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Three-Way (Triple-Lumen) Foley Catheter

A three-way catheter has separate channels for drainage, balloon inflation, and irrigation. Continuous bladder irrigation (CBI) helps maintain drainage and prevent further clot retention during significant hematuria or after selected urologic operations. It does not replace evacuation of an obstructing clot or definitive treatment of ongoing bleeding.[1][2]

Device selection​

FeatureWhat to check
Drainage and irrigation channelsFrench size describes the outside diameter, not the size of each lumen or drainage eye. Catheters of the same French size can have different flow characteristics.
DiameterClot evacuation commonly requires a large-bore catheter, often 22–24 Fr, but choose for urethral anatomy, clot burden, and the operation. A small postoperative reconstructive catheter should not be blindly exchanged for a larger one.
BalloonUse the model-specific labeled inflation volume and fluid. Do not treat a 30-mL balloon as permission to inflate to 50–60 mL. Any operative balloon traction requires a documented specialist plan.
MaterialSilicone, latex-containing, and other designs exist. Check the entire device for latex; a PVC shaft does not establish that its balloon is latex-free.
TipStandard rounded, curved, and open/whistle-tip designs have different handling requirements. Use an experienced operator for unfamiliar or specialized designs.

EAUN provides device-selection and balloon-handling guidance. For example, Teleflex's Soft Simplastic three-way 30-mL product has a PVC shaft and a latex balloon; this is a product-specific construction and does not define all three-way catheters.[3][4]

The three channels differ in size and role.

ChannelRoleNotes
DrainageOutflow of urine and irrigant to the collecting bagLargest lumen. Cross-sectional area (CSA) at a given French size varies by brand.
Balloon inflationFills the retention balloonSmallest lumen. Labeled volume is commonly 30 mL for three-way models, as in the Teleflex product above.
Irrigation inflowDelivers irrigant to the catheter tipConnects to the irrigation set through a side port.

Sizes from 16 to 26 Fr were tested in the bench studies below.[14] A 22 Fr or larger catheter is recommended for clot retention in the CATCH-22 protocol.[7]

Flow evidence​

Bench studies show that lumen cross-sectional area and drainage-eye design affect flow. Increasing French size does not necessarily improve every irrigation or washout measure. These experiments explain device behavior. They do not show that one brand prevents clinical bleeding, infection or rupture better than another.[5][6]

  • Davis 2016 measured 22 Fr catheters from four brands. Irrigation-channel and drainage-channel CSA predicted flow, whereas overall CSA and French size did not. The Rusch Simplastic had the largest irrigation channel (2.87 mm²) and the highest flow (irrigation 5.27 ± 0.02 mL/s). The Rusch Golden had the smallest (1.34 mm²) and the lowest (irrigation 1.83 ± 0.03 mL/s). The authors proposed labeling by channel CSA in place of outer diameter alone.[5]
  • Braasch 2006 tested Bardex and Dover catheters (16 to 26 Fr) with a 2-L bag 80 cm above the catheter and a 30-mL balloon. Bardex 22 and 24 Fr gave higher manual irrigation flow through the irrigation port (8.9 ± 1.3 and 9.5 ± 1.5 mL/s) than the same sizes of Dover. Manual flow through the drainage port was equal between brands. Continuous gravity flow was 1.6 ± 0.1 mL/s (22 Fr) and 1.7 ± 0.0 mL/s (24 Fr) for Bardex, and lower for Dover.[14]
  • Manikandan 2009 tested 14 catheters from four manufacturers. For manual washout through the drainage port, 18 and 20 Fr Rusch catheters outperformed the other brands. At 22 and 24 Fr the brands were equivalent, and larger size did not improve continuous irrigation.[6]

When irrigation is appropriate​

CBI may be used for persistent bleeding after clot clearance, anticipated clot obstruction after prostate or bladder surgery, or selected hemorrhagic cystitis. It is not automatically required after TURBT, radical cystectomy, urethroplasty, or every bladder reconstruction. Mucus management in a bowel reservoir is a separate, procedure-specific problem.[1][2][3]

After a fresh bladder repair, urinary anastomosis, or deep bladder resection, confirm the irrigation and catheter-exchange plan with the operating or urology team. The August 2026 NSW Agency for Clinical Innovation toolkit emphasizes gentle irrigation and experienced review because pressure or reinstrumentation can disrupt sutures or cause perforation.[1]

