Effect of Time of Day for Urinary
Catheter Removal on Voiding
Behaviors in Stroke Patients
Jan Coleman Gross
Frances Hardin-Fanning
Mary Kain
C
linical practices in cath-
eter management vary
widely and frequently
are not evidence based
(Smith, 2003). Indwelling uri-
nary catheterization is often
required in the acute stage of hos-
pitalization after stroke and
many stroke patients are trans-
ferred to rehabilitation with an
indwelling catheter in place. The
return of normal voiding is an
important goal in rehabilitation
and in assuring patients can fully
participate in therapy; however,
common sequella of urinary
catheterization, including bac-
teruria, urinary tract infection
(UTI), dysuria, and urine reten-
tion after removal, may interfere
with quality of life and rehabili-
tation. Limited research has been
conducted to evaluate the best
Jan Coleman Gross, PhD, ARNP-S,
is an Assistant Professor, the
University of Kentucky College of
Nursing, Lexington, KY, and a
Consultant to the Stroke Unit, Cardinal
Hill Rehabilitation Hospital (CHRH),
Lexington, KY. She runs a Continence
Clinic in the Womens Health and
Rheumatology Clinic at the University
of Kentucky and an Outpatient Clinic
at CHRH.
Frances Hardin-Fanning, MSN, is a
Lecturer, the University of Kentucky
College of Nursing, Lexington, KY.
Mary Kain, BSN, CRRN, is a Nursing
Unit Coordinator, the Stroke Unit,
Cardinal Hill Rehabilitation Hospital,
Lexington, KY.
UROLOGIC NURSING / June 2007 / Volume 27 Number 3
Elizabeth A. Faulkner
Stacey Goodrich
This study was designed to determine if the time of day a urinary
catheter was removed impacted length of time to the first void after
catheter removal, the amount of the first void, post-void residual urine,
and the number of subjects requiring re-catheterization in stroke reha-
bilitation patients. A randomized two group comparative design was
used. Study results did not indicate a difference in voiding based on
whether the catheter was removed at 7:00 a.m. or 10:00 p.m. in this sam-
ple of stroke rehabilitation patients. This study is a beginning step in
identifying parameters to consider when developing an individualized
plan for indwelling urinary catheter removal in post-stroke patients.
Purpose stroke unit, were approached about
The purpose of this study was to study participation. Forty-five subjects
compare the effect of urinary catheter were enrolled: 26 in Group A (10:00
removal at 7:00 a.m. with removal at p.m. removal) and 19 in Group B (7:00
10:00 p.m. on (a) the length of time to a.m. removal). Groups were compared
using t-tests and Chi-square.
first void after catheter removal, (b) the
amount of the first void, (c) post-
void-residual urine, and (d) the number Findings
of subjects requiring re-catheterization. No significant differences were
identified between the two groups with
Methods regard to time to void, volume of first
A randomized, comparative void, post-void residual urine, or the
design was used. Stroke patients, over number of subjects requiring re-
the age of 18 years, admitted to a catheterization.
practice for catheter removal to results in a longer interval to the
facilitate return of normal blad- first void, larger volumes at first
der function. The timing for void, and a more rapid return to
catheter removal has primarily normal voiding in multiple
been based on unit policy and patient populations (Crowe, Clift,
reflected the preferences of med- & Bolton, 1994; Griffiths &
ical or nursing staff (Watt & Fernandez, 2005; Kelleher, 2002;
Lillibridge, 1998). Studies to date Noble, Menzies, Cox, & Edwards,
have shown that catheter 1990; Smith, 2003). This study
removal late in the evening was designed to determine if the
Elizabeth A. Faulkner, RN, CRRN, was Director, the Stroke Program, Cardinal
Hill Rehabilitation Hospital, Lexington, KY, at the time this study was conducted.
Stacey Goodrich, BSN, CRRN, is a Nursing Unit Coordinator, the Stroke Unit,
Cardinal Hill Rehabilitation Hospital, Lexington, KY.
231
time of day a urinary catheter
was removed influenced length
of time to the first void after
catheter removal, the amount of
the first void, post-void residual
urine, and the number of subjects
requiring recatheterization in
stroke rehabilitation patients.
