URINARY CATHETERS

Selecting a urinary catheter and drainage system

John Robinson

t some point most nurses will care for a patient who requires initial urethral or suprapubic catheterization, or who already has a catheter in situ that requires changing. Therefore, knowledge is required concerning the selection of a urinary catheter prior to insertion and choosing the appropriate drainage system following insertion, as there is a vast array of urinary catheters and drainage systems available from various companies.

Abstract
Selecting the most appropriate urinary catheter and drainage system is an important factor towards patient comfort. Inappropriate selection may introduce an array of unnecessary catheter-associated problems and discomfort for the patient. The author has found that nurses may be able to name or recognize catheters they use, but not other makes and models of similar products produced by other companies. Therefore, selecting a catheter and drainage system can be confusing due to the vast array of catheters, materials used and drainage systems available from various companies. Consideration should also be given as to when catheter care begins: before or following catheter insertion. This article is written to help in the selection of a urinary catheter and drainage system which is best suited for the patient. Key words: Urinary catheters Drainage systems Patient: education

Patient education
The insertion of an indwelling catheter can be an unpleasant experience for most patients. Some patients may also take the view that having a catheter inserted is 'the beginning of the end' (Getliffe and Dolman, 2003) when this should not be the case. Therefore, to overcome this problem catheter care should begin before the catheter is inserted, except in an emergency when education should commence as soon as possible following insertion. Patient education should cover such issues as how a catheter works, catheter management.

Table 1. indications for urinary catiieter insertion

I. Short term

what types of drainage systems are available, how they work, and how they are secured correctly. Although urinary indwelling catheterization plays an important role in patient care and management, it should be avoided where possible and only be used for a short a period of time (Pellowe et al, 2001; Pratt et al, 2001).

Investigations - urodynamics Pre- and postoperative bladder drainage During iabour and deiivery Monitor urinary output in renai and intensive care units To instili cytotoxic drugs to the bladder in treating papillary bladder carcinomas.
2. Medium to long term

Reasons for catheterization

Before a urinary catheter is inserted, it must be determined why urinary catheterization is required and how long the catheter will remain in situ. Authorization from the doctor responsible for that patient's care and patient consent (Department of Health (DH), 2001) are required before insertion, where possible. The insertion of a urinary catheter falls into three categories {Table 1). Although indwelling urinary catheterization is a common procedure undertaken by nurses, it is a skilled procedure which requires appropriate teaching and training to become competent.

To drain the urinary biadder if there is a urinary obstruction, e.g. biadder tumour, prostatic enlargement, urethral stricture, until treatment/surgery is undertaken The patient's health may be deemed as unsuitable for surgery Patient choice in not wanting surgery Being the oniy way to drain the urinary biadder Urinary incontinence management after other methods have been tried and failed.
3. Intermittent

Catiieter seiection
Indwelling urinary catheters (IUC) fall into two groups: Specialized catheters: these are either 3-way or 2-way. The 3-way catheters consist of the main drainage lumen, catheter
John Robinson is District Charge Nurse, Continence Advisory Service, Morecambe Bay Primary Care Trust NHS, Queen Victoria Centre, Lancashire
Accepted for publication: August 2006

Patients being taught intermittent self-catheterization to drain their bladder Patients being taught intermittent self-urethral dilatation to free urethral strictures. Pomfret (1996); Getliffe and Doiman (2003)

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balloon inflation channel and an irrigation channeLThe 2-way specialized catheters do not have an irrigation channel. Both types of catheter usually remain in situ up to 7 days following urological surgery. These catheters are rigid and usually made firam polyvinyl chloride (PVC) or nylon spiral latex hydrogel coated reinforced materials. However, some 3-way catheters if bonded with polytetrafluoroethylene (PTFE) may stay in situ up to 28 days {Table 2),These catheters again are primarily used following urological surgery or in cases of bleeding from a bladder/prostate tumour and the bladder may need continuous or intermittent irrigation to clear blood clots/debris, 2-way (Foley soft catheters): These catheters consist of the main drainage lumen and separate catheter balloon inflation channel. These catheters are softer, more flexible than specialized catheters and are used to catheterize patients either in the hospital or in the community setting. They are available in both latex and non-latex (100% silicone) with various bonding or coatings. This type of catheter may remain in situ from 184 days {Table 2). An important issue in catheter selection is that although all urinary catheters are licensed for urethral use, not all catheters are licensed for suprapubic use. Therefore, if the catheter selected is for suprapubic insertion, it is important to check in the NHS Logistics Catalogue (NHS, 2005) or contact the manufacturer.

