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Urethral catheter selection

Robinson J (2001) Urethral catheter selection. Nursing Standard. 15, 25, 39-42. Date of acceptance: December 27 2000 Urinary catheterisation is primarily a nursing procedure and promoting best nursing practice is integral to enhancing good patient care. Catheterisation is a sensitive issue that requires effective communication and diplomacy skills, and practitioner confidence and skill can promote patient comfort and dignity. The large variety of catheters can raise concerns for practitioners who are not experienced in this area. Some nurses, including students, might not have dealt with a catheterised patient before. Nurses might be unsure about the indications for using different types of catheter or the difference between male-length and female-length catheters. The literature suggests that each of the three methods of catheterisation urethral, suprapubic and intermittent has specific problems (Lowthian 1995, Lowthian 1998, Roe 1991, Schonebeck et al 1987, Woollons 1996). Urologists and surgeons continue to debate the advantages and disadvantages of urethral and suprapubic methods of catheterisation (Horgan et al 1992, Sethia et al 1987) and their respective management (Peate 1997, Pomfret 2000). Accurate patient assessment and evidencebased decision making are important aspects of care; record keeping, including time and date of insertion, type and size of catheter used, and any complications identified, is becoming an increasingly important area of practice (Buckley 1999). Catheters The history of catheterisation is interesting. Around 3000BC, river reeds and onion stems were used to drain the bladder. This was followed by the development of metal catheters using gold, tin, lead and silver tubes: in the 1920s, latex was vulcanised. Latex is a product of the Hevea Brasiliensis tree and is collected by tapping the tree trunk. Chemicals known as accelerators were added during the process, which resulted in a durable and flexible material. A single hollow drainable tube was then produced. In 1934, Frederick Foley, an American urologist, developed a catheter with a separate channel that could be used to inflate a balloon with water to keep the catheter positioned inside the bladder. The Foley catheter is a selfretaining, flexible tube which is held in position by an inflated balloon. John Robinson RGN, RMN, NDN (Cert), is District Charge Nurse, Catheter Specialist, Bay Community NHS Trust, Morecambe. Summary Many patients undergo urethral catheterisation. Selecting the most appropriate catheter for an individual patient requires knowledge and a practical understanding of the types of catheter available. A number of factors should be considered in catheter selection, including patient needs, indications for catheterisation, the type of material, the balloon size and the length and diameter of the catheter. The aim of this article is to provide information that will clarify some of the concerns nurses might have regarding urethral catheterisation.

RINARY CATHETERISATION is a relatively common procedure experienced in acute and community settings. Patients might require catheterisation for a variety of reasons. These include acute or chronic urine retention, accurate urine measurement, drainage of hypotonic bladder or neurogenic bladder, urodynamic investigation, bladder irrigation and pre- and post-operative management. Urethral catheters can also be used to manage urinary incontinence, However, indwelling catheters have a number of associated complications for the patient (Box 1), and should only be used when all other interventions have failed or are inappropriate (Winn 1998). Urinary catheterisation can be intermittent or indwelling and the two most common methods for catheter insertion are urethral and suprapubic. The factors affecting the decision to catheterise a patient are frequently interrelated and multifactorial and can change over time. Each patient should be regularly assessed and the available treatment options fully discussed with him or her before the procedure is carried out. Patients needs and expectations should also be established to decide the optimum method and type of catheter to use. The large number of urinary catheters available offers a variety of options, but also makes selection more complex. The type, size, material and design should be considered when selecting the most appropriate catheter for a patient. Choosing the right catheter is crucial to prevent associated risks, minimise complications and promote patient comfort and quality of life.

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Key words

I Nursing care I Urinary catheters

These key words are based on subject headings from the British Nursing Index. This article has been subject to double-blind review.

