Which route of short-term bladder drainage is best for adults in hospital?

The evidence for this question is up-to-date as of 26 February 2015

Number of trials: 42

Number of participants: 4577

Key messages:

This Cochrane review found that there was not enough evidence to determine whether one route of bladder drainage was more likely to reduce urinary tract infection than another. The evidence suggests that participants with suprapubic catheters were less likely to have catheter-associated pain compared with those with indwelling urethral catheters. The quality of evidence in this review was low, and many of the trials did not report important outcomes such as catheter-associated quality of life and ease of use. The included trials reported few adverse effects, but it is not clear if this is because the adverse effects did not occur or were simply not reported. Because of the limited evidence, we need more high-quality trials. It is important that these trials report symptomatic urinary tract infection, pain from using catheters, quality of life, adverse effects and ease of use.

Background: what routes of short-term bladder drainage are there?

Urinary catheters are tubes that drain urine from the bladder. They are often used in people who are unable to go to the toilet easily during their hospital stay. About one in four hospital patients requires short-term bladder drainage using a urinary catheter. Catheters can be used in different ways. The main routes of urinary catheterisation are:

1. Urethral : a drainage tube is inserted into the bladder via the urethra, and is either left in place (indwelling catheter), or removed after the bladder is emptied (intermittent catheter).

2. Suprapubic catheterisation: a drainage tube is inserted into the bladder through a small cut in the abdominal wall.

A common complication of short-term bladder drainage is urinary tract infection. Infections have many serious implications for patients and healthcare providers. Insertion of a suprapubic catheter may also be associated with more risks than urethral routes, such as bleeding or damage to the bowel.

Key results

The Cochrane review looked at studies which made one of three comparisons:

1. Indwelling versus suprapubic catheterisation
2. Indwelling versus intermittent catheterisation
3. Suprapubic versus intermittent catheterisation

1. Twenty-five trials (2622 participants) compared indwelling urethral and suprapubic catheterisation. There was not enough evidence from five trials to determine whether people had a lower risk of symptomatic urinary tract infection with indwelling urethral or suprapubic catheterisation. There was low quality evidence from four trials that people with indwelling urethral catheters were at greater risk of catheter-associated pain compared with participants with suprapubic catheters. None of the twenty-five trials reported ease of use, quality of life or economic outcomes.

2. Fourteen trials (1596 participants) compared indwelling and intermittent urethral catheterisation. There was very low quality evidence from two trials reporting on urinary tract infection, and the review could not determine which route of bladder drainage had a lower risk. None of the fourteen trials reported pain, ease of use, quality of life or economic outcomes.

3. Three trials (359 participants) compared suprapubic and intermittent urethral catheterisation. Only one trial reported on urinary tract infection. The evidence was inconclusive and of low quality. Only one trial had evidence on pain. Again, the evidence was inconclusive and the quality of the evidence was very low. None of the three trials reported ease of use, quality of life or economic outcomes.

Concluding messages

Although many trials have been conducted not enough have looked at important outcomes. Many questions are still unanswered about short-term bladder drainage. Which route is the least likely to cause urinary tract infection? Is one route associated with more pain than the others? Is there a significant difference in cost or convenience for patients and hospitals between the three routes? Until these questions are answered with higher-quality evidence, we need more and better trials.

Authors' conclusions: 

Suprapubic catheters reduced the number of participants with asymptomatic bacteriuria, recatheterisation and pain compared with indwelling urethral. The evidence for symptomatic urinary tract infection was inconclusive.

For indwelling versus intermittent urethral catheterisation, the evidence was inconclusive for symptomatic urinary tract infection and asymptomatic bacteriuria. No trials reported pain.

The evidence was inconclusive for suprapubic versus intermittent urethral catheterisation. Trials should use a standardised definition for symptomatic urinary tract infection. Further adequately-powered trials comparing all catheters are required, particularly suprapubic and intermittent urethral catheterisation.

Read the full abstract...
Background: 

Indwelling urethral catheters are often used for bladder drainage in hospital. Urinary tract infection is the most common hospital-acquired infection, and a common complication of urinary catheterisation. Pain, ease of use and quality of life are important to consider, as well as formal economic analysis. Suprapubic catheterisation can also result in bowel perforation and death.

Objectives: 

To determine the advantages and disadvantages of alternative routes of short-term bladder catheterisation in adults in terms of infection, adverse events, replacement, duration of use, participant satisfaction and cost effectiveness. For the purpose of this review, we define 'short-term' as intended duration of catheterisation for 14 days or less.

Search strategy: 

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 26 February 2015), CINAHL (searched 27 January 2015) and the reference lists of relevant articles.

Selection criteria: 

We included all randomised and quasi-randomised trials comparing different routes of catheterisation for short-term use in hospitalised adults.

Data collection and analysis: 

At least two review authors extracted data and performed 'Risk of bias' assessment of the included trials. We sought clarification from the trialists if further information was required.

Main results: 

In this systematic review, we included 42 trials.

Twenty-five trials compared indwelling urethral and suprapubic catheterisation. There was insufficient evidence for symptomatic urinary tract infection (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.61 to 1.69; 5 trials, 575 participants; very low-quality evidence). Participants with indwelling catheters had more cases of asymptomatic bacteriuria (RR 2.25, 95% CI 1.63 to 3.10; 19 trials, 1894 participants; very low quality evidence) and more participants reported pain (RR 5.62, 95% CI 3.31 to 9.55; 4 trials, 535 participants; low-quality evidence). Duration of catheterisation was shorter in the indwelling urethral catheter group (MD -1.73, 95% CI -2.42 to -1.05; 2 trials, 274 participants).

Fourteen trials compared indwelling urethral catheterisation with intermittent catheterisation. Two trials had data for symptomatic UTI which were suitable for meta-analysis. Due to evidence of significant clinical and statistical heterogeneity, we did not pool the results, which were inconclusive and the quality of evidence was very low. The main source of heterogeneity was the reason for hospitalisation as Hakvoort and colleagues recruited participants undergoing urogenital surgery; whereas in the trial conducted by Tang and colleagues elderly women in geriatric rehabilitation ward were recruited. The evidence was also inconclusive for asymptomatic bacteriuria (RR 1.04; 95% CI 0.85 to 1.28; 13 trials, 1333 participants; very low quality evidence). Almost three times as many people developed acute urinary retention with the intermittent catheter (16% with urethral versus 45% with intermittent); RR 0.45, 95% CI 0.22 to 0.91; 4 trials, 384 participants.

Three trials compared intermittent catheterisation with suprapubic catheterisation, with only female participants. The evidence was inconclusive for symptomatic urinary tract infection, asymptomatic bacteriuria, pain or cost.

None of the trials reported the following critical outcomes: quality of life; ease of use, and cost utility analysis.

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