Modern day indwelling Foley catheters, whether latex or 100% silicone come with various coatings, or bondings, sometimes termed as encapsulated and it is this bonding which determines how long the catheter can remain in situ as recommended by the manufacturer,The bonding material is applied to the inner and outer surfaces during production, Hydrophilic polymer bonding is applied to the Foley latex, 100% silicone, or occasionally, specialized catheters and may also be called hydrogel or polymer hydromer (Robinson, 2001), This bonding, when rehydrated by bodily fluid allows the catheter surface to become smoother, thus reducing surface friction bet\veen the catheter and urethral wall (Stewart, 1998), Hydrophilic polymer is compatible with body tissue and is thought to be resistant to bacterial colonisation and encrustation (Stewart, 1998), Other coatings are PTFE (polytetrafluoroethylene) or Teflon (medium-term) and silicone-elastomer (long-term). However, hydrogel may be applied to certain specialized catheters with a lifespan of 1-7 days and catheters with Bacti-Guard coating, i,e, Bardex LC, Silver hydrogel latex Foley catheter, has a lifespan of up to 28 days. Companies use diflerent names for their brand of catheter which can be confusing, e,g, Biocath, Curity, Lubro-Sil or Ultramer, A list of various companies, their catheter materials and catheter names is indicated in Table 2.

Selecting a urinary catheter

In selecting a Foley catheter, certain factors need to be taken into consideration, including: Catheter length Catheter lengths fall into three groups: paediatric length, standard length and female length {Table 3). Catheter materials, bonding and lifespan The author feels there may be some confusion from Dougherty and Lister (2005) in the 'Royal Marsden Hospital Manual of Clinical Nursing Procedures' who state that short-term catheters can remain in situ for 1-14 days, short-to-medium-term for 26 weeks, and medium-tolong-term for 6 weeks to 3 months. The manual also states that the silicone-elastomer catheter is a mediumterm catheter of 6 weeks' duration when it is actually a long-term catheter of 12 weeks' duration (Pomfret, 1996; Robinson, 2001,2004b), Further possible confijsion is that the NHS Logistics Catalogue (NHS, 2005) states that long-term catheters may stay in situ up to 90 days. If a long-term catheter is left in situ for 3 months, choosing any three consecutive months totalling 8992 days (12,5-13,1 weeks) or 90 days (12,6 weeks), the manufacturer's recommendations for insertion lifespan of the catheter has been exceeded (Pomfret, 1996; Robinson 2001, 2004b) {Table 2). The correct lifespan of indwelling catheters is as follows: Short-term catheters usually remain in situ for up to 7 days, e,g. PVC or specialized catheters Medium-term catheters usually remain in situ up to 4 weeks or 28 days, e,g, PTFE Long-term catheters remain for 12 weeks or 84 days, e,g. silicone-elastomer, hydrogel, polymer hydromer.

Charriere size selection

Charriere (Ch) identifies the size of catheter being inserted and may sdll be identifled as F (French) or Fg (French gauge). Patient comfort and maximum drainage of what needs to be drained determines the Charriere size {Table 4), The greater the size selected, the greater the urethra is dilated,This sizing scale (Ch) measures the outer circumference of a catheter or instrument, e,g, 1 Ch=0,33 mm. All urinary catheters have different coloured inflation valves representing the Ch size of catheter. Some catheters may also have the make, size, material and balloon inflU volume printed on the inflation valve. The smallest Ch catheter possible should be inserted, e,g, a 12 Ch latex catheter over a 24 hour period will drain: 100 litres of urine at approximately 4166.6 ml per hour 1.5 litres of urine at approximately 62,5 ml per hour (Pomfret, 2000). High Charriere sizes may sometimes be required to drain heavy bladder debris and blood clots. Inappropriate large sizes can produce catheter-associated problems {Table 5). It is advisable to seek guidance prior to selecting and inserting catheters above 16 Ch in case urological intervention is required (Lowthian, 1998; Robinson, 2004b), Latex vs silicone Drainage via a catheter may be increased without inserting a higher Ch catheter. When examining the drainage lumen of a latex catheter by cutting it in half, the drainage lumen is approximately one-third the diameter of the catheter, whereas a 100% silicone catheter is slightly wider. Latex catheters also have thicker walls than silicone catheters. Therefore, if using a 14 Ch latex catheter and changing to a 14 Ch silicone catheter, the drainage lumen is then equivalent to using a 16 Ch latex catheter (Pomfret, 1996; Robinson, 2004b),

