What is a Foley Catheter?

Foley catheters are passed through the urethra into the bladder to allow continuous drainage of urine. They are typically inserted by a trained healthcare professional using a sterile technique, although some patients may be taught to manage intermittent self-catheterisation.

These are commonly used in both short-term and long-term situations, such as during and after surgery, for urinary retention, accurate urine output monitoring, or when patients are unable to empty their bladder effectively. A small balloon at the tip of the catheter is inflated once inside the bladder to help keep it securely in place.

Foley catheter selection

Appropriate Foley catheter selection is essential to minimise urethral trauma, reduce catheter-associated urinary tract infection (CAUTI) risk, optimise patient comfort, and maintain effective urinary drainage. Selection should be based on individual patient assessment, anticipated duration of catheterisation, urine characteristics, and any underlying urological conditions. ^[1,4]

The choice of catheter material should reflect the intended duration of use, patient sensitivity, and history of catheter-related complications. ^[3,5]

The smallest catheter capable of providing adequate drainage should be selected. Larger catheter sizes increase the risk of urethral trauma, discomfort, and bladder neck irritation. ^[3,5]

Correct catheter length is essential to prevent inadvertent balloon inflation within the urethra. ^[4,5]

Most routine catheterisations can be performed using a standard Foley catheter with a straight (Nelaton) tip. Alternative tip designs may be required in specific circumstances. ^[4,5]

Indications for Foley Catheterisation

Indwelling urinary catheterisation may be appropriate in the following circumstances: ^[6,9]

Acute or Chronic Urinary Retention

• Acute urinary retention requiring immediate bladder decompression.^[6,8,9]
• Chronic urinary retention with significant post-void residual volume causing symptoms or renal impairment. ^[8,9]
• Bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), urethral stricture, or other obstructive pathology. ^[8,9]

Accurate Urine Output Monitoring

• Critically ill or haemodynamically unstable patients requiring precise measurement of urine output. ^[6,7]
• Perioperative monitoring during major surgical procedures. ^[6,8]
• Monitoring fluid balance in selected patients with acute kidney injury or severe cardiac disease. ^[6,8]

Perioperative Use

Procedures anticipated to last several hours where accurate urine output measurement is necessary. ^[6,8]

During surgical procedures where bladder decompression is required. ^[6,8]

Following urological, pelvic, colorectal, or major abdominal surgery. ^[8,9]

Contraindications for Foley Catheterisation

There are few absolute contraindications to urinary catheterisation; however, certain clinical situations require specialist assessment or an alternative approach.

Suspected Urethral Injury

Urethral catheterisation should not be attempted in patients with suspected urethral trauma, particularly following pelvic injury. ^[9,10]

Signs may include:

• Blood at the urethral meatus. ^[9,10]
• Perineal or scrotal haematoma. ^[9,10]
• High-riding or non-palpable prostate on rectal examination. ^[9,10]
• Inability to void following pelvic trauma. ^[9,10]

Urgent urological assessment and imaging should be obtained before catheter insertion is attempted. ^[9,10]

Relative Contraindications

• Recent Urological or Urethral Surgery

Patients who have undergone recent urethral reconstruction, prostate surgery, or complex urological procedures may require specialist catheterisation techniques and should be managed according to surgical instructions. ^[8,10]

• Known Urethral Stricture Disease

Insertion may be technically difficult and increase the risk of urethral trauma. Specialist advice may be required, particularly if previous catheterisation attempts have been unsuccessful. ^[9,10]

• Severe Benign Prostatic Enlargement

Catheterisation can be challenging in patients with significant bladder outlet obstruction. A Tiemann (Coudé) tip catheter or specialist support may be necessary. ^[9,10]

• Patient Refusal

Where the patient has capacity, informed consent should be obtained whenever possible. ^[8]

Insertion technique

Prior to catheterisation, clinicians should:

• Confirm the clinical indication for catheterisation and document the rationale. _^[6,8]
• Verify patient identity and obtain informed consent where possible.^[8]
• Review any history of difficult catheterisation, urethral stricture, urological surgery, or prostate enlargement. ^[8,10]
• Select the appropriate catheter type, size, length, and balloon volume. ^[8,10]
• Gather all required equipment and ensure the catheterisation pack is intact and within expiry date. ^[7,8]
• Perform hand hygiene and don appropriate personal protective equipment (PPE) in accordance with local infection prevention policies. ^[6,7]

Male Catheterisation:

