intermittent catheter, where the catheter is temporarily inserted into the bladder and removed once the bladder is empty
indwelling catheter, which stays in place for many days or weeks
An indwelling catheter, such as a Foley catheter, can be used to collect urine for the short or long term. It can be attached to a drainage bag or to a valve that can be opened to allow urine to flow out. Near its tip, the Foley catheter has a small balloon that can be inflated with sterile water after it has been inserted into the bladder. When inflated, the balloon keeps the catheter securely in place. When the catheter needs to be removed, the balloon is deflated. To prevent complications from infection, the catheter is regularly exchanged for a new one from 3 to 12 weeks.
The development of an indwelling catheter that was retained in the bladder presented quite a challenge. And originally they were using catheters with balloons attached to them, balloons that were used from the small intestine of animals.
But it wasn’t until Doctor Foley in the 1930’s developed his catheter which he called “The finally perfected catheter.” It was made from latex and it was retained in the bladder with a balloon. A balloon that in fact he designed as a haemostatic balloon when he was performing prostate surgery. And he would blow the balloon up in the prostate cavity in order to stop the bleeding.
But his then developed into an indwelling catheter. And this is the example of the Foley catheter which he designed and this was introduced in 1937. And it really has not in fact altered in design apart from the materials which are being used. He described the all-latex catheter, well of course latex is now, is not used as a pure bio material because you can get quite severe latex allergies.
The Foley catheter is retained in the bladder by means of a balloon and this is filled with 5 to 10 millilitres of sterile water. Attached here with a side arm and a balloon is distended, and that is what retains the catheter in the bladder. The problem here is that the eye holes are at the tip of the catheter at the top here, and the balloon will be at the base of the bladder. So inevitably it’s leaving a little pool of residual urine in the bladder. Now the bladder also has a tip which can damage that mucin coating within the bladder. And we are concerned that that is maybe one of the causes for the high instance of infections that develop with this catheter.
What other materials are used to make catheters these days?
A wide variety of materials have been used. Silicone has been popular. Silicone tends to be a little bit stronger than the plastic catheters and the advantage is that you have a thinner wall and a wider lumen to the catheter itself.
There have been many attempts in recent years to find a coating which is anti-bacterial, and silver alloy has been used. But the results so far have not shown any convincing advantages of these more expensive catheters. But people have been seeking for a long time better materials for catheters.
An indwelling catheter can be inserted into the bladder in two ways:
through the urethra, the tube that carries urine from the bladder to the outside of the body. This is called urethral catheterisation
Urethral catheters and suprapubic catheters differ only in how they are inserted into the bladder.
Urethral catheters come in several basic designs. The relative size or diameter of a Foley catheter is described using the French gauge (F). The smallest size allowing effective drainage should be used as larger ones are more likely to cause trauma. However, where there is infection or postoperative bleeding, a larger size minimises the risk of obstruction.
The size of the catheter that is used to drain the bladder is an important aspect of bladder drainage. Over the past few years, we have turned to using much smaller diameter catheters than we did 20, 30 years ago. The urethra, for example, which is the conduit that leads from the bladder to the exterior, that collapses really rather like a fireman’s hose. But we put in a big tube which keeps it distended and affects its blood supply.
We want something that will allow the urethra to collapse and not remain distended. I think we should be using quite small diameter catheters. The catheter gauge is what we term the French gauge. Now that the French gauge 12 catheter, that’s the circumference of the catheter. That means the diameter is about ? of that, is about 4 millimetres. And we should be using those smaller diameters. When I was a medical student we were using catheters of sort of 24 or even 26 French gauge, so they were much wider and much more damaging than these smaller catheters.
Urethral catheters are usually made of silicone rubber or natural rubber. Sara, who has had a urethral catheter since 1999, said she preferred the silicone ones. Martin, who had a spinal cord injury, was allergic to latex catheters and said they gave him bladder spasms and brought on autonomic dysreflexia. This is a potentially life threatening condition that occurs when the blood pressure in a person with a spinal cord injury above T5-6 becomes excessively high.
Carol was a chartered accountant before she retired due to ill health. She is single. Ethnic background/nationality: White British.
You say you think your catheter is made of silicone?
Have you ever had any choice about what sort of catheter?
