Urinary Catheter Care for Older Adults

INDICATIONS FOR AND PREVALENCE OF URINARY CATHETERS
Indwelling urethral or suprapubic catheters are commonly used to treat urinary retention in those who cannot perform clean intermittent catheterization (CIC) due to limited hand dexterity or alterations in cognition. Retention can be caused by a neurogenic bladder that fails to empty satisfactorily or by obstruction to the bladder outlet.¹ People with long-term urinary retention often include those with spinal cord injury/disease, multiple sclerosis, enlarged prostate, or cerebrovascular accident.^2-5 Indwelling urinary catheters may be used as well to provide supportive care for those with severe incontinence who cannot manage otherwise, are terminally ill, or need short-term treatment of pressure ulcers. Many of these conditions increase in prevalence with advancing age. Other short-term indications include postoperative care, instillations into the bladder, and monitoring urinary output.¹ However urinary catheters are associated with a number of risks or complications, including urinary tract infection, leakage, recurrent blockage, and long-term catheterization should only be considered when alternative care strategies are unavailable or unsuccessful.
__________________________________________________________________________________________________________________________
RELATED CONTENT
Urinary Tract Infections in Long-Term Care
Try This: Urinary Incontinence Assessment in Older Adults Part I – Transient Urinary Incontinence
__________________________________________________________________________________________________________________________

Urinary catheter care is a significant clinical issue because of widespread prevalence of the device, and with the increased aging of the population, use is expected to increase. In nursing homes in the United States, it is estimated that about 100,000 people use indwelling catheters,⁶ or about 7.5-10% of the residents.⁷ Duration of catheter use in home settings may be rather long, with a median of 3-4 years, with some individuals using them for more than 20 years.^3,5,8-10

CATHETER-ASSOCIATED COMPLICATIONS
Prevalence of urinary catheter use and urinary tract infection (UTI) are among the indicators used by the U.S. federal government to monitor quality of care in nursing homes. Because a long-term indwelling urinary catheter contributes to associated morbidity and mortality, catheter use is closely monitored by the Centers for Medicare & Medicaid Services (CMS).¹¹

Individuals using long-term urinary catheters are at risk for many serious complications, some of which may be life threatening, including pyelonephritis, bacteremia, and bladder cancer.^12-15 In addition, this population is susceptible to chronic obstructions due to urinary calculi and to periurethral infections, including epididymitis and prostatitis in men.^13,16,17

Other than removal of the catheter, little is available to prevent UTI in this population. While bacteria are present in the urine of virtually all who have been catheterized for more than 30 days,^18-20 the presence of bacteria may remain asymptomatic. A life-threatening situation can occur if symptomatic UTI is not controlled and develops into deadly sepsis.^{13,14,17,21,22} Moreover, preventive antibiotic treatment is not feasible as drug resistance develops easily; therefore, antibiotics are reserved for symptomatic infections.^16,18,20,23

EVIDENCE FOR PRACTICE
Recent Cochrane systematic reviews indicate that there is a paucity of evidence to guide practice related to catheter care, particularly for people with long-term catheters who need to use them indefinitely. Most research focuses on hospitalized patients with short-term catheter use, and very few randomized clinical trials take place (in short- or long-term users).^24,25 The lack of comprehensive research in this area restricts development of guidelines for evidence-based practice to inform and help long-term catheter users. Research on short-term catheter use also is limited.

Currently, Cochrane systematic reviews are in progress (protocols developed) for identifying best practices for irrigations (washouts),²⁶ and for determining which catheters might contribute to fewer episodes of catheter-associated UTI and other complications, such as catheter blockage or formation of stones.²⁷

ASSISTING OLDER ADULTS WITHLONG-TERM CATHETER CARE
Long-term catheter users are in special need of guidance because their quality of life may be strongly influenced by appropriate and effective catheter management. Adjusting to living with such a device is not always easy, and it often takes a year or more.²⁸ Clinicians can facilitate this adjustment by helping persons choose the right equipment and by promoting insight into the process of adjustment.

