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(Getliffe 1996b, Yates 2004). In patients in whom no clear pattern emerges, or for whom frequent catheter changes are traumatic, acidic bladder washouts can be beneficial in reducing catheter encrustations (Getliffe 1996a, McCarthy and Hunter 2001, Rew 1999, Yates 2004). The administration of catheter maintenance solutions to eliminate catheter encrustation can also be timed to coincide with catheter bag changes (every 5–7 days) so that the catheter system is not opened more than necessary (Yates 2004).

Preprocedural considerations

Equipment

Catheters used for irrigation

A three-way urinary catheter must be used for irrigation in order that fluid may simultaneously be run into, and drained out from, the bladder (Cutts 2005, Getliffe 1996a, Ng 2001). A large-gauge catheter (16–24) is often used to accommodate any clot and debris which may be present. This catheter is commonly passed in theatre when irrigation is required, for example after prostatectomy (Forristal and Maxfield 2004). Occasionally, if a patient is admitted with a heavily contaminated bladder, for example blood clots, bladder irrigation may be started on the ward. If the patient has a two-way catheter, this must be replaced with a three-way type (Scholtes 2002).

It is recommended that a three-way catheter is passed if frequent intravesical instillations of drugs or antiseptic solutions are prescribed and the risk of catheter obstruction is not considered to be very great. In such cases, the most important factor is minimizing the risk of introducing infection and maintaining a closed urinary drainage system, for which the three-way catheter allows (Figure 6.9).

Figure 6.9 Closed urinary drainage system with provision for intermittent or continuous irrigation.

Occasionally blood clots can cause a catheter blockage which requires the catheter and drainage tube to be ‘milked’ using rubber-tipped ‘milking’ tongs in order to prevent damaging the catheter. This encourages the removal of clots from within the drainage system and ensures the catheter remains free flowing (Lowthian 1991).

Pharmacological support

The agent most commonly recommended for irrigation is 0.9% sodium chloride which should be used in every case unless an alternative solution is prescribed. 0.9% sodium chloride is isotonic; consequently it does not affect the body’s fluid or electrolyte levels, enabling large volumes of the solution to be used as necessary (Cutts 2005). In particular, 3-litre bags of 0.9% sodium chloride are available for irrigation purposes. It has been proposed that sterile water should never be used to irrigate the bladder as it can be readily absorbed by osmosis (Addison 2000a). However, a recent study has demonstrated that sterile water is a safe irrigating fluid for transurethral resection of prostate (TURP) (Moharari et al. 2008).

Although not a common complication, absorption of irrigation fluid can occur during bladder irrigation. This can produce a potentially critical situation, as absorption leads to electrolyte imbalance and circulatory overload (Getliffe 1996a). Absorption is most likely to occur in theatre where glycine irrigation fluid, devoid of sodium or potassium, is forced under pressure into the prostatic veins (Forristal and Maxfield 2004). The 0.9% sodium chloride cannot be used during surgery as it contains electrolytes which interfere with diathermy (Forristal and Maxfield 2004). However, the risk of absorption still remains while irrigation continues postoperatively. For this reason it is important that fluid balance is monitored carefully during irrigation (Scholtes 2002).

Procedure guideline 6.8 Commencing bladder irrigation

Essential equipment

Sterile dressing pack

Antiseptic solution

Bactericidal alcohol handrub

Clamp

Disposable irrigation set

Medicinal products

Sterile irrigation fluid

Infusion stand

Sterile jug

Absorbent sheet

Gloves

Preprocedure

Action Rationale

1 Explain and discuss the procedure with the patient. To ensure that the patient understands the procedure and gives their valid consent (NMC 2008a, C).

2