Foley catheter explained

In urology, a Foley catheter is one of many types of urinary catheters (UC). The Foley UC was named after Frederic Foley, who produced the original design in 1929. Foleys are indwelling UC, often referred to as an IDCs (sometimes IDUCs). This differs from in/out catheters (with only a single tube and no valves, designed to go into the bladder, drain it, and come straight back out). The UC is a flexible tube if it is indwelling and stays put, or rigid (glass (very rarely) or rigid plastic(usually)) if it is in/out, that a clinician, or the client themselves, often in the case of in/out UC, passes it through the urethra and into the bladder to drain urine.

Foley and similar brand catheters usually have two separated channels, or lumina (or lumen), running down its length. One lumen, opens at both ends, drains urine into a collection bag. The other has a valve on the outside end and connects to a balloon at the inside tip. The balloon is inflated with sterile water or saline while inside the bladder to prevent it from slipping out. Manufacturers usually produce Foley catheters using silicone or coated natural latex. Coatings include polytetrafluoroethylene, hydrogel, or a silicone elastomer – the different properties of these surface coatings determine whether the catheter is suitable for 28-day or 3-month indwelling duration. A third type of UC has three lumens for using for bladder washouts post prostate surgery: one lumen is for urine flow out, one lumen is for saline flow in (bladder washouts solution), and the third is for the balloon to be inflated.

Indwelling catheters/IDCs should be used only when indicated, as use increases the risk of catheter-associated urinary tract infection (UTI) and other adverse effects.^[1] While female sex is generally recognised as a risk factor for UTIs, the differences in biological sex are reduced while carrying catheters.^[2]

History

The name comes from the designer, Frederic Foley, a surgeon who worked in Boston, Massachusetts in the 1930s.^[3] His original design was adopted by C. R. Bard, Inc. of Murray Hill, New Jersey, who manufactured the first prototypes and named them in honor of the surgeon. There are now multiple companies worldwide who produced IDCs and in/out catheters, that are made of a range of materials, such is silicone, plastic, latex (although due to the rise in latex allergies, medical equipment made of latex is becoming less common). There are even still glass in/out catheters in use today (although very rare) as many older people who have been self catheterising for a very long time prefer them to the plastic ones, as there's no wastage. Currently in most countries the plastic in/out catheters have to be discarded after use. There is a study currently under way called "Single use versus reusable catheters in intermittent catheterisation for treatment of urinary retention: a protocol for a multicentre, prospective, randomised controlled, non-inferiority trial".^[4]

Types

Indwelling urinary catheters come in several types:

• Coudé (French for elbowed) catheters have a 45° bend at the tip that facilitates easier passage through an enlarged prostate.
• Councill tip catheters have a small hole at the tip so they can be passed over a wire.
• Three-way, or triple lumen catheters have a third channel used to infuse sterile saline or another irrigating solution. These are used primarily after surgery on the bladder or prostate, to wash away blood and blood clots.
• In/out catheters that are almost always made of a semi rigid plastic. The in/out catheters are simply a double open ended tube, with no valves. The average female would use a 10Fr to a 12Fr and the average male would use a 12Fr to 14Fr.

Sizes

The relative size of an indwelling urinary catheter is described using French units (Fr).^[5] Alternatively, the size of a 10 Fr catheter might be expressed as 10 Ch (Charriere units – named after a 19th century French scientific instrument maker, Joseph-Frédéric-Benoît Charrière). The most common sizes are 10 Fr to 28 Fr. 1 Fr is equivalent to 0.33 mm = .013" = 1/77" of diameter. Foley catheters are usually color coded by size with a solid color band at the external end of the balloon inflation tube, allowing for easy identification of the size.^[6] Note: Colors for French sizes 5, 6, 8, 10 may vary significantly if intended for pediatric patients. Color for French size 26 may also be pink instead of black.

Color		French units	mm
	Yellow-green	6	2.0
	Cornflower Blue	8	2.7
	Black	10	3.3
	White	12	4.0
	Green	14	4.7
	Orange	16	5.3
	Red	18	6.0
	Yellow	20	6.7
	Purple	22	7.3
	Blue	24	8.0
	Black	26	8.7

Medical uses

Urinary tract

Indwelling urinary catheters are most commonly used to assist people who cannot urinate on their own.^[7] Indications for using a catheter include providing relief when there is urinary retention, monitoring urine output for critically ill persons, managing urination during surgery, and providing end-of-life care.^[7]

Foley catheters are used during the following situations:

• On patients who are anesthesized or sedated for surgery or other medical care
• On comatose patients
• On some incontinent patients
• On patients whose prostate is enlarged to the point that urine flow from the bladder is cut off
• On patients with acute urinary retention
• On patients who are unable due to paralysis or physical injury to use either standard toilet facilities or urinals
• Following urethral surgeries
• Following ureterectomy
• On patients with kidney disease whose urine output must be constantly and accurately measured
• Before and after cesarean section
• Before and after hysterectomy
• On patients who have had genital injury
• On anorexic patients who are unable to use standard toilets due to physical weakness and whose urine output must be constantly measured
• On patients with fibromyalgia who cannot control their bladder
• On patients who have severe skin impairment and/or breakdown

