Preventing UTIs in Intermittent Catheter Users: Evidence-Based Strategies

If you perform clean intermittent catheterization (CIC), urinary tract infections are likely something you've experienced or worried about. UTIs are the most common complication of intermittent catheterization. Canadian best practice recommendations estimate the rate at about 2.5 UTIs per person per year, with over 80% of people experiencing at least one UTI over a five-year period.^[1] A national survey of Canadians with spinal cord injury who use intermittent catheterization found a similar figure: an average of 2.6 UTIs in the previous 12 months.^[2]

Those numbers can feel discouraging. The good news is that the main risk factors are well understood, and several are within your control. This article draws on the Canadian Best Practice Recommendations for Clean Intermittent Urethral Catheterization in Adults — developed collaboratively by NSWOCC, CNCA, the Urology Nurses of Canada, and IPAC Canada — to outline what they recommend.

Bacteriuria vs. UTI: An Important Distinction

First, a clarification that matters clinically. People who catheterize commonly have bacteria in their urine without being ill — this is called asymptomatic bacteriuria. Within about three weeks of starting intermittent catheterization, more than half of users have bacteria in their urine.^[1] This does not mean they have a UTI, and it does not require treatment.

A UTI means bacteria in the urine plus new symptoms. Typical symptoms include fever or chills, burning on urination, increased frequency or urgency, new leaking, blood in the urine, and pelvic or lower back pain.^[1] For people with a spinal cord injury, symptoms may look different — especially without normal bladder sensation. New or worsening spasticity, autonomic dysreflexia, or an unexplained sense of feeling unwell can also be signs of a UTI.^[4] Cloudy or strong-smelling urine on its own is not enough to diagnose a UTI.^[1]

What Increases UTI Risk in CIC Users

Understanding risk factors is the first step toward addressing them. Canadian best practice recommendations list the following factors that increase UTI risk in intermittent catheter users:^[1]

Evidence-Based Prevention Strategies

1. Hand Hygiene — The Single Most Important Step

Canadian best practice recommendations describe hand hygiene as the single most important practice for preventing the spread of infection.^[1] Hands must be washed thoroughly with soap and water — or alcohol-based hand rub if visibly clean — before gathering supplies, immediately before catheterization, and immediately after. This applies to both patients and caregivers.

It sounds simple, but in practice it's often rushed. Wash for at least 15–20 seconds, including between your fingers and around your nails.

2. Use a Single-Use, Pre-Lubricated Catheter

Canadian best practice recommendations advise that a single-use, pre-lubricated sterile catheter be recommended, especially for people with repeated symptomatic UTIs. This is a Grade A recommendation — the document's strongest grade — based on a randomized trial in people with acute spinal cord injury.^[1]

Hydrophilic catheters have a polymer coating that binds water, creating a slippery surface along the length of the catheter that reduces friction during insertion and removal. Hydrophilic coating has been shown to reduce microscopic bleeding, a sign of urethral micro-trauma.^[1] The evidence on whether hydrophilic catheters reduce UTIs is mixed: one meta-analysis found about 16% fewer UTIs with single-use hydrophilic catheters than with reused uncoated catheters, while another found fewer UTIs that did not reach statistical significance.^[3]

Catheters sold in Canada are generally labelled for single use, and the Canadian recommendations do not support reusing them, describing reuse as a contentious and evolving subject.^[1] Some international guidelines consider multiple-use catheters acceptable for people catheterizing at home,^[4] but reusing a catheter labelled for single use goes against the manufacturer's instructions. If you get repeated UTIs, the Canadian recommendations strongly advise a new, pre-lubricated sterile catheter every time.^[1] If cost is a barrier, ask your care team about coverage options.

3. Catheterize at Regular Intervals — Don't Skip

Infrequent catheterization and an overfilled bladder are both established risk factors for UTI.^[1] An overstretched bladder wall is thought to be less able to resist infection, and urine that sits longer gives bacteria more time to grow.

