Urinary catheter securement: what are the options?

Abstract

Traction on indwelling urinary catheters can traumatise the lower urinary tract and external genitalia, although this can be counteracted by catheter securement. This can provide shock absorption in the case of sudden tugging of the catheter and prevent ongoing traction, for example, from the weight of the drainage bag. This article looks at alternatives to indwelling urinary catheterisation but then discusses the securement of urinary catheters. The devices available are divided into two main types: straps and adhesive devices. These are discussed and actual examples are described. The reasons why caution must be taken when using securement devices are looked at, as are the possible consequences of not using securement.

Full text

620
nRC |
November 2015, vol 17, no 11
CLINICAL REVIEW
© 2015 MA Healthcare Ltd
Urinary catheterisation can be carried out ure-
thrally or suprapubically and is frequently
long-term. Traction on catheters can trauma-
tise the lower urinary tract and external geni-
talia. However, this can be counteracted by catheter se-
curement, providing shock absorption for sudden tugging
and preventing ongoing traction from the drainage bag.
Catheter securement is advocated in national guidance
(Health Protection Surveillance Centre (HPSC), 2011;
National Institute for Health and Care Excellence (NICE),
2012; Royal College of Nursing (RCN), 2012; Loveday et
al, 2014), underlining its importance.
Urinary catheterisation is widespread. A Royal College
of Physicians (RCP, 2010) UK-based audit identied ‘per-
manent catheterisation’ in patients ≥65 as 16% in acute
hospitals, 6% in primary care, 4% in mental health and
10% in care homes. In those <65, the proportions were
7% in acute hospitals, 3% in primary care, 3% in mental
health and 28% in care homes. The indications for long-
term urethral catheterisation are in Box 1.
Alternatives to indwelling
urinary catheterisation
Where continence is unachievable and intermittent self-
catheterisation is not an option, and if the patient is not in
retention of urine, management choices may include wash-
able or disposable absorbent underwear or pads, including,
for male patients, pouches, penile sheaths or appliances
(Wilson, 2015).
Following catheterisation for acute retention in benign
prostatic hyperplasia (an enlarged prostate), the commence-
ment of alpha blockers (a class of drugs used to treat men
with an enlarged prostate who have trouble passing urine)
before a trial without catheter reduces the likelihood of re-
catheterisation being necessary (NICE, 2010; RCN, 2012).
The Queen Square bladder stimulator, a vibrating mas-
saging device pressed over the suprapubic area, is some-
times effective for neurogenic retention (Prasad, 2003).
Preventing traction and catheter-
securement devices: adhesive or strap?
It is good practice to empty leg bags before they reach
two-thirds full or, where appropriate, to consider a cath-
eter valve or a waist-strap-supported drainage bag (e.g.
Rusch/Teleex Medical Belly Bag) (Wilson, 2013).
The benets of using catheter securement include the
patient’s comfort, peace of mind and reduced anxiety
(Wound, Ostomy and Continence Nurse Society (WOCN)
2012); they should feel comfortable (Healthcare Improve-
ment Scotland, 2004). The selection of securement devices
should rest on which product is suited to the patient’s indi-
vidual requirements, including personal choice. There are
two main choices available, strap or adhesive devices.
Straps
Straps are elasticated, non-latex and non-slip, with a hook
and loop fastening, of lengths appropriate for use round
the abdomen or the thigh. Great Bear Healthcare, for ex-
ample, provide, in their GB x-it range, abdominal straps
of 80 cm and for use round the thigh, 45 cm or 35 cm for
children. Manufacturers often make use of a narrower
strip that wraps round the catheter, which is secured to
the strap using a hook and loop fastening (Bard Lok-Strap
(Figure 1), Great Bear GB Fix-It, Simpla G-Strap, Optimum
Medical Ugo Fix Catheter Strap). However, straps are at
risk of becoming soiled (WOCN 2012).
An alternative is Manfred Sauer’s p.grip: a self-adhesive
tab is adhered round the bag inlet tubing (manufacturer’s
recent recommendation) or round the catheter (taking
care not to exert excess pressure, occluding the lumen).
This tape is attached to a leg strap using Velcro, over which
another Velcro strip is positioned.
Long-term and permanent urinary catheterisation are common, but they can
cause pain, tissue damage and even disgurement. Mary Wilson questions whether
catheter securement could be the answer
Urinary catheter securement:
what are the options?
Mary Wilson Retired Nurse Practitioner for Bladder and
Bowel Health, Humber NHS Foundation Trust