Cervical

A Foley catheter can also be used to ripen the cervix during induction of labor. When used for this purpose, the procedure is called extra-amniotic saline infusion.^[8] In this procedure, the balloon is inserted behind the cervical wall and inflated, for example with 30-80 mL of saline.^[8] The remaining length of the catheter is pulled slightly taut and taped to the inside of the leg. The inflated balloon applies pressure to the cervix as the baby's head would prior to labor, causing it to dilate. As the cervix dilates over time, the catheter is readjusted to again be slightly taut and retaped to maintain pressure. When the cervix has dilated sufficiently, the catheter drops out.^[9]

Other

They are also used in cases of severe epistaxis (nosebleed) to block blood from freely flowing down the nasal passage into the mouth.^[10] Foley catheters are also used in abdominal surgery.

Contraindications

Indwelling urinary catheters should not be used to monitor stable people who are able to urinate or for the convenience of the patient or hospital staff. Urethral trauma is the only absolute contraindication to the placement of a urinary catheter. Examination findings such as blood at the urethral meatus, or a high riding prostate necessitate a retrograde urethrogram prior to insertion.^[7]

In the United States, catheter-associated urinary tract infection is the most common type of hospital-acquired infection.^[7] While UTIs are generally more common among females, the risk factor associated to anatomy is reduced while carrying catheters, some studies even showing no significant differences between the sex. Indwelling catheters should be avoided when there are alternatives, and when patients and caregivers discuss alternatives to indwelling urinary catheters with their physicians and nurses then sometimes an alternative may be found.^[7] Physicians can reduce their use of indwelling urinary catheters when they follow evidence-based guidelines for usage, such as those published by the Centers for Disease Control and Prevention.^[7]

Adverse effects

Catheterized bladders become colonized by microorganisms very quickly, with a daily incidence of 3-10%; after four days, between 10-30% of patients develop bacteriuria.^[11] Whilst the presence of a catheter does increase the incidence of bloodstream infections secondary to a urinary origin, there is a huge amount of unnecessary, and likely harmful, antimicrobial prescribing on the basis of detection of asymptomatic bacteriuria. The industry is moving to silver-coated catheters in an attempt to reduce the incidence of urinary tract infections, although there is limited evidence of efficacy. An additional problem is that Foley catheters tend to become coated over time with a biofilm that can obstruct the drainage. This increases the amount of stagnant urine left in the bladder, which further contributes to urinary tract infections. When a Foley catheter becomes clogged, it must be flushed or replaced. There is currently not enough adequate evidence to conclude whether washouts are beneficial or harmful.^[12]

There are several risks in using a Foley catheter (or catheters generally), including:

• The balloon can break as the healthcare provider inserts the catheter. In this case, all balloon fragments must be removed.
• The balloon might not inflate after it is in place. In some institutions, the healthcare provider checks the balloon inflation before inserting the catheter into the urethra. If the balloon still does not inflate after placement into the bladder, it is discarded and replaced.
• Urine stops flowing into the bag. The healthcare provider checks for correct positioning of the catheter and bag, or for obstruction of urine flow within the catheter tube.
• Urine flow is blocked. The Foley catheter must be discarded and replaced.
• The urethra begins to bleed. The healthcare provider monitors the bleeding.
• Catheterization introduces an infection into the bladder. The risk of bladder or urinary tract infection increases with the number of days the catheter is in place.
• If the balloon is opened before the Foley catheter is completely inserted into the bladder, bleeding, damage and even rupture of the urethra can occur. In some individuals, long-term permanent scarring and strictures of the urethra occur.^[13]
• Defective catheters may be supplied, which break in situ. The most common fractures occur near the distal end or at the balloon.
• Catheters can be pulled out by patients while the balloon is still inflated, leading to major complications or even death. This may occur when patients are mentally impaired (e.g. they have Alzheimer's) or are in a mentally altered state (e.g. they are coming out of surgery).

References

Sources

• Book: Handbook of Urology: Diagnosis and Therapy (Lippincott Williams & Wilkins Handbook Series). 65. 3rd. Siroky MB, Oates RD, Babayan RK . 2004. 978-0781742214. Lippincott Williams & Wilkins. .

