BLADDER IRRIGATION

INTRODUCTION
Bladder irrigation is a medical procedure that flushes the bladder with sterile liquid. Healthcare
providers use it to prevent or remove blood clots after surgery in the urinary system. Sterile
solution enters the bladder through a thin tube, then the fluid is removed and collected in a bag.
The process happens over a few days.

DEFINITION
Bladder irrigation means to flush out the urinary bladder with a liquid. Bladder is a natural
reservoir of urine. When the urine does not flow freely from the bladder, it forms a stagnant pool
which is an excellent media for the growth of bacteria. This stagnant urine also allows the
settling of crystals in the bladder which forms bladder stones. In order to avoid these problems,
the urinary flow must be maintained by natural or artificial means by the use of urinary catheters.

PURPOSE OF BLADDER IRRIGATION

1. To cleanse the bladder from decomposed urine, bacteria, excess of mucus, pus and blood clots
and to maintain the patency of the urinary catheter.

2. To relieve congestion and pain in case of inflammatory conditions by the application of heat.

3. To promote healing.

4. To prevent clot formation in case of bladder surgeries.

5. To prevent or treat infection e.g., cystitis.

6. To arrest bleeding.
ARTICLES:

1. Disposable gloves.

2. Disposable, water resistant, sterile towel/mackintosh.

3. 3 - way retention catheter in situ.

4. Sterile drainage tubing and bag in place.

5. Sterile antiseptic swab.

6. Sterile receptacle.

7. Sterile irrigating solution warmed or at room temperature

A. Normal saline.

B. Distilled water.

C. Solution as prescribed by physician.

8. Infusion tubing.

9. IV pole.

10. Kidney basin

Solutions used for bladder irrigations

1. Distilled water

2. Normal saline

3. Glucose solution 5 percent

4. Boric acid 2 percent

5. Potassium permanganate 1 in 10,000

6. Acriflavin 1 in 10,000

7. Silver nitrate 1 in 5000 (astringent)

8. Acetic acid 1 in 400 to treat pseudomonas infection

The solution should be administered at body temperature. In inflammatory conditions, it may be

used as hot as 43.3 degree celcius according to the tolerance of the patient.

HAZARDS OF CATHETERIZATION AND BLADDER

IRRIGATION
1. INFECTION

Urinary bladder is a sterile cavity. It is inherently resistant to infection. The acidity of the normal
urine is unfavourable to the growth of microorganisms. The mechanical action of voiding also
removes organisms from the urinary tract. However, if an infection is present in one part of the
urinary tract, it may travel to other parts because of the continuity of the mucus membranes. The
urinary tract also offers a favorable environment for the multiplication of bacteria because it is
dark, moist and warm.

The common cause of urinary infection is:

a. Placement of catheter into the bladder: during the introduction of catheter, it may cause injury
to the bladder mucosa which is a potential hazard for the growth of bacteria in the bladder.
Infection is introduced into the bladder along with the catheters during the catheterization and
bladder irrigation. Placement of catheter in the bladder prevents the washing action of voiding.

b. Dehydration of the patient highly concentrated urine and may cause infection.
c. Changing the pH value of urine by medications.

d. Force of the fluid introduced into the bladder during the bladder irrigation can cause injury to
the bladder mucosa.

e. Over distension of the bladder due to blockage of the urinary flow.

2. TISSUE TRAUMA

During the insertion of the catheter and procedures applied to the bladder, tissue trauma may take
place. Even the slight movements of the catheter can cause tissue trauma and tissue breakdown.

3. URETHRAL IRRIGATION

Symptoms of urethral irritation such as burning sensation and pain at the urethral meatus will be
experienced especially by the male patients due to indwelling catheters. Presence of catheter
induces fibrin reaction which will lead to the urinary tract infection.

4. MUSCULAR SPASMS

Bladder spasms may occur due to the balloon of an indwelling catheter resting directly on the
bladder neck. Forcing fluid more than what is tolerable by the patient will lead to muscle spasms
and pain.