Background
Bladder dysfunction is a
common occurrence in the early
days after stroke (Brittain, Peet, &
Castleton, 1998; Nakayama,
Jorgensen, Pedersen, Raaschou, &
Olsen, 1997; Ween, Alexander,
DEsposito, & Roberts, 1996).
Urinary retention, frequency,
urgency, and urinary inconti-
nence (UI) are among the prob-
lems frequently reported after
stroke. Indwelling urinary
catheters, often used in the acute
care period, may contribute to
the development of voiding prob-
lems upon catheter removal. For
example, urinary retention has
been identified as a common
occurrence after indwelling uri-
nary catheter removal in stroke
subjects (Gross, 1990). If in-
dwelling urinary catheter re-
moval at night results in a longer
interval to the first void, larger
volumes at first void, and a more
rapid return to normal voiding,
the incidence of common blad-
der problems after stroke, in par-
ticular urinary frequency, reten-
tion, and UI may be reduced.
Moreover, a more rapid return to
a pre-stroke voiding pattern may
also benefit stroke rehabilitation
patients ability to participate in
therapy and, in turn, lead to
improvements in functional out-
comes.
In randomized, comparative
studies investigating the effect
the time of day an indwelling uri-
nary catheter is removed, hospi-
talized patients whose catheter
was removed at midnight had
greater volumes at the first void
and a longer time interval to first
void than the 6:00 a.m. group
(Crowe et al., 1994; Noble et al.,
1990). The subjects in both of
these studies were primarily uro-
logic and urologic surgical
patients. The time of day the
catheter is removed has not been
232
shown to significantly affect the
proportion of participants who
develop urinary retention requir-
ing catheterization (Crowe et al.,
1994; Wyman, 1987). In one
study, two groups did not differ
on the proportion experiencing
urinary retention 10 hours after
catheter removal; however, ap-
proximately 24% of the total
sample failed a voiding trial due
to urinary retention (greater than
150 cc) or painful urinary reten-
tion necessitating recatheteriza-
tion (Wyman, 1987). Subjects
with a history of urinary reten-
tion prior to surgery were more
likely to require recatheterization
(Wyman, 1987).
More recently, Kelleher
(2002) conducted a prospective
clinical trial (N=160) to deter-
mine the impact midnight
removal of indwelling urinary
catheters would have on sub-
jects voiding pattern and subse-
quent hospital discharge. Sub-
jects were randomly assigned to
either midnight or 6:00 a.m.
indwelling urinary catheter
removal. Subjects in the mid-
night removal group passed a
greater volume of urine with both
their first (268 ml compared with
177 ml; p<0.0001) and second
voids (322 ml compared with
195 ml; p<0.0001) than subjects
in the 6:00 a.m. removal group.
Moreover, subjects in the mid-
night removal group were dis-
charged earlier from the hospital
than those in the 6:00 a.m.
removal group.
Study Hypotheses
Systematic evaluations of the
effects of catheter removal at dif-
ferent times of day in stroke
patients have not been reported.
Hypotheses for the study reported
here were: Stroke patients whose
indwelling urinary catheters are
removed at 10:00 p.m. in compar-
ison to those whose urinary
catheters are removed at 7:00 a.m.
were expected to have:
1. A longer time interval from
catheter removal to first void.
2. A larger volume of urine in
the first void after catheter
removal.
UROLOGIC NURSING / June 2007 / Volume 27 Number 3
3. Smaller post-void residual
urine after their first void.
4. A smaller proportion of
patients requiring intermit-
tent catheterization after
indwelling catheter.
Methods
Design. A randomized two
group comparative design was
used. Subjects were randomized
to groups by drawing sealed
envelopes indicating group desig-
nation. Group A subjects includ-
ed those for whom indwelling
urinary catheter removal oc-
curred at 10:00 p.m. Group B sub-
jects underwent indwelling uri-
nary catheter removal at 7:00 a.m.
Sample and setting. The
study was conducted on the
stroke unit, a 34-bed unit, in a
freestanding rehabilitation hospi-
tal. Patients admitted with a med-
ical diagnosis of stroke who met
inclusion criteria were recruited
for possible study enrollment.
Inclusion criteria included (a)
presence of an indwelling urinary
catheter on admission or inserted
during the rehabilitation program,
(b) age > 18 years, and (c) medical
order for catheter removal.
