Urethral (indwelling or intermittent) or suprapubic routes for short‐term catheterisation in hospitalised adults

Emily A Kidd; Fiona Stewart; Nadine C Kassis; Emily Hom; Muhammad Imran Omar

doi:10.1002/14651858.CD004203.pub3

. 2015 Dec 10;2015(12):CD004203. doi: 10.1002/14651858.CD004203.pub3

Urethral (indwelling or intermittent) or suprapubic routes for short‐term catheterisation in hospitalised adults

Emily A Kidd ¹, Fiona Stewart ², Nadine C Kassis ³, Emily Hom ⁴, Muhammad Imran Omar ^2,^✉

Editor: Cochrane Incontinence Group

PMCID: PMC8612698 PMID: 26661940

Abstract

Background

Indwelling urethral catheters are often used for bladder drainage in hospital. Urinary tract infection is the most common hospital‐acquired infection, and a common complication of urinary catheterisation. Pain, ease of use and quality of life are important to consider, as well as formal economic analysis. Suprapubic catheterisation can also result in bowel perforation and death.

Objectives

To determine the advantages and disadvantages of alternative routes of short‐term bladder catheterisation in adults in terms of infection, adverse events, replacement, duration of use, participant satisfaction and cost effectiveness. For the purpose of this review, we define 'short‐term' as intended duration of catheterisation for 14 days or less.

Search methods

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 26 February 2015), CINAHL (searched 27 January 2015) and the reference lists of relevant articles.

Selection criteria

We included all randomised and quasi‐randomised trials comparing different routes of catheterisation for short‐term use in hospitalised adults.

Data collection and analysis

At least two review authors extracted data and performed 'Risk of bias' assessment of the included trials. We sought clarification from the trialists if further information was required.

Main results

In this systematic review, we included 42 trials.

Twenty‐five trials compared indwelling urethral and suprapubic catheterisation. There was insufficient evidence for symptomatic urinary tract infection (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.61 to 1.69; 5 trials, 575 participants; very low‐quality evidence). Participants with indwelling catheters had more cases of asymptomatic bacteriuria (RR 2.25, 95% CI 1.63 to 3.10; 19 trials, 1894 participants; very low quality evidence) and more participants reported pain (RR 5.62, 95% CI 3.31 to 9.55; 4 trials, 535 participants; low‐quality evidence). Duration of catheterisation was shorter in the indwelling urethral catheter group (MD ‐1.73, 95% CI ‐2.42 to ‐1.05; 2 trials, 274 participants).

Fourteen trials compared indwelling urethral catheterisation with intermittent catheterisation. Two trials had data for symptomatic UTI which were suitable for meta‐analysis. Due to evidence of significant clinical and statistical heterogeneity, we did not pool the results, which were inconclusive and the quality of evidence was very low. The main source of heterogeneity was the reason for hospitalisation as Hakvoort and colleagues recruited participants undergoing urogenital surgery; whereas in the trial conducted by Tang and colleagues elderly women in geriatric rehabilitation ward were recruited. The evidence was also inconclusive for asymptomatic bacteriuria (RR 1.04; 95% CI 0.85 to 1.28; 13 trials, 1333 participants; very low quality evidence). Almost three times as many people developed acute urinary retention with the intermittent catheter (16% with urethral versus 45% with intermittent); RR 0.45, 95% CI 0.22 to 0.91; 4 trials, 384 participants.

Three trials compared intermittent catheterisation with suprapubic catheterisation, with only female participants. The evidence was inconclusive for symptomatic urinary tract infection, asymptomatic bacteriuria, pain or cost.

None of the trials reported the following critical outcomes: quality of life; ease of use, and cost utility analysis.

Authors' conclusions

Suprapubic catheters reduced the number of participants with asymptomatic bacteriuria, recatheterisation and pain compared with indwelling urethral. The evidence for symptomatic urinary tract infection was inconclusive.

For indwelling versus intermittent urethral catheterisation, the evidence was inconclusive for symptomatic urinary tract infection and asymptomatic bacteriuria. No trials reported pain.

The evidence was inconclusive for suprapubic versus intermittent urethral catheterisation. Trials should use a standardised definition for symptomatic urinary tract infection. Further adequately‐powered trials comparing all catheters are required, particularly suprapubic and intermittent urethral catheterisation.

Plain language summary

Which route of short‐term bladder drainage is best for adults in hospital?

The evidence for this question is up‐to‐date as of 26 February 2015

Number of trials: 42

Number of participants: 4577

Key messages:

This Cochrane review found that there was not enough evidence to determine whether one route of bladder drainage was more likely to reduce urinary tract infection than another. The evidence suggests that participants with suprapubic catheters were less likely to have catheter‐associated pain compared with those with indwelling urethral catheters. The quality of evidence in this review was low, and many of the trials did not report important outcomes such as catheter‐associated quality of life and ease of use. The included trials reported few adverse effects, but it is not clear if this is because the adverse effects did not occur or were simply not reported. Because of the limited evidence, we need more high‐quality trials. It is important that these trials report symptomatic urinary tract infection, pain from using catheters, quality of life, adverse effects and ease of use.

Background: what routes of short‐term bladder drainage are there?

Urinary catheters are tubes that drain urine from the bladder. They are often used in people who are unable to go to the toilet easily during their hospital stay. About one in four hospital patients requires short‐term bladder drainage using a urinary catheter. Catheters can be used in different ways. The main routes of urinary catheterisation are:

1. Urethral : a drainage tube is inserted into the bladder via the urethra, and is either left in place (indwelling catheter), or removed after the bladder is emptied (intermittent catheter).

2. Suprapubic catheterisation: a drainage tube is inserted into the bladder through a small cut in the abdominal wall.

A common complication of short‐term bladder drainage is urinary tract infection. Infections have many serious implications for patients and healthcare providers. Insertion of a suprapubic catheter may also be associated with more risks than urethral routes, such as bleeding or damage to the bowel.

Key results

The Cochrane review looked at studies which made one of three comparisons:

1. Indwelling versus suprapubic catheterisation  2. Indwelling versus intermittent catheterisation  3. Suprapubic versus intermittent catheterisation

1. Twenty‐five trials (2622 participants) compared indwelling urethral and suprapubic catheterisation. There was not enough evidence from five trials to determine whether people had a lower risk of symptomatic urinary tract infection with indwelling urethral or suprapubic catheterisation. There was low quality evidence from four trials that people with indwelling urethral catheters were at greater risk of catheter‐associated pain compared with participants with suprapubic catheters. None of the twenty‐five trials reported ease of use, quality of life or economic outcomes.

2. Fourteen trials (1596 participants) compared indwelling and intermittent urethral catheterisation. There was very low quality evidence from two trials reporting on urinary tract infection, and the review could not determine which route of bladder drainage had a lower risk. None of the fourteen trials reported pain, ease of use, quality of life or economic outcomes.

3. Three trials (359 participants) compared suprapubic and intermittent urethral catheterisation. Only one trial reported on urinary tract infection. The evidence was inconclusive and of low quality. Only one trial had evidence on pain. Again, the evidence was inconclusive and the quality of the evidence was very low. None of the three trials reported ease of use, quality of life or economic outcomes.

Concluding messages

Although many trials have been conducted not enough have looked at important outcomes. Many questions are still unanswered about short‐term bladder drainage. Which route is the least likely to cause urinary tract infection? Is one route associated with more pain than the others? Is there a significant difference in cost or convenience for patients and hospitals between the three routes? Until these questions are answered with higher‐quality evidence, we need more and better trials.

Summary of findings

Background

Description of the condition

Indwelling urinary catheters are commonly used for bladder drainage during hospital care. The most common complication is infection. Urinary tract infections (UTIs) account for about 20% of hospital‐acquired (nosocomial) infections (Smyth 2008), and about 80% of these are associated with urinary catheters. Such infections not only prolong hospital stay and are expensive to treat (Elvy 2009; Nasr 2010), but also cause unpleasant symptoms such as fever and chills in up to 30% of the patients. Patients with infection of the urinary tract can go on to develop bacteraemia (presence of bacteria within circulation). About 17% of hospital bacteraemia is due to catheter‐associated UTI (Gould 2009) . When used in patients who are acutely ill, the risk of a catheter‐associated infection may be higher and hence pose a greater threat to life.

Bacteria get into the catheterised bladder by direct inoculation at the time of catheter insertion and via the following routes: extraluminally by ascending from the urethral meatus along the catheter‐urethral interface, and intraluminally by reflux of the organisms into the catheter lumen (Tambyah 1999; Warren 2001). The normal mechanical wash‐out effect of the urinary stream is interrupted when there is a urinary catheter. The presence of a urinary catheter, plus other factors such as the formation of biofilm, allows bacteria to multiply quickly (Elvy 2009; Newman 2010; Trautner 2004).

There are various micro‐organisms that can cause catheter‐associated urinary tract infection. The most common of these is Escherichia coli, a gram‐negative coliform. Other common infective organisms include Candida spp, Enterococcus spp, Pseudomonas aeruginosa, Klebsiella pneumonia and Enterobacter spp. This list, however, is not exhaustive, with other less common micro‐organisms also causing catheter‐associated urinary tract infection (Elvy 2009).

The Center for Disease Control and Prevention (CDC) defines catheter‐associated UTI as a UTI in the presence of an indwelling catheter which has been in place for more than two calendar days on the day of UTI; or the catheter was in place on the day of the UTI or the previous day and then removed. The UTI criteria must be met on the day of catheter removal or the following day. The UTI CDC criteria must also be met, which include at least one of the following symptoms: fever, suprapubic tenderness, frequency, dysuria, costovertebral pain or tenderness. As well as signs and symptoms, a positive urine culture of 10⁵ colony‐forming units (CFU)/ml with no more than two species of micro‐organisms must be identified. CDC includes intermittent catheters but not suprapubic in its definition (CDC 2015).

The Infectious Diseases Society of America (IDSA) published guidelines for diagnosing catheter‐associated UTIs, which include all three types of catheter: indwelling, intermittent and suprapubic catheters. It recommended that a diagnosis be made when symptoms and signs compatible with UTI were present, plus at least 10³ cfu/ml of one or more bacterial species in a single catheter urine specimen or in a midstream voided urine specimen from a patient whose catheter was removed in the previous 48 hours.

Signs and symptoms that are compatible with UTI include:

new onset or worsening fever
rigors
altered mental status
malaise, or lethargy with no other identified cause
flank pain
costovertebral angle tenderness
acute haematuria
pelvic discomfort
dysuria
urgent or frequent urination
suprapubic pain or tenderness (Hooton 2010).

In this review, we use the IDSA definition of catheter‐associated UTI as it includes indwelling urethral, intermittent urethral and suprapubic catheters in its definition. The CDC definition includes urethral catheters, but does not include suprapubic and we therefore did not use this definition.

The IDSA defines asymptomatic bacteriuria as the presence of at least 10⁵ cfu/ml of one or more bacterial species in a sample of urine in a patient with no symptoms of urinary tract infection (Hooton 2010).

Management of symptomatic UTI varies greatly. Some clinicians will treat patients with asymptomatic bacteriuria, some will use prophylactic antibiotics and others will only treat patients with symptomatic UTI. The European and Asian guidelines on Management and Prevention of Catheter‐Associated Urinary Tract Infections recommend that asymptomatic bacteriuria should not be treated with antibiotics, as the infection will not be eradicated or, if it is, it will return rapidly. They recommend that symptomatic infections in catheterised patients be treated with broad‐spectrum systemic antibiotics, as well as removal and replacement of the catheter (Tenke 2008).

Description of the intervention

In this review, we consider only short‐term urinary catheterisation in hospitalised adults. We define 'short‐term' as 14 days or less.

Indwelling urethral catheterisation

Indwelling urethral catheterisation is most commonly used, in both the short term and the long term. It involves the insertion of a catheter through the urethra into the bladder, although it is associated with various complications. The most common of these is UTI, which can have a heavy cost for both patient and healthcare provider. The first step in reducing UTIs and other complications is to avoid unnecessary catheterisation; the second is to remove the catheter as soon as possible. Indications for indwelling urethral catheterisation include acute urinary retention or bladder outlet obstruction, the need for precise urinary output monitoring, and in patients undergoing urological or gynaecological surgery who might be expected to be unable to micturate immediately after surgery (Gould 2009).

While the most common method of bladder drainage is indwelling urethral catheterisation, intermittent catheterisation and suprapubic catheterisation are alternative approaches. From a theoretical point of view, it is possible that either of these methods may be associated with a lower risk of UTI.

Suprapubic catheterisation

Suprapubic catheterisation involves insertion of a catheter into the bladder through an incision in the abdominal wall. Bacterial colonisation of the urethral tract is less likely because of the lower density of (gram‐negative) micro‐organisms on the abdominal skin than in the periurethral area. However, suprapubic catheterisation involves puncturing the bladder after inserting the catheter through the abdominal wall; the concern is unintended visceral or vascular injury. Contraindications for suprapubic catheterisation include bladder cancer, anticoagulation and antiplatelet treatment, abdominal wall sepsis and presence of subcutaneous vascular graft in the suprapubic region (Harrison 2011).