TYPES OF URINARY CATHETERS USED FOR THE BLADDER

IRRIGATION

The tubes used to draw urine from any part of the urinary system are called urinary catheters.
The types of catheters commonly used are:

1. Straight Catheters

The straight catheter is a single lumen tube which may have single eye or many eyes. It may
have a round tip or whistle tip. These catheters are not self retaining, so they are used only for a
short period and must be secured with adhesive tapes when utilized as indwelling catheters.
These are made up of rubber, plastic or metal.

2. Self Retaining/Indwelling/retention Catheters

Indwelling catheters are inserted with an intention of retaining them in place for several hours to
several months or years. They may contain more than one lumen throughout its length on the
inside. The indwelling catheter used commonly is:

a. Double Lumen Foley’s Catheter

This is a single eyed round tip catheter with a double lumen. One lumen provides the drainage of
the urine, while the other lumen connects to a balloon located just above the drainage eye on the
catheter. Once the catheter is placed in the bladder this balloon is inflated with sterile water to fix
it in position. Now the balloon is too large to pass into the urethra and keeps the catheter in
place. It is important to test the balloon for leakage prior to the insertion, with the sterile water
injected into the lumen of the catheter which fills the balloon.

b. Triple Lumen Foley’s Catheter

The malecot and pesser catheters are single lumen catheters with self retaining protuberances at
their tips. They must be elongated with a stylet is removed and the protuberance secures the
catheter in place.

3 . SUPRA-PUBIC CATHETERS

These are inserted directly into the bladder through a incision made on the anterior abdominal
wall. Malecot’s and mushroom catheters are used as supra-pubic catheters.

4. URETERIC CATHETERS

The renal pelvis may be drained by urethral catheter which is passed by means of a cystoscope to
the bladder and up into the renal pelvis.

CARE OF THE PATIENT WITH INDWELLING CATHETERS

PURPOSE

1. MAINTAINING THE PATENCY OF THE CATHETER AND THE TUBE

1. NURSING ACTIONS:

1. Frequent checking of the urinary drainage will help in the early detection of catheter blockage.

2. Secure the catheter safely to prevent accidental dislodgement of the catheter.

3. Care should be taken not to obstruct the lumen of the tube when securing it to the bed. A
rubber band or adhesive plaster around the tubing attached to a safety pin, which is pinned to the
bed is convenient and is unlikely to squeeze or kink the tube.

4. See that the patient is not lying over the catheter or tubing and obstructing the urinary flow.
5. The catheters should never be left clamped even for a short period unless ordered by the
physician. Occasionally, the nurses may forget to remove the clamp which will lead to retention.

6. Bladder irrigation is indicated when a blockage in the catheter is anticipated with clots, mucus
plugs etc. remember that the safest and most effective way of irrigating the urinary system is by
internal irrigation, that is by administering plenty of fluids orally or parenterally.

7. Avoid pinching the drainage tubings between the side rails or under the wheel of wheel chairs.

2. PREVENTION OF INFECTION

1. Practice strict aseptic techniques. Everything that touches the urinary tract should be sterile,
namely, the fluid, the catheter, the tubings and other equipments used for the procedures
connected with the urinary system.

2. Practice through hand washing before and after the procedures related to catheter.

3. Avoid urinary catheterization and irrigations as far as possible. Repeated catheterization

increases the chances of urinary tract infection.

4. Separate the patients with catheters from the patients without catheters.

5. Maintain a closed drainage system whenever an indwelling catheter is put in. A closed
drainage system is one in which the entire system from the catheter to the collection bag is
closed to the atmosphere. Thus, it is protected from the microbial invasion from the environment.

6. Prevent the back flow of urine from the tubing into the urinary bladder. One of the frequent
causes of back flow of urine is the raising of the collection bag above the level of the patient’s
bladder. If the bag is raised above the patient’s bladder (e.g., when transferring a patient) apply a
clamp or tie the tubing to prevent the back flow of urine.