The Canadian recommendations aim for no more than about 500 mL per catheterization unless your health professional directs otherwise — which typically works out to 4–6 catheterizations a day for someone who relies on catheterization for all urine output.^[1] Your schedule should be set with your continence or urology team, and some bladder conditions call for smaller volumes. If you're regularly draining more than 500 mL, talk to your care team about adjusting your schedule. For people with a spinal cord injury at T6 or above, an overfull bladder is also the most common trigger of autonomic dysreflexia.

4. Drink Enough Fluid

Adequate fluid intake dilutes the urine and keeps urine moving through the bladder. The Canadian recommendations suggest fluid intake based on body weight (roughly 25–35 mL per kg per day) and a urine output of at least 1,200 mL per day.^[1] The right amount also depends on your kidney and heart health, fluid losses, and your bladder program, so confirm your target with your care team. Drinking far more than usual can overfill the bladder between catheterizations.^[1]

Urine colour is a practical guide. Light straw yellow indicates adequate hydration. Dark yellow or amber urine signals dehydration and the need to drink more. This is particularly easy to forget for CIC users who instinctively limit fluids to reduce catheterization frequency — but the result is more concentrated urine and higher infection risk.

5. Clean the Urethral Meatus Before Each Catheterization

Before inserting a catheter, the area around the urethral opening should be cleaned. For male users: retract the foreskin if present and clean the glans in a circular motion moving away from the meatus using warm water and soap or a clean wipe. For female users: spread the labia and clean front-to-back.

Canadian best practice recommendations note that tap or sterile water is an acceptable option for cleaning around the urethral opening, and that soap and water is convenient and cost-effective at home. Antiseptic solutions like chlorhexidine may be used in hospitals per local policy, but can irritate mucous membranes.^[1]

6. Catheterize in a Clean Environment

The environment matters. Set up on a clean, hard surface — not the floor, bed or a fabric surface — and keep pets out of the area.^[1] Equipment should be clean before use. This is less about achieving a sterile field and more about avoiding obvious contamination sources that can introduce bacteria to the catheter or the periurethral area.

Recognizing a True UTI

Knowing when to act — and when not to — is as important as prevention. A change in the look or smell of your urine, on its own, is not a reason to start antibiotics. Contact your healthcare provider if you notice any of these, especially if they are new or getting worse:

If you think you have a UTI, contact your healthcare provider. Don't change your fluid intake or catheterization schedule without advice — for people with a spinal cord injury, a sudden increase in fluids can overfill the bladder and trigger autonomic dysreflexia. Your provider will usually ask for a urine specimen, collected midstream or with a new sterile catheter, for culture so the right antibiotic can be chosen.^[1] Avoid taking leftover or unprescribed antibiotics, which contributes to antibiotic resistance.

A Note on Catheter Choice and UTI Risk

If you get recurrent UTIs despite good technique and hygiene, it's worth reviewing your catheter with your care team. If you currently reuse catheters or use an uncoated catheter with separate lubricant, a single-use, pre-lubricated catheter is what the Canadian recommendations point to for people with repeated UTIs.^[1] Hydrophilic coatings lubricate the full length of the catheter, whereas gel applied to an uncoated catheter tends to be wiped off at the urethral opening.^[1]

The IQ Catheter is a single-use intermittent catheter, available in hydrophilic and gel versions, with a soft, rounded tip on a flexible front section and a firmer guiding shaft. Whether it — or any catheter — is right for you is a decision to make with your urologist or continence nurse.

This article was written by IQ Catheter Canada, which distributes the IQ Catheter in Canada. It is general information, not medical advice. Talk to your healthcare provider about your own situation.

References

1. Nurses Specialized in Wound, Ostomy and Continence Canada, Canadian Nurse Continence Advisors, Urology Nurses of Canada, and Infection Prevention and Control Canada. Clean Intermittent Urethral Catheterization in Adults – Canadian Best Practice Recommendations for Nurses. 1st ed. 2020. PDF
2. Woodbury MG, Hayes KC, Askes HK. Intermittent catheterization practices following spinal cord injury: a national survey. Can J Urol. 2008;15(3):4065–4071. PubMed
3. Campeau L, et al. Canadian Urological Association Best Practice Report: Catheter use. Can Urol Assoc J. 2020. Full text
4. Hooton TM, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(5):625–663.