Settings in which irrigation is used​

  • After prostate surgery. A three-way catheter with a 30-mL balloon is the usual configuration after TURP and open simple prostatectomy, both to tamponade the prostatic fossa and to run CBI. Balloon traction, where used, follows the surgeon's plan (see the balloon row above).
  • After TURBT and other bladder resections. CBI is used when clot formation is anticipated, not routinely.
  • Gross hematuria with clot retention. In a single-center retrospective series of 120 admissions for macroscopic hematuria, 62% (74/120) needed bladder irrigation for a mean of 3 days, and 10% (12/120) needed emergency rigid cystoscopy and washout. One-year mortality in that older cohort (mean age 78 years) was 23%.[15]
  • After reconstruction. Most urethroplasty and bladder-repair patients are drained with a plain two-way catheter, so irrigation pressure does not reach the repair. Irrigation is added only when active bleeding requires it.[1]

Safe CBI setup and monitoring​

Use a documented indication or order, trained personnel, sterile equipment, aseptic technique, and sterile 0.9% sodium chloride for standard CBI. Confirm catheter position and free drainage before starting. Connect inflow to the irrigation port and outflow to the closed drainage system; balloon inflation is a separate port.[1][2]

Adjust gravity inflow to the clinical bleeding and clot burden while repeatedly checking drainage, pain, bladder distension, and the patient's observations. Pale effluent can reflect dilution and does not alone establish control of bleeding. Do not improvise a pressure system to overcome an obstructed catheter.[1][2]

If drainage falls behind inflow

Stop the irrigation inflow for absent or inadequate drainage, increasing pain or distension. Check tubing, catheter patency, fluid balance, and position; obtain prompt experienced help when obstruction cannot be relieved. Continuing to fill an obstructed bladder can cause overdistension, extravasation, or rupture. New autonomic dysreflexia in a susceptible patient is an emergency.[1]

Record irrigant instilled and total drainage separately:

Estimated urine output = total collected drainage − irrigation fluid instilled.

For example, 2,400 mL drained after 2,000 mL irrigant gives 400 mL estimated urine output. Incomplete return, leakage, inaccurate measurement, or retained irrigant makes this estimate unreliable and requires assessment. Monitor hematuria, clots, hemoglobin and hemodynamics as appropriate; persistent bleeding may need cystoscopy or clot evacuation and hemostasis.[1][2]

Irrigation methods and outcomes​

Traditional gravity CBI depends on adjusting inflow to the color of the effluent, which is subjective. A 2025 device paper reports complications in roughly 50% of patients receiving CBI and attributes them to manual flow adjustment and subjective color assessment.[13] Two alternatives have been tested:

  • Pressurized inflow. In a prospective series, a sphygmomanometer bulb added to the irrigant bag reduced clot retention about twofold after open prostatectomy, TURP and TURBT compared with the department's earlier gravity system (545 comparison cases; p = 0.001), with no bladder perforation reported.[11] This was a single-center study with a non-concurrent comparator. It does not change the rule against improvising pressure systems on the ward.
  • Automated flow control. In a randomized trial of 146 patients after TURP (n = 76 automated, n = 70 manual), a wireless-sensor controller lowered mean irrigation volume from 54.6 ± 5.4 to 24.2 ± 3.8 L, clot retention from 21/70 to 8/76, and cystospasm from 39/70 to 12/76. Irrigation time was similar (about 29 hours).[12]

Manual clot evacuation​

A trained clinician may perform gentle manual washout through the drainage lumen with sterile saline and a catheter-tip syringe, stopping CBI inflow during the maneuver. Avoid accumulating fluid when return is poor. Persistent blockage, pain, inability to recover irrigant, or a recent reconstruction warrants specialist review rather than forceful repeated flushing or unsupervised recatheterization.[1][2]

The 2018 CATCH-22 report highlighted inadequate catheter size and incomplete clot clearance at referral. Its “last clot plus 1 L” rule was a proposed local protocol; the approximately 5.4 L reported was a mean observed washout volume, not a required dose for every patient. The endpoint is safe clot clearance and drainage, with the bladder and repair protected; achieving a fixed volume is not the endpoint.[7]