7. Prevent pooling of the urine in the drainage tube. The drainage tube should be long enough to
allow the patient’s movements in bed, but it should not be too long to form loops which increases
the chances for collection of urine in the tubing thereby the chances for back flow. Pooling of the
urine in the tubing may take place when the tubing is passed over the patient’s thigh. Loops are
formed when a long tube runs to the floor and then up into the collection bag. Tubing should run
straight from the mattress into the collection bag, without forming loops.
8. It is necessary to empty the collection bag at least every 8 hours or even more frequently. If
the urine is left to stand in, it is an excellent media for the growth of microbes.

9. Give the perineal care at least twice a day in order to reduce the number of bacteria on the
perineum and prevent their transfer into the bladder along the catheter.

10. Cleaning of the catheter that is lying outside the urethra reduces the chances of urinary tract
infection.

11. Increased intake of fluid reduces the chances of urinary tract infection and stone formation. It
provides internal irrigation of the urinary system.

12. Maintaining the pH value of urine towards the acidic side decreases the chances of urinary
infection.

13. Use of antibiotics and urinary antiseptics prevents urinary tract infection.

14. Every patient and his relatives should be explained about the care of the catheter to prevent
urinary tract infection and other disorders.

15. Changing the catheter, drainage tubings and the collection bags at specified intervals reduces
the chances of urinary tract infection. The catheters are changed infrequently but the drainage
tubings and the bags are changed frequently.

3. MAINTAINING THE COMFORT AND SAFETY OF PATIENT

1. Explain the patient what is to be expected during and after the catheterizations and irrigations
e.g., they have an urgency of urination for a brief period after the catheter is put in.

2. Teach the patient how to move in bed with the catheter in place.
Instruct the patient to take plenty of fluids especially if he has burning sensations on urination.

3. Teach the patient how to keep the perineum clean and dry.
Use restraints for those patients who are irrational and are continually pulling out the catheter.

4. Proper fixation of the catheter may add to the comfort of the patient. Good tapping prevents
constant friction on the neck of bladder and urethra. The catheters may be taped to the inner
aspect of the thigh. Taping on the hairy portion of the perineum is to be avoided.
5. If the patient gets bladder spasm and pain, gently manipulate the catheter to change the
position of the balloon resting on the neck of the bladder.

6. Never force fluid into the urinary bladder. Use gentle pressure during the bladder irrigation
etc.

7. During the catheterization, never force the catheter into the bladder. If any obstruction is
experienced, withdraw the catheter a little, rotate it and then introduce it into the bladder.

4. RESTORING NORMAL BLADDER FUNCTIONS.

When the bladder is continually drained with an indwelling catheter, the bladder becomes
increasingly flaccid, it loses its tone. It gives rise to retention of urine on removal of catheter.
One way of avoiding this is by establishing a bladder training programme. The catheter is
clamped for increasing lengths of time and then released at specified intervals to allow the
drainage of urine. By this way, the bladder is alternatively stretched and allowed to be empty;
thus restoring its normal function. Sometimes a tidal drainage apparatus is used to provide
automatic filling and emptying of the bladder.

TYPES OF BLADDER IRRIGATION

1. MANUAL BLADDER IRRIGATION

2. CONTINUOUS BLADDER IRRIGATION

Manual Bladder Irrigation

 Manual bladder irrigation is used for clot retention

 Catheter blockage is a very complication in long term catheter users complication is long
term catheter users.
 Up to 50% to long term catheter are changed prematurely due to catheter blockage.

Signs of a blocked catheter

 No urine flow from the catheter.

  Patient complaining of suprapubic pain, be more pronounced as the bladder
fills.
 If unrelieved vaso-vagal symptoms may i.e. sweating tachvcardia and
hypotension.
 By passing around the catheter.