Intermittent catheterisation

Intermittent catheterisation involves inserting and removing a sterile urethral catheter using an aseptic technique. Micro‐organisms are less likely to gain entry into the bladder by tracking along the catheter wall because the catheter is no longer constantly present.

As with other catheters, intermittent catheterisation can be used diagnostically and therapeutically. Diagnostically, it can be used to obtain a sample of urine, or to assess urodynamics or urinary output. Therapeutically, it is indicated in patients who have problems with bladder voiding due to various reasons, such as spinal cord injury, non‐neurogenic bladder dysfunction or incomplete emptying due to intravesical obstruction. Intermittent catheterisation is contraindicated in patients with priapism, and urethral catheterisation generally is contraindicated in patients with suspected or confirmed urethral damage, or urethral cancer (Geng 2006).

How the intervention might work

Once a catheter is in place, the aim is to minimise the risk of infection. There are two accepted basic principles: keeping the catheter system closed, and removing the catheter when it is no longer needed. Antibiotic prophylaxis is controversial and is addressed in another Cochrane review (Lusardi 2013). Another possible strategy for reducing the risk of infection due to indwelling (i.e. urethral or suprapubic) catheters is to use different materials, such as catheters coated with an antibacterial substance. The effects of using different types of indwelling urethral catheters have been evaluated in another Cochrane review (Lam 2014).

Why it is important to do this review

The aim of this review is to assess the effectiveness of different routes of catheterisation (urethral (indwelling or intermittent) or suprapubic) for short‐term use in hospitalised adults, primarily focused on symptomatic urinary tract infection. Other important outcomes included adverse effects, the need for replacement, duration of use, patient satisfaction and cost effectiveness. For the purposes of this review, we define short term as intended duration of catheterisation for up to 14 days.

Objectives

Methods

Criteria for considering studies for this review

Types of studies

We included all randomised controlled trials (RCTs) and quasi‐randomised trials (quasi‐RCTs) comparing alternative routes of short‐term catheterisation in hospitalised adults. We define 'short‐term' as intended duration of catheterisation for 14 days or less. Where the intended duration of catheterisation was not stated, we used the reason for hospitalisation as an indicator of the approximate length of catheterisation.

Types of participants

We included studies of adults requiring short‐term urethral catheterisation in hospital for any reason such as urine monitoring, investigations, acute retention problems, and after surgery. These included those suffering from acute illness, urinary retention, perioperative, postoperative, during labour, and during or following surgery.

Types of interventions

The interventions considered were urethral (indwelling or intermittent) or suprapubic catheterisation.

We used the following definition for this review:

Indwelling catheterisation: The European Association of Urology (EAU) definition for indwelling catheterisation: indwelling catheterisation was defined by the passage of a catheter into the urinary bladder via the urethra using an inflatable balloon or other means to retain it in position (EAU 2014).

Intermittent catheterisation: The EAU definition for intermittent catheterisation: intermittent catheterisation, also known as in‐out catheterisation, was defined as emptying of the bladder via the urethra by a catheter that is removed after the procedure, mostly at regular intervals (EAU 2014).

Suprapubic catheterisation: The European Association of Urology Nurses (EAUN) definition of suprapubic catheterisation: suprapubic catheterisation was defined as the insertion of a catheter into the bladder via the anterior abdominal wall, using sutures or other means to retain it in position (Geng 2012).

We have not considered the following interventions for inclusion in this review:

catheterisation insertion techniques (e.g. clean, sterile, with or without antiseptic or antibiotic cream);
meatal care management techniques (e.g. routine hygiene, antiseptic or antibiotic cream);
types of drainage (e.g. continuous, clamp‐and‐release, pressure valves);
types of drainage container (e.g. flexible, rigid, disposable);
treatment of drainage bag (e.g. washouts, use of antiseptic or clean washing techniques, use of antiseptic solutions in the bag);
antibiotic prophylaxis;
type of catheter material (e.g. latex rubber, silicone latex, silicone);
type of catheter coating (e.g. silver alloy, antibiotic coated, electrified).

We made three specific comparisons:  1. indwelling urethral catheterisation versus suprapubic catheterisation;  2. indwelling urethral catheterisation versus intermittent catheterisation;  3. suprapubic catheterisation versus intermittent catheterisation.

Types of outcome measures

Primary outcomes

Number of participants with symptomatic urinary tract infection (UTI)

We used the IDSA definition. If UTI was reported but symptoms were not described, then we reclassified the outcomes as asymptomatic bacteriuria.

Secondary outcomes

Participant‐reported:

number of participants with pain;
ease of use for participant;
participant discomfort;
participant satisfaction;
need to change catheters;
number of catheters used.

Clinician‐reported:

ease of use for practitioner;
length of time catheters used.

Complications/adverse effects:

asymptomatic bacteriuria, using IDSA definition (Hooton 2010) or as defined by trialists;
urethral stricture;
wound infection (for suprapubic catheters);
urgency/bladder spasms/detrusor overactivity;
other adverse effects of intervention (other than UTI).

Co‐interventions:

use of rescue antibiotics.

Health status/Quality of life:

quality of life (using SF‐36, Ware 1992) or other standard tool;
psychological outcome measures (e.g. HADS, Zigmond 1983).

Economic outcomes:

cost utility analysis (using EQ‐5D) or other standard tool of cost effectiveness or cost utility;
costs of intervention(s);
resource implications of differences in outcomes;
formal economic analysis (cost effectiveness, cost utility).

Other outcomes:

any other non‐prespecified outcomes judged to be important when performing the review.

Quality of evidence:

We assessed the quality of evidence using the GRADE approach. We organised a group discussion through the Urological Cancer Charity (UCAN) with participants who underwent urethral or suprapubic catheterisation, in order to identify outcomes which were important from their perspective. We identified five individuals (four men and one woman) who had undergone urethral catheterisation or suprapubic catheterisation. Most of the participants had both types of catheterisation during different stages of their treatment. The participants suggested that infections, pain and discomfort were certainly the most important outcomes from their point of view. They described the pain sensation of suprapubic catheterisation in a number of different ways, such as " very painful", "extremely painful" and "quite painful". They also stressed the impact of catheterisation on their quality of life and identified it as an important outcome. These results were similar to the focus group conducted by Omar 2013 for another Cochrane review of the types of indwelling urethral catheters for short‐term catheterisation in hospitalised adults (Lam 2014). We finally selected the following outcomes for 'Summary of findings' tables:

Number of participants with symptomatic UTI;
Asymptomatic bacteruria;
Number of participants with pain;
Ease of use for participant;
Quality of life (using SF‐36);
Cost utility analysis (using EQ‐5D).

Search methods for identification of studies

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

Electronic searches

This review drew on the search strategy developed for the Cochrane Incontinence Group. We identified relevant trials from the Cochrane Incontinence Group Specialised Register of trials. For more details of the search methods used to build the Specialised Register please see the Group's module in the Cochrane Library. The Register contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings. Most of the trials in the Cochrane Incontinence Group Specialised Register are also contained in CENTRAL. The date of the last search was: 26 February 2015.

We searched the Incontinence Group Specialised Register using the Group's own keyword system. The search terms used are given in Appendix 1.

For this update we also searched CINAHL (on EBSCO) covering 1 January 1981 to 27 January 2015 (searched on 27 January 2015). The search strategy used is given in Appendix 1.

Searching other resources

We also searched the reference lists of all relevant articles.

Data collection and analysis

Selection of studies

Two review authors independently assessed all titles and abstracts of potentially eligible studies identified by the search. Where there was any possibility that the study might be included, we obtained the full‐text paper. We resolved any disagreements that could not be resolved by discussion by consultation with an independent third person.

Data extraction and management

Two review authors extracted data independently and compared them. If the data in trials had not been fully reported, we sought clarification directly from the trialists. We entered extracted data into Review Manager 5 software (RevMan 5.3). We processed the included trial data as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

Assessment of risk of bias in included studies

We used the Cochrane 'Risk of bias' assessment tool for judging the risk of bias of the included studies (Higgins 2011). We assessed the following areas for each of the studies:

random sequence generation (selection bias)
allocation concealment (selection bias)
blinding of participants (performance bias)
blinding of personnel (performance bias)
blinding of microbiological outcome assessment
blinding of outcome assessment (detection bias)
incomplete outcome data (attrition bias)
selective reporting (reporting bias)
other bias

Two of the review authors independently assessed the studies, and rated each as 'low risk', 'unclear risk' or 'high risk'.

Measures of treatment effect

For categorical outcomes, the numbers reporting an outcome were related to the numbers at risk in each group to derive a risk ratio (RR), and the number needed to treat for an additional beneficial outcome (NNT). For continuous variables, we used means and standard deviations to derive a mean difference (MD). As a general rule, we combined the outcome data using a fixed‐effect model to calculate pooled estimates and their 95% confidence intervals (CIs). However, we considered the use of a random‐effects model where there were concerns that heterogeneity might have been complicating an analysis. When appropriate, we undertook meta‐analysis.

Unit of analysis issues

In single parallel‐group designed trials, the primary analysis was by participant in the trial. In trials with a non‐standard design, such as multiple observations taken, cluster‐randomised trials and cross‐over trials, we conducted the analysis as directed in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

Dealing with missing data

We used an intention‐to‐treat (ITT) analysis where possible, meaning that participants were analysed based on the intervention group to which they were randomised, regardless of whether they actually received the intervention they were originally assigned. We tried to contact trialists from eight of the trials for which we required further information (Barry 1992 PE; Dixon 2010; Hakvoort 2011; Ichsan 1987; Korkes 2008; Kringel 2010; Naik 2005; Ratnaval 1996).

If we had noted a difference in dropout rates between the randomised groups, we would have performed sensitivity analysis.

Assessment of heterogeneity

We considered the likelihood of important clinical heterogeneity in each meta‐analysis. We assessed heterogeneity visually using forest plots to assess overlap of 95% confidence intervals, the Chi² test for statistical heterogeneity and the I² statistical test (Higgins 2011). If the P value for the Chi² test was low (P < 0.10) or if the I² test was higher than 50%, we considered it statistically significant. Values of the I² test and the corresponding level of heterogeneity are detailed in the Cochrane Handbook for Systematic Reviews of Interventions. If there was significant heterogeneity, we used a random‐effects model.

Assessment of reporting biases

In order to reduce the risk of reporting and publication bias, we searched multiple databases and other sources comprehensively. If the meta‐analysis included more than 10 trials, we used a funnel plot to assess reporting biases (Higgins 2011).

Data synthesis

We combined trials if we considered the interventions to be sufficiently similar, and used a fixed‐effect model to carry out meta‐analysis. If there was significant heterogeneity, we used a random‐effects analysis.

Subgroup analysis and investigation of heterogeneity

We conducted subgroup analyses for:

different types of surgery (urogenital versus non‐urogenital surgery or other reason for catheterisation)
women in labour versus caesarean section
gender: men versus women
antibiotic prophylaxis used or not
timing of taking of urine sample

Sensitivity analysis

We conducted sensitivity analyses where there was significant heterogeneity, comparing different types of surgical intervention. We also performed sensitivity analysis on any trials that did not report their definition for symptomatic UTI and asymptomatic bacteriuria.

Results

Description of studies

Results of the search

We screened 958 records found by the literature search for this review: we further assessed the full text of 74 of these articles for eligibility for inclusion. Fifty‐one reports of 42 studies were included in the review, and 16 reports of 16 studies were excluded from the review. There were six reports of six ongoing studies, details of which can be found in the Characteristics of ongoing studies table. We are still seeking one conference abstract (Kringel 2007) that appears to be a further report of the included study Kringel 2010, and has been detailed in the Characteristics of studies awaiting classification table pending its arrival. The flow of literature through the assessment process is shown in the PRISMA flow diagram (Figure 1).

New included trials

In this update, we re‐assessed 18 reports of trials that were excluded in the previous version of the review. Of these, we found 13 reports of 11 trials to be eligible for inclusion. Two were reports of an already‐included trial (Hakvoort 2011), and another two were reports of the same trial (Naik 2005). Overall, we included 11 additional reports of 10 new trials (Barry 1992 PE; Ichsan 1987; Katz 1992; Kerr‐Wilson 1986; Michelson 1988; Naik 2005; Rasmussen 1977; Ratnaval 1996; Skelly 1992; Tangtrakul 1994).

We identified six reports after performing a new search. Of these, a further three new trials were eligible for inclusion (Dixon 2010; Halleberg 2013; Rivard 2012).

Included studies

The trials are described in detail in the Characteristics of included studies table.

We required more information for eight of the included trials. Of these, we were able to contact six: five by email (Dixon 2010; Hakvoort 2011; Korkes 2008; Kringel 2010; Naik 2005) and one by ResearchGate (Ratnaval 1996). We could not find contact details for two trials (Barry 1992 PE; Ichsan 1987). Only three of the six trialists we contacted responded (Dixon 2010; Korkes 2008; Ratnaval 1996).