622
nRC |
November 2015, vol 17, no 11
CLINICAL REVIEW
© 2015 MA Healthcare Ltd
Adhesive devices
These anchor the catheter to the skin using hypoallergenic
adhesives for up to 7days. The HPSC (2011) advise that
securement devices should be placed at the stiffest part of
the catheter, usually just below the bifurcation, to prevent
lumen occlusion.
The Bard StatLock stabilisation device secures the
catheter at the bifurcation point, with a clamp allow-
ing swivelling movements. This is mounted on to a pad
that adheres strongly to area of previously cleansed and
prepared skin. The pad and residue are removed using al-
cohol wipes and a new pad placed on the opposite thigh.
Although water-resistant, the device requires protection
for bathing and showering.
The Optimum Medical Ugo Fix Gentle catheter clip (Fig-
ure 2), a comparable device, also has a rotating clip to
which the bifurcation point is attached. It has a gentle,
shower-proof, soft silicone adhesive gel pad that allows re-
moval and re-adhesion, to the same area if preferred, with-
out skin preparation or leaving residue.
CliniMed CliniFix (Figure 3) has a skin-friendly hydrocol-
loid base adhesive. The catheter is either attached using Vel-
cro securing tape or, for extra security, onto an adhesive area
exposed when required. Bathing and showering may reduce
the adhesive grip. If removed before 7days or from sensitive
areas, warm water or adhesive remover may be used.
Blue Box Ltd Grip-Lok (Figure 4) is a fabric strip, avail-
able in two widths, with hypoallergenic adhesion. It re-
tains the catheter at the bifurcation point in a foam chan-
nel, using two wrap-over fabric tapes, one above and one
below the valve.
Why caution must be taken
during catheter xation
If the catheter is held taut above a securing device, trac-
tion could still result, so leeway must be allowed (Vai-
dyanathan et al, 2005). Although xation devices use
hypoallergenic adhesive, skin should be monitored for ir-
ritation and dermatitis, especially when the patient is un-
Box 1. Indications for long-term
urethral catheterisation
 Chronic urinary retention when intermittent or
suprapubic catheterization is not an option or not
agreed to by the patient
 Accurately monitoring urinary output in critically
ill patients
 Increasing comfort for terminally ill patients
 Allow healing of category 3 or 4 pressure ulcers on the
trunk, where other measures have been inadequate
 Intractable urinary incontinence – as the last resort
From: Wilson, 2015
Figure 1. Lok-Strap, available in 50cm length. Reproduced by courtesy of Bard Medical
Figure 2. Ugo Fix Gentle. Reproduced by courtesy of Optimum Medical
Figure 3. CliniMed CliniFix. Reproduced by courtesy of CliniMed
Figure 4. Grip-Lok. Reproduced by courtesy of TIDI