No. I’ve never had a choice. But I have sometimes asked for it to be changed because it had been uncomfortable. Some of them seem to be harder and the softer ones I think are much easier.
Do you have a choice of how big it is? Do they come in different…?
They do come in different widths. I have had some issues on widths because after surgery, if there’s going to be a lot of blood or sort of clots coming down, that sounds really awful, then they try and put a wider one in, but they’re difficult to have longer term.
Not so comfortable?
They’re not as comfortable, so you need a narrower one. But then they block easily if you’ve got clots coming down.
Sometimes do you go back and ask for a smaller one?
Yes. I have had smaller ones put in before.
What’s the ideal width for you?
I think I have 12 or 14. But you can get smaller ones.
An indwelling catheter is used long-term when all other types of treatment have failed. When Peter had a car accident and became paralysed, he used a condom catheter for over 30 years. After several infections and urinary retention, though, he was fitted with a urethral catheter. He felt that he wasn’t given any other options or alternatives. Martin also had a condom catheter first and then a urethral.
Peter manages the 21st Century Catheter Project website and is single. Ethnic background/nationality: White British.
I had, this is a recurring theme, I had another quite big period of stress in my business life because I have, although I’m in a wheelchair, I have worked all my life more or less, not immediately after the accident but very quickly afterwards. And, as a result, I found I wasn’t passing water during the day. I was passing water at night, fairly filthy looking stuff, but I wasn’t passing it during the day which was yeah, is bizarre.
So I went to my GP and it actually took nine months to refer this to a consultant at the local hospital, which was too long and I was feeling pretty groggy by the time the catheter went in. The approach I take with all general hospitals is that get in and get out as soon as you can, for all sorts of reasons.
The first consultation with the first consultant I met at the interview, before I went into hospital, although I went in within two or three days, was that I’d got one option. There was no choice. It was simply a urethral catheter. I was unhappy about that really and wondered if, you know, what’s the problem? Why can’t I have something else after all the choices there were. I haven’t done my Googling and so I wasn’t aware of various choices. Which I wish I had.
Age at interview:
Martin is single and lives with a full-time carer. Ethnic background/nationality: White British.
Well first of all it was a condom catheter. Well it’s not a catheter is it, it’s a condom, Conveen.
They weren’t even around then, but these were made up by the hospital and you bought all the bits. And then after time, like I said, the catheter, it’s always been the same 16 and long term. In the last ten, twelve years I’ve gone over to Bard Hydro-elastic I think, size 16, 10ml balloon. And they seem very good. I’m allergic to latex I found, the coating. I go into autonomic dysreflexia, do you know about that?
I go into dysreflexia and also I get loads of spasms, so that’s a no-no.
Is that a urethral catheter or suprapubic?
Urethral. I did try a suprapubic for about eight months, and it never ever, I know it doesn’t heal up, but it smelled and just didn’t work as well as I thought what it did. So we gave it eight months and then took it out and put the old one in.
Carol, who was diagnosed with endometriosis in 2003, has erratic bladder function and occasionally uses a catheter. After several operations, she had a urethral catheter because of a perforated bladder. Sometimes she has to self catheterise because of urinary retention. The longest she had a urethral catheter was for 4 months.
Carol was a chartered accountant before she retired due to ill health. She is single. Ethnic background/nationality: White British.
How many times have you had to have a catheter put in and then left for a few weeks?
It has been, I think five times. Sorry let me just think back. Its 2005, 2006 I just had one for a few days, so that wasn’t so bad. Actually in 2008 I ended up having an operation, a normal laparoscopy and they didn’t do anything to my bladder because he saw that the endometriosis was on the ureter and it was too dangerous to operate without a urologist, so I had one then. And then I one in 2009, 2010 and 2011. So that’s been five.
Five episodes of having a catheter. Of increasing length unfortunately.
Yes. What’s the longest you’ve had a catheter do you think?
Four months in 2010.
And that was purely because they didn’t realise that I had this perforating bladder, and it was so thin it didn’t heal. And they’d take the catheter out, and it would be okay for a few hours and then it would perforate again. And I was in hospital and they’d just re-catheterise me. So it was sort of in and out for four months, I think it was four months.
