Foley Catheter
A Foley catheter provides indwelling bladder drainage through a drainage lumen and a separate balloon channel. It is the standard indwelling urethral catheter, and about 100 million urinary catheters are used worldwide each year.[10] Frederic Foley introduced the balloon-retained design into urologic practice in 1937, and its basic design has changed little since.[11][12] In reconstructive practice it is the usual postoperative drainage device after urethroplasty, fistula repair, ureteral reimplantation, diversion and prostatectomy. It is also a source of urethral injury and stricture when placed or secured badly.
After reconstruction, catheter size, route, duration, and removal assessment follow the repair-specific plan.[1][2]
Choose the device for the task
| Feature | Practical selection |
|---|---|
| Two-way catheter | Routine continuous drainage; one drainage lumen and one balloon channel. |
| Three-way catheter | Adds an irrigation inflow lumen for continuous bladder irrigation when clot obstruction is anticipated or needs treatment, for example after prostate surgery or with gross hematuria. SeeThree-Way Catheter. |
| Diameter | Use the smallest bore that drains adequately. EAUN gives 12–14 Fr as an adult example for clear urine without debris; blood, debris, a reconstruction, or a particular device may require a different size. |
| Length | A male urethra requires a standard male-length catheter. Never use a short female-length Foley in a male urethra. |
| Balloon | Use the inflation volume and fluid specified for that model. Sterile water is common; some products specify another solution. A 30-mL balloon is a specialized option, for example for prostatic-fossa tamponade after prostate surgery, and is not a treatment for leakage around a routine catheter. |
| Latex / coated latex | Coating does not eliminate the latex core. Check all components when latex allergy is present. |
| All-silicone | An option for latex avoidance and longer-term drainage. CDC notes a possible advantage in patients with frequent encrustation/obstruction. In a bench comparison, all-silicone catheters kinked less and flowed better than latex-based catheters, but needed greater force to remove.[13] |
| Hydrogel or antimicrobial coating | Lubricity, bacteriuria, symptomatic infection, and comfort are different outcomes. |
| Catheter valve | An outlet valve at the catheter tip can replace a leg bag for a long-term indwelling catheter, offering more discreet drainage and freedom of movement; many designs still connect to a bag when needed. It is not suitable for every patient: impaired hand function can prevent operation, and overactive bladder symptoms or poor bladder function can make intermittent opening inappropriate. Check local product approval.[2] |
These choices follow EAUN 2024 and CDC recommendations; the package instructions remain the source for model-specific handling and maximum dwell time.[1][2]
Indications and alternatives
Appropriate uses include acute retention or obstruction; accurate output measurement in selected critically ill patients; selected perioperative care; drainage protecting a urinary repair; assistance with healing an open sacral or perineal wound in an incontinent patient; and patient-centered comfort care. A catheter is not a routine response to incontinence, staff workload, or the need for a urine specimen from someone who can void.[1]
Consider intermittent catheterization when emptying support is needed and it is feasible, an external collection device for appropriate incontinence without retention, or suprapubic drainage when the urethral route is unsuitable.[1][2][3] The choice depends on anatomy, bladder pressures, function, patient preference, and caregiver support.[1][2][3]
Contraindications and cautions
Suspected urethral injury (for example, blood at the meatus or perineal hematoma) warrants caution before blind urethral catheterization; consider a retrograde urethrogram first when feasible. If imaging is unavailable and drainage is needed, the ACS guideline allows one attempt by an experienced trauma team member.[4]
Before attempting insertion
Review prior difficult catheterization, urethral reconstruction or stricture, bladder-neck surgery, and any implanted continence device. Acute prostatitis and suspected urethral injury require a deliberate drainage plan.[2]
In trauma with strong suspicion of urethral injury, such as meatal blood with a pelvic fracture, obtain appropriate urethral assessment, usually retrograde urethrography in a male, before instrumentation when feasible. ACS allows a single careful experienced attempt in selected circumstances when assessment is unavailable; it is not permission for repeated blind attempts. Its trauma guidance favors a straight tip, with the attempt stopped for resistance or failure to obtain urine.[4]
Insertion safety
For acute-care insertion, use hand hygiene, trained personnel, aseptic technique, sterile equipment, and compatible single-use lubricant. Follow the product instructions for preparation and insertion.[1][2]
- Advance gently; stop for unexpected resistance, marked pain, or bleeding. A catheter is not a urethral dilator.