1. Retract the foreskin if present and cleanse the glans penis and urethral meatus.^[8,9]
2. Instil sterile lubricating anaesthetic gel into the urethra in accordance with local policy. ^[9,10]
3. Allow sufficient time for the lubricant to take effect. ^[9]
4. Insert the catheter slowly using gentle, continuous advancement. ^[9,10]
5. Advance the catheter to the bifurcation (Y-junction) before inflating the balloon. ^[9,10]
6. Confirm urine flow before balloon inflation. ^[9,10]
7. Inflate the balloon using the manufacturer’s recommended volume of sterile water. ^[9]
8. Gently withdraw the catheter until resistance is felt, indicating balloon seating within the bladder. ^[9]
9. Replace the foreskin to reduce the risk of paraphimosis. ^[9]
10. Secure the catheter appropriately and connect to a sterile drainage system. ^[6,8,9]

Female Catheterisation:

1. Separate the labia to expose the urethral meatus.^[9]
2. Cleanse the periurethral area using sterile technique. ^[8,9]
3. Apply sterile lubricating gel to the catheter tip. ^[9]
4. Insert the catheter gently into the urethra until urine is observed. ^[9]
5. Advance the catheter a further 5–7 cm to ensure the balloon is fully within the bladder. ^[9,10]
6. Inflate the balloon using the manufacturer’s recommended volume of sterile water. ^[9]
7. Gently withdraw the catheter until resistance is felt. ^[9]
8. Connect the catheter to a sterile closed drainage system and secure appropriately. ^[6,8,9]

Confirmation of Correct Placement

Correct catheter placement should be confirmed before balloon inflation. ^[9,10]

Indicators include:

• Free flow of urine through the catheter. ^[9]
• Advancement of the catheter to the recommended insertion depth. ^[9,10]
• Absence of significant patient discomfort or resistance.^[9]

Securing the Catheter

Following insertion:

• Secure the catheter using an appropriate fixation device. ^[8,9]
• Avoid tension on the catheter or drainage tubing.^[8,9]
• Ensure the drainage bag remains below bladder level. ^[6,8]
• Maintain a closed drainage system.[^6,8]
• Prevent tubing kinking or obstruction. ^[6,8]

Appropriate fixation may reduce urethral trauma, bladder neck irritation, and accidental catheter displacement. ^[8,9]

complication management

Although Foley catheterisation is a common and generally safe procedure, complications can occur during insertion or throughout the duration of catheter use. Early recognition and appropriate management are essential to minimise patient discomfort, prevent infection, and reduce the risk of long-term urological complications.

Catheter-associated urinary tract infection is the most common complication of indwelling urinary catheterisation and is responsible for a significant proportion of healthcare-associated infections.^[6,8]

Catheter Blockage – Catheter blockage may occur due to mineral encrustation, biofilm formation, debris, mucus, blood clots, or sediment accumulation within the catheter lumen. ^[8,10]

Haematuria – Minor haematuria may occur following catheter insertion due to urethral or bladder mucosal irritation. Significant or persistent bleeding requires further assessment.

Urethral Trauma – Urethral trauma may occur during difficult catheterisation or repeated insertion attempts.

Accidental Catheter Removal – Accidental removal may occur due to patient movement, confusion, inadequate fixation, or balloon-related complications.

Catheter Balloon Failure – Balloon failure may result from manufacturing defects, crystallisation, overinflation, or prolonged catheter dwell time.

Foley Catheters and CAUTI Prevention

Catheter-associated urinary tract infection (CAUTI) remains one of the most common healthcare-associated infections worldwide and represents a significant burden for patients and healthcare systems. The risk of bacteriuria increases with each day an indwelling catheter remains in situ, making catheter necessity and duration of use key considerations in infection prevention. ^[6,8]

While no Foley catheter can eliminate the risk of CAUTI, appropriate catheter selection, insertion, maintenance, and timely removal can help minimise infection risk when catheterisation is clinically indicated.

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References:

1. NHS Ayrshire & Arran. Types of Material Used for Urethral and Suprapubic Catheters.
2. NHS Borders. Urinary Catheterisation Policy (Adults).
3. NHS Highland. Catheterisation Guidelines.
4. NHS. Types of Urinary Catheters.
5. Urology & Continence Care Today. Indwelling Urinary Catheterisation: Evidence-Based Practice.
6. National Institute for Health and Care Excellence (NICE) Clinical Guideline CG139: Healthcare-associated infections.
7. NHS England National Infection Prevention and Control Manual.
8. Royal College of Nursing Catheter Care: RCN Guidance for Nurses.
9. European Association of Urology Nurses Evidence-Based Guidelines for Best Practice in Urethral Catheterisation.
10. British Association of Urological Nurses catheterisation best practice resources.