Institutional review board ap-
proval was obtained. Informed
consent for study participation
was obtained from the stroke
patient and the patients physi-
cian. A medical order for
catheter removal per study pro-
tocol was required for all sub-
jects.
To detect differences between
groups with a power of 0.80 at an
alpha of 0.05, assuming a large
effect size, it was determined that a
sample size of 26 subjects per group
was needed (Cohen, 1992). A total
sample size of 62 was proposed to
allow for attrition and the poten-
tial of missing data.
Measures. A data collection
tool was developed by the investi-
gators to record demographic
information and data on depen-
dent variables. Demographic data
collected included age, gender,
concurrent medical diagnosis, and
medications on admission. A uro-
logic history of previous voiding
problems and urologic procedures
or surgery was obtained from the
subjects medical record and,
when possible, from a face-to-face
interview with the subject. The
presence of a UTI prior to or upon
admission was also determined
from transfer information and uri-
nalysis upon catheter removal.
The Centers for Disease Control
and Prevention criteria for UTI
provided the defining characteris-
tics to determine the presence of
infection on admission to rehabili-
tation (Horan & Gaynes, 2004).
Additional data collected on void-
ing behaviors after catheter removal
included whether the void was
continent or incontinent, the pres-
ence of urgency, frequency or dis-
comfort with the void, and
whether the patient or staff initiat-
ed the void. Data on dependent
variables also were recorded on
the data form. The dependent vari-
ables were defined and measured
as described below.
Length of time to first void was
recorded in minutes by calculat-
ing the number of minutes
between the times of catheter
removal and the first void. The
volume of the first void was mea-
sured in cc of urine, using stan-
dard output graduates such as uri-
nals or urine collection hats
placed in commodes. To objective-
ly document the presence and
amount of urine loss with inconti-
nent voids, a perineal pad test was
used. Pads were pre-weighed in a
labeled and sealed plastic bag.
Worn pads were returned to the
sealed plastic bags and weighed
within 24 hours of collection on a
digital electronic scale. The Scout
electronic balance scale (Ohaus
Corporation) is a precision weigh-
ing instrument, with the capacity
to weigh up to 600 grams to the
nearest 0.1 gram. The scale has
calibration weights that were used
to check accuracy of weights prior
to use of the scale. The volume of
urine lost was calculated from the
differences in pad weight before
and after use. A perineal pad test
has acceptable reliability and
validity in estimating the amount
of urine lost during daily activities
(Jorgensen, Lose, & Thunedburg,
1989).
A post-void residual urine
(PVR) was obtained within 15
UROLOGIC NURSING / June 2007 / Volume 27 Number 3
minutes of the subjects first void
using a noninvasive bladder scan-
ner. The time and volume of PVR
was recorded on the subjects bed-
side chart. The BladderScan BVI
3000J is a portable, automated
three-dimensional ultrasound de-
vice for noninvasive determina-
tion of bladder volume and was
reliable and valid across a range of
0 to 1,015 cc in 249 adult outpa-
tients (0.90, p<0.001) (Marks,
Dorey, Macairan, Park, & de-
Kernion, 1997).
Procedures
Subjects who met study criteria
and gave consent to participate
were randomly assigned to Group
A (indwelling urinary catheter
removal at 10:00 p.m.) the day the
order for removal was written or
Group B (indwelling urinary
catheter removal at 7:00 a.m.) the
day after the order for catheter
removal was written. The actual
times selected for removal were
comparable to those in the back-
ground studies, but modified to be
congruent with subjects routine
bedtime (or time to complete
evening shift care) and usual time
for awakening in acute rehabilita-
tion.
Preweighed pads were placed
on subjects after catheter removal.
Pads were checked hourly after
catheter removal to determine if
subjects had voided. During wak-
ing hours or if awake at night, sub-
jects were asked regularly if they
needed to use the bathroom. The
exact time the catheter was
removed and the time of first void
were recorded on the bedside
chart.
Usual care was followed for
those who did not void for several
hours after removal. If participants
did not urinate upon arising in the
morning (or after breakfast for 10
p.m. removal) or after lunch (by
1:00 p.m. for 7:00 a.m. removal),
they were taken to the commode
and given an opportunity to void.
