that the bladder has retained urine. Incontinence should be managed with a condom in all compliant men without urinary retention.
- Urine retention.
- Urine outlet blockage.
- In sacral wound management in patients with urine incontinence.
- In terminal conditions such as coma and end stage disease.
- In strictly immobilized patients.
“A Foley catheter is used with many disorders, procedures, or problems such as these:
- Retention of urine leading to urinary hesitancy, straining to urinate, decrease in size and force of the urinary stream, interruption of urinary stream, and sensation of incomplete emptying.
- Obstruction of the urethra by an anatomical condition that makes it difficult for one to urinate: prostate hypertrophy, prostate cancer, or narrowing of the urethra
- Urine output monitoring in a critically ill or injured person
- Collection of a sterile urine specimen for diagnostic purposes
- Nerve-related bladder dysfunction, such as after spinal trauma (A catheter can be inserted regularly to assist with urination.)
- An imaging study of the lower urinary tract
- After surgery”7
Intra-operative catheterization needs
- Urological or other procedures in enclosed environments.
- Long duration surgeries.
- Intra-operative use of high volumes of intravenous fluids or diuretics.
- As a means of maintaining the intra-operative input/output fluid chart.
Other medical needs
- To gauge fluid intake and output.
- To deal with sudden and total urine retention.
- To quickly decompress the bladder.
- Due to urinary blockage which can follow:
- Hypertrophied prostate.
- Urethral narrowing (stricture).
- Prolapsed pelvic organ.
- Failure of intermittent catheterization due to chronic urine outlet obstruction.
- Surgery on the urinary tract.
- Other instances include:
- Advanced cases of pressure sores following chronic urine leakage.
- Absence of continuous urinary incontinence care.
Use of Foley catheters in acute care
“In acute care hospital settings, approximately 12-16% of adult patients and up to 25% of all hospitalized patients usually for surgery, urine output measurement, urinary retention, or UI. Their use is greater in high acuity patient units, with critical care and intensive care units having the highest. At least 8%-23% of patients admitted through the emergency room have an IUC. Nearly 50% of surgical patients remain catheterized beyond 48 hours postoperatively; approximately 50% of medical patients do not have a clear indication for an IUC.”8
Surgery, monitoring of input/output fluid charts and retention are some of the reasons hospitals take the lead in catheterization cases. These remain in place for only 2-4 days in an effort to reduce the incidence of bacteriuria (bacteria in the urine). Elderly patients who have to retain a catheter and are discharged to a nursing facility have a higher rate of re-hospitalization due to catheter-associated urinary tract infections. Mortality within 30 days of discharge is also higher among these patients in comparison with those who had their catheters removed before discharge. Chances of infection are determined by the following:
- Catheterization duration.
- Immune status of the patient.
- How well the catheter is managed.
- Some cases of bacteriuria can remain symptomless but others become serious enough to complicate health and quality of life.
“The catheter is intended to remain in place for several hours or longer. It is important that a catheter only remains in place as long as it is necessary, as the risk of infection increases the longer the catheter is in place.”9
Facts about long-term Foley catheter use
- The incidence in nursing homes is about 7%.
- Facilities with poor urinary incontinence management use it as a way to maintain patient dryness and dignity.
- Urinary tract infections account for up to 40% of cases in nursing homes.
- 80% of UTIs in nursing homes are catheter-associated.
- Long-term catheter use in urinary incontinence is mostly due to the presence of pressure sores.
“Insertion of an indwelling urethral catheter (IDC) is an invasive procedure that should only be carried out by a qualified competent health care professional using aseptic technique. Catheterization of the urinary tract should only be done when there is a specific and adequate clinical indication, as it carries a risk of infection.”10
“Approximately 10% of all hospitalized and long-term care patients in the United States require an indwelling urethral catheter. Bladder catheterization via the urethra is the most frequent retrograde procedure performed on the urinary tract and is a common occurrence for many patients undergoing surgery with general anesthetics, including cardiac surgery patients. In critically ill patients, urethral catheterization is used to assess urinary output.”11
(1, 3, 5) Urinary Catheters: history, current status, adverse events and research agenda. Feneley, R., Hopley, I., & Wells, P. Journal of Medical Engineering and Technology. 2015. https://www.tandfonline.com/doi/full/10.3109/03091902.2015.1085600
(2) S-Nitroso-N-acetylpenicillamine (SNAP) Impregnated Silicone Foley Catheters: A Potential Biomaterial/Device To Prevent Catheter-Associated Urinary Tract Infections. Colletta, A., Wu, J., Wo, Y., Kappler, M., Chen, H., Xi, C., & Meyerhoff, M. ACS Biomaterials, Science & Engineering. 2015. https://pubs.acs.org/doi/10.1021/acsbiomaterials.5b00032
(4, 7)Foley Catheter Insertion: Care, Removal, Use & Types. Thangavelu-Veluswamy, A., & Thangavelu, D. EMedicineHealth. 2019. https://www.emedicinehealth.com/foley_catheter/article_em.htm#foley_catheter_introduction
(6, 9) Overview of the Foley Catheter and Surgery. Whitlock, J. VeryWell Health. 2019. https://www.verywellhealth.com/what-is-a-foley-catheter-3157319
(8) Indwelling catheters and indications using indwelling catheters. Gould, C., Umscheid, C., Agarwal, R., Kuntz, G., & Pegues, D. UroToday: The World’s Leading Resource For Urology News. 2013. https://www.urotoday.com/urinary-catheters-home/indwelling-catheters/description/indications.html
(10) Indwelling urinary catheter – insertion and ongoing care. Richards, S., & Cabato, M. Clinical Guidelines: Nursing. 2017. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Indwelling_urinary_catheter_insertion_and_ongoing_care/
(11) Indwelling Foley Catheters. Fallis, W. Critical Care Nurse: The Journal for High Acuity, Progressive and Critical Care Nursing. 2005. http://ccn.aacnjournals.org/content/25/2/44.long