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URINARY CATHETERS
Catheter balloon infill volume
Infill volume refers to the amount of sterile water required to inflate the catheter balloon in accordance with manufacturer's recommendations. Depending on the type of catheter being used, balloon infill volumes can vary between 2.5 ml for paediatric catheters to 80 ml for standard and female length catheters; the norm is a 10 ml balloon infill volume to help avoid catheter-associated problems. Should the catheter information indicate a 30 ml balloon, this amount has to be inserted to inflate the balloon correctly, i.e. do not infiate with 10 ml when the balloon is designed for 30 ml total volume. Some catheter information may indicate a range for the balloon inflation volume; in this situation use the higher volume (Table 6). The greater the catheter balloon infill volume, the greater the weight of the catheter inside the urinary bladder. For example a 10 ml balloon weighs 17 g while a 30 ml balloon weighs 48.2 g (Robinson, 2004b). Catheter balloon inflation valves are single inflation and deflation only. Catheter balloons should not be deflated and 'topped' up in case damage has occurred during deflation or reinflation (Robinson, 2004a).

Problems when selecting catheters

There are catheter-associated problems in selecting the wrong catheter, these include:

Wrong length
Paediatric-length catheters must not be used to catheterize adult patients Female-length catheters must not be used for male urethral catheterization, as they are too short and the balloon may inflate in the prostatic urethra/bladder neck, which could lead to trauma. The distance of the shaft of the female-length catheter between the base of the catheter balloon to the inflation valve arm is 18-19 cm (despite being 23-26 cm in overall length). Inserting a catheter of a shorter length in males could cause external pressure to the urethral orifice where the inflation valve and connection port meet. The male urethra varies considerably between erection and flaccid state. If penile erection occurs, extra torsion and external pressure will occur causing possible catheter dislodgement and further discomfort and trauma for the patient.

Table 2. Catheters, material and lifespans

1 Company Rusch Rusch Rusch Rusch Bard Bard Bard Bard Bard Bard Kendall Kendall Kendall L.IN.C Medical Material Catheter name Bonding PTFE Hydrogel PTFE Silver/hydrogel Hydrogel Silicone-elastomer Hydrogel Polymer hydromer _ Lifespan 28 days 12 weeks 12 week 12 weeks 28 days 28 days 12 weel 12 weelcs 12 weeks 12 weeks 12 weeks 12 weeks 12 weeks 12 weeks Latex AquaFlate Latex Simpacath AquaFlate 100%Silicone Brillant AquaFlate 100%Silicone Brillant SilFlate Latex Latex Bardex I.C. Latex Biocath Aquamatic Latex 100% Silicone Lubri-Sil 100%Silicone 100% Silicone Curity Latex Ultramer 100% Silicone Argyle 100% Silicone (with integral balloon) Rusch (2002); Bard (2004); Coloplast (2004);

NHS Logistics (2005); TeleHex Medical (2005)

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Wrong material
Latex can cause serious allergic reactions, and so must be used with caution. Symptoms include: anaphylaxis, shock, asthma, bronchospasm, rhinitis, vesicles, scaling, conjunctivitis, local and systemic urticaria (Woodward, 1997). If latex allergy symptoms occur or are suspected, immediately change the catheter to a non-latex material (e.g. silicone). Incorrect Charriere sizes Trauma may occur during insertion/removal resulting in urethral strictures. Other problems are included in Table 5.

Incorrect balloon infill

There are risks involved if catheter balloons are under- or over-inflated (Table 6). As mentioned, catheter balloons must only be inflated to the recommended amount as printed on the catheter packaging by the catheter manufacturer.