I have to do intermittent self-catheterisation now, and that’s actually quite straightforward. Although when I first started to learn that I thought it was quite difficult. But I’ve since discovered there are better products so actually the knowledge of the products I’ve found quite difficult. You have to sort of ask around about the products. And I think that’s one of the things on the urinary, the indwelling catheters that I found' you’re not offered any choice, and there are apparently choices out there.
I think, although they hadn’t anticipated for me that I was going to have them for four months, having some sort of dialogue on what you like wearing and what might be the most suitable product for you, would be good. And because I’ve only had a urethral catheter as well I think knowing that, you know I’ve had them for periods of time, maybe the other sort, the suprapubic might have worked better. But then it’s difficult to know when they didn’t really know how long I’d be left with a catheter.
Some people we interviewed had a spinal injury and were fitted with a urethral catheter when they were first injured.
Melanie is a journalist. She is married and has one child. Ethnic background/nationality: White British.
When I had the urethral catheter, it was at that stage I was still so in shock from my total paralysis that I had no awareness of what was happening. I had no concept of my own body. I had lost my own body. At the time, I was wearing a body brace and a neck brace. I could hardly sit up.
I knew I had a bag strapped to my leg but I wasn’t even sure where everything was coming out. You know, it was all somebody else’s responsibility. I didn’t even realise I had to go and get my bag emptied ‘cos I could hardly reach down and feel my bag at that stage.
So the urethral catheter was, it was something that happened when I wasn’t at all in contact with my own body.
Age at interview:
Vicky is single and lives with a full-time carer. She is a trustee of two charities. Ethnic background/nationality: White British.
Life before my injury was quite active. I worked as a marketing development manager and worked long hours, but also had quite a few pastimes that were very adventurous and outdoorsy. I used to mountain bike and climb and sky dive and did a lot of running. So I think it was quite an active busy life to say the least.
When I was 31, I jumped out of an aeroplane. I’d done it three hundredish times before, but just had a fast landing. I was in Spain at the time for a long weekend and just had a fast landing. Nothing dramatic happened but I landed on my feet but fell over and couldn’t get up. So I had a horrible feeling that I’d managed to break something important and paralyse myself, and sadly was right.
I was two and a half weeks in intensive care in Spain before I came back to the UK. So during that time I was catheterised urethrally, which I had no idea about. There was a fair amount of morphine going on and how aware I was, looking back, I don’t think I was particularly aware of a lot of things.
When I came back to the UK after my two and a half weeks, it was only then that I was told that I had indeed paralysed myself permanently. And that I wouldn’t be able to walk again or be able to use my hands. So I broke my C5 vertebrae, which makes me paralysed from the shoulders down, and half my arms work but my hands don’t.
Some of the people we talked to got on well with a urethral catheter and didn’t see the need to change to any other type. Gordon, aged 96, was offered a suprapubic catheter but did not want an operation at his age. Sara, a woman with multiple sclerosis, was also quite happy with her urethral catheter. She said that she didn’t even notice her catheter even though she had to sit in her wheelchair.
Rob is a Chartered Electrical Engineer who was forced into retirement by his illness. He is married and has six children. Ethnic background/nationality: White British.
The urethral catheter obviously comes out of the penis; it’s put into the penis.
The suprapubic one is inserted through the stomach wall; did they ever have that discussion with you?
I have had that discussion once with the rehab specialist and he did discuss it as a possibility. But at that time, this was quite early on, a couple of years ago in my post rehab era. I go back to rehab once every six months or once a year now just to have a check-up and a discussion of how I’m getting on and so forth. And he did discuss these alternative concepts but, in fact I mean I don’t see a reason to change…..
I don’t think anybody had ever suggested it since and I have, I mean I’ve learnt to live with what I’ve got. I’m a little lacking in enthusiasm for further experimentation.
Other people we interviewed, though, had had problems with a urethral catheter. Kenneth was concerned because the balloon had burst on several occasions.
Kenneth was an engineer and surveyor before he retired. He is married and he has two grown up children. Ethnic background/nationality: White British
So you had a urethral catheter put in. Can you tell me what it was like to have a catheter? What was it like living with a catheter?
Dreadful. I hated every moment of it. I hated it when it went in. Sometimes the thing, the bulb that held it in would burst, so it would come out. It could come out when you were in the bed. It could come out when you were out walking.
And of course having it replaced, if you had somebody that was good at it, it was fine. But if you had somebody that wasn’t good at it, that again was another horrible time. I didn’t like it at all.