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Box 1. Catheter-related problems I Bladder irritability/spasm I Bypassing I Urine/urethral infection/bacteraemia I Catheter blockage I Trauma (accidental traction) I Haematuria I Urethral perforation I Catheter encrustation I Bladder calculi I Urethral stricture I Neoplastic changes
(Lowthian 1998)

Box 2. Different categories of catheter I Foley (soft/non-rigid) indwelling catheters for short- to medium-term use (up to 28 days depending on the material used). These are not rigid like some specialised catheters I Foley (soft/non-rigid) indwelling catheters for medium- to long-term use (up to 12 weeks) I Rigid (specialised) catheters for urological use made from plastic and reinforced nylon (three to five days) I Single-use plastic catheters used for intermittent self-catheterisation (ISC)

Catheter manufacturers are striving to produce better materials for indwelling catheters, to improve drainage, resistance to bacterial colonisation and reduce encrustation, which frequently causes catheters to become blocked (Bard 1987, Roe 1991, Roe 1992). A list of catheters can be found in the Drug Tarrif (DoH 2000), the NHS Logistics Authority Catalogue (NHS Logistics Authority 2000), or the Continence Products Directory (Continence Foundation 1999). The majority can be divided into four categories (Box 2). Packaging Accurate record keeping is essential to good catheter care and the packaging has important information clearly marked on it. This includes: I The reference number. I The catheter material being used. I The length of the catheter paediatric, standard or female length. I Charrire (Ch) size and balloon infil, and whether the catheter is prefilled or not. I The lot number and expiry date. Selecting catheter size Catheter length There are three lengths of catheter currently in use: female (23-26cm), paediatric (30cm), and standard (40-44cm). The standard-length catheter is now termed the male-length catheter, which is confusing because there is no such thing as a male catheter. The standard-length catheter must be used on male patients. This length can also be used when catheterising female patients. Some females prefer the standard-length catheter; female-length catheters may cause pressure and discomfort in the groin area of obese women (Pomfret 1996, 2000). Until the 1980s the standard-length catheter was the only length available to catheterise either sex. The female-length catheter was manufactured in the late 1980s. This length should only be used for catheterising female patients if a female-length catheter is used to catheterise a male patient in error, it could result in severe trauma to the prostatic urethra, urethra, or both. Disciplinary action could be taken against the person who catheterised the patient for using the wrong length of catheter. Extreme care must be taken to identify the correct length of catheter before insertion. Ideally, the catheter should be categorised as standard and female length and also by whether it is suitable for intermittent, short- or long-term use depending on the material used. It would be useful if manufacturers printed male/female use on the packaging of all standard-length catheters and strictly for female catheterisation only on female length-catheters. Charrire size The external diameter of the

catheter is measured in Charrire (Ch), French gauge (Fg) or French (F) units. One Charrire unit is 0.33mm, therefore a 12Ch catheter is 4mm and a 16Ch catheter is 5.3mm in diameter. The Charrire size determines the type of fluid the catheter should be used to drain (Getliffe 1993, McGill 1982, Pomfret 2000). Smaller Charrire sized catheters have smaller drainage eyes. The Charrire size is also important for patient comfort a large Charrire size can cause urethral discomfort and trauma. In general, the smallest diameter catheter that is able to provide adequate urine drainage should be used (Pomfret 2000). The urethra is lined with paraurethral glands, which produce a mucus substance that lines the urethra and protects against ascending infection (Norton 1986, Wilson and Waugh 1996). This lining is flushed away on micturition, but burning or stinging on micturition could indicate the presence of cystitis, or a urine infection. However, in catheterised patients the mucus coating is not flushed away and drains away by gravity and peristaltic action. This results in a dried staining to the patients underwear or a dark dried coating outside the urethra and on the catheter surface. The smaller the Charrire size, the easier it is for the mucus to drain away. The higher the Charrire size and the longer the catheter is in situ, the greater the risk of the catheter pressing against the urethral wall, which could prevent drainage from the paraurethral glands. This could result in inflammation of the urethra which can result in urethritis or another ascending infection (Blandy et al 1989). In addition, catheters of a high Charrire size will not move as easily as a smaller size inside the urethra, which could cause urethral irritation and sores (Lowthian 1998). Charrire sizes, colour coding and indications for use are outlined in Table 1. Inflation valves are colour coded according to the Charrire size. The make, material, Charrire size and balloon infil is printed on most valves. Practitioners should avoid inserting a high Charrire sized catheter immediately after using a small Charrire size for example, inserting a 18Ch catheter directly after 12Ch catheter unless the patients condition determines that a higher size is required, such as in haematuria with large clots. If the patient needs a higher Charrire size, higher sizes should be introduced gradually to avoid causing trauma by sudden dilatation of the urethra. If a large Charrire size is used, the patient should be regularly assessed and, where possible, a smaller Charrire size should be inserted. Urethral dilation can result in urethral sway movement of the smaller size catheter inside the