If subjects were unable to void and
reported suprapubic discomfort or
if a bladder scan revealed > 400 cc
in the bladder, intermittent sterile
urethral catheterization (ISC) was
performed and documented.
Subjects who did not void or were
not catheterized at these times
were evaluated every 1 to 2 hours
until bladder emptying occurred
or ISC was indicated.
Data Analysis
Independent t-tests were used
to determine differences between
Group A and Group B subjects
with regard to the length of time to
the first void, volume of first void,
and PVR. Determination of differ-
ences in the proportion of subjects
per group who required ISC was
calculated using Chi square analy-
sis.
Results
Forty-five subjects were re-
cruited. Table 1 includes a descrip-
tion of the sample. Twenty-six sub-
jects were assigned to Group A
(10:00 p.m.) and 19 were assigned
to Group B (7:00 a.m.) removal.
The mean age for the sample was
70.3 years (SD=11.7). Indwelling
urinary catheters had been in place
an average of 18.2 days (SD=19.3),
a time interval closely correspond-
ing to the length of time since
stroke onset (M=20.5 days,
SD=21.3). There was no significant
difference between subjects in the
two groups in terms of the pres-
ence of a UTI or UI after catheter
removal. The association between
sedative/narcotic use and group
was not significant.
There were no significant dif-
ferences between the groups on
time to void (t [35] = 0.94,
p =0.3525), volume voided (t [32]
= 0.55, p=0.5877), or post-void
residual urine (t [39] = -0.32,
p=0.7542) (see Table 2).
The proportion of subjects
who were unable to void after uri-
nary catheter removal did not dif-
fer between the two groups ( 2 [df
= 1] = 0.02, p=0.88). Nine of the
45 subjects (20%) did not void
after indwelling urinary catheter
removal. Further comparison of
those who did not void after
catheter removal with those who
did void revealed the two groups
did not differ according to gender,
age, UTI, location of stroke, time
from stroke onset, presence of
diabetes mellitus, or use of a
sedative/hypnotic the night of
catheter removal.
233
 Table 1.
Demographic Description of the Sample (N = 45)

Total Sample Group A Group B

Variable (N = 45) (n = 26) (n = 19) p Value
Gender 0.55
Female 57.8% (25) 61.5% (16) 47.4% (9)
Male 42.2% (20) 38.5% (10) 52.6% (10)
Location of Stroke 0.24
Right hemisphere 48.8% (21) 50.0% (13) 42.1% (8)
Left hemisphere 39.5% (17) 30.8% (8) 47.4% (9)
Brainstem 4.7% (1) 3.8% (1) 0.0 (0)
Not specified 7.0% (6) 15.4% (4) 10.5% (2)

Sphincter Control 0.79

Continent 44.4% (20) 53.8% (14) 57.9% (11)
Incontinent 55.6% (25) 46.1% (12) 42.1% (8)
UTI 0.58
Yes 55.6% (25) 53.8% (14) 57.9% (11)
No 35.6% (16) 34.6% (9) 36.8% (7)
Not available 8.9% (4) 11.5% (3) 5.3% (1)

Sedative 0.10
Yes 51.1% (23) 61.5% (16) 36.8% (7)
No 48.9% (22) 38.5% (10) 63.2% (12)
Ability to Void 0.88
Able to void 80.0% (36) 80.8% (21) 78.9% (15)
Unable to void 20.0% (9) 19.2% (5) 21.1% (4)

Discussion standard deviation estimates for ence voiding provides interesting

Study results did not indicate
a difference in voiding based on
whether the catheter was removed
at 7:00 a.m. or 10:00 p.m. in this
sample of stroke rehabilitation
patients. These findings conflict
with the results of Crowe et al.
(1994) and Noble et al. (1990) who
reported subjects who had
catheters removed at midnight
returned to a more normal voiding
pattern faster than those whose
catheters were removed in the
morning. It is possible that the fail-
ure to detect a difference in the
voiding behaviors evaluated in our
study is the result, at least in part,
of sample size.
An initial power analysis
indicated 52 subjects were need-
ed to have at least 80% power to
detect a group difference.
