Strategies for the removal of short‐term indwelling urethral catheters in adults

Awaiss Ellahi; Fiona Stewart; Emily A Kidd; Rhonda Griffiths; Ritin Fernandez; Muhammad Imran Omar

doi:10.1002/14651858.CD004011.pub4

. 2021 Jun 29;2021(6):CD004011. doi: 10.1002/14651858.CD004011.pub4

Strategies for the removal of short‐term indwelling urethral catheters in adults

Awaiss Ellahi ¹, Fiona Stewart ², Emily A Kidd ², Rhonda Griffiths ³, Ritin Fernandez ⁴, Muhammad Imran Omar ^5,^6,^✉

Editor: Cochrane Incontinence Group

PMCID: PMC8240009 PMID: 34184246

Abstract

Background

Urinary catheterisation is a common procedure, with approximately 15% to 25% of all people admitted to hospital receiving short‐term (14 days or less) indwelling urethral catheterisation at some point during their care. However, the use of urinary catheters is associated with an increased risk of developing urinary tract infection. Catheter‐associated urinary tract infection (CAUTI) is one of the most common hospital‐acquired infections. It is estimated that around 20% of hospital‐acquired bacteraemias arise from the urinary tract and are associated with mortality of around 10%.

This is an update of a Cochrane Review first published in 2005 and last published in 2007.

Objectives

To assess the effects of strategies for removing short‐term (14 days or less) indwelling catheters in adults.

Search methods

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 17 March 2020), and reference lists of relevant articles.

Selection criteria

We included all randomised controlled trials (RCTs) and quasi‐RCTs that evaluated the effectiveness of practices undertaken for the removal of short‐term indwelling urethral catheters in adults for any reason in any setting.

Data collection and analysis

Two review authors performed abstract and full‐text screening of all relevant articles. At least two review authors independently performed risk of bias assessment, data abstraction and GRADE assessment.

Main results

We included 99 trials involving 12,241 participants. We judged the majority of trials to be at low or unclear risk of selection and detection bias, with a high risk of performance bias. We also deemed most trials to be at low risk of attrition and reporting bias. None of the trials reported on quality of life. The majority of participants across the trials had undergone some form of surgical procedure.

Thirteen trials involving 1506 participants compared the removal of short‐term indwelling urethral catheters at one time of day (early morning removal group between 6 am to 7 am) versus another (late night removal group between 10 pm to midnight). Catheter removal late at night may slightly reduce the risk of requiring recatheterisation compared with early morning (RR 0.71, 95% CI 0.53 to 0.96; 10 RCTs, 1920 participants; low‐certainty evidence). We are uncertain if there is any difference between early morning and late night removal in the risk of developing symptomatic CAUTI (RR 1.00, 95% CI 0.61 to 1.63; 1 RCT, 41 participants; very low‐certainty evidence). We are uncertain whether the time of day makes a difference to the risk of dysuria (RR 2.20; 95% CI 0.70 to 6.86; 1 RCT, 170 participants; low‐certainty evidence).

Sixty‐eight trials involving 9247 participants compared shorter versus longer durations of catheterisation. Shorter durations may increase the risk of requiring recatheterisation compared with longer durations (RR 1.81, 95% CI 1.35 to 2.41; 44 trials, 5870 participants; low‐certainty evidence), but probably reduce the risk of symptomatic CAUTI (RR 0.52, 95% CI 0.45 to 0.61; 41 RCTs, 5759 participants; moderate‐certainty evidence) and may reduce the risk of dysuria (RR 0.42, 95% CI 0.20 to 0.88; 7 RCTs; 1398 participants; low‐certainty evidence).

Seven trials involving 714 participants compared policies of clamping catheters versus free drainage. There may be little to no difference between clamping and free drainage in terms of the risk of requiring recatheterisation (RR 0.82, 95% CI 0.55 to 1.21; 5 RCTs; 569 participants; low‐certainty evidence). We are uncertain if there is any difference in the risk of symptomatic CAUTI (RR 0.99, 95% CI 0.60 to 1.63; 2 RCTs, 267 participants; very low‐certainty evidence) or dysuria (RR 0.84, 95% CI 0.46 to 1.54; 1 trial, 79 participants; very low‐certainty evidence).

Three trials involving 402 participants compared the use of prophylactic alpha blockers versus no intervention or placebo. We are uncertain if prophylactic alpha blockers before catheter removal has any effect on the risk of requiring recatheterisation (RR 1.18, 95% CI 0.58 to 2.42; 2 RCTs, 184 participants; very low‐certainty evidence) or risk of symptomatic CAUTI (RR 0.20, 95% CI 0.01 to 4.06; 1 trial, 94 participants; very low‐certainty evidence). None of the included trials investigating prophylactic alpha blockers reported the number of participants with dysuria.

Authors' conclusions

There is some evidence to suggest the removal of indwelling urethral catheters late at night rather than early in the morning may reduce the number of people who require recatheterisation. It appears that catheter removal after shorter compared to longer durations probably reduces the risk of symptomatic CAUTI and may reduce the risk of dysuria. However, it may lead to more people requiring recatheterisation. The other evidence relating to the risk of symptomatic CAUTI and dysuria is too uncertain to allow us to draw any conclusions.

Due to the low certainty of the majority of the evidence presented here, the results of further research are likely to change our findings and to have a further impact on clinical practice. This systematic review has highlighted the need for a standardised set of core outcomes, which should be measured and reported by all future trials comparing strategies for the removal of short‐term urinary catheters. Future trials should also study the effects of short‐term indwelling urethral catheter removal on non‐surgical patients.

Plain language summary

What are the best strategies for removing drainage tubes (urinary catheters) from the urinary bladder after 14 days or less?

Key messages

• Removing drainage tubes late at night instead of early in the morning might reduce the number of people who need to have the drainage tube reinserted.

• Removing drainage tubes sooner rather than later probably reduces the risk of infection caused by the drainage tube and painful urination. However, it may lead to more people needing to have the tube reinserted.

• We need future studies to research the effects of drainage tube removal for people who did not have surgery.

What are urinary catheters?

Urinary catheters are flexible, hollow tubes that are used to empty the urinary bladder and collect urine in a bag. They are often used for short periods of time for people who cannot pass urine themselves, for example during or after surgery, or when healthcare staff need to measure someone’s urine. One harmful effect of catheters is the risk of developing urinary tract infections (UTIs). If catheters are removed quickly, the risk of infection is reduced, but if they are removed too soon, they may need to be reinserted.

What did we want to find out?

We wanted to investigate the effects of different strategies on the risk of:

• needing to have the catheter reinserted; • developing a urinary tract infection (UTI); • experiencing pain when urinating.

What did we do?

We searched for studies that looked at the use of short‐term urinary catheters in adults. We defined ‘short‐term’ as 14 days or less. Studies could take place anywhere and participants could have any condition or illness.

We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.

What did we find?

We found 99 studies with 12,241 participants. Most participants were surgical patients and many of the studies (50) assessed women only.

The studies investigated:

• removing the catheter early in the morning compared with late at night (13 studies); • retaining the catheter for shorter or longer times (68 studies); • clamping catheters or allowing them to drain freely (7 studies); and • giving men treatment (alpha blockers) to relax the prostate compared to no treatment before removing the catheter (3 studies). The prostate is a small gland located between the penis and the bladder.

Early‐morning compared to late‐night removal

Late‐night catheter removal might reduce the risk of needing to have the catheter reinserted compared with early‐morning removal. We are uncertain if there is any difference between early‐morning and late‐night removal for developing UTI or painful urination.

Shorter compared to longer use of catheters

People who have their catheters removed after a shorter length of time are probably less likely to develop UTIs and may be less likely to experience painful urination compared with those who have their catheters for longer. However, we also found that people may be more likely to need the catheter reinserting if they have the catheter for a shorter compared with a longer time.

Clamping

There may be little to no difference between clamping and free drainage on the risk of needing the catheter to be reinserted. We are uncertain if there is any difference in the risk of UTIs or painful urination.

Treatment to relax the prostate

We are uncertain whether giving alpha‐blockers before the catheter is removed has any effect on the need to have catheters reinserted or the risk of developing UTIs. There was no evidence about the risk of experiencing painful urination.

What are the limitations of the evidence?

Many of the included trials had design flaws, did not recruit enough people, or did not report enough information about their results. This means our confidence in the evidence is limited.

How up‐to‐date is this evidence?

The evidence is current up to 17 March 2020.

Summary of findings

Background

This is an update of a Cochrane Review first published in 2005 and last published in 2007. See Appendix 1 for a glossary of medical terms.

Description of the condition

Catheterisation is an important and common clinical procedure. Approximately 15% to 25% of all people who are hospitalised will be catheterised at some point during their management (CDC 2016). However, it should be noted that not every patient who has a urethral catheter inserted requires one. Trials have shown that it is common for catheters to be placed in patients without an appropriate indication (Loeb 2008; Meddings 2014). Catheterisation could be for the short term (up to 14 days) or long term (14 days or longer). The indications for short‐term catheterisation include monitoring of urine output during the perioperative stage or in acutely unwell patients, as part of a urological procedure, or the treatment of patients with acute urinary retention. Short‐term catheterisation could also be used for investigative purposes, such as imaging of the urinary tract and urodynamic trials (Dunn 2000a). Long‐term catheterisation is usually a last resort option in people with recurrent urinary retention, reduced bladder contractility or urinary incontinence.

Retention of urine has been reported as a common problem following the removal of indwelling urethral catheters, particularly following surgery and anaesthesia, where post‐operative urinary retention has a reported incidence between 5% and 70% (Baldini 2009). The risk factors associated with an increase the risk of developing post‐operative urinary retention have been thoroughly researched and include age (over 50 years), sex (male), type of surgery, duration of surgery, type of anaesthesia (general or regional, e.g. epidural), analgesia (use of opiates) and the amount of intravenous fluids used. Post‐operative urinary retention may lead to urinary tract infections, abnormal autonomic responses (e.g. cardiac arrhythmias) as well as over‐distension of the bladder resulting in permanent detrusor muscle damage (Baldini 2009; Madersbacher 2012; Rosseland 2002; Zaouter 2009). For hospital inpatients, the duration of catheterisation in the peri‐operative period remains controversial and is one that is ultimately down to the preference of the surgeon or anaesthetist responsible for the patient. Removal too early, however, may result in the patient developing urinary retention again and thus risking requiring recatheterisation alongside the complications associated with it (Baldini 2009).

The procedure of indwelling urethral catheterisation is associated with complications such as catheter‐associated urinary tract infection (CAUTI), bacteruria, stricture formation, structural damage to the urinary tract, bleeding, cystitis or prostatitis, and patient discomfort (Igawa 2008; Fisher 2017). CAUTI is the most common cause of hospital‐acquired infections with some 70% to 80% of these associated with the use of indwelling urethral catheters (Lo 2014; Nicolle 2014). CAUTI arise from the formation of a biofilm on both the extraluminal and intraluminal portal surfaces of the catheter. This biofilm mainly consists of extraluminal organisms, which adhere to the surfaces of the catheter as soon as it has been inserted. It has the ability to defend microbes from the host's defences as well as antimicrobials (Haque 2018; Nicolle 2014). It is estimated that around 20% of hospital‐acquired bacteraemias arise from the urinary tract and are associated with a mortality of around 10%. The incidence of bacteraemia following a single catheterisation episode has been shown to be as high as 8%, with the duration of catheterisation being the most important risk factor (EAU 2020). Development of symptomatic CAUTI can have serious consequences in some patients and has been shown to increase the length of hospital stay, worsen patient renal function, increase patient mortality and lead to increased costs for healthcare providers. However, with aseptic technique during placement of the catheter, the risk of CAUTI can be reduced (Baldini 2009; EAU 2020; Fisher 2017; Gould 2009; Lo 2014; NICE 2012).

Indwelling urethral catheters are prone to various other complications that prevent effective drainage of urine. The most common non‐infective cause is due to urethral stricture formation. Urethral strictures can develop after repeated urethral catheterisation with long‐term urinary catheter use, as well as after urethral trauma. The most common infective cause is the development of encrustation within the catheter. This is when crystalline compounds (such as calcium phosphate and struvite) precipitate in the alkaline conditions of urine to form solid deposits in the catheter lumen. This process is accelerated in the presence of micro‐organisms such as Proteus mirabilis which resides in the body's own bowel flora. These micro‐organisms produce the enzyme urease, allowing the production of ammonia, which causes further alkalinisation of the urine and catalyses the encrustation process. Catheter encrustation and blockage is thought to be experienced by roughly 50% of patients with long‐term catheters (Stickler 2010). Once a urethral catheter is failing to drain properly, flushing them with saline can often help in trying to relieve the obstruction. However, if this fails it is likely that the urethral catheter will need to be removed and the patient's need for a urinary catheter reassessed (Cravens 2000).

There are two routes of infection through which symptomatic urinary tract infections (UTIs) occur: endogenous and exogenous. Endogenous infections are due to bacteria naturally present in the human body. Typical routes of infection of the urinary tract are rectal, vaginal and meatal (bodily passages). Exogenous sources of infection include contamination by healthcare workers or non‐sterile equipment.

Pathogens typically gain access to the urinary tract either by migrating alongside the exterior surface of the lumen, or by movement alongside the inner lumen of the catheter via contaminated urine collection bags. Thus, maintenance of a sterile, closed urinary drainage system is key to prevent symptomatic CAUTIs. Clinical features of symptomatic UTIs include dysuria, urinary frequency or urgency, haematuria, suprapubic pain or tenderness, loin or flank pain, rigors, fever, altered mental status (e.g. confusion, particularly in the elderly), and nausea and vomiting (CDC 2016; Gould 2009; Grabe 2015; Hollingsworth 2013).

The Centers for Disease Control and Prevention (CDC) has defined symptomatic CAUTI as a UTI in the presence of an indwelling catheter which is in place for two or more calendar days on the date of the UTI, where day one was the date upon which the catheter was placed; or, the catheter was in place on the date of the UTI or the day before and then removed. The patient’s urine culture (from a mid‐stream or catheter bag sample) must also contain no more than two species of organisms, where one of which has a bacterial colony count of ≥ 10⁵ colony forming unit (cfu)/mL. The CDC criteria for symptomatic UTI must also be met, which states that the patient must also have at least one of the following signs or symptoms: fever (> 38 °C); suprapubic tenderness; urinary urgency; increased urinary frequency or dysuria (pain during voiding) (CDC 2016; Gould 2009).

The Infectious Disease Society of America (IDSA) definition differs slightly according to their published guidelines. The IDSA considers symptomatic CAUTI as any UTI associated with a catheter in the presence of clinical features consistent with UTI, with no other identified sources of infection and a bacterial count of ≥ 10³ cfu/mL of ≥ 1 bacterial species in a single midstream urine (MSU) or catheter specimen. The IDSA definition of symptomatic CAUTI covers patients with indwelling, intermittent and suprapubic catheters, unlike the CDC definition, which excludes intermittent catheterisation (Hooton 2010).

Patients who do not meet this criterion may still meet the various criteria for asymptomatic bacteraemic urinary tract infections (ABUTI), which is defined by the CDC as people who are asymptomatic but have a urine culture of at least 10⁵ cfu/mL of a bacterial species in their urine sample. Between 75% to 90% of people who have ABUTIs have been shown not to produce a systemic inflammatory response or other indications, which would indicate infection (Gould 2009). The decision on how to monitor and treat these individuals is still undecided and varies amongst health providers. The CDC guidelines on symptomatic CAUTI state that the treatment of ABUTI has not been shown to provide any clinical benefit.

Description of the intervention

For the purpose of this review, we only considered short‐term indwelling urethral catheterisation. We defined short term as an intended duration of urethral catheterisation of 14 days or less. While there is extensive literature on the type, maintenance and techniques for insertion of urinary catheters, limited attention has been given to the policies and procedures for their removal. Although the insertion, removal and management of the catheter are usually undertaken by nurses, decisions about the removal of the catheter often remain with the medical practitioner. While the importance of short‐term urethral catheter management is recognised, there is no consensus among clinicians about the optimal time and method for removal of indwelling urethral catheters. Policies are likely to be based on personal preference and established practices rather than on research evidence (Irani 1995). While clinicians have established policies, there has been no objective and systematic examination of the effect of the time of day the catheter is removed, the length of time the catheter is left in place or if clamping the catheter prior to removal influences patient outcomes.

Indwelling urethral catheters are catheters that are inserted into the bladder, via the urethra, to allow continuous drainage of urine into a closed urine collection system. In some clinical contexts, valves may also be used as an alternative to continuous drainage. The urethral route is most commonly used by health professionals. Other routes of urinary catheterisation include intermittent urethral and suprapubic urinary catheterisation. However, these routes of urinary catheterisation are outwith the scope of this systematic review. Urethral catheterisation usually requires the use of a lubricant gel, which often contains a local anaesthetic, and can be used both in short‐term and long‐term catheterisation. The length of duration of urethral catheterisation is commonly associated with the development of complications, the most common being UTI (Nicolle 2014). Around 60% to 80% of hospitalised patients with indwelling catheters will require antibiotics at some stage of their care, although this is usually for reasons other than UTI (Durojaiye 2015; Foxman 2003). A recent prevalence survey published in The New England Journal of Medicine found that urinary catheters are the most common indwelling device in hospitals, used in 23.6% of patients in 183 hospitals in the USA and roughly 17.5% of patients in 66 European hospitals (Magil 2014).

As a result, the bacteria present in urine are continuously exposed to antimicrobials, thus aiding the development of antimicrobial‐resistant organisms. This rise in antimicrobial‐resistant organisms has proven to be a huge burden for healthcare providers from both an economic and medical standpoint, with many providers struggling to control devastating outbreaks. There is limited evidence for the use of antibiotic prophylaxis in short‐term indwelling urethral catheters (Lusardi 2013).

