Catheter Care Jacinta Stewart Urology & Continence Nurse

Indications for Long Term Catheter Use Long term urinary catheters should only be used with Clients who cannot satisfactorily be managed with less invasive means For example: Neurological disorders causing paralysis, or loss of sensation leading to voiding difficulties Urinary retention – when ISC not an option To manage severe incontinence - as a last resort When incontinence poses a risk of skin breakdown, or infection to nearby surgical sites Palliative care at end of life

Catheter Types Indwelling urethral catheter Indwelling suprapubic catheter Clean Intermittent Self Catheterisation Intermittent catheterisation (less common) Intermittent catheterisation would be used by someone who uses other means to manage their bladder and wants a break for a short time e.g. MS pt who does ISC

Catheter Types Polyvinylchloride (PVC) Latex Silicone Nelaton catheter for ISC large internal diameter so drains easily inexpensive intended for single use according to manufacturers’ instructions Latex Not commonly used disadvantages due to allergies high risk of encrustation can only be used for short term Silicone Commonly used larger lumen (uncoated), drains more easily less inclined to become encrusted softer, therefore comfortable balloons tend to lose water over time through osmosis 12 weeks insitu (e.g. Releen®)

Catheter Types Silicone elastomer-coated Hydrogel-coated Silver-coated latex catheter coated with silicone behaves like a silicone catheter unsuitable for latex sensitivities 2 to 4 weeks insitu (e.g. Bardia®) Hydrogel-coated very soft; coating designed to absorb fluid (hydrophilic) which forms a smooth surface, so reduces friction and urethral irritation good choice for clients with Urethral pain 12 weeks insitu (e.g. Biocath®) Silver-coated manufactured using silver alloy with hydrogel reduces and delays the incidence and onset of biofilm formation, but only for less than one week may be useful in symptomatic UTI available in both silicone and latex 12 weeks insitu (e.g. BARDEX® I.C.)

Catheter Equipment Catheter change pack Long term catheters Sterile gloves Cleaning solution, e.g. sterile water, chlorhexidine Lubricant - Sterile anaesthetic lubricating gel (as per policy) 10mls sterile H2O for balloon inflation 10ml syringe Catheter of appropriate size and length Long term catheters 100% silicone Biocath Releen Cath straps & leg bag holders Leg bags Different types and sizes; consider ease of use for client Overnight drainage Bag or bottle Catheter Valves Silicone Simpla Releen Bardia - Silicone Elastomer coated Biocath - Hydrogel coated Bardex – Lubricious/silver coated Nelaton

FlexiTrak Is not recommended in my experience because it doesn’t stick very well. Better to use an elastic/velco strap e.g. Cathstrap or similar

Tips when Inserting Urinary Catheters Consent, reassurance and explanation for client Aseptic technique Male and female length catheters What size should be used? Lubricant gel How far do you insert the catheter? What do you inflate the balloon with? How much fluid in the balloon? Secure attachment of catheter Aseptic technique – bladder is a sterile environment & we are introducing a foreign body into it Rarely use female length IDC’s Generally 14Fg for females & 16Fg for males Lignoacaine gel Insert until urine flow – Males – all the way to bifurcation then inflate; females insert approx 5 to 7 cm then inflate. Don’t inflate until urine flows Only sterile H2O

Insertion Tips Aseptic technique: is mandatory for all catheter insertions to prevent infection Length: Male length (41- 45 cm) is standard for both male & female use Female length (20 - 25cm) not commonly used; provides discretion & comfort for long-term, ambulant client. Not appropriate for bed bound or obese clients due to high risk of urethral trauma. Must never be used for male clients Size: Catheters are measured in Charriere (Ch) or French gauge (Fg or Fr) which indicates the external diameter. Sizes range from 6 - 24 Fg. There is an international colour code for catheter sizes (usually on the inflation port) General Guide 6 - 10 Fg Paediatric 12 - 14 Fg Females 14 - 18 Fg Males 14 - 20 Fg Suprapubic 18 - 22 Fg Haematuria