Recruitment became an issue
after several months as referring
facilities began to remove urinary
catheters immediately prior to
transfer to rehabilitation. Thus, a
decision was made to halt recruit-
ment at 45 subjects. An analysis
given the preliminary mean and
the three outcome variables (time
to void, PVR, and volume voided)
revealed the need for a much larg-
er sample than originally identi-
fied. The heterogeneity of stroke
presents major challenges in the
recruitment of an adequate num-
ber of subjects to evaluate inter-
ventions in stroke rehabilitation
(Louw, 2002).
The difference in outcome
may also reflect a difference in
the nature of voiding dysfunction
exhibited. The majority of sub-
jects in the Crowe et al. (1994)
and Noble et al. (1990) studies
were urologic surgical patients
where voiding problems were
more likely to result from manip-
ulation of the bladder. Bladder
dysfunction after stroke is typi-
cally a result of interference in
central nervous system control
and/or coordination of voiding
reflexes. Cerebral influence may
not be impacted by catheter man-
agement strategies.
Further consideration of
mechanisms by which the timing
of catheter removal would influ-
insights and direction for practice
and future research. Noble et al.
(1990) suggested the use of seda-
tion plus midnight removal
enabled patients to return to sleep
after removal. This could length-
en the time to the first void and
allow the bladder to fill more
fully through the night, and in
turn, facilitate a more normal
voiding pattern. In contrast, seda-
tion the night before did not sig-
nificantly alter anxiety and dis-
tress in those having their
catheters removed at 6:00 a.m.
Voiding often occurs opportunis-
tically at convenient times or
more frequently by choice to pre-
vent UI. Hypervigilance on void-
ing (and the frequency and
urgency that can result) may be
less likely to develop if the indi-
vidual delays voiding until the
morning and empties the bladder
upon arising in a more normal pat-
tern. Research revealing a strong
relationship between sleep apnea
and stroke (Mohsenin, 2004) and
demonstrating the impact of sleep
apnea on nocturia (Chasens &

234 UROLOGIC NURSING / June 2007 / Volume 27 Number 3


Mean for Group A
Outcome (10:00 p.m. Removal)
Time to first void 332.5 + 172.5 minutes
Post-voided residual urine
Volume voided (1st void)
Umlauf, 2003) suggests another
mechanism that may have influ-
enced these findings. Nocturia is
a common consequence of sleep
apnea; the need to urinate during
the night after catheter removal at
10:00 p.m. may have been influ-
enced by sleep apnea rather than
the time of catheter removal.
Future research should include
sleep apnea as a factor in findings
and include information from the
patient concerning the influence
of anxiety and distress. In fact,
review of the literature and emer-
gence of data from our study con-
cerning sleep apnea, stroke, and
nocturia prompted a secondary
analysis (Hardin-Fanning &
Gross, 2007) (see this article else-
where in this issue).
Implications for Practice
This study is a beginning step
in identifying parameters to con-
sider when developing an individ-
ualized plan for indwelling uri-
nary catheter removal in post-
stroke patients. The data reported
here do not support an advantage
to removing an indwelling uri-
nary catheter at midnight com-
pared to removal in the morning
in stroke rehabilitation patients.
Removal of an indwelling urinary
catheter need not wait until morn-
ing, a typical practice, thus poten-
tially decreasing the time a
catheter is in place. The longer an
indwelling catheter is in place the
greater the likelihood of bacturia
and UTI.
Findings highlight the impor-
tance of having a policy in place to
manage possible voiding problems
that may develop upon catheter
removal. Twenty percent of the
subjects in our study required
intermittent urinary catheteriza-
tion after removal of an indwelling
urinary catheter; thus, urinary
UROLOGIC NURSING / June 2007 / Volume 27 Number 3
Table 2.
Summary of Outcomes
Mean for Group B
(7:00 a.m. Removal)
374.1 + 202.3 minutes
157.3 + 256.0 cc 182.8 + 358.6 cc
188.5 + 151.4 cc 154.9 + 203.0 cc
retention remains a concern
regardless of the timing of
indwelling urinary catheter re-
moval. Urinary retention has also
been observed in other studies of
stroke patients after catheter
removal (Garrett, Scott, Costitch,
Aubrey, & Gross, 1989; Gross,
1990). The proportion of stroke
rehabilitation patients with uri-
nary retention in this study is sim-
ilar to that found after catheter
removal in urologic surgical
patients (Crowe et al., 1994) sug-
gesting catheter placement may
temporarily interfere with normal
detrusor function in certain per-
sons. Monitoring bladder capacity
and instituting an intermittent
catheterization routine to prevent
over-distention remains an impor-
tant component of a bladder man-
agement after stroke.