- Urine return alone does not establish that the balloon is safely inside the bladder. In a male, advance to the catheter bifurcation or hub before inflation, provided passage is free and bladder placement is established. Follow the relevant technique for female or reconstructed anatomy.
- Inflate only after intravesical position is established, using the specified fluid and volume. Stop if inflation causes pain or resistance, and reassess.
- Secure the catheter without traction, connect closed drainage, and return a retracted foreskin to its normal position.
These safeguards are emphasized in EAUN guidance and the manufacturer's male insertion demonstration.[2][5]
Maintenance and removal
Maintain a closed system, keep tubing unkinked and the bag below bladder level and off the floor, and use routine daily hygiene rather than repeated antiseptic meatal cleaning. Replace the catheter and collection system aseptically if the closed system is compromised. Obtain a culture specimen from the sampling port using the recommended technique, not from the drainage bag.[1]
Do not schedule every catheter for a universal four-week change.[1] Change for clinical indications such as obstruction, infection requiring replacement, or loss of system integrity, while respecting the manufacturer's maximum dwell time and an individualized plan for recurrent blockage. Fluid advice must account for cardiac or renal restrictions. Routine irrigation or antibiotics do not substitute for appropriate drainage and care.[1][2]
Remove promptly when the indication ends. The CDC preference for removal within 24 hours after surgery applies unless an appropriate continued indication exists. Deflate and remove according to the device instructions without force. Plan a trial of void and residual assessment when relevant to the original indication and retention risk, with clear instructions for pain or inability to void. Void-trial timing and PVR thresholds vary by operation and patient.[1][2]
A 2021 Cochrane review found that shorter postoperative catheter duration probably reduces symptomatic CAUTI but may increase recatheterization. This supports removal decisions specific to the procedure; no single duration applies to every repair.[6]
Troubleshooting and complications
Ultrasound at the bedside can show a catheter within a distended bladder, clot, or a balloon that is not functioning. Point-of-care ultrasound has been described for troubleshooting poor drainage, hematuria and balloon malfunction, and it may avoid unnecessary exchanges.[14]
| Problem | First assessment |
|---|---|
| Little or no drainage | Check kinks, bag position, fluid status, blockage and catheter position. Distension, pain, hematuria or a recent reconstruction may require prompt urologic assessment and imaging; avoid forceful manipulation. A flush technique and branch logic are given below. |
| Leakage around the catheter | Assess obstruction, spasm, constipation, traction and an excessively large catheter. Reflex upsizing or increasing balloon volume can worsen irritation. |
| Pain or blood after insertion | Consider urethral/balloon malposition or trauma; stop further blind attempts. |
| Balloon will not deflate | Follow the stepwise pathway below. Do not pull an inflated balloon through the urethra. |
| Chronic urethral pressure injury | Reassess securement, size and the drainage route; consider suprapubic drainage where appropriate. |
EAUN describes these complications and emphasizes correcting the cause of bypass leakage.[2] In Saint's 2018 multicenter cohort, 1,184/2,076 evaluable patients reported at least one catheter-associated problem within 30 days; most were noninfectious.[7] Noninfectious complications were reported by 55.4% and infectious complications by 10.5%.[7] Pain or discomfort, blood in the urine and urgency were the commonest noninfectious complaints.[7] These were patient-reported outcomes in a largely perioperative cohort (79.6% short-term surgical catheters).[7]
Little or no drainage: flush technique
When catheter position is confirmed and the postoperative drainage plan allows irrigation, a trained operator can flush and aspirate sterile saline through the drainage port with a 60-mL catheter-tipped syringe, documenting instilled and returned volumes; if resistance is felt or fluid does not return, stop and reassess.[10][28] If the same volume returns but the catheter still does not drain, evaluate the patient for anuria (document intake and output, check renal function) rather than assume catheter malfunction. In a male, a catheter that will not flush well may be sitting in the prostatic urethra rather than the bladder; deflating the balloon and advancing the catheter further can correct this. A catheter that is correctly positioned but obstructed and will not flush should be exchanged, using a hematuria catheter with continuous bladder irrigation when clot is likely. If fluid is instilled but nothing returns, obtain bladder ultrasound, the simplest first study, to confirm placement and exclude bladder perforation before further instrumentation.