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urethra and it might be necessary to change the Charrire size in stages to avoid this. When assessing patients for catheter selection, it is important to use the smallest Charrire size and balloon infil possible, to avoid catheter-related problems. Balloon infill size Balloon infill can vary from 2.5-5ml in paediatric catheters, 10-30ml in adult catheters and 20-50ml, and even up to 80ml, in specialised urological catheters. The correct balloon infill is printed on the packaging. However, balloon infill should be no greater than 10ml for routine use. The 30ml balloon was designed to aid haemostasis by adding downward pressure on the bladder neck following prostatic surgery. Infilled catheter balloons add weight to the bladder neck, internal sphincter valve and pelvic floor. A 10ml balloon weighs 17g compared with a 30ml balloon which weighs 48.2g. The greater the balloon infill, the greater the weight pressing down on the bladder neck and pelvic floor. If the pelvic floor is weak, the catheter can dislodge or, in some cases, fall out with the balloon still inflated. The bladder in the normal state is designed to stretch on filling with urine and to shrink on voiding. However, with a catheter in situ the bladder remains shrunk and the inflated catheter balloon rests on the base of the bladder. Using a high balloon infill means that the balloon surface comes into contact with the bladder wall. The greater the balloon infill the higher the balloon sits inside the bladder, which means the catheter tip can irritate the trigone area. This stimulates the bladder muscle which can cause spasm, urinary bypassing, haematuria, trauma and possible erosion of the bladder wall. Care should be taken to ensure that the balloon is fully deflated before catheter removal. Removal can also cause urethral trauma, as the balloon can become creased on deflation causing trauma (Robinson 2000, Semjonow et al 1995). Catheter balloons are either prefilled or nonprefilled. Currently, only one company produces prefilled catheters. Non-prefilled catheters should be inflated with sterile water (Belfield 1988). Tap or boiled (cooled) water will stagnate and may cross through the balloon membrane into the bladder, causing infection. Tap water also contains many chemicals. Normal saline will evaporate and resultant salt crystals can block the narrow infill channel, making balloon deflation difficult. Air should never be used as the catheter may float above the level of urine in the bladder. Care must be taken not to over- or underinflate the balloon infill (Belfield 1988, Britton et al 1990, Chrisp et al 1990, Gulmez et al 1996).

Table 1. Urethral catheter charrire sizes, colour coding and indications for use Charrire size 10Ch/3.3mm 12Ch/4mm 14Ch/4.7mm 16Ch/5.3mm Colour coding Black White Green Orange Indications for use Initial catheterisation (female). Clear urine. No grit (encrustation), debris, or haematuria Initial catheterisation (male or female) Clear urine, no grit, debris, or haematuria Initial catheterisation (male or female). Clear urine, no grit or debris, no haematuria Initial catheterisation (male). Clear or slightly cloudy urine, both sexes. No or mild grit. Light haematuria with no clots Initial catheterisation (male). Moderate to heavy grit and debris. Haematuria with moderate clots

18Ch/6mm

Red

You are advised to seek urology guidance on the use of charrire sizes 20-24 as the patient may require urological intervention 20Ch/6.7mm Yellow Avoid unless urine is very cloudy, with heavy grit and debris. Heavy haematuria with large clots. Following prostatectomy and bladder surgery Severe haematuria with large blood clots. Following prostatectomy and bladder surgery Severe haematuria with large blood clots. Following prostatectomy and bladder surgery
REFERENCES Bard (1987) You, Your Patients and Urinary Catheters. Crawley, West Sussex, Bard Ltd. Belfield P (1988) Urinary catheters. British Medical Journal. 296, 6625, 836-837. Blandy J et al (1989) Catheters and catheterisation. In Blandy J et al (Eds). Urology for Nurses. First Edition. Oxford, Blackwell Scientific Publications Ltd. Britton R et al (1990) Catheters: making an informed choice. Professional Nurse. 5, 4, 194-198. Buckley R (1999) Keep it legal. Nursing Times. 95, 6, 75-77. Chrisp J et al (1990) Foley catheter balloon puncture and the risk of free-fragment formation. British Journal of Urology. 66, 5, 500-502. Continence Foundation (1999) Continence Products Directory. London, Continence Foundation. Department of Health (2000) Drug Tarrif. London, The Stationery Office. Evans A et al (2000) Bladder washouts in the management of long-term catheters. British Journal of Nursing. 9, 14, 900-906. Getliffe K (1994) The use of bladder washouts to reduce urinary catheter encrustation. British Journal of Urology. 73, 6, 696-700. Getliffe K (1993) Care of urinary catheters. Nursing Standard. 7, 44, 31-36.