How the intervention might work

Some investigators have hypothesised the potential advantage of morning or midnight removal of catheters. One argument for the removal of urethral catheters early in the morning is that reduced staff at night might fail to respond to complications, such as urinary retention, that can develop following the removal of the catheter (Blandy 1989; Crowe 1993; Ganta 2005; Kelleher 2002; Webster 2006). Other suggested benefits of removing the catheter early in the morning include allowing the patient to rest through the night and then to adjust back to their normal voiding pattern during the day (Gross 2007).

Researchers have also reported that patients whose catheters were removed in the night had larger volumes at first void compared to other people whose catheters were removed in the morning (Chillington 1992; Noble 1990; Webster 2006). It has been suggested that the timing of catheter removal may affect a patient's length of stay in hospital with consequent resource implications. In one trial it was found that removal of catheters at midnight resulted in patients being discharged a mean of 14 hours earlier than patients whose catheters were removed in the morning (Chillington 1992), thus resulting in economic benefits related to a shorter length of hospitalisation and efficient discharge planning (Kelleher 2002).

There has been some debate about whether flexible policies are better than relatively fixed policies for catheter removal (Wyman 1987). However, practice is known to vary. For example, local clinical audits for catheter removal have indicated that 49% of catheters are removed either at the discretion of the nurse or at the time of the medical rounds and only 34% were removed at midnight (Watt 1998). Of those indwelling urethral catheters that were scheduled for removal in the morning, only 70% were removed on time (Noble 1990; Watt 1998).

Practice also varies with respect to the length of time the catheter is left in situ and the procedure for its removal. The factors that influence this decision include: the condition/reason for which the patient is catheterised; clinician/surgeon preference; patient tolerance; and hospital policy (EAUN 2012). Various international guideline panels agree that indwelling urethral catheters should be removed as soon as they are no longer necessary (CDC 2016; EAU 2020; Grabe 2015; Hooton 2010; NICE 2012). The removal of indwelling urethral catheters after shorter durations may prove to be beneficial, as it has the potential to reduce hospital stays and the number of patients developing symptomatic CAUTIs, thus saving healthcare costs and improving patient outcomes (Baldini 2009; Lo 2014).

Bladder dysfunction and post‐operative voiding impairment has been documented following catheterisation and can lead to infections of the urinary tract. The intermittent clamping of the indwelling urethral catheter draining tube prior to withdrawal has been suggested on the basis that this simulates normal filling and emptying of the bladder (EAUN 2012). While clamping catheters might minimise post‐operative neurogenic urinary dysfunction, it could also result in bladder infection or distension if the clamps are not released as scheduled (Roe 1990; Wang 2016).

Another strategy practised prior to removal of urethral catheters is the use of alpha adrenergic blocker drugs. It is thought that post‐operative urinary retention is potentially linked to the stress‐induced, high sympathetic activity occurring around the peri‐operative period. Counteracting its activity with the inhibition of alpha receptors located in the bladder and urethra may potentially reduce the risk of acute urinary retention (Ghuman 2018; Madani 2014; Patel 2018). It has also been reported that alpha blockers are effective in the treatment of voiding dysfunction by enhancing detrusor contractibility and lowering urethral resistance in patients with underactive bladder (Yamanishi 2004). Thus, prophylactic usage of alpha blockers in people with indwelling urethral catheters could reduce the episodes of developing voiding dysfunction after catheter removal.

Why it is important to do this review

This systematic review summarises the evidence from randomised controlled trials (RCTs) related to alternative approaches to the removal of short‐term indwelling urethral catheters. The findings of this review will help determine the safest method of short‐term catheter removal as well as potentially help reduce the risks associated with catheterisation for patients. Since the last version of this review was published (Griffiths 2007), the evidence base has grown substantially and it is important to incorporate findings from new trials into the review in a manner that will enable clinicians to develop evidence‐based policies for practice.

Objectives

To assess the effects of strategies for removing short‐term (14 days or less) indwelling catheters in adults.

Methods

Criteria for considering studies for this review

Types of studies

We included RCTs and quasi‐RCTs that evaluated the effects of strategies for removing short‐term indwelling urethral catheters.

For the purposes of this review, we defined 'indwelling catheterisation' in accordance with the European Association of Urology (EAU), which states that it is the passage of a urinary catheter into the bladder via the urethra and held in place by an inflatable balloon (EAU 2020; Grabe 2015; Tenke 2008). We defined as 'short‐term' cases where the intended duration of catheterisation was 14 days or less (Dunn 2000a; Kidd 2015; Lam 2014).

Types of participants

We included trials of adults requiring short‐term indwelling urethral catheterisation in any setting (hospital, community, nursing home) for any reason. These included individuals who were acutely unwell, required surgery, had urinary retention or women during childbirth.

Types of interventions

We included all interventions involving short‐term indwelling urethral catheterisation and made the following comparisons.

Removal of indwelling urethral catheters at one specified time of day (6 am to 7 am) versus another specified time of day (10 pm to midnight)
Shorter durations of indwelling urethral catheterisation versus longer durations of indwelling urethral catheterisation e.g. immediate/early removal versus removal of the indwelling urethral catheter one day post‐surgery
Flexible durations of indwelling urethral catheterisation versus fixed duration of indwelling urethral catheterisation
Clamping of indwelling urethral catheterisation versus free drainage of indwelling urethral catheterisation prior to removal
Prophylactic use of alpha blocker prior to indwelling urethral catheter removal versus no intervention or placebo

We defined early removal of catheters as the removal of an indwelling urethral catheter up to eight hours post‐operatively.

We have not considered the following interventions as they are either covered in separate Cochrane Reviews or do not meet the objectives of this review:

Suprapubic or intermittent urethral catheterisation (Kidd 2015)
Long‐term catheterisation (Cooper 2016)
Differing catheter insertion techniques (e.g. use of aseptic liquid/cream based agents or topical antibiotic creams)
Meatal care management techniques
Types of catheter materials for short‐term catheters (e.g. latex, silicone) (Lam 2014)
Types of catheter coatings for short‐term catheters (e.g. antibiotic coating, silver) (Lam 2014)
Types of drainage container
Treatment of drainage bag with antiseptic/antibiotic
The use of antibiotic prophylaxis as a primary or secondary outcome (Foon 2012; Lusardi 2013)
The use of reminders or protocols for catheter removal, for example, stop‐orders

It should be noted that the use of alpha blockers prior to urethral catheter removal in acute urinary retention (AUR) is covered by another Cochrane Review (Fisher 2014). Our review only looks at the use of prophylactic alpha blockers in short‐term indwelling urethral catheters in instances other than AUR. We excluded trials that looked at the use of antibiotic prophylaxis as a primary or secondary outcome on the basis that this is covered by another Cochrane Review and is not related to the intervention of interest of this review (Lusardi 2013). We did not exclude trials that used antibiotic prophylaxis for both intervention and control groups as part of their hospital policy.

Types of outcome measures

We analysed the following outcomes in this review. It should be noted that we did not use them as a basis for including or excluding trials.

Primary outcomes

Number of participants who required recatheterisation following removal of indwelling urethral catheter

Secondary outcomes

Complications/adverse effects
- Incidence of UTI
  - symptomatic CAUTI
  - asymptomatic bacteriuria
- Incidence of urinary retention
- Other complications of catheterisation (or recatheterisation), for example, haemorrhage, stricture formation, fever
Patient‐reported
- Patient pain or discomfort
- Patient satisfaction
- Urinary incontinence
- Number of patients reporting dysuria
Clinician‐reported
- Volume of first void (mL)
- Time to first void (hours)
- Post‐void residual volume (mL)
- Length of hospitalisation (days)
- Time between removal of catheter to discharge (days)
Health status/quality of life
- Condition‐specific or generic quality‐of‐life measures (e.g. Short Form 36 (Ware 1992))
- Psychological outcome measures (e.g. Hospital Anxiety and Depression Scale (Zigmond 1983))

Main outcomes for summary of findings tables

Number of participants requiring recatheterisation
Symptomatic CAUTI
Dysuria
Condition‐specific or generic quality‐of‐life measures (e.g. Short Form 36)

Search methods for identification of studies

We did not impose any language or other restrictions on any of the searches described below.

Electronic searches

We identified relevant trials from the Cochrane Incontinence Specialised Register. For more details of the search methods used to build the Specialised Register, please see the Group's webpages where details of the Register's development (from inception) and the most recent searches performed to populate the Register can be found. The Register contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, Be Part of Research and handsearching of journals and conference proceedings. Many of the trials in the Cochrane Incontinence Specialised Register are also contained in CENTRAL.

The date of the last search was: 17 March 2020.

The terms used to search the Cochrane Incontinence Specialised Register are given in Appendix 2.

For an earlier version of this review update we searched CINAHL (on EBSCO), covering December 1981 to 11 May 2016 (searched on 12 May 2016). For the most recent update of the search (17 March 2020) only the Cochrane Incontinence Specialised Register was searched, as this now incorporates the CINAHL search. The search strategy used in CINAHL is given in Appendix 3.

The search strategies used to search for the previous version of this review (Griffiths 2007) are given in Appendix 4.

Searching other resources

We also searched the reference lists of all relevant articles.

Data collection and analysis

For this update, we used the following methods to assess the new reports that were identified as a result of the updated search. For methods used in the previous version of this review, see Griffiths 2007.

Selection of studies

Two review authors (AE and IO) independently screened the titles and abstracts of each trial using Covidence before obtaining the full text for all potentially eligible trials. If the title and abstract were inconclusive, we obtained the full text for further assessment. We attempted to obtain any missing trial data by contacting the trial authors for further information. Duplicate trials that had been reported in more than one publication were included only once. We reached decisions about trial eligibility by a discussion between the author team and resolved any disagreements by consulting an independent third party.

Data extraction and management

Four review authors (AE, FS, EK, IO) extracted data independently using a standardised form and AE compared their results. If the data in trials had not been fully reported, we attempted to contact the trial authors for further classification. We entered the extracted data into Review Manager 5 software (Review Manager 2020).

We have only reported those outcomes that were pre‐specified in the Types of outcome measures. However, there were occasions where the outcomes reported were worded differently despite belonging to the same underlying theme ‐ for example, asymptomatic bacteriuria was also reported as positive urine culture. As these are the same underlying concepts, omitting this information was not appropriate. We therefore chose to collate all data from trials that reported positive urine culture with asymptomatic bacteriuria if they met the CDC definition for asymptomatic bacteriuria.

Assessment of risk of bias in included studies

Four review authors (AE, FS, EK, IO) assessed the included trials for risk of bias using Cochrane's 'Risk of bias' tool (Higgins 2011). We assessed the following domains: random sequence generation (selection bias); allocation concealment (selection bias); blinding of participants and personnel (performance bias); blinding of outcome assessment (detection bias); blinding of microbiological outcome (detection bias); incomplete outcome data (attrition bias); selective reporting of outcomes (reporting bias); and other potential sources of bias.

Two of the review authors (AE and one of either IO, FS or EK) independently assessed each of the trials and rated each as 'low risk', 'unclear risk' or 'high risk'. We resolved any difference in opinion by discussion or by consulting an independent third party.

Measures of treatment effect

We processed all trial data as outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Li 2021). Where appropriate, we undertook meta‐analysis. We combined outcome data by using a fixed‐effect model to calculate pooled estimates and their 95% confidence intervals (CI). We considered the random‐effects model only when there were concerns about heterogeneity affecting the analysis. For categorical outcomes, we related the numbers reporting an outcome to the numbers at risk in each group to calculate a risk ratio (RR) with 95% CI. For continuous variables, we used means and standard deviations to derive the mean difference (MD) with 95% CI.

Unit of analysis issues

In parallel‐group trials, the primary analysis was per participant randomised. Where there were trials that involved a variation of this type of randomisation, for example, cross‐over trials or cluster‐randomised trials, we performed analysis as outlined by the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2021).

Dealing with missing data

We analysed the data on an intention‐to‐treat (ITT) basis where possible, meaning that all participants were analysed according to the group they were randomised in irrespective of whether they received their assigned intervention.

Where participants were excluded after allocation or withdrew from the trial, we reported any details provided in full. If there were data missing, we attempted to contact the original trial authors to obtain the missing trial data. If there was evidence of differential dropout between the groups, the review authors imputed data for the missing results once we had contacted the trial authors. Where trials reported mean values without standard deviations (SDs) but with P values or 95% CI, we used a conversion Excel document designed by a statistician to obtain the SDs. In cases of missing SDs with no P values or 95% CIs, we estimated the SD from another trial in the same meta‐analysis.

Assessment of heterogeneity

We only combined trials if there was evidence that they were clinically similar. We assessed heterogeneity by visual inspection of forest plots, the Chi² test for heterogeneity and the I² statistic (Higgins 2003). If significant heterogeneity existed, we used a random‐effects model. We considered statistical heterogeneity significant if either the P value for the Chi² test was low (P < 0.10) or if the I² statistic suggested heterogeneity. We used the following thresholds for interpreting the I² statistic (Deeks 2021):

0% to 40%: heterogeneity might not be that important
30% to 60%: moderate heterogeneity
50% to 90%: substantial heterogeneity
75% to 100%: considerable heterogeneity

Assessment of reporting biases

In view of the difficulties associated with the detection and correction of publication bias, as well as various other reporting biases, we employed a comprehensive search strategy involving multiple databases and sources. We assessed the likelihood of any potential publication bias by using funnel plots.

Data synthesis

We combined trials for analysis if the interventions were considered to be clinically similar and used a fixed‐effect approach to carry out meta‐analysis. We considered using a random‐effects model if there was substantial statistical heterogeneity (as judged by the Chi² test or I² statistic).

For illustrative purposes, we displayed data in subgroups in the meta‐analysis to help identify the different types of surgery and catheter durations participants were undergoing.

Subgroup analysis and investigation of heterogeneity

We performed the following subgroup analyses for the primary outcome for each comparison.

The type of surgery (urological versus non‐urological) that participants underwent is likely to have an impact with regard to infection, dysuria, haemorrhage and stricture formation etc. If a participant was to be admitted for surgery involving the urological tract (e.g. transurethral resection of the prostate (TURP)), it is likely that the passage of a urethral catheter in these participants would have a potentially worsening impact than those participants with urethral catheters who did not have any urological surgery. This is because the urological tract is likely to have sustained some damage as a result of the trauma involved during the surgery.
The sex of an individual can impact the intervention being studied. Women are more prone to urinary tract infections due to their shorter urethra when compared to the anatomy of men. However, the passage of urethral catheters in women is likely to be less challenging than men. Many men in this review were hospitalised for TURP, implying that passing a urethral catheter is likely to be more technically difficult in men.
Antibiotic prophylaxis: the use of antibiotic prophylaxis for participants with short‐term indwelling urethral catheters is likely to impact outcomes looking at infections (e.g. the number of participants developing symptomatic CAUTI and asymptomatic bacteriuria). Attitudes towards antibiotic prophylaxis in short‐term urethral catheterisation vary, as their use is also associated with an increased risk of developing a hospital‐acquired infection by Clostridium difficile.

Where data were available, we performed post hoc subgroup analysis to assess the impact of prophylactic antibiotics on the number of participants developing symptomatic CAUTI. The use of prophylactic antibiotics is a confounding factor in the number of participants developing CAUTI. We also conducted post hoc subgroup analysis for the outcome of length of hospitalisation to explore the effect of type of surgery as a possible explanation for very high heterogeneity in the meta‐analysis.

For outcomes other than the primary outcome and CAUTI, we used the subgroup function for illustrative purposes only to show the different types of surgery that participants underwent and the different catheter durations. It should be noted that, in these cases, we did not report any results of subgroup analysis in relation to the statistical test for subgroup differences.

Sensitivity analysis

Where data were available, we conducted sensitivity analyses for our primary outcome by excluding trials we judged as high risk of bias for the domains relating to random sequence generation and allocation concealment.

Summary of findings and assessment of the certainty of the evidence

We prepared summary of findings tables for our main comparisons and presented the results for the outcomes prespecified in the Types of outcome measures.

We assessed the certainty of the body of evidence using the GRADE approach. When choosing which outcomes to select, we looked at previous Cochrane Reviews involving urethral catheterisation, the review teams for which had conducted group discussions with people who had undergone short‐term indwelling urethral catheterisation to assist with the selection of appropriate outcomes for inclusion in the summary of findings tables (Kidd 2015; Lam 2014; Omar 2013). We classified the primary and secondary outcomes as critical, important or not important from the patients' perspective for decision‐making.

Results

Description of studies

Results of the search

We screened 1583 records, which were identified by the literature search for this review, and retrieved the full texts of 223 reports of trials to assess their eligibility for inclusion. We included 124 reports of 99 trials in this review, and excluded 89 reports of 85 trials from the review. There are nine reports of eight ongoing trials, details of which can be located in the Characteristics of ongoing studies. One trial is still awaiting classification after we obtained further information regarding the trial during the final stages of this review (NCT02602132). Please see the Characteristics of studies awaiting classification for more details. The flow of literature through the assessment process is shown in the PRISMA diagram (Page 2020; Figure 1).

Newly included trials

In this update, we re‐assessed the 26 trials included in the previous version of this review and re‐extracted their data (Griffiths 2007). We also evaluated their risk of bias. After performing a new search, we identified a further 73 eligible trials.

