Urinary catheterisation carries a high risk of urinary tract infection (UTI) and is one of the leading causes of hospital-acquired UTIs. Studies indicate that over 80% of hospital-acquired UTIs can be traced to indwelling urinary catheters.

Urinary catheters:

• provide micro-organisms with a route of entry into the normally sterile bladder
• prevent the normal flushing action of urine
• act as a foreign body, irritating the mucosa and providing a focus for bacterial growth.

There is a direct relationship between the method and duration of catheter use and the risk of infection. Long-term indwelling catheterisation is generally associated with a higher infection rate than short-term, intermittent or condom catheterisation. Infection risk is also associated with the quality of catheter care and host susceptibility.

Causes of infection associated with urinary catheterisation include:

• poor aseptic technique during catheter insertion causing peri-urethral flora to be inserted into the bladder
• migration of bacteria along the outer surface of the catheter
• open drainage
• breaks in closed drainage systems.

National evidence-based guidelines provide recommendations for preventing infections associated with the insertion and maintenance of urinary catheters. The epic guidelines cover short-term indwelling urinary catheters in acute care, and the NICE guidelines cover long-term urinary catheters in primary and community care. A Scottish best practice statement on urinary catheterisation and catheter care is also available.

In summary, these guidelines make the following recommendations regarding urinary catheter insertion:

• urinary catheters must be inserted by trained healthcare workers, using sterile equipment and an aseptic technique
• clean the urethral meatus prior to catheter insertion. The epic guidelines state that there is no advantage in using antiseptic preparations for cleansing the urethral meatus prior to inserting a catheter
• apply an appropriate sterile lubricant (from a single-use container) to minimise urethral trauma and infection
• connect the indwelling catheter to a sterile, closed urinary drainage system
• document the insertion of the catheter in the patient’s records.

Other important recommendations include:

• prepare necessary equipment and supplies, and explain the procedure to the patient before you begin
• ensure that there is adequate lighting, particularly when catheterising women. Inadequate lighting can result in the catheter inadvertently touching the surrounding area or being placed in the vagina. If this occurs, leave the catheter in place to avoid repeating this, change your gloves and use a new catheter
• following male catheterisation, make sure that the foreskin is returned to its original position
• secure the catheter and drainage system in a comfortable position for the patient, to prevent movement and urethral traction and ensure good bladder drainage.

Always follow the manufacturer's instructions and adhere to local procedures and policies.

Only use indwelling urethral catheters after considering alternative methods of management. The choice of catheter will depend on clinical experience, patient assessment, patient predisposition to blockage, anticipated duration of catheterisation and local policy.

Select the smallest catheter gauge that will allow free urinary outflow (usually 12 to 14 Ch, for urethral catheters, 16 Ch for suprapubic catheters). Generally, use a catheter with a 10ml balloon for an adult and a 3 to 5ml balloon for a child. Balloons must be filled with sterile water. Studies indicate that silver alloy coated catheters may be associated with a lower incidence of bacteruria than catheters coated with silicone, hydrogel or latex. It is now recommended that appropriate use of silver alloy coated catheters are considered when choosing the most appropriate catheter for patients. Be aware that there is a risk of incomplete deflation of the balloon when removing some silicone Foley catheters, resulting in discomfort and injury, particularly when used suprapubically. Refer to the MHRA Medical Device Warnings for further information about this. Always ensure that the catheter chosen is suitable for the intended use and follow the manufacturer’s instructions.

Use an appropriate sterile lubricant (from a single-use container) to minimise urethral trauma and infection. Use a catheter valve as an alternative to a catheter drainage bag in appropriate patients (e.g. dextrous patients).

Drainage receptacles should be either disposable (such as disposable urinals/jugs) or decontaminated in-between uses by returning jugs to Sterile Services Department. Clean, non-sterile gloves should be worn and hands decontaminated before and after emptying urinary drainage bags. Always follow the manufacturer’s instructions and adhere to local procedures and policies.

Select personal protective equipment, such as aprons and gloves, following assessment of the level of risk associated with the catheterisation.

Remove the catheter using a clean technique. Dispose of the catheter and catheter bag according to local procedures. For more information on disposal of urinary catheters and catheter bags, refer to the Decontamination module.

Always follow the manufacturer’s instructions and adhere to local procedures and policies.

Effective hand decontamination is vital to control the spread of infections. Choose an appropriate method of hand decontamination for the procedure, according to your local policy. Refer to Hand Decontamination for further guidance.

The Department of Health has published the ‘essential steps to safe, clean care’. This is a delivery programme which aims to reduce healthcare associated infections, including MRSA. The ‘essential steps’ programme provides tools and guidance to support different organisations and settings, including residential and nursing homes, as they work towards reducing and eradicating healthcare associated infections. Click here for more information on the ‘essential steps’ programme.

As part of the ‘essential steps to safe, clean care’ programme, the Department of Health has launched a specific step relating to urinary catheter care. The aim of this document is to reduce the risk of infection associated with urinary catheters. Please click here for further information.

As part of the same series, the Department of Health has also launched a specific step relating to preventing the spread of infection. The aim of this document is to reduce the risk of microbial contamination in everyday practice and to ensure there is a managed environment that minimises the risk of infection to patients, clients, staff and visitor. Please click here for further information.