Suprapubic trial without catheter in community settings


Author: Linda Nazarko, an independent consultant nurse

Abstract

An estimated 90 000 people living in the community have long-term indwelling urinary catheters (Gage et al, 2017). Most urinary catheters are initially inserted in hospital (Shackley et al, 2017). In some cases, there are plans to carry out a trial without catheter (TWOC) but in other cases the indication for urinary catheterisation is unclear and/or there are no plans to remove the catheter. Around 50–70% of people with long-term catheters experience problems such as bladder pain, catheter leakage, blockage and urinary tract infection (Youssef et al, 2023). In the past TWOC was routinely carried out in dedicated hospital clinics (Tay et al, 2016), but in recent years increasing numbers of TWOCs have been carried out in the community (Logan and Coghlan, 2022). Suprapubic catheters are often inserted when it is difficult to catheterise urethrally and there can be the sense that suprapubic catheters are permanent (British Association of Urological Surgeons (2025). This article explores suprapubic TWOC in community settings.
Key words
Bladder dysfunction, Suprapubic catheter, Trial without catheter

Introduction

An estimated 90 000 people living in the community have long-term indwelling urinary catheters (Gage et al, 2017). These may be indwelling (Foley) or suprapubic – up to 40% are suprapubic catheters (Gage et al, 2024). Most urinary catheters are initially inserted in hospital (Shackley et al, 2017). Evidence indicates that between 19 and 40% of indwelling urinary catheters inserted in hospital are not clinically required (Fakih et al, 2010; Tiwari et al, 2012; Hu et al, 2015, 2019; Zhao et al, 2022). The individual may be inappropriately catheterised because of staff concerns regarding skin integrity, urinary incontinence or for nursing convenience. Zhao et al (2022) found that the most common reason for older people to be inappropriately catheterised is to reduce nursing workload. 

Urinary catheters are invasive medical devices and there are risks and benefits associated with their use. Around half of adults who have long-term indwelling urinary catheters experience adverse effects (Gage et al, 2017). Figure 1, based on Zhao et al (2022), illustrates the possible level of inappropriate catheterisations. 
 
Figure 1. Use of indwelling urinary catheters in community settings. Based on Zhao et al (2022).
Figure 1. Use of indwelling urinary catheters in community settings. Based on Zhao et al (2022). 

Case history

George McGregor is an 83-year-old man (the patient’s name and details have been changed to protect patient confidentiality). He has had a stroke in the past, and has some left-sided weakness and impaired mobility. Mr McGregor lives alone and has a four times a day package of care and support. He has an indwelling urethral catheter that becomes blocked at least once a week and he requires re-catheterisation often on a weekly basis. Strategies to reduce blockage, including bladder washouts, using a silver catheter and prescribing anticholinergics, have been unsuccessful, as was a community-based trial without catheter (TWOC). A suprapubic catheter was inserted in hospital in an effort to resolve the problem. This was unsuccessful and blockages continued. When the catheter blocked the community rapid response team would visit, attempt to unblock the catheter and re-catheterise if necessary. 

Mr McGregor found this distressing and was becoming quite depressed. His medical records did not indicate why he had been catheterised. Mr McGregor did not know why he had originally been catheterised and his family were also unaware. 

Mr McGregor was under the care of urology and the urology consultant had inserted the suprapubic catheter in an effort to resolve his bladder problems. He was reviewed by the urologist, who advised that Mr McGregor had prostatic hypertrophy. He was commenced on tamsulosin and finasteride and a TWOC planned 3 months later. 

This planned TWOC was successful. Mr McGregor was able to void but complained of severe dysuria. He was treated with an antibiotic on urology advice and the dysuria settled. 

Although consulting with urology and carrying out a TWOC was time consuming it made a huge difference to Mr McGregor’s quality of life, reduced the community nursing workload and ultimately was cost effective. 

Indwelling urinary catheterisation

 

Indications 


In many cases long-term indwelling urinary catheters are necessary and appropriate (Adams et al, 2012), for example:
  • People with neurological disease who are unable to carry out intermittent self-catheterisation may have indwelling urinary catheters as they are unable to void
  • Men with urinary retention may require indwelling urinary catheters on a long- or short-term basis (Fitzpatrick et al, 2012; Serlin et al, 2018)
  • Urinary catheters can enable people with urinary incontinence to remain dry when other methods have failed
  • People who are dying can be enabled to remain at home with use of an indwelling urinary catheter
  • People with severe pressure ulcers may have an indwelling urinary catheter to help the ulcer to heal.

Adverse effects 


The main risks of long-term catheterisation include reduction in bladder capacity, infection, pain, tissue damage, hospital attendances associated with blockage and decreased mobility (Tay et al, 2016; Gage et al, 2024). Suprapubic catheterisation is especially risky in people who are old and frail and carries a 1-year mortality rate of 15.4% (Taheem et al, 2020). Taheem et al (2020) urged clinicians to carefully consider whether suprapubic catheterisation is necessary in this vulnerable group. 

