Version May 2024
INTRODUCTION — Urinary bladder catheters are used for urinary drainage or as a means to collect urine for measurement. Many clinical situations are appropriate for the placement of indwelling urethral catheters (table 1), but too frequently they are used without proper indication or continued longer than needed [1]. Daily evaluation of the ongoing need for the indwelling catheters with removal when no longer indicated is essential to reduce complications.
This topic will discuss the complications associated with urinary bladder catheter use. The indications for placement, types, and management of urinary catheters are discussed in detail elsewhere. (See "Placement and management of urinary bladder catheters in adults".)
GENERAL COMPLICATIONS
Bacteriuria and urinary tract infection — The presence of bacteria in the urine is almost universal in patients with catheters in place for over one week. Rates vary depending upon the type of catheter and duration of use. The evaluation of bacteriuria and diagnosis of catheter-associated urinary tract infection is discussed in detail elsewhere. (See "Catheter-associated urinary tract infection in adults", section on 'Asymptomatic bacteriuria' and "Catheter-associated urinary tract infection in adults", section on 'Diagnosis'.)
Recurrent urinary tract infections as a result of chronic catheter use can lead to acute or chronic pyelonephritis or bladder cancer. (See "Epidemiology and risk factors of urothelial (transitional cell) carcinoma of the bladder" and "Non-urothelial bladder cancer".)
Epididymitis — Urethral instrumentation of any type can cause epididymitis, which may, rarely, disseminate to the testes as orchitis [2]. (See "Acute scrotal pain in adults".)
Retained balloon fragments — Spontaneous rupture of the urinary catheter balloon can occur. If the catheter spontaneously falls out, the integrity of the balloon should be examined carefully for any missing material. If balloon fragments cannot be located, cystoscopy should be performed to identify and remove fragments retained in the bladder as these have the potential to cause urethral obstruction [3,4].
Balloon rupture can occur spontaneously, but also from the attempt to bluntly rupture or overdistend a balloon that will not deflate; this practice is not advised. Sharp balloon puncture to manage a nondeflating balloon (ie, percutaneous spinal needle) was not found to be associated with retained balloon fragments in one experimental study [3]. (See "Placement and management of urinary bladder catheters in adults", section on 'Troubleshooting catheter removal'.)
Bladder fistula — The presence of air or feces in the urine of a patient with an indwelling catheter may indicate the formation of a fistula. Fistulas can occur between the bladder and small intestine, colon, rectum, or vagina (ie, enterovesical, colovesical, rectovesical, and vesicovaginal). They are an uncommon complication of indwelling bladder catheters and more likely to occur in the setting of prolonged catheterization with risk factors that include malignancy, inflammation, radiotherapy, or trauma [5].
Bladder perforation — Bladder perforation, both intraperitoneal and extraperitoneal, is rare but has been reported with long-term indwelling catheters [6-8]. Hematuria and abdominal pain may indicate acute perforation; free air is seen only with intraperitoneal perforation.
Bladder stone formation — Stones can form in the bladder due to the presence of a foreign body. Bacteria that are urea splitting (eg, Proteus mirabilis) are frequently associated with stone formation. The type of catheter may influence stone formation; however, there are no data to support the use of one catheter material (ie, latex, silicone) over another.
COMPLICATIONS SPECIFIC TO TYPE OF CATHETER
External catheters — Most complications related to condom catheter usage are due to improper or prolonged application and inadequate monitoring of the device when in place. Most complications are minor and self-limited; however, significant penile injury resulting in scarring and deformity can occur.
Patients with penile skin sensory loss (ie, spinal injury patients) are at the highest risk for more severe complications [9]. Instruction of the patient, relatives, and medical personnel on the proper application of the condom device is essential in preventing associated complications. (See "Placement and management of urinary bladder catheters in adults", section on 'External catheter placement'.)
Pressure effects — Skin depigmentation can occur but is more likely in patients with underlying dermatologic conditions.
Constrictive effects of the condom catheter's adhesive band or roller ring can lead to superficial ulceration. Reapplication exacerbates the ulcer and can prevent healing. The condom catheter should be temporarily discontinued and a catheter (intermittent or indwelling) used until the site is healed.
Prolonged continuous pressure of the penis from an improperly placed condom catheter can cause tissue ischemia, which may lead to penile and/or urethral necrosis. Treatment with surgical debridement is necessary to remove devitalized tissue, and reconstruction with skin grafts to the penis may be required.
Urethral catheters — Mechanical catheter problems such as leakage, catheter blockage, and catheter rejection are common and can frustrate and annoy both patient and clinician [10,11]. Knowledge of catheter technology and routine catheter care can help reduce mechanical problems. (See "Placement and management of urinary bladder catheters in adults", section on 'Catheter technology' and "Placement and management of urinary bladder catheters in adults", section on 'Catheter care'.)
Patient discomfort — Indwelling urethral catheters are invasive medical devices, which can cause significant complications. Although infectious complications of urethral catheters have been reported extensively, noninfectious complications are less studied.
In a multicenter prospective cohort study of 2076 adults with an indwelling urethral catheter, 57 percent reported at least one catheter-related complication, and noninfectious complications (55 percent) were five times as common as infectious complications (11 percent) [12]. In this study, noninfectious complications for participants whose catheters had been removed included "a sense of urgency or bladder spasms, blood in the urine, leaking urine, and difficulty with starting or stopping the urine stream." For those with a catheter still in place, noninfectious complications included "pain or discomfort, a sense of urgency or bladder spasms, blood in the urine, and trauma to the skin associated with catheter placement or securement."