I didn’t realise it could, the little balloon could burst and it could come out.
Yes, unfortunately that happened to me, I think I can remember three times, once when I was out and twice when I was in bed.
That must have been awful.
It’s quite embarrassing, especially when you’re out.
Faye first became ill in 2007 and found it impossible to pass urine. She used an intermittent catheter until 2009 and then a urethral catheter for a while. She now has a suprapubic catheter because her body kept expelling the urethral catheter.
Faye was a health care assistant before she had to stop work due to ill health. She is single. Ethnic background/nationality: White British.
You say that you kept expelling it, it kept coming out?
Did they have any explanation for that?
They just said my bladder’s too unstable. It’s too overactive.
Overactive? Oh right. And what happened after that?
That went on for about, I’m not sure, maybe six months. It was coming out every day to every three days. I kept having to have it re-done until eventually the nurses got fed up of coming. So they arranged with the urologist for me to have a suprapubic catheter in.
When you had the urethral one, did they blow up a little balloon with water to try and keep it in position?
It still came out?
Yeah, it hurt.
Jennifer, who had Fowler’s Syndrome, had many urinary tract infections (UTIs). At the age of 19, she could not pass urine. At first she tried self catheterisation and then a urethral catheter. She had bladder spasms, blockages and bleeding with it. She later had sacral nerve stimulation, a procedure where electrical currents are used to reset the faulty nerves causing bladder dysfunction. Jennifer found that she could pass urine again normally afterwards but then her body rejected the battery. She then had to have a suprapubic catheter inserted.
Jennifer is a secretary. She is single. Nationality/Ethnic background: White British.
Personally, at first it [urethral catheter] was fine, didn’t have any problems. But then the more active I got, the more problems I had. My bladder really didn’t like it.
By active do you mean physical activity?
Just walking around, running up flights of stairs, anything you’d do on a day to day. I didn’t go running marathons but I did what a normal 19, 20 year old, 21 year old would do. But, no, my bladder really wasn’t happy with it. My bladder was, the bladder spasms were quite horrendous from it.
They’d suddenly come on during the day?
Yeah. During the day, during the night. It used to block quite a lot, my catheter, ‘cos my bladder was squeezing it so hard that it wouldn’t drain properly. Further on down the line when I had my urethral catheter the balloon used to, obviously that’s inflated to keep it in. The bladder was rubbing the side of the bladder wall and was just making it bleed, so it became totally impractical to have a urethral catheter really at that stage because I was having all these problems with it.I went back to my local hospital who discussed about putting a suprapubic catheter into me. So a catheter through my stomach, through my abdomen but lower down. And straight into my bladder.
And what sort of discussion did you have? Were you well informed about the advantages and disadvantages?
I think I was well informed. I was well informed in the fact that it would be an easy way to empty my bladder. My bladder wouldn’t be able to push it out. It wouldn’t hurt to walk as much anymore, and that thing.
What I really didn’t expect was how bad the bladder spasms would be and how painful it was afterwards. And how long it took really to get into a routine with it. It took a good six to eight weeks after having it done.
Maybe it was just me but I was under the impression when my consultant discussed it with me that having a urethral catheter can just be done in an out-patients, it seemed dead quick, ten minute job. That’s the end of it. Suprapubic catheter, he said, “Yes, oh it’s alright. Yeah we do it in theatre so you’ll be asleep. You’ll have a little wound on your stomach, that’s it, and a bit of a tube coming out. Not a big deal.” So he really played the whole situation down, maybe for my benefit I don’t know, but I was really not prepared for the way it was.
Jade, a 22-year-old with Fowler’s Syndrome, had a suprapubic catheter for a number of years. She then had it removed and started intermittent self catheterisation. When she became pregnant, though, that became harder because of the position of the baby. She was given a urethral catheter at 27 weeks. The last few weeks of pregnancy were very difficult because Jade had constant urine infections, and her body often expelled the catheter. She had to have a caesarean at 36 weeks because of the catheter problems and bladder infections, which couldn’t be treated properly while she was pregnant. As soon as the baby was born, she had the urethral catheter removed and went back to self catheterising again.
Jade is a student mental health nurse. She is single, and has a baby and is on maternity leave. Nationality/ethnic background: White British.
