Catheter Removal (Urinary)

Where a urinary catheter has been deemed clinically necessary, the underlying principle of continuing care is that daily assessment and review is undertaken and it should be removed as soon as possible (Loveday et al. 2014, National Institute for Health and Care Excellence (NICE) 2017). The Royal College of Nursing (RCN) (2019) guidelines indicate that a urinary catheter and drainage system are likely to become colonised with bacteria within 48 h and the longer it remains in place the greater the risk. The longer the catheter is in place; the more likely it is that the patient will develop a catheter-associated urinary tract infection (CAUTI) (NICE 2014). The effective strategy for prevention of CAUTI is early removal of urinary catheters (Tyson 2020).

Careful planning is needed when the decision is taken to remove a urinary catheter. The clinical goal is that its removal is permanent and the patient will return to normal, unassisted voiding. The term used for the process is trial without catheter (TWOC). The overall aim of TWOC is to determine if the patient is able to effectively empty the bladder (pass urine) again.

Prior to TWOC, the patient should be encouraged to drink normally (1.5–2.0 L in 24h) as too much fluid or over-consumption may compromise the functioning of the bladder (RCN 2019). It is important also that assessment be undertaken to reduce the risk of an unsuccessful TWOC. Factors to be considered include:

  • The patient’s medical status, e.g. presence of a large urogenital prolapse, enlarged prostate.

  • Their catheter history, such as indiction and how long it has been in situ.

  • Previous failed TWOC.

  • Regular bowel habit/no constipation (Maung & Singh 2019).

  • The patient's ability to consent and cooperate.

  • The patient's mobility and dexterity and ability to get to a toilet or bathroom.

In addition, an appropriate time of day must be chosen for catheter removal. Catheters are usually removed first thing in the morning so that any problems that may arise can be dealt with during the day. In some cases, however, an alternative time might be chosen; for example, in patients who have nocturnal polyuria (urinary frequency at night) it may be beneficial to remove the catheter at night (RCN 2019). 

Preparation and safety

  • Explain the procedure to the patient and inform them of potential post-catheter symptoms, such as urinary frequency, urgency of urination, and discomfort, to gain consent and cooperation.

  • Ensure the patient’s privacy and dignity are maintained throughout.

  • Perform hand hygiene and put on a disposable apron and non-sterile gloves. Personal protective equipment should be worn where necessary.

  • Empty the urine drainage bag prior to removal as this will mean that the catheter can be removed without disconnecting it from the bag. Ensure support systems such as leg straps and catheter securement device are removed where applicable.

  • If required, prior to removal of the catheter obtain a catheter specimen of urine (CSU) for laboratory analysis in order to determine if infection is present and if there is a need for antibiotic therapy.

Procedure

  1. Take the equipment to the bedside. Rationale – The trolley or tray provides the working area for undertaking the procedure.

  2. Turn back the bedclothes and if necessary help the patient into a supine position and if possible with knees and hips flexed and slightly apart (in women). Rationale – The supine position enables greater visibility.

  3. Position the clinical waste bag for easy access. Rationale – Having the clinical waste bag nearby facilitates easy disposal of the urinary catheter and reduces the risk of environmental contamination.

  4. Place the disposable pad under the patient's pelvis and have the receiver ready to place between the patient’s thighs to capture any leakage from the catheter. Rationale – The disposable pad prevents leakage of urine onto the bedclothes. The receiver acts as a container for the urinary catheter.

  5. Clean the urethral meatus using gauze soaked in 0.9% sodium chloride and always swabbing away from the urethral opening. Note: in women, clean away from urethra towards the vagina/perineum. Rationale – To reduce risk of infection. Also in women, to help reduce the risk of bacteria from the vagina and perineum contaminating the urethra (Yates 2017).

  6. Check the volume of water in the balloon. This should be written on the catheter or on the catheter sticker placed in patient’s healthcare record. This is usually 10 mL.  Rationale – It is important to confirm how much water is in the balloon to ensure that it is all removed before catheter removal.