Procedure
 Explain to patient.
 Maintain asepsis (this is done a an aseptic procedure prevent a UTI as the
closed urinary drainage being broken).
 Place blue sheet under the catheter and drair connection.
 Prepare sterile setup with 500ml N/S in kidney place unsterile jug on bottom
of trolly.
 PPE and sterile gloves.
 Place sterile towel under site where catheter and drainage bag attached.
 Clean catheter and drainage bag connection chlorhexidine wipes, disconnect
and drainage bag end ina chlorhexidine.
 Possible give to the patient to hold. It not keep the end wrapped in clean
Packaging or gauze.
 Using 50ml volumes of normal saline, irrigation catheter by flushing in and
drawing evacuate any clot or debris. if resistance encountered reasonable
pressure can (except following renal transplant or surgery). Empty each
returned syringe directly into the unsterile jug on the bottom of the trolly.
 Continue to irrigate with 50ml volume you achieve a clear or clot free
return.
 Reconnect catheter to drainage beg contaminating either.
 Calculate the difference between volume infused and volume returned and
record on the fluid balance chart.

CONTINUOUS BLADDER IRRIGATION

PURPOSE
  To prevent blood clot formation, allow free flow of urine and maintain
Patency by continuously irrigation the bladder with normal saline.

Articles

 3way catheter
 0.9% sodium chloride irrigation bags as per facility policey.
 Continuous bladder irrigation set and closed urinary drainage reflux valve.
 Alcohol wipes.
 Non sterile gloves.
 Personal protective equipment (PPE).
 Under pad
 I/V stand.

Procedure
 Explain procedure to the patient and ensure privacy.
 Position the patient for easy access to the catheter maintaining patient
comfort.
 Ensure that the patient has a three – way urinary.
 Hang Irrigation flasks on I/V stand and prime irrigation set maintaining
asepsis of irrigation set.
 Don goggles and impervious gown, place pad underneath catheter
connection.
 Attend hand wash and don non-sterile glove.
 Swab IDC irrigation and catheter alcohol swabs and allow to dry.
 Open the irrigation lumen of the catheter.

GENERAL INSTRUCTIONS FOR BLADDER IRRIGATION

1. The bladder irrigations should not be done without a specific order. As far as possible, the
bladder irrigations are to be avoided for the fear of introducing infection and trauma to the
urinary system. Remember the safest and most effective means of irrigating the urinary system is
by ‘internal irrigation’, that is by forcing fluid by mouth or parenterally.

2. Patients with dwelling catheters should be kept separate because there is a great risk of
microbial transmission between catheterized patients.

3. Vigorous irrigation or introducing fluids with great force will destroy the mucus lining of the
bladder and spread infection. If the force is much, it can carry the bladder contents up into the
ureters. The fluid should be instilled gently and allowed to drain back by gravity. if the fluid
flows readily into the bladder but fails to return, there is a clot acting as a valve over the eye of
the catheter. In such situations, no more fluid is introduced into the bladder, but tries to dislodge
the clot by milking the tubing. The catheter may be rotated slightly to be sure that it is not
occluded by its position in the bladder. If the fluid is retained in the bladder, examine the whole
irrigating system to detect any displacement, a blockage, a kink etc. that may obstruct the return
flow.

4. Practice strict aseptic technique. All the articles that are used for the irrigation must be sterile
and great care must be taken to prevent introduction of infection into the bladder.

5. Wash hands before and after the procedure to prevent cross infection.

6. Maintain accurate records of the amount of fluid used for irrigation and the total amount of
urinary drainage. Subtract the total amount of fluid used, from the total amount of urinary
drainage to find out the amount of urine secreted by the kidneys.

7. For patients who are on restricted salt intake, use 5 percent, dextrose solution instead of
normal saline, because some absorption will take place when the irrigation is constant and the
doctor may not wish sodium chloride to be absorbed.

8. Irrigations are carried out until the return flow is clear. The color of the drainage should be
checked and recorded. If bleeding takes place, stop the procedure and inform the doctor
immediately.

