What is an indwelling catheter

An indwelling catheter also called indwelling Foley catheter, is a flexible tube placed in the urethra and the bladder to help you urinate and collect urine in a drainage bag. Indwelling urinary catheters usually remain in place for many days or weeks, and are held in position by a water-filled balloon in the bladder.

An indwelling catheter collects urine by attaching to a drainage bag. The bag has a valve that can be opened to allow urine to flow out. Some of these bags can be secured to your leg. This allows you to wear the bag under your clothes.

An indwelling urinary catheter can either be inserted through the tube that carries urine out of the bladder (urethral catheter) or through a small opening made in your lower tummy (suprapubic catheter).

The urinary catheter usually remains in the bladder, allowing urine to flow through it and into a drainage bag.

Indwelling catheters are sometimes fitted with a valve. The valve can be opened to allow urine to be drained into a toilet, and closed to allow the bladder to fill with urine until drainage is convenient.

Most indwelling catheters need to be changed at least every three months. Common problems are blockages, pain and recurrent infections, but most people manage well. It is inevitable that you will get bacteria in your urine but this does not need treating; you only need antibiotics if you have symptoms of infection. If you do have problems, your nurse or doctor can usually resolve the issues for you.

Different types of catheter are made from different materials, including latex. If you have any history of latex allergy, please let your doctor or nurse know. They will then use a latex-free catheter.

Your catheter may feel strange at first, and you may feel very conscious of it. At first, you may have a constant desire to pass urine, even though your bladder is being emptied continuously by the catheter. This is not unusual and usually settles very quickly. It happens because your bladder tries to push the catheter out by contracting and going into spasm. Your bladder soon learns to tolerate the catheter, and this constant urge to pass urine disappears.

Figure 1. Indwelling catheter (female)

Figure 2. Indwelling catheter (male)

When are indwelling catheters are used?

An indwelling urinary catheter is usually used when people have difficulty urinating naturally. It can also be used to empty the bladder before or after surgery and to help perform certain tests.

Specific reasons a urinary catheter may be used include:

• to allow urine to drain if you have an obstruction in the tube that carries urine out of the bladder (urethra) – for example, because of scarring or prostate enlargement
• to allow you to urinate if you have bladder weakness or nerve damage that affects your ability to pee
• to drain your bladder during childbirth if you have an epidural anesthetic
• to drain your bladder before, during or after some types of surgery
• to deliver medication directly into the bladder, such as during chemotherapy for bladder cancer
• as a last resort treatment for urinary incontinence when other types of treatment have been unsuccessful

Depending on the type of catheter you have and why it’s being used, the catheter may be removed after a few minutes, hours or days, or it may be needed for the long term.

Types of urinary catheter

There are two main types of urinary catheter:

• intermittent catheters – these are temporarily inserted into the bladder and removed once the bladder is empty
• indwelling catheters – these remain in place for many days or weeks, and are held in position by an inflated balloon in the bladder

Catheters come in many sizes, materials (latex, silicone, Teflon), and types (Foley, straight, coude tip). A Foley catheter, for example, is a soft, plastic or rubber tube that is inserted into the bladder to drain the urine.

In most cases, your provider will use the smallest catheter that is appropriate.

Many people prefer to use an indwelling catheter because it’s more convenient and avoids the repeated insertions needed with intermittent catheters. However, indwelling catheters are more likely to cause problems such as infections.

Inserting either type of catheter can be uncomfortable, so anesthetic gel is used to reduce any pain. You may also experience some discomfort while the catheter is in place, but most people with a long-term catheter get used to this over time.

Indwelling catheter insertion

Indwelling urinary catheters are usually inserted by a doctor or a nurse.

An indwelling catheter may be inserted into the bladder in 2 ways:

1. Most often, the catheter is inserted through the urethra. This is the tube that carries urine from the bladder to the outside of the body.
2. Sometimes, your healthcare provider will insert a catheter into your bladder through a small hole in your belly. This is done at a hospital or provider’s office.

