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Catheter Irrigation in the Management of the Urinary Tract in Spinal Cord Injury

Damage to the spinal cord or nerves by the end of the spinal canal commonly impairs certain body functions permanently, including urination. Spinal cord injury (SCI) changes the voiding process and requires catheter irrigation. Prevalence of symptomatic urinary tract infections (UTIs) increases due to the use of catheters, higher intravesical pressure, and additional post-void residuals. Using antibiotics also enhances the risk of infection with antibiotic-resistant organisms, complicating the management of UTIs. Despite medical advances, improved catheter design and antibiotics, irrigation still causes problems to SCI patients and caregivers. 

“Irrigation is a procedure to open a plugged urinary catheter. Normal saline (NS) is inserted into the catheter to remove the plug, so that the urine can drain from the bladder.”1 

Reasons for Catheter Irrigation

  1. To assess the patency of the catheter
  2. To prevent urine stones. Use acetic acid, renacidin or Solution G (which contains citric acid, anhydrous sodium carbonate, and magnesium oxide) for this purpose.

“Urinary bladder irrigation is done in cases of both hematuria and as a part of any intervention in bladder and prostate such as transurethral prostatic resection and mensa irrigation. This is done using a 3-way irrigation urethral catheter. Usually, the size available is 16-Fr and above; however, in cases of stricture, smaller size is required. We describe a technique for this situation.”2

Intermittent Irrigation of Indwelling Catheters

“The literature indicates that IUCs (intermittent irrigation of indwelling urinary catheters) should only be irrigated if there is evidence of a blood clot. Blood clots may be present after bladder, kidney, or prostate surgery, or with encrustation of long-term catheters. Routine intermittent irrigation of an IUC, especially if the IUC is disconnected from the drainage bag, is thought to increase the possibility of introducing microorganisms into the bladder, resulting in an infection. According to experts, even if biofilm (bacterial colonies) are suspected to have caused encrustation on the IUC sides, and are causing blockage, routine irrigation is not effective and could even increase the risk of infection.5 In addition, the IUC itself may be part of the problem causing the obstruction and should then be replaced rather than irrigated.”3

Necessary items for catheter irrigation

  • Catheter tip syringe.
  • Alcohol swabs.
  • Disposable paper towels.
  • Catheter clamp if using renacidin.
  • A sterile urine container.
  • Irrigation solution.
  • Alcohol wipes to keep the drainage tube end sterile in case you want to reuse it.

Catheter irrigation procedure

“Irrigate through the catheter every four hours during the day using Normal Saline (do not use tap water). It is important to irrigate more frequently if the urine output has diminished or if the Blake drain or Penrose drain seems to have a significant increase in the amount of output. No need to wake up overnight to irrigate, last irrigation should be before you go to bed, and then upon waking in the morning. It is important to irrigate in order to keep the catheter free of mucous plugs, or blood clots so that urine is able to drain out and not back up into the kidneys.”4

Irrigation requires following these steps

  • Have the supplies ready.
  • Use towelettes or soap and water to wash your hands
  • Place disposable paper towels under the catheter system
  • Pick up the irrigating solution touching the outside part of the glass only. Measure 2 ounces and pour into the container.
  • Arrange the urine container under the open catheter end.
  • Swab the catheter-drainage tube connection with the alcohol-infused cotton swabs.
  • Disconnect the catheter from the tube and put the tube away after covering its end. Ensure the catheter end does not touch the urine tray.
  • Withdraw one ounce of the irrigating solution into the syringe, making sure to push out any residual.
  • Insert the syringe into the end of the catheter. Apply gentle pressure on the syringe plunger and push the solution into the catheter and up into the bladder. If finding resistance during insertion, change the catheter. Avoid suction to the catheter while inserted, this may cause physical trauma to the bladder.
  • Grasp the catheter end with 2 fingers in a pinching position and gently apply pressure to pull out the syringe.