Catheter Equipment Selection
Terminology varies about what constitutes short-term as compared with long-term catheters; yet this information is needed when selecting a catheter and deciding approximately how often it should be changed. Definitions seem to vary according to the purpose of the defining organization.^29-31 For persons who will be using an indwelling catheter indefinitely, it is essential that the type of catheter material be considered carefully. While latex catheters with Teflon® coatings (polytetrafluoroethylene, or PTFE) may be left in place for up to 28 days, silicone (or silicone-coated latex) and hydrogel-coated catheters have been shown to minimize friction during insertions and removals, and to be more comfortable in situ; thus, silicone and hydrogel catheters are recommended by the International Continence Society (ICS), as well as manufacturers, for long-term use.¹

A broad assessment of the patient, family, and setting will provide information for deciding on the appropriate catheter drainage equipment, such as leg bags and straps to support the bag. Factors to consider include mental acuity, mobility, dexterity, visual ability, physical characteristics, lifestyle, personal preferences, and whether there are caregivers involved.¹ In addition, catheter users and their families need to know what equipment is available. Showing them a number of different equipment catalogs might empower them to make decisions on supplies that better suit their lifestyles and abilities. For instance, individuals lacking in manual dexterity might wish to consider or try out several kinds of drainage bag clamps to find the one that is easiest to manipulate.

For people going out regularly, the advantages of switching from an overnight to a leg bag (or belly bag), which can be emptied as required, need to be considered. Increased mobility and the aesthetic benefit of wearing a covered bag may outweigh the benefit of keeping the bag totally closed. Because many long-term catheter users are often at the mercy of insurance intermediaries who assign one catheter bag per month, this one bag may not be totally clean. That is, people with this device may be using a totally closed but very “dirty” system when a large overnight bag is left in place for a month. Catheter users may have one extra bag on hand for replacing a leaking bag. With more ample supplies, such as occurs in other countries with different forms of medical payment, drainage bags are often changed every 5-7 days (based on clinical or expert opinion).¹ Clinicians in the United States, however, may need to talk with representatives of insurance companies to advocate for their patients to assure that they obtain the equipment they need.

In the past, often persons were taught to clean urine drainage bags every 3 days with a weak vinegar solution, or to change the bag every 1-2 weeks if not cleaning them.³ While some persons may be taught to clean drainage bags, it is no longer standard practice. Limited research into bag decontamination suggests that daily cleaning with a weak bleach solution (1:10 bleach/water) can be effective in cleaning drainage bags and in extending the life of the bag to 1 month.³² Using bleach requires safety considerations, though, such as gloves, an apron or old clothes, and eye protection.33 While bleach has been shown to kill bacteria in urine drainage bags better than vinegar,³⁴ individuals who are not able to use bleach can use a 1:4 vinegar/water solution.³³

The “purple urine bag syndrome” can be a mysterious and worrisome phenomenon for long-term catheter users. In a recent case report and systematic review, various theories were proposed about its cause and treatment.³⁵ At least 12 different organisms have been implicated, and most studies indicate that alkaline urine and a higher level of bacteriuria facilitate the process of color production by bacterial action. While generally considered a benign condition, practitioners need to know about this syndrome.

Improvements in Urinary Catheters
Further improvements in urinary catheters are still needed. Current studies involve the use of silver-alloy coatings on catheters, an electrified catheter, and instillations of the antibiotic triclosan into the catheter balloon. Of these, only silver-alloy catheters are currently available. While silver-alloy coated catheters have been shown to be cost-effective for short-term catheter use in hospitalized patients,^36-39 no research was found on their effectiveness for long-term use, and the added expense has not yet been justified for this population.

Electrification of the catheter is a recent and promising approach to providing antibacterial action through iontophoresis of silver electrodes in the catheter, resulting in a reduced bacterial count, encrustation of the catheter, and the pH staying below 6.5 for approximately 100 hours.⁴⁰ The approach of instilling triclosan (a commonly used antiseptic agent in soaps and toothpaste) into the catheter balloon reduced encrustations for 7 days.⁴¹ Catheter instillation procedures are widely utilized in the United Kingdom, using citric acid solutions with buffering agents, with preliminary in vitro studies showing their effectiveness.^42,43 Clinical trials are being planned for testing efficacy in persons with urinary catheters.