Notes and References

1. Karlsson . Philip A. . Pärssinen . Julia . Danielsson . Erik A. . Fatsis-Kavalopoulos . Nikos . Frithiof . Robert . Hultström . Michael . Lipcsey . Miklos . Järhult . Josef D. . Wang . Helen . Antibiotic use during coronavirus disease 2019 intensive care unit shape multidrug resistance bacteriuria: A Swedish longitudinal prospective study . Frontiers in Medicine . 7 February 2023 . 10 . 10.3389/fmed.2023.1087446 . free . 36824610 . 9941185 .
2. Lee JH, Kim SW, Yoon BI, Ha US, Sohn DW, Cho YH . Factors that affect nosocomial catheter-associated urinary tract infection in intensive care units: 2-year experience at a single center . English . Korean Journal of Urology . 54 . 1 . 59–65 . January 2013 . 23362450 . 3556556 . 10.4111/kju.2013.54.1.59 .
3. Foley, FE . A hemostatic bag catheter: one piece latex rubber structure for control of bleeding and constant drainage following prostatic resection . Journal of Urology . 38 . 134–139 . 1937. 10.1016/S0022-5347(17)71935-0 .
4. van Doorn . Tess . Berendsen . Sophie A . Scheepe . Jeroen R . Blok . Bertil F M . Single use versus reusable catheters in intermittent catheterisation for treatment of urinary retention: a protocol for a multicentre, prospective, randomised controlled, non-inferiority trial (COMPaRE) . BMJ Open . 10 April 2022 . 12 . 4 . e056649 . 10.1136/bmjopen-2021-056649 . 35410930 . 9003620 .
5. Web site: Dorland's Illustrated Medical Dictionary . 2006-06-18 . https://web.archive.org/web/20080229011412/http://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszSzcommonzSzdorlandszSzdorlandzSzdmd_u_02zPzhtm#12837098 . 2008-02-29 . dead .
6. Web site: Indwelling Urinary Catheters: Types. 22 Jan 2020. UroToday. Catheter sizes are colored-coded at the balloon inflation site for easy identification. .
7. , which cites
   • Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ . Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs . Infection Control and Hospital Epidemiology . 32 . 2 . 101–114 . February 2011 . 21460463 . 10.1086/657912 . 24729897 .
   • Lo E, Nicolle L, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Coffin SE, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Klompas M, Marschall J, Mermel LA, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS . 6 . Strategies to prevent catheter-associated urinary tract infections in acute care hospitals . Infection Control and Hospital Epidemiology . 29 Suppl 1 . s1 . S41–S50 . October 2008 . 18840088 . 10.1086/591066 . 43797520 .
   • Munasinghe RL, Yazdani H, Siddique M, Hafeez W . Appropriateness of use of indwelling urinary catheters in patients admitted to the medical service . Infection Control and Hospital Epidemiology . 22 . 10 . 647–649 . October 2001 . 11776352 . 10.1086/501837 . 43530303 .
   • Hazelett SE, Tsai M, Gareri M, Allen K . The association between indwelling urinary catheter use in the elderly and urinary tract infection in acute care . BMC Geriatrics . 6 . 1 . 15 . October 2006 . 17038177 . 1618836 . 10.1186/1471-2318-6-15 . free .
   • Gardam MA, Amihod B, Orenstein P, Consolacion N, Miller MA . Overutilization of indwelling urinary catheters and the development of nosocomial urinary tract infections . Clinical Performance and Quality Health Care . 6 . 3 . 99–102 . Jul–Sep 1998 . 10182561 .
   • Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA . Guideline for prevention of catheter-associated urinary tract infections 2009 . Infection Control and Hospital Epidemiology . 31 . 4 . 319–326 . April 2010 . 20156062 . 10.1086/651091 . 31266013 .
   • Scott RA, Oman KS, Makic MB, Fink RM, Hulett TM, Braaten JS, Severyn F, Wald HL . 6 . Reducing indwelling urinary catheter use in the emergency department: a successful quality-improvement initiative . Journal of Emergency Nursing . 40 . 3 . 237–44; quiz 293 . May 2014 . 23477920 . 10.1016/j.jen.2012.07.022 .
8. Guinn DA, Davies JK, Jones RO, Sullivan L, Wolf D . Labor induction in women with an unfavorable Bishop score: randomized controlled trial of intrauterine Foley catheter with concurrent oxytocin infusion versus Foley catheter with extra-amniotic saline infusion with concurrent oxytocin infusion . American Journal of Obstetrics and Gynecology . 191 . 1 . 225–229 . July 2004 . 15295370 . 10.1016/j.ajog.2003.12.039 .
9. https://www.who.int/reproductive-health/impac/Procedures/Induction_P17_P25.html WHO article on induction of labour
10. Holland NJ, Sandhu GS, Ghufoor K, Frosh A . The Foley catheter in the management of epistaxis . International Journal of Clinical Practice . 55 . 1 . 14–15 . Jan–Feb 2001 . 10.1111/j.1742-1241.2001.tb10969.x . 11219312 . 44835941 .
11. Web site: Complications -- Indwelling Catheters . UroToday . January 1, 2023.
12. Shepherd AJ, Mackay WG, Hagen S . Washout policies in long-term indwelling urinary catheterisation in adults . The Cochrane Database of Systematic Reviews . 2017 . CD004012 . March 2017 . 3 . 28262925 . 6464626 . 10.1002/14651858.CD004012.pub5 .
13. Web site: December 18, 2012 . Foley Catheter Causes, Symptoms, Treatment – Foley Catheter Risks on eMedicineHealth . Emedicinehealth.com . 2012-12-19.