“Catheter irrigation should be on schedule. This erroneous concept presupposes that irrigation of the bladder is a cleansing process and beneficial to maintaining physiology. The error in this concept is that any interruption of the closed drainage system, especially by careless personnel or poor technique, can introduce bacteria and infection. Naturally, there is no benefit to be gained by irrigating the catheter for any purpose unless it is to prevent encrustations by using Renacidin, or to medicate the bladder for specific purposes known to the attending physician. 

Since the advent of closed drainage systems and appropriate antibacterials, there is absolutely no indication on a regular basis for scheduled bladder irrigations. Primary indication for catheter irrigation is poor or obstructed drainage. This can be determined by noting the presence or absence of fluctuation of the urine in the catheter tubing. Absence of fluctuation suggests obstruction and therefore the need for aspiration or irrigation (aspiration preferred).”5

Using renacidin as the irrigating solution

“Renacidin (Citric Acid, Glucono delta-lactone, and Magnesium Carbonate) is a sterile, non-pyrogenic irrigation solution for use within the lower urinary tract in the dissolution of bladder calculi of the struvite or apatite variety, and prevention of encrustations of urethral catheters and cystostomy tubes.”6

  • Ensure sterility of the solution
  • Drip the second ounce of the solution into the catheter and clamp it.
  • Unclamp the catheter and allow to drain after 10 minutes
  • Drain the urine into the receptacle
  • Repeat the process with the unused solution.
  • Swab the connector with cotton alcohol swabs and attach back to the urine bag tubing.
  • Discard the disposable items and wash the remaining supplies.
  • Thoroughly wash your hands.

“Renacidin use should be stopped immediately if the patient develops fever, urinary tract infection, signs and symptoms consistent with urinary tract infection, or persistent flank pain. Irrigation should be stopped if elevated serum creatinine develops. The contents of individual Renacidin containers should not be combined for use as continuous irrigation of the urinary tract because of complications that may arise from inadequate aseptic technique. Terminal sterilization processes that are not adequate may result in sepsis and/or injury to product handlers (e.g., irritation to exposed, unprotected areas of the skin). Serious adverse reactions, including sepsis and hypermagnesemia, have been reported to occur when Renacidin was used for continuous irrigation of the upper urinary tract. Renacidin is not indicated for continuous irrigation of the upper urinary tract.”7

Suggestions 

  • Have your prescription ready. “Urinary catheter/bladder irrigation requires a prescriber’s order. The order must include type and amount of irrigating solution and frequency of irrigation. The following assessment and troubleshooting steps should be taken prior to the decision to irrigate catheter:  No urine output x 1 hour. Patient complaints of urinary retention (abdominal discomfort, urge to void) Palpate for distended bladder. Site-to-source check (system intact, kinks, clamps, etc.)  Reposition patient to optimize drainage. Scan bladder. Discuss assessment findings with the team and obtain order.”8 
  • Perform irrigation at the time of changing from a leg bag to a drainage bag. This is usually during bedtime and upon waking up in the morning.
  • If you do your catheter irrigation twice in a day, sterilize 2 irrigation sets at the same time.
  • It is much more affordable to prepare the irrigation solution on your own.
  • If you notice blood in urine, avoid irrigation solutions containing acetic acid. These include Renacidin and Solution G
  • Avoid introducing air into the bladder inadvertently.
  • Keep the irrigation equipment in a safe and clean place. “It is not uncommon to enter a patient’s room and find irrigation equipment on the bedside stand. This is to be prohibited at all times. Such irrigation equipment is to be always sterile and by leaving it at the bedside, patients, relatives, visitors, have access to this equipment, may handle it, may curiously examine it, may drop cigarette ashes into it, or any other ill-advised activity which cannot be monitored from the nurses’ station. It may be convenient for the nurse or personnel to have the sterile equipment at the bedside but it is poor public policy, poor patient policy, and poor infection control to have this condition exist. The sterile equipment should be kept at the nursing station under careful control and supervision.”9
  • Drink enough fluids to stay hydrated. “You should drink at least 2 liters of decaffeinated liquids per day. There may be some incidental light bleeding during or after irrigation. This is normal as things are healing.”10
  • Preserve hygiene during the catheter irrigation procedure to avoid UTIs. “Despite the current preference for IC as the bladder emptying method of choice, recurrent UTI is nevertheless a frequent complication among patients who practice IC. Patients with SCI may be significantly affected by a UTI, which can cause malaise, hyperpyrexia, abdominal pain, increased spasticity and symptoms of autonomic dysreflexia. In the long term, there is a risk of impaired kidney function. Prevalence of bacteriuria and UTI varies widely in the literature. Publications indicate that 12–88% of subjects practicing IC have bacteriuria, but far from all develop symptomatic UTI.”11