Balloon will not deflate
A Foley balloon that will not deflate is usually from a faulty valve mechanism, an obstructed inflation channel or, rarely, crystallization of the fluid within the balloon.[20] A stepwise pathway avoids blind traction on an inflated balloon:[19]
- Cut the catheter's inflation side arm proximal to the valve to bypass a faulty valve mechanism. This alone often lets the water drain; the deflated balloon can form a cuff that resists withdrawal; if resistance is encountered, stop and reassess rather than apply force.[2][10]
- In the Teleflex Rüsch catalog's technique for a nondeflating Foley balloon, inject 10 mL paraffin (mineral) oil through the filling lumen and another 5–10 mL after 5–10 minutes if needed; prefill the bladder with 100–200 mL saline and inspect cystoscopically for retained fragments after catheter removal.[30]
- A ureteral-stent stylet or wire passed down the balloon port can clear debris from the channel or pop the balloon; this gives no direct visualization and can be uncomfortable.
- If these fail, puncture the balloon directly with a needle, with the patient's consent, in a controlled setting. In females this can be done transurethrally or transvaginally, with gentle traction on the balloon to bring it to the bladder neck first; in males, ultrasound-guided suprapubic puncture of a nondeflating balloon with a 22-gauge needle has been described.[27] In a bench comparison of 50 balloons per method, needle puncture produced free fragments in none, versus 83% with overinflation and 100% with instilled ether.[21]
- If all techniques fail, image for balloon encrustation; a large calcified balloon or stone may require surgical removal.
Long-term complications
Chronic indwelling drainage can cause encrustation and obstruction, urethral erosion, urethral stricture and loss of bladder compliance. Erosion of the ventral male urethra (acquired hypospadias) is associated with traction and poor securement. See Male Urethral Stricture.[2]
Bacteriuria is not CAUTI
CDC estimates that bacteriuria develops in approximately 3–7% of patients with indwelling urinary catheters per day (the EAU 2026 guideline gives 3–8%), becoming nearly universal after a month.[8][18] Do not routinely screen for or treat asymptomatic bacteriuria; pregnancy and selected urologic procedures that breach the mucosa are important exceptions. Evaluate compatible symptoms and other causes before diagnosing CAUTI.[8] Two operational facts sit behind these colonization rates: IDSA defines catheter-associated UTI by compatible symptoms and bacteriuria during catheterization or within 48 hours after catheter removal, without a minimum 48-hour catheter dwell time,[22] and a 33-catheter observational study detected biofilm on removed urinary catheters after several hours of indwelling time.[23]
The strongest prevention strategy is appropriate use, good insertion and maintenance practice, and limiting unnecessary duration. Silver-alloy catheters did not reduce symptomatic CAUTI in the large trial summarized by the 2014 Cochrane review; nitrofurazone produced a small reduction with more discomfort. CDC reserves consideration of antimicrobial/antiseptic catheters for persistently high CAUTI rates despite a comprehensive prevention strategy.[1][9] The EAU 2026 infections guideline gives strong recommendations to keep catheterization time to a minimum, not to apply topical antiseptics or antimicrobials to the catheter, urethra or meatus, not to use prophylactic antimicrobials to prevent CAUTI, and to replace or remove the indwelling catheter before starting antimicrobial treatment of a symptomatic CAUTI.[18] It states that long-term indwelling catheters should not be changed routinely, that silver-alloy catheters have not reduced CAUTI (nitrofurazone was borderline, RR 0.84, and not confirmed in a later transplant RCT), and that antibiotic prophylaxis after urethral catheter removal is not recommended routinely (weak; a meta-analysis of seven controlled studies of short-term catheter removal, including six RCTs and one nonrandomized study, found symptomatic UTI RR 0.45 and NNT 17, but five of seven studies were compatible with no benefit).[18][29]
Duration of catheterization is the most important modifiable risk factor for CAUTI.[15]
For drug choices, see UTI Suppressive & Prophylactic Therapy and Non-Antibiotic UTI Prevention.