An indwelling catheter has a small balloon inflated on the end of it. This prevents the catheter from sliding out of your body. When the catheter needs to be removed, the balloon is deflated.

Indwelling catheter problems

Some problems may occur with your catheter but your district nurse, doctor or nurse practitioner can advise you on what to do:

Bladder spasms

Bladder spasms feel like abdominal (tummy) cramps. They are usually caused by the bladder trying to squeeze out the balloon that holds your catheter in place. If spasms are causing you distress, your doctor can prescribe a drug which helps relax your bladder.

Leakage around the catheter

This is called “by-passing”. It is sometimes caused by bladder spasms (see above) or can happen when you open your bowels. It can also happen if your catheter is blocked and stops draining (see below).

Blood or debris in the urine

Debris causing cloudy urine is inevitable and is commoner the longer a catheter has been in your bladder. It can sometimes block the catheter. If this happens, you should contact your catheter nurse or doctor.

If you see blood coming through your catheter, contact your catheter nurse, district nurse or doctor. It is usually due to infection but, if not, you may need further tests to work out why it is happening.

Blockage

This can cause a lot of pain and needs urgent attention. Check that your drainage bag is below the level of your bladder (the lower part of your tummy), that the catheter and tubing are not kinked or twisted, and that there are no clots or debris in the catheter. If the catheter will not unblock, and no urine is draining, contact your district nurse or doctor immediately.

Catheter falling out

If your catheter falls out, contact your district nurse or catheter nurse immediately so it can be replaced. If this keeps happening, your doctor may refer you to a urologist for further advice.

Urine infection

You will always have bacteria in your urine if you have had a catheter for more than a few days. This does not mean you have a urine infection, and you do not need to take antibiotics. Antibiotics are only needed if you develop symptoms of a urine infection.

If you have symptoms (a high temperature, a lot of bladder discomfort, a painful urethra), you should contact your district nurse, catheter nurse or doctor. They will decide whether you need antibiotics and may send a urine sample for laboratory testing.

Indwelling catheter complications

The main risk of using a urinary catheter is that it can sometimes allow bacteria to enter the body. This can cause an infection in the urethra, bladder or, less commonly, in the kidneys. These types of infection are known as urinary tract infections (UTIs).

Urinary tract infections (UTIs)

UTIs caused by using a catheter are one of the most common types of infection that affect people staying in hospital. This risk is particularly high if your catheter is left in place continuously (an indwelling catheter).

Symptoms of a catheter-associated UTI include:

• pain low down in your tummy or around your groin
• a high temperature (fever)
• feeling cold and shivery
• confusion

Contact your doctor or community nurse if you think you have a UTI. You may need a course of antibiotics.

Other risks and side effects

Bladder spasms, which feel like stomach cramps, are also quite common when you have a catheter in your bladder. The pain is caused by the bladder trying to squeeze out the balloon. You may need medication to reduce the frequency and intensity of the spasms.

Leakage around the catheter is another problem associated with indwelling catheters. This can happen as a result of bladder spasms or when you open your bowels. Leakage can also be a sign that the catheter is blocked, so it’s essential to check that it’s draining.

Blood or debris in the catheter tube is also fairly common with an indwelling catheter. This could become a problem if the catheter drainage system becomes blocked

Get medical advice as soon as possible if you think your catheter may be blocked, or if you’re passing large pieces of debris or blood clots.

Other, less common, potential complications of catheter include:

• injury to the urethra (the tube that carries urine out of the body) when the catheter is inserted
• narrowing of the urethra because of scar tissue caused by repeated catheter use
• injury to the bladder or rectum (back passage) caused by incorrectly inserting the catheter
• bladder stones (although these usually only develop after years of using a catheter)
• allergy or sensitivity to latex
• blood infections (septicemia)
• blood in the urine (hematuria)
• kidney damage (usually only with long-term, indwelling catheter use)
• bladder cancer (only after long-term indwelling catheter)

Preventing infections and other complications

Having a long-term urinary catheter increases your risk of developing urinary tract infections (UTIs), and can also lead to other problems, such as blockages.

