Catheter care in the community

There are some bizarre contradictions in our attitude to indwelling urinary catheters (IDC).

  • We are quick to put them in but are reluctant to take them out. In nearly a half of patients their use is inappropriate.
  • Many urological problems would be impossible to manage without an IDC but urologists consider them to be a last resort.
  • They are amongst the oldest of medical instruments but there is still no satisfactory design.
  • They usually drain into a bag but a flip/flow valve (tap) is more convenient and safer for the patient.
  • By one month after insertion 95% of men will have asymptomatic bacteriuria and be given inappropriate antibiotics
  • Many will have repeated symptomatic infections but there is no proven prophylaxis.
  • When there is a complication in the community patients usually go to accident and emergency departments (A & E) although three quarters of the problems could be dealt with at home.
  • Home treatment should be fairly easy but the right (simple) equipment is seldom available.

Some of these are big problems that will only be solved by laboratory and hospital-based research. From the patient’s point of view, day to day management is needed at home.

When there is a complication, a visit to A & E is very inconvenient. Most of the problems are simple and so what are the blocks to home management? Please let us know your thoughts. 

Comments (8) Add yours ↓
  1. Antoine Kass-Iliyya ST5 Urology

    I completely agree, A/E see patients with blocked catheters quite frequently. Usually all that is done is a simple flush before discharging the patient home. Patients with long term catheters (MS patients/ neuropaths) should learn how to flush their catheters regularly to prevent blockages and stone formation. (It is a very simple concept and no harm could be caused by it). The first step towards a solution here might be educating patients and their family/carers and providing them with the necessary knowledge and equipments to deal with catheter problems. (Continence nurses could be best suited for this role if they are provided with the time and the means to do so, they could also serve as a point of contact for patients who are having problems with their catheters).

    I also think as urologists we should perhaps encourage more and more patients who have the necessary cognitive ability and manual dexterity to try ISC (Intermittent Self Catheterisation) rather than have indwelling catheters (for example patients with detrusor failure or TURP failures, patients who are waiting for TURP, patients with refractory retention who are against surgical intervention or not particularly fit for it, patients with high residuals and UTIs, young ladies with retention, etc…). This gives patients some autonomy and minimize their reliance on health professionals.

    August 7, 2018 Reply
  2. Roger Kirby Professor of Urology

    Professor Woodhouse raises some excellent points here and his more detailed article on the subject is scheduled to appear in the next issue of Trends and I strongly recommend that you read it. By coincidence the obituary of Professor Roger Feneley was published very recently in the Times: https://www.thetimes.co.uk/article/professor-roger-feneley-xtcps9j5w?shareToken=2af79240afd869eb3855a035d952a1fd
    I also recommend that you read this, as Roger devoted much of his career to the development of a new catheter that would be less prone to the problems highlighted in this blog of the time honoured Foley design.

    August 8, 2018 Reply
  3. Dr John Havard GP

    I totally agree with Christopher Woodhouse about the list of ‘bizarre contraindications’ around the use of the Foley catheter. It is amazing that a medical device currently in situ in 100m people worldwide was designed in 1937! As a country GP, I like to think that we deal with most of the catheter complications in the community along with first insertions but OOH/A&E do sometimes get involved. Catheter complications can be serious and expensive (gram neg septicaemia for instance) and infection is largely due to poor design. A back of the envelope calculation based on NHS data suggests that a Foley catheter patient costs on average £450 per quarter. When you consider that a Foley only costs a few quid it can easily been seen how the costs of managing infections in and out of hospital is so enormous!

    The answer must be a fundamental redesign and I feel the same frustration as Henry Ford when he was told we just need faster horses! As a simple GP it seems that the flaws of the Foley are clear and should be addressed:

    1. Drain the bladder completely so a festering pool of microbiological culture medium is not allowed to remain at the base.

    2. Get rid of that hard tip that damages the sensitive mucosal dome of the bladder since we know damaged mucosa cannot resist infection. Not only does the bladder collapse repeatedly on the hard tip yielding the cystoscopic finding of ‘bladder change’ but mucosa gets sucked in and torn by the hydrostatic pressure.

    3. Use a shorter device in the bladder so there is less foreign body to cause bladder spasms. Getting rid of that tip also helps!

    I have been working on a new design for 5 years but am now making real progress since teaming up with Roger and Kate Holmes. We have now won our third grant and start our first in human trials at Bristol and Southampton in April 2019 under expert leadership of Prof. Marcus Drake and Prof. Mandy Fader. We received some really positive comments from NIHR that give us great encouragement for the definitive RCT. The design idea is simple but more complicated than imagined in execution – but we are almost there. Do take a look at http://www.flumecatheter.com to see how obvious the design is. Then again the motor car seems simple enough nowadays and yet Henry Ford had to look out his spurs before setting off at a gallop!

    August 8, 2018 Reply
  4. Tim obrien Consultant urologist

    Neuroscience. The great uncracked frontier…

    I wonder when we will see a device that can transcutaneously & reliably stimulate the bladder to contract and/or the urethra to relax

    August 8, 2018 Reply
  5. Bill Dunsmuir Consultant Urologist

    Wow! Christopher Woodhouse’s article could very well be an advertisement for the National Catheter Training Project. The “Secret Life of Catheters” is an eleven module animation programme with structured inter-modular feedback. It is currently being funded by Health Education England and is a truly multi-professional learning tool. It is linked to a systems-change agenda whereby we seek evidence for improvements in practice in response to our teaching. Currently in its 11th iteration, it is a dynamically evolving consenus product that is being constantly re-written in response to feedback from doctors, nurses and community staff. All of the issues mentioned in this blog (and more) – are covered in depth in this project.

    August 9, 2018 Reply
  6. Culley Carson Professor of Urology

    Thank you Chris for bringing forth a big area focus as urologists, yet one that is little studied, discussed or has any significant evidence based information regarding. Catheters are a true mystery for most physicians and their use and care are poorly understood. Indeed, clear guidelines and use principles are published. The best catheter use that I have experienced was as a resident at Mayo Clinic where there was a 24 hour a day catheter team of techs who discussed the need for the catheter, visited catheterized patients daily and took care of the catheter in a clinically expert fashion. Too often we place the catheter and forget it until someone (usually the uncomfortable patient) asks us when it can come out! I fully agree that an oft used and more oft abused medical device has little data and there should be careful study of catheters as there is for other urological devices and treatments. What we need are good evidence based guidelines for all medical professionals and institutions.

    August 13, 2018 Reply
  7. gordon muir consultant urolpogist

    Good points and brings home the fact that urethral catheters are the last resort. At every stage in a patient’s journey we must ask if there is an alternative. Almost all retention patients can be safely managed by safe and minimally invasive surgery, and for patients who are genuinely unable to void or stay dry suprapubic or intermittent catheterisation may be better options.
    Patients and their families should challenge the long term urethral catheter and health professionals should respond by looking at all the options.

    August 14, 2018 Reply
  8. christopher woodhouse Emeritus Professor of Adolescent Urology

    It looks as though I have opened an important topic. It must be said that the problem of poor design has not been neglected. It has been extensively researched by several people in my working life-time. Roger Feneley was working on the problem until the day he died and I agree with Roger Kirby that he had a particularly nice obituary in the Times.

    For the present, we have to work with the tools available, but, as this chain shows, we need to be much more efficient and imaginative.

    August 14, 2018 Reply

Your Comment

All comments are moderated. Trends in Urology & Men’s Health reserves the right not to publish material we deem inappropriate.

Web design and marketing agency Leamington Spa