Thus, in addition to avoiding catheter-associated urinary tract infection, efforts should also be made to reduce the noninfectious harms of urethral catheters and improve patient comfort. This is especially pertinent to males, who reported more noninfectious than infectious complications [12].
Effects of urethral trauma — Traumatic urethral catheter placement can lead to urethral injury (image 1). A systematic review found that the pooled percentage of patients who developed urethral stricture or erosion was 3.4 percent among seven high-quality studies [11]. The presence of pain and bleeding following attempted catheter insertion and subsequent inability to pass the catheter into the bladder suggest that a false urethral passage may have been created. Such injuries usually require significant reconstructive surgery.
Inflammation and infection of the periurethral soft tissues may create an abscess as a consequence of the creation of a false passage [13]. If the abscess is not visible on physical examination, diagnosis may be delayed and the infection can spread into surrounding tissues. Urethrocutaneous fistulas may result as the infection tracks to the skin. Fournier's gangrene has been reported as a consequence of urethral catheterization [14]. (See "Necrotizing soft tissue infections" and "Acute scrotal pain in adults".)
Stricture associated with urethral catheterization occurs almost exclusively in male patients [13]. Repeated urethral trauma from intermittent catheterization can cause urethral stricture formation, which in turn increases the likelihood of traumatic catheterization [15]. The incidence of urethral stricture increases with duration of chronic catheterization; most have developed following at least five years of intermittent catheterization [15,16].
Incontinence — Incontinence can occur due to catheterization and is also related to urethral sphincter dysfunction. (See "Female urinary incontinence: Evaluation".)
Suprapubic catheters — When performed properly, complications from suprapubic catheter placement are uncommon. Complications associated with initial placement include cutaneous or bladder bleeding and bowel injury, which is more common if suprapubic catheter placement is attempted when the bladder is not fully distended [17]. Bowel injury after a routine change of a suprapubic catheter has been reported [18].
Long-term complications include skin erosion and problems with chronic leakage.
PREVENTION OF COMPLICATIONS — Appropriate urinary catheter implementation and management can reduce the incidence of complications. The most effective strategies to reduce infectious complications of urinary catheters are avoidance of unnecessary catheterization and catheter removal when the catheter is no longer indicated. Adherence to a protocol for indwelling catheter placement, care, and removal can reduce the incidence of urinary tract infection and other complications [1,19].
Measures that help prevent complications associated with urinary catheters include:
●Use of urinary catheters only for appropriate indications (table 1). (See "Placement and management of urinary bladder catheters in adults", section on 'Indications for catheterization'.)
●Considering alternatives to indwelling urethral catheters. (See "Placement and management of urinary bladder catheters in adults", section on 'Choice of catheter'.)
●Provision of adequate training to medical staff, patients, and other caregivers on catheter placement and management. (See "Placement and management of urinary bladder catheters in adults".)
●Removal of catheters when no longer indicated. (See "Placement and management of urinary bladder catheters in adults", section on 'Catheter care'.)
●Not routinely replacing urethral catheters. (See "Placement and management of urinary bladder catheters in adults", section on 'Catheter care'.)
Specific measures to prevent catheter-associated urinary tract infection include:
●Using a continuously closed drainage system. (See "Placement and management of urinary bladder catheters in adults", section on 'Catheter technology'.)
●Not routinely irrigating catheters; catheters are irrigated only under select circumstances. (See "Placement and management of urinary bladder catheters in adults", section on 'Catheter care'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Urinary tract infections in adults" and "Society guideline links: Urinary catheters" and "Society guideline links: Genitourinary tract trauma in adults".)
SUMMARY AND RECOMMENDATIONS
●General complications – The most common complication of urinary bladder catheters is catheter-associated urinary tract infection. In males, urinary infection can lead to epididymitis or orchitis. Other rare complications of indwelling catheters include urinary tract obstruction from retained balloon fragments, bladder fistula, bladder perforation, or bladder stone formation. (See 'General complications' above.)
●Catheter-specific complications
•External catheters – Improper or prolonged application of condom catheters can cause pressure-related complications including skin depigmentation, ulceration, or penile necrosis. These complications are more frequent in patients with penile sensory loss and can be prevented with proper application of the device and frequent patient monitoring. (See 'External catheters' above.)
•Urethral catheters – The traumatic insertion of urethral catheters can create a false passage, which, if infected, may lead to periurethral abscess. This complication is more frequent in patients with prior urethral stricture and can result in significant soft tissue infection. (See 'Effects of urethral trauma' above.)
Long-term complications associated with chronic urethral catheters (indwelling or intermittent) include urethral stricture and incontinence. (See 'Urethral catheters' above.)
•Suprapubic catheters – When properly placed, complications from the placement of suprapubic catheters are uncommon. Inadvertent bowel injury can occur during percutaneous suprapubic catheter placement if the bladder is not fully distended or the needle is not visualized with cystoscopy when performing the procedure in patients with prior pelvic surgery. (See 'Suprapubic catheters' above.)
●Prevention of complications – The most effective strategy to reduce complications of urinary bladder catheters is the avoidance of unnecessary catheterization. When urinary bladder catheters are required, adequate training of the patient, hospital personnel, and caregivers is essential to avoid complications related to placement, to ensure proper care, and to promptly recognize and treat complications expeditiously when they do occur. (See 'Prevention of complications' above.)
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