To minimize these risks you should:

• wash the skin in the area where the catheter enters your body with mild soap and water at least twice a day
• wash your hands with warm water and soap before and after touching your catheter equipment
• make sure you stay well hydrated – you should aim to drink enough fluids so that your urine stays pale
• avoid constipation – staying hydrated can help with this, as can eating high-fiber foods, such as fruit and vegetables and wholegrain foods
• avoid having kinks in the catheter and make sure any urine collection bags are kept below the level of your bladder at all times

Indwelling catheter care

Your catheter should be treated as a part of your own body and needs to be kept clean in the same way. The bags and valves should be changed every week and the catheter should be changed at least every 3 months. To care for an indwelling catheter, clean the area where the catheter exits your body and the catheter itself with soap and water every day, when you take a bath or shower. Also clean the area after every bowel movement to prevent infection.

Wash your hands before and after handling the drainage device. DO NOT allow the outlet valve to touch anything. If the outlet gets dirty, clean it with soap and water.

Sometimes urine can leak around the catheter. This may be caused by:

• Catheter that is blocked or that has a kink in it
• Catheter that is too small
• Bladder spasms
• Constipation
• The wrong balloon size
• Urinary tract infections

With a catheter in place, you need to drink plenty of fluid to help prevent urine infections. If your urine becomes dark, this may mean you are not drinking enough and you should increase your fluid intake.

You should take care not to kink or compress the catheter tubing. Do not raise the drainage bag above the level of your bladder as this will stop it draining.
Once your catheter is in place, the nurses looking after you will show you how to empty it and look after it. They will also give you spare catheters and bags. They will keep in touch with your doctor and your district nursing team. Once your doctor has been alerted, you can get any additional items you need from your local chemist with a doctor’s prescription. Your team will also give you details of who to contact if you have any problems with the catheter.

You should empty the bag before it’s completely full (around half to three-quarters full). Valves should be used to drain urine at regular intervals throughout the day to prevent urine building up in the bladder. Leg bags and valves should be changed every seven days.

The bag can be attached to your right or left leg, depending on which side is most comfortable for you.

At night, you’ll need to attach a larger bag. Your night bag should either be attached to your leg bag or to the catheter valve. It should be placed on a stand next to your bed, near the floor, to collect urine as you sleep.

Depending on the type of night bag you have, it may need to be thrown away in the morning or it may be emptied, cleaned and reused for up to a week.

The catheter itself will need to be removed and replaced at least every three months. This is usually done by a doctor or nurse, although sometimes it may be possible to teach you or your carer to do it.

Indwelling catheter parts

The different parts of the catheter are:

The catheter itself

You do not need to do anything to the catheter, apart from keeping it clean by washing yourself and the catheter daily. You should dry yourself gently and thoroughly to prevent any soreness. If you do notice soreness where the catheter goes in, let your nurse know so you can get advice about how to relieve this.

The leg-bag for daytime use

This is attached directly to the end of the catheter and collects all the urine you produce during the day. It will become heavier as it fills. Do not let it get too full or it will pull on the catheter and cause pain, bladder spasm or even catheter displacement.
Always wash your hands before and after emptying your drainage bag into the toilet or a urine bottle. Leg-bags may last up to seven days, after which they should be replaced.

The leg-bag support

This is rather like a footless sock and is used to keep your leg-bag securely attached to your leg.

The G-strap

This stops your catheter from being pulled out. It has a Velcro strap which goes around the catheter and your leg, holding the catheter firmly in position.

The night drainage bag

A larger night bag connects directly to your leg-bag at night without disconnecting it from the catheter. It holds more urine than your leg-bag, so you should not need to empty it during the night.

