• Removing drainage tubes late at night instead of early in the morning might reduce the number of people who need to have the drainage tube reinserted.
• Removing drainage tubes sooner rather than later probably reduces the risk of infection caused by the drainage tube and painful urination. However, it may lead to more people needing to have the tube reinserted.
• We need future studies to research the effects of drainage tube removal for people who did not have surgery.
What are urinary catheters?
Urinary catheters are flexible, hollow tubes that are used to empty the urinary bladder and collect urine in a bag. They are often used for short periods of time for people who cannot pass urine themselves, for example during or after surgery, or when healthcare staff need to measure someone’s urine. One harmful effect of catheters is the risk of developing urinary tract infections (UTIs). If catheters are removed quickly, the risk of infection is reduced, but if they are removed too soon, they may need to be reinserted.
What did we want to find out?
We wanted to investigate the effects of different strategies on the risk of:
• needing to have the catheter reinserted;
• developing a urinary tract infection (UTI);
• experiencing pain when urinating.
What did we do?
We searched for studies that looked at the use of short-term urinary catheters in adults. We defined ‘short-term’ as 14 days or less. Studies could take place anywhere and participants could have any condition or illness.
We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 99 studies with 12,241 participants. Most participants were surgical patients and many of the studies (50) assessed women only.
The studies investigated:
• removing the catheter early in the morning compared with late at night (13 studies);
• retaining the catheter for shorter or longer times (68 studies);
• clamping catheters or allowing them to drain freely (7 studies); and
• giving men treatment (alpha blockers) to relax the prostate compared to no treatment before removing the catheter (3 studies). The prostate is a small gland located between the penis and the bladder.
Early-morning compared to late-night removal
Late-night catheter removal might reduce the risk of needing to have the catheter reinserted compared with early-morning removal. We are uncertain if there is any difference between early-morning and late-night removal for developing UTI or painful urination.
Shorter compared to longer use of catheters
People who have their catheters removed after a shorter length of time are probably less likely to develop UTIs and may be less likely to experience painful urination compared with those who have their catheters for longer. However, we also found that people may be more likely to need the catheter reinserting if they have the catheter for a shorter compared with a longer time.
There may be little to no difference between clamping and free drainage on the risk of needing the catheter to be reinserted. We are uncertain if there is any difference in the risk of UTIs or painful urination.
Treatment to relax the prostate
We are uncertain whether giving alpha-blockers before the catheter is removed has any effect on the need to have catheters reinserted or the risk of developing UTIs. There was no evidence about the risk of experiencing painful urination.
What are the limitations of the evidence?
Many of the included trials had design flaws, did not recruit enough people, or did not report enough information about their results. This means our confidence in the evidence is limited.
How up-to-date is this evidence?
The evidence is current up to 17 March 2020.
There is some evidence to suggest the removal of indwelling urethral catheters late at night rather than early in the morning may reduce the number of people who require recatheterisation. It appears that catheter removal after shorter compared to longer durations probably reduces the risk of symptomatic CAUTI and may reduce the risk of dysuria. However, it may lead to more people requiring recatheterisation. The other evidence relating to the risk of symptomatic CAUTI and dysuria is too uncertain to allow us to draw any conclusions.
Due to the low certainty of the majority of the evidence presented here, the results of further research are likely to change our findings and to have a further impact on clinical practice. This systematic review has highlighted the need for a standardised set of core outcomes, which should be measured and reported by all future trials comparing strategies for the removal of short-term urinary catheters. Future trials should also study the effects of short-term indwelling urethral catheter removal on non-surgical patients.
Urinary catheterisation is a common procedure, with approximately 15% to 25% of all people admitted to hospital receiving short-term (14 days or less) indwelling urethral catheterisation at some point during their care. However, the use of urinary catheters is associated with an increased risk of developing urinary tract infection. Catheter-associated urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. It is estimated that around 20% of hospital-acquired bacteraemias arise from the urinary tract and are associated with mortality of around 10%.
This is an update of a Cochrane Review first published in 2005 and last published in 2007.
To assess the effects of strategies for removing short-term (14 days or less) indwelling catheters in adults.
We searched the Cochrane Incontinence Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 17 March 2020), and reference lists of relevant articles.
We included all randomised controlled trials (RCTs) and quasi-RCTs that evaluated the effectiveness of practices undertaken for the removal of short-term indwelling urethral catheters in adults for any reason in any setting.
Two review authors performed abstract and full-text screening of all relevant articles. At least two review authors independently performed risk of bias assessment, data abstraction and GRADE assessment.
We included 99 trials involving 12,241 participants. We judged the majority of trials to be at low or unclear risk of selection and detection bias, with a high risk of performance bias. We also deemed most trials to be at low risk of attrition and reporting bias. None of the trials reported on quality of life. The majority of participants across the trials had undergone some form of surgical procedure.
Thirteen trials involving 1506 participants compared the removal of short-term indwelling urethral catheters at one time of day (early morning removal group between 6 am to 7 am) versus another (late night removal group between 10 pm to midnight). Catheter removal late at night may slightly reduce the risk of requiring recatheterisation compared with early morning (RR 0.71, 95% CI 0.53 to 0.96; 10 RCTs, 1920 participants; low-certainty evidence). We are uncertain if there is any difference between early morning and late night removal in the risk of developing symptomatic CAUTI (RR 1.00, 95% CI 0.61 to 1.63; 1 RCT, 41 participants; very low-certainty evidence). We are uncertain whether the time of day makes a difference to the risk of dysuria (RR 2.20; 95% CI 0.70 to 6.86; 1 RCT, 170 participants; low-certainty evidence).
Sixty-eight trials involving 9247 participants compared shorter versus longer durations of catheterisation. Shorter durations may increase the risk of requiring recatheterisation compared with longer durations (RR 1.81, 95% CI 1.35 to 2.41; 44 trials, 5870 participants; low-certainty evidence), but probably reduce the risk of symptomatic CAUTI (RR 0.52, 95% CI 0.45 to 0.61; 41 RCTs, 5759 participants; moderate-certainty evidence) and may reduce the risk of dysuria (RR 0.42, 95% CI 0.20 to 0.88; 7 RCTs; 1398 participants; low-certainty evidence).
Seven trials involving 714 participants compared policies of clamping catheters versus free drainage. There may be little to no difference between clamping and free drainage in terms of the risk of requiring recatheterisation (RR 0.82, 95% CI 0.55 to 1.21; 5 RCTs; 569 participants; low-certainty evidence). We are uncertain if there is any difference in the risk of symptomatic CAUTI (RR 0.99, 95% CI 0.60 to 1.63; 2 RCTs, 267 participants; very low-certainty evidence) or dysuria (RR 0.84, 95% CI 0.46 to 1.54; 1 trial, 79 participants; very low-certainty evidence).
Three trials involving 402 participants compared the use of prophylactic alpha blockers versus no intervention or placebo. We are uncertain if prophylactic alpha blockers before catheter removal has any effect on the risk of requiring recatheterisation (RR 1.18, 95% CI 0.58 to 2.42; 2 RCTs, 184 participants; very low-certainty evidence) or risk of symptomatic CAUTI (RR 0.20, 95% CI 0.01 to 4.06; 1 trial, 94 participants; very low-certainty evidence). None of the included trials investigating prophylactic alpha blockers reported the number of participants with dysuria.