Included studies

The trials are detailed in the Characteristics of included studies. We were unable to include 12 trials (13 reports) in the meta‐analysis because they reported data in insufficient detail (Azarkish 2005; Bristoll 1989; Dunn 1999; Dunn 2000b; Iversen Hansen 1984; Nguyen 2012; Ruminjo 2015; Talreja 2016; Wilson 2000; Yee 2015), or they were single trials reporting an outcome for a particular comparison (Liu 2015; Williamson 1982), or reported zero events for a particular outcome and so the result was not estimable (Liu 2015). We contacted the trial authors by email to request further data.

Design

Ninety‐four trials included in the review were RCTs and five trials were quasi‐RCTs (Li 2014; Liu 2015; Noble 1990; Valero Puerta 1998; Zhou 2012).

Sample sizes

The number of participants randomised in the included trials ranged from eight (Williamson 1982), to 501 (Barone 2015). In total, the 99 trials randomised 12,241 participants.

Reason for hospitalisation/catheterisation

The reasons for catheterisation varied between the trials (see Table 5).

1. Types of participants.

Trial ID	Reason for hospitalisation	Type of surgery/reason for being admitted	Gender
Ahmed 2014	Elective gynaecological surgery	Total abdominal hysterectomy with or without bilateral salpingo‐oophorectomy	Female
Alessandri 2006	Elective gynaecological surgery	Vaginal hysterectomy	Female
Allen 2016	Patients undergoing cardiothoracic surgery	General thoracic surgical procedure, in whom an epidural catheter was placed for analgesia	Mixed
Alonzo‐Sosa 1997	Elective gynaecological surgery	Anterior colporrhapy, anterior and posterior colporrhaphy with or without vaginal hysterectomy	Female
Aref 2020	Elective CS	Participants admitted for elective CS	Female
Aslam 2019	Elective gynaecological surgery	Participants undergoing minimally invasive pelvic organ prolapse surgery	Female
Azarkish 2003	Elective CS	Participants admitted for elective CS	Female
Azarkish 2005	Emergency CS	Participants admitted for emergency CS	Female
Barone 2015	Elective gynaecological surgery	Participants admitted for vaginal fistula repair	Female
Basbug 2020	Elective CS	Participants admitted for elective CS	Female
Benoist 1999	Elective GI surgery	Extensive rectal resection (total or subtotal proctectomy)	Mixed
Bristoll 1989	Not reported	Not reported	Unknown
Carpiniello 1988	Elective orthopaedic surgery	Total joint replacement (hip or knee)	Female
Carter‐Brooks 2018	Elective gynaecological surgery	Participants undergoing pelvic organ prolapse surgery	Female
Chai 2011	Elective gynaecological surgery	Total abdominal hysterectomy with or bilateral salpingo‐oophorectomy for various benign gynaecological diseases	Female
Chen 2013	Admitted to ICU	Patients requiring mechanical ventilation for respiratory failure	Mixed
Chia 2009	Elective cardiothoracic surgery	Thoracotomy	Mixed
Chillington 1992	Elective urological surgery	TURP	Male
Cornia 2003	Admitted to medicine and cardiology services	Patients admitted to the medicine and cardiology services	Mixed
Coyle 2015	Elective GI surgery	Elective transabdominal colectomy, proctectomy or coloproctectomy	Mixed
Crowe 1993	Admitted to urology ward	Patients admitted to the urology ward with IUCs or who were catheterised during their inpatient stay	Mixed
Dunn 1999	Elective obstetric and gynaecological surgery	Patients undergoing elective obstetric or gynaecological surgery	Female
Dunn 2000b	Elective gynaecological surgery or CS	Patients undergoing hysterectomy or CS who do not require bladder suspension or strict fluid management	Female
Dunn 2003	Elective gynaecological surgery	Women undergoing hysterectomy for various benign diseases (e.g. fibroid tumours, abnormal uterine bleeding, chronic pain, and persistent cervical dysplasia or micro invasive cancer	Female
Durrani 2014	Elective urological surgery	Patients with bladder outflow obstruction due to benign prostatic enlargement undergoing TURP	Male
El‐Mazny 2014	Primary or elective CS	Patients admitted to the prenatal wards for primary or repeat elective CS	Female
Ganta 2005	Elective urological surgery	TURP	Male
Glavind 2007	Elective gynaecological surgery	Patients undergoing any type of vaginal prolapse surgery	Female
Gong 2017	Elective gynaecological surgery	Patients undergoing radical hysterectomy for cervical cancer FIGO stage IB‐IIB	Female
Gross 2007	Admitted to stroke ward	Patients with a stroke admitted to the ward	Mixed
Gungor 2014	Elective gynaecological surgery	Patients with pelvic organ prolapse and/or urinary incontinence undergoing anterior colporrhaphy	Female
Guzman 1994	Elective gynaecological surgery	Patients undergoing vaginal surgery	Female
Hakvoort 2004	Elective gynaecological surgery	Patients undergoing anterior colporrhaphy for vaginal prolapse surgery	Female
Hall 1998	Elective general surgery	Patients admitted to the general surgery wards	Mixed
Han 1997	Elective urological surgery	Patients with benign prostatic enlargement undergoing TURP	Male
Hewitt 2001	Elective urological surgery	Patients requiring radical perineal prostatectomy	Male
Huang 2011	Elective gynaecological surgery	Patients with cystocele of at least stage II, who were symptomatic and desired operative treatment with anterior vaginal repair with or without other concomitant pelvic surgeries	Female
Ind 1993	Elective hysterectomy, posterior exenteration, colposuspension, anterior colporrhaphy, total/radical vulvectomy, radical oophorectomy, ovarian cystectomy, adhesiolysis myomectomy	Patients which were admitted for any of the following operations: hysterectomy, posterior exenteration, colposuspension, anterior colporrhaphy, total/radical vulvectomy, radical oophorectomy, ovarian cystectomy, adhesiolysis myomectomy	Female
Irani 1995	Elective transurethral prostatic surgery	Patients admitted for transurethral prostatic surgery due to benign hyperplasia	Male
Iversen Hansen 1984	Urethral strictures	Patients with urethral strictures	Not reported
Jang 2012	Surgery for rectal cancer	Patients undergoing elective rectal surgery for cancer	Mixed
Jeong 2014	Robot‐assisted laparoscopic radical prostatectomy	Patients with localised or advanced prostate cancer	Men
Joshi 2014	Elective hysterectomy with salpingo‐oophorectomy	Patients undergoing uneventful hysterectomy with salpingo‐oophorectomy	Female
Jun 2011	Elective TURP	Patients admitted for TURP	Male
Kamilya 2010	Vaginal prolapse surgery	Patients undergoing vaginal prolapse surgery	Female
Kelleher 2002	Urological surgery	Patients admitted to urology or renal unit	Not reported
Kim 2012	Radical prostatectomy	Patients undergoing extraperitoneal laparoscopic radical prostatectomy	Men
Koh 1994	Elective TURP	Patients admitted for TURP	Men
Kokabi 2009	Anterior colporrhaphy for pelvic organ prolapse	Patients undergoing anterior colporrhaphy due to pelvic organ prolapse and stress incontinence	Female
Lang 2020	Elective gynaecological surgery	Patients admitted for elective benign gynaecological surgery	Female
Lau 2004	Elective general surgery	Patients admitted for elective general surgery	Mixed
Li 2014	Elective TURP	Patients admitted for TURP	Men
Liang 2009	Laparoscopic vaginal hysterectomy	Patients admitted for laparoscopic vaginal hysterectomy	Female
Lista 2020	Elective urological surgery	Patients admitted for robot‐assisted radical prostatectomy for localised prostate cancer	Male
Liu 2015	Neurosurgery	Patients undergoing neurosurgery	Mixed
Lyth 1997	TURP or bladder neck incision	Patients undergoing TURP or bladder neck incision	Unclear
Mao 1994	Elective gynaecological surgery	Patients undergoing surgery for total hysterectomy or salpingo‐oophorectomy	Female
Matsushima 2015	Surgery for prostate cancer removal (unclear what operation was done)	Patients with prostate cancer	Male
McDonald 1999	TURP	Patients undergoing TURP	Male
Naguimbing‐Cuaresma 2007	Elective CS	Participants admitted for elective CS	Female
Nathan 2001	Elective gynaecological surgery	Patients undergoing surgery for benign gynaecological conditions	Female
Nguyen 2012	Elective urological surgery for urethral strictures	Patients undergoing surgery for urethral strictures	Unclear
Nielson 1985	Elective urological surgery for urethral strictures	Patients undergoing surgery for urethral strictures	Unclear
Noble 1990	Elective urological surgery and procedures	Patients admitted to the urological unit	Mixed
Nyman 2010	Orthopaedic surgery	Patients admitted with hip fractures in need of surgery	Mixed
Oberst 1981	Elective general surgery	Patients undergoing surgery for bowel cancer; low anterior bowel resection or abdominoperineal resection	Mixed
Onile 2008	Elective CS	Patients admitted for elective CS	Female
Ouladsahebmadarek 2012	Elective gynaecological surgery	Patienst admitted for elective abdominal hysterectomy or laparotomy for being pathology (fibroma, AUB, chronic pelvic pain, ovarian cysts etc.)	Female
Pervaiz 2019	Elective urological surgery	Patients undergoing TURP	Male
Popiel 2017	Elective gynaecological surgery	Patients undergoing robotic sacrocolpopexy for vaginal prolapse	Female
Rajan 2017	Elective gynaecological surgery	Patients undergoing surgery for Ward Mayo operation; Manchester repair; vaginal hysterectomy and amputation of cervix	Female
Ruminjo 2015	Elective gynaecological surgery	Patients undergoing fistula repair surgery	Female
Sahin 2011	Elective urological surgery	Patients admitted for TURP due to benign prostate hypertrophy	Male
Sandberg 2019	Elective gynaecological surgery	Patients undergoing laparoscopic hysterectomy	Female
Schiotz 1995	Elective gynaecological surgery	Patients admitted for vaginal plastic surgery (anterior colporrhaphy, anterior plus posterior colporrhaphy or a full Manchester repair)	Female
Schiotz 1996	Elective urogynaecological surgery	Patients admitted for elective retro‐pubic surgery for stress incontinence	Female
Sekhavat 2008	Elective gynaecological surgery	Patients undergoing anterior colporrhaphy	Female
Shahnaz 2016	Elective gynaecological surgery	Patients undergoing surgery for pelvic organ prolapse	Female
Shrestha 2013	Elective gynaecological surgery	Patients admitted for vaginal hysterectomy, anterior colporrhaphy or Manchester operations	Female
Souto 2004	Elective urological surgery	Patients admitted for retropubic radical prostatectomy	Male
Sun 2004	Elective urogynaecological surgery	Patients admitted for Burch's colposuspension	Female
Tahmin 2011	Elective gynaecological surgery	Patients with genital prolapses admitted for vaginal hysterectomy and or pelvic floor repair	Female
Talreja 2016	Elective urological surgery	Patients with benign prostatic enlargement undergoing TURP	Male
Taube 1989	AUR	Patients admitted to the hospital with AUR	Male
Toscano 2001	Elective urological surgery	Patients with benign prostatic enlargement undergoing TURP	Male
Valero Puerta 1998	Elective urological surgery	Patients with benign prostatic enlargement undergoing TURP	Male
Vallabh‐Patel 2020	Elective gynaecological surgery	Patients undergoing robotic sacrocolpopexy for pelvic organ prolapse	Female
Webster 2006	General surgery and medical patients	Patients who required IUC on general surgery and medical wards	Mixed
Weemhoff 2011	Elective gynaecological surgery	Patients admitted for anterior colporrhaphy	Female
Williamson 1982	Elective surgery (unspecific)	Patients undergoing surgery (not specified by trial)	Female
Wilson 2000	Elective urological surgery	Patients with benign prostatic enlargement undergoing TURP	Male
Wu 2015	Elective gallbladder or biliary tree surgery	Pateints undergoing gallbladder or biliary tree surgery	Mixed
Wyman 1987	Elective urological surgery	Patients with benign prostatic enlargement undergoing TURP	Male
Yaghmaei 2017	Elective CS	Patients who underwent CS	Female
Yee 2015	Elective CS	Patients who underwent CS under spinal anaesthesia	Female
Zaouter 2009	Elective major abdominal and thoracic surgery	Patients admitted for elective major abdominal and thoracic surgery	Mixed
Zhou 2012	Elective CS	Patients who underwent CS	Female
Zmora 2010	Elective colon and rectal surgery with pelvic dissection	Patients admitted for elective colon and rectal surgery	Mixed
Zomorrodi 2018	Elective renal transplant surgery	Patients with end‐stage renal failure undergoing renal transplant surgery	Mixed