Drainage systems
There are two ways in which urine from inside the bladder may be drained via an indwelling catheter. The first is into a drainage bag system consisting of a leg bag, connecting to an overnight drainage bag known as a total closed link system. The second is by using a catheter valve. Total closed link system The catheter and drainage system is on a continual circuit until change of catheter or drainage bag is required (Pomfret, 1996). Depending on the manufacturer and drainage bag selected, leg bags come in four sizes: direct, short tube, long tube and extra-long tube. Drainage bag capacity can vary between 350750 ml depending on the size of bag and part of the leg to which it will be attached. Direct: secured to the thigh Short tube: secured with straps above and below the inner aspect of the knee Long tube/extra-long tube: secured to inner aspect of the calf. Drainage bags are usually changed every 57 days following the manufacturers' guidelines and the Drug Tariff (DH, 2005). Drainage bags also have different operating mechanisms for opening and closing: push-through, or 90-180 rotational opening/closing. It is important that patients are shown how to change and secure drainage bags and their operation, not only for routine changes but in case of leakage. At night, an overnight single-use disposable 2 litre drainage bag is attached to the connecting port at the base of the leg bag. There are several versions of disposable night bags. The first version requires the corner to be cut to empty the bag. The second has a tear away section. The problem with both these bags is the risk of spillage and contamination during the emptying process. The third version has a single-use tap mechanism. Disposable 2 litre drainage bags are not sterile and should not be connected directly to the connecting port at the base of the leg bag. If a 2 litre drainage bag is to be attached directly to the catheter it must be packaged as sterile. Drainage bags should be compatible with the catheter used to avoid unnecessary disconnection and leaking. Drainage bags are often fitted in the wrong position leading to drainage problems which can cause bypassing or urinary retention from tube kinking and restricted drainage (Robinson, 2004a). Long-term use of drainage bags can cause bladder health deterioration as a result of the bladder not being able to function properly (Addison, 2001). Catheter valves The second drainage system which can be used is a catheter valve. Patients should have good cognitive function to operate the catheter valve themselves and an adequate bladder capacity

Table 3. Catheter lengths

Paediatric length Approximately 30cm long. For catheterizing small babies and children. Not to be used catheterizing adults. This catheter is approximateiy 40 - 44cm long. The male urethra is approximately 19 - 20cm long. Must be used for male urethral catheterization. Can be used for female urethral catheterization. Can be used for supra-pubic catheterization in either gender if licensed fbr use. - Standard length catheters until the late 1980s, was the only length of c:atheter available to catheterize adults of either gender. Is often called the 'male catheter' while the correct terminology is standard length. - This catheter is approximately 23 - 26cm long. - The female urethra is approximately 4cm in length. - For female urethral catheterization. - Not to be used for male urethral catheterization. - May be used for supra-pubic catheterization if licensed fbr use in either gender, providing obesity, clothing, mobility cind drainage system being used are taken into consideration. ACA (2004); Pomfret (1996); Robinson (2004b)

Standard length

Female iength

Table 4. Catheter charriere (Ch) sizing and use

Ch./ mm. and Valve colour Drainaee indicator

lOCh/3.3mm. Black 12Ch/4mm White 14Ch/4.7mm Green 16Ch/5.3mm Brown / orange 18Ch/6mm. Red 20Ch / 6.7mm. Yellow 22Ch / 7.3mm. Violet 24Ch / 8mm. Blue

Initial catheterization (female). Clear urine. No debris. No grit (encrustation). Initiai catheterization (male/female). Clear urine. No haematurea. No grit. No debris. Initial catheterization (maie/female). Clear urine. No haematurea. No grit. No debris. Initial catheterization (male). Clear or slightly cloudy urine. Light haematurea with or without small dots. None or mild grit. None or mild debris. Initial catheterization (male). Moderate to heavy grit. Moderate to heavy debris. Haematurea with moderate clots. Usually used post bladder / prostate surgery. Haematurea with moderate to heavy clots. Very cloudy urine. Very heavy grit. Very heavy debris. As size 20Ch. As size 20Ch. Robinson (2001, 2004a, 2004b)

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Table 5. Problems using high charriere sizes

Blockage of paraurethral glands Urethritis Urethral pressure sores Urethral friction Pain and discomfort Over dilation of urethra Urethral abscesses Offensive urethral discharge. Lowthian (1998); Robinson (2004a)