Design

The review includes 40 randomised trials and two quasi‐randomised trials, as listed below:

Sample sizes

The number randomised in the included trials ranged from 24 participants (Nwabineli 1993) to 344 participants (Hammarsten 1992). In total, 4577 participants were randomised in the 42 trials.

25 trials including 2622 participants compared indwelling urethral and suprapubic catheterisation
14 trials including 1596 participants compared indwelling urethral and intermittent urethral catheterisation
3 trials including 359 participants compared suprapubic and intermittent urethral catheterisation

Participants

We included 42 trials with 4577 participants, who received one route of catheterisation.

Reason for hospitalisation

Thirty‐seven trials had participants hospitalised for a surgical procedure. They were as follows:

Urogenital surgery (Ahmed 1993; Andersen 1985; Barents 1978; Bergman 1987; Dixon 2010; Hakvoort 2011; Hammarsten 1992; Harms 1985; Jannelli 2007; Korkes 2008; Kringel 2010; Prasad 2014; Schiotz 1989; Stekkinger 2011; Wiser 1974)
Abdominal surgery (Baan 2003; Barry 1992 PE; Botsios 1997; Dobbs 1997; Naik 2005; Nwabineli 1993; O'Kelly 1995; Perrin 1997; Rasmussen 1977; Ratnaval 1996; Sethia 1987)
Orthopaedic surgery (Carpiniello 1988; Halleberg 2013; Knight 1996; Michelson 1988; Skelly 1992; Van den Brand 2001)
Caesarean section (Kerr‐Wilson 1986; Tangtrakul 1994)
General surgery (Piergiovanni 1991; Vandoni 1994)
Cardiac surgery (Katz 1992)

The remaining five trials included participants hospitalised for non‐surgical reasons.

Women in labour: three trials (Evron 2008; Millet 2012; Rivard 2012)
Acute urinary retention: one trial (Ichsan 1987)
Elderly women admitted to a geriatric rehabilitation ward for persistent abnormal post‐void residual volumes: one trial (Tang 2006)

We describe reasons for hospitalisation, reason for catheterisation and type of surgery in more detail in Table 4.

1. Types of participants.

Study ID	Reason for Hospitalisation	Reason for catheterisation	Type of surgery	Gender
Ahmed 1993	Urogenital surgery	Acute urinary retention	TURP for men who present with AUR	Men only
Andersen 1985	Urogenital surgery	Postoperative bladder drainage	Colposuspension or vaginal repair for SUI and/or genital descensus	Women only
Baan 2003	Abdominal surgery	Surgery‐indicated catheterisation	Elective laparotomy	Men and women
Barents 1978	Urogenital surgery	Unclear	Vaginal surgery	Women only
Barry 1992 PE	Abdominal surgery	Major abdominal surgery	Elective abdominal surgery	Men and women
Bergman 1987	Urogenital surgery	Surgery‐indicated catheterisation	Vaginal urethropexy (+ hysterectomy) in women with SUI	Women only
Botsios 1997	Abdominal surgery	Surgery‐indicated catheterisation	Elective abdominal surgery of long length	Men and women
Carpiniello 1988	Orthopaedic surgery	Prevent postoperative urinary complications	Total joint replacement	Women only
Dixon 2010	Urogenital surgery	Prevent postoperative urinary retention	Surgery for pelvic organ prolapse and/or SUI	Women only
Dobbs 1997	Abdominal surgery	Prevent postoperative urinary retention	Total hysterectomy for non‐malignant reasons under general anaesthetic	Women only
Evron 2008	Labour	Prevent intrapartum urinary retention	Labour with epidural	Women only
Hakvoort 2011	Urogenital surgery	Abnormal PVR following vaginal prolapse surgery	Vaginal prolapse surgery	Women only
Halleberg 2013	Orthopaedic surgery	Prevent postoperative urinary retention	Hip fracture or hip replacement surgery	Men and women
Hammarsten 1992	Urogenital surgery	Postoperative bladder drainage	TURP	Men only
Harms 1985	Urogenital surgery	Postoperative bladder drainage	Vaginal hysterectomy with front plastic	Women only
Ichsan 1987	AUR	AUR	None	Men and women
Jannelli 2007	Urogenital surgery	Postoperative bladder drainage	Surgery for SUI or anterior vaginal wall prolapse	Women only
Katz 1992	Cardiac surgery	Major cardiac surgery	Coronary artery bypass graft	Men only
Kerr‐Wilson 1986	Caesarean section	Avoid trauma to the bladder during surgery and to ensure unobstructed access to the lower uterine segment	Elective caesarean under epidural anaesthesia	Women only
Knight 1996	Orthopaedic surgery	Prevent postoperative urinary retention	Primary total hip or knee arthroplasty	Men and Women
Korkes 2008	Urogenital surgery	Prevent postoperative urinary retention	Open prostatectomy for BPH	Men only
Kringel 2010	Urogenital surgery	Postoperative bladder drainage	Anterior colporrhaphy plus optional additional procedure (i.e. hysterectomy)	Women only
Michelson 1988	Orthopaedic surgery	Prevent postoperative urinary complications	Total joint replacement	Men and women
Millet 2012	Labour	Prevent intra‐ and postpartum urinary retention	Labour with epidural	Women only
Naik 2005	Abdominal surgery	Postoperative bladder dysfunction	Radical hysterectomy for early stage cervical cancer	Women only
Nwabineli 1993	Abdominal surgery	Prevent postoperative urinary complications (retention and inability to void)	Stage IB or IIA cervical cancer with view for radical hysterectomy	Women only
O'Kelly 1995	Abdominal surgery	Postoperative bladder drainage	Abdominal surgery with full‐length abdominal incision	Men and Women
Perrin 1997	Abdominal surgery	Postoperative bladder drainage	Rectal surgery	Men and women
Piergiovanni 1991	General surgery	Bladder drainage for non‐urological reasons (perioperative, urinary retention, prostatic hypertrophy, incontinence, nursing)	Information not given	Men and women
Prasad 2014	Urogenital surgery	Postoperative bladder drainage	Robot‐assisted laparoscopic radical prostatectomy for newly diagnosed prostate cancer	Men only
Rasmussen 1977	Abdominal surgery	Postoperative bladder drainage	Abdomino‐perineal resection or low anterior resection for rectal cancer	Men and women
Ratnaval 1996	Abdominal surgery	Monitoring of urine during surgery	Pelvic colorectal surgery	Men only
Rivard 2012	Labour	Indicated during birth	Labour with epidural	Women only
Schiotz 1989	Urogenital surgery	Postoperative bladder drainage	Vaginal plastic surgery	Women only
Sethia 1987	General surgery	Monitor urine output postoperatively	Extensive pelvic dissection with or without an anastomosis.	Men and Women
Skelly 1992	Orthopaedic surgery	Postoperative urinary retention	Surgical repair of hip fracture	Men and women
Stekkinger 2011	Urogenital surgery	Prevent postoperative urinary retention	Anterior colporrhaphy ± hysterectomy ± PRS for pelvic prolapse	Women only
Tang 2006	Persistently abnormal PVR	Persistently abnormal PVR in elderly patients	None	Women only
Tangtrakul 1994	Caesarean section	Avoid bladder injury during surgery	Caesarean section	Women only
Van den Brand 2001	Orthopaedic surgery	Prevent postoperative urinary retention	Primary total hip or knee arthroplasty	Men and Women
Vandoni 1994	General surgery	Monitoring or nursing reasons in surgical patients	Information not given	Men and women
Wiser 1974	Urogenital surgery	Postoperative bladder drainage	Vaginal hysterectomy and anterior‐posterior repair	Women only

Study ID	Intervention A	Intervention B	Age (A), years	Age (B), years	Age (overall), years
Ahmed 1993	Indwelling urethral	Suprapubic	71.6 (mean)	71.9 (mean)	Not reported
Andersen 1985	Indwelling urethral	Suprapubic	Not reported	Not reported	61 (34 ‐ 86) (median, range)
Baan 2003	Indwelling urethral	Suprapubic	59.8 (26 ‐ 81) (mean, range)	60.4 (37 ‐ 87) (mean, range)	Not reported
Barents 1978	Indwelling urethral	Suprapubic	Not reported	Not reported	Not reported
Barry 1992 PE	Indwelling urethral	Suprapubic	Not reported	Not reported	Not reported
Bergman 1987	Indwelling urethral	Suprapubic	Not reported	Not reported	53 (35 ‐ 68) (mean, range)
Botsios 1997	Indwelling urethral	Suprapubic	64.3 (1.2) (mean, SD)	63.8 (1.4) (mean, SD)	Not reported
Carpiniello 1988	Indwelling urethral	Intermittent urethral	70 (8.6) (mean, SD)	73 (6.6) (mean, SD)	Not reported
Dixon 2010	Indwelling urethral	Intermittent urethral	66 (median)	57 (median)	Not reported
Dobbs 1997	Indwelling urethral	Intermittent urethral	45 (mean)	42.6 (mean)	Not reported
Evron 2008	Indwelling urethral	Intermittent urethral	26 (4) (mean, SD)	25 (4) (mean, SD)	Not reported
Hakvoort 2011	Indwelling urethral	Intermittent urethral	61 (10) (mean, SD)	60 (12) (mean, SD)	Not reported
Halleberg 2013	Indwelling urethral	Intermittent urethral	72.1 (12.7) (mean, SD)	71.9 (12.1) (mean, SD)	Not reported
Hammarsten 1992	Indwelling urethral	Suprapubic	73 (7) (mean, SE)	71 (7) (mean, SE)	Not reported
Harms 1985	Indwelling urethral	Suprapubic	Not reported	Not reported	Not reported
Ichsan 1987	Indwelling urethral	Suprapubic	Not reported	Not reported	Not reported
Jannelli 2007	Suprapubic	Intermittent urethral	54.6 (13.7) (mean, SD)	55.0 (10.5) (mean, SD)	Not reported
Katz 1992	Indwelling urethral	Suprapubic	60 (9) (mean, SD)	55 (8) (mean, SD)	Not reported
Kerr‐Wilson 1986	Indwelling urethral	Intermittent urethral	29.5 (0.97) (mean, SD)	27.0 (1.03) (mean, SD)	Not reported
Knight 1996	Indwelling urethral	Intermittent urethral	Not reported	Not reported	66 (35‐86) (mean, SD)
Korkes 2008	Indwelling urethral	Suprapubic	71.4 (8.0) (52‐84) (mean, SD, range)	74.1 (6.8) (61 ‐ 91) (mean, SD, range)	Not reported
Kringel 2010	Indwelling urethral	Suprapubic	63.5 (11.3) (mean, SD)	61.1 (9.92) (mean, SD)	64.2 (10.6) (mean, SD)
Michelson 1988	Indwelling urethral	Intermittent urethral	65.7 (mean)	61.7 (mean)	63.5 (mean)
Millet 2012	Indwelling urethral	Intermittent urethral	27.1 (5.6) (mean, SD)	28.2 (5.8) (mean, SD)	Not reported
Naik 2005	Suprapubic	Intermittent urethral	Not reported	Not reported	45 (20‐78) (median, range)
Nwabineli 1993	Indwelling urethral	Suprapubic	45 (mean)	42 (mean)	Not reported
O'Kelly 1995	Indwelling urethral	Suprapubic	65 (42‐81) (median, range)	68 (35‐79) (median, range)	Not reported
Perrin 1997	Indwelling urethral	Suprapubic	62 (mean)	64 (mean)	Not reported
Piergiovanni 1991	Indwelling urethral	Suprapubic	63 (mean)	64 (mean)	Not reported
Prasad 2014	Indwelling urethral	Suprapubic	57.6 (8.6) (mean, SD)	60.0 (6.4) (mean, SD)	Not reported
Rasmussen 1977	Indwelling urethral	Suprapubic	< 70 years old: 8 participants  ≥ 70 years old: 7 participants	< 70 years old: 25 participants  ≥ 70 years old: 15 participants	Not reported
Ratnaval 1996	Indwelling urethral	Suprapubic	63 (42‐80) (median, range)	64 (32‐81) (median, range)	66 (32 ‐ 81) (median, range)
Rivard 2012	Indwelling urethral	Intermittent urethral	27.6 (mean)	28.7 (mean)	Not reported
Schiotz 1989	Indwelling urethral	Suprapubic	63.8 (9.1) (mean, SD)	63.6 (8.5) (mean, SD)	Not reported
Sethia 1987	Indwelling urethral	Suprapubic	62.3 (mean)	63.7 (years)	Not reported
Skelly 1992	Indwelling urethral	Intermittent urethral	78 (8.2) (mean, SD)	78 (8.6) (mean, SD)	Not reported
Stekkinger 2011	Indwelling urethral	Suprapubic	61.7 (11.2) (mean, SD)	62.2 (11.5) (mean, SD)	Not reported
Tang 2006	Indwelling urethral	Intermittent urethral	81.4 (8.9) (mean, SD)	80.0 (6.8) (mean, SD)	Not reported
Tangtrakul 1994	Indwelling urethral	Intermittent urethral	30.4 (4.6) (mean, SD)	29.1 (4.5) (mean, SD)	Not reported
Van den Brand 2001	Indwelling urethral	Intermittent urethral	68.6 (8.8) (42 ‐ 85) (mean, SD, range)	68.2 (9.0) (36 ‐ 84) (mean, SD, range)	Not reported
Vandoni 1994	Indwelling urethral	Suprapubic	66.4 (mean)	66 (mean)	Not reported
Wiser 1974	Indwelling urethral	Suprapubic	Not reported	Not reported	Not reported

