title: Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults.
abstract: BACKGROUND
  Indwelling urethral catheters are often used for bladder drainage in hospital. Urinary tract infection is the most common hospital-acquired infection, and a common complication of urinary catheterisation. Pain, ease of use and quality of life are important to consider, as well as formal economic analysis. Suprapubic catheterisation can also result in bowel perforation and death.
  
  
  OBJECTIVE
  To determine the advantages and disadvantages of alternative routes of short-term bladder catheterisation in adults in terms of infection, adverse events, replacement, duration of use, participant satisfaction and cost effectiveness. For the purpose of this review, we define 'short-term' as intended duration of catheterisation for 14 days or less.
  
  
  METHODS
  We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 26 February 2015), CINAHL (searched 27 January 2015) and the reference lists of relevant articles.
  
  
  METHODS
  We included all randomised and quasi-randomised trials comparing different routes of catheterisation for short-term use in hospitalised adults.
  
  
  METHODS
  At least two review authors extracted data and performed 'Risk of bias' assessment of the included trials. We sought clarification from the trialists if further information was required.
  
  
  RESULTS
  In this systematic review, we included 42 trials.Twenty-five trials compared indwelling urethral and suprapubic catheterisation. There was insufficient evidence for symptomatic urinary tract infection (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.61 to 1.69; 5 trials, 575 participants; very low-quality evidence). Participants with indwelling catheters had more cases of asymptomatic bacteriuria (RR 2.25, 95% CI 1.63 to 3.10; 19 trials, 1894 participants; very low quality evidence) and more participants reported pain (RR 5.62, 95% CI 3.31 to 9.55; 4 trials, 535 participants; low-quality evidence). Duration of catheterisation was shorter in the indwelling urethral catheter group (MD -1.73, 95% CI -2.42 to -1.05; 2 trials, 274 participants).Fourteen trials compared indwelling urethral catheterisation with intermittent catheterisation. Two trials had data for symptomatic UTI which were suitable for meta-analysis. Due to evidence of significant clinical and statistical heterogeneity, we did not pool the results, which were inconclusive and the quality of evidence was very low. The main source of heterogeneity was the reason for hospitalisation as Hakvoort and colleagues recruited participants undergoing urogenital surgery; whereas in the trial conducted by Tang and colleagues elderly women in geriatric rehabilitation ward were recruited. The evidence was also inconclusive for asymptomatic bacteriuria (RR 1.04; 95% CI 0.85 to 1.28; 13 trials, 1333 participants; very low quality evidence). Almost three times as many people developed acute urinary retention with the intermittent catheter (16% with urethral versus 45% with intermittent); RR 0.45, 95% CI 0.22 to 0.91; 4 trials, 384 participants.Three trials compared intermittent catheterisation with suprapubic catheterisation, with only female participants. The evidence was inconclusive for symptomatic urinary tract infection, asymptomatic bacteriuria, pain or cost.None of the trials reported the following critical outcomes: quality of life; ease of use, and cost utility analysis.
  
  
  CONCLUSIONS
  Suprapubic catheters reduced the number of participants with asymptomatic bacteriuria, recatheterisation and pain compared with indwelling urethral. The evidence for symptomatic urinary tract infection was inconclusive.For indwelling versus intermittent urethral catheterisation, the evidence was inconclusive for symptomatic urinary tract infection and asymptomatic bacteriuria. No trials reported pain.The evidence was inconclusive for suprapubic versus intermittent urethral catheterisation. Trials should use a standardised definition for symptomatic urinary tract infection. Further adequately-powered trials comparing all catheters are required, particularly suprapubic and intermittent urethral catheterisation.
authors.affiliation: Cochrane Incontinence Group, University of Aberdeen, Health Sciences Building (second floor), Aberdeen, UK, AB25 2ZD.
authors.forename: Emily A
authors.initials: EA
authors.lastname: Kidd
authors.forename: Fiona
authors.initials: F
authors.lastname: Stewart
authors.forename: Nadine C
authors.initials: NC
authors.lastname: Kassis
authors.forename: Emily
authors.initials: E
authors.lastname: Hom
authors.forename: Muhammad Imran
authors.initials: MI
authors.lastname: Omar
mesh_terms: D000328:Adult; D000368:Aged; D058345:Asymptomatic Infections; D001437:Bacteriuria / Q000209:etiology; D002408:Catheters, Indwelling / Q000009:adverse effects* / Q000592:standards*; D004322:Drainage; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D014546:Urinary Catheterization / Q000009:adverse effects / Q000379:methods* / Q000592:standards; D014552:Urinary Tract Infections / Q000209:etiology / Q000517:prevention & control