The outbreak of COVID-19, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic by the World Health Organization (Burki, 2020; Harapan et al, 2020; Lazzerini and Putoto, 2020). In addition to its acute respiratory manifestations, SARS-CoV-2 may also adversely affect other organ systems (Baggiani et al, 2020; Heldwein et al, 2020; Porreca et al, 2020). Neuropsychiatric disorders related to both the viral infection and patient isolation have been well documented (Abad et al, 2010; Puliatti et al, 2020).
Delirium occurring in critically ill patients is an acute central nervous system disorder (Mao et al, 2020). Although usually underestimated in the daily care of critically ill COVID-19 patients, early identification of delirium is critical because its occurrence may represent an early symptom of worsening respiratory failure, additional organ failure, or infectious spread to the central nervous system, mediated by potential neuroinvasive mechanisms of SARS-CoV-2 (Hawkins et al, 2021). Moreover, delirium may cause severe psychomotor agitation leading to self-extraction of medical devices, such as urinary bladder indwelling catheters. Traumatic, unintended patient-initiated Foley catheter extractions can cause permanent urological complications, affect hospital length of stay, decrease patient satisfaction ratings, increase catheter-associated urinary tract infections (CAUTIs) and lower hospital quality scores.
The aim of this study was to evaluate the prevalence of transurethral catheter self-removal in critically ill COVID-19 non-sedated adult patients when compared with non-COVID-19 controls. Simple and practical guidelines will be discussed for preventing these events by a timely identification of patients at risk, for early recognition of malpositioned Foley catheters and for assessing management.
Between October 2020 and April 2021, data from 48 consecutive, non-sedated adult patients with severe COVID-19 disease who self-extracted transurethral catheter with consequent need of a urological intervention (group A) were prospectively collected in a customised database and retrospectively analysed. The study was conducted in a tertiary referral hospital (San Donato Hospital, Arezzo, Italy). COVID-19 diagnosis was according to World Health Organization interim guidelines (Kobayashi et al, 2022), with all patients receiving a positive result on a reverse transcription polymerase chain reaction (RT-PCR) test targeting SARS-CoV-2. Severe COVID-19 conditions were defined as (Chinese Society of Critical Care Medicine et al, 2020):
- Respiratory distress (respiratory rates ≥30 breaths per minute),
- Pulse oxygen saturation ≤93% on room air
- PaO2/FiO2 ≤ 300 mmHg.
Control groups (group B) consisted of hospitalised non-COVID-19 patients who required urological intervention following self-removal of their transurethral catheter both in the urology unit (subgroup B1) and geriatric unit (subgroup B2) of the same hospital and during the same period.
Exclusion criteria were patients with a previous diagnosis of delirium, dementia or history of agitation from central nervous system disorders or medications.
To comparatively assess the prevalence of urinary bladder catheter self-removal between the described groups and to identify risk factors that were significantly associated with catheter self-removal.
The study was conducted in accordance with the Good Clinical Practice rules and with the ethical principles contained in the Declaration of Helsinki adopted by the World Medical Association. Ethical approval was granted by the local ethics committee.
Main outcome measures
All medical and nursing records were assessed; data on age, sex, medications, comorbidities, agitation and anxiety status and nervous system symptoms, as well as the severity of the complications caused by catheter self-removal were collected and registered to a customised database. Agitation and anxiety in COVID-19 patients were assessed by the Richmond Agitation and Sedation Scale (RASS), a tool designed to evaluate the level of consciousness and agitated behaviour. RASS was administered before sedation in those patients who required it for catheter reinsertion. COVID-19 patients who presented with agitation or delirium were treated with dexmedetomidine (0.2-1.4 mcg/kg/hour), often associated with antipsychotic drugs (quetiapine, haloperidol, tiapride) or valproic acid (Ostuzzi et al, 2020). Evaluation of the level of consciousness and agitated behaviour with RASS can be performed in a few minutes, following three sequential steps: observation, response to auditory stimulation, and response to physical stimulation (Han et al, 2015). Total score ranges from +4 to -5: a RASS score of 0 represents normal level of consciousness, whereas a RASS score other than 0 documents the presence of altered level of consciousness and delirium. A score greater than +1 or below –1 suggests an increased likelihood of delirium (Han et al, 2015).