Study ID	Comparison	With or without antibiotic prophylaxis	Details
Ahmed 1993	1	Without	Routine prophylactic antibiotics were not used in either group
Andersen 1985	1	Not reported	Not reported
Baan 2003	1	With	Prophylactic antibiotics were used in all participants perioperatively for 24 hours
Barents 1978	1	Both	Results were stratified according to antibiotic prophylaxis or not. It was not reported whether the prophylactic protocol was the same for all participants
Barry 1992 PE	1	Not reported	Not reported
Bergman 1987	1	With	All participants received the same antibiotic prophylaxis (cefoxitin 2 g intramuscularly 1 hour before and 6 and 12 hours after surgery)
Botsios 1997	1	Not reported	Not reported
Carpiniello 1988	2	With	Prophylactic cefazolin sodium (Ancef) or clindamycin (Cleocin) until 3rd postoperative day
Dixon 2010	3	Not reported	Not reported
Dobbs 1997	2	With	Participants received Augmentin® at the induction of general anaesthetic and again 6 hours after surgery (1.2 g); it was not explicitly stated whether other antibiotics except prophylaxis were administered pre‐ or postoperatively
Evron 2008	2	Not reported	Not reported if antibiotic prophylaxis used in study but women on antibiotics were excluded
Hakvoort 2011	2	With	All participants received prophylactic antibiotics during surgery
Halleberg 2013	2	Both	During surgery: cefuroxime, clindamycine, cloxacillin, No antibiotic prophylaxis
Hammarsten 1992	1	With	Participants received pivmecillinam and pivampicillin if had no bacteriuria at time of operation as prophylaxis, or if had bacteriuria at time of operation was used as treatment. First dose was given 1 hour preoperatively, and last dose on the day the catheter was removed
Harms 1985	1	Not reported	Not reported
Ichsan 1987	1	Without	None of the participants who completed the trial received antibiotics
Jannelli 2007	3	With	All participants received appropriate preoperative antibiotics
Katz 1992	1	Not reported	Not reported
Kerr‐Wilson 1986	2	Without	Antibiotic prophylaxis was not used
Knight 1996	2	With	All participants received routine antibiotic prophylaxis (cefazolin) every 8 hours for 48 hours; it was not explicitly stated whether other antibiotics except prophylaxis were administered pre‐ or postoperatively
Korkes 2008	1	Not reported	Not reported
Kringel 2010	1	With	All participants received 2 g cefotiam i.v. before starting surgery as antibiotics prophylaxis
Michelson 1988	2	With	Perioperative prophylactic antibiotic therapy (cephalosporin with or without gentamicin) was given to all participants. Participants requiring secondary Foley catheter received antibiotics while device was in place
Millet 2012	2	Both	Some women received antibiotics during labour, some received antibiotics in postpartum period and some received no antibiotics
Naik 2005	3	With	All women received a single dose of intraoperative antibiotics. Prophylactic antibiotics were not given at any other time in the study. Antibiotics were prescribed when clinically indicated, i.e. positive urine sample or positive SPC site swab
Nwabineli 1993	1	With	All participants received the same antibiotic prophylaxis (a single dose of 5 g of methyl penicillin). Antibiotics were not administered routinely in the postoperative period
O'Kelly 1995	1	Not reported	Not reported
Perrin 1997	1	With	All participants received a single dose of tinidazole and/or ticarcillin
Piergiovanni 1991	1	Both	Some participants received antibiotics (65% in each group)
Prasad 2014	1	Not reported	Not reported
Rasmussen 1977	1	With	Neomycin sulphate + bacitracin were given, 1.5 g every 6 hours 3 days before operation
Ratnaval 1996	1	Not reported	Not reported
Rivard 2012	2	Not reported	Not reported
Schiotz 1989	1	Not reported	Not reported
Sethia 1987	1	With	All participants received the same antibiotic prophylaxis (single dose of metronidazole 500 mg and cephadrine 1 g intravenously on induction of anaesthesia). These antibiotics were continued for 48 hours in high‐risk participants and 5 days when sepsis was already present
Skelly 1992	2	Not reported	Not reported
Stekkinger 2011	1	With	All women received a single dose of prophylactic antibiotics (cefazolin 1 g and metronidazole 500 mg) during surgery
Tang 2006	2	Not reported	Not reported
Tangtrakul 1994	2	Without	No participants received prophylactic antimicrobial drug
Van den Brand 2001	2	With	1 dose of cefazolin, 1 g, intravenously immediately before surgery; no postoperative antibiotics were used
Vandoni 1994	1	With	Identical single‐dose pre‐operative antibiotic prophylaxis was routinely applied (2 g of cefacetrile and 500 mg of metronidazole)
Wiser 1974	1	Without	Did not use antibiotic prophylaxis

Study ID	Gender of Participants	Intervention A	Intervention B
Ahmed 1993	Men only	Indwelling urethral catheterisation placed preoperatively using 1& Xylocaine gel under aseptic technique	Suprapubic catheter (Stamey‐type, 12 French or 14 French), placed preoperatively under local anaesthetic
Andersen 1985	Women only	Indwelling urethral catheterisation (Charriere16, Foley) inserted preoperatively	Suprapubic catheter (Charriere 12, Ingram) introduced after termination of the operation
Baan 2003	Men and women	Indwelling urethral catheter (Foley) placed before surgery after surgical scrub	Suprapubic catheter (Braun) placed at the time of surgery
Barents 1978	Women only	Indwelling urethral catheter (Silicath Foley) introduced after termination of the operation	Suprapubic catheter (12 Charriere, Silastic Cystocath) introduced perioperatively or after termination of the operation
Barry 1992 PE	Men and women	Indwelling urethral catheterisation. Inserted at induction	Suprapubic catheterisation. Inserted at laparotomy
Bergman 1987	Women only	Indwelling urethral catheterisation (14 F Foley) introduced before surgery	Suprapubic catheterisation (5F Bonnano) introduced after termination of the operation
Botsios 1997	Men and women	Indwelling urethral catheterisation (14‐ or 16‐french Foley) introduced after induction of anaesthesia	Suprapubic catheterisation (Cystofix B) introduced intraoperatively
Carpiniello 1988	Women only	Indwelling urethral catheter (Foley) placed preoperatively and maintained for 24 hours	Intermittent catheter performed in recovery room
Dixon 2010	Women only	Indwelling suprapubic catheter inserted in theatre, left on free drainage for 48 hours postoperatively	Intermittent catheterisation postoperatively if unable to pass urine within 6 hours of return from theatre or earlier if uncomfortable or if passing frequent (< 2‐hourly), small volumes of urine (< 200 ml). Continued until can void > 200 ml with post‐void residual volumes < 100 ml
Dobbs 1997	Women only	Indwelling urethral catheter (14 F, Foley) inserted under anaesthetic and removed the night after surgery (about 36 hours after operation). In case of urinary retention thereafter, a urethral catheter was inserted for a further 24 hours	Intermittent catheterisation: 'In‐out' catheterisation with a disposable female catheter. Participants who felt the need to pass urine but were unable to do so, or had not passed urine by 12 hours after surgery, had a further IC. When, thereafter, participants required IC again, a urethral catheter was inserted for 24 hours
Evron 2008	Women only	Indwelling urethral catheterisation (multi‐orifice Foley catheter) placed 90 minutes after epidural induction (average 3 cm cervical dilation) and removed after delivery	Intermittent catheterisation (multi‐orifice Foley catheter) placed 90 minutes after epidural induction (average 6 cm cervical dilation) and removed. Process repeated when clinical indication of urinary retention
Hakvoort 2011	Women only	Indwelling urethral (14 french silicone) catheter was inserted by nursing staff for 3 days on first postoperative day if PVR ≥ 150 ml	Intermittent A SpeediCath® (Coloplast, Humlebaek, Denmark) catheter was inserted with maximum interval 6 hours over 3 days on first postoperative day if PVR ≥ 150 ml
Halleberg 2013	Men and women	Indwelling Foley catheter inserted by registered nurses (RNs) or assistant nurses (ANs). Participants with hip fracture had catheter inserted upon arrival on orthopaedic ward. Participants with osteoarthritis were given the catheter in the morning on the day of the surgery	Intermittent catheterisation introduced if participant was unable to urinate and bladder scan indicated ≥ 400 ml urine in the bladder
Hammarsten 1992	Men only	Indwelling urethral catheter (either teflon‐ or PVC‐coated)	Suprapubic catheter (PVC)
Harms 1985	Women only	Indwelling urethral catheterisation (14 Charriere Foley) introduced after termination of the operation	Suprapubic catheterisation (Cystofix)
Ichsan 1987	Men and women	Indwelling urethral catheter inserted by members of nursing staff. Urine sample obtained every 2 days until catheter removed for bacteriological culture, organism count + repeat specimens	Suprapubic catheter inserted by resident medical officers. Urine sample obtained every 2 days until catheter removed for bacteriological culture, organism count + repeat specimens
Jannelli 2007	Women only	Bonanno suprapubic catheter placed intraoperatively	CISC (14French disposable vinyl catheter) started on 1st postoperative day. (16 FRench silicone Foley catheter placed intraoperatively to monitor urine output in the immediate postoperative period)
Katz 1992	Men only	Indwelling urethral catheterisation (12F silicone‐coated or Teflon‐coated Foley catheter lubricated with paraffin oil) in the operating room after anaesthetic or after surgery completion	Suprapubic catheterisation (8F Cystocath manufactured by Dow Corning Corporation) in the operating room after completion of surgery
Kerr‐Wilson 1986	Women only	Indwelling urethral catheterisation (Foley catheter) inserted immediately before surgery after epidural had been inserted. Removed once the participant was ambulant.	Intermittent catheterisation ‘in‐out’ (Nelaton catheter) inserted immediately before surgery after epidural had been inserted. Removed at the end of operation
Knight 1996	Men and women	Indwelling urethral catheter (Foley) placed just prior to surgery. Remained in place for 48 hours. Thereafter, urinary retention was treated with intermittent catheterisation	Intermittent catheterisation every 6 hours if participants were unable to void or were voiding in volumes of 50 ml or less
Korkes 2008	Men only	Discharged with indwelling urethral catheter following surgery	Discharged with suprapubic catheter following surgery
Kringel 2010	Women only	Indwelling urethral catheter (silicone Foley) placed intraoperatively left indwelling for 24 or 96 hours	Suprapubic catheter (silicone Foley) placed intraoperatively left for 96 hours
Michelson 1988	Men and women	Indwelling urethral catheter inserted just before surgery. Removed the morning after surgery. Urinary retention was treated with intermittent catheterisation following this. If retention continued > 48 hours, indwelling catheter was inserted again	Intermittent catheterisation performed postoperatively by nursing staff only if urinary retention occurred. Performed at least every 6 hours. If retention continued > 48 hours, indwelling catheter was inserted
Millet 2012	Women only	Indwelling Foley catheter (14 French Bard Foley tray, with Bardex Lubricath, anti‐reflux chamber drainage bag, and EZ lock sampling port) inserted after epidural placement. Removed in the 2nd stage of labour at the start of pushing	Intermittent catheter (Bard™ urethral catheterisation tray and 15Fr red, rubber catheter) every 4 hours and as needed after epidural placement. Stopped at delivery
Naik 2005	Women only	Suprapubic catheterisation. Insertion of Bonanno suprapubic catheter (Becton Dickenson, Franklin Lakes, New Jersey, USA) at the time of surgery. On free drainage for 5 days. Woman asked to pass urine normally every 4 hrs, then measure residual volume using catheter. Catheter was removed when residual volume < 100 ml	Intermittent catheterisation. Transurethral indwelling catheter was inserted at the time of surgery. Removed on day 5, women would pass urine every 4 hours then measure residual volume using intermittent catheter. Intermittent catheterisation ceased when residual volume < 100 ml. (hydrophilic coated LoFric – Astra Tech Ltd, Stroudwater Business Park, Stonehouse)
Nwabineli 1993	Women only	Indwelling urethral catheterisation placed before operation	Suprapubic catheterisation introduced after termination of the operation
O'Kelly 1995	Men and Women	Indwelling urethral catheterisation (14‐Fr; Foley) before operation	Suprapubic catheterisation (14‐Fr; Foley) after the abdomen was opened
Perrin 1997	Men and women	Indwelling urethral catheterisation (16‐French; Foley) inserted following induction of anaesthesia	Suprapubic catheterisation (16‐French; Foley) inserted after the opening of the abdomen
Piergiovanni 1991	Men and women	Indwelling urethral catheterisation (Charriere 12 to 20; Foley )	Suprapubic catheterisation (Charriere 10; Cystofix)
Prasad 2014	Men only	Indwelling urethral catheter placed intraoperatively, removed on postoperative day 7	Suprapubic catheter placed 24 hours after surgery, removed on postoperative day 7. Had indwelling urethral catheter prior to this
Rasmussen 1977	Men and women	Indwelling urethral catheter (Foley, No. 16 French) was inserted before surgery and kept on during first 24 hours. After this was closed and opened every 6 hours. Removed on 5th day.	Suprapubic catheter (No. 5 French polyethylene tube) was inserted before surgery and drained continuously for 24 hours. After this, was opened and closed for 10 minutes every 6 hours. Removed when post‐voidal volume < 100 ml during each of 2 subsequent measurements
Ratnaval 1996	Men only	Indwelling urethral catheter placed during surgery. Removed based on participant well‐being	Suprapubic Bonanno catheter placed at end of surgery. When suprapubic catheter was going to be removed, it was clamped and the residual volume measured. If it was < 50 ml, the catheter was removed
Rivard 2012	Women only	Indwelling urethral catheter. Removed during 2nd stage of labour when woman started pushing	Intermittent catheter inserted every 2 to 4 hours
Schiotz 1989	Women only	Indwelling urethral catheter (No.14, Foley) introduced at the end of surgery	Suprapubic catheter (No.10, Cystofix) introduced at the end of surgery
Sethia 1987	Men and women	Indwelling urethral catheterisation (14 F Foley) inserted immediately before operation	Suprapubic catheterisation (14 F Foley) placed perioperatively
Skelly 1992	Men and women	Indwelling urethral catheter inserted preoperatively and left in place until 48 hours after surgery. If could not void in following 24 hours, intermittent catheterisation performed every 8 hrs for 24 hrs. If still not able to void indwelling catheter inserted again for 48 hours	Intermittent catheter inserted every 6 ‐ 8 hrs, with 400 ‐ 600 ml of urine removed each time. Catheterisation stopped when residual volume of urine < 150 ml on 2 consecutive occasions
Stekkinger 2011	Women only	Indwelling urethral catheterisation using 14 French (brand not specified) placed intraoperatively, removed postoperative day 3; measurements begun in morning of postoperative day 4	Suprapubic catheterisation using 15Fr Cystofix™ SPT catheter, sutured to participant's skin (B. Braun Medical, Oss, Netherlands) placed intraoperatively, clamped on the 3rd night after surgery
Tang 2006	Women only	Indwelling Foley catheter, placed after randomisation. Removed at least once weekly, replaced if PVR > 300 ml.	CISC, monitored by bladder scan 3 times a day. CISC performed when PVR > 500 ml or > 300 ml and symptomatic.
Tangtrakul 1994	Women only	Indwelling urethral catheter placed just before operation. Removed following day after operation	Intermittent catheterisation. Catheterised just before operation. Removed immediately after operation
Van den Brand 2001	Men and women	Indwelling urethral catheter (Foley) introduced in the operating room just before the start of surgery. Catheter remained in place for 48 hours	In‐out catheterisation every 6 hours or earlier when clinically needed by a trained staffed nurse until spontaneous voiding occurred
Vandoni 1994	Men and women	Indwelling urethral catheterisation (Charriere 12 latex Foley catheter)	Suprapubic catheterisation (Cystofix(R), Braun‐SSC, Switserland)
Wiser 1974	Women only	Indwelling urethral catheterisation (16 Foley) inserted postoperatively	Suprapubic catheterisation (16 Foley)