Insertion Tips Lubricant gel: Minimises pain & urethral trauma. Must be water soluble. Local anaesthetic gel is preferable for all catheterisations Males: Use Lignocaine gel. Apply a small amount to the then instill the remainder of lubricant syringe contents into the urethra. Warn the client that the gel may sting. Hold urethral meatus closed with thumb & forefinger to prevent gel from escaping from urethra. Aim is to get lubricant to bladder neck, to reduce discomfort Females: Apply a generous amount of lubricant to the catheter prior to insertion How far to insert Catheter? Males: Urethra is approx 15 – 25cm long. Insert the entire length of catheter, to the Y bifurcation at the inflation port. Don’t inflate balloon until urine flows, stop if client has pain. This will ensure IDC correctly placed and not in the prostatic urethra or bladder neck Females: Urethra is approx 4cm long, so insert catheter about 7cm. Insert another 2 to 3 cm further, then inflate balloon once urine flows

Insertion Tips What to inflate balloon with: Use only sterile water. Never use normal saline; balloons can lose fluid due to osmosis, leaving salt crystals in balloon making deflation & removal difficult and traumatic How much fluid in the balloon: Inflate to size indicated on inflation port (5ml to 10 ml) No need to check balloon prior to insertion by inflating - can cause balloon ridging, therefore trauma (quality tested at manufacture) If client requires less in balloon, inflate to full size then remove required amount

Correct Inflation of the Balloon

Catheter Securement Remember, a catheter is not a bungee….

Catheter Securement IDC’s should be well secured for Client comfort and in order to prevent bladder neck and urethral trauma, bladder spasm, traumatic dislodgment or haematuria There are several devices available to provide securement. Use the device which suits your Client best The device will only work to secure the IDC if it is correctly fitted and checked regularly. Ensure the Client or Client’s family and Carers know how to adjust it appropriately

Catheter Securement: Cathstrap

Catheter Securement: Cathstrap & Holder

Catheter Securement: Flip-Flo Valve

Complications Associated with Long Term Catheters Infection - CAUTI Bladder spasm Haematuria – cause?... Infection, trauma… Leakage, bypassing Paraphimosis Urethral trauma Balloon inflation within the urethra False passage Un-prescribed removal – usually traumatic Obstruction due to encrustation Alternate strapping to prevent pressure ulcers. Clean around foreskins, replace foreskins

Complications Associated with Long Term Catheters Stones (bladder) Periurethral abscess Pain – bladder, urethral, penile tip Urethral erosion Fistula formation Epididymitis, epidiymal orchitis Urethritis, blepharitis

Encrustation & Blocking Results from bacteria in urine, commonly Proteus Produces an enzyme called urease which splits urinary urea into carbon dioxide & ammonia This makes urine more alkaline, an ideal environment for crystals to develop around catheter eyelets, balloons and internal lumens, leading to encrustation Debris: urothelial cells from the bladder blood from infection tumour cells urological surgery or from mucous ‘Blockers’ are usually less active than ‘non blockers’ An alkaline pH has a strong association with catheter encrustation Urine normally acidic – between pH 5 and pH 6 Blockers have high urinary pH, plus high ammonia and calcium concentrations compared to non-blockers Establish a pattern of catheter dwell time and change IDC accordingly

So Basically… Don’t give Clients Ural or similar (it makes urine alkaline) Make sure Clients are drinking enough – spread fluids evenly throughout the day Make sure their bowels are working Change IDC’s at regular intervals, before blocking occurs

Examples of Encrustation

An option for difficult cases…

Suprapubic Catheters Indicated in wheelchair bound or immobile clients e.g. MS, spinal cord injury Thought to have lower infection rates, increased acceptance and ease of self care Contraindicated in clients with chronically unstable bladders UTI’s, leakage, bladder spasm and difficult removal may occur 36% of people with a suprapubic for over 10years will develop stones (Nomura et al 2000) People with long term IDC using ditropan decrease the incidence of kidney disease i.e. 3% compared to 23% in Pt not taking ditropan

