8. BLADDER WASHOUT, IRRIGATION AND INSTILLATION
In clinical practice, the most extensively used terms are “manual washout or bladder lavage” defined as the washing out of the bladder with sterile fluid, and “bladder irrigation” as the continuous washing out of the bladder with sterile fluid. [192-194] Bladder instillations appear to have several indications; one of which is to prevent or treat catheter blockages.
Indications for bladder washout / irrigation:
- Urinary sediment
- Debris in the bladder
- Haematuria
- Catheter blockage
- Catheter not draining correctly
Indication for bladder instillation
- Introduction of medication
Instillations are not limited to saline or citric acid solutions. There are others such as chemotherapeutic drugs (e.g., mitomycin C or epirubicin) or anti-inflammatory drugs (e.g., hyaluronic acid), or drugs to reduce toxicity of brachytherapy, [195] or vesicoureteral reflux. [196]
8.1 Washout policies/catheter maintenance in long-term urethral catheterisation
In some cases, bladder irrigation with solutions containing citric acid or polyhexanide are used for catheter blockage. Solutions with citric acid are supposed to dissolve encrustations, while polyhexanide is a disinfectant and antiseptic solution that has been developed as an improved, second-generation chlorhexidine. It is a broad-spectrum biocide that is not only effective against bacteria, but also against some fungi and protozoa. [161] Polyhexanide is supposed to help minimise biofilm formation by preventing microorganisms attaching to surfaces and forming colonies, and in this way, reduce bacterial load in catheters. [197] The effect of polyhexanide is still to be proved. [161]
Routine use of acidic washouts to reduce catheter encrustations cannot be recommended according to an Cochrane review comparing washout versus no washout; different washout solutions; frequency, duration, volume and concentration of washouts; and method of administration in any setting with an indwelling urethral or suprapubic catheter for > 28 days. [157] They found 7 relevant articles and conclude that the evidence is not adequate to show whether washouts are beneficial or harmful.
Despite this conclusion, in daily practice, bladder washouts are still often recommended in special circumstances, such as removal of encrustation in some long-term indwelling catheters, removal of blood clots after urological surgery, or in palliative treatment of intractable haematuria. [198, 199] From a patient perspective, use of a maintenance solution has been reported to improve health-related quality of life. [200] As stated in the Cochrane review [39, 157] there is no evidence of what kind of solutions should be given and for how long.
Bladder washout and catheter maintenance are options to be discussed with patients and their clinical teams on an individual basis. [100] Based on the evidence, the Working Group cannot recommend routine bladder washout except in patients with bleeding and undergoing certain urological surgical procedures.
| Recommendation | LE | GR |
| Bladder irrigation and instillation of maintenance solutions do not prevent catheter-associated infections. However, they may be recommended in special circumstances, such as management of blood clots [39, 157] | 1b | A |