Indwelling catheterisation in adults – Urethral and suprapubic (2024)

4. ALTERNATIVES, INDICATIONS, AND CONTRAINDICATIONS

4.1 Alternatives to placing an indwelling catheter

An indwelling catheter should only be placed when there is a clear indication. It should not stay in place longer than necessary. It is important first to consider alternatives before placing an indwelling catheter. A catheter is usually the last resort when other options have failed or proved to be insufficient but may be placed by patient choice in preference to other alternatives. To insert a catheter only for the comfort of the nursing staff and or carers is irresponsible.

The following alternatives to an indwelling catheter should be considered:

1. Male external catheter or sheath [11-22]
2. Female external urinary catheter [23]
3. Intermittent catheterisation by a nurse, carer, family member or the patient [12, 13, 18-21, 24, 25]
4. Continence pad/containment product. [16, 19]

GR, grade of recommendation; LE, level of evidence.

4.2 Indications for urethral catheterisation

4.3 Relative contraindications for urethral catheterisation

• Acute [32] or symptomatic chronic prostatitis
• Suspicion of urethral trauma [33]
• Traumatic hypospadias secondary to previous long-term indwelling urethral catheterisation

4.4 Indications for suprapubic catheterisation

In addition to the indications of the urethral catheterisation the following indications apply:

• Acute and chronic urine retention that cannot be adequately drained with a urethral catheter. [27, 32]
• Preferred by patient due to their needs, e.g., user of a wheelchair, sexual issues. [15, 27]
• Acute prostatitis [32]
• Fournier’s gangrene
• Urethral stricture or obstruction, abnormal urethral anatomy
• Urethral or pelvic trauma [27]
• Complications to long-term urethral catheterisation
• When long-term catheterisation is used to manage incontinence
• Complex urethral or abdominal surgery
• Patients with faecal incontinence who are constantly soiling the urethral catheter
• To protect a perineal wound from urinary contamination

4.5 Absolute contraindications for suprapubic catheterisation

• Known or suspected carcinoma of the bladder [18, 27, 34-36]
• In the absence of an easily palpable or ultrasonographically localised distended urinary bladder [18, 27, 35]
• Visible (gross/frank) haematuria

4.6 Relative contraindications for suprapubic catheterisation

• Previous lower abdominal surgery [27]
• Prosthetic devices in lower abdomen; e.g., lower hernia mesh [36]
• Coagulopathy (until the abnormality is corrected) [18, 27] and anticoagulation therapy for blood clotting disorders [27]
• Ascites [27]
• Pregnancy [27]

4.7 Advantages of suprapubic catheterisation

There is little evidence-based research on the use of suprapubic catheters. However, experts believe that there may be several advantages to their use when compared with urethral catheterisation:

• Less risk of urethral trauma or necrosis, e.g., traumatic hypospadias in men or patulous urethra in female, or catheter-induced urethritis [18, 27, 35, 37]
• Reduced risk of catheter contamination with microorganisms commonly found in the bowel [18, 27, 34, 35, 37, 38]
• Greater comfort, particularly for patients who use a wheelchair [18, 27, 34, 35, 38]
• Easier access to the entry site for cleansing and catheter change [18, 27, 34, 35]
• More appropriate in respect of a person’s sexual activity (intercourse) [27, 35]
• Can be blocked off and the ability to void urethrally assessed prior to removal of the suprapubic catheter [18, 27, 34, 35, 37, 38]
• Greater preservation of patient dignity
• Easier to maintain and care for

Limitations of suprapubic catheters:

• Insertion is an invasive procedure with the risk of bleeding, visceral injury, and peritoneal perforation [39]
• The patient may still leak urine via the urethra [39]
• Specialised training may be required for healthcare professionals and carers for changing a suprapubic catheter [39]
• Patients with artificial heart valves may require antibiotic therapy prior to initial insertion or routine catheter change; however, this depends on local healthcare management policy
• Patients on anticoagulant therapy require their coagulation levels to be checked prior to insertion of a suprapubic catheter. Anticoagulant therapy and coagulations levels depend on local healthcare management policy.

4.8 Short-term versus long-term catheterisation

Short-term catheterisation is mostly used:

• During surgical procedures, prolonged labour and post-operative care
• For a variable period of time following certain interventions, e.g., prostate artery embolisation
• For exact monitoring of urine output in acute illness
• For relief of acute urinary retention
• Instillation of medication directly in the bladder (intravesical)
• To facilitate bladder washout and irrigation

Long-term catheterisation can be necessary in:

1. Bladder outlet obstruction in patients who are unsuitable for surgical relief of the obstruction
2. Chronic retention; often as a result of neurological injury or disease where intermittent catheterisation is not possible [8]
3. Acontractile bladder in patients who are unable or unwilling to perform intermittent self-catheterisation
4. Debilitated, paralysed or comatose patients in presence of skin breakdown and infected pressure ulcers – only as a last resort when alternative non-invasive approaches are unsatisfactory or unsuccessful
5. Cases where a patient insists on this form of management after discussion of the risks [40]
6. Intractable incontinence when all other measures have been tried and proven to be ineffective or are contraindicated [41]