Where the baby was moving, the catheter was being forced out with the balloon fully inflated still. So it was expelling catheters constantly, more than once a day. So then my urethra was bleeding, everything was dreadful. But they had to put something in because otherwise I couldn’t go to the toilet. But as soon as I stood up the catheter was coming straight out fully inflated. And it was awful.
They tried numerous things. They tried to put the catheter, urethral catheter in without inflating the balloon, and taping it to my leg and to me to try and see if that would help. Which this one doctor thought was a great idea. But I knew as soon as I stood up it would come out. Which indeed it did.
It must have been so painful.
It was, it was bad. And they said to me, “Just lie down.” But obviously you can’t just lie down, like you can’t. So I increasingly struggled. The baby then started getting distressed, so they told me that there was no way I could have a natural birth and I’d have to have a Caesarean early.
Was that because of the baby or was that, that wasn’t connected with the urethral?
No, that was because of the urethral catheter.
There’s definitely no catheter designed for pregnancy. Because usually if people have catheters in pregnancy it’s just when they’ve had an epidural, when they’re giving birth, isn’t it? It’s not day to day, having to carry on your pregnancy weeks.
Have you got any ideas how they could improve it?
I’ve no idea. In the last like week of my pregnancy my consultant had a genius idea, which he said he didn’t know why no one else had thought of. So that when he put the catheter in, he did inflate the balloon and he physically put his hands in and forced the balloon above the baby’s head so that…Because obviously before, whoever was putting the catheter in constantly, they were just putting the balloon there. And the balloon was here and the baby’s head was here. So as soon as the baby moved the catheter was going bang,
So he put the catheter in and then pushed his fingers, and pushed it underneath the head, and that kept it in for about four days. So even though it was then still expelling it, four days compared to more than once a day, my bladder was getting a bit better.
Some people we spoke to with a spinal cord injury said they had a urethral catheter at first but later changed to a suprapubic. Dave became paralysed after a diving accident in Portugal in 2005. He had a urethral catheter first but, when doctors realised that he would need a catheter long-term, they replaced it with a suprapubic. Because of his injury, Dave couldn’t feel the urethral catheter but said the suprapubic was less ‘intrusive’ (see ‘Indwelling catheters: suprapubic catheters’).
Annie, who had a spinal injury after a horse riding accident, said a urethral catheter was very uncomfortable if she sat on it without realising.
Annie is married and has 3 adult children. She is a retired nurse. Ethnic background/nationality: White British.
In the end It was my decision to do what I have done, which is go onto the free drainage. But the suprapubic catheter I’m really just, I really had to, I kept on being taken, starved and then taken to theatre. And then they wouldn’t have time on the operating list, you know that sort of thing. So I waited for ages to have it done. And it was an advance, even then it was an improvement, even then actually. When I was in hospital even, it was better.
Right, yes. What kind of improvements did you notice almost straightaway?
There was no longer the problem of sitting on the catheter and being uncomfortable, even though you didn’t know what it was that was hurting you, being uncomfortable. And the business at night of rolling on your catheter and things, that was not an issue any more once I had the suprapubic. Or pulling it without realising. ‘Cos without the sensation, it’s very easy to traumatise the surroundings of the catheter, can be quite traumatised without you being aware of it. That’s the trouble.
Roger had a spinal injury while on a cricket tour in India. He wasn’t aware when a urethral catheter had been inserted or of any infections. He was told that a suprapubic catheter would be better long-term.
Roger was a university lecturer before he retired. He is married. Ethnic background/nationality: White British.
I’d even forgotten at that stage that I had a urethral catheter because there was hardly any sensation. But a little sensation came back, as time went on. And I suddenly learned from the consultant that I was going to have what they called a ‘SPC’, which was a suprapubic catheter. And I did my best, although I was still feeling very weak and not breathing as satisfactorily as I might because my SATS were quite low, and I was liable to pass out if I sat up too straight in bed even.
I went through all sorts of funny palpitations and had odd feelings of losing consciousness or going in and out of consciousness. But I did have the strength to try to contest that transferring from the urethral catheter to a suprapubic catheter, as it was called.
The consultant said, “Oh no, no it’s standard procedure here. If you have your urethral catheter for too long it’s liable to infection. So we actually insert this new catheter into your bladder under local anaesthetic, or some modified form of local anaesthetic.” And a date was arranged for this and then I was transferred to the table.