Suprapubic Catheters Initial insertion As Inpatient Wound care until cystostomy heals – simple gauze and Betadine dressing Routine changes – schedule according to need First change is often done in Urologist’s Rooms Subsequent changes by DNS or RN/EN in Residential facility. Normally uncomplicated Dislodged SPC must be reinserted very promptly (within ½ hr) Difficulty in removing catheter Check deflation of balloon; balloon memory/ridging Encrustation issues? Releen & Bard 16Fg are recommended to avoid these issues Localised pain related to skin tags, securement issues

Suprapubic Catheters If unsecured may cause enlargement and erosion of SPC tract, therefore leakage Urethral bypassing can still occur Use of anti-cholinergic (Ditropan) in Clients with long term indwelling catheters can significantly reduced the incidence of bladder spasm and kidney damage (hydronephrosis). Be aware of side effects

SPC Securement Secure with Cathstrap to thigh Or Abdominal Cathstrap is an option: Technically, this Pt has a continent stoma rather than a SPC, but it illustrates the abdo cathstrap

Looking after IDC’s Luckily it’s not…… ….Rocket science

IDC’s - General Care Maintain Closed drainage system Hand Hygiene Good meatal hygiene – soap and water or cleansing wipes; avoid talc & creams around IDC Adequate fluid intake, including in the evening prior to bed and during the night if awake Empty leg bags when ½ to 2/3 full

IDC’s - General Care +/-Cranberry Juice Preventing Constipation Preventing trauma and traction on catheter Remember, there should never be tension on the IDC Good practice is to alternate legs for securement, which reduces incidence of penile or labial erosions Regular IDC & bag changes as per Policy & Manufacturers’ guidelines Generally for Community clients: IDC’s 12 weeks Leg bags weekly Night bags weekly. Wash out between uses

Urethral trauma due to poor securement

Keeping Track – Documentation Recording IDC insertion and changes should be simple and easy Use a sticker placed in Client’s Record or an approved MR Form that travels with the Client

Keeping Track – Documentation

IDC’s - Troubleshooting Sediment in the urine Increase fluid intake Blood in the urine Small amounts of blood can make urine quite red Check securement Increase fluids Investigate if it doesn’t clear Bladder spasm or cramps Can be common with new catheter Constipation? May need an anticholinergic if very troublesome

IDC’s - Troubleshooting Leaking and Bypassing Common issue IDC’s do not form a watertight seal May be due to bladder spasm Ensure well secured! Rule out constipation Tubing kinked or blocked? IDC may need changing more frequently e.g. 6 to 8 weeks (blocking)

IDC’s - Troubleshooting No urine drainage Kinked or blocked tubing Not drinking enough, dehydration Constipation? Bag below bladder level? Bag connected incorrectly, particularly leg bag to night bag

IDC’s - Troubleshooting Expelling IDC’s May be due to bladder spasm +/- constipation Balloon too large? Try deflating by 2-3mls with next IDC Seek advice from Continence Nurse May need anticholinergic Client may have bladder stones – if balloon is broken, this may be the culprit! Check balloon inflation, especially if IDC has been in for a few weeks. May have lost fluid (osmosis) Check securement Can your Client manage without the IDC?

IDC’s - Troubleshooting Unable to deflate Balloon Manipulate the valve with a different syringe. Can take time to deflate Insert an 18g needle into the inflation channel and aspirate the fluid Don’t cut the inflation port or the catheter May need to be removed with U/S guidance

Catheter Flushing Contentious issue; evidence is thin whether it’s of value, BUT practice suggests it’s helpful in the Clinical setting for blockers Advice of Doctor/Urologist required No prescribed regime of what to use, how much to use or how often to do Some use Normal Saline; others a weak acetic acid solution (vinegar and water 1:5 or 1:10) up to 50mls. Commercial products available. Instil at varying intervals depending on frequency of blockages Can assist in removing debris, mucous Doesn’t remove crystal trapped in biofilm on catheter Can cause inflammation and damage to bladder lining (urothelium) Requires the closed drainage system to be broken – increased risk of infection

Thanks for Your Attention  My Puppy, Ellie

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