Study ID	Outcome as defined by trialists	Definition	When urine sample was taken	Outcome as defined by IDSA criteria
Baan 2003	UTI	≥ 1 clinical symptoms (fever, increased micturition frequency, burning pain during voidance, pain in lower abdomen); positive sediment (> 10 leukocytes); positive urine culture of > 10⁵ bacterial colonies + < 3 bacterial species	48 hours after catheter removal	Symptomatic UTI
Barry 1992 PE	UTI	No definition	Daily until catheter removal	Unknown, so collect data assuming symptomatic UTI
Dixon 2010	UTI	Catheter specimen of urine or a midstream urine specimen showing a single bacterium growing at a colony count of > 10⁵ cfu/ml. Specimen only taken if UTI suspected on the basis of: pyrexia > 37.5° C, frequent voiding + discomfort when passing urine and positive urinalysis for leukocytes + nitrites	Preoperatively, and postoperatively if UTI suspected	Symptomatic UTI
Hakvoort 2011	UTI	> 10⁵ cfu/ml + ≥ 1 of the following: fever, urinary frequency (> 7 voids/day), dysuria, lower abdominal pain	After PVR had normalised and catheterisation had stopped	Symptomatic UTI
Korkes 2008	UTI	No definition	No information	Unknown, so collect data assuming symptomatic UTI
Kringel 2010	Symptomatic UTI	CDC definition: Indwelling urinary catheter was in place for > 2 calendar days on the date of event, with day of device placement being Day 1, AND an indwelling urinary catheter was in place on the date of event or the day before. If an indwelling urinary catheter was in place for > 2 calendar days and then removed, the UTI criteria must be fully met on the day of discontinuation or the next day. Patient has at least one of the following signs or symptoms: fever (> 38.0° C), suprapubic tenderness, costovertebral angle pain or tenderness, urinary urgency, urinary frequency, dysuria. Patient has a urine culture with no more than 2 species of organisms, at least one of which is a bacteria of ≥ 10⁵ cfu/ml.	4th postoperative day	Symptomatic UTI
Ratnaval 1996	UTI	No definition	Prior to removal of catheter and if participants developed urinary symptoms after catheter removal	Unknown, so collect data assuming symptomatic UTI
Schiotz 1989	UTI	Bacteriuria > 10⁵ organisms/ml AND ≥ 1 of following: dysuria, pain, fever (rectal temp > 38.5° C measured twice), rigors, sepsis	Preoperatively, at catheter removal and at follow‐up 6 ‐ 8 weeks postoperatively	Symptomatic UTI
Tang 2006	symptomatic UTI	Fever in the absence of other sites of infection with or without symptoms of dysuria or suprapubic discomfort on day 14	1st and 14th days	Symptomatic UTI

Indwelling urethral catheterisation compared to suprapubic catheterisation for short‐term catheterisation in adults
Patient or population: Adults with short‐term catheterisation  Settings: Hospital  Intervention: indwelling urethral catheterisation  Comparison: suprapubic catheterisation
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect  (95% CI)	No of Participants  (studies)	Quality of the evidence  (GRADE)	Comments
	Assumed risk	Corresponding risk
	Suprapubic catheterisation	Indwelling urethral catheterisation
Number of participants with symptomatic UTI	Study population		RR 1.01   (0.61 to 1.69)	575  (5 studies)	⊕⊝⊝⊝  very low^1,2,3
	121 per 1000	122 per 1000   (74 to 204)
Asymptomatic bacteruria	Study population		RR 2.25   (1.63 to 3.10)	2316  (19 studies)	⊕⊝⊝⊝  very low^4,5
	125 per 1000	282 per 1000 (204 to 288)
Number of participants with pain	Study population		RR 5.62   (3.31 to 9.55)	535  (4 studies)	⊕⊕⊝⊝  low^3,6
	73 per 1000	413 per 1000   (243 to 701)
Ease of use for participants ‐ not reported			Not estimable	‐	not reported
Quality of life ‐ not reported			Not estimable	‐	not reported
Cost utility analysis ‐ not reported			Not estimable	‐	not reported
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; RR: Risk ratio;
GRADE Working Group grades of evidence  High quality: Further research is very unlikely to change our confidence in the estimate of effect.  Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.  Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.  Very low quality: We are very uncertain about the estimate.

Indwelling urethral catheterisation compared to intermittent urethral catheterisation for short‐term catheterisation in adults
Patient or population: Patients with short‐term bladder drainage  Settings: Hospital  Intervention: indwelling urethral catheterisation  Comparison: intermittent urethral catheterisation
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect  (95% CI)	No of Participants  (studies)	Quality of the evidence  (GRADE)	Comments
	Assumed risk	Corresponding risk
	Intermittent urethral catheterisation	Indwelling urethral catheterisation
Number of participants with symptomatic UTI	See comment	see comment	Not estimable	162  (2 studies; not pooled)	⊕⊝⊝⊝  very low^1,2	Due to evidence of significant clinical and statistical heterogeneity, we did not pool the results, which were inconclusive (Analysis 2.1). The main source of heterogeneity was the reason for hospitalisation: Urogenital surgery (Hakvoort 2011); Elderly women in geriatric rehabilitation ward (Tang 2006).
Asymptomatic bacteruria	199 per 1000	207 per 1000 (169 to 255)	RR 1.04 (0.85 to 1.28	143  (1610 studies)	⊕⊝⊝⊝  very low^3,4,5
Number of patients with pain ‐ not reported			Not estimable	‐	not reported
Ease of use for participants ‐ not reported			Not estimable	‐	not reported
Quality of life ‐ not reported			Not estimable	‐	not reported
Cost utility analysis ‐ not reported			Not estimable	‐	not reported
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; RR: Risk ratio;
GRADE Working Group grades of evidence  High quality: Further research is very unlikely to change our confidence in the estimate of effect.  Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.  Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.  Very low quality: We are very uncertain about the estimate.

Suprapubic catheterisation compared to intermittent urethral catheterisation for short‐term catheterisation in adults
Patient or population: patients with short‐term catheterisation  Settings: Hospital  Intervention: suprapubic catheterisation  Comparison: intermittent urethral catheterisation
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect  (95% CI)	No of Participants  (studies)	Quality of the evidence  (GRADE)	Comments
	Assumed risk	Corresponding risk
	Intermittent urethral catheterisation	Suprapubic catheterisation
Number of participants with symptomatic UTI	Study population		RR 1.67   (0.68 to 4.10)	72  (1 study)	⊕⊕⊝⊝  low^1,2
Number of participants with symptomatic UTI	167 per 1000	0 per 1000   (0 to 0)	RR 1.67   (0.68 to 4.10)	72  (1 study)	⊕⊕⊝⊝  low^1,2
Asymptomatic bacteruria	Study population
Asymptomatic bacteruria	359 per 1000	187 per 1000 (72 to 485)	RR 0.52   (0.20 to 1.35)		⊕⊝⊝⊝  very low^2,3,4,5
Number of patients with pain			Not estimable	72  (1 study)	⊕⊝⊝⊝  very low^6,7
Ease of use for participants ‐ not reported			Not estimable	‐	not reported
Quality of life ‐ not reported			Not estimable	‐	not reported
Cost utility analysis ‐ not reported			Not estimable	‐	not reported
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; RR: Risk ratio;
GRADE Working Group grades of evidence  High quality: Further research is very unlikely to change our confidence in the estimate of effect.  Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.  Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.  Very low quality: We are very uncertain about the estimate.