Statistical analysis was performed with IBM-SPSSv17 for Windows. All continuous variables are expressed as means and standard deviations. Age, comorbidities, catheter extraction (number of events), RASS score and hospital stay (days) were evaluated with Student's t test and the Mann-Whitney U test. Categorical variables (sex) were expressed as counts and percentages. Student's t test and the Mann-Whitney U test were performed to compare continuous parametric and non-parametric variables, as appropriate. Spearman correlations were used to test for the strength of linear association between variables along with the Wilcoxon and Mann-Whitney. A P value of less than 0.05 was considered statistically significant.
A total of 472 patients were hospitalised because of COVID-19 disease in the hospital during the evaluated period. Group A consisted of 48 patients, predominantly males (77%), with 9/48 patients having an indwelling transurethral/suprapubic catheter for longer than 2 months before the self-removal. Mean age (±SD) was 74.3 years (±12.7) while mean RASS score (±SD) was 3.1 (±1.8). Demographic and clinical data are reported in Table 1. The main comorbidities (Table 2) were systemic arterial hypertension (29/48, 60%) and diabetes mellitus (12/48, 25%). Lower urinary tract symptoms caused by benign prostate hyperplasia were reported in 29/48 cases (60%), and all patients were on alpha1-blockers before hospital admission. In these patients, alpha 1-blockers might have contributed to an increased risk of confusion. In terms of ventilation support, 22/48 patients did not need any support, while 9/48 required a non-invasive ventilation (NIV) helmet and 17/48 an NIV face mask. None of the patients were administered any antipsychotic drugs.
Table 1. Demographic and clinical data of COVID-19, urology and geriatric patients
|Population||COVID-19 patients n=48 (Group A)||Urology patients n=5 (Subgroup B1)||Geriatric patients n=11 (Subgroup B2)||P|
|Sex n (%)|
|Male||37 (77)||5 (100)||5 (45)||–|
|Female||11 (22)||–||6 (55)||–|
|Age (mean ± SD)||74.3 ± 12.7||70.3 ± 8.2||81.1 ± 4.6||0.3|
|Comorbidities (mean ± SD)||2.1 ± 1.3||2 ± 1.6||4.4 ± 2.6||0.01|
|Catheter extraction (number of events; mean ± SD)||3.2 ± 0.8||0.9 ± 0.6||1.1 ± 0.3||0.001|
|RASS score (mean ± SD)||3.1 ± 1.8||1.8 ± 0.6||1.9 ± 0.9||0.006|
|Hospital stay (days; mean ± SD)||29.3 ± 6.2||4.2 ± 2.1||7.4 ± 3.6||0.001|
Table 2. Types of comorbidities of COVID-19, urology and geriatric patients
|COVID-19 patients n=48 (Group A)||Urology patients n=5 (Subgroup B1)||Geriatric patients n=11 (Subgroup B2)|
Subgroup B1 consisted of 5 patients, all males with a mean age of 70.3 years (±8.2). Subgroup B2 consisted of 11 patients, 5 males and 6 females, with a mean age of 81.1 years (±4.6).
A total of 213 patients were hospitalised in the urology unit and 332 in the geriatric unit (2.3% and 3.3%, respectively, required urological intervention). The mean RASS score (± SD) in group B was 1.9 (± 0.6). The main comorbidities of these subgroups were systemic arterial hypertension, chronic obstructive pulmonary disease, osteoarthritis, cardiovascular disease and depression (Table 2). All males of subgroup B1 and B2 were taking alpha1-blockers therapy and two patients of subgroup B2 were on antipsychotic and antidepressant drugs, respectively.
A statistically significant higher mean rate of catheter self-extraction events (both transurethral and suprapubic) was observed for group A (3.2±0.8) vs subgroup B1 (0.9±0.6) and subgroup B2 (1.1±0.3), respectively (P<0.001). Rates of severe urethrorrhagia were found to be 40% (19/48) in group A, 20% (1/5)in group B1 and 45% (5/11) in group B2. An increased hospital stay was observed in 31% (15/48) patients in group A; mean duration of hospitalisation of COVID-19 patients (group A) was 29.3±6.2 days, 4.2±2.1 and 7.4±3.6 days for patients in group B1 and group B2, respectively (P<0.001) (Table 1).