Difficult catheterization
After an unsuccessful attempt, reassess the likely cause and obtain experienced help. A correctly oriented coudé catheter can help selected patients with prostatic angulation. Known stricture, a false passage, prior repair, bleeding, or persistent resistance may favor early cystoscopy and Council-tip placement over a confirmed intravesical wire, or suprapubic drainage.[2][4]
In the Liss maneuver, the floppy end of a stiff guidewire is passed down the Foley lumen. Bench testing showed a mean 359% increase in catheter-body stiffness with no significant tip stiffening, and it succeeded in five of six patients in the original report.[16] Do not force a catheter against resistance, because forced passage can injure the urethra and lead to false passage or stricture.
Prospective series report iatrogenic urethral catheterization injury in hospitalized men, using different denominators: 3.2 per 1,000 male admissions before a targeted nursing-education intervention (falling to 0.7 per 1,000 afterward) in a single-center series; 6.7 per 1,000 catheters inserted, with 81% of injured patients sustaining a Clavien-Dindo grade II or higher complication, in a two-center series; and a mean 6.2 (range 3.2–14.4) per 1,000 catheterizations, with urological intervention required in 54/57 evaluable injured patients (95%), in a seven-center UK/Ireland series.[24][25][26]
Alternatives to indwelling urethral drainage
The AUA/SUFU neurogenic LUTD guideline strongly recommends (Statement 35) intermittent catheterization rather than indwelling catheters to facilitate bladder emptying . For appropriately selected patients who require a chronic indwelling catheter, it strongly recommends (Statement 36) suprapubic catheterization over an indwelling urethral catheter .[17] External collection devices suit incontinence without retention. See Intermittent Catheter, Condom Catheters and Suprapubic Catheter.
References
1. CDC. Guideline for prevention of catheter-associated urinary tract infections (2009): Summary of recommendations. Web summary updated 2024.
2. European Association of Urology Nurses. Indwelling catheterisation in adults—urethral and suprapubic. 2024. Chapters 4–10.
3. Kidd EA, Stewart F, Kassis NC, Hom E, Omar MI. Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults. Cochrane Database Syst Rev. 2015;(12):CD004203. doi:10.1002/14651858.CD004203.pub3
4. Johnsen N, Wessells H, Archer-Arroyo K, et al. Best Practices Guidelines: Management of Genitourinary Injuries. American College of Surgeons Trauma Quality Programs; August 2025. Initial evaluation and urethral catheter placement, pp. 8–9.
5. BD. SureStep Foley catheter in-service video. Manufacturer insertion demonstration; use the current package instructions for the selected device.
6. Ellahi A, Stewart F, Kidd EA, et al. Strategies for the removal of short-term indwelling urethral catheters in adults. Cochrane Database Syst Rev. 2021;6:CD004011. doi:10.1002/14651858.CD004011.pub4
7. Saint S, Trautner BW, Fowler KE, et al. A multicenter study of patient-reported infectious and noninfectious complications associated with indwelling urethral catheters. JAMA Intern Med. 2018;178(8):1078-1085. doi:10.1001/jamainternmed.2018.2417