Duration of catheterisation
Study	INDWELLING URETHRAL	SUPRAPUBIC
Ahmed 1993	mean 8.0 days (n = 50)	mean 8.3 days (n = 47)
Baan 2003	median 5.9 days (n = 71)	median 6.5 days (n = 75)
Barry 1992 PE	mean 5 days (n = 36)	mean 5 days (n = 24)
Bergman 1987	mean  6.8 days (n = 27)	mean  3.7 days (n = 24)
Botsios 1997	mean  4.4 days (range 3 ‐ 11) (n = 88)	mean  3.3 days (range 3 ‐ 10) (n = 85)
Hammarsten 1992	mean 5.0 (SE ± 3) days (n = 94)	PVC mean 2.9 (SE ± 2) days Latex mean 3.2 (SE ± 3) days (n = 102)
Harms 1985	mean  8.4 days (n = 69)	mean  6.7 days (n = 88)
Nwabineli 1993	mean  16.5 days median, range 9 (7 ‐ 63) (n = 14)	mean  13.1 days mean, range 11 (7 ‐ 26) (n = 10)
O'Kelly 1995	median  4 days (range 2 ‐ 11) (n = 29)	median  5 days (range 4 ‐ 10) (n = 28)
Ratnaval 1996	mean 7.5 days (range 2 ‐ 13) (n = 26)	mean 7.2 days (3 ‐ 14) (n = 24)
Stekkinger 2011	median 4.0 days (range 3 ‐ 18) (n = 62)	median 4.0 days (range 2 ‐ 69) (n = 64)
Vandoni 1994	mean  4.96 days (n = 25)	mean  4.48 days (n = 25)
Wiser 1974	5.8 days (n = 75)	3.9 days (n = 75)

Duration of hospital stay
Study	Indwelling	Suprapubic	Notes
Baan 2003	Median 15.6 days (n = 71)	Median 13.1 days (n = 75)	‐

Duration of catheterisation
Study	Indwelling	Intermittent	Notes
Hakvoort 2011	median, range 72 (72 ‐ 144) hours (n = 42)	median, range 18 (5 ‐ 112) hours (n = 45)	‐
Kerr‐Wilson 1986	mean 1 day after surgery (n = 25)	mean 9 hours 37 minutes (n = 25)	‐

Cost
Study	Indwelling	Suprapubic	Notes
Ichsan 1987	Catheter: AUD 1.10 Other: AUD 7.67 Labour: AUD 4 Adjustment: x 2.6 Total: AUD 33.20 (n = ?)	AUD 14 AUD 7.47 AUD 5 x 1.05 AUD 27.77 (n = ?)	‐

Cost
Study	INDWELLING URETHRAL	INTERMITTENT URETHRAL	Notes
Halleberg 2013	EUR 16.62 EUR 3.80 EUR 2.45 EUR 16.60 (13.1) n = 85 EUR 13.00 (7.7) n = 85 EUR 45.00 (10.2) n = 85 EUR 3954 (1743) n = 85 EUR 3791 (1736) n = 85 EUR 5173 (1306) n = 85	EUR 17.98 EUR 8.90 EUR 3.26 EUR 18.00 (13.6) n = 84 EUR 16.00 (11.8) n = 84 EUR 41.00 (6.5) n = 84 EUR 3642 (1605) n = 84 EUR 3619 (1638) n = 84 EUR 3862 (1329) n = 84	Total material + labour cost Unit price for catheter Costs incurred due to UTI (mean) Catheterisation cost (mean, SD, N) Catheterisation cost with no UTIs (mean, SD, N) Catheterisation cost with UTIs (mean, SD, N) Total costs (mean, SD, n) Total costs with no UTIs (mean, SD, n) Total costs with UTIs (mean, SD, n)
Kerr‐Wilson 1986	GBP 0.53	GBP 0.10	Cost of catheter
Knight 1996	USD 8.33 (n = 62) USD 17.96 (n = 10)	USD 53.20 (n = 57) USD 34.58 (n = 20)	Total cost per patient within 1st 48 hours Total cost per patient after 48 hours
Rivard 2012	USD 6.28 (n = 72)	USD 5.98 (n = 67)	Cost per catheter
Van den Brand 2001	USD 6.15 (n = 46)	USD 7.75 (n = 53)	Total cost per patient within 1st 48 hours

Post‐catheter quality of life
Study	Transurethral Catheter	Clean Intermittent Catheter	Significance
Postcatheter Pain Score (VAS 0‐100)
Hakvoort 2011	34 (n = 42)	29 (n = 45)	P = 0.45
Catheterisation difficulty (VAS 0‐100)
Hakvoort 2011	36 (n = 42)	28 (n = 45)	P = 0.20
Postcatheter Patient Satisfaction (VAS 0‐100)
Hakvoort 2011	76 (n = 42)	80 (n = 45)	P = 0.41
EQ‐5D scores; mean score (n of patients)
Halleberg 2013	Discharge 0.32 (n = 52) 4 weeks 0.62 (n = 52) 4 months 0.68 (n = 52) Gained QALYs 0.093 (n = 52)	0.32 (n = 57) 0.56 (n = 57) 0.73 (n = 57) 0.090 (n = 57)	P = 0.904
EQ VAS scores; mean score (n of patients)
Halleberg 2013	Discharge 0.52 (n = 51) 4 weeks 0.65 (n = 51) 4 months 0.68 (n = 51) Gained QALYs 0.044 (n=51)	0.52 (n = 54) 0.63 (n = 54) 0.69 (n = 54) 0.045 (n = 54)	P = 0.978
SF‐6D scores; mean scores (n of patients)
Halleberg 2013	Discharge 0.50 (n = 45) 4 weeks 0.60 (n = 45) 4 months 0.63 (n = 45) Gained QALYs 0.036 (n = 45)	0.51 (n = 45) 0.58 (n = 45) 0.65 (n = 45) Gained QALYs 0.032 (n = 45)	P = 0.616

Cost
Study	Suprapubic	Intermittent	Notes
Dixon 2010	GBP 30.30 (n = 38)	GBP 26.80 (n = 37)	consumable + staff costs (based on nursing time)

Date	Event	Description
1 December 2015	New search has been performed	In this update, the review authors have added 25 trials. They performed 'Risk of bias' assessment on all 42 trials in accordance with the current methodology. We held a group discussion with participants who underwent urethral or suprapubic catheterisation in order to identify outcomes which were important from their perspective. We used these outcomes to assess the quality of evidence with the GRADE approach.
1 December 2015	New citation required but conclusions have not changed	The review was updated however the conclusions did not changed.

Date	Event	Description
13 October 2008	Amended	Converted to new review format.
15 August 2007	New search has been performed	An updated search (performed on 29 May 2006) of the Incontinence Group Specialised Register found no new relevant trials for this review. The existing synopsis was replaced by a plain language summary in accordance with Cochrane guidelines.
25 May 2005	New citation required and conclusions have changed	Substantive amendment

#	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

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Symptomatic UTI	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
1.1 Overall	5	575	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.61, 1.69]
1.2 Men	1	59	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.12, 3.83]
1.3 Women	2	310	Risk Ratio (M‐H, Fixed, 95% CI)	1.30 [0.62, 2.74]
1.4 After urogenital surgery	3	369	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.59, 2.29]
1.5 After non‐urogenital surgery	2	206	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.40, 1.85]
1.6 With antibiotic prophylaxis	2	378	Risk Ratio (M‐H, Fixed, 95% CI)	1.10 [0.47, 2.59]
1.7 Without antibiotic prophylaxis	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Asymptomatic bacteriuria	19		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only
2.1 Overall	19	1894	Risk Ratio (M‐H, Random, 95% CI)	2.25 [1.63, 3.10]
2.2 Men	4	282	Risk Ratio (M‐H, Random, 95% CI)	1.67 [1.09, 2.57]
2.3 Women	9	895	Risk Ratio (M‐H, Random, 95% CI)	2.30 [1.37, 3.85]
2.4 After urogenital surgery	8	1004	Risk Ratio (M‐H, Random, 95% CI)	2.60 [1.53, 4.42]
2.5 After non‐urogenital surgery	10	793	Risk Ratio (M‐H, Random, 95% CI)	2.02 [1.24, 3.28]
2.6 With antibiotic prophylaxis	7	676	Risk Ratio (M‐H, Random, 95% CI)	2.57 [1.05, 6.26]
2.7 Without antibiotic prophylaxis	3	341	Risk Ratio (M‐H, Random, 95% CI)	2.97 [1.47, 5.98]
2.8 Urine sample collected during catheterisation	4	378	Risk Ratio (M‐H, Random, 95% CI)	3.69 [1.73, 7.88]
2.9 Urine sample collected once catheterisation stopped	11	1325	Risk Ratio (M‐H, Random, 95% CI)	1.85 [1.30, 2.65]
3 Recatheterisation	11	1180	Risk Ratio (M‐H, Random, 95% CI)	2.21 [1.19, 4.09]
4 Mean duration of catheterisation in days	2	274	Mean Difference (IV, Fixed, 95% CI)	‐1.73 [‐2.42, ‐1.05]
5 Duration of catheterisation			Other data	No numeric data
6 Number of participants catheterised more than five days	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
7 Number of participants with acute urinary retention	2	282	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.35, 1.94]
8 Number of participants with chronic urinary retention	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
9 Number of participants with bladder dysfunction	2	276	Risk Ratio (M‐H, Fixed, 95% CI)	1.53 [0.56, 4.18]
10 Number of participants with pain	4	535	Risk Ratio (M‐H, Fixed, 95% CI)	5.62 [3.31, 9.55]
11 Number of catheter days with pain	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
12 Mean pain score (VAS 0 ‐ 10)			Other data	No numeric data
13 Number of participants with discomfort	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
13.1 Overall	3	438	Risk Ratio (M‐H, Fixed, 95% CI)	3.77 [2.68, 5.32]
13.2 Men	1	52	Risk Ratio (M‐H, Fixed, 95% CI)	2.57 [0.78, 8.43]
13.3 Women	1	56	Risk Ratio (M‐H, Fixed, 95% CI)	2.15 [0.64, 7.27]
14 Number of participants with catheter obstruction	5	694	Risk Ratio (M‐H, Random, 95% CI)	0.37 [0.08, 1.78]
15 Number of participants with catheter that fell out	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
16 Number of participants that had urine leak around the catheter	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
17 Number of participants with gross haematuria	4	557	Risk Ratio (M‐H, Fixed, 95% CI)	0.39 [0.16, 0.96]
18 Number of participants with microscopic haematuria	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
19 Number of participants with pyuria	2	330	Risk Ratio (M‐H, Random, 95% CI)	2.35 [1.13, 4.90]
20 Number of participants with urethral stricture	4	516	Risk Ratio (M‐H, Fixed, 95% CI)	2.38 [1.02, 5.56]
21 Urinary symptoms after surgery	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
22 Number of participants with epididymitis	2	156	Risk Ratio (M‐H, Random, 95% CI)	1.82 [0.08, 43.16]
23 Number of participants with postoperative pyrexia	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
24 Febrile morbidity	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
25 Number of participants who needed antibiotic therapy	2	254	Risk Ratio (M‐H, Fixed, 95% CI)	2.10 [1.36, 3.24]
26 Number of participants requiring drugs for relief of dysuria	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
27 Duration of hospital stay			Other data	No numeric data
28 Mean duration of hospital stay	4		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
29 Number of participants with extended hospital stay	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
30 Cost			Other data	No numeric data

Methods	RCT or quasi‐RCT: 3‐arm RCT Setting: district hospital in UK Period: participants recruited over period of one year
Participants	Population: Men who underwent TURP who presented with acute urinary retention Inclusion criteria: not reported Exclusion criteria: not reported Age (mean): A 71.6 year; B 71.9 years; C 72.4 years. Number of participants: Eligible: not reported Randomised: 160 Reported: 160 Dropouts (n of participants + reasons): Not described. Follow‐up: outpatient review
Interventions	A (n = 50): Transurethral catheterisation (type not listed) placed preoperatively using 1& Xylocaine gel under aseptic technique B (n = 47): Suprapubic catheter (Stamey‐type, 12 French or 14 French), placed preoperatively under local anaesthetic C (n = 63): No preoperative bladder drainage Intended duration of intervention: "Short term basis"
Outcomes	Primary outcome (symptomatic UTI): not reported Preoperative bacteriuria: A: 16/50; B: 7/47; C: 5/63 Postoperative bacteriuria: A: 20/50; B: 12/47; C: 4/63, P < 0.001 Definition of bacteriuria: urine culture with bacterial count > 10⁸ colonies/litre. Urine cultures were obtained at the time of catheterisation and repeated if delay in the operation; at the time of catheter removal, and at 6 weeks follow‐up if symptomatic of UTI Number of participants who received antibiotics as indicated by clinical course: A: 20/50; B: 12/47; C: 4/63 Positive cultures from prostatic chippings: A: 26/38; B: 16/38; C: 10/51 Positive culture for pathogenic organisms from prostatic chippings: A: 12/38; B: 5/38; C: 6/51 Number of participants with epididymitis at 6 weeks follow‐up: A: 4/50; B: 0/47; C: 0/63 Urethral stricture: A: 0/50; B: 0/47; C: 0/63 Secondary haemorrhage: A: 0/50; B: 1/47; C: 1/63 Duration of preoperative catheterisation (mean) (days): A: 8.3; B: 8.0
Sponsorship/Funding	Not reported
Notes	No power analysis. Routine prophylactic antibiotics were not used in either group Prostatic chippings were obtained in all participants, usually from the superficial part of the middle lobe
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"these patients were divided into 3 groups" "patients presenting with urinary retention were randomly included" ‐ not clear on method of randomisation
Allocation concealment (selection bias)	Unclear risk	No information given
Blinding of participants	High risk	No information given but can assume no blinding as indwelling vs suprapubic vs no catheter
Blinding of personnel	High risk	"Both types of catheter were introduced by residents on call" ‐ no information on blinding but can assume no blinding occurred if involved in insertion
Blinding of microbiological outcome assessment	Low risk	Bacteriuria would be assessed by microbiologist who would not know the catheter the participant had
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given
Incomplete outcome data (attrition bias)   All outcomes	Low risk	160 participants randomised. Incomplete data for prostatic chippings culture but evenly distributed between 3 intervention groups
Selective reporting (reporting bias)	Low risk	All outcomes in Methods have data reported in Results. Length of preoperative catheterisation has results but no information given in Methods. Unable to access protocol so some uncertainty surrounding reporting bias
Other bias	Low risk	Appears to be free of other sources of bias