References
Brittain, K.R., Peet, S.M., & Castleton, C.M.
(1998). Stroke and incontinence.
Stroke, 29, 524-528.
Chasens, E., & Umlauf, M. (2003). Nocturia:
A problem that disrupts sleep and pre-
dicts obstructive sleep apnea.
Geriatric Nursing, 24(2), 76-81.
Cohen, J. (1992). A power primer.
Psychological Bulletin, 112(1), 155-
159.
Crowe, H., Clift, R., & Bolton, D. (1994).
Randomized study of the effect of
midnight removal of urinary catheters.
Urologic Nursing, 14, 18-20.
Garrett, V.E., Scott, J.A., Costitch, J., Aubrey,
D.L., & Gross, J. (1998). Bladder emp-
tying assessment in stroke patients.
Archives of Physical Medicine and
Rehabilitation, 70(1), 41-43.
Griffiths, R., & Fernandez, R. (2005).
Policies for removal of short-term
indwelling urethral catheters. Coch-
rane Database Systematic Review, 1,
CD004011.
Gross, J.C. (1990). Bladder dysfunction after
stroke: Its not always inevitable.
Journal of Gerontological Nursing,
16(4), 20-25.
Hardin-Fanning, F., & Coleman Gross, J.
(2007). The effects of sleep-disordered
breathing symptoms on voiding pat-
p Value
0.35
0.75
0.59
terns in stroke patients. Urologic
Nursing, 27(3), 221-224, 227.
Horan, T.C., & Gaynes, R.P. (2004).
Surveillance of nosocomial infections.
In C.G. Mayhall (Ed.), Hospital epi-
demiology and infection control (3rd
ed.) (pp. 1652-1702). Philadelphia:
Lippincott Williams & Wilkins.
Jorgensen, L., Lose, G., & Thunedburg, P.
(1989). 24-hour pad weighing test ver-
sus 1-hour ward test in the assessment
of mild stress incontinence. Acta
Obstetrics and Gynecology
Scandanavia, 68(3), 211- 215.
Kelleher, M.M. (2002). Removal of urinary
catheters at midnight versus 0600
hours, British Journal of Nursing,
11(2), 84-90.
Louw, S.J. (2002). Research in stroke reha-
bilitation: Confounding effects of the
heterogeneity of stroke, experimental
bios and inappropriate outcome mea-
sures. The Journal of Alternative and
Complementary Medicine, 8(6), 691-
693.
Marks, L.S., Dorey, F.J., Macairan, M.L.,
Park, C., & deKernion, J.B. (1997).
Three-dimensional ultrasound device
for rapid determination of bladder vol-
ume. Urology, 50(3), 341-348.
Mohsenin, V. (2004). Is sleep apnea a risk
factor for stroke? A critical analysis.
Minerva Medical, 95(4), 291-305.
Nakayama, H., Jorgersen, H.S., Pedersen,
M.A., Raaschou, H.O., & Olsen, T.S.
(1997). Prevalence and risk factors of
incontinence after stroke. The
Copenhagen Stroke Study. Stroke, 28,
58-62.
Noble, G., Menzies, D., Cox, P.J., & Edwards,
L. (1990). Midnight catheter removal:
An improved approach to removal of
catheters. British Journal of Urology,
65, 615-617.
Smith, J.M. (2003). Indwelling catheter
management: From habit-based to evi-
dence-based practice. Ostomy Wound
Management, 49(12), 34-45.
Watt, E., & Lillibridge, J. (1998). Time of
day urinary catheters are removed: A
study of current practices. Urologic
Nursing, 18(1), 23-25.
Ween, J.E., Alexander, M.P., DEsposito,
M., & Roberts, M. (1996).
Incontinence after stroke in a rehabil-
itation setting: Outcome associations
and predictive factors. Neurology, 47,
659-663.
Wyman, A. (1987). What time of day
should a urethral catheter be
removed? Journal of the Royal
Society of Medicine, 80, 755-756.
235
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