TrialID	InterventionA	Intervention B	Age (A), years Mean (SD)	Age (B), years Mean (SD)	Age (overall), years
Ahmed 2014	IUC removal immediately post‐op	IUC removal 24 h post‐op	59.1(8.3)	61.3 (10.5)	Not reported
Alessandri 2006	IUC removal immediately post‐op	IUC removal 12 h post‐op	51 (4.3)	47 (5)	Not reported
Allen 2016	IUC removed within 48 h post‐op	IUC removed within 6 h after epidural removal	61.1 (range 31–85)	61.7 (range 21–87)	61.5 (range 21‐87)
Alonzo‐Sosa 1997	IUC removal 1 day post‐op	IUC removal 3 days post‐op	53.5 (range 37‐63)	47.1 (range 37‐67)	Not reported
Aref 2020	IUC removal 6 h post‐op	IUC removal 24 h post‐op	25.3 (2)	25.6 (3)	Not reported
Aslam 2019	IUC removal immediately post‐op	IUC removal 1‐day post‐op	Not reported	Not reported	Not reported
Azarkish 2003	IUC removal 2‐3 h after surgery	IUC removal the morning after surgery	24.96 (4.88)	27.06 (5.56)	Not reported
Azarkish 2005	IUC removal 2‐3 h after surgery	IUC removal 24 h after surgery	Not reported	Not reported	Not reported
Barone 2015	IUC removal 7 days after surgery	IUC removal 14 days after surgery	31.9 (11.5)	30.6 (11.7)	Not reported
Basbug 2020	IUC removal 2 h after surgery	IUC removal 12 h after surgery	30.13 (5.83)	29.96 (4.71)	Not reported
Benoist 1999	IUC removal 1 day post‐op	IUC removal 5 days post‐op	55 (18)	56 (17)	Not reported
Bristoll 1989	threshold clamping	complete drainage	Not reported	Not reported	Not reported
Carpiniello 1988	IUC removal immediately post‐op	IUC removal 1‐day post‐op	73 (6.6)	70 (8.6)	Not reported
Carter‐Brooks 2018	IUC removal 4 h after surgery	IUC removal 6 am on post‐op day 1	64.9 (11.5)	65.2 (10.3)	Not reported
Chai 2011	IUC removal immediately post‐op	IUC removal 1 day post‐op	46.4 (3.9)	46.4 (4.0)	Not reported
Chen 2013	IUC removal ≤ 7 days	IUC removal > 7 days	77 (12.7)	78 (10.5)	Not reported
Chia 2009	IUC removal 1 day post‐op	IUC removal 3 days post‐op	54.7 (11.2)	55.7 (10.3)	Not reported
Chillington 1992	IUC removal at midnight	IUC removal at 6 am the next morning	Not reported	Not reported	Not reported
Cornia 2003	A computer study order was used to remind staff to remove the IUC after 3 days	A computer study order was not used to remind staff to remove the IUC after 3 days	Not reported	Not reported	Not reported
Coyle 2015	IUC removal 2 days post‐op	IUC removal within 12 h of withdrawal of epidural anaesthesia	63.5 (SD not reported)	62 (SD not reported)	Not reported
Crowe 1993	IUC removal at 6 am	IUC removal at midnight	Not reported	Not reported	Not reported
Dunn 1999	IUC removal immediately post‐op	Delayed IUC removal post‐op	Not reported	Not reported	Not reported
Dunn 2000b	IUC removal immediately post‐op	IUC removal 1 day post‐op	Not reported	Not reported	Not reported
Dunn 2003	IUC removal immediately post‐op	IUC removal 1 day post‐op	Not reported	Not reported	Not reported
Durrani 2014	IUC removal 1 day post‐op	IUC removal 4 or 5 days post‐op	Not reported	Not reported	71.32 (5.94)
El‐Mazny 2014	IUC removal immediately post‐op	IUC removal 12 h post‐op	24.5 (4.2)	23.8 (3.9)	Not Reported
Ganta 2005	IUC removal at midnight	IUC removal at 6 am	69.9 (SD not reported)	68.2 (SD not reported)	68.9 (SD not reported)
Glavind 2007	IUC removal 3 h post‐op	IUC removal the next morning	Not reported	Not reported	61 (range 31‐88)
Gong 2017	IUC for 48 h with intermittent clamping	IUC for 48 h without intermittent clamping	46.14 (8.33)	45.70 (9.63)	Not Reported
Gross 2007	IUC removal at 10 pm the day the order for removal was written	IUC removal at 7 am the day after the order for removal was written	Not reported	Not reported	70.3 (11.7)
Gungor 2014	IUC removal 2 days post‐op	IUC removal 3 or 4 days post‐op	55.7 (8.8)	3 days: 58.5 (10.1) 4 days: 55.8 (9.0)	Not reported
Guzman 1994	IUC removal 1 day post‐op	IUC removal 3 days post‐op (with and without bladder‐clamping)	56 (range 40‐75)	No clamping: 58 (range 8‐79) Clamping: 57 (range 36‐75)	Not reported
Hakvoort 2004	IUC removal on the morning after surgery	IUC removal 5 days post‐op	67 (range 36 ‐ 86)	66 (range 33‐87)	Not reported
Hall 1998	IUC removal between 7 am and 9 am	IUC removal between 9 pm and 11 pm	Not reported	Not reported	Not reported
Han 1997	IUC removal 2 days post‐op	IUC removal ≥ 3 days post‐op	64.6 (range 50‐86)	68.2 (range 50‐90)	Not reported
Hewitt 2001	IUC removal 4‐6 days post‐op	IUC removal at 14 days post‐op	Not reported	Not reported	Not reported
Huang 2011	IUC removal 2 days post‐op	IUC removal 3 or 4 days post‐op	61.21, (10.17)	3 days: 63.93 (10.43) 4 days: 63.7 (12.5)	62.9 (10.93)
Ind 1993	IUC removal at 6 am	IUC removal at midnight	49.59 (14.2)	49.84 (16.6)	Not reported
Irani 1995	IUC removal within 48 h	IUC removal at surgeon's discretion	70.7 (range 42‐88)	70 (range 58‐85)	Not reported
Iversen Hansen 1984	IUC removal 1 day post‐op	IUC removal 14 days post‐op	Not reported	Not reported	70 (range 24‐85)
Jang 2012	No alpha blockers given	Prophylactic alpha blockers given	54 (range 48‐62)	59 (range 54‐66)	Not reported
Jeong 2014	Prophylactic alpha blockers given	No alpha blockers given	63.6 (6.6)	63.4 (8)	Not reported
Joshi 2014	IUC removal immediately post‐op	IUC removal 1 day post‐op	46.8 (6.9)	45.09 (6.44)	Not reported
Jun 2011	Prophylactic alpha blockers given	No alpha blockers given	68.71 (7.6)	71.4 (7.85)	Not reported
Kamilya 2010	IUC removal 1 day post‐op	IUC removal 4 days post‐op	46.9 (12.02)	47.9 (12.78)	Not reported
Kelleher 2002	IUC removal at 6 am	IUC removal at midnight	Not reported	Not reported	Not reported
Kim 2012	IUC removal on post‐op day 3/4	IUC removal on post‐op day 7/8	Not reported	Not reported	Not reported
Koh 1994	IUC removal 1 day post‐op	IUC removal 2 days post‐op	68.8, 7.3 (mean, SD)	73, 7.6 (mean, SD)	Not reported
Kokabi 2009	IUC removal 1 day post‐op	IUC removal 2 days post‐op OR 4 days post‐op (3‐arm trial)	Not reported	Not reported	Not reported
Lang 2020	IUC removal 4 h post‐op	IUC removal day 1 post‐op	Not reported	Not reported	44.4 (8.8)
Lau 2004	"In out" catheterisation	IUC overnight	Not reported	Not reported	63.3 (4.9)
Li 2014	IUC removal on day 1‐2 post‐op	IUC removal on day 5‐7 post‐op	Not reported	Not reported	Range 56 ‐ 92
Liang 2009	IUC removal immediately	IUC removal 1 day post‐op OR 2 days post‐op (3‐arm trial)	43.7 (3.9)	B) 45.7 ( 3.5) C) 45.7 ( 5.8)	Not reported
Lista 2020	IUC removal on day 3 post‐op	IUC removal on day 5 post‐op	63 (range 48 ‐ 75)	64 (range 45 – 75)	Not reported
Liu 2015	Clamping of IUC	No clamping of IUC i.e. free drainage	51 (13.2)	52 (16.4 SD)	Not reported
Lyth 1997	IUC removal at 6 am	IUC removal at midnight	Not reported	Not reported	Not reported
Mao 1994	IUC duration 7 am to 8 pm (same day)	IUC duration 7 am to 6 am (next day)	Not reported	Not reported	Not reported
Matsushima 2015	IUC removal 2 days post‐op	IUC removal 4 days post‐op	Not reported	Not reported	65.9 (5.5)
McDonald 1999	IUC removal at midnight	IUC removal at 6 am	66.7 (range 51‐81)	68.7 (range 57‐89)	67.8 (range 51‐89)
Naguimbing‐Cuaresma 2007	IUC removal 4 h post‐op	IUC removal day 1 post‐op	Not reported	Not reported	Not reported
Nathan 2001	IUC removal at 6 am	IUC removal at midnight	46.5 (5.6)	45.7 (5.4)	Not reported
Nguyen 2012	IUC removal 2 days post‐op	IUC removal 10 days post‐op	Not reported	Not reported	Not reported
Nielson 1985	IUC removal 3 days post‐op	IUC removal 28 days post‐op	64 (range 21‐81)	64 (range 16‐78)	Not reported
Noble 1990	IUC removal at 6 am	IUC removal at midnight	Not reported	Not reported	Not reported
Nyman 2010	Clamping of IUC	No clamping of IUC	79 (11)	80 (11.2)	Not reported
Oberst 1981	Clamping of IUC	No clamping of IUC	64.5 (10.26)	59 (11.92)	Not reported
Onile 2008	IUC removal 1 day post‐op	IUC removed immediately post‐op	31.67 (6.042)	32.72 (5.96)	Not reported
Ouladsahebmadarek 2012	IUC removed immediately post‐op	IUC removal 1 day post‐op	37.48 (8.85)	39.48 (9.54)	Not reported
Pervaiz 2019	IUC removal on day 1 post‐op	IUC removal on day 4 post‐op	67.00 (9.11)	65.56 (9.25)	Not reported
Popiel 2017	IUC removal within 6 h of operation completion	IUC removal on day 1 post‐op	Not reported	Not reported	Not reported
Rajan 2017	IUC removal within 3 h of operation completion	IUC removal on day 1 post‐op	50 (18)	48 (2.4)	Not reported
Ruminjo 2015	IUC removal on day 7 post‐op	IUC removal on day 14 post‐op	Not reported	Not reported	Not reported
Sahin 2011	IUC removal 1 day post‐op	IUC removal 2 days post‐op AND 3 days post‐op (3‐arm trial)	62.5 (SD not reported)	B: 61.5, C: 62 (SD not reported)	62 (range 48‐77)
Sandberg 2019	IUC removal immediately post‐op	IUC removal 18‐24 h post‐op	49.3 (10.5)	51.5 (11.9)	Not reported
Schiotz 1995	IUC removal 1 day post‐op	IUC removal 3 days post‐op	Not reported	Not reported	65.9 (range 29.9‐95.2)
Schiotz 1996	IUC removal 1 day post‐op	IUC removal 1 day post‐op	Not reported	Not reported	50.3 (range 26.9‐72.6)
Sekhavat 2008	IUC removed immediately post‐op	IUC removal 1 day post‐op	38.9 (2.9)	39 (3.8)	Not reported
Shahnaz 2016	IUC removal 24 h post‐op	IUC removal 72 h post‐op	39.4 (3.2)	38.8 (2.8)	Not reported
Shrestha 2013	IUC removal 1 day post‐op	IUC removal 3 days post‐op	Not reported	Not reported	53.35 (10.94)
Souto 2004	IUC removal 7 days post‐op	IUC removal 14 days post‐op	64 (7.3)	61 (7.3)	62 (range 50‐73)
Sun 2004	IUC removal on the next morning post‐op	IUC removal 5 days post‐op	46.7 (6.7)	48.3 (8.3)	Not reported
Tahmin 2011	IUC removal 2 days post‐op	IUC removal 5 days post‐op	51.75 (10.8)	53.95 (12.8)	Not reported
Talreja 2016	Clamping of IUC	No clamping of IUC i.e. free drainage	63.05 (4.69)	64.21 (5.36)	Not reported
Taube 1989	IUC removal immediately after emptying of bladder	IUC removal 1 day post‐op AND 2 days post‐op (3‐arm trial)	Not reported	Not reported	Not reported
Toscano 2001	IUC removal 1 day post‐op	IUC removal 2 days post‐op	Not reported	Not reported	Not reported
Valero Puerta 1998	IUC removal on day 2 post‐op	IUC removal according to usual care	70 (range 53‐83)	69 (range 50‐87)	Not reported
Vallabh‐Patel 2020	IUC removal 6 h post‐op	IUC removal 1 day post‐op	59.52 (8.5)	59.57 (11.2)	Not reported
Webster 2006	IUC removal at 6 am	IUC removal at 10 pm	55.02 (19.97)	55.05 (18.99)	Not reported
Weemhoff 2011	IUC removal 2 days post‐op	IUC removal 5 days post‐op	59.9 (10.2)	60.7 (11.1)	Not reported
Williamson 1982	Clamping of IUC	No clamping of IUC i.e. free drainage	Not reported	Not reported	Range 22‐40
Wilson 2000	Bladder infusion with normal saline by gravity until bladder was full	IUC removal at 6 am	Not reported	Not reported	Not reported
Wu 2015	Catheter clamped when patient woke up post‐op. On Day 1 morning post‐op, when the patient felt urge to pass urine, the urinary catheter balloon was deflated and the catheter allowed to be self‐dislodged during urination	On the morning of Day1 post‐op, after the patient passed urine (through the catheter), saline was used to wash the bladder and the catheter clamped. 10 min after clamping, the balloon was deflated and the catheter allowed to be self‐dislodged during urination	45.6 (7.2)	46.1 (7)	Not reported
Wyman 1987	IUC removal between 6 am and 7 am	IUC removal between 10 pm and 11 pm	Not reported	Not reported	70.8 (range 50‐89)
Yaghmaei 2017	IUC removal 6 h post‐op	IUC removal 12‐24 h post‐op	28.19 (5.80)	28.01 (5.83)	Not reported
Yee 2015	IUC removal 8 h post‐op	IUC removal 1 day post‐op	Not reported	Not reported	Not reported
Zaouter 2009	IUC removal on the same morning as the surgery	IUC removal when the epidural anaesthesia was removed	57 (15)	63 (11)	Not reported
Zhou 2012	IUC removal 6‐8 h post‐op	IUC removal 24 h post‐op	25.11(4.88)	26.33 (5.08)	Not reported
Zmora 2010	IUC removal 1 day post‐op	IUC removal 3 days post‐op AND 5 days post‐op (3‐arm trial)	57.4 (range 18‐85)	B: 54.6 (range 25‐81) C: 54.2 (range 22‐78)	Not reported
Zomorrodi 2018	IUC removal 3 days post‐op	IUC removal 7 days post‐op	43.52 (13.6)	43.20 (14.39)	Not reported

TrialID	Comparison	Antibiotic prophylaxis used	Details
Ahmed 2014;	2	Yes	Prophylaxis was given to all patients on the morning of surgery in the form of 1 g of ceftriaxone IM
Alessandri 2006	2	Yes	Prophylaxis was given as a single dose before operation
Allen 2016	2	No	N/A
Alonzo‐Sosa 1997	2	No	N/A
Aref 2020	2	Yes	Single dose of prophylactic antibiotic in the form of ceftriaxone 1 g IM
Aslam 2019	2	Not reported	Not reported
Azarkish 2003	2	Not reported	Not reported
Azarkish 2005	2	Not reported	Perineum wash by povidone iodine 10% before catheter insertion
Barone 2015	2	No	N/A
Basbug 2020	2	Yes	All participants received 1 g IV cefazolin as prophylaxis
Benoist 1999	2	Yes	All participants received IV antibiotics as a single dose at the induction of anaesthesia
Bristoll 1989	3	Not reported	N/A
Carpiniello 1988	2	Yes	Prophylactic cefazolin sodium or clindamycin was given on post‐op day 3
Carter‐Brooks 2018	2	Not reported	N/A
Chai 2011	2	No	N/A
Chen 2013	2	No	Routine prophylaxis was not given. Antibiotics were only used in symptomatic participants.
Chia 2009	2	Yes	Single dose of prophylactic antibiotic was given IV in all participants
Chillington 1992	1	Not reported	Not reported
Cornia 2003	2	Not reported	Not reported
Coyle 2015	2	Not reported	Not reported
Crowe 1993	1	Not reported	Not reported
Dunn 1999	N/A	Not reported	Not reported
Dunn 2000b	N/A	Not reported	Not reported
Dunn 2003	2	Yes	Single dose of antibiotic prophylaxis before operation
Durrani 2014	2	Yes	Cephalosporin 1 g was administered IV at the time of induction of anaesthesia
El‐Mazny 2014	2	Yes	Cefazolin 2 g IV single dose 30 min before surgery
Ganta 2005	1	Not reported	Not reported
Glavind 2007	2	Yes	Participants who had vaginal hysterectomy or high uterosacral suspension received 1 pre‐op injection of cefuroxime. No antibiotic prophylaxis was used in the remaining participants.
Gong 2017	3	Not reported	Not reported
Gross 2007	1	Not reported	Not reported
Gungor 2014	2	Not reported	Not reported
Guzman 1994	2 and 3	Yes	All participants received Quemicetina as prophylaxis
Hakvoort 2004	2	Not reported	Not reported
Hall 1998	1	Not reported	Not reported
Han 1997	2	Not reported	Not reported
Hewitt 2001	2	Not reported	Not reported
Huang 2011	2	Yes	Ciprofloxacin used during all days of hospitalisation in all 3 groups
Ind 1993	1	Not reported	Not reported
Irani 1995	2	Yes	Antibiotics (quinolones) were given from the day of operation until the participant was discharged home
Iversen Hansen 1984	2	Yes	Antibiotics were not administered routinely but participants with urinary infections pre‐ or post‐op were treated with antibiotics according to urine culture results.
Jang 2012	4	Yes	All participants were given an IV dose of antibiotic during anaesthesia induction before operation
Jeong 2014	4	Not reported	Not reported
Joshi 2014	2	Yes	All participants received 1 dose of antibiotic prophylaxis at the time of surgery and continued post‐op as per department protocol
Jun 2011	4	Not reported	Not reported
Kamilya 2010	2	Yes	All participants received 2 doses of antibiotic injection ceftriaxone 1 g, one just before the operation and another 12 h after the first dose
Kelleher 2002	1	Not reported	Not reported
Kim 2012	2	Not reported	Not reported
Koh 1994	2	Yes	Antibiotics were given at induction to participants with IUCs or proven urinary tract infections
Kokabi 2009	2	Not reported	Not reported
Lang 2020	2	Yes	All participants received pre‐op antibiotics with either American College of Obstetricians and Gynecologists approved dosing of cefazolin (78%) or a combination of gentamicin and clindamycin (22%) with no difference between fast‐track or conventional Foley management groups
Lau 2004	2	Yes	Single dose of parenteral antibiotic was given upon induction of general anaesthesia in most cholecystectomies, hernia repairs, gastrointestinal and anorectal operations
Li 2014	2	Not reported	Not reported
Liang 2009	2	Yes	IV antibiotics consisting of cefazolin 500 mg after induction of general anaesthesia
Lista 2020	2	Not reported	Not reported
Liu 2015	3	Not reported	Not reported
Lyth 1997	1	Not reported	Not reported
Mao 1994	2	Not reported	Not reported
Matsushima 2015	2	Not reported	Not reported
McDonald 1999	1	Not reported	Not reported
Naguimbing‐Cuaresma 2007	2	Not reported	Not reported
Nathan 2001	1	Not reported	Not reported
Nguyen 2012	2	Not reported	Not reported
Nielson 1985	2	Not reported	Not reported
Noble 1990	1	Not reported	Not reported
Nyman 2010	3	Not reported	Not reported
Oberst 1981	3	Not reported	Not reported
Onile 2008	2	Not reported	Not reported
Ouladsahebmadarek 2012	2	Yes	Cephazoline 1 g IV half an hour before surgery started and continued every 6 h for another 2 doses
Pervaiz 2019	2	Not reported	Not reported
Popiel 2017	2	Not reported	Not reported
Rajan 2017	2	Not reported	Not reported
Ruminjo 2015	2	Not reported	Not reported
Sahin 2011	2	Not reported	Not reported
Sandberg 2019	2	Not reported	Not reported
Schiotz 1995	2	Not reported	Not reported
Schiotz 1996	2	Not reported	Not reported
Sekhavat 2008	2	Not reported	Not reported
Shahnaz 2016	2	No	"antibiotic was not regularly given except for patients who had abnormal urinary symptoms and unusual urinary analysis in urinary sample 48 h after the surgery"
Shrestha 2013	2	Yes	Antibiotics given for 7 days
Souto 2004	2	Not reported	Not reported
Sun 2004	2	Yes	All participants were given prophylactic antibiotics for 2 days (1 g cefazolin IV 3 times daily)
Tahmin 2011	2	Not reported	Not reported
Talreja 2016	3	Yes	Participants were given 1 dose of third‐generation cephalosporin in pre‐op period
Taube 1989	2	Not reported	Not reported
Toscano 2001	2	Yes	Antiobiotic prophylaxis with first generation cephalosporin was given at the induction of anaesthesia for up to 7 days after the operation
Valero Puerta 1998	2	Yes	1 g of ceftriaxone every 24 h for 2 days
Vallabh‐Patel 2020	2	Yes	All participants received appropriate perioperative antibiotics per American College of Obstetricians and Gynecologists guidelines
Webster 2006	1	Not reported	Not reported
Weemhoff 2011	2	Yes	All participants received antibiotic prophylaxis at the beginning of the operation.
Williamson 1982	3	Not reported	Not reported
Wilson 2000	1	Not reported	Not reported
Wu 2015	3	Not reported	Not reported
Wyman 1987	1	Not reported	Not reported
Yaghmaei 2017	2	Yes	Cefazolin 1 g
Yee 2015	2	Not reported	Not reported
Zaouter 2009	2	Yes	2 g cefazolin with or without 500 mg of metronidazole was given IV
Zhou 2012	2	Not reported	Not reported
Zmora 2010	2	Yes	Prophylactic antibiotics were given 24 h in the perioperative period according to department protocol
Zomorrodi 2018	2	Not reported	Not reported

