Urinary catheters are used in three instances: (1) temporarily, for people who cannot urinate following a surgery or for monitoring urinary output; (2) long term for people who cannot urinate well; and (3) for people with terrible incontinence for whom there appears to be no other solution. This article is concerned with the management of patients on “permanent” urinary catheterization – either an indwelling catheter or intermittent catheterization. An indwelling catheter refers to one that is left in all the time and changed about once a month. Indwelling catheters are placed either through the urethra or the lower abdomen (suprapubic catheter). Intermittent catheterization refers to a technique whereby the patient (or a caregiver) passes the catheter periodically throughout the day instead of urinating.
There are two major reasons why a patient cannot urinate: either the bladder does not contract well, or there is a blockage (bladder outlet obstruction). The muscle around the bladder that causes it to contract is called the “detrusor.” Impaired detrusor contractility is how we refer to a bladder that does not contract well, and an acontractile detrusor is a bladder muscle that will not contract at all.
What comes first?
Patients are often treated with an indwelling catheter when they are not able to urinate well. Because of the risk of infection, catheters should stay in for the least amount of time possible. If an indwelling catheter is necessary, it should be changed every three to four weeks, but for the vast majority of patients intermittent catheterization is preferable and much safer – see our last blog post for more information.
When presented with a patient who has an indwelling catheter, in most instances, an “active voiding trial” is recommended; the bladder is filled up with fluid using the catheter that is already in place. When the patient feels that he is full, the catheter is removed and the patient is instructed to try to urinate into a urine flow meter, and the bladder is checked to see how completely it empties with an ultrasound. The active voiding trial differs from a regular voiding trial in the amount of time it takes. The voiding trial involves removing the catheter and waiting until the patient has to urinate. Sometimes when the patient has voided a little, he is sent home and develops urinary retention (is unable to urinate at all) later that night. The active voiding trial provides more information about bladder function in a shorter amount of time.
If a patient cannot void during the active voiding trial, in our judgment, the patient should be taught intermittent catheterization and should catheterize every three to six hours. Each time, he can attempt to void first. As soon as the patient improves, both he and his doctor will know.
Will I have a catheter for the rest of my life?
We believe that a large percentage of men treated with permanent catheterization could be better treated by medication or an operation to relieve the bladder outlet obstruction that often coexists with impaired detrusor contractility. In a study we conducted (and recently updated) with fifty-four men being treated with intermittent catheterization for impaired detrusor contractility – only seventeen still needed to catheterize following a TURP (trans-urethral resection of the prostate) or KTPLAP (KTP laser ablation of the prostate). So, almost 70% of patients who had been condemned to a life with a catheter were catheter free after a simple operation. In a separate study, we demonstrated that reduction cystoplasty can also be an effective operation for patients being treated with catheterization.
Why hasn’t my doctor treated me with Medication or Surgery before?
In our opinion, many doctors do not diagnose obstruction accurately in patients presenting with impaired detrusor contractility. At least thirty percent of men with lower urinary tract symptoms have a weak bladder, which many doctors will treat with a catheter. But with a proper urodynamic study – a sophisticated diagnostic test for urinary symptoms – it is possible to diagnose obstruction even when the bladder only contracts weakly. Most men treated with a permanent catheter can turn in their catheters for medication or surgery instead.
Listen to Dr. Blaivas explain Underactive Bladder in this video:
 Blaivas, J., M. Tyler, J. Aizen, A. Badri, M. Benedon, and J. Weiss. “TURP/KTPLAP Is an Effective Treatment for Men with Detrusor Underactivity.” Neurourology and Urodynamics 33.6 (2014): 988-89.
 Blaivas, Jerry, Jeffrey Weiss, Johnson Tsui, Mahyar Kashan, James Weinberger, and Daniel Thorner. “Outcomes of Reduction Cystoplasty in Men With Impaired Detrusor Contractility.” Urology 83.4 (2014): 882-87. Apr. 2014. Web.