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.

On this page:

• Health professionals who can perform bladder irrigation
• Compliance with relevant guidelines
• Required documentation
• Three-way catheters
• Patient care considerations

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
• Registered nurse

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:

• Insertion and Management of Urethral Catheters for Adult Patients (GL2021_015)
  Best practice principles for inserting and managing urethral catheters for adult patients.
• Catheter-associated Urinary Tract Infection (CAUTI) Prevention (Clinical Excellence Commission)
  An aseptic technique must be used to minimise the risk of CAUTI resulting from contamination or a breach in the closed urinary drainage system.
• Infection Prevention and Control in Healthcare Settings (PD2023_025)
  Policy directive outlining the broad principles of infection prevention and control.
• Medication Handling (PD2022_032)
  Standards for the procurement, storage, prescribing, supply, dispensing, administration and documentation of medications in NSW public health facilities.

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

Manual bladder irrigation involves flushing a 3-way or 2-way urinary catheter manually with sterile sodium chloride 0.9% using a catheter-tipped syringe to evacuate all clots.

Manual irrigation may be followed by continuous bladder irrigation to minimise the risk of further clot formation and overdistention of the bladder.

The optimal outcome is removal of clots from the bladder, with the urine draining freely. Some sub‑optimal outcomes include the following:

• Overdistention of the bladder.
• Bladder rupture.
• Inability to clear clot in bladder, which may require catheter replacement or surgical removal of the clot. Consider replacement with a larger gauge (with larger drainage holes) or 3-way catheter, if the blocked catheter was a smaller gauge or a 2-way catheter.
• Development of a catheter-associated urinary tract infection (CAUTI) secondary to contamination during the procedure.
• Development of a CAUTI secondary to a break in the closed urinary drainage system and possible contamination during the procedure.

Manual irrigation must be gentle, as the increased pressure in the bladder can result in suture disruption or bladder perforation with resultant extravasation of urine.

Use sterile equipment and aseptic techniques for this procedure.

Use the Manual (intermittent) bladder irrigation checklist (PDF 226.4 KB) to demonstrate competency to safely perform this procedure.

Ordering and documenting manual bladder irrigation

While not contraindicated in patients who have had deep resection of bladder tumours, open bladder or renal transplant surgery, manual bladder irrigation must be ordered and documented by a urology medical officer or practitioner and be performed by an experienced clinician.

Documentation should include the reason for irrigation, volume instilled and returned, presence of clots or debris, patient tolerance, catheter patency post-procedure and any escalation.

If the catheter is blocked and the patient is within 72 hours of urological surgery, notify the urology registrar or consultant urologist. This is important following a transurethral resection of prostate (TURP) due to the risk of prostatic capsular perforation or sub‑trigonal catheter placement on reinsertion. It is also important following radical prostatectomy and bladder resection due to the risk of possible damage to surgical anastomosis and bladder perforation.

Nursing staff (unless an experienced urology nurse) and resident medical officers must not attempt re‑catheterisation unless authorised by a urology registrar or consultant urologist.

Equipment

• Personal protective equipment (PPE)
• Alcohol‑based hand rub
• 1 sterile catheter pack, a sterile dressing pack, or similar, to provide a sterile field
• 1 sterile kidney dish or sterile receptacle of at least 1 L volume (pending pack inclusion)
• 1 sterile catheter-tip 50 mL syringe
• Cleaning wipes, as per LHD supply and environmental cleaning protocols
• 6 x alcohol swabs, as per LHD supply (70% alcohol swabs, or 2% chlorhexidine and 70% alcohol swabs)
• 1 bottle 500 mL sterile sodium chloride 0.9%
• 1 sterile urinary drainage bag
• Disposable underpad
• Sterile gloves
• For clean, no-touch technique: a clean, non-sterile receptacle placed on lower shelf of the trolley, or on a separate trolley for drainage collection
• For sterile technique: an additional sterile kidney dish or sterile 1 L jug positioned within the sterile field.

Manual bladder irrigation procedure

Manual bladder irrigation aims to remove clots, restore urinary drainage and maintain catheter patency. Throughout the procedure:

• maintain aseptic technique
• minimise contamination
• support patient comfort and safety
• accurately document outcomes and fluid balance.

Continuous bladder irrigation (CBI) is used to reduce the risk of clots forming and maintain indwelling urinary catheter (IDC) patency by continuously irrigating the bladder via a 3‑way catheter.

The 3‑way catheter allows fluid to flow in and out of the bladder simultaneously. A large gauge IDC allows for drainage of clots and debris.

The use of 0.9% sodium chloride is recommended. Use sterile equipment and aseptic technique.

Monitor continuous bladder irrigation closely to ensure adequate outflow, prevent overdistension, and promptly identify increased bleeding or obstruction.

Use the Continuous bladder irrigation checklist (PDF 210.7 KB) to demonstrate competency to safely perform this procedure.

Equipment

• Personal protective equipment (PPE)
• Alcohol‑based hand rub
• Dressing trolley
• Dressing pack
• 1 or 2 sodium chloride 0.9% irrigation bags, as per LHD policy (irrigation bag volume as per facility procedure)
• Cleaning wipes, as per LHD supply and environmental cleaning protocols
• 6 x alcohol swabs, as per LHD supply (70% alcohol swabs or 2% chlorhexidine and 70% alcohol swabs)
• CBI set
• IV pole
• Sterile gloves
• Waste bag
• Disposable underpad

Continuous irrigation

Continuous bladder irrigation procedure

Continuous bladder irrigation aims to remove clots, restore urinary drainage and maintain catheter patency. Throughout the procedure:

• maintain aseptic technique
• minimise contamination
• support patient comfort and safety
• accurately document outcomes and fluid balance.

Intermittent bladder irrigation provides clinicians with an effective management option for specific clinical scenarios, when required. It is performed via an existing indwelling 2-way or 3-way catheter using a special urinary drainage system with an irrigation port for instilling irrigation fluid.

Maintain the closed catheter system to minimise risk of catheter-associated urinary tract infection.

This intermittent irrigation system can be used for the following patients:

• Patients with moderate haematuria with a 2- or 3‑way catheter. This system can be the first‑line treatment. The catheter does not have to be changed to a 3‑way for continuous irrigation and changed back to 2‑way when haematuria settles.
• Palliative patients whose catheters are frequently blocked with clots or debris. This system will minimise the discomfort associated with catheter changes.
• Patients with a problematic supra‑pubic catheter. This is preferable to manual irrigation, which repeatedly breaks down the closed catheter system.

Review and consider frequency of prior irrigation. Based on the degree of bleeding, and number of clots or amount of debris returned, consider continuous bladder irrigation.

Use the Manual (intermittent) bladder irrigation checklist (PDF 226.4 KB) to demonstrate competency to safely perform this procedure.

Irrigation pump bag

Equipment

• Personal protective equipment (PPE)
• Irrigation set (single spike)
• Irrigation fluid: 1–2 L sodium chloride 0.9% for irrigation (use IV sodium chloride 0.9% if dedicated irrigation fluid is not available)
• Bard irrigation pump bag, or similar (2 L urine collection bag with T irrigation port and hand pump bulb)
• Disposable underpad
• Cleaning wipes, as per LHD supply and environmental cleaning protocols
• 6 x swabs, as per LHD supply (70% alcohol swabs, or 2% chlorhexidine and 70% alcohol swabs)
• Non‑sterile gloves
• IV pole
• Irrigation chart or fluid balance chart

Intermittent bladder irrigation

Intermittent bladder irrigation procedure

Intermittent bladder irrigation aims to remove clots, restore urinary drainage and maintain catheter patency. Throughout the procedure:

• maintain aseptic technique
• minimise contamination
• support patient comfort and safety
• accurately document outcomes and fluid balance.

Bladder irrigation is a common and important clinical procedure performed across NSW Health hospitals.

It maintains urinary catheter patency, prevents clot retention, supports patient recovery following urological surgery and assists with the management of haematuria. It is undertaken by a range of healthcare professionals, including registered nurses, enrolled nurses, nurse practitioners, medical officers, urology registrars and urologists.

Bladder irrigation is performed frequently across a variety of clinical settings, so healthcare professionals need access to practical, evidence-informed guidance that supports safe, consistent and high-quality care.

This toolkit replaces the 2022 guide Bladder Irrigation: Management of Haematuria.

Why we developed this resource

The Urology Network developed this resource to provide clinicians with accessible, best practice guidance on bladder irrigation practice. It supports clinicians to quickly access guidance at the point of care and promotes a consistent approach across NSW Health services.

The resource addresses the need for contemporary, practical guidance on the 3 key methods of bladder irrigation:

• Manual bladder irrigation
• Continuous bladder irrigation
• Intermittent bladder irrigation

It also provides information on equipment, documentation requirements, patient care considerations, cultural safety, troubleshooting and clinician competency assessment.

How we developed this resource

We developed this resource through consultation and collaboration with clinicians and organisations involved in urological and continence care across NSW. This included urology and continence nurses, clinical nurse consultants, nurse practitioners, and specialist urologists working in both hospital and community settings.

Representatives from the following organisations provided input:

• Local health districts and specialty health networks
• Clinical Excellence Commission
• Urological Society of Australia and New Zealand
• Australia and New Zealand Urological Nurses Society (NSW-ACT Section)

The content was developed through a review of current evidence, clinical practice guidance and expert clinical consensus to ensure information reflects contemporary best practice.

Who this resource is for

This resource has been designed for healthcare professionals working in acute and inpatient settings who are involved in the assessment, management and performance of bladder irrigation for adult patients. It supports both experienced clinicians and those developing competence in bladder irrigation practice.

Considerations for culturally safe care

Care should be sensitive to cultural, religious and interpersonal differences, including (but not limited to) sexual orientation, gender identity, and physical and intellectual abilities.

As bladder irrigation involves close personal care and can be a sensitive procedure, clinicians should:

• use clear, respectful communication
• seek patient preferences, including clinician gender, where possible
• provide culturally safe, trauma-informed care.

Engage a professional interpreter service for individuals, their partners or support people who are deaf and hearing impaired, or from culturally and linguistically diverse backgrounds. Interpreters can be accessed via NSW Health Care Interpreting Services.

Provide care in a culturally safe and responsive way. For Aboriginal patients, include Aboriginal Health Workers and Aboriginal Liaison Officers in care pathways to help promote cultural safety, assist with navigating the health system, advocate for patient needs, and facilitate effective communication.

Bladder irrigation may be considered sensitive for many Aboriginal women, often recognised as Women’s Business, and should be approached with privacy and respect. Where possible, offer care from female clinicians to support cultural preferences.

Clinicians should take time to yarn with patients and engage in respectful, open conversations about their care. This helps clinicians understand individual preferences, avoid assumptions and, where appropriate, involve family or community supports. These discussions should:

• be guided by what is important to the patient
• be informed by best clinical practice
• use plain language and culturally appropriate resources.

Shared decision-making is important when making decisions in healthcare. The Finding Your Way shared decision-making model is a holistic, 2-way process where Aboriginal people and clinicians make decisions together.

Acknowledgements

We recognise and thank the following people who were involved in the development of this resource.

• Tammie Jones, Clinical Nurse Consultant, John Hunter Hospital and Co-Chair, Urology Network
• Jemma Archbold, Clinical Nurse Consultant Urology, Gosford Hospital
• Virginia Ip, Certified Urology Nurse Practitioner, private practice
• Eon Lee, Transitional Nurse Practitioner, War Memorial Hospital
• Jinwa Li, Clinical Nurse Consultant, Prince of Wales Community Health
• Anju Somanathan Nair, Continence Clinical Nurse Consultant, Western Sydney LHD
• Jennifer Mojica, Clinical Nurse Consultant Urology, Royal North Shore Hospital
• Madhuri Manandhar, Clinical Nurse Consultant Continence, St George Integrated Community Health
• Professor Manish Patel, Urological Cancer Surgeon, Westmead Hospital and Co-Chair, Urology Network
• Michelle Paul, Nurse Practitioner Continence, John Hunter Hospital