Removal of short‐term indwelling urethral catheters in adults at one time of day (6 am to 7 am) versus another time of day (10 pm to midnight)
Patient or population: adults with short‐term indwelling urethral catheters that need to be removed Setting: secondary care Intervention: removal of indwelling urethral catheters at 10 pm to midnight Comparison: removal of indwelling urethral catheters at 6 am to 7am
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (trials)	Certainty of the evidence (GRADE)	Comments
	Risk with removal of IUC at 6 am to 7 am	Risk with removal of IUC at 10 pm to midnight
Number of participants requiring recatheterisation	Trial population		RR 0.70 (0.52 to 0.94)	1920 (10 RCTs)	⊕⊕⊝⊝ Low^a
	94 per 1000	66 per 1000 (50 to 90)
Symptomatic catheter‐associated urinary tract infection (CAUTI)	Trial population		RR 1.00 (0.61 to 1.63)	41 (1 RCT)	⊕⊝⊝⊝ Very low^b,c
	611 per 1000	611 per 1000 (373 to 996)
Dysuria	Trial population		RR 2.20 (0.70 to 6.86)	170 (1 RCT)	⊕⊕⊝⊝ Low^c
	48 per 1000	105 per 1000 (33 to 327)
Condition‐specific QoL or generic QoL measure	‐	‐	‐	‐	‐	Not reported
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).  CI: confidence interval; IUC: indwelling urethral catheter; QoL: quality of life; RCT: randomised controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Volume of first void (median and range)
Study	Midnight removal	Morning removal	Significance
Following gynaecological surgery
Ind 1993	275 ml (10 to 600 ml) 49 participants	100 ml (5 to 450 ml) 46 participants	P < 0.0001 (95% CI 124.9 to 225.5)

Time to first void (median)
Study	Midnight removal	Morning removal	Significance
Following gynaecological surgery
Ind 1993	Median time 3 hours 20 minutes 49 participants	Median time 5 hours 46 participants	P = 0.012 (95% CI 0.33 to 2.58)

Length of hospitalisation in days
Study	Midnight removal	Morning removal	significance
Urological surgery and procedures (mean, total)
Chillington 1992	4.7 (35)	5.4 (48)
Gynaecological surgery involving the bladder /urethra (median, range)
Ind 1993	9 days (4 to 17 days)	12 days (5 to 20 days)	p=0.043
Gynaecological surgery not involving the bladder/urethra (median, range)
Ind 1993	6 days (1 to 14 days)	7 days (2 to 18 days)

TrialID	Outcome as defined by trial authors	Trial definition	Relevant definition outlined by International Guideline Panel
Ahmed 2014	Symptomatic UTI	Significant bacteriuria with at least one of the following symptoms: dysuria, frequency of micturition, urgency, suprapubic pain ir burning sensation at micturition	CDC
Alessandri 2006	UTI	Significant bacteria which is determined by: urine culture and defined as at least 10⁵ cfu/mL	EAU: symptomatic bacteriuria
Allen 2016	UTI	Not reported	N/A
Alonzo‐Sosa 1997	UTI	Defined as a positive urine sample associated with: dysuria, polyuria, incomplete emptying, pain, fever or sepsis. A positive urine sample was defined as the presence of > 10⁵ cfu/mL if MSU and 10⁴ cfu/mL in a catheter sample.	CDC
Aref 2020	Symptomatic UTI	“The diagnosis of symptomatic urinary tract infection was based on the following criteria: significant bacteriuria with at least one of the following symptoms; dysuria, frequency of micturition, urgency, supra pubic pain, or burning sensation at micturition.”	CDC
Aslam 2019	UTI	Not reported	N/A
Azarkish 2003	UTI	Not reported	N/A
Azarkish 2005	Not reported	Not reported	N/A
Barone 2015	UTI	Not reported	N/A
Basbug 2020	Significant bacteruria	Significant microscopic bacteriuria was defined as ≥ 100,000 bacteria/ mL MSU	EAU: asymptomatic bacteriuria
Benoist 1999	UTI	Culture yield of > 10⁵ cfu/mL with or without symptoms	With symptoms: CDC Without symptoms: EAU definition for "Asymptomatic bacteriuria"
Bristoll 1989	Not reported	Not reported	N/A
Carpiniello 1988	UTI	Culture yield of 10⁵ cfu/mL	EAU: asymptomatic bacteriuria
Carter‐Brooks 2018	UTI	Defined as a positive culture or symptoms and antibiotic treatment	N/A
Chai 2011	Symptomatic UTI	Positive urine culture: > 10⁵ cfu/mL of an identified single uropathogen/mL of urine Symptomatic UTI: fever (> 38 °C) and dysuria with a positive urine culture	CDC
Chen 2013	CAUTI	CDC criteria used to define symptomatic UTI and asymptomatic bacteriuria	CDC
Chia 2009	CAUTI	Not reported	N/A
Chillington 1992	Not reported	N/A	N/A
Cornia 2003	CAUTI	Growth from a urine specimen aseptically aspirated from the catheter of ≥ 100 cfu of a predominant pathogen OR ≥ 10 leukocytes per high‐power field on urinalysis in a patient with a clinical diagnosis of UTI	N/A
Coyle 2015	Bacteriuria	Symptomatic or asymptomatic bacteriuria used. No definition given	N/A
Crowe 1993	Not reported	N/A	N/A
Dunn 1999	Not reported	N/A	N/A
Dunn 2000b	UTI	Not reported	N/A
Dunn 2003	UTI	Determined by either microscopic abnormality or any patient symptoms	N/A
Durrani 2014	UTI	Not reported	N/A
El‐Mazny 2014	Significant bacteriuria	Significant bacteriuria: > 10⁵ cfu/mL of urine in a MSU sample collected 24 h post‐op	EAU: asymptomatic bacteriuria
Ganta 2005	Not reported	N/A	N/A
Glavind 2007	Positive urine culture	Defined as the presence of ≥ 10⁵ cfu/mL	EAU: asymptomatic bacteriuria
Gong 2017	Symptomatic UTI	Defined as bacteriuria with fever, frequent or painful urination or burning on urination	CDC
Gross 2007	UTI	Used CDC criteria	CDC
Gungor 2014	Not reported	N/A	N/A
Guzman 1994	UTI	Urine culture of > 10⁵ cfu/mL reported as outcome. Definition is not provided	EAU: asymptomatic bacteriuria
Hakvoort 2004	UTI	Signs of UTI: having > 10 WBC/high‐powered field and significant microscopic bacteriuria (1/high‐powered field) in the urine sediment UTI: presence of > 10⁵ cfu/mL in urine culture	EAU: asymptomatic bacteriuria
Hall 1998	Not reported	N/A	N/A
Han 1997	Not reported	N/A	N/A
Hewitt 2001	Not reported	N/A	N/A
Huang 2011	UTI	Not reported	N/A
Ind 1993	Not reported	N/A	N/A
Irani 1995	UTI	Not reported	N/A
Iversen Hansen 1984	Not reported	N/A	N/A
Jang 2012	Not reported	N/A	N/A
Jeong 2014	Not reported	N/A	N/A
Joshi 2014	Symptomatic UTI	Symptomatic UTI: based on the presence of significant bacteriuria accompanied by at least 1 of the following symptoms: fever, dysuria, increased frequency of micturition, urinary urgency, suprapubic pain and dysuria	CDC
Jun 2011	Not reported	N/A	N/A
Kamilya 2010	Symptomatic UTI	Symptomatic UTI: positive urine culture of > 10⁵ cfu/mL plus 1 of the following symptoms: dysuria, fever (> 38 °C) or rigors	CDC
Kelleher 2002	Not reported	N/A	N/A
Kim 2012	Not reported	N/A	N/A
Koh 1994	UTI	Not reported	N/A
Kokabi 2009	UTI	Not reported	N/A
Lang 2020	UTI	Not reported	N/A
Lau 2004	Positive urine culture	Not reported	N/A
Li 2014	Infection	Not reported	N/A
Liang 2009	UTI	UTI: positive urine culture of > 10⁵ cfu/mL. However, treatment was only given for positive urine cultures if participant had adverse urinary symptoms or post‐op pyrexia (> 38 °C)	CDC
Lista 2020	UTI	Not reported	N/A
Liu 2015	Not reported	N/A	N/A
Lyth 1997	Not reported	N/A	N/A
Mao 1994	Not reported	N/A	N/A
Matsushima 2015	Not reported	N/A	N/A
McDonald 1999	Not reported	N/A	N/A
Naguimbing‐Cuaresma 2007	Not reported	N/A	N/A
Nathan 2001	Positive catheter specimen urine (CSU)	Not reported	N/A
Nguyen 2012	Not reported	N/A	N/A
Nielson 1985	Not reported	N/A	N/A
Noble 1990	Not reported	N/A	N/A
Nyman 2010	Not reported	N/A	N/A
Oberst 1981	Not reported	N/A	N/A
Onile 2008	Significant bacteriuria	Significant bacteriuria: positive urine culture of > 10⁵ cfu/mL in a sample of MSU collected 72 h post‐op with signs of a fever ( a temperature of > 38 °C on 2 occasions within 10 days of the procedure, excluding the first 24 h)	CDC
Ouladsahebmadarek 2012	Symptomatic UTI	Not reported	N/A
Pervaiz 2019	UTI	Urine sample was obtained to assess UTI (bacterial colony count > 10⁵ cfu/mL on urine culture after removal of catheter assessed on day 7)	EAU: catheter‐associated asymptomatic bacteriuria
Popiel 2017	UTI	Not reported	N/A
Rajan 2017	UTI	Urinary infections defined as when microscopic examination of the urine revealed pus cells or when urine culture showed growth of pathogenic organisms	N/A
Ruminjo 2015	Not reported	N/A	N/A
Sahin 2011	Not reported	N/A	N/A
Sandberg 2019	UTI	Standard urine test for nitrite and leucocytes in combination with clinical symptoms	Not clear whether test is dipstick only or whether it involves microscopy/culture
Schiotz 1995	UTI	Positive cultures: culture of > 10⁵ cfu/mL in a sample of MSU or CSU culture of > 10⁴ cfu/mL UTI: positive urine culture in the absence of symptoms. Patients were defined as having UTI if there was any doubt	EAU: asymptomatic bacteriuria
Schiotz 1996	UTI	Positive cultures: culture of > 10⁵ cfu/mL in a sample of MSU or CSU culture of > 10⁴ cfu/mL UTI: positive urine culture in the absence of symptoms. Participants were defined as having UTI if there was any doubt	EAU: asymptomatic bacteriuria
Sekhavat 2008	Positive urine culture	Positive urine culture: prevalence of symptomatic UTI was confirmed through a positive urine culture OR through signs of UTI such as: frequency, urgency, dysuria, suprapubic pain or fever	Does not fully meet the criteria for CDC. Must be positive cultures AND clinical features
Shahnaz 2016	Positive urine culture	The presence of positive urinary culture or > 100,000 colony counts in each mL of urine or > 10 pieces of leukocyte in each microscopy field was considered as a urinary infection.	EAU: asymptomatic bacteriuria
Shrestha 2013	Asymptomatic bacteriuria	Asymptomatic bacteriuria: pus cells of > 5 per high‐power field in routine examination of urine and bacterial culture positive	EAU: asymptomatic bacteriuria
Souto 2004	Not reported	N/A	N/A
Sun 2004	UTI	UTI: positive urine culture of > 10⁵ cfu/mL or WBC > 5/high‐power field in urine analysis	EAU: asymptomatic bacteriuria
Tahmin 2011	UTI	UTI: positive urine culture of > 10⁵ cfu/mL	EAU: asymptomatic bacteriuria
Talreja 2016	Not reported	N/A	N/A
Taube 1989	Not reported	N/A	N/A
Toscano 2001	Not reported	N/A	N/A
Valero Puerta 1998	Not reported	N/A	N/A
Vallabh‐Patel 2020	UTI	For the purpose of this trial, participants were considered positive for a UTI if they had (1) positive urine cultures per CDC guidelines or (2) treated empirically over the phone for symptoms of UTI, even in the absence of a urine culture	CDC
Webster 2006	Not reported	N/A	N/A
Weemhoff 2011	UTI	UTI: > 25 WBC/high‐power field, nitrate production, > 20 bacteria/high‐power field, positive urine culture of > 10⁵ cfu/mL	EAU: asymptomatic bacteriuria
Williamson 1982	Not reported	N/A	N/A
Wilson 2000	Not reported	N/A	N/A
Wu 2015	Not reported	N/A	N/A
Wyman 1987	Not reported	N/A	N/A
Yaghmaei 2017	Not reported	N/A	N/A
Yee 2015	Not reported	N/A	N/A
Zaouter 2009	UTI	UTI: pyrexia of > 38 °C, clinical features of UTI (dysuria, frequency, urgency, suprapubic pain, urinary incontinence) and a positive urine culture (10⁷ bacterial colonies of micro‐organism‐forming units/L within 2 weeks after the removal of bladder catheter)	CDC EAU: complicated UTI
Zhou 2012	Not reported	Defined as post‐catheter removal MSU clean catch culture of ≥ 10⁴ cfu/mL for Gram positive organisms or ≥ 10⁵ cfu/mL for Gram negative organisms	EUA: asymptomatic bacteriuria
Zmora 2010	UTI Asymptomatic bacteriuria	UTI: positive urine culture and symptoms suggestive of UTI	CDC
Zomorrodi 2018	UTI	Not reported	N/A

Guideline Committee	Population	Clinical features	Microbiological findings
Centres for Disease Control and Prevention (CDC) (CDC 2016; Gould 2009)	CAUTI ‐ UTI in patients who have IUCs that have been in place for > 2 days (day 1 being when the catheter was placed)	At least one of the following: Urgency Dysuria Frequency Suprapubic tenderness Fever (> 38 °C) Costovertebral angle pain or tenderness	AND a urine culture of at least ≥ 10⁵ cfu/mL with no more than 2 species of organisms
Infectious Diseases Society of America (IDSA) (Hooton 2010)	UTI in patients with urethral (indwelling or intermittent) or suprapubic catheters that are inserted at the time or removed in the previous 48 h	Patient must have clinical features compatible with UTI (not specified)	AND a MSUor CSU with a urine culture of ≥ 10³ cfu/mL of ≥ 1 species of bacterial organism (single‐catheter specimen or MSU)
European Association of Urology (EAU) (EAU 2020; Grabe 2015)	Asymptomatic bacteriuria	No clinical features	A single, catheterised sample bacterial growth may be as low as 10² cfu/mL to be considered representing true bacteriuria in both men and women > 10⁵ cfu/mL on 2 consecutive MSU in women or 1 MSU in men
	Uncomplicated UTI (see Table 10 for definition)	Urgency Dysuria Frequency Suprapubic tenderness No urinary symptoms in 4 weeks before this episode	Positive urine culture of ≥ 10⁵ cfu/mL and pyuria of > 10 WBC/mm³
	Complicated UTI (see Table 10 for definition)	Urgency Dysuria Frequency Suprapubic pain Fever Chills Flank pain No urinary symptoms 4 weeks before	> 10⁵ cfu/mL for women > 10⁴ cfu/mL for men or in women with straight catheters > 10 WBC/mm³

Uncomplicated UTIs	Acute, sporadic or recurrent lower (uncomplicated cystitis) and/or upper (uncomplicated pyelonephritis) UTI, limited to non‐pregnant, premenopausal women with no known relevant anatomical and functional abnormalities within the urinary tract or co‐morbidities
Complicated UTIs	All UTIs that are not defined as uncomplicated. Meaning in a narrower sense UTIs in a patient with an increased chance of a complicated course: i.e. all men, pregnant women, patients with relevant anatomical or functional abnormalities of the urinary tract, IUCs, renal diseases, and/or with other concomitant immunocompromising diseases for example, diabetes
Recurrent UTIs	Recurrences of uncomplicated and/or complicated UTIs, with a frequency of at least 3 UTIs/year or 2 UTIs in the last 6 months
Catheter associated UTIs (CAUTI)	Catheter‐associated urinary tract infection (CAUTI) refers to UTIs occurring in a person whose urinary tract is currently catheterised or has had a catheter in place within the past 48 h
Urosepsis	Urosepsis is defined as life‐threatening organ dysfunction caused by a disregulated host response to infection originating from the urinary tract and/or male genital organs

Reported outcomes in this review	Similar outcomes reported by trials
Asymptomatic bacteriuria	Positive urine culture
Incidence of urinary retention	Post‐discharge urinary retention Short‐term retention Acute urinary retention Delayed voiding after catheter removal Chronic urinary retention
Loin pain	Post‐discharge loin pain
Fever	Post‐discharge fever
Dysuria	Post‐discharge pain on passing urine
Difficulty in passing urine	Post‐discharge difficulty in passing urine Post‐operative voiding dysfunction
Incontinence	Post‐discharge incontinence

Post‐void residual volume (median and range) (mL)
Study	Outcome	IUC for 2 days	IUC for 10 days
Nguyen 2012	Median (range) post‐void residual volume (mls)	Pre‐op: 100 (20 ‐ 400) 3 months post‐op: 35 (30 ‐ 200)	Pre‐op: 50 (0 ‐ 180) 3 months post‐op: 20 (0 ‐ 180) 6 months post‐op: 20 (0 ‐ 65) 12 months post‐op: 30 (0 ‐ 100)

Length of hospitalisation in days (median and range)
Study	Early Removal; median and range	Later Removal; median and range
Allen 2016	5 (4‐42)	5 (3‐24)
Alonzo‐Sosa 1997	2 (range not reported)	3 (range not reported)
Lista 2020	4 (3‐7)	6 (4‐8)
Sandberg 2019	1.5 (0‐4)	1 (1‐4)
Weemhoff 2011	3 (2‐42)	5 (1‐59)
Zaouter 2009	7 (5‐11)	9 (6‐14)

