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Three-Way (Triple-Lumen) Foley Catheter

Triple-lumen Foley catheter with separate channels for drainage, balloon inflation, and continuous-irrigation inflow — the standard device for continuous bladder irrigation (CBI) after TURP, simple prostatectomy, TURBT, and gross-hematuria / clot-retention management. The large-bore (22–24 Fr typical) shaft, dedicated irrigation channel, and 30 mL retention balloon distinguish it from the 2-way Foley described on the Foley catheter page.[1][2]

Design​

Three distinct channels run the length of the catheter:

LumenPurposeTypical features
Drainage (largest)Urine + irrigant outflow to gravity bagSized to maximize CSA at a given French
Balloon inflation (smallest)Retention balloon — 30 mL the standard for post-TURP prostatic-fossa tamponadeStandard Luer-style inflation port
Irrigation inflowSaline (or antimicrobial solution) infusion at the catheter tipSide inflow port for spike / drip set
  • Sizes — 16–26 Fr; 22 Fr and 24 Fr are the standard CBI choices.[2][3]
  • Material — usually PVC (the rigidity tolerates the triple-lumen wall geometry); silicone and latex variants exist.[1]
  • Balloon — 30 mL standard for post-TURP prostatic-fossa hemostasis; can be set to 50–60 mL under direct vision for active fossa bleeding (with the caveats that high-volume inflation risks bladder-neck injury and ischemic necrosis if over-traction is applied).

Flow Characteristics — Brand and CSA Matter​

French gauge alone does not predict flow. Davis 2016 measured channel cross-sectional area (CSA) across brands at 22 Fr and found:[4]

  • Rusch Simplastic 22 Fr — largest irrigation-channel CSA at 2.87 mm² and highest flow.
  • Rusch Golden 22 Fr — smallest irrigation-channel CSA at 1.34 mm² and lowest flow.

Braasch 2006 in-vitro testing:[2]

CatheterManual irrigation flow (port)Continuous gravity flow
Bardex 22 Fr8.9 ± 1.3 mL/s1.6 ± 0.1 mL/s
Bardex 24 Fr9.5 ± 1.5 mL/s1.7 ± 0.0 mL/s
Dover (same sizes)Lower (p < 0.05)Lower

Manikandan 2009 confirmed that larger French ≠ better CBI flow; in their bench testing, 18 and 20 Fr Rusch catheters out-performed other brands for drainage-port washout flow.[5]

These data have prompted proposals for an alternative labeling system based on individual-channel CSA rather than overall outer diameter.[4]

Reconstructive-Urology Uses​

Postoperative continuous bladder irrigation (CBI)​

  • Post-TURP — 22 Fr (or larger) three-way catheter with 30 mL balloon for fossa tamponade and CBI; the standard configuration since the 1970s.[1][6]
  • Post-TURBT — CBI to prevent clot formation in the immediate postoperative period.[7]
  • Open simple prostatectomy — CBI to clear clot from the bladder and capsulotomy bed.
  • Radical cystectomy / open stone surgery — CBI for the early postoperative period when gross hematuria is anticipated.
  • Post-reconstructive drainage with irrigation — selected cases of urethroplasty, augmentation cystoplasty, or bladder-repair where active irrigation is needed (most reconstructive cases use a 2-way Foley to protect the anastomosis without irrigation pressure).

Gross hematuria with clot retention​

  • The international (Lancet ID 2020) RICAT framework lists CBI as one of the appropriate indications for urinary catheterization — implying the three-way catheter is the appropriate device.[8]
  • Pavithran 2022 inpatient series — 62% of macroscopic-hematuria admissions required bladder irrigation for a mean of 3 days; 10% required emergency rigid cystoscopy and washout when catheter-based management failed.[9]

Antimicrobial bladder irrigation​

  • The FDA-labeled neomycin / polymyxin B irrigation solution is designed for delivery through the irrigation port at ~ 1,000 mL / 24 h for up to 10 days to prevent bacteriuria in selected catheterized patients.[10]
  • Prophylactic gentamicin bladder irrigation in critically ill trauma patients was associated with zero CAUTI vs 4.3 / 1,000 catheterized days in controls (p = 0.018) in Rieger 2022.[11]

CBI Technique​

  1. Insert the three-way catheter with aseptic technique and sterile lubricant; size 22 Fr or larger if clot management is the goal.
  2. Inflate the balloon to 30 mL (or higher for fossa traction in post-TURP bleeding).
  3. Connect the irrigation inflow to a 2–3 L normal-saline bag suspended ~ 80 cm above the catheter.
  4. Connect the drainage lumen to a closed gravity bag below bladder level.
  5. Titrate inflow rate to effluent color — target light pink to clear; the assessment is subjective and labor-intensive.[7][12]

CBI Outcomes and Refinements​

  • ~ 50% complication rate with traditional gravity CBI — largely from labor-intensive manual flow adjustment and subjective color assessment.[12]
  • Pressurized irrigant (sphygmomanometer-bulb system) reduced clot retention 2× vs gravity (p = 0.001) without bladder perforation in Moslemi 2010.[7]
  • Automated CBI with wireless sensors reduced mean irrigation volume from 54.6 ± 5.4 L → 24.2 ± 3.8 L (p < 0.001) in Ding 2016.[13]

Manual Bladder Washout (MBW) — the CATCH-22 Protocol​

When the three-way catheter obstructs with clot, manual bladder washout via the drainage port is the corrective maneuver. Clarebrough 2018 proposed the CATCH-22 protocol:[3]

  • Use a catheter ≥ 22 Fr.
  • "Last clot + 1 L" rule — irrigate at least 1 L beyond the last visible clot.
  • Audit data showed referring teams routinely used 16–20 Fr catheters and mean washout volume 145 mL vs the recommended ~ 5,400 mL — an explanation for repeated washout failure.