To connect the night drainage bag:

• remove the leg-bag support;
• wash your hands carefully;
• empty the leg-bag and, with the tap still open, push the end of the night bag into the tubing below the tap to form a direct route for urine into the night bag;
• attach the night bag to its stand on the floor by the side of your bed; and
• in the morning, turn off the tap at the bottom of your leg-bag, disconnect the night bag and empty it into the toilet. The night bag can then be discarded or rinsed with warm water to be used the next night. Your nurse will advise you about this.

If you need to dispose of a bag, rinse it out with water, put it in a plastic bag and leave it with your normal household waste. Your doctor will continue to prescribe your new bags and other equipment.

Cleaning your skin

You will need these supplies for cleaning your skin around your catheter and for cleaning your catheter:

• 2 clean washcloths
• 2 clean hand towels
• Mild soap
• Warm water
• A clean container or sink

Follow these skin care guidelines once a day, every day, or more often if needed:

• Wash your hands well with soap and water. Be sure to clean between your fingers and under your nails.
• Wet one of the washcloths with warm water and soap it up.
• Gently wash all around the area where the catheter goes in with the soapy washcloth. Females should wipe from front to back. Males should wipe from the tip of the penis downward.
• Rinse the washcloth with water until the soap is gone.
• Add more soap to the washcloth. Use it to gently wash your upper legs and buttocks.
• Rinse off the soap and pat dry with a clean towel.
• DO NOT use creams, powders, or sprays near this area.

Cleaning the catheter

Follow these steps two times a day to keep your catheter clean and free of germs that can cause infection:

• Wash your hands well with soap and water. Be sure to clean between your fingers and under your nails.
• Change the warm water in your container if you are using a container and not a sink.
• Wet the second washcloth with warm water and soap it up.
• Gently hold the catheter and begin washing the end near your vagina or penis. Move slowly down the catheter (away from your body) to clean it. NEVER clean from the bottom of the catheter toward your body.
• Gently dry the tubing with the second clean towel.

You will attach the catheter to your inner thigh with a special fastening device.

You may be given two bags. One bag attaches to your thigh for use during the day. The second one is larger and has a longer connection tube. This bag holds enough so you can use it overnight. You will be shown how to disconnect the bags from the Foley catheter in order to switch them. You will also be taught how to empty the bags through a separate valve without needing to disconnect the bag from the Foley catheter.

Making sure your catheter is working

You will need to check your catheter and bag throughout the day.

• Always keep your bag below your waist.
• Try not to disconnect the catheter more than you need to. Keeping it connected to the bag will make it work better.
• Check for kinks, and move the tubing around if it is not draining.
• Drink plenty of water during the day to keep urine flowing.

Your regular activities

Having a urinary catheter shouldn’t stop you from doing most of your normal activities. You’ll be advised about when it’s safe for you to go to work, exercise, go swimming, go on holidays, and have sex.

Indwelling catheters can be a problem when it comes to having sex, but it’s still usually possible to have sex with them in place. For example, men can fold the catheter along the base of their penis and cover them both with a condom.

In some cases, you may be taught how to remove and replace the catheter so you can have sex more easily.

Troubleshooting for your indwelling urinary catheter

If you have an indwelling urinary catheter you may experience some common problems with the drainage system from time to time.

Contact your doctor or nurse if the problem is ongoing or cannot be easily resolved.

The indwelling urinary catheter won’t go in

This information only applies to those performing clean intermittent self-catheterization.

If you cannot get the catheter in do not force it.

Remove the catheter and try again in an hour. However if your bladder is full and you are uncomfortable you will need to visit your nearest emergency department for assistance immediately.

There is no urine draining

This information only applies to those performing clean intermittent self-catheterization.

This can happen sometimes because the lubricating gel has blocked the drainage holes on the catheter. As the gel is water-based it will dissolve in the urine but this may take a minute or two. Try coughing as this will help start the flow of urine.

Check that you have inserted your catheter correctly.