Methods	RCT or quasi‐RCT: RCT Setting: Denmark Period: not reported
Participants	Population:women undergoing colposuspension or vaginal repair for stress urinary incontinence and/or genital descensus Inclusion criteria: women with stress urinary incontinence and/or genital descensus; colposuspension or vaginal repair operations indicated Exclusion criteria:Recurrent UTI, treatment with steroids, significant bacteriuria at the time of operation, if protocol not followed strictly Age (median, range): overall 61 years (34 ‐ 86 years) Number of participants: Eligible: 107 Randomised: 92 Reported: 92 Dropouts (n of participants + reasons): 15 patients were excluded according to the exclusion criteria Follow‐up: 1 year postoperatively
Interventions	A (n = 44): indwelling urethral catheterisation (Charriere16, Foley) inserted preoperatively B (n = 48): Suprapubic catheter (Charriere 12, Ingram) introduced after termination of the operation Intended duration of intervention:  The SPC was clamped on the 3rd postoperative day and removed if the participant could micturate spontaneously and the residual urine was < 80 ml. The UC was left until the 5th postoperative day
Outcomes	Primary outcome (symptomatic UTI): not reported Bacteriuria:   Overall: A:20/44; B:10/48  In subgroups: a) After colposuspension: A:7/17; B:1/18. b) After vaginal repair: A:13/27; B:9/30 Definition of bacteriuria: 10⁵ cfu/ml on the 5th postoperative day. Specimens were obtained by the catheter in the control group and by midstream in the treatment group Recatheterisation: A:8/44; B:3/48 Mean duration of catheterisation: A: 5.0 days; B: 3.7 days
Sponsorship/Funding	Simonsen & Weel Company Ltd., Albertslund, Denmark – supplied Ingram^® catheters (suprapubic)
Notes	A participant was recatheterised when the volume of residual urine was > 150 ml on the 7th postoperative day despite receiving bladder tonica Not reported whether prophylactic antibiotics were used
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"patients were randomized... using random numbers (Geigy's tables)" ‐ randomisation using random numbers table is an adequate method of random sequence generation
Allocation concealment (selection bias)	Unclear risk	No information given
Blinding of participants	High risk	No information given but as suprapubic vs transurethral can assume no blinding
Blinding of personnel	High risk	No information given, but transurethral inserted preoperatively and suprapubic intraoperatively can assume clinician not blinded
Blinding of microbiological outcome assessment	Low risk	Bacteriuria would be assessed by microbiologist who would not know what catheter the participant had
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	76 participants (83%) met for the follow‐up trial, 16 (17%) lost to follow‐up at 1 year. No details given of number in each intervention group or reason for loss to follow‐up
Selective reporting (reporting bias)	Unclear risk	1‐year data not presented by type of catheter because numbers deemed too small. Unable to access protocol so uncertainty about reporting bias
Other bias	Low risk	Catheters supplied by Simonson & Weel. No other funding source reported. Unlikely to have influenced outcomes.

Methods	RCT or quasi‐RCT: RCT Setting: The Netherlands Period: not reported
Participants	Population: patients undergoing major abdominal procedure who required standard bladder catheterisation Inclusion criteria: patients undergoing major abdominal procedure who required standard bladder catheterisation Exclusion criteria: < 18 years old; UTI or urinary incontinence at the time of catheterisation; history of urological disease or renal insufficiency; immunocompromised; unable to speak and write the Dutch language; undergone a rectum extirpation and an ileoanal pouch; history of surgery for thoracic or abdominal aortic aneurysm Age (mean, range): A 59.8 years (26 ‐ 81); B 60.4 years (37 ‐ 87) Number of participants: Eligible: 165 Randomised: 146 Reported: 146 Dropouts (n of patients + reasons): 13 participants for "protocol deviation" (A: 3; B: 10) Follow‐up: Outcomes recorded during hospital stay and 6 weeks postoperatively
Interventions	A (n = 71): Urethral catheter (Foley) placed before surgery after surgical scrub B (n = 75): Suprapubic catheter (Braun) placed at the time of surgery Intended duration of intervention: Urethral catheters were removed when condition stable, or when the epidural catheter had been removed 24 hours. SPC was removed after spontaneous voiding with a PVR of < 50 ml.
Outcomes	Primary outcome (symptomatic UTI): A: 8/71; B: 9/75 Definition of symptomatic UTI: At least 1 or more of the clinical symptoms (fever, increased micturition frequency, burning pain during voidance, and pain in the lower abdomen), a positive sediment (> 10 leukocytes), and a positive urine culture (> 10⁵ bacterial colonies and < 3 bacterial species) within 6 weeks after surgery Bacteriuria: A 8/71; B 9/75 Definition of bacteriuria: "positive culture" > 10⁵ bacterial colonies and < 3 bacterial species Postoperative hospital stay (median) (days): A: 15.6; B: 13.1 Number of re‐operations (laparotomies): A: 4/71; B: 7/75 Number of participants requiring recatheterisation: A: 4/71; B: 9/75 Duration of catheterisation (median) (days): A: 5.9; B: 6.5 UTI in participants who received their allocated catheter: A: 8/68; B: 8/65 Incidence of UTI in participants by sex: 4/82 men, 13/64 women Participant opinions about comfort and pain: no differences
Sponsorship/Funding	Not reported
Notes	Urine cultures sent 48 hours after catheter removal. Recatheterisation done for relaparotomy or sepsis Prophylactic antibiotics were used in all participants perioperatively for 24 hours
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"patients were randomly allocated ‐ stratified for sex... using a computerized randomization program" ‐ adequate method of randomisation
Allocation concealment (selection bias)	Unclear risk	No information given
Blinding of participants	High risk	"blinding for patients... was not possible" ‐ blinding did not occur
Blinding of personnel	High risk	"blinding for nursing staff was not possible" ‐ blinding did not occur
Blinding of microbiological outcome assessment	Low risk	Symptomatic UTI would be assessed by microbiologist who would not know the type of catheter the participant had
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	"assessment of primary end point... was performed blinded" "a coded data form of each patient ... was provided to two of the investigators who independently scored for urine tract infections" ‐ primary outcome of UTI was blinded
Incomplete outcome data (attrition bias)   All outcomes	Low risk	146 participants randomised: 75 suprapubic, 71 transurethral No participants lost to follow‐up
Selective reporting (reporting bias)	Low risk	Outcomes in Methods all have data in Results. Unable to access protocol so cannot fully assess risk of reporting bias
Other bias	Low risk	Appears to be free of other sources of bias

Methods	RCT or quasi‐RCT: quasi‐RCT Setting: The Netherlands
Participants	Population: patients undergoing vaginal operations Inclusion criteria: women with sterile urine undergoing vaginal operations Exclusion criteria: initial positive urine cultures Age: not reported Number of participants: Eligible: 150 Randomised: 130 Reported: 130 Dropouts (n of participants + reasons): 20 patients were excluded because of initial positive urine cultures: (A: 6; B: 14)
Interventions	A (n = 50): Indwelling urethral catheter (Silicath Foley) introduced after termination of the operation B (n = 100): Suprapubic catheter (12 Charriere, Silastic Cystocath) introduced perioperatively or after termination of the operation
Outcomes	Primary outcome (symptomatic UTI): not reported Bacteriuria: A:16/44; B:5/86  Subgroups: a) In participants without antibiotic prophylaxis: A: 14/29; B: 5/65. b) In participants with antibiotic prophylaxis: A: 2/15; B: 0/21 Definition of bacteriuria: 10⁵ cfu/ml or more on postoperative day 5. Specimens were aspirated from the drainage tube on the 5th and 7th postoperative day and on the day of catheter removal. Mean duration of catheterisation: At least 7 days in both groups
Sponsorship/Funding	Not reported
Notes	Results were stratified according to antibiotic prophylaxis or not. It was not reported whether the prophylactic protocol was the same for all participants.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Quasi‐randomised 1st and 2nd patients to Group I (suprapubic) 3rd patient to group II (urethral) – no randomisation
Allocation concealment (selection bias)	High risk	No allocation concealment based on quasi‐randomisation method
Blinding of participants	High risk	Can assume no blinding occurred as suprapubic vs urethral
Blinding of personnel	High risk	Can assume no blinding occurred as suprapubic vs urethral
Blinding of microbiological outcome assessment	Low risk	Bacteriuria would be assessed by microbiologist who would not know the catheter participants had
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Initially 150 patients allocated – suprapubic:100 + urethral: 50; outcome reporting suprapubic: 86 + urethral: 44 – no information on reason for exclusion/dropouts
Selective reporting (reporting bias)	Unclear risk	No information given. Unable to access protocol, some uncertainty about selective reporting
Other bias	Low risk	Appears to be free from other sources of bias

Methods	RCT or quasi‐RCT: RCT Setting: Dublin, Ireland Period: not reported
Participants	Population: patients undergoing bladder catheterisation during elective surgery Inclusion criteria: unclear Exclusion criteria: preoperative urinary tract infection Age (mean, SD)/(median, range): not reported Number of participants: · Eligible: 60 · Randomised: 60 · Reported: 60 Dropouts (n of participants + reasons): 0 Follow‐up: not reported
Interventions	Time of intervention:   A (n = 36): indwelling urethral catheterisation. Inserted at induction B (n = 24):suprapubic catheterisation. Inserted at laparotomy Intended duration of catheterisation: Not reported
Outcomes	Primary outcome (symptomatic UTI): A: 3/36; B: 3/24 Definition of symptomatic UTI: not reported Bacteriuria: not reported Definition of bacteriuria: not reported Quality of life: not reported Duration of catheterisation, days (mean, n): A: 5, 36; B: 5, 24 Gross haematuria: A: NR; B: 1/24 Catheter leaks: A: NR; B: 2/24 Technical failures of insertion: A: NR; B: 4/24
Sponsorship/Funding	Not reported
Notes	Assume 0 for group B where number of events not reported? Antibiotic prophylaxis use not reported
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	No information given on method of randomisation
Allocation concealment (selection bias)	Unclear risk	No information given on method of allocation concealment
Blinding of participants	High risk	No information given. As suprapubic vs indwelling can assume that blinding did not occur
Blinding of personnel	High risk	No information given. As suprapubic vs indwelling can assume that blinding did not occur
Blinding of microbiological outcome assessment	Unclear risk	No definition given for symptomatic UTI so do not know if assessed by microbiologist from urine culture, or assessed by clinician based on symptoms
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given
Incomplete outcome data (attrition bias)   All outcomes	Low risk	60 participants randomised (suprapubic 24, urethral 36). No dropouts
Selective reporting (reporting bias)	Unclear risk	Outcomes that were to be reported not stated. Unable to access protocol so some uncertainty surrounding reporting bias
Other bias	Low risk	Appears to be free of other sources of bias

Methods	RCT or quasi‐RCT: RCT Setting: California, USA
Participants	Population: patients undergoing vaginal urethropexy (Pereyra procedure) (and hysterectomy) Inclusion criteria: women with stress urinary incontinence and negative urine culture undergoing vaginal urethropexy (Pereyra procedure) (and hysterectomy). Stress urinary incontinence was diagnosed clinically and urodynamically Exclusion criteria: not reported Age (mean, range): 53 years (35 ‐ 68) Dropouts (n of participants + reasons): none Follow‐up: length of hospital stay
Interventions	A (n = 27): Indwelling urethral catheterisation (14 F Foley) introduced before surgery B (n = 24): Suprapubic catheterisation (5F Bonnano) introduced after termination of the operation. During surgery participants had indwelling urethral catheter. Duration of intervention:   The suprapubic and indwelling urethral catheters were clamped on the 3rd postoperative day and the participant was allowed to micturate spontaneously with a symptomatic full bladder. The catheter was removed when the residual urine was < 50 ml on 2 consecutive occasions. In the urethral group, the residual urine was measured by reinserting a fresh Foley catheter. Some participants were discharged with a catheter and were seen every other day in the outpatient clinic.
Outcomes	Bacteriuria: A:13/27; B:3/24 Definition of bacteriuria: more than 1000 cfu/ml in the 1st 5 postoperative days. Specimens were aspirated from the drainage tube before surgery and every 2 days thereafter Duration of catheterisation (mean): A: 6.8 days; B: 3.7 days Febrile morbidity (measured by 'Fever index') (mean ± SD): A: 22.3 ± 6.4; B: 8.8 ± 2.1 Number of participants leaving hospital with catheter: A: 15/27; B:4/24 Hospital stay (mean ± SD): A: 4.7 ± 1.6; B: 3.6 ± 1.3
Sponsorship/Funding	Not reported
Notes	Comment: All participants had urethral catheters during the operation.  Mean fever index was calculated as (degree) X (hours a participant's temperature exceeded 37.2 C, except for the first 48 hours).  Comment: In 3 participants (1 in the urethral group and 2 in the suprapubic group) UTI was not the source of fever All participants received the same antibiotic prophylaxis (cefoxitin 2 g intramuscularly 1 hour before and 6 and 12 hours after surgery).
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"patients were assigned (using a randomisation table)"
Allocation concealment (selection bias)	Unclear risk	No information given on method of allocation concealment
Blinding of participants	High risk	No information given but as suprapubic or transurethral can assume no blinding
Blinding of personnel	High risk	No information given but as surgical procedure can assume clinician not blinded
Blinding of microbiological outcome assessment	Low risk	Bacteriuria would be assessed by microbiologist who would not know which catheter the participant had
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given
Incomplete outcome data (attrition bias)   All outcomes	Low risk	51 participants randomised; suprapubic 24, Foley 27. No dropouts reported
Selective reporting (reporting bias)	Unclear risk	No detailed information given on outcomes in Methods, therefore cannot judge if selective reporting occurred. Unable to access protocol so some uncertainty surrounding reporting bias
Other bias	Low risk	Appears to be free of other sources of bias

PERMALINK

Urethral (indwelling or intermittent) or suprapubic routes for short‐term catheterisation in hospitalised adults

Emily A Kidd

Fiona Stewart

Nadine C Kassis

Emily Hom

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

Indwelling urethral catheterisation

Suprapubic catheterisation

Intermittent catheterisation

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

Participant‐reported:

Clinician‐reported:

Complications/adverse effects:

Co‐interventions:

Health status/Quality of life:

Economic outcomes:

Other outcomes:

Quality of evidence:

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

Results

Description of studies

Results of the search

1.

