Scientific review of intermittent vs indwelling catheterisation

Available clinical evidence supports the strategy to always consider intermittent catheterisation as the first therapeutic choice, before considering the use of an indwelling catheter. Intermittent catheterisation is the first therapeutic choice and is a safer bladder management method than both urethral and suprapubic indwelling catheters. Intermittent catheterisation can lead to reduced morbidity relating to renal failure and neurogenic bladder dysfunction.

Intermittent catheterisation is a type of continence management that allows normal bladder dynamics, and has very few contraindications.1 Indwelling catheters involve more invasive placement, either through the abdominal wall (suprapubic indwelling) or through the urethra (urethral indwelling),2-4 and has a constant in and out flow with potential to cause a static bladder. Catheter-associated urinary tract infection (UTI) is the most common complication of all catheterisation.1,3,5,6 The daily increase in UTI risk when using an indwelling catheter is approximately 5% and there is a 3-10% daily bacteriuria incidence.2,5,6,7

Intermittent catheters are reported to reduce the risk of infections as compared to indwelling catheters5,6,8-10 and a 20% reduction has been reported after just short-term post-operative use.11,12

Recent research suggests

a) that infection rates correlate with an occurrence of multidrug-resistant bacteria, 

b) that multidrug-resistant bacteria is more common among users of indwelling catheterisation (suprapubic 3.3% and urethral 2.6%) than intermittent catheterisation (0.7%).13

Other reported complications from catheterisation are trauma,1-3,14 catheter blockage2,14 and recurrent bladder stones.15-18 The last two are mainly applicable for indwelling catheters. It has also been proposed that the use of indwelling catheters can be associated with bladder cancer.2,19,20 Guidelines in the literature identify intermittent catheterisation as the first and preferred choice when possible, both for short and long-term bladder management, and it is recommended to completely avoid or minimise use and duration of indwelling catheters.e.g.5,6,8,10,21-25

The safety of suprapubic placement of an indwelling catheter is debated but recently it has been concluded that it is not superior to the urethral route3,4,8,26,27 and should only be considered for short-term use5,22 when intermittent catheterisation is not an option. Urological complications related to bladder management method have been studied by several authors and intermittent catheterisation has been found to reduce the risk of upper urinary tract deterioration, enable faster return to normal voiding, shorten hospital stay after surgery, and to improve the possibility of renal recovery.7,28-30 It furthermore reduces the risk of bladder stones by approximately 20 times compared with indwelling catheter use.3,15,16 In addition, intermittent catheterisation, when practiced on demand only, appears to be best practice for bladder management in more general areas, such as women in labour with epidural31 and management of post-operative urinary retention.32 It might also be one of the solutions to the problem with indwelling catheter misuse. Inappropriate use of indwelling catheters has been reported to lie somewhere between 24-62%.33

Although there is a consensus that intermittent catheterisation is a better treatment option than an indwelling catheter, it is sometimes still discarded due to the perception that it is an added burden for patients.34 

It has however been shown that intermittent catheterisation can be successfully taught to a very high proportion of patients (84%)34 and has a high reported preference among users (97-99%).11,35 Evidence suggests that patients given the chance would see the benefit, not the burden of intermittent catheter use.

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