8. CDC. Indwelling urinary catheter culture stewardship: overview.
9. Lam TB, Omar MI, Fisher E, Gillies K, MacLennan S. Types of indwelling urethral catheters for short-term catheterisation in hospitalised adults. Cochrane Database Syst Rev. 2014;(9):CD004013. doi:10.1002/14651858.CD004013.pub4
10. Cameron AP, Werneburg GT. Foley catheter management: a review. JAMA Surg. 2025;160(6):701-707. doi:10.1001/jamasurg.2025.0565
11. Feneley RC, Kunin CM, Stickler DJ. An indwelling urinary catheter for the 21st century. BJU Int. 2012;109(12):1746-1749. doi:10.1111/j.1464-410X.2011.10753.x
12. DuBose JJ, Feliciano DV. Frederic Eugene Basil Foley (1891-1966) and the Foley-type balloon catheter. Am Surg. 2023;89(6):2931-2933. doi:10.1177/00031348221088969
13. Lawrence EL, Turner IG. Kink, flow and retention properties of urinary catheters part 1: conventional Foley catheters. J Mater Sci Mater Med. 2006;17(2):147-152. doi:10.1007/s10856-006-6818-0
14. Boivin Z, Li JJ, Gottlieb M, Liu RB. Troubleshooting Foley catheter problems using point-of-care ultrasound. J Emerg Med. 2025;78:12-18. doi:10.1016/j.jemermed.2025.07.049
15. Chenoweth CE. Urinary tract infections: 2021 update. Infect Dis Clin North Am. 2021;35(4):857-870. doi:10.1016/j.idc.2021.08.003
16. Liss MA, Leifer S, Sakakine G, Esparza M, Clayman RV. The Liss maneuver: a nonendoscopic technique for difficult Foley catheterization. J Endourol. 2009;23(8):1227-1230. doi:10.1089/end.2009.0043
17. Ginsberg DA, Boone TB, Cameron AP, et al. The AUA/SUFU guideline on adult neurogenic lower urinary tract dysfunction: treatment and follow-up. J Urol. 2021;206(5):1106-1113. doi:10.1097/JU.0000000000002239
18. European Association of Urology. EAU Guidelines on Urological Infections (section 3.8, catheter-associated UTI). 2026 limited update, March 2026. Full guideline.
19. Wagner KR, Bird ET, Coffield KS. Urinary catheterization: a paradigm shift in difficult urinary catheterization. Curr Urol Rep. 2016;17(11):82. doi:10.1007/s11934-016-0641-z
20. Daneshmand S, Youssefzadeh D, Skinner EC. Review of techniques to remove a Foley catheter when the balloon does not deflate. Urology. 2002;59(1):127-129. doi:10.1016/s0090-4295(01)01483-2
21. Gülmez I, Ekmekcioglu O, Karacagil M. A comparison of various methods to burst Foley catheter balloons and the risk of free-fragment formation. Br J Urol. 1996;77(5):716-718. doi:10.1046/j.1464-410x.1996.98017.x
22. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(5):625-663. doi:10.1086/650482
23. Werneburg GT, Nguyen A, Henderson NS, et al. The Natural History and Composition of Urinary Catheter Biofilms: Early Uropathogen Colonization with Intraluminal and Distal Predominance. J Urol. 2020;203(2):357-364. doi:10.1097/JU.0000000000000492
24. Kashefi C, Messer K, Barden R, Sexton C, Parsons JK. "Incidence and prevention of iatrogenic urethral injuries." J Urol. 2008;179(6):2254-7. doi:10.1016/j.juro.2008.01.108
25. Davis NF, Quinlan MR, Bhatt NR, et al. "Incidence, Cost, Complications and Clinical Outcomes of Iatrogenic Urethral Catheterization Injuries: A Prospective Multi-Institutional Study." J Urol. 2016;196(5):1473-1477. doi:10.1016/j.juro.2016.05.114
26. Croghan SM, Hayes L, O'Connor EM, et al. "A Prospective Multi-Institutional Evaluation of Iatrogenic Urethral Catheterization Injuries." J Invest Surg. 2022;35(10):1761-1766. doi:10.1080/08941939.2022.2109226
27. Higgins WL, Mace AH. "Puncture of a nondeflatable Foley balloon using ultrasound guidance." Radiology. 1984;151(3):801. doi:10.1148/radiology.151.3.6718745
28. Reid S, Brocksom J, Hamid R, et al. "British Association of Urological Surgeons (BAUS) and Nurses (BAUN) consensus document: management of the complications of long-term indwelling catheters." BJU Int. 2021;128(6):667-677. doi:10.1111/bju.15406
29. Marschall J, Carpenter CR, Fowler S, Trautner BW. "Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter: meta-analysis." BMJ. 2013;346:f3147. doi:10.1136/bmj.f3147
30. Teleflex. Rüsch Standard Urology. 2009. "Eight removal methods which can be used when the Foley catheter will not deflate," appendix, p. 62. Manufacturer catalog.