Urinary catheters increase the risk of infection and life-threatening bacteraemia (National Institute for Health and Care Excellence, 2018). Urinary catheters can trigger bladder spasm and cause urinary leakage, pain and discomfort. They can discourage mobility and affect quality of life. Leakage and blockage can lead to a person seeking urgent care including attending the emergency department. 
 
Figure 2. How a urinary catheter can harm health
Figure 2. How a urinary catheter can harm health

Suprapubic catheterisation

Suprapubic catheterisation involves inserting a standard length urinary catheter into the bladder through a small cut in the abdomen. The catheter is held in place with either a suture or more commonly a Foley balloon catheter. The initial insertion of a suprapubic catheter must be undertaken by a clinician with the appropriate skills. Insertion can be done under a local or general anaesthetic and different insertion kits are available for different clinical presentations. The procedure is usually carried out in hospital theatres but some specialist clinicians can insert the initial catheter in home or community settings (Yates, 2016). 
Suprapubic catheterisation is often viewed as ‘permanent’ although it is used to treat some reversible problems (British Association of Urological Surgeons, 2025). 
There are few data on how commonly suprapubic catheters are used in community settings. Gage and colleagues (2024) analysed data from 2009–10 from GP and district nursing records of 624 people who had indwelling catheters for 3 months or more. They found that 60% of people with long-term catheters were male and most of these (71%) were aged 70 years or more. Most (61%) had urethral catheters but almost 40% had suprapubic catheters. Women with long-term catheters tended to be younger, more likely to have neurological disease and suprapubic catheters. Some people managed well, but others required GP, community and hospital support. The researchers found that, in a year, 63% required GP input, 43% contacted out of hours services, 33% required additional community nurse support, 15% attended the emergency department and 14% were admitted to hospital because of problems related to their catheter (Gage et al, 2024). 

Trial without catheter (TWOC)

 

Indications 


The reasons for performing a TWOC include when the indication for catheterisation is unclear – 30–50% of cases (Tiwari et al, 2012; Zhao et al, 2022). Discharge summaries can be incomplete and sometimes may not be received (Langelaan et al, 2017). The catheter may have been inserted because the individual was unable to pass urine but the cause of retention, such as constipation, urethral stricture or prostatic hypertrophy, has now been treated. Sometimes the person may request a TWOC as the adverse effects of the catheter are considered to outweigh any benefits. 
 

Where should a TWOC be carried out?


Traditionally these trials have been carried out as day cases in hospital TWOC clinics. This is changing and TWOCs are increasingly carried out in the community. The Royal College of Nursing (2021) recommends that a TWOC is carried out in the person’s home, if possible, as it is a more relaxed environment and may reduce the infection risks associated with a hospital visit. 
The nurse should follow local procedure regarding TWOC. It is important to assess a person’s suitability for a home-based TWOC and to follow local procedures. There are different considerations for performing a TWOC in patients with a suprapubic catheter and in those with a urethral catheter, as outlined in Table 1. 
 
Table 1. Assessing suitability for home-based trial without catheter (TWOC)
Concern Urethral catheter Suprapubic catheter Action
Issues with urinary output Renal failure, cardiac failure Renal failure, cardiac failure Seek specialist advice as some degree of heart or renal failure is common in older people
Risk of bleeding If the person is taking anticoagulants If the person is taking anticoagulants Seek specialist advice from haematology. If a person is on warfarin and their INR (international normalised ratio) is within range or if the person is on a non-vitamin K antagonist oral anticoagulant such as rivaroxaban or dabigatran and there are no signs of overdose it may be acceptable to do a TWOC at home
Requires continuous supervision May have cognitive impairment or dementia and inability to follow instructions May have cognitive impairment or dementia and inability to follow instructions People with cognitive impairment may find a TWOC clinic very distressing and will do better in a familiar environment. Check if the person has a caregiver, spouse or relative who can spend the day with the person and is able to supervise and to contact the nurse if there are concerns
Possible problems with re-catheterisation If it likely that any required re-catheterisation would be difficult This is not a concern with a suprapubic TWOC as the catheter will not be removed until it is clear the person can void Check if the patient has a history of any problems with re-catheterisation. If so, refer to a hospital-based TWOC clinic
Complex needs Risk of acute urinary retention, possible delay in attending to patient and potential delay in catheterisation This is not a concern with a suprapubic TWOC as the catheter will not be removed until it is clear the person can void With urethral catheters refer to a hospital-based TWOC clinic
Based on Royal College of Nursing (2021)

Who should carry out a TWOC?


TWOC may be carried out by community nurses or by bladder and bowel specialist nurses. This will be determined by local policy and contracting arrangements. 
 

Preparation


The nurse should assess the person’s suitability for a community-based TWOC (Table 2). In some NHS trusts TWOCs must be authorised by the person’s GP. 
Before the TWOC the nurse should contact the patient and assess the individual’s understanding of TWOC. It is important to check if the person is constipated as this can affect the ability to void. If so, this should be treated before performing a TWOC (Holroyd, 2020). 