623
nRC |
November 2015, vol 17, no 11
CLINICAL REVIEW
© 2015 MA Healthcare Ltd
able to do this (HPSC, 2011; WOCN, 2012). Where skin
is fragile, those with gentler adhesion could avoid risking
skin trauma. As some devices are less complicated to use,
some patients may be less likely to abandon their use or
use them incorrectly if they are guided towards those that
are less complex. Concern has been documented regard-
ing the use of strap devices by patients with poor circu-
lation, phlebitis or diabetes, but Woodward (2014) con-
cluded that there was no supporting evidence.
Possible consequences when
stabilisation is not used
Prolonged traction can cause necrosis and ulceration
within the bladder, the bladder neck and adjacent urethra,
as a result of downward pressure from the balloon (Vai-
dyanathan et al, 2005; WOCN, 2012). LeBlanc and Chris-
tensen (2005) extrapolate the grading of pressure ulcers to
urethral erosion, paralleling the depth of tissue necrosis to
stage 3 or 4 pressure ulcers.
At the penoscrotal junction, the urethra passes over
the fundiform ligament, angling down, when the penis is
directed downwards. Traction may lead here to urethral
necrosis and be visible externally if a penoscrotal stula
develops (Lowthian, 1998; Igawa et al, 2008).
Vaidyanathan et al (2005) warned that in females, trac-
tion could cause catheter migration through the tissues to
the pubic symphysis.
Iatrogenic hypospadias occurs when downward traction
on the ventral male urethra causes pressure necrosis, result-
ing in painful cleavage, initially dividing the glans penis ven-
trally, but extending up. The labia can also be damaged as a
result of catheter traction (Igawa et al, 2008; WOCN, 2012;
Woodward, 2014). Fixation can also avoid linear pressure
lesions from patients lying on their catheters (WOCN, 2012).
Suprapubic
Lowthian (1998) warned that traction on a suprapubic
catheter could cause trauma to the anterior bladder wall
and the abdominal wall. Vaidyanathan and colleagues
have cited on more than one occasion a suprapubic cath-
eter migrating due to inadequate securement (e.g. Vaidy-
anathan et al, 2011).
Key points
 Although urinary catheterisation can be a necessary intervention,
without xation, serious tissue damage can be caused as a result of
traction on the catheter
 As there are dierent devices available to prevent traction, patients can be
given a choice of which of these is most appropriate to their needs
 There are two main types of xation available, straps or adhesive devices
 Although there is limited evidence only, the use of catheter xation has been
associated with a reduction of catheter-associated urinary tract infection
Infection
Although there is little evidence that catheter secure-
ment can reduce catheter-associated urinary tract
infections (CAUTIs), two small studies report positive nd-
ings. Carignan (2004) cited unpublished research carried
out by Patronik in 2002, where, in a 6-week trial of Stat-
Lock for 23 individuals, a previous CAUTI rate of 3.46%
fell to zero, but rose to 4.93% when use was discontinued.
Darouiche et al (2006) identied that the to and fro piston-
ing of vascular catheters promoted the invasion of organ-
isms from the skin surface along the catheter. Extrapolating
this, he and his co-workers surmised that anchoring urinary
catheters and limiting pistoning would reduce tissue dam-
age and pathogen penetration. A trial of 127 patients dem-
onstrated a reduction of 45% of symptomatic CAUTIs in the
experimental group compared with the control.
Conclusion
The use of catheter securement, provided that the device
used is patient-appropriate and applied according to the
manufacturer’s guidelines, will prevent tissue damage,
pain and potential disgurement that could be both in-
capacitating and psychologically devastating. Its use,
therefore, should be universal.
nRC
This paper was subject to double-blind peer review.
Carignan M (2004) Mechanical Reduction of Catheter-Associated Urinary
Tract Infection Risk. Infection Control Today 4. http://tinyurl.com/dxfsh5h
(accessed 25 September 2015)
Darouiche RO, Goetz L, Kaldis T, Cerra-Stewart C, Al Sharif A, Priebe M
(2006) Impact of StatLock securing device on symptomatic catheter-relat-
ed urinary tract infection: a prospective, randomized, multicenter clinical
trial. Am J Infect Control 34(9): 555–60
Healthcare Improvement Scotland (2004) urinary catheterisation and cath-
eter care. Best Practice Statement. http://bit.ly/1Zb2aeP (accessed 25 Sep-
tember 2015)
Health Protection Surveillance Centre (2011) Guidelines for the prevention
of catheter associated urinary tract infections. http://bit.ly/1Olbg51 (ac-
cessed 25 September 2015)
Igawa Y, Wyndaele J-J, Nishizawa O (2008) Catheterization: Possible compli-
cations and their prevention and treatment. Int J Urol 15(6): 481–5
LeBlanc K, Christensen D (2005) Addressing the challenge of providing nurs-
ing care for elderly men suffering from urethral erosion. J Wound Ostomy
Continence Nurs 32(2): 131–4
Loveday HP, Wilson JA, Pratt RJ et al (2014) Epic 3: national evidence-based
guidelines for preventing healthcare-associated infections in NHS hospi-
tals in England. J Hosp Infect 86(suppl. 1): S1–S70
Lowthian P (1998) The danger of long-term catheter drainage. Br J Nurs
7(7): 366–8, 370, 372
National Institute for Health and Care Excellence (2010) Lower urinary tract
symptoms in men: assessment and management. http://bit.ly/1jcKbnW
(accessed 25 September 2015)
National Institute for Health and Care Excellence (2012) Infection: Preven-
tion and control of healthcare-associated infections in primary and com-
munity care. http://bit.ly/1CK83Vv (accessed 25 September 2015)
Prasad RS, Smith SJ, Wright H (2003) Lower abdominal pressure versus ex-
ternal bladder stimulation to aid bladder emptying in multiple sclerosis: a
randomized controlled study. Clin Rehabil 17(1): 42–7
Royal College of Nursing (2012) Catheter Care: RCN Guidance for Nurses.
http://bit.ly/1KZslOe (accessed 25 September 2015)
Royal College of Physicians (2010) National Audit of Continence Care, Com-
bined Organisational and Clinical Report. RCP, London. http://tinyurl.com/
o2rtrsw (accessed 25 September 2015)
Vaidyanathan S, Soni BM, Brown E, Singh G (2005) Erosion of urethra in
female patients with spinal cord injury. Spinal Cord 43(7): 451
Vaidyanathan S, Soni B, Hughes P, Singh G, Oo T (2011). Preventable long-
term complications of suprapubic cystostomy after spinal cord injury:
Root cause analysis in a representative case report. Patient Saf Surg 5(27)
Wilson M (2013) Catheter lubrication and xation: interventions. Br J Nurs
22(10): 566, 568–9
Wilson M (2015) Assessing and treating urinary incontinence in men. Br J
Community Nurs 20(6): 268, 270
Wound, Ostomy and Continence Nurses Society (2012)Indwelling urinary
catheter securement: best practice for clinicians. http://bit.ly/1Ly0ubi (ac-
cessed 25 September 2015)
Woodward S (2014) Securing urethral catheters can help to reduce their
complications. British Journal of Neuroscience Nursing 10(4): 162–5