22Ch/7.3mm

Violet

24Ch/8mm

Blue

Risks associated with over-inflation are: I Balloon rupture leaving fragments inside the bladder. I Distortion of the catheter/balloon inside the bladder. I The catheter tip can rise and irritate the trigone area. I Irritation of the detrusor muscle. I Pain, spasm, bypassing and haematuria. Risks associated with under-inflation are: I Catheter dislodgement into the prostatic urethra (males) and urethra in both sexes. I Drainage eyes can become blocked if they enter the balloon area. I Failure of the catheter to drain urine and catheter dislodgement. I Bladder neck and urethral irritation, bypassing, pain, haematuria and urethral trauma Catheter materials Catheters are made from various materials, which determine use and how long the catheter remains in situ (Pomfret 1996, Woollons 1996). Catheters can be made from plain latex, bonded latex, plastic, pure silicone or nylon re-inforced materials (used in specialised catheters for urological use). Choosing the appropriate catheter

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Gulmez I et al (1996) A comparison of various methods to burst Foley catheter balloons and the risk of free-fragment formation. British Journal of Urology. 77, 5, 716-718. Horgan A et al (1992) Acute urinary retention: comparison of suprapubic and urethral catheterisation. British Journal of Urology. 70, 2, 149-151. Lowthian P (1998) The dangers of long-term catheter drainage. British Journal of Nursing. 7, 7, 366-379. Lowthian P (1995) An investigation of the uncurling forces of indwelling catheters. British Journal of Nursing. 4, 6, 328-334. McGill S (1982) Catheter management: its the size thats important. Nursing Mirror. 154, April 7, 48-49. Morris N et al (1997) Which indwelling urethral catheters resist encrustation by Proteus mirabilis biofilms. British Journal of Urology. 80, 1, 58-63. NHS Logistics Authority (2000) NHS Logistics Authority Catalogue. Normanton, Elanders Hindson. Norton C (1986) Catheterisation. In Norton C (Ed). Nursing for Continence. Beaconsfield, Beaconsfield Publishers. Peate I (1997) Patient management following suprapubic catheterisation. British Journal of Nursing. 6, 10, 555-562. Pomfret I (2000) Catheter care in the community. Nursing Standard. 14, 27, 46-51. Pomfret I (1996) Catheters: design, selection and management. British Journal of Nursing. 5, 4, 245-250. Robinson J (2000) Removing catheters. Journal of Community Nursing. 14, 12, 8. Roe B (1992) From Pompeii to the present. Nursing Times. 88, 31, 57-60. Roe B (1991) Catheters: looking at the evidence. Nursing Times. 87, 37, 72-74. Schonebeck J et al (1987) The dangers of catheterisation: 12 photographs. In Schonebeck J, Hakansson L (1987) (Eds) The Atlas of Cystoscopy. Sweden, Grune and Stratton. Issued by Molnlycke. Semjonow A et al (1995) Reducing trauma whilst removing long-term indwelling balloon catheters. British Journal of Urology. 75, 2, 241. Sethia K et al (1987) Prospective randomised controlled trial of urethral versus supra-pubic catheterisation. British Journal of Surgery. 74, 7, 624-625. Wilson KJW, Waugh W (1996) Protection and survival. In Wilson KJW, Waugh W (Eds). Ross and Wilson: Anatomy and Physiology. Eighth edition. London, Churchill Livingstone. Winn C (1998) Complications with urinary catheters. Professional Nurse. 13, 5 (Suppl), S7-10. Woodward S (1997) Complications of allergies to latex urinary catheters. British Journal of Nursing. 6, 14, 786-792. Woollons S (1996) Urinary catheters for long-term use. Professional Nurse. 11, 12, 825-832.