Safety Profile​

  • Clot retention / catheter obstruction — the most common complication; managed by MBW per CATCH-22.[3]
  • Bladder spasms — anticholinergics or β3-agonists; B&O suppositories are still used in some institutions.[14]
  • CAUTI — risk increases with dwell time; minimize duration and consider prophylactic irrigation in high-risk populations per Rieger 2022.[11]
  • Urethral trauma from large-bore insertion — generous sterile lubricant, gentle technique; avoid 24 Fr if a 22 Fr will do the work.[14]
  • Bypass leakage around the catheter — usually obstruction or spasm; investigate before increasing balloon volume.[14]
  • Over-traction injury — when the inflated balloon is used for fossa traction, excessive or prolonged traction can cause bladder-neck necrosis, fistula, or incontinence.

Limitations​

  • Drainage and irrigation channels are both smaller per French than the equivalent 2-way; flow is therefore less than the same-French 2-way Foley.
  • Subjective effluent-color titration is unreliable and labor-intensive — the most cited problem with CBI workflow.[12]
  • PVC stiffness can increase urethral trauma on insertion vs softer silicone variants.

References​

1. Phipps S, Lim YN, McClinton S, et al. "Short-term urinary catheter policies following urogenital surgery in adults." Cochrane Database Syst Rev. 2006;(2):CD004374. doi:10.1002/14651858.CD004374.pub2

2. Braasch M, Antolak C, Hendlin K, et al. "Irrigation and drainage properties of three-way urethral catheters." Urology. 2006;67(1):40–4. doi:10.1016/j.urology.2005.07.007

3. Clarebrough E, McGrath S, Christidis D, Lawrentschuk N. "CATCH-22: a manual bladder washout protocol to improve care for clot retention." World J Urol. 2018;36(12):2043–50. doi:10.1007/s00345-018-2346-z

4. Davis NF, Abdelrahman M, Cunnane CV, et al. "The variable flow characteristics for different brands of 3-way urinary catheters: proposing an alternate and accurate standardised labelling system." Urology. 2016;89:155–9. doi:10.1016/j.urology.2015.12.022

5. Manikandan R, Selvaratnam V, Philip J, et al. "Evaluation of flow characteristics of 3-way catheters." J Urol. 2009;181(4):1922–5. doi:10.1016/j.juro.2008.11.094

6. Wu Y, Chen B, Liu C. "Multivariate analysis of the failure of removal of the urinary catheter within 48 hours after transurethral enucleation and resection of the prostate." Biomed Res Int. 2020;2020:8241637. doi:10.1155/2020/8241637

7. Moslemi MK, Rajaei M. "An improved delivery system for bladder irrigation." Ther Clin Risk Manag. 2010;6:459–62. doi:10.2147/TCRM.S13525

8. Laan BJ, Maaskant JM, Spijkerman IJB, et al. "De-implementation strategy to reduce inappropriate use of intravenous and urinary catheters (RICAT): a multicentre, prospective, interrupted time-series and before-and-after study." Lancet Infect Dis. 2020;20(7):864–72. doi:10.1016/S1473-3099(19)30709-1

9. Pavithran A, Bhatt NR, Banerjee G, Hawizy A. "Management of inpatient macroscopic haematuria: a typical urology emergency with a high mortality." Urology. 2022;166:22–8. doi:10.1016/j.urology.2022.05.015

10. US Food and Drug Administration. "Neomycin and polymyxin B sulfates solution for irrigation — product labeling." Accessed 2025.

11. Rieger RM, Bonnin SS, Hopp MJ, et al. "Can we really make catheter-associated urinary tract infections a never event? A level 1 trauma center's experience with prophylactic antibiotic bladder irrigation." J Trauma Acute Care Surg. 2022;93(5):627–31. doi:10.1097/TA.0000000000003671

12. Agrawal A, Chabbi A, Chan R, et al. "Automated and intuitive UTI and blood clot prevention device for continuous bladder irrigation." IEEE Pulse. 2025;16(3):72–5. doi:10.1109/MPULS.2025.3572587

13. Ding A, Cao H, Wang L, et al. "A novel automatic regulatory device for continuous bladder irrigation based on wireless sensor in patients after transurethral resection of the prostate: a prospective investigation." Medicine. 2016;95(52):e5721. doi:10.1097/MD.0000000000005721

14. Fletke KJ, Jeong DH, Herrera AV. "Urinary catheter management." Am Fam Physician. 2024;110(3):251–8.