that nurses become familiar with the options to be sure their patients are receiving the most appropriate care. IBS
Association of Continence Advice (2000) Notes of good practice. ACA,London Addison R (1999) Catheter valves: a special focus on the Baid FUp-Flo catheter. BrJ Nurs 8(9): 576-80 Addison R (2001) Bladder health and continence care. Nurs Times 97(40): 5S-6 Baid (2004) Prescriber's Cuide and Price List. Bard Ltd, Brighton Road Coloplast (2004) Product Cuide. Coloplast Ltd., Peterborough Departinent of Health (2001) Cuides for Consent for Examination or Treatment. DH, London Department of Health (2005) Drug Tariff. D H , London Dougherty L, Lister S (2005) Elimination: Urinary Catheterization. In: Dougherty L, Lister S eds. The Royal Marsden Hospital of Clinical Nursing Procedures. 6th edn. BlackweU PubUshing: 330-47 Fader M, Pettenson I, Brooks R et al (1997) A multicentre comparative evaluation of catheter valves. BrJ Nurs 6(7): 359-67 Cetliffe K, Dolman M (2003) Catheters and Catheterization. In: Gediffe K, Dolman M eds. Promoting Continence 3rd edn. Bailiere Tindell, London: 259-301 Culmez I, Ekmekcioglu O, Karacagil M (1996) A comparison of various methods to burst foley catheter balloons and the risk of free-fragment formation. BrJ Urol 77(5): 716-8 Lowthian P (1998) The dangers of long-term catheter drainage. BrJ Nurs 7(7): 336-72 NHS (2005) NHS Logistics Authority. NHS Logistics Catalogue, Normanton, West Yorkshire Pellowe C, Loveday H, Harper P, Robinson N, Pratt R (2001) Preventing infection fix)m short term ind'welling catheters. Nurs Times 97(14): 345 Pomfret I (1996) Catheters: design, selection and management. BrJ Nurs 5(4): 245-51 Pomfret I (2000) Urinary catheters: Selection, management and prevention of infection. British Journal of Community Nursing 5(1): 6-13 Pratt R, Pellow C, Loveday H, Robinson N (2001) Guidelines for preventing infections and maintenance of short-term indwelling urethral catheten in acute arcJHosp Infect 47(Suppl 1): S39-S46 Robinson J (2001) Urethral catheter selection. Nurs Stand 15(25): 39-42 Robinson J (2003) Choosing a catheter. Journal of Community Nursing 17(3): 37-42 Robinson J (2004a) A practical approach to catheter-associated problems. Nurs Stand lS{31):3SrA2 Robinson J (2004b) Fundamental principles of indwelling urinary catheter selection. BrJ Community Nurs 9(7): 281-4 Rusch (2002) Transurethral Foley catheters. Rusch UK, High Wycombe Stewart,E (1998) Urinary catheters: selection, maintenance and nursing care. Br J N w c 7(19): 1152-^1 Teleflex Medical (2005) Brillant Foley catheters. Teleflex Medical, High Wycombe Woodward S (1997) Complications of allergies to latex urinary catheten. BrJ Nurs 6(14): 7 8 ^ 7 9 3

(Addison, 1999). However, there are areas to be considered prior to fitting a catheter valve and its use is not recommended for all patients, e.g. patients with known ureteric reflux, renal impairment, uncontrolled bladder (detrusor) overactivity and hyper-reflexia (Fader et al 1997; Addison 1999). At night an overnight drainage bag may be attached. The main advantage of using a catheter valve instead of drainage bags is that bladder health is maintained by (Addison, 2001): Helping to maintain an intact bladder wall Allowing the bladder to expand and fiU with urine Giving good blood and nerve supply to the bladder wall Giving the sensation to want to pass urine Helping to constrict the bladder when voiding urine.

Securing devices
Drainage bags may be secured to the leg by straps, or in cases of swollen legs/circulatory problems, inside a sleeve, e.g. Bard Uri-sleeve^"^ or Coloplast Aquasleeve^*^. Both of these come in various leg circumferences so leg measurement must be taken for correct sizing. To avoid what is known as catheter sway, the catheter may be secured using a catheter restraining strap, e.g. Bard Comfasure^'^ or Simpla Catheter G-Strap.

Conclusion
Discussing catheterization is an important part of nurse patient relationships and if possible should be discussed with the patient before the initial insertion to allow the patient (or family) to ask questions and provide clear understandable answers. Patients should be given information booklets or leaflets on the care and management of their catheter and drainage system. Morecambe Bay Primary Care Trust issues patients with information leaflets concerning the catheter, management and care. As one type of catheter wiU not be suitable for every patient, it is recommended

KEY POINTS
I Only catheterize if required. I Ensure the catheter is licensed for urethral or suprapubic use. I Select correct catheter length for gender and choose the smallest charriere size for purpose. I Educate patients on catheter care and management of drainage system used.

Table 6. Using incorrect catheter baiioon infill volumes

Under-inflation Catheter dislodgement into prostatic urethra in males, or the urethra in females, causing trauma and haematurea Catheter drainage becoming occluded, resulting in no drainage of urine, risk of causing urinary retention Expulsion of the catheter with balloon still partially inflated. Bladder neck irritation. Over-inflation Distortion of the catheter baiioon and catheter tip inside the urinary biadder Detrusor muscie irritation and spasm resuiting in bypassing of urine. Trigone Irritation. Haematurea Catheter balloon bursting, causing free-fragment formation or bladder trauma Gulmez et al (1996); Lowthian (1998); Robinson (2003)

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