Makindo Medical Notes

Urinary catheters (usually Foley catheters) are used to drain urine from the bladder when voiding is not possible or accurate urine measurement is needed. In older adults, catheterisation is common but carries high risks, so the indication must be clear and regularly reviewed.

• 🚨 Acute urinary retention: Common in elderly men (BPH, constipation, drugs, neurological causes).
• ⚖️ Chronic high-pressure retention: To protect kidneys in obstructive uropathy (e.g. hydronephrosis on ultrasound).
• 🧪 Monitoring: Accurate hourly urine output in acute illness (e.g. sepsis, shock, AKI).
• 🛏️ Wound/pressure sore care: Promote healing where incontinence worsens skin breakdown.
• 🧠 Palliative/end-of-life: To maximise dignity and reduce distress from frequent toileting.

🩺 Risks & Complications of Catheter Use

• 🦠 Infection: Catheter-associated UTI (CAUTI) risk ↑ 5–10% per day.
• 🔄 Colonisation: Long-term catheters almost always become bacteriuric.
• 💧 Blockage/encrustation: Common in long-term use (Proteus infection, alkaline urine).
• 🩸 Trauma: Urethral injury, bleeding, false passage.
• 😔 Psychosocial impact: Loss of dignity, body image issues, reduced mobility.

🛡️ Catheter Care Principles in Older Adults

• 🧼 Aseptic insertion: Sterile technique, appropriate size (usually 12–14Ch).
• 🔒 Closed drainage system: Prevents ascending infection.
• ⬇️ Positioning: Keep bag below bladder level; avoid kinks/tension.
• 🧴 Hygiene: Daily meatal cleaning with soap/water; no antiseptic needed.
• 🧾 Review: Document indication; review daily in hospital, at least every 3 months in community.
• ❌ No prophylactic antibiotics: Not recommended; only treat symptomatic infections.
• 🩸 Securement: Leg straps or fixation devices to prevent trauma.
• 💬 Dignity: Explain clearly, offer privacy, consider impact on quality of life.

🔀 Alternatives to Long-Term Indwelling Catheter

• 🖐️ Intermittent self-catheterisation (ISC): Preferred in suitable patients — lower infection risk, maintains independence.
• 🧍 Condom (sheath) catheters: Option in men with incontinence and intact penile anatomy.
• 🔄 Bladder training & continence services: Especially for urge/stress incontinence.
• 💊 Medication review: Treat reversible contributors (e.g. constipation, anticholinergics, BPH).

📊 Special Considerations in the Elderly

• 🧠 Dementia & delirium: Catheters may worsen confusion; high risk of pulling them out → avoid unless essential.
• 🚺 Elderly women: Catheterisation technically easier but infection risk high.
• 🧔 Elderly men: BPH common cause of retention; consider α-blocker (tamsulosin) before trial without catheter (TWOC).
• 🛏️ Care home residents: Catheter care protocols essential; review need regularly.
• ⚖️ Safeguarding & dignity: Avoid catheterisation for “nursing convenience” in institutions.

🧑‍⚕️ Clinical Scenarios

🔄 Trial Without Catheter (TWOC) – Overview

A TWOC = planned removal of a urinary catheter to assess whether a patient can pass urine spontaneously. It is especially relevant in elderly men with BPH-related acute retention, but also used after post-op retention or following reversible causes (e.g. constipation, drugs, delirium).

📋 Indications for TWOC

• ✅ Acute urinary retention treated with catheterisation (after stabilisation).
• ✅ Following reversible cause: constipation, UTI, medication (anticholinergics, opioids).
• ✅ Post-op retention after GA/spinal anaesthesia.
• ✅ Women with temporary bladder dysfunction after illness or immobility.

⛔ Contraindications / Delay TWOC

• 🚨 High-pressure chronic retention with hydronephrosis/AKI (keep catheter until specialist review).
• 🚨 Urethral trauma or suspected stricture (requires urology input).
• 🚨 Ongoing need for accurate urine output monitoring (e.g. critical illness).

🧑‍⚕️ How to Perform TWOC

1. 📅 Timing: Usually after 48–72 hours in men with AUR (allows bladder recovery + α-blocker to work).
2. 💊 Medication: Ensure α-blocker (e.g. tamsulosin 400 mcg OD) has been started at least 48h before in men with BPH unless significant postural hypotension.
3. 🧼 Preparation: Explain procedure, gain consent, check for UTI/haematuria.
4. 🚽 Catheter removal: Deflate balloon, remove catheter aseptically, document time.
5. 🕒 Monitoring:
   • Encourage oral fluids.
   • Observe voiding within 4–6h.
   • Perform bladder scan if no urine passed, or if symptomatic.

📊 Assessing Success

• Passes urine comfortably, without straining.
• Post-void residual (PVR) < 100 ml = successful (up to 200 ml may be acceptable in elderly if asymptomatic).
• No recurrent retention or significant symptoms.

❌ Failure of TWOC

• Unable to void within 4–6h.
• Severe lower abdominal pain + palpable bladder.
• PVR > 300–500 ml (depending on guideline).
• Recurrent retention symptoms (straining, dribbling, overflow).

👉 If TWOC fails: re-catheterise, continue α-blocker, arrange

📝 OSCE / Exam Pearls

• ❓ Q: "When should you catheterise?" → Only if essential (acute retention, accurate urine monitoring, pressure sore healing, end-of-life comfort).
• ⚠️ Always mention infection risk and daily review of need.
• 🚫 Never catheterise purely for staff convenience.
• 📋 In OSCEs: explain to patient, gain consent, use aseptic technique, secure catheter, document indication.

🧑‍⚕️ Case Examples — Role of Urinary Catheters in the Elderly

• Case 1 (Acute urinary retention): 🚨 An 82-year-old man with benign prostatic hyperplasia presents with painful inability to pass urine for 12 hours. Bladder scan shows >800 mL retention. A Foley catheter is inserted, immediately relieving discomfort. A trial without catheter (TWOC) is planned with initiation of an alpha-blocker. Teaching point: catheterisation is lifesaving in acute retention but should be removed as soon as feasible.
• Case 2 (Monitoring urine output in sepsis): 🧪 A 78-year-old woman with pneumonia and septic shock is admitted to ICU. She is catheterised to enable accurate hourly urine output measurement for fluid balance and AKI monitoring. The catheter is removed as soon as the patient stabilises to reduce infection risk. Teaching point: short-term catheterisation has an important role in acute illness but requires daily review.
• Case 3 (Long-term catheter use): ♿ A 90-year-old woman with advanced dementia and immobility develops recurrent pressure ulcers worsened by incontinence. After MDT discussion, a long-term indwelling catheter is placed to improve skin integrity and comfort. She is placed on a catheter care pathway with regular monitoring for infection and blockage. Teaching point: long-term catheters are a last resort, used only for symptom control when other continence strategies fail.