  7. Open the syringe and attach the syringe to the inflation port on the catheter and allow water to drain out of the balloon naturally. Rationale – Avoid pulling on the syringe as this may create a vacuum and cause the balloon to cuff making removal of the catheter difficult (RCN 2019).  Make sure you have withdrawn the full amount from the balloon. Rationale – Incomplete deflation of the balloon can cause urethral trauma and pain and discomfort for the patient during removal. 

  8. Catheter removal should not proceed if the full amount of water cannot be withdrawn, and medical advice should be sought. Place the receiver between the patient’s legs and gently but firmly withdraw the catheter into the receiver. Rationale – The catheter should be withdrawn slowly and gently in order to reduce the trauma to the urethra caused by the creases and ridges in the balloon. Rotating the catheter as it is slowly withdrawn may also make removal easier.

  9. Detach the catheter from the drainage bag and hook the tubing over the top of the stand to prevent it touching the floor.
     Rationale – The tubing and the bag should not touch the floor, as this would be an infection risk.

  10. Check the catheter tip and balloon for completeness. Rationale – Seek medical help if any of these is missing as catheter remnant in the bladder will be a source of infection. 

  11. Place the catheter and receiver into the clinical waste and remove the absorbent pad. Rationale – Correct disposal of clinical waste prevents environmental contamination.

  12. Clean meatus (male) using gauze soaked in 0.9% sodium chloride and make the patient comfortable. Female: clean area around the genitalia and make the patient comfortable. Rationale – To maintain patient comfort and dignity. 

  13. Cover the patient. Rationale – To maintain patient dignity and promote comfort.

  14. Take the clinical waste and catheter bag to the sluice room for measuring and disposal. Rationale – To ensure correct disposal of clinical waste thus reducing the risk of contamination. Urine output should be measured to ensure an accurate record of output is maintained.

  15. Remove gloves and apron and perform hand hygiene.

Ongoing care, monitoring and support

  • Assist the patient into a comfortable position and ensure a urinal or commode is nearby or that the patient has easy access to a toilet.

  • The patient may well experience feelings of wanting to pass urine following removal of the catheter.

  • Advise the patient regarding the possibility of frequency, urgency, hesitancy, haematuria (blood in the urine, which may be a result of trauma following catheter removal), dysuria (pain when passing urine owing to inflammation of the urethra), feeling as though they have full bladder (retention) but cannot void, and the need to report any incidence.

  • Bladder scan should be performed after first and second void to assess post void residual volume (Bardsley 2020).

  • Should the patient show signs and symptoms of urinary retention a bladder ultrasound should be performed (Loveday et al. 2014, RCN 2019).

  • Male patients should be discouraged from placing a urinal in position ‘just in case’, as this may encourage frequent small volumes to be passed, or ‘dribbling’. A fluid chart may be required for the first 24 h.

  • Monitor fluid intake and urine output for 24 hours after the catheter is removal or until the patient is passing urine normally (Tyson 2020).

  • If the patient’s condition allows, advise them to increase oral fluid intake (2–2.5 L in 24 h) and ensure they have access to oral fluids.

  • Ask the patient to inform the nurse when urine is passed (micturition).

Documentation and reporting

  • Record the amount of urine in the urine drainage bag on the fluid balance chart.

  • Document the time of catheter removal and when the patient subsequently passes urine.

  • The RCN (2019) catheter care guidelines recommend that detailed documentation should accompany catheter removal to include:

    • the length of time the catheter was in situ

    • if the balloon deflated properly and the catheter tip and balloon were intact on removal

    • if encrustation was evident

    • if the part of the catheter that was in the bladder was clean or dirty, or if there was evidence of debris

    • if the removal was painful and if there was any blood present

    • any inflammation or discharge in the meatus should be reported and urine should be observed for signs of infection (e.g., cloudy, debris, colour, smell).

Equipment

  • Non-sterile gloves and disposable apron.

  • Clean trolley or tray.

  • Sachet of 0.9% sodium chloride.

  • Syringe to remove the water from the balloon. The size of syringe required will depend on the amount of water in the catheter balloon; 10 mL is the usual volume. This is written on the catheter and catheter sticker placed in patient’s healthcare record.

  • Large disposable absorbent pad.

  • Receiver.

  • Clinical waste bag for disposal of the catheter and receiver.