If you are female, check you have not inserted the catheter into your vagina by mistake. If you have, you should remove the catheter and try again using a new or clean catheter.

Do not reuse the catheter that has been in the vagina as you may transfer germs from the vagina into the bladder and you may become unwell with a urinary tract infection.

If you are male, check you have inserted the catheter far enough into your urethra. There should be about 10 cm of catheter visible.

If you cannot get urine to drain, remove your catheter slowly and seek advice from your doctor or nurse.

If your bladder is full and you are uncomfortable you will need to visit your nearest emergency department for assistance immediately.

There is no urine draining into the urine bag

This information applies only to suprapubic or indwelling urinary catheters.

This can happen if there are kinks in the catheter or the drainage bag tubing. Firm fitting underwear can sometimes cause kinks, therefore males are advised to wear loose fitting underwear.

It could also be that your catheter is blocked.

Catheter blockage is an emergency and needs to be fixed as soon as possible.

If there is no urine draining into your bag, take the following steps:

1. Check for and remove any kinks in the catheter or the drainage bag tubing.
2. Check the position of your catheter and drainage bag. Ensure the bag is positioned below your bladder when you are lying, sitting or standing.
3. Check that the leg bag straps are fitted correctly and are not causing drainage bag obstruction.
4. You will need to visit your local emergency department immediately if you have performed the above checks and you:
   • have abdominal discomfort
   • are feeling the need to pass urine
   • are unable to feel bladder fullness.
5. If you are not experiencing abdominal discomfort, or the urge to urinate, increase your fluid intake. Drink 2 glasses of water immediately and if there is no urine drainage after 30 minutes contact your nurse or go to an emergency department.

There is urine leaking around the catheter

This information applies only to suprapubic or indwelling urinary catheters.

This is called bypassing and happens when the urine cannot drain down the catheter. This will cause it to leak around the outside of the catheter.

Check for and remove any kinks in the catheter or the drainage bag tubing.

This could also indicate your catheter is blocked (see above). Go to your local emergency department immediately as the catheter may need to be changed.

Do not increase the amount of fluid in the balloon which holds the catheter in place.

If you are having bladder spasms speak to your doctor or nurse for further advice

Avoid constipation. Eat a balanced diet and drink 1.5 to 2 L per day unless otherwise advised by your doctor or nurse.

You are having stomach cramps

Cramp type pains can happen as a result of the catheter irritating the bladder or as a result of pressure on the bladder from constipation.

These are commonly referred to as bladder spasms.

If you are experiencing bladder spasms due to irritation of the bladder, your doctor or nurse will be able to give you further advice.

Some people need to take tablets to calm the bladder but this will be discussed with you at the time.

Cloudy, smelly, discolored urine, pain and discomfort

You may have a urinary tract infection (UTI). The signs and symptoms of a UTI are:

• cloudy, strongly offensive smelling urine
• burning sensation around the catheter
• bleeding
• itching and soreness
• high temperature
• feeling unwell
• discomfort in the lower back or loin areas.

If you have any of these symptoms you should see your doctor immediately.

Your doctor may need to send a specimen of urine to the laboratory for testing.

You may need a course of antibiotics to treat the infection.

When taking a urine specimen, ideally the catheter should be changed and the sample taken from a new catheter.

Increasing your fluid intake, unless advised otherwise by your doctor or nurse, will help to flush the bacteria through the system quickly.

Your catheter has fallen out

This information applies only to indwelling urinary catheters.

Your catheter should not fall out because it is held in place by a small balloon which is inflated with sterile water after the catheter is inserted into the bladder.

On rare occasions the balloon might be faulty and deflate and your catheter will fall out.

In this case, or if you accidentally pull out your catheter, you must contact your doctor or nurse immediately or visit your local emergency department.

There is blood in the urine

There should not be any blood in the urine except following some surgical operations on the prostate or bladder.

Any blood in the urine should be assessed immediately by your doctor or nurse.