9. Keep the following precautions when an open method of irrigation is used:

a. The part of the equipment that must be kept sterile are the tip and the inside of the irrigating
syringe, the irrigating solution, the open ends of the catheter and the drainage tubing.

b. Wash hands thoroughly for a surgical procedure.

c. Cleanse the catheter-drainage tubing junction with an antiseptic solution before they are
disconnected to prevent infection entering into the drainage system.

d. Separate the catheter from the drainage tubing, taking care not to contaminate either end.
Cover the end of the tubing with a sterile dry gauze and place the tubing safely to prevent it
failing off from the bed. The distal end of the catheter is held in hand without contaminating it.

e. Hold the catheter and the irrigation syringe perpendicular to the floor so that no air is injected
into the bladder, because; air, if introduced into the bladder causes bladder spasms.

f. Slowly inject the solution into the catheter using either gravity flow or slight pressure on the
bulb of the irrigating syringe. No undue force should be applied.

g. Introduce only 75 to 100 ml of solution at a time into the bladder. Never introduce more fluid
than what a patient can tolerate without pain. If a drip method is used, introduce fluid at a rate of
40 to 60 drops per minute.

h. After the solution is introduced, pinch the catheter with the fingers and remove the irrigating
syringe from the catheter. Hold the end of the catheter over the collection basin for drainage.
Never use suction with the syringe to withdraw the fluid from the bladder. It may suck the
bladder mucosa into the drainage holes of the catheter and cause trauma to the bladder mucosa.

i. After the irrigation is over, cleanse the end of the catheter with an antiseptic solution and re-
connect it to the drainage tubing, taking care to maintain the sterility of the two ends.

10. As far as possible use the ‘closed method of irrigation’. A closed method is used for
either intermittent or continuous irrigation. The following precautions are taken when a
closed method of irrigation is set up.

a. Regulate the flow of fluid into the bladder at a specified rate – a rate similar to an intravenous
infusion.

b. When the intermittent irrigation is set up, apply clamps on the inflowing tubings to regulate
the flow of fluid into the bladder and to stop it when a sufficient quantity of fluid is flowed into
the bladder.

c. Since a large amount of fluid is used for irrigation, the collection bag will need to be emptied
more frequently to avoid reverse flow of drainage fluid into the bladder.
d. When the urethral and supra-pubic catheters are introduced into the bladder, as seen in case of
prostatectomy, allow the irrigating fluid enter in the urethral catheter and drain out through the
supra-pubic catheter.

e. Do not allow the irrigating fluid to run out completely form the irrigating can and prevent the
air entering the bladder.

11. Record the procedure on the nurse’s record with date and time.

Record the following:

a. The purpose of the procedures.

b. Amount and the kind of solution used.

c. Amount and characteristics of the drainage from the bladder.

d. Results of irrigation.

e. Problems encountered during the procedure.

f. Any fluid retained and urine removed before, during and after the procedure.

12. Keep the following points in mind when the indwelling catheters are removed:

a. To remove an indwelling catheter, deflate the balloon first by removing the fluid with a
syringe. Ask the patient to take a deep breath to enhance relaxation. Then slowly remove the
catheter.

b. Record the time and date on which catheter was removed.

c. After the catheter is removed, clean and dry the perineum. Inspect the meatus for signs of
infection, trauma or oedema.

d. The nurse should assess the bladder functions for atleast 24 hours to ensure that there is no
retention of urine.
e. The patients should be instructed to take plenty of fluids following the removal of catheter.
Patient with adequate fluid intake should void within 6 to 8 hours or even more frequently.

f. For few hours or few days (if the catheter was put in for a long period) the patient may have
some dribbling because of the sphincters of the bladder have been dilated. g. Dribbling can be
controlled by teaching the patient to do the perineal exercise. Observe the patient whether the
dribbling is ‘constant’ or ‘on urgency’.

g. The color and consistency of urine voided should be noted.