Length of hospitalisation in days (median, range, N)
Study	Alpha Blocker	No Intervention
Jang 2012	9, (7.0‐12.0), 47	9, (8.0‐11.0), 47

#	Query
S29	(S23 AND S28)
S28	S24 OR S25 OR S26 OR S27
S27	TI urin* N6 catheter* OR AB urin* N6 catheter*
S26	(MH "Catheter Removal") OR (MH "Sheath Removal") OR (MH "Urinary Catheter Care (Saba CCC)") OR (MH "Urinary Catheter Insertion (Saba CCC)") OR (MH "Urinary Catheter Irrigation (Saba CCC)") OR (MH "Urinary Tract Infections, Catheter‐Related") OR (MH "Urinary Catheterization+") OR (MH "Catheters, Urinary+")
S25	(MH "Catheter Occlusion")
S24	(MH "Catheter Care, Urinary+")
S23	S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22
S22	TI ( singl* N25 blind* OR singl* N25 mask* OR doubl* N25 blind* or doubl* N25 mask* OR trebl* N25 blind* OR trebl* N25 maskOR tripl N25 blind* OR tripl* N25 mask* ) or AB ( singl* N25 blind* OR singl* N25 mask* OR doubl* N25 blind* or doubl* N25 mask* OR trebl* N25 blind* OR trebl* N25 maskOR tripl N25 blind* OR tripl* N25 mask* )
S21	(MH "Comparative Studies")
S20	(MH "Clinical Research+")
S19	(MH "Static Group Comparison")
S18	(MH "Quantitative Studies")
S17	(MH "Crossover Design") or (MH "Solomon Four‐Group Design")
S16	(MH "Factorial Design")
S15	(MH "Community Trials")
S14	(MH "Random Sample")
S13	TI balance* N2 block* or AB balance* N2 block*
S12	TI "latin square" or AB "latin square"
S11	TI factorial or AB factorial
S10	TI clin* N25 trial* or AB clin* N25 trial*
S9	(MH "Study Design")
S8	(AB random) OR (TI random)
S7	(AB placebo) OR (TI placebo)
S6	(MH "Placebos")
S5	(PT Clinical Trial) OR (PT "randomized controlled trial")
S4	(MH "Clinical Trials+")
S3	MH (random assignment) OR (crossover design)
S2	cross‐over
S1	crossover

Length of hospitalisation (median days)
Study	Catheter Removal at 72 hours without bladder re‐training (median)	Catheter Removal at 72 hours with bladder re‐training i.e. clamping (median)
Guzman 1994	6.9	6.9

Date	Event	Description
21 June 2021	New search has been performed	This update, published in 2021, includes the following changes.  1. The search was updated to March 2020 and a further 73 trials have been included (taking the total of included trials to 99): Ahmed 2014; Alessandri 2006; Allen 2016; Alonzo‐Sosa 1997; Aref 2020; Aslam 2019; Azarkish 2003; Azarkish 2005; Barone 2015; Basbug 2020; Bristoll 1989; Carpiniello 1988; Carter‐Brooks 2018; Chai 2011; Chen 2013; Chia 2009; Cornia 2003; Coyle 2015; Dunn 1999; Dunn 2000b; Durrani 2014; El‐Mazny 2014; Glavind 2007; Gong 2017; Gross 2007; Gungor 2014; Hall 1998; Han 1997; Hewitt 2001; Huang 2011; Jang 2012; Jeong 2014; Joshi 2014; Jun 2011; Kamilya 2010; Kim 2012; Kokabi 2009; Lang 2020; Li 2014; Liang 2009; Lista 2020; Liu 2015; Mao 1994; Matsushima 2015; Naguimbing‐Cuaresma 2007; Nathan 2001; Nguyen 2012; Nyman 2010; Onile 2008; Ouladsahebmadarek 2012; Pervaiz 2019; Popiel 2017; Rajan 2017; Ruminjo 2015; Sahin 2011; Sandberg 2019; Schiotz 1995; Sekhavat 2008; Shahnaz 2016; Shrestha 2013; Souto 2004; Tahmin 2011; Talreja 2016; Valero Puerta 1998; Vallabh‐Patel 2020; Weemhoff 2011; Wu 2015; Yaghmaei 2017; Yee 2015; Zaouter 2009; Zhou 2012; Zmora 2010; Zomorrodi 2018. 2. We revised the outcomes in line with the GRADE recommendations in order to include outcomes deemed important for clinical and patient decision‐making. 3. We performed post‐hoc subgroup analysis for or one outcome in one comparison to assess whether the use of prophylactic antibiotics would impact the number of participants developing symptomatic catheter‐associated urinary tract infection. We also performed post hoc subgroup analysis for length of hospitalisation in one comparison to explore possible reasons for very high heterogeneity. 4. The review was substantially updated in accordance with current Cochrane methodology, including performing a risk of bias assessment on all 99 included trials and adopting the GRADE approach for assessing the certainty of evidence.
21 June 2021	New citation required but conclusions have not changed	The review has been updated; however, the conclusions did not change.

Date	Event	Description
13 October 2008	Amended	Converted to new review format.
21 February 2007	New citation required and conclusions have changed	Substantive amendment. Update Issue 2, 2007. Twenty‐six trials (eight new) involving a total of 2933 participants were included in this first update of the review. One trial (Guzman 1994) included three treatment groups. Eleven (three new) compared late night versus early morning removal of catheters (Chillington 1992; Crowe 1994; Ganta 2005; Ind 1993; Kelleher 2002; Lyth 1997; McDonald 1999; Noble 1990; Webster 2006; Wilson 2000; Wyman 1987); thirteen (five new) compared various durations of catheterisation (Benoist 1999; Dunn 2003; Guzman 1994; Hakvoort 2004; Hansen 1984; Irani 1995; Koh 1994; Lau 2004; Nielson 1985; Schiotz 1996; Sun 2004; Taube 1989; Toscano 2001); and three (Guzman 1994; Oberst 1981; Williamson 1982) compared clamping to free drainage.

Time required to return to normal bladder function (hours)
Study	Clamping	Free Drainage
Nyman 2010	6 (4‐8); median (quartiles)	4 (3‐7.25); median (quartiles)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Number needing to be recatheterised	10	1920	Risk Ratio (M‐H, Fixed, 95% CI)	0.70 [0.52, 0.94]
1.1.1 Urological surgery and procedures	6	1400	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.60, 1.27]
1.1.2 Gynaecological surgery	2	202	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.15, 0.69]
1.1.3 General medical and surgical patients	2	318	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.36, 1.46]
1.2 Number needing to be recatheterised: subgroup analysis based on sex	6	1200	Risk Ratio (M‐H, Fixed, 95% CI)	0.44 [0.25, 0.76]
1.2.1 Men only	4	998	Risk Ratio (M‐H, Fixed, 95% CI)	0.63 [0.28, 1.44]
1.2.2 Women only	2	202	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.15, 0.69]
1.3 Symptomatic catheter‐associated urinary tract infection (number of participants)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.3.1 General medical and surgical patients	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.4 Asymptomatic bacteriuria (number of participants)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.4.1 Gynaecological surgery	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.5 Incidence of urinary retention	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.5.1 General medical and surgical patients	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.6 Difficulty in passing urine	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.6.1 General medical and surgical patients	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.7 Loin pain	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.7.1 General medical and surgical patients	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.8 Fever	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.8.1 General medical and surgical patients	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.9 Incontinence	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.9.1 General medical and surgical patients	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.10 Dysuria (number of participants)	1	170	Risk Ratio (M‐H, Fixed, 95% CI)	2.20 [0.70, 6.86]
1.10.1 General medical and surgical patients	1	170	Risk Ratio (M‐H, Fixed, 95% CI)	2.20 [0.70, 6.86]
1.11 Volume of the first void (mL)	11	1198	Mean Difference (IV, Fixed, 95% CI)	21.98 [3.04, 40.92]
1.11.1 Urological surgery and procedures	8	923	Mean Difference (IV, Fixed, 95% CI)	11.63 [‐10.65, 33.91]
1.11.2 Gynaecological surgery	1	107	Mean Difference (IV, Fixed, 95% CI)	34.00 [‐11.30, 79.30]
1.11.3 General medical and surgical patients	2	168	Mean Difference (IV, Fixed, 95% CI)	74.54 [15.35, 133.73]
1.12 Volume of first void (median and range)	1		Other data	No numeric data
1.12.1 Following gynaecological surgery	1		Other data	No numeric data
1.13 Time to first void (hours)	10	1140	Mean Difference (IV, Fixed, 95% CI)	0.71 [0.41, 1.01]
1.13.1 Urological surgery and procedures	6	703	Mean Difference (IV, Fixed, 95% CI)	0.72 [0.39, 1.06]
1.13.2 Gynaecological surgery	1	107	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐1.46, 1.66]
1.13.3 General medical and surgical patients	3	330	Mean Difference (IV, Fixed, 95% CI)	0.79 [0.02, 1.57]
1.14 Time to first void (median)	1		Other data	No numeric data
1.14.1 Following gynaecological surgery	1		Other data	No numeric data
1.15 Post‐void residual volume	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.15.1 General medical and surgical patients	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.16 Length of hospitalisation in days	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.16.1 Gynaecological surgery	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.17 Length of hospitalisation in days	2		Other data	No numeric data
1.17.1 Urological surgery and procedures (mean, total)	1		Other data	No numeric data
1.17.2 Gynaecological surgery involving the bladder /urethra (median, range)	1		Other data	No numeric data
1.17.3 Gynaecological surgery not involving the bladder/urethra (median, range)	1		Other data	No numeric data
1.18 Time between removal of catheter to discharge	2	272	Mean Difference (IV, Fixed, 95% CI)	0.08 [‐5.96, 6.12]
1.18.1 Urological surgery and procedures	1	72	Mean Difference (IV, Fixed, 95% CI)	0.00 [‐6.06, 6.06]
1.18.2 General medical and surgical patients	1	200	Mean Difference (IV, Fixed, 95% CI)	15.50 [‐67.34, 98.34]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Number needing to be recatheterised	44	5870	Risk Ratio (M‐H, Random, 95% CI)	1.81 [1.35, 2.41]
2.1.1 Early removal versus later	19	2528	Risk Ratio (M‐H, Random, 95% CI)	2.59 [1.47, 4.57]
2.1.2 1‐day policy versus later	16	1874	Risk Ratio (M‐H, Random, 95% CI)	1.45 [0.93, 2.25]
2.1.3 2‐day to 7‐day policy versus later	10	1468	Risk Ratio (M‐H, Random, 95% CI)	1.67 [0.93, 2.99]
2.2 Number needing to be recatheterised: subgroup analysis based on type of surgery	37	4736	Risk Ratio (M‐H, Random, 95% CI)	1.85 [1.36, 2.51]
2.2.1 Urological surgery	9	1104	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.50, 1.67]
2.2.2 Gynaecological surgery	24	2935	Risk Ratio (M‐H, Random, 95% CI)	2.25 [1.58, 3.22]
2.2.3 Obstetric surgery	4	697	Risk Ratio (M‐H, Random, 95% CI)	3.36 [0.93, 12.15]
2.3 Number needing to be recatheterised: subgroup analysis based on sex	37	4736	Risk Ratio (M‐H, Random, 95% CI)	1.85 [1.36, 2.51]
2.3.1 Men only	9	1104	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.50, 1.67]
2.3.2 Women only	28	3632	Risk Ratio (M‐H, Random, 95% CI)	2.29 [1.64, 3.18]
2.4 Number needing to be recatheterised: subgroup analysis based on antibiotic prophylaxis	27	3839	Risk Ratio (M‐H, Random, 95% CI)	1.72 [1.11, 2.65]
2.4.1 Antibiotic prophylaxis given	22	3040	Risk Ratio (M‐H, Random, 95% CI)	1.73 [1.04, 2.89]
2.4.2 No antibiotic prophylaxis	5	799	Risk Ratio (M‐H, Random, 95% CI)	1.65 [0.70, 3.86]
2.5 Symptomatic catheter‐associated urinary tract infection (number of participants)	41	5759	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.45, 0.61]
2.5.1 Early versus later	17	2220	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.43, 0.71]
2.5.2 1 day versus later	15	1879	Risk Ratio (M‐H, Fixed, 95% CI)	0.48 [0.37, 0.62]
2.5.3 2 to 7 days versus later	9	1660	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.39, 0.78]
2.6 Symptomatic catheter‐associated urinary tract infection: post‐hoc subgroup analysis by antibiotic prophylaxis	24	3516	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.38, 0.59]
2.6.1 Antibiotic prophylaxis	20	2871	Risk Ratio (M‐H, Fixed, 95% CI)	0.49 [0.39, 0.62]
2.6.2 No antibiotic prophylaxis given	4	645	Risk Ratio (M‐H, Fixed, 95% CI)	0.28 [0.11, 0.72]
2.7 Asymptomatic bacteruria (number of participants)	18	2611	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.38, 0.58]
2.7.1 Early versus later	10	1461	Risk Ratio (M‐H, Fixed, 95% CI)	0.59 [0.45, 0.77]
2.7.2 1 day versus later	6	683	Risk Ratio (M‐H, Fixed, 95% CI)	0.37 [0.26, 0.54]
2.7.3 2 to 7 days versus later	3	467	Risk Ratio (M‐H, Fixed, 95% CI)	0.32 [0.18, 0.59]
2.8 Incidence of urinary retention	19		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
2.8.1 Early versus later	7	1108	Risk Ratio (M‐H, Random, 95% CI)	1.07 [0.57, 2.00]
2.8.2 1 day versus later	7	680	Risk Ratio (M‐H, Random, 95% CI)	1.36 [1.03, 1.81]
2.8.3 2 to 7 days versus later	6	881	Risk Ratio (M‐H, Random, 95% CI)	1.37 [0.88, 2.12]
2.9 Delayed voiding after catheter removal	2	176	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.53, 1.97]
2.9.1 1 day versus later	2	176	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.53, 1.97]
2.10 Chronic urinary retention	2	339	Risk Ratio (M‐H, Fixed, 95% CI)	0.84 [0.29, 2.44]
2.10.1 1‐day policy versus later	2	230	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.26, 2.59]
2.10.2 2 to 7 days versus later	1	109	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.07, 15.87]
2.11 Other complications of catheterisation: fever	2	470	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [0.40, 3.40]
2.11.1 Early versus later	2	470	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [0.40, 3.40]
2.12 Other complications of catheterisation: epididymitis	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2.12.1 2 to 7 days versus later	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2.13 Pain or discomfort (dichotomous)	5	510	Risk Ratio (M‐H, Random, 95% CI)	0.52 [0.21, 1.27]
2.13.1 Immediate post‐op removal versus removal 24 hours post‐op	3	230	Risk Ratio (M‐H, Random, 95% CI)	0.31 [0.04, 2.64]
2.13.2 Removal 4 hours post‐op versus removal 24 hours post‐op	1	240	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.78, 1.29]
2.13.3 Removal 3 days post‐op versus removal 28 days post‐op	1	40	Risk Ratio (M‐H, Random, 95% CI)	0.20 [0.01, 3.92]
2.14 Pain or discomfort: 0‐10 VAS (higher score = greater pain)	5	695	Mean Difference (IV, Fixed, 95% CI)	‐0.34 [‐0.47, ‐0.20]
2.14.1 Removal 4 hours post‐op versus removal at 6am 1 day post‐op	1	57	Mean Difference (IV, Fixed, 95% CI)	‐0.60 [‐1.65, 0.45]
2.14.2 Immediate post‐op removal versus removal 24 hours post‐op	3	433	Mean Difference (IV, Fixed, 95% CI)	‐0.37 [‐0.52, ‐0.23]
2.14.3 Immediate removal post‐op versus removal 3‐5 days post‐op	1	205	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.37, 0.56]
2.15 Patient satisfaction	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2.16 Urinary incontinence	7	1195	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.35, 0.86]
2.16.1 Early versus later	2	396	Risk Ratio (M‐H, Fixed, 95% CI)	0.13 [0.03, 0.55]
2.16.2 2 to 7 days versus later	5	799	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.52, 1.32]
2.17 Dysuria	7	1398	Risk Ratio (M‐H, Random, 95% CI)	0.42 [0.20, 0.88]
2.17.1 Early versus later	7	1398	Risk Ratio (M‐H, Random, 95% CI)	0.42 [0.20, 0.88]
2.18 Volume of first void (mL)	3	364	Mean Difference (IV, Fixed, 95% CI)	27.02 [1.00, 53.04]
2.18.1 Early removal versus later	1	227	Mean Difference (IV, Fixed, 95% CI)	12.00 [‐21.97, 45.97]
2.18.2 2‐day to 7‐day policy versus later	2	137	Mean Difference (IV, Fixed, 95% CI)	48.36 [7.88, 88.84]
2.19 Time to first void (hours)	2	277	Mean Difference (IV, Random, 95% CI)	‐8.59 [‐16.16, ‐1.01]
2.19.1 Early removal versus later	2	277	Mean Difference (IV, Random, 95% CI)	‐8.59 [‐16.16, ‐1.01]
2.20 Post‐void residual volume (mL)	2	137	Mean Difference (IV, Fixed, 95% CI)	6.37 [‐9.14, 21.88]
2.20.1 2‐day to 7‐day policy versus later	2	137	Mean Difference (IV, Fixed, 95% CI)	6.37 [‐9.14, 21.88]
2.21 Post‐void residual volume (median and range) (mL)	1		Other data	No numeric data
2.22 Length of hospitalisation in days	27		Mean Difference (IV, Random, 95% CI)	Subtotals only
2.22.1 Early removal versus later	13	2012	Mean Difference (IV, Random, 95% CI)	‐0.54 [‐0.82, ‐0.27]
2.22.2 1‐day policy versus later	10	1249	Mean Difference (IV, Random, 95% CI)	‐1.66 [‐2.25, ‐1.07]
2.22.3 2‐day to 7‐day policy versus later	5	474	Mean Difference (IV, Random, 95% CI)	‐5.00 [‐5.89, ‐4.11]
2.23 Length of hospitalisation in days: subgrouping based on type of surgery	27	3735	Mean Difference (IV, Random, 95% CI)	‐1.13 [‐1.42, ‐0.83]
2.23.1 Urological procedures	7	1005	Mean Difference (IV, Random, 95% CI)	‐3.40 [‐4.75, ‐2.05]
2.23.2 Gynaecological procedures	13	1453	Mean Difference (IV, Random, 95% CI)	‐0.92 [‐1.33, ‐0.51]
2.23.3 Obstetric procedures	6	1217	Mean Difference (IV, Random, 95% CI)	‐0.50 [‐0.87, ‐0.13]
2.23.4 General surgical procedures	1	60	Mean Difference (IV, Random, 95% CI)	‐1.10 [‐2.77, 0.57]
2.24 Length of hospitalisation in days (median and range)	6		Other data	No numeric data
2.25 Frequency of micturition	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
2.25.1 Early versus later	2	521	Risk Ratio (M‐H, Fixed, 95% CI)	0.18 [0.06, 0.53]
2.26 Time to first ambulation (hours)	9	1688	Mean Difference (IV, Fixed, 95% CI)	‐5.06 [‐5.24, ‐4.88]
2.26.1 Early versus later	9	1688	Mean Difference (IV, Fixed, 95% CI)	‐5.06 [‐5.24, ‐4.88]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Number needing to be recatheterised	5	569	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.55, 1.21]
3.1.1 Clamping versus removal at 48 hours	2	311	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.51, 1.71]
3.1.2 Clamping versus removal at 72 hours or longer	3	258	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.44, 1.21]
3.2 Number needing to be recatheterised: subgroup analysis based on type of surgery and sex	5	569	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.55, 1.21]
3.2.1 Gynaecological surgery (women)	2	267	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.48, 1.77]
3.2.2 Non‐gynaecological surgery (men and women)	3	302	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.47, 1.23]
3.3 Symptomatic catheter‐associated urinary tract infection (number of participants)	2	267	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.60, 1.63]
3.3.1 Clamping versus removal at 48 hours	1	198	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [0.65, 1.95]
3.3.2 Clamping versus removal at 72 hours or longer	1	69	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.15, 2.01]
3.4 Incidence of urinary retention (number of participants)	2	169	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [0.69, 2.02]
3.4.1 Clamping versus removal at 24 hours	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.31, 2.37]
3.4.2 Clamping versus removal at 72 hours or longer	1	69	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [0.74, 2.61]
3.5 Dysuria (number of participants)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.5.1 Clamping versus removal at 72 hours or longer	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.6 Volume of first void (mL)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.6.1 Clamping versus removal at 72 hours or longer	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.7 Time to first void (minutes)	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.7.1 Clamping versus removal at 24 hours	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.7.2 Clamping versus removal at 72 hours or longer	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.8 Length of hospitalisation (median days)	1		Other data	No numeric data
3.9 Length of hospitalisation (days)	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.9.1 Clamping versus removal at 48 hours	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.10 Time required to return to normal bladder function (hours)	1		Other data	No numeric data