Promoting Adjustment and High Quality of Life
Quality of life (QOL) has been studied very little in this diverse population. Most studies that address QOL have viewed it as a measure in longitudinal research comparing different methods of bladder drainage in relation to long-term complication rates. Comparisons of outcomes among studies are hampered because there is no agreement about the best measures of QOL for this population.¹

Several issues need to be considered to promote adjustment in long-term catheter users. Based on research in persons with long-term catheters, thoughtful attention and guidance are needed because of the embodied changes brought on by an indwelling catheter.^44,45 Issues include “sexuality, shame and stigma, embarrassment, loss of control of bodily function, reminders of illness/mortality, and the inconvenience and worries of catheter-related problems.”¹ On the positive side, users of the device also may recognize how a catheter can be convenient, can free them from urine accidents, and are necessary for bladder drainage.¹

Embarrassment during catheter changes, while obvious, may not be considered by clinicians because such changes can seem routine. Nonetheless, individuals are likely to feel embarrassed, particularly if exposed by a person of the opposite sex. Both male caregiver/female patient sensitivity and female caregiver/male patient sensitivity may occur during catheter changes.^46,47 Paradoxically, acknowledging that changing a catheter is an invasive and somewhat embarrassing procedure (to both parties) might diminish vulnerability associated with the act.⁴⁷

Disease or neurological injury, such as spinal cord injury, requires a major lifestyle adjustment. A catheter adds to the adaptation needed, and sexuality issues can figure into this adjustment.⁴⁸ While clinicians may hesitate to offer information about sexual behavior, patients might welcome the opportunity for a frank discussion about how to make modifications for sexual activity.

Autonomic dysreflexia (AD) in persons with spinal cord injury also needs to be addressed proactively by clinicians. Learning to recognize this painful, and sometimes life-threatening syndrome, is essential to adjustment and quality of life for persons who need to know how to prevent it. Catheter users or those providing care can be taught to empty the drainage bag before it is too full and to prevent pulling, kinks, or twists on the catheter or tubing. Gentle catheter insertion may also be helpful. In one study, catheter users complained that some care providers did not know about AD, or they minimized its significance, contributing to worry.⁴⁹ A catheter user in a different study of incontinence and sexuality complained that others viewed him as perverted while attempting to untangle drainage tubing to avoid AD.⁵⁰ Because AD requires immediate attention, those prone to it must be prepared to deal with the situation, despite circumstances or setting.

Concealing the urine bag is essential for emotional well-being. Covering the bag may be related more to aesthetics than modesty, as catheter wearers want to appear as much like others as possible.⁴⁴ Urine bag placement and comfort need to be considered as well. Wearing a urine bag was viewed as negative in one study by 25% of the catheter users, and 89% preferred concealing the drainage bag.⁵¹ People can use coverings made of cloth or plastic (eg, grocery bags) as long as the material is not transparent. Some may prefer placing a towel over the lap.⁴⁷ Leg bag placement may also require an extension of soft rubber tubing so the bag can be worn comfortably. Rigid extension tubing should not be used because it could buckle and cause a urine accident.⁴⁷

For catheter users who will need to use the device indefinitely, informing them that adjustment can take at least a year might be helpful.²⁸ For those cognitively able, learning to pay attention to one’s body and to changes in urine flow—including the weight of the urine bag and the color and character of the urine—could help to promote this adjustment. Being aware of early signs of disruption in urine flow can prevent some catheter problems such as kinks, twists, or full blockage.^44,45 Over time, if the catheter is working correctly, it should shift into the background and become a part of the individual’s everyday life, much like eyeglasses that are hardly noticed. One catheter user noted that after 4 years, the catheter became “an everyday thing now. It just became second nature.”⁴⁴