Chronic comorbidities were more frequent in patients in group B compared with group A (P<0.01). A significantly higher RASS score was observed in group A (P<0.006) (Table 1). In all cases a successful replacement of the urinary bladder catheter was achieved at the bedside, without the need for cystoscopic manoeuvres. In order to undertake catheter replacement in patients in group A, general sedation was requested due to agitation in the case of 19% (9/48).
To the authors' knowledge, this is the first report assessing the rates and risk factors for the self-removal of a transurethral/suprapubic catheter in hospitalised COVID-19 patients. There was a higher incidence of catheter self-removal in this group, compared with controls, and those in the COVID-19 group had higher RASS scores. PubMed, Scopus and Web of Sciences were searched from March 2020 to December 2021, using the terms ‘COVID-19, catheter self-extraction’, ‘COVID-19, transurethral catheter’, ‘COVID-19, urinary dysfunction’, ‘COVID-19, urinary symptoms’.
In the authors' practice, more than 10% of these patients experienced a traumatic, patient-initiated removal of the bladder catheter, leading to frequent involvement of urology professionals (both for need for catheter replacement and management of the complications following self-removal). The procedure of catheter replacement can be challenging, since a urologist may be performing it for a critical and often agitated patient with concomitant urethrorrhagia, frequently following failed attempts at catheter replacement by nursing staff. The high rate of catheter self-removal observed in COVID-19 patients, the frequent use of sedation (19%) for its replacement and the associated longer hospital stay may also pose an additional economic burden for healthcare systems.
Indeed, in this pandemic era, the hospital resources for the admission of these patients in COVID-19 areas are limited, due to their huge number. Therefore, the longer hospitalisation due to this urological complication should be considered as one of the factors that may further reduce the capability to admit patients seeking help.
The comparison with control groups allowed the authors to rule out that transurethral/suprapubic catheter self-extraction was provoked solely by hospitalisation (P<0.001), RASS score (P<0.006) and comorbidities (P<0.01). Indeed, it has been shown that some of the patients in COVID-19 areas developed specific pathological characteristics related to higher anxiety levels. As the majority of hospitalised patients are elderly with multiple chronic comorbidities (Buckner et al, 2020), anxiety and agitation levels can easily be elevated during the long weeks of hospitalisation in isolation wards (both intensive care unit (ICU) and non-ICU). Disconnection from the ‘outside’ world, reduced contact with physicians and nurses wearing protective equipment, requirement for multiple devices such as ventilation support or bladder catheters, and uncertainties due to the unpredictable COVID-19 clinical course may be some of the causative agents for the anxiety experienced (Fan et al, 2020). Emotional condition and anxiety related to urological clinical tests is present also for basic ambulatory examinations, as documented in a recent study by Rubilotta et al (2021). Therefore, it is easy to understand that an invasive device such as an intra-urethral or suprapubic catheter can have an additional negative psychological impact on COVID-19 patients. This can be even more relevant in individuals with pre-existing neurological diseases. A recent study demonstrated that confusion and delirium are important complications of COVID-19 and are twice as common in COVID-19 as in other diseases (Mendes et al, 2021). The pathophysiology of delirium in COVID-19 patients has been demonstrated to be multifactorial. COVID-19 can invade the central nervous system, infecting neural cell lines. Due to the infection and the other forms of damage, neuroglial cells become reactive, giving rise to the scenario of neuro-inflammation (Steardo et al, 2020). Another direct pathway of COVID-19 damage is vascular injury. Indirect mechanisms of tissue destruction are represented by pyrexia, hypoxia, dehydration, metabolic derangements and medications (Mcloughlin et al, 2020). Neuro-inflammation together with prolonged hypoxia may promote neuropsychiatric developments and cognitive impairments, both acute and chronic. Thereby, delirium and psychiatric disorders may be significant, especially for elderly individuals who are more vulnerable to post-infectious neurocognitive sequelae. These findings confirm the results here and could explain the significant differences in anxiety and psychiatric status between the COVID-19 and geriatric patients.