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
4.1 Number of participants needing to be recatheterised	2	184	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [0.58, 2.42]
4.2 Symptomatic catheter‐associated urinary tract infection (number of participants)	1	94	Risk Ratio (M‐H, Fixed, 95% CI)	0.20 [0.01, 4.06]
4.3 Incidence of urinary retention (number of participants)	2	308	Risk Ratio (M‐H, Fixed, 95% CI)	0.38 [0.20, 0.73]
4.4 Post‐void residual volume	2	301	Mean Difference (IV, Fixed, 95% CI)	‐2.00 [‐11.42, 7.42]
4.5 Length of hospitalisation in days	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.6 Length of hospitalisation in days (median, range, N)	1		Other data	No numeric data

*Study characteristics*
Methods	Study design: RCT Dates study conducted: April 2010‐December 2012
Participants	Number of participants: 233 eligible; 221 randomised; 221 reported Setting: Ismailia Country: Egypt Population: women Age (mean (SD)): A 59.1 (8.3); B 58.3 (6.9); C 61.3 (10.5) Inclusion criteria: women undergoing total abdominal hysterectomy with or without bilateral salpingo‐oophorectomy for various benign gynaecological diseases (uterine fibroids, abnormal uterine bleeding) Condition for hospitalisation: hysterectomy Exclusion criteria: known history of neurological disorders, women who had UTI pre‐operatively confirmed by urine analysis ± culture and sensitivity, women for whom a complicated procedure was encountered during hysterectomy so that an IUC had to be kept post‐operatively on surgeon’s decision, women had spinal anaesthesia by choice or when general anaesthesia was contraindicated, women who had urge incontinence, women who refused to participate in study Use of antibiotic prophylaxis: on the morning of surgery, all participants received a single dose of prophylactic antibiotic in the form of ceftriaxone 1 g IM
Interventions	A (n = 73): IUC removed immediately after surgery B (n = 81): IUC removed 6 h post‐operatively C (n = 67): IUC removed 24 h post‐operatively Size and type (e.g. silver‐coated/PTFE) of catheter used: 12F Foley catheter, latex Study definition of short‐term catheterisation (days): not reported Intended duration of catheterisation for each group: A: immediately after surgery; B: 6 h post‐operatively; C: 24 h post‐operatively
Outcomes	Urine retention and re‐catheterisation (%) Symptomatic UTI (%) Post‐operative urine culture First ambulation Hospital stay Urinary symptoms 1 week post‐operatively Fever Dysuria Frequency Urgency Loin pain Positive urine culture 1 week post‐operatively
Definition of CAUTI or bacteriuria	The diagnosis of symptomatic UTI was based on the following criteria: significant bacteriuria with at least one of the following symptoms; dysuria, frequency of micturition, urgency, suprapubic pain or burning sensation at micturition
Sponsorship/funding	Not reported
Ethical approval	The study was carried out in accordance to the ethical principles for medical research involving human subjects included in Helsinki declaration and was approved by the Suez Canal University (SCU) Ethical Committee.
Notes	All participants had continuous bladder drainage during the surgery The time to ambulation was defined as the period between the end of surgery and the time when the patient first walked supported by a nurse or relative. The length of hospital stay was defined as the time between the end of surgery and hospital discharge Patients were recatheterised with a disposable female catheter if they were not able to empty their bladders 6 h after catheter removal. If unable to empty bladder 12 h after catheter removal, an indwelling catheter was inserted
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: “The remaining 221 women were divided into three groups by simple randomization using computer‐generated random numbers” Comment: adequate method of randomisation used
Allocation concealment (selection bias)	Unclear risk	Not reported Comment: probably not done
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not reported. Comment: unlikely blinding was possible due to the intervention
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Not reported Comment: no information given. Outcomes such as urinary symptoms could be affected by detection bias
Blinding of microbiological outcome (detection bias)	Low risk	Not reported Comment: likely urine samples were sent to a laboratory where the microbiologist would not know which patients were in the trial
Incomplete outcome data (attrition bias) All outcomes	High risk	Quote: “Twelve patients were finally excluded from the study; five patients had intra‐operative complications (iatrogenic bladder injury)… while seven did not complete the postoperative follow‐up…” Comment: patients should have been analysed according to ITT analysis of patients lost to follow‐up.
Selective reporting (reporting bias)	Low risk	All pre‐specified outcomes have been accounted for in both the methods and results
Other bias	Low risk	Appears to be free from other sources of bias

*Study characteristics*
Methods	Study design: RCT (multicenter trial) Dates study conducted: not reported
Participants	Population: women Setting: USA Inclusion criteria: participants undergoing minimally invasive pelvic organ prolapse surgery Condition for hospitalisation: pelvic organ prolapse Exclusion criteria: not reported Number of participants: 73 eligible (planned to recruit 100); 73 randomised; 73 reported Age (mean and SD): not reported Use of antibiotic prophylaxis: not reported
Interventions	Group A (n = 32): IUC removal immediately after surgery Group B (n = 41): IUC removal day 1 post‐op Size and type of catheter used: not reported Study definition of short‐term catheterisation (days): not reported Intended duration of catheterisation for each group: Group A: immediate removal Group B: day 1 post‐op
Outcomes	Length of hospital stay (h ± SD) Number of participants requiring recatheterisation UTI Patient satisfaction Pain scores Patient responses on whether they would use the same treatment
Definition of CAUTI or bacteriuria	Not reported
Sponsorship/funding	Not reported
Ethical approval	Not reported
Notes	Conference abstract
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not reported. Given nature of intervention, unlikely to be possible
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Not reported
Blinding of microbiological outcome (detection bias)	Low risk	Not reported. Assume microbiologist blinded to trial participants
Incomplete outcome data (attrition bias) All outcomes	Low risk	No incomplete outcome data
Selective reporting (reporting bias)	Low risk	Appears to be free from reporting bias
Other bias	High risk	Trial stopped early due to poor recruitment resulting in an imbalance across the 2 groups

PERMALINK

Strategies for the removal of short‐term indwelling urethral catheters in adults

Awaiss Ellahi

Fiona Stewart

Emily A Kidd

Rhonda Griffiths

Ritin Fernandez

Muhammad Imran Omar

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Main outcomes for summary of findings tables

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

Summary of findings and assessment of the certainty of the evidence

Results

Description of studies

Results of the search

1.

Newly included trials

Included studies

Design

Sample sizes

Reason for hospitalisation/catheterisation

1. Types of participants.

Sex

Age

2. Interventions and age of participants.

Participants who received antibiotics during hospitalisation

3. Use of antibiotic prophylaxis.

Interventions

Outcome measures

Excluded studies

Ongoing studies

Risk of bias in included studies

2.

3.

Allocation

Random sequence generation

Allocation concealment

Blinding

Blinding of participants and personnel

Blinding of outcome assessment

Blinding of assessment of microbiological outcomes

Incomplete outcome data

Selective reporting

*Study characteristics*
Methods	Study design: RCT Setting: Iran Dates study conducted: not reported
Participants	Population: women Inclusion criteria: pregnant women age 18‐35, gravid 0‐4, gestational age 37‐42 with normal urine culture, colony count, gram staining) before surgery and taken 3 litres IV fluid during 24 h after surgery Exclusion criteria: women with urinary incontinence, frequent urination and dysuria more than twice, diabetes. History of kidney stone, fever/chills, secondary kidney disorder over the past year, history of smoking, rupture of chorionic membranes for > 6 h during labour, stimulation or acceleration of labour over 6 h, and oral temperature > 38 C in labour. In addition, mothers who have had a bladder injury during CS, uterine incision expansion, longitudinal uterine incision, prolonged operation for > 60 min, or haematocrit < 33% after surgery, acute bleeding, re‐catheterisation more than twice Condition for hospitalisation: CS Number of participants: 60 eligible; 60 randomised; 60 reported Age (mean and SD): A 24.96 ± 4.88; B 27.06 ± 5.56 Use of antibiotic prophylaxis: not reported
Interventions	Group A (n = 30): IUC removal 2‐3 h after surgery Group B (n = 30): IUC removal morning after surgery Size and type of catheter used: Foley catheter 14 gauge (5‐10 cc balloon) Study definition of short‐term catheterisation (days): not reported Intended duration of catheterisation for each group: Group A: 2‐3 h after surgery Group B: morning after surgery
Outcomes	UTI Microscopic pyuria
Definition of CAUTI or bacteriuria	Not reported
Sponsorship/funding	Not reported
Ethical approval	Not reported
Notes	Original trial report in Farsi. Data extraction performed by Persian translator
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not reported
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Not reported. Unlikely given nature of intervention
Blinding of microbiological outcome (detection bias)	Low risk	Not reported. Assume urine samples were sent to a laboratory where the microbiologist would not know which patients were in the trial
Incomplete outcome data (attrition bias) All outcomes	Low risk	Data reported in full
Selective reporting (reporting bias)	High risk	Baseline data collected however not reported by authors in results section
Other bias	Unclear risk	Appears to be free from other sources of bias

*Study characteristics*
Methods	Study design: not reported. Described as “small multiple single case study” and “single case experimental design” Dates study conducted: not reported
Participants	Setting: St Joseph’s Hospital, Milwaukee Country: USA Number of participants: eligible – not reported; 6 randomised; 6 reported Population: adults (no further information given) Condition for hospitalisation: not reported Age (mean and SD): not reported Use of antibiotic prophylaxis: not reported Inclusion criteria: “Patients who had not voided for 6 hours or more, appears to have more than 1000mLs of urine in their bladder, requiring catheterisation for retention according to physicians request” Exclusion criteria: “Obstetric patients, spinal cord injuries, patients undergone urological procedures in the past 6 months”
Interventions	Group A (n = 3): threshold clamping Group B (n = 3): complete drainage Size and type of catheter used: Foley catheter Study definition of short‐term catheterisation (days): not reported Intended duration of catheterisation for each group: not reported
Outcomes	Blood pressure Pulse rate Haematuria “Patients were monitored for any untoward reactions to the procedure, such as pain, diaphoresis, or frank bleeding, which would be expected to occur within 30 min of catheterization. Each patient’s urine was also cultured for the presence of infection, which might explain any hematuria
Definition of CAUTI or bacteriuria	Not reported
Sponsorship/funding	Not reported
Ethical approval	Not reported
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Quote: “Participants were randomised” Comment: no description of how randomisation was performed
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants and personnel (performance bias) All outcomes	High risk	Blinding not possible. Lack of blinding could have an impact on the outcome
Blinding of outcome assessment (detection bias) All outcomes	High risk	Quote: “While one investigator took each patient's blood pressure and pulse at predetermined intervals, the nurse caring for the patient inserted a Foley catheter, and a second investigator took urine samples at one‐minute intervals. Each sample was tested for blood using a Hemastix reagent strip. One investigator and the patient’s nurse verified the results” Comment: outcome assessors do not appear to be blinded
Blinding of microbiological outcome (detection bias)	Low risk	Not reported but likely that the urine samples were sent to a laboratory where the microbiologist would not know which patients were in the trial
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	No data reported
Selective reporting (reporting bias)	High risk	No data reported for any outcomes
Other bias	Low risk	Appears to be free from other sources of bias

*Study characteristics*
Methods	Study design: RCT Setting: Denver, Colorado, USA Dates study conducted: January 1998‐December 2001
Participants	Number of participants: 323 eligible; 250 randomised; 250 reported Setting: Denver, Colorado Country: USA Population: women Age (median, range): 47 (25‐72) Inclusion criteria: consenting women undergoing hysterectomy for various benign diseases (e.g. fibroid tumours, abnormal uterine bleeding, chronic pain, and persistent cervical dysplasia or micro invasive cervical cancer) Condition for hospitalisation (e.g. hysterectomy or TURP): hysterectomy Exclusion criteria: women for whom a complicated surgical procedure was anticipated (i.e. patients who underwent bladder suspension or colporrhaphy, diagnosis suspicious for severe endometriosis or for whom strict fluid treatment was required) Use of antibiotic prophylaxis: single dose of antibiotic prophylaxis before operation
Interventions	Group A (n = 125): immediate removal of the IUC in the operating room Group B (n = 125): removal of IUC on post‐operative day 1 Size and type of catheter used (e.g. Foley 16F): 16F with 10 cc balloon, latex Study definition of short‐term catheterisation (days): not reported Intended duration of catheterisation for each group: Group A: duration of operation, removal in the operating room after operation finished Group B: post‐op day 1
Outcomes	Post‐operative fever UTI Recatheterisation Pain (data cannot be incorporated as trial reports percentages without information on the number of participants in each group)
Definition of CAUTI or bacteriuria	Determined by either microscopic abnormality or any patient symptoms
Sponsorship/funding	Not reported
Ethical approval	Institutional Review Board of the University of Colorado
Notes	Pain was assessed with a pictorial questionnaire Post‐operative fever = temperature > 38.5 °C
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: “… computer generated randomisation” Comment: adequate randomisation method
Allocation concealment (selection bias)	Low risk	Quote: “… sealed opaque envelopes” Comment: adequate concealment method
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not reported, can assume blinding was not performed/possible
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Not reported, VAS may be prone to bias and misinterpretation
Blinding of microbiological outcome (detection bias)	Low risk	UTI was diagnosed with either microscopic abnormality or any patient symptoms. If only microscopic abnormality was used, would be low risk of bias
Incomplete outcome data (attrition bias) All outcomes	Low risk	No withdrawals or exclusions/dropouts
Selective reporting (reporting bias)	Low risk	All outcomes in methods are reported in results. Protocol not available
Other bias	Low risk	Appears to be free from other sources of bias