New included trials

Included studies

Design

Sample sizes

Participants

Reason for hospitalisation

1. Types of participants.

Gender (Men/Women)

Age

2. Age of participants.

Participants who received antibiotics during hospitalisation

3. Use of antibiotic prophylaxis.

Interventions

4. Interventions.

Indication for catheter removal

Outcomes

5. Measurement of symptomatic urinary tract infection.

6. Measurement of asymptomatic bacteriuria.

Excluded studies

Methods	RCT or quasi‐RCT: RCT Setting: Greece Period: March 1992 ‐ December 1995
Participants	Population: patients undergoing elective abdominal surgery of long duration Inclusion criteria: patients undergoing elective abdominal surgery of long duration Exclusion criteria: patients with preoperative dysuric complaints, abnormal findings at urine analysis, rectal diseases in which urethral catheterisation is the preferable method Age (mean, SD): A: 64.3 (1.2) years; B 63.8 (1.4) years Dropouts (n of participants + reasons): 7 participants were excluded because of faults in urine sampling or processing
Interventions	A (n = 88): Indwelling urethral catheterisation (14‐or 16‐french Foley) introduced after induction of anaesthesia B (n = 85): Suprapubic catheterisation (Cystofix B) introduced intraoperatively Duration of intervention:   The SPC was clamped on the 2nd postoperative day and removed the next day if the participant could micturate normally and the residual urine was ≤ 100 ml. The UC was removed on the 3rd or 4th postoperative day, depending on the severity of the operation
Outcomes	Primary outcome (symptomatic UTI): not reported Bacteriuria: A: 2/88; B: 0/85 Definition of bacteriuria: Significant bacteriuria was defined as > 10⁵ cfu/ml. A midstream specimen was taken on the 2nd day after removal of the catheter Recatheterisation: A: 8/88; B: 0/85 Mean duration (range) of catheterisation: A: 4.4 days (3 ‐ 11); B: 3.3 days (3 ‐ 10) Number of participants with pain: A: 50/88; B: 10/85 Gross haematuria: A: 4/88; B: 4/85 Microscopic haematuria: A: 36/88; B: 16/85 Pyuria: A: 23/88; B: 6/85
Sponsorship/Funding	Not reported
Notes	Recatheterisation occurred when normal micturition failed The urine was inspected daily for gross haematuria and specimens were taken daily for biochemical analysis and microscopy. The last was considered abnormal if it showed > 6 white blood cells and/or 2 red blood cells per high‐power field Each participant kept a daily record of catheter‐related pain, scoring discomfort on a standard visual analogue scale (no pain = 0; worst possible pain = 10) Not reported whether prophylactic antibiotics were used.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	"randomly assigned (using their departmental record number)" ‐ non‐random sequence generation
Allocation concealment (selection bias)	High risk	"randomly assigned (using their departmental record number)" ‐ allocation could be easily broken using departmental record number, high risk of selection bias
Blinding of participants	High risk	No information given, but as suprapubic vs indwelling can assume blinding did not occur
Blinding of personnel	High risk	No information given, but as suprapubic inserted perioperatively and indwelling pre‐operatively can assume no blinding
Blinding of microbiological outcome assessment	Low risk	Bacteriuria would be assessed by microbiologist who would not know what catheter participant had
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	180 randomised, 7 excluded. Remaining 173 participants: indwelling 88, suprapubic 85 "7 were excluded because their urine samples were either insufficient in number or poorly collected and processed" ‐ no information given on which arm of trial 7 participants were in.
Selective reporting (reporting bias)	Unclear risk	Results on recatheterisation and duration of catheterisation not detailed in Methods. Unable to access protocol, so some uncertainty about risk of reporting bias
Other bias	Low risk	Appears to be free of other sources of bias

Methods	RCT or quasi‐RCT: RCT Setting: Pennsylvania, USA Period: November 1985 ‐ March 1986
Participants	Population: Elderly women undergoing total joint replacement Inclusion criteria: Elderly women undergoing total joint replacement Exclusion criteria: Men; non‐primary total joint replacement; positive preoperative urine cultures (> 10⁵ cfu/ml); receiving general anaesthesia; confined to postoperative bed rest Age (mean, SD): A: 70 (8.6) years; B: 73 (6.6) years Number of participants: Eligible: 218 Randomised: 77 Reported: 77 Dropouts (n of participants + reasons): none
Interventions	A (n = 23): Indwelling urethral catheter (Foley) placed preoperatively and maintained for 24 hours B (n = 31): Intermittent catheter performed in recovery room C (n = 23): No catheter used Intended duration of intervention: For approximately 24 hours postoperatively in Group A
Outcomes	Primary outcome (symptomatic UTI): not reported Bacteriuria: A: 1/23; B: 5/31; C: 2/23 Definition of bacteriuria: 10⁵ cfu/ml Straight catheter volume obtained after recovery room (mean, SD) (ml): A: N/A; B: 457 (640); C: 454 (494) Recatheterisation after Foley removal: A: 1/23; B: 20/31; C: 13/23 "Deep sepsis": A: 0/23; B: 0/31; C: 0/23. (No definition of deep sepsis)
Sponsorship/Funding	Not reported
Notes	Treatment Group B (CISC) had urethral catheter replaced once in recovery room, and repeated if clinically in urinary retention after recovery room Pre‐operative positive culture was defined as > 10⁵ cfu/ml. No distinction made between Treatment B participants who needed a repeat in‐and‐out catheter and those in Treatment A or Control who needed a Foley placed because of urinary retention, which was not defined Prophylactic antibiotics were used until postoperative day 3; either prophylactic cefazolin sodium (Ancef) or clindamycin (Cleocin)
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"patients were randomly assigned to one of three groups" ‐ no information given on method of randomisation
Allocation concealment (selection bias)	Unclear risk	No information given on method of allocation concealment
Blinding of participants	High risk	No information given but possible that group A and B remained blinded (A: intermittent in recovery room; B: no catheterisation performed in recovery room). Group C (indwelling) unlikely to remain blinded, therefore high risk of bias
Blinding of personnel	High risk	No information given but unlikely that clinician was blinded in perioperative or postoperative period
Blinding of microbiological outcome assessment	Low risk	Bacteriuria would be assessed by microbiologist who would not know what catheter the participant had
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given
Incomplete outcome data (attrition bias)   All outcomes	Low risk	77 participants randomised; Group A 31, Group B 23, Group C 23 No participants lost to follow‐up
Selective reporting (reporting bias)	Unclear risk	Outcomes detailed in Methods covered in Results: urine cultures, number + volume of catheterisations, need for + duration of Foley catheter, results of any urologic tests (including occurrence of UTI) Unable to access protocol so some uncertainty about reporting bias
Other bias	Low risk	Appears to be free of other sources of bias.

Methods	RCT or quasi‐RCT: RCT Setting: UK Period: March 2004 ‐ July 2004
Participants	Population: women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence Inclusion criteria: women electively admitted for surgery for pelvic organ prolapse and/or stress urinary incontinence Exclusion criteria: • women undergoing surgery where postoperative catheterisation is not routinely used • women requiring continuous postoperative bladder drainage Age (median): A: 66 years; B: 57 years Number of participants: · Eligible: · Randomised: 75 · Reported: 72 Dropouts (n of participants + reasons): 2 from group A (operative bladder injury, latex allergy); 1 from group B (cancelled operation) Follow‐up: duration of hospital stay
Interventions	Time of intervention: A (n = 38): indwelling suprapubic catheter inserted in theatre, left on free drainage for 48 hours postoperatively B (n = 37): intermittent catheterisation postoperatively if unable to pass urine within 6 hrs of return from theatre or earlier if uncomfortable or if passing frequent (< 2 hourly), small volumes of urine (< 200ml). Continued until can void > 200 ml with post‐void residual volumes < 100 ml Intended duration of catheterisation:   A: 48 hours; B: until able to void > 200 ml and post‐void residual volumes < 100 ml
Outcomes	Primary outcome (symptomatic UTI): A: 10/36; B: 6/36. (P = 0.44) from text A: 9/36; B: 13/36 (P = 0.44) from table Definition of symptomatic UTI: Catheter specimen of urine or a midstream urine specimen showing a single bacterium growing at a colony count of > 10⁵ cfu/ml. Specimen only taken if UTI suspected on the basis of pyrexia > 37.5° C, frequent voiding + discomfort when passing urine and positive urinalysis for leukocytes + nitrites Bacteriuria: Not reported Definition of bacteriuria: Not reported Length of postoperative stay in days (median, range, N): A: 6 (2 ‐ 15); B: 5 (2 ‐ 19) (P = 0.003) Days of catheterisation (median, range, N): A: 5 (4 ‐ 36); 4 (2 ‐ 36). (P = 0.01) Any pain: A: 10/36; B: 6/36 *Hayward pain score (1 ‐ 5 scale, where 1 is no pain) (total score per group, N): A: 31 (36); B: 15 (36) Consumable costs per participant: A: GBP 24.90; B: GBP 10.60 Nursing time (mins/participant): A: 30; B: 90 Nursing time costs per participant: A: GBP 5.40; B: GBP 16.20 Total costs per participant: A: GBP 30.30; B: GBP 26.80 Quality of life:** Not reported
Sponsorship/Funding	No funding received
Notes	Contacted Liz Dixon (liz.dixon@nuth.nhs.uk) and received information about median age of each group, and confirmed days of catheterisation is median, range (not SD as reported in trial)
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	“The randomization sequence was generated using a random number generator programme” – adequate method of randomisation, low risk of selection bias
Allocation concealment (selection bias)	Low risk	“using opaque sealed envelopes” – adequate method of concealment
Blinding of participants	High risk	“No blinding of patient, surgeon, nurses, or outcome assessor was feasible.”
Blinding of personnel	High risk	“No blinding of patient, surgeon, nurses, or outcome assessor was feasible.”
Blinding of microbiological outcome assessment	Low risk	Symptomatic UTI would be assessed by microbiologist who would not know what catheter the participant had
Blinding of outcome assessment (detection bias)   All outcomes	High risk	“No blinding of patient, surgeon, nurses, or outcome assessor was feasible.”
Incomplete outcome data (attrition bias)   All outcomes	Low risk	75 randomised, 38 SPC and 37 IC. SPC had 2 withdrawals (1 operative bladder injury, 1 latex allergy), IC had 1 withdrawal (cancelled operation)
Selective reporting (reporting bias)	Low risk	The primary and secondary outcomes all had results reported. Unable to access protocol so uncertainty about reporting bias
Other bias	Low risk	Appears to be free of other sources of bias

Methods	RCT or quasi‐RCT: RCT Setting: UK Period: not reported
Participants	Population: patients undergoing total abdominal hysterectomy for non‐malignant reasons under general anaesthetic Inclusion criteria:100 women undergoing total hysterectomy for non‐malignant reasons under general anaesthetic Exclusion criteria: not reported Age (mean): A: 45 years; B: 42.6 years Dropouts (n of participants + reasons): 5 participants were excluded because of incomplete follow‐up data
Interventions	A (n = 48): Indwelling urethral catheter (14 French) inserted under anaesthetic and removed the night after surgery (about 36 hours after operation). In case of urinary retention thereafter, an urethral catheter was inserted for a further 24 hours. B (n = 47): Intermittent catheterisation: 'In‐out' catheterisation with a disposable female catheter. Participants who felt the need to pass urine but were unable to do so, or had not passed urine by 12 hours after surgery, had a further intermittent catheter. When patients thereafter required intermittent catheter, a urethral catheter was inserted for 24 hours. Intended duration of catheterisation: 36 hours after surgery
Outcomes	Primary outcome (symptomatic UTI): not reported Bacteriuria: A: 14/48; B: 6/47 Definition of bacteriuria: Significant bacteriuria was defined as > 10⁵ cfu/ml. Specimens were collected on the second postoperