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Catheters help manage urinary incontinence

by Diane K. Newman, DNP, FAAN, BCB-PMD

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Catheters can help you manage urinary incontinence symptoms, especially when surgery, medications and behavioral treatment may not have cured your urinary incontinence problem or are not appropriate for you. Some of you will use catheters including a foley or indwelling catheter, an intermittent catheter, suprapubic or even an external (condom-type) catheter for men.

Even if you will be using catheters, it will be helpful to learn about the different devices and products that will contain the urinary leakage including incontinence pads, and other absorbent products, penile clamps and condom catheters for men, pelvic organ support devices (pessaries) for women, toileting devices and skin care. We review different products that are available in your local pharmacy, medical equipment dealer (DMEs) or directly from the SeekWellness Store.

Medicare and other major insurances will pay for most of these products in a limited monthly number. HMOs and managed care insurers do not routinely pay for these products. Absorbent products (pads, adult diapers) found in drug stores are considered personal hygiene products and are not paid for by insurers.

Catheters: Introduction

Your bladder is a hollow organ, like a balloon in your pelvis behind your pubic (pelvic) bone. Your bladder collects and stores urine from your kidneys. It is made of muscle and is free of germs. Some people need help to pass urine from their bladder because of certain medical problems that do not let the bladder empty completely. Two common medical problems where a catheter is used are urinary incontinence (unexpected urine leakage) and urinary retention (incomplete bladder emptying). Inserting catheters (called catheterization) into the bladder is one way to manage the problem of urinary incontinence. A catheter is a thin, flexible, soft tube which is inserted through the urethra to drain the urine from the bladder. It may stay in place for a short or long time depending on the type and reason for its use.

Catheters are used in several different ways: put intermittently into the bladder, placed on a more permanent basis (indwelling urethral catheterization) or placed through the stomach (suprapubic) into the bladder by way of surgery. Catheters are also used on the outside for men (external condom catheters).

Catheters: Types

Intermittent catheters

Intermittent catheters (IC) are used in persons with spinal cord injuries (quadrapelegics & paraplegics) and for those persons with urinary retention (incomplete bladder emptying). During urination, the bladder contracts, and the pelvic floor muscles relax to allow urine to pass through the urethra. Normally, after the bladder empties, there is a small amount of urine (less than 3 ounces) left in the bladder. What is left is known as the Post-Void Residual Volume. If you cannot urinate or completely empty your bladder, a large residual volume will build up. A large build-up of urine in the bladder is unhealthy. This condition can cause bladder infections, urinary incontinence, and permanent damage to the bladder and kidneys.

You will finish emptying the urine from your bladder by inserting a slim tube known as a catheter down the urethra and into the bladder after you urinate. This catheter will drain the remaining urine, and then it is removed. Removing the catheter is safer than leaving it in. By inserting the catheter several times during the day you lessen the episodes of over distension (when the bladder becomes overfilled) of the bladder. This type of catheterization is usually done by the person or by a family member using sterile or clean catheters.

A routine bladder emptying schedule is done usually 3 to 4 times per day. Long-term use of intermittent catheterization is preferable to leaving a catheter in the bladder (indwelling urethral catheterization) because of the low chance of infection and other problems. Problems that can happen from doing this type of catheterization are swelling of the urethra, stricture, false passage, kidney damage, and epididymitis.

The non-sterile clean approach is called clean intermittent catheterization (CIC.) This has a low risk of infection and if an infection occurs it is usually managed without causing damage to your kidneys. Older persons and those with impaired immune systems (e.g. persons with AIDS or those receiving chemotherapy) are at risk for developing urinary infections. The sterile approach may be better. It is not known if elderly persons should also perform the catheterization using sterile catheters.

Anyone can insert these catheters because it is a safe and a simple procedure to learn. Older persons, family members, and/or caregivers who have the physical and mental abilities and who are motivated can be taught to perform CIC. Considerations for CIC are age, the physical ability of the person to perform catheterization, willingness, and the self-discipline.

Indwelling catheter

An indwelling urethral catheter, often called a foley catheter, is a closed, sterile system inserted into the urethra to allow the bladder to drain. It is used for persons with urinary incontinence that is caused by obstruction (blockage in the urethra) or urinary retention (incomplete bladder emptying) that cannot be treated with other methods like surgery, medications or by CIC. It is also used in very sick persons where the incontinence interferes with monitoring of urinary output and in terminally ill or severely impaired persons for whom moving is painful.

An indwelling catheter is also used in persons with skin irritation or pressure ulcers (Stage 3 or 4) that are caused by incontinence. Catheters are also used in situations when a person is homebound, lives alone and a family member or a caregiver is not available to help.

Indwelling catheters are used in 2 to 4 percent of nursing home residents.

These catheters are usually inserted by a doctor and nurse. You do not need to stop doing the things you usually do because you are afraid the catheter will fall out. The catheter is held in place in the bladder by a balloon filled with water.

Common catheter problems

Burning or spasms -- You may sometimes feel "burning" or "spasms" when urine passes through the catheter. This is a normal reaction, and there is no cause for alarm. These "spasms" may cause some urine to leak out around the catheter. If they continue without stopping, call your doctor or nurse. A mild pain killer or medication to relieve the spasms may be prescribed. This may also indicate that the catheter needs to be changed.

Falling out -- Catheters falling out unexpectedly is common. The person may pull out the catheter by mistake, it may fall out because of too much tension on the catheter or because of bladder spasms. The balloon may still be in place when the catheter falls out.

Catheter leakage or bypass -- Leakage of urine around the catheter happens in most persons. Leakage may be due to involuntary bladder spasms (detrusor hyperreflexia or overactive bladder), infection, the catheter or balloon size being too large, or the bladder is irritated from catheter use. Bladder spasms are common after bladder or prostate surgery. If urine leakage occurs and the catheter falls out, this is probably due to involuntary bladder spasms from too large a catheter, too large size balloon (> 5cc), catheter composition; or catheter blockage.

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The general belief is if the catheter is leaking then a larger size should be used but this will only worsen the problem. Remember a catheter may occasionally leak. There is no reason to be alarmed unless the catheter leaks continuously or if there is no urine in the drainage bag.

Catheter blockage or obstruction -- Obstruction or blockage is the result of the formation of encrustations which is caused by the collection of bacteria, crystallization of protein, or mucus plugs. Another common problem is encrustation of the catheter tip with calculous material causing blockage of the urine flow. This encrusted material is a combination of calcium, phosphorus, magnesium, uric acid and protein debris. This occurs more frequently when the pH of the urine is alkaline.

Obstruction of the catheter is the primary reason for frequent catheter changes. If this is occurring the person should drink more liquids or consider acidifying the urine by taking ascorbic acid 500-1000mg per day. If your catheter does become blocked do not disconnect the system and irrigate the catheter. If it stops draining, call your nurse or doctor.

Catheter infection -- Use of indwelling catheters over months and years causes bacteriuria (germs in the urine) and infection. Bacteriuria develops in most persons within 2 - 4 weeks after the catheter is inserted. Bacteria (germs) may enter the bladder either by traveling up from the bag to the bladder from inside the catheter system or outside on the surface of the system.

Care of indwelling catheters varies. The usual practice is to change them every 4-5 weeks. This changing schedule is based on insurance reimbursement allowance. Persons who have problems with leakage, blockage (encrustations) might do better if their catheters were changed more often. If you think you have a bladder infection, the entire catheter and system should be changed and a specimen for urine culture taken from the newly inserted catheter system.

The usual catheter size is 14FR (French), 16FR, or 18FR with a 5-cc balloon filled with 10 cc of sterile water.

Types of indwelling catheters

There are several different catheters that can be used including a 5-inch and olive tip for women, Coude or curved tip for men. Using a coude or curved tip catheter will make it easier for men to thread the catheter past their prostate. The clear more rigid catheter makes insertion easier. There are also self-contained systems that may decrease chances of infection.

Notify your nurse or doctor if any of the following occurs:

  • The urine has a strong odor, becomes cloudy or gets red. The urine coming through the catheter should be light yellow. There may be occasional blood clots.
  • You get chills, fever above 99.4 F, lower back pain, and/or leakage around the catheter.
  • There is swelling at site where the catheter is inserted.
  • The catheter is not draining any urine.

Helpful tips for managing your catheter

  • Always wash your hands before and after touching the catheter or drainage bag. Wash the skin around the catheter with soap and water every day and after each bowel movement.
  • Prevent kinks or loops in the catheter and tubing which might stop the flow of urine. Do not clamp the catheter or drainage tube.
  • Urine must always drain "downhill", so keep the urine drainage bag below the level of the bladder at all times. This allows the urine to drain by gravity and will prevent the urine from flowing back into the bladder.
  • Anchor the catheter securely to the thigh by using an anchor strap, but do not pull the catheter tightly. Leave some "slack" on the catheter to prevent pressure in the bladder.
  • Empty the drainage bag at least every 4 to 8 hours or if it becomes filled before four hours. Do not touch the end of the drainage spout.
  • Do not disconnect any portion of the drainage system. If the tubing does become disconnected, clean the ends with an alcohol pad and reconnect immediately. Then call your nurse or doctor because the catheter may need to be changed.

Indwelling catheters are attached to drainage bags, overnight or leg. An overnight bag is a bag with a long tube that is used during the night. The bag should be hung over the side of the bed below the level of your catheter so that the urine will flow easily.

A leg bag is a smaller collection bag for use at home or when you go out of your house. The smaller bag is easy to hide under your clothing. The care of both bags is the same.

Suprapubic catheter

A suprapubic catheter is a catheter which is inserted through a small incision (cut) made in the wall of your lower abdomen just above your pubic bone and below your belly button. A doctor inserts the catheter during a short surgical procedure. It is used for a short time after surgery on the bladder, prostate or if a woman has a hysterectomy.

A suprapubic may be used in persons who need to have a catheter placed for a long period of time because it is more convenient than an indwelling urethral catheter. It may be more comfortable, less prone to infection and it has a less likely chance to fall out or leak. It needs to be changed just like an indwelling catheter at least every four weeks. There are some problems that can occur at the time of inserting the catheter and they include swelling at the site of insertion, bleeding, and bowel injury. But these are rare.

A government panel (AHCPR) concluded that a suprapubic catheter is preferable to an indwelling catheter in persons who require chronic bladder drainage and for whom no other alternative therapy is possible, because it eliminates damage to the urethra. However, management of suprapubic catheters presents potential problems such as uncontrolled urine leakage, skin erosion, and hematoma, and problems with catheter reinsertion.

External catheter systems

External catheter systems, called condom catheters are available for men. Condom catheters are used to collect urine leakage. They are safer to use than internal catheters because a tube does not need to be placed in the bladder. This catheter fits over the penis and connects to a drainage bag that is strapped to your leg.

There are several different external condom catheters available. They are made from latex rubber, polyvinyl, or silicone that are attached on the shaft of the penis by several different methods; a double-sided adhesive, latex inflatable cuff, jockey's type strap, or foam strap. They are then attached to urine drainage bags by a tube. Catheters with a circumferential band may be too restricting to the shaft of the penis.

There are several different sizes. Most manufacturers have sizing charts. It is important that you choose the current size. These catheters are disposable and generally, are not reliable for greater than 24 to 48 hours. There are also reusable condom catheters that are for men who are active and have incontinence. These reusable condom catheters are great in men who have urinary incontinence after prostate surgery. Many man do not want to use "diapers" and pads.

Common problems with external urinary catheters

There is a chance of infection but the risk is less than with catheters that are placed in the bladder. Skin irritation can occur from the friction caused by an external catheter. In older men, the penis may have retracted (decreased in size) and it may be difficult to keep this type of catheter from falling off. Careful attention must be given to avoid skin rash, maceration of the penis, ischemia, and penile obstruction.

The catheter has adhesive inside that sticks to your penis or an adhesive strip that wraps around your penis.

  • Wash your hands.
  • Gather your equipment: correct-sized condom catheter, leg drainage bag with tubing, clamp, manicure scissors, soap, wash cloth, towel, and protective ointment.
  • Trim the hairs on the shaft and base of your penis so they won't stick to the adhesive tape.
  • Before each catheter change, wash, rinse, and dry your penis.
  • To protect your skin from urine, coat your penis with protective ointment and let the ointment dry (it will feel sticky).
  • Tightly roll the condom sheath (balloon-like part) to the edge of the connector tip. Now place the catheter sheath on the end of your penis, leaving about half an inch of space between the tip of your penis and the connector tip.
  • Gently stretch your penis as you unroll the condom. Roll the condom catheter smoothly. When the condom is unrolled, gently press it against your penis, so that it sticks.
  • Connect one end of the tubing to the connector tip and the other end to the drainage bag. Strap the drainage bag to your thigh.
  • To remove the drainage bag, clamp the tube closed. Release the leg straps, and disconnect the extension tubing at the top of the bag. Remove the condom catheter and the tape by rolling them forward.

External collection devices exist for women, but none has proven to be totally useful for woman in wheelchairs or who are bed-bound. The devices for woman are pouches or form-fitting pericups. These can be flexible or plastic pouches which are attached to the skin by adhesive or straps. The ideal device for women would be easy, quick to place, and work well for persons who transfer from beds to chairs and are in wheelchairs. This ideal device does not exist at present.

References

Newman, DK. Managing and Treating Urinary Incontinence. Health Professions Pr. 2002.

Posted: December 2003
Updated March 2013

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