Performing bladder irrigation

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Who can perform bladder irrigation, the relevant guidelines that must be followed, required documentation, and patient care considerations.

Bladder irrigation involves flushing the bladder with a sterile solution to prevent blood clot formation, maintain urinary catheter patency, and ensure the free flow of urine. It is usually performed following urological surgery, or when haematuria or blood clots are present.

Bladder irrigation is generally not recommended in community or home settings due to limitations in equipment, staffing and escalation pathways. In exceptional circumstances, such as patients with spinal cord injury experiencing autonomic dysreflexia or patients receiving end-stage palliative care, bladder irrigation may be considered in the community. In these cases, clinicians must follow local policies and escalation processes.

Separate clinical guidance should be developed for community practice to ensure safety and compliance with relevant guidelines.

This resource is not intended for use in maternity settings. In these settings, bladder irrigation should only be undertaken following medical assessment and in accordance with local maternity and local health district (LHD) policies.

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Health professionals who can perform bladder irrigation

The following health professionals can perform bladder irrigation:

  • Medical officers
  • Registered nurses (RNs) and higher-grade nursing positions
  • Accredited endorsed enrolled nurses
  • Undergraduate student nurses under the direct supervision of an RN who has been assessed as competent (at the discretion of the university the student attends and local LHD guidelines)
  • Urologists or urology registrars

Roles and responsibilities

Medical officer

  • Documents the order and clinical indication for bladder irrigation in clinical progress notes
  • Reviews the bladder irrigation at least daily
  • Responds to escalation for review

Registered nurse

  • Maintains patient comfort
  • Educates the patient on the bladder irrigation process
  • Ensures urinary catheter patency and that urine drains freely
  • Monitors the degree of haematuria and the presence of clots, adjusting the irrigation fluid infusion rate accordingly
  • Ensures an adequate supply of infusing fluids is nearby and stored at room temperature to avoid bladder spasm
  • Completes documentation (accurate record of urine output, urine colour and degree of haematuria, presence of clots, and whether manual bladder irrigation was required)
  • Completes documentation at least daily and adjusts medical order as required
  • Provides catheter care, securing the indwelling urinary catheter (IDC) appropriately to minimise movement
  • Escalates to medical officer for review if worsening haematuria or unable to maintain catheter patency

Note: Nurse practitioners who are authorised within their specialty scope can assess the need for bladder irrigation, order the procedure and provide ongoing management of bladder irrigation.

Competency

All health professionals performing bladder irrigation should have completed a clinical skills or competency assessment. They must demonstrate the necessary knowledge, understanding of associated risks and competency to the standard required by the LHD or healthcare provider.

Compliance with relevant guidelines

Health professionals should follow the LHD or healthcare provider’s guidelines on urinary catheterisation and bladder irrigation. The following guidelines should also be followed:

Compliance with these guidelines will:

  • maintain urinary catheter patency
  • improve patient comfort
  • prevent or minimise blood clot formation
  • reduce risk of CAUTI.

Required documentation

When performing bladder irrigation, the following documentation is required.

Clinical progress notes:

  • Indication/order for irrigation, e.g. post transurethral resection of the prostate (TURP) or transurethral resection of bladder tumour
  • Report on clot retention, haematuria and catheter blockage
  • Method of bladder irrigation (continuous bladder irrigation, intermittent bladder irrigation via irrigation pump bag and manual bladder irrigation)
  • Complications, e.g. bladder spasm, lower abdominal pain, leakage around catheter, negative fluid balance
  • Medical review at least daily
  • Order for irrigation to cease

Fluid balance chart:

  • Amount of irrigation fluid instilled
  • Urine output
  • Degree of haematuria
  • Presence of clots

True urine output is measured by subtracting the volume of irrigation fluid instilled from the total volume emptied. For example, if the patient has had a 2 L irrigation bag instilled and the total output is 2400 mL, the true urine output is 400 mL (2400 mL output – 2000 mL irrigation fluid).

Clinicians may choose to record patient information in a bladder irrigation chart before entering the information into the electronic medical record.

Three-way catheters

Three-way urinary catheters are used in bladder irrigations. A 3‑way standard (round) tip catheter has 3 ports, these are:

  • irrigation channel
  • drainage channel
  • balloon channel.

A 3‑way whistle tip catheter has the same ports but a differently shaped tip, which is open and bevelled to facilitate drainage of blood clots. Insertion of whistle tip catheter is usually performed by urologists or urology registrars.

Patient care considerations

Clinicians should be aware of the following signs and symptoms of a blocked catheter:

  • No urine flow from the catheter
  • Suprapubic distention and lower abdominal pain, becoming more pronounced as the bladder fills
  • Urine leaking around the catheter (bypassing)
  • Development of vasovagal symptoms, such as sweating, tachycardia and hypotension
  • Autonomic dysreflexia in patients with a spinal cord injury at or above T6 level. This is a medical emergency characterised by a sudden and dangerous rise in blood pressure.

More on the treatment of autonomic dysreflexia for adults and adolescents with spinal cord injuries

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IssueActions

Leakage around the catheter (bypassing)

  • Assess for obstruction.
  • Assess for bladder spasm.
  • Avoid cold irrigation fluid.
  • Ensure the IDC is secured to the patient’s thigh to minimise catheter movement.

The patient is experiencing pain

  • Turn off the irrigation and check for kinks, loops or clots in the catheter or drainage bag tubing.
  • Assess the bladder for distention via palpation.
  • Performing a bladder scan may be useful to determine bladder volume (if bladder scanner is available).
  • Check drainage to determine if output is adequate.

The amount of drainage is less than the irrigant instilled

  • Turn off the irrigation and check for kinks, loops or clots in the catheter or drainage bag tubing.
  • Palpate the bladder and note any patient pain or discomfort.
  • Performing a bladder scan may be useful to determine bladder volume.
  • Try ‘milking’ the IDC to dislodge clots.
  • Check the height of the IV pole and for overflowing of the drip chamber (can affect patency).
  • Recalculate the true output, i.e. subtract the volume of irrigation fluid instilled from the total volume emptied for the true output volume.
  • Use of a closed intermittent irrigation system (preferred) or manual irrigation may be required if obstruction is the cause (refer to facility guidelines). If unsuccessful, notify the relevant medical officer.

There is an increase in haematuria or clots present

  • Increase the infusion rate and observe the drainage and patient comfort.
  • Use of a closed intermittent irrigation system (preferred) or manual irrigation may be indicated to aid in clot evacuation if obstruction is suspected (refer to facility guidelines). If unsuccessful, notify the relevant medical officer.

The patient becomes confused or agitated post-TURP

TURP syndrome occurs when there is an overload of irrigation fluid through the prostatic sinuses during the operative procedure. This can lead to confusion, hypertension and hyponatraemia. This is uncommon.

Assess patient for orientation to time, person and place and notify relevant medical officer of patient’s changed status.

Ensure relevant information is available for the medical officer to review, including:

  • time of change in orientation
  • administration of any pain relief
  • amount of irrigant instilled and true output (subtract the volume of irrigation fluid instilled from the total volume emptied for the true output volume).
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