Traumatic and repeated intra-urethral or suprapubic catheter extractions can cause important urological complications, affect length of stay in hospital, increase the incidence of urinary tract infections and lower patients' quality of life (Bierman and Carignan, 2007; Fisher, 2010; Loveday et al, 2014). In worst cases, it can cause severe haematuria or traumatic damage to the urethra. Moreover, urethral damage is related to multiple catheterisations (Rozzini et al, 2020). This problem is still under-evaluated among the multiple difficult situations of COVID-19 wards but should be investigated and preventive measures implemented. In addition, other factors such as irritation from the catheter, the tube size and irritation from infections may also contribute to catheter self-extraction, particularly in cases of confusion or delirium.
Early identification of patients at risk, such as those who are overactive or those who are constantly pulling on their Foley catheters or with a previous history of catheter self-removal, is the first step and should always be assessed during hospitalisation. Indeed, evidence from the literature shows that individuals at higher risk of inappropriate self-extraction of bladder catheters are:
- Any patient with delirium, agitation or dementia, particularly those who have come from an elderly nursing home and who have a recently placed catheter
- Patients who are constantly pulling or tugging on their catheters
- Patients with a history of prior Foley catheter self-extractions
- Any patient being transferred where the catheter may become caught and accidentally pulled or tugged (Leslie et al, 2020).
Therefore, simple measures, such as positioning the catheter under the thigh, might reduce the possibility of self-extraction in patients at risk or at least give enough time for nursing staff to intervene even if there could be a potential risk of tube occlusion (Wagner et al, 2016). In addition, catheter fixation devices can be helpful in preventing dislocation and they should also be used in such a population (Yates, 2013). Similarly, suprapubic catheters should be secured with fixation device because they are even easier for patients to remove themselves compared with transurethral catheters. Indwelling catheters should be avoided if not strictly necessary.
Moreover, when applicable, personalised care should be promoted by always keeping the patient directly updated on their condition and giving them the opportunity to bring personal items with them to hospital, to help make the hospital environment a little more familiar; daily video calls with relatives should be encouraged to reduce anxiety and isolation (Yates, 2013; Nardo et al, 2021).
The strength of this real-life study was to uncover a relevant underestimated clinical issue. Limits of the study are the low-sample size and the short enrolment period. However, due to the present pandemic, the authors consider it relevant to report these data in order to focus attention on this potential critical problem for the management of patients with COVID-19.
This is, to the authors' knowledge, the first study investigating the prevalence and complications of transurethral and suprapubic catheter self-removal occurring in COVID-19 patients. It has demonstrated an increased prevalence of urological complications due to agitation and delirium correlated with COVID-19. The significant increase in bladder and suprapubic catheters self-extractions observed among hospitalised COVID-19 patients in the authors' hospital warrant greater attention during daily nursing responsibilities and care of these patients. The neurological and psychiatric aspects of the viral attack must therefore be considered as part of patient management during hospitalisation. Patients at risk should be identified and carefully monitored to prevent this significant and potentially avoidable complication.
- Delirium may cause severe psychomotor agitation leading to self-extraction of medical devices, such as urinary bladder indwelling catheters
- Hospitalised COVID-19 patients have a higher incidence of catheter self-removal
- Early identification of COVID-19 patients at risk, such as those who are overactive or those who are constantly pulling their Foley catheters or who have a previous history of catheter self-removal, should always be part of assessment during hospitalisation
- Simple measures might reduce the possibility of catheter self-extraction in patients at risk or at least give enough time for nursing staff to intervene even if there could be a potential risk of tube occlusion
CPD reflective questions
- Older adults with COVID-19 are at particular risk of cognitive impairment. Reflect on some of the reasons for this
- What kind of urological complications are likely to occur due to urinary catheter self-removal by patients with agitation and delirium related to COVID-19? What short- and long-term effects would these have for patients?
- The study concluded that identification and monitoring of this type of patient is essential. How could you incorporate this in practice at your place of work?