*Study characteristics*
Methods	Study design: RCT Setting: The Christ Hospital, Cincinnati, USA Dates study conducted: November 2014‐August 2017
Participants	Population: women Inclusion criteria: all women presenting to The Christ Hospital for gynaecologic surgery anticipated to require at least a 1‐night stay and who would be expected to have an IUC overnight Condition for hospitalisation: benign gynaecological surgery Exclusion criteria: patients with a current UTI being treated with antibiotic(s), or anticipated to undergo concomitant prolapse or incontinence surgery, or a pre‐operative diagnosis of gynaecologic malignancy, or a history of chronic IUC use, or a history of renal transplant or current dialysis use, or intraoperative lower urinary tract injury necessitating prolonged post‐op catheter use Number of participants: 200 eligible; 200 randomised; 164 reported Age (mean and SD): 44.4 ± 8.8 years Use of antibiotic prophylaxis: all participants received pre‐operative antibiotics with either The American College of Obstetricians and Gynecologists approved dosing of cefazolin (78%) or a combination of gentamicin and clindamycin (22%) with no difference between fast‐track or conventional Foley management groups (P = 0.54).
Interventions	Group A (n = 81): IUC removal 4‐h post‐op (“fast track”) Group B (n = 83): IUC removal day 1 post‐op (“conventional”) Size and type of catheter used: not reported Study definition of short‐term catheterisation (days): 1 day Intended duration of catheterisation for each group: Group A: 4 h post‐op Group B: 1 day post‐op
Outcomes	Median dwell time for Foley catheters Voiding trial failure rate Incidence of UTI
Definition of CAUTI or bacteriuria	Not reported
Sponsorship/funding	Not reported
Ethical approval	The institutional review board at The Christ Hospital approved this trial investigating 2 catheter management strategies among postgynaecologic surgery patients
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: “Permuted block randomization was performed, via “Microsoft Excel,” with a block size of 4 used to ensure balanced enrolment.” Comment: adequate method of restricted randomisation
Allocation concealment (selection bias)	Low risk	Quote: “The allocation sequence was concealed from the researcher enrolling patients through the use of sequentially numbered, opaque sealed envelopes” Comment: adequate allocation method
Blinding of participants and personnel (performance bias) All outcomes	High risk	Not reported. Unlikely possible given intervention
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Not reported
Blinding of microbiological outcome (detection bias)	Low risk	Not reported. Assumed microbiologist was blinded
Incomplete outcome data (attrition bias) All outcomes	High risk	Quote: "In addition, our study had a dropout rate of 38%. This is likely due to the fact that postoperative follow‐up was obtained via phone calls and not in‐person at the time of a clinic visit." Comment: 124 participants included in the final analysis from the original 200 participants who were randomised. Large dropout due to loss to follow‐up
Selective reporting (reporting bias)	Low risk	Outcomes mentioned in methods are reported in results section. Protocol not available for assessment
Other bias	Low risk	Appears to be free from other sources of bias

*Study characteristics*
Methods	Study design: quasi‐RCT, single‐centre study Dates study conducted: not reported
Participants	Number of participants: 128 randomised Setting: not reported Country: Mongolia Population (men/women/mixed): patients in the hospital with benign prostatic hyperplasia Condition for hospitalisation (e.g. hysterectomy or TURP): benign prostatic hyperplasia Age (mean and SD): range 56–92. No further details reported Use of antibiotic prophylaxis: not reported
Interventions	Group A (n = 64): removal of IUC on post‐op day 1‐2 Group B (n = 64): removal of IUC on post‐op days 5‐7 Size and type of catheter used (e.g. Foley 16F): not reported Study definition of short‐term catheterisation (days): not reported Intended duration of catheterisation for each group: Group A: removal of IUC on post‐op day 1‐2 Group B: removal of IUC on post‐op days 5‐7
Outcomes	Length of hospital stay Residual urine Infection Complication (urethral strictures)
Definition of CAUTI or bacteriuria	Not reported
Sponsorship/funding	None reported
Ethical approval	None reported
Notes	Paper translated
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Patients were allocated to intervention and control group using a random number chart, based on the order they completed surgery
Allocation concealment (selection bias)	Unclear risk	Allocation concealment not reported
Blinding of participants and personnel (performance bias) All outcomes	High risk	Likely not possible given intervention
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Not reported in translation of trial
Blinding of microbiological outcome (detection bias)	Low risk	Not reported. Unlikely that microbiologist knew participants belonged to the trial
Incomplete outcome data (attrition bias) All outcomes	Low risk	All data accounted for
Selective reporting (reporting bias)	Low risk	Appears to be free from reporting bias
Other bias	Low risk	Nothing to suggest any other source of bias from translation

*Study characteristics*
Methods	Study design: quasi‐RCT Dates study conducted: February 2012‐June 2012
Participants	Number of participants: 89 eligible; 79 randomised; 79 reported Setting: Beijing Country: China Population: mixed Age (mean ± SD): A 51 ± 13.2; B 52 ± 16.4 Inclusion criteria: undergone neurosurgery; IUC in situ upon return from the operating theatre; planned IUC duration of 1‐14 days; aged 18‐85 years; willingness to participate in the study; pre‐operatively able to urinate without problem and express the intention to urinate Condition for hospitalisation: patients undergoing neurosurgery Exclusion criteria: IUC in situ pre‐operatively; history of UTI; prostatic hyperplasia; urologic problems or sensory disorders; unable to communicate; signs of cognitive impairment defined as: disorientation to place, time or person, disorganised thinking or agitation Use of antibiotic prophylaxis: not reported
Interventions	Group A (n = 39): no clamping of participants' IUC i.e. control group Group B (n = 40): clamping of participants' IUC i.e. observation group Size and type of catheter used: not reported Study definition of short‐term catheterisation (days): not reported Intended duration of catheterisation for each group: A: no clamping of participants' IUC i.e. control group B: clamping of participants' IUC i.e. observation group
Outcomes	Time to first void Urinary retention requiring re‐catheterisation Abnormal micturition function Volume of first void Dysuria Incomplete voiding
Definition of CAUTI or bacteriuria	Not reported
Sponsorship/funding	Not reported
Ethical approval	“The study was approved by a University Ethics Review Board and Director of Nursing. The research protocol conformed with the provisions of the Declaration of Helsinki (1995).”
Notes	“the IDC [indwelling catheter] was clamped immediately upon return from the operating theatre and unclamped at certain intervals. The intervals were adjusted by the bedside nurse depending on the patient’s input and output volumes, in order to avoid over distension of the bladder. If the patient was receiving intravenous fluids, the IDC was unclamped at 2–3 h intervals for 10 min at a time. If the patient was not receiving intravenous fluids, the IDC was unclamped at 3–4 h intervals. During catheter clamping periods, patients were told to notify the nurse when they felt the need to urinate and that the nurse would then unclamp the catheter. The duration of each unclamping period was 10 min to allow for complete bladder emptying. For removal, nurses clamped the catheter again and removed it clamped when the patient felt the need to urinate.”
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Quote: “The neurosurgical ward has four structural divisions: A, B, C and D. Participants admitted to divisions A and B were in the observation group, and those admitted to C and D, the control group” Comment: used quasi‐randomisation
Allocation concealment (selection bias)	High risk	Quote: “The neurosurgical ward has four structural divisions: A, B, C and D. Participants admitted to divisions A and B were in the observation group, and those admitted to C and D, the control group” Comment: no allocation concealment as used quasi‐randomisation
Blinding of participants and personnel (performance bias) All outcomes	High risk	Quote: “The study was not blinded. This was not actually possible and might have increased the risk of observer bias.”
Blinding of outcome assessment (detection bias) All outcomes	High risk	Quote: “The study was not blinded.” Comment: blinding not performed
Blinding of microbiological outcome (detection bias)	Low risk	Not reported. Unlikely that microbiologist would know which patient belonged to the study when samples were sent to the laboratory
Incomplete outcome data (attrition bias) All outcomes	Low risk	No withdrawals reported
Selective reporting (reporting bias)	Low risk	All outcomes are reported in full.
Other bias	Low risk	No other indications to other sources of bias

Study	Reason for exclusion
2004‐005138‐38	Trial looked at the prophylactic usage of cefuroxime
ACTRN12617001191381	Intervention not relevant
Agrawal 1993	Not an RCT or quasi‐RCT
Airaksinen 1979	Intervention was not relevant
Aunruean 2007	Intervention was not relevant
Bach 1990	Intervention was not relevant
Benjamin 2018	Intervention not relevant
Bergqvist 1979	The study compares catheter materials for long‐term usage
Boyd 2019	Intervention not relevant
Christensen 1983	Intervention was not relevant. Trial looks at intermittent drainage in long‐term IUC
Cleland 1971	Comparative study of interventions to prevent infection
CTRI/2019/02/017836	Participants of trial are children aged 1‐10 years
Dhariwal 2019	Intervention not relevant
Downey 1997	Not an RCT or quasi‐RCT
Efimenko 2004	Intervention not relevant
Farag 2018	Intervention not relevant
Farrell 1989	Intervention not relevant. Involved suprapubic catheterisation
Fattah 2013	Not an RCT or quasi‐RCT
Fernandez‐Gonzalez 2019	Trial uses intermittent self‐catheterisation
Ghoreishi 2003	Intervention not relevant. Trial compared catheterisation to no catheterisation in women undergoing cesarean deliveries
Gillespie 1962	Intervention not relevant. Trial looked at catheter disinfection and also involved intermittent catheterisation
Gross 1990	Intermittent catheterisation used
Halaska 1991	Intervention not relevant. Trial involved suprapubic catheters
Hollingsworth 2013	Not an RCT
Hu 1999	Intervention not relevant
ISRCTN44339585	Intervention was not relevant
ISRCTN48516968	Intervention not relevant
Jankowska 1995	Intervention not relevant. Trial compares no catheterisation to 24‐h catheterisation
Ledermair 1970	Intervention not relevant
Loeb 2008	Intervention not relevant. Trial uses stop orders for the removal of IUCs under specified criteria and does not compare durations of catheterisation. There were no fixed time points for when catheters were removed.
Mamo 1991	Retrospective study ‐ not an RCT or quasi‐RCT
Mayer 1973	Intervention not relevant
Medina 2005	Intervention not relevant. Trial compares physiological and retrograde filling of the bladder to determine if one method would substantially shorten the evaluation of bladder emptying.
Menshawy 2020	Not an RCT
Michelson 2005	Intervention not relevant. Catheter protocols are not related to catheter removal
Miller 1960	Intervention not relevant. Describes outcomes between closed and open drainage systems
Mills 2018	Intervention not relevant
Moon 2012	Study involves long‐term catheterisation
Mustafa 1968	Study compares catheterisation and no catheterisation
Nadu 2001	Not an RCT or quasi‐RCT
Nardos 2011	Catheterisation is part of intervention (vesicovaginal fistula repair)
Nardos 2012	Catheterisation is part of intervention (vesicovaginal fistula repair)
NCT00182832	Intervention not relevant. Study compares two methods of measuring post‐void residual volume
NCT00392210	Intervention not relevant. Study compares voiding techniques post‐surgery
NCT00446732	Intervention not relevant. Study compares efficacy of Uroshield treatment with standard therapy
NCT00959920	Study compared intermittent and indwelling catheterisation
NCT01067768	Intervention not relevant. Study compared efficacy of daily nurse reviews of the IUC
NCT01108757	Interention not relevant. Study compared efficacy of antibiotic prophylaxis
NCT01343784	Intervention not relevant. Study compares various sling procedures
NCT01525498	Study withdrawn prior to recruitment stages
NCT01646190	Intervention not relevant. Study compares fast track programme to regular practice
NCT01797146	Intervention not relevant. Study compares catheter reminder programmes
NCT01926756	Study compares catheterisation to no catheterisation
NCT02054065	Intervention not relevant. Study looks at catheter reminder systems
NCT02126813	Intervention not relevant. Study looking at fast track programmes in surgery
NCT02357251	Intervention not relevant. Study compares current perioperative care of the investigators' gynaecologic oncology patients with a standardised perioperative "enhanced recovery" pathway
NCT02996968	Intervention not relevant. Uses intermittent catheterisation
NCT03646136	Intervention not relevant
NCT03684941	Trial registration. Uses intermittent catheterisation
NL2677	Study compares indwelling and intermittent catheterisation
Norton 1987	Study uses suprapubic catheterisation
Okrainec 2017	Not an RCT. Prospective cohort study
Panknin 2007	This is a commentary on a non‐randomised study
Patel 2018	Intervention only partially meets criteria for review. Trial compares shorter durations of catheterisation and also includes the use of alpha blockers
Pellegrini 1995	Intervention not relevant. Compares intermittent catheterisation
Peniakov 2004	Intervention not relevant. Study involved intermittent catheterisation
Perera 2002	Not an RCT or quasi‐RCT
Priefer 1982	Long‐term catheterisation
Rabkin 1998	Not an RCT or quasi‐RCT
Ratahi 2005	Study compares catheterisation to no catheterisation
Rehm 1962	Not an RCT or quasi‐RCT
Ross 1966	This trial compares infection rates when IUCs were inserted with and without the application of topical antibiotics
Salem Mohamed 2018	Intervention not relevant
Sandberg 2018	Not an RCT
Souto 2000	Group allocation determined on clinical criteria i.e. not an RCT or quasi‐RCT
Symonds 1967	Intervention not relevant
Tomaszewski 2015	Not an RCT or quasi‐RCT
Uberoi 2013	Not a RCT or quasi‐RCT
UMIN000014474	Intervention not relevant. Compares catheterisation to no catheterisation
UMIN000015289	Intervention not relevant
Watt 1998	Not an RCT or quasi‐RCT
Weitzel 2008	Not an RCT or quasi‐RCT
Wilson 2013	Not an RCT or quasi‐RCT
Zhang 1999	Intervention not relevant
Zhao 1994	Compares suprapubic versus urethral catheterisation

Methods	Study design: RCT
Participants	Inclusion criteria: adult patients of both sexes, aged 18‐85 years who require IUC short‐term (1‐14 days) in the units of internal medicine at University Hospital Alcorcón Foundation. Patients who express a desire to participate in the study by signing the informed consent. Exclusion criteria: patients with permanent long‐term (≥ 15 days) urinary catheter; patients with recurrent episodes of UTI, which has submitted episodes of urinary retention in the last month, or who have urologic pathology; patients with cognitive impairments that hinder communication with the medical staff; disoriented patients in person, time and place; anatomical and physiological genito‐urinary system alterations; patients taking a drug that affects the bladder and kidney function the week prior to catheterisation; pregnant patients; patients with a known history of benign prostatic hyperplasia
Interventions	Group A: to clamp before the removal of short‐term IUC Group B: IUC is clamped before removal and unclamped when the patient expresses desire to urinate
Outcomes	Complications of IUC
Notes	This trial is currently listed as suspended. We contacted the trial author to provide further information and confirmed that this trial had been suspended due to poor recruitment.

Study name	Bladder care following laparoscopy for benign non‐hysterectomy gynaecological conditions – a randomised controlled trial (ACTRN12611000414910)
Methods	Study design: RCT
Participants	Patients undergoing laparoscopic surgery for benign non‐hysterectomy gynaecological conditions Inclusion criteria: elective laparoscopy for a benign gynaecological condition; patients to be aged ≥ 18 years at time of surgery; patients who understand the conditions of the study and are willing to participate for the length of the prescribed term of follow‐up; patients who are capable of, and have given written informed consent to their participation in the study; patients presenting with benign gynaecological conditions that require surgical intervention as agreed to by the patient and her attending medical team Exclusion criteria: concurrent involvement in other research studies; past history of incontinence surgery; surgery for urinary incontinence or prolapse; suspected or confirmed gynaecological malignancy; patients scheduled for hysterectomy as part of their surgical procedure; patients with long‐term bladder catheterisation (intermittent or permanent); suspected or confirmed pregnancy at the time of surgery; intermittent flow pattern on uroflowmetry (indicative of pre‐existing voiding dysfunction); pre‐operative PVR ≥ 150 mL
Interventions	Group A: immediate removal of the IUC post‐laparoscopic surgery for benign non‐hysterectomy gynaecological conditions Group B: removal of the IUC at 6 am on the 1st post‐op day following laparoscopic surgery for benign non‐hysterectomy gynaecological conditions
Outcomes	Incidence of post‐op UTI Incidence and pattern of post‐op voiding dysfunction PVR urine volume in patients before surgery Duration of hospital stay Re‐admission to hospital (incidence and indication) Unscheduled presentation to general practitioner Emergency department or outpatient service (clinic/rooms) Economic analyses of the 2 modalities for care
Starting date	1 March 2012
Contact information	Associate Professor Jason Abbott Royal Hospital for Women Barker Street Randwick NSW 2031 Country: Australia Phone: +61 2 93826111 Email: j.abbott@unsw.edu.au
Notes	Recruitment status: not yet recruiting

Study name	Randomized control study of early extubation of indwelled urinary catheter after rectal cancer radical operation
Methods	Study design: randomised controlled trial Setting: Sixth Affiliated Hospital of Sun Yat‐sen University, China
Participants	Inclusion criteria: aged 18‐75 years old; pre‐operative fibrosis colonoscopy and pathological biopsy confirmed colorectal cancer as the primary cancer; no difficulty in urination and no UTI before operation; provision of written informed consent Exclusion criteria: patients with colorectal cancer palliative surgery, Miles operation and emergency surgery; patients with obvious urinary diseases including urinary tract stone, tumour, prostatic hyperplasia; patients having a history of urinary enuresis within 72 h; patients with history of pelvic surgery or with severe systemic diseases such as heart, lung, kidney, etc.; patients required lateral lymph node dissection; patients with recurrent rectal cancer or multiple rectal cancer and with other tumour; patient unconscious and unable to express the intention of urination correctly; patients with dementia, stroke or mental illness. Antibiotic treatment was applied 1 week before surgery.
Interventions	Group A: removal of IUC within 24 h directly after surgery Group B: removal of IUC after training bladder function on the 3rd day regularly after surgery
Outcomes	AUR UTI Urethral bleeding Residual volume Urinary incontinence Discomfort of lower urinary tract
Starting date	14 May 2018
Contact information	Tenghui Ma, austin_2004@163.com
Notes