Did you say that you’d tried to argue against having one?
Yes, because I didn’t like the thought of somebody planting something in my bladder forever. Because I anticipated the discomfort and the problems it might cause.
Why does the consultant think you’re more likely to get an infection through a catheter through the penis than a catheter through the abdominal wall?
I’m afraid you’ll have to ask him that because I don’t know. He said, “It is our policy to do this”, as if to say, “Well I don’t care if you agree or not really. And this is what we are going to do”.
So one day this was arranged, so I went down and the fellow from the bladder department, what do they call it now?
Yes, the urological man performed this operation.
Iain, a 35-year-old with multiple sclerosis, used an intermittent catheter for 5 years and then a urethral catheter for about 8 months. He changed to a suprapubic catheter, though, because he felt it would easier when having sex (see ‘Sex and intimate relationships’).
Iain is a married IT Officer. He works for the local council. Ethnic background/nationality: White British.
The pros were, I mean it [urethral catheter] was fine in respect it was always there. It was always draining through my bag, no problems. But because of the MS symptoms I get, the bladder spasms I experience, my bladder would more or less be that empty then close around the catheter eyelets and be still choking the bladder, wrapped around it and be unable to drain.
So I then would get bypassing around the urethra, around the catheter site, or around the catheter which was then, it led to the medication from my GP to try and relieve the bladder spasms I was experiencing. Which are very painful and not the most pleasant thing to undergo, and that seemed to help a lot with that.
But, over time, things changed and I lost a lot of sensation to do things and bit and pieces, but it was probably the best solution for me. So I spoke to my GP and tried to be re-referred back to the hospital Urology Department and they went down the suprapubic route instead. Which just seems a better, less infection-prone way of having an intermittent or a permanent catheter in situ, because it doesn’t get, it’s easier to keep it clean, the site etcetera clean and elsewhere. I was getting repeated infections with it urethrally.
Certainly a suprapubic catheter I found far preferable to the urethral in the fact that it causes much less pains probably I would say. For me it’s been the main point of view anyway. It’s much less painful because you don’t have a gigantic long tube going through your entire anatomy to get into your bladder. It’s being passed through my abdominal wall straight into my bladder. And it’s there and you don’t really know it’s there. You just get on with normal daily life.
Stewart, in contrast, had a suprapubic catheter first but had problems with it. It was a long time ago and, though he couldn’t remember the details, he recalled having a lot of leaking. He was later fitted with a urethral catheter.
Stewart is a retired teacher. He is widowed and has 2 adult sons. Ethnic background/Nationality: White British.
I’ve had a suprapubic, and I didn’t like that. It didn’t seem to be working for me. And I went onto the other one.
The other one. What kind of problems were you having with the suprapubic, because some people have mentioned that they did have problems with it?
Well there again I’m rather vague because I don’t remember, but I have a feeling that it was leaking. And that of course I found is one of the main problems with most of the catheters. No matter how careful you are, there’s a certain amount of leakage, and that can be rather unpleasant and….. But I have to wear pads, I have to wear a pad as well as the…
As the catheter?
As the catheter.
A few men were unsure which type of catheter they had. They said that it was inserted through their penis, which is a urethral catheter. Derek had a urethral catheter for 9 years but often bled a lot during catheter changes. Eventually he had laser surgery to his prostate, which had become enlarged, and is now catheter-free.
Derek is a retired fork lift truck driver. He is married and has 2 adult children. Ethnic background/nationality: White British.
Derek' I think it’s been more of a proper life change. It’s been a big thing. I mean when they said, “Do you want to be catheter free?” I just couldn’t believe it, you know, what do you have to do to be catheter free? Only an operation.
So it’s had a big impact on your life having the catheter and being free of it.
Derek' It’s had a big impact on my life for a few years now. For long enough, I could never, I couldn’t have a decent carry on because of the catheter always having to be there.
Yes. And I guess that also had an impact on you as well?
Wife' Yeah, yeah.
Derek' I don’t stop out of bed lately. I go to bed a bit earlier than what I’ve ever used to. I go to bed about nine, quarter past nine, and I can go through to the next morning, about 5 o’clock in the morning before I need to go to the toilet.
That’s good. So you get…
Derek' I’ve never done that, I’ve never done that for years.