Infection prevention and medicated irrigation​

CDC recommends closed continuous irrigation when obstruction is anticipated, but not routine antimicrobial bladder irrigation to prevent infection. Use appropriate indications, aseptic handling, a closed system, and the shortest necessary duration.[8]

A 2022 retrospective trauma-center comparison associated gentamicin irrigation with fewer CAUTIs; it excluded traumatic bladder injuries and used a historical control. It does not establish a general prophylaxis policy for postoperative reconstructions or all catheterized patients. The EAU 2026 infections guideline gives strong recommendations against applying topical antiseptics or antimicrobials to the catheter, urethra or meatus and against prophylactic antimicrobials to prevent catheter-associated UTI.[16] Medicated instillations have their own indications, absorption risks and prescriptions; see the UTI prophylaxis pharmacology hub.[9]

Complications​

  • Clot retention and catheter obstruction. These are the usual problems. Manual washout (above) and a catheter of adequate size treat them.[7][10]
  • Bladder spasm. Spasm is a recognized catheter complication and is usually treated with antimuscarinics or beta-3 agonists.[10]
  • Bypass leakage. Obstruction or spasm is the usual cause, and both are excluded before the balloon volume is increased.[10]
  • Infection. CAUTI risk increases with catheter duration, so duration is kept as short as possible.[8][10]
  • Urethral trauma. Large-bore insertion needs generous sterile lubricant and gentle technique. A 24 Fr catheter is not chosen when 22 Fr clears the clot.
  • Balloon traction injury. Excessive or prolonged traction on an inflated balloon has been described to cause bladder-neck necrosis, fistula or incontinence.
  • Lower flow than a two-way catheter. The drainage and irrigation lumens are smaller per French size than the drainage lumen of a two-way catheter of the same size.

Stopping irrigation and ongoing care​

Reassess the indication daily and follow the operation-specific plan. Before stopping, assess stability of bleeding, clot burden and drainage during an appropriate observation period. Irrigation cessation and catheter removal are separate decisions. Continue to assess blockage, bypass leakage, spasm, urethral pressure injury and infection using the Foley catheter principles.[1][2][3]

References​

1. NSW Agency for Clinical Innovation. Bladder irrigation toolkit. August 2026. Adult acute/inpatient practice guidance.

2. British Association of Urological Surgeons. Bladder washout and continuous bladder irrigation. Trainee guidance.

3. European Association of Urology Nurses. Indwelling catheterisation in adults—urethral and suprapubic. 2024. Equipment, complications and irrigation chapters.

4. Teleflex. Soft Simplastic Foley—three-way, 30 mL. Manufacturer product information; consult the package instructions.

5. 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;89:155-159. doi:10.1016/j.urology.2015.12.022

6. Manikandan R, Selvaratnam V, Philip J, et al. Evaluation of flow characteristics of 3-way catheters. J Urol. 2009;181(4):1922-1925. doi:10.1016/j.juro.2008.11.094

7. 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):2043-2050. doi:10.1007/s00345-018-2346-z

8. CDC. CAUTI prevention: summary of recommendations. 2009 guideline; web summary updated 2024.

9. 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):627-631. doi:10.1097/TA.0000000000003671

10. Fletke KJ, Jeong DH, Herrera AV. Urinary catheter management. Am Fam Physician. 2024;110(3):251-258. PMID 39283848

11. Moslemi MK, Rajaei M. An improved delivery system for bladder irrigation. Ther Clin Risk Manag. 2010;6:459-462. doi:10.2147/TCRM.S13525

12. 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 (Baltimore). 2016;95(52):e5721. doi:10.1097/MD.0000000000005721

13. 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):72-75. doi:10.1109/MPULS.2025.3572587

14. Braasch M, Antolak C, Hendlin K, et al. Irrigation and drainage properties of three-way urethral catheters. Urology. 2006;67(1):40-44. doi:10.1016/j.urology.2005.07.007

15. Pavithran A, Bhatt NR, Banerjee G, Hawizy A. Management of inpatient macroscopic haematuria: a typical urology emergency with a high mortality. Urology. 2022;166:22-28. doi:10.1016/j.urology.2022.05.015

16. European Association of Urology. EAU Guidelines on Urological Infections (section 3.8.4.h). 2026 limited update, March 2026. Full guideline.