Patients with SCI face multiple difficulties, including emptying their bladder. Although catheter irrigation helps them with this process, it may cause urinary tract infections and other complications. Also, frequent use of antibiotics may lead to infection with antibiotic-resistant organisms, so nurses and caregivers should sterilize the catheterization implements and keep them in a safe cabinet.

As with any other procedure, physicians and nurses must explain the pros and cons of catheter irrigation to patients, and obtain their consent before performing the procedure.

 

References:

(1) Urinary catheter irrigation. Children’s Hospitals and Clinics of Minnesota. 2010. https://www.childrensmn.org/references/pfs/homecare/urinary-catheter-irrigation.pdf

(2) Improvised Urinary Bladder Irrigation System. Agarwal, A., Bora, A., & Banerjee, A. Annals: The Royal College of Surgeons of England. 2008. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728318/

(3) Standardizing Practice for Intermittent Irrigation of Indwelling Urinary Catheters. Weber, J., Purvis, S., Van Den Bergb, S., & Stevens, L. Journal Of Nursing Care Quality. 2017. https://nursing.ceconnection.com/ovidfiles/00001786-201707000-00004.pdf

(4) Hematuria Catheter Irrigation Procedure. Keck Medicine of USC Urology. 2016.https://urology.keckmedicine.org/wp-content/uploads/sites/30/2016/12/Hematuria-Catheter-Irrigation-Procedure.pdf

(6, 9) Basics of Catheterization and Catheter Care. Becker, L. Journal Of The National Medical Association. 1980. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2552415/pdf/jnma00036-0087.pdf

(6, 7) Renacidin (Citric Acid, Glucono Delta-Lactone, and Magnesium Carbonate) Irrigation Solution. Smith Medical ASD. Guardian Laboratories. 2015. https://www.google.com.mx/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=2ahUKEwj1j-GQ_47jAhWFAWMBHelRC8wQFjABegQIARAC&url=https%3A%2F%2Fdailymed.nlm.nih.gov%2Fdailymed%2FgetFile.cfm%3Fsetid%3D13a9bbba-db21-4cba-991c-5d8afaf2ed74%26type%3Dpdf%26name%3D13a9bbba-db21-4cba-991c-5d8afaf2ed74&usg=AOvVaw1p1XBJ9Ymd9UiGR091Nhhe

(8) Catheter/ Bladder Irrigation. BC Children’s Hospital. BC Children’s Hospital Child & Youth Health Policy and Procedure Manual. 2016. http://policyandorders.cw.bc.ca/resource-gallery/Documents/BC%20Children%27s%20Hospital/CC.15.06%20Catheter-Bladder%20Irrigation%20-%20Syringe%20Method.pdf

(11) Bladder Irrigation with Chlorhexidine Reduces Bacteriuria in Persons with Spinal Cord Injury. Wikström, M., Levi, R., & Antepohl, W. Journal of rehabilitation medicine, 50(2), 181-184. 2018. https://www.researchgate.net/publication/322639771_Bladder_irrigation_with_Chlorhexidine_reduces_bacteriuria_in_persons_with_spinal_cord_injury 

 

María Laura Márquez
13 October, 2018

Written by

María Laura Márquez, general doctor graduated from The University of Oriente in 2018, Venezuela. My interests in the world of medicine and science, are focused on surgery and its breakthroughs. Nowadays I practice my profession...read more:

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