material is important as certain materials are more resistant to encrustation. Encrustation occurs when urine pH is greater than 7.2 (Getliffe 1994, Evans et al 2000). Material deposits of struvite (ammonium, magnesium and phosphate) and calcium phosphate accumulate, which can lead to partial or complete catheter blockage (Morris et al 1997). Practitioners should not be afraid to try different catheter materials to establish which suits a patients needs. Before selecting a catheter it is important to check if the patient has a latex allergy not only in relation to the catheter material, but in terms of sterile glove use (Woodward 1997). Foley catheters, the most common used in hospital and community settings, can be divided into two subcategories: short-to-medium-term and long-term catheters. Short-to-medium-term catheters PolyvinyI chlorine or plastic There are two types of catheter made from this material. In the indwelling balloon version, the balloon is made from latex. However, these indwelling catheters are fairly rigid and therefore are rarely used. They can be left in situ for 7-14 days. The second type is a single, non-ballooned catheter, which is mainly used for intermittent selfcatheterisation (ISC). These catheters are for single use (ISC) or as directed by local policy. Plain latex This type is very rarely used. It has a thin outer coating of silicone to aid insertion. The surface is not smooth and is prone to swelling, caused by the absorption of body fluids through its surface. This causes the external diameter of the catheter to increase while decreasing the drainage lumen. They are prone to encrustation. The lifespan is 7-14 days. Polytetrafluoroethylene (PTFE) This is a latex catheter which is bonded with Teflon, making it smoother than plain latex catheters and easier to insert. This material also reduces the absorption of body fluid through the catheter surface. These catheters are for medium-term use, with a lifespan of up to four weeks. Long-term catheters Silicone elastomer This is a latex catheter with silicone bonding to the outer and inner surface. This makes both surfaces smooth and reduces the potential for encrustation. The silicone elastomer coating makes the latex less absorbent. The catheter lifespan is 12 weeks. Hydrogel This is made of latex, bonded with a hydrogel coating, which the manufacturers state is more compatible with body tissue. This surface reduces bacterial colonisation and encrustation (Pomfret 1996). The hydrogel surface absorbs a

small amount of body fluid to keep it smooth, reducing friction between the catheter and urethral surfaces. The lifespan is 12 weeks. Polymer hydromer Latex is bonded with polymer hydromer to create a material suitable for long-term catheter use. Similar to hydrogel catheters, the surface of this catheter absorbs a small amount of body fluid to keep the surface smooth. The catheter lifespan is 12 weeks. These catheters all contain latex and should not be used in patients who have a latex allergy. Pure silicone This is a latex-free catheter for use in patients with latex allergy. However, the balloon material allows diffusion to occur the water in the balloon slowly passes through the balloon membrane into the bladder. The balloon infill should be checked and corrected half way through its lifespan, otherwise the balloon will slowly deflate causing the catheter to dislodge or fall out. The advantage of this type is that the catheter walls are thinner and the internal drainage channel is equal to a higher Charrire size, for example 12Ch = 14Ch (Getliffe 1993, Woollons 1996). The lifespan is up to 12 weeks. Conclusion Selecting the most appropriate catheter length, material and balloon infill reduces the risk of catheter-related problems, such as trauma, blockage, haematuria, urethral perforation and encrustation. In using small Charrire sizes (1216 Ch) with an appropriate balloon infill (10ml) nurses can enhance patient comfort. Guidance should be sought from suitably qualified and experienced staff before using larger sized catheters. Consultation with the patient and his or her carers is important to establish the patients individual needs and discussion should occur before the patient is catheterised. Patients and carers should be offered explanation and clarification regarding the procedure and ongoing catheter management. This can help to allay the patients fears and anxieties, and enhance understanding of the reasons for catheterisation and the need to report any problems that occur while the catheter is in situ. Catheterisation is often termed a basic nursing task. However, choosing the correct catheter to meet each patients needs requires a good understanding of the indications and reasons for catheterisation, experience of catheter management, and knowledge of the different catheters available. By integrating clinical experience with the relevant theory, nurses can improve catheter selection and offer patients reassurance and comfort while maintaining a high standard of care

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