If the individual was catheterised for acute retention the nurse should check if any identified cause of retention such as constipation, urethral stricture or in men, more commonly prostatic hyperplasia, has been treated. 
The nurse should obtain consent from the patient for TWOC. If the patient lacks capacity, then TWOC can be carried out in the patient’s best interests under the Mental Capacity Act 2005. This must be fully documented. 

The nurse should gather the necessary equipment. The patient may require a urinal or a measuring jug to measure urine, and incontinence pads. The nurse should have access to a bladder scanner, which should be charged and checked before the TWOC. 
 

The procedure


The nurse should follow local procedure. When the person has a urethral catheter, this may be removed at midnight or in the morning. Ellahi et al (2021) found that removal at 10pm or midnight makes successful TWOC more likely, but in community settings TWOCs generally start at around 8am. 

The nurse will visit at around 8am, assess the patient and if the patient appears unwell the TWOC will be deferred. In a suprapubic TWOC the catheter is not removed, but drainage bags are removed, and a catheter valve is applied. 

The nurse will ask the patient to drink 200 ml of fluid each hour and to record fluid intake and output on a fluid balance chart (Figure 3). The nurse will provide a measuring jug or a urinal as appropriate. If the person was incontinent before the TWOC or is planning to use an incontinence pad just in case, it can be helpful for the person to retain any wet pads so that the nurse can estimate any volume or urine passed. 
Figure 3. Example of a trial without catheter (TWOC) chart
Time Fluid intake: type and amount (ml) Intake running total Urine passed(ml) Output running total Continent void?
(yes/no)
Post-void residual volume by bladder scan (ml)
Time of TWOC
am/pm
           
 Time post-TWOC
1 hour
           
2 hours            
3 hours            
4 hours            
5 hours            
6 hours            
7 hours            
8 hours            
9 hours            
10 hours            
11 hours            
12 hours            
It is important to explain that the first void may sting and that this is not abnormal. If a man feels the need to pass urine he should be advised to do that standing up if at all possible as this helps to fully empty the bladder. 
 
The nurse will check if the patient has any questions and ensure that the patient has the contact details of the service in case of any problems or concerns. Contact is usually via the single point of access service. 
At around 1pm the nurse will visit as planned and check that the patient has passed urine and has no discomfort. The nurse will check the fluid balance chart to ensure that the person has been drinking the recommended amount of fluids and look at the amount of urine voided. The nurse will perform a bladder scan. 
 
At around 3pm the nurse will visit as planned and check that the patient has passed urine and has no discomfort. The nurse will check fluid intake and urine output and perform a bladder scan. 
  • If the patient is able to pass urine and the post-void residual is less than 100 ml the TWOC is considered successful. 
  • If the patient is able to pass urine, has no pain or discomfort and the post-void residual is 100–300 ml the nurse will arrange a follow-up bladder scan the next day. 
  • If the patient has a post-void residual of 300 ml or more or is uncomfortable or unable to void the nurse will remove the catheter value and connect a drainage bag.

Safety netting 


Some procedures state that the nurse can remove the suprapubic catheter if TWOC is successful, others recommend it is left in place for 48 hours. If TWOC is successful, the person should be advised on actions to take if he or she experiences voiding difficulties or any signs of urinary retention. 
The nurse should assess whether the person is able to maintain continence or requires further assessment. If further assessment is required, this should be arranged with continence specialist nurses.
If TWOC is unsuccessful the person should be advised on next steps. This will be determined by local procedure, but if this is the first TWOC a second community-based TWOC is normally arranged within 2 weeks. It this is the second failed TWOC the person is normally referred to specialist services. 
 

Documentation


The nurse should document actions and the outcome of the TWOC in the patient record, including any required follow up and referrals. 

Discussion


Some community TWOC policies exclude people who have dementia or cognitive impairment. If at all possible, the nurse should consider carrying out a community-based TWOC for a person with dementia. The person with mild to moderate cognitive impairment may be able to be managed in the community. It is often possible to perform a TWOC for a person with more significant impairment if a relative or caregiver can be present. The caregiver can encourage and record fluid intake and output and contact the nurse if there are clinical concerns. 

As suprapubic catheterisation and care for these patients becomes more common in community settings it is important that clinicians are aware that these are not all permanent and some people with suprapubic catheters can benefit from TWOC.

Conclusions


Although community-based TWOC is time consuming, and community nursing and continence services are busy, TWOC can be lifechanging for some people. Community TWOC is effective, evidence based and can reduce pressures on community services and acute hospitals. It is important that such services are adequately resourced. It makes economic sense and is important from a quality perspective that community nursing is enabled to provide services such as TWOC. 


Learning points 


Around 40% of older men and over 50% of younger women who have long-term catheters have suprapubic catheters. 
Suprapubic catheters are not necessarily permanent and it may be possible to remove them. 
It is important that when an indwelling urinary catheter is no longer required that a TWOC is carried out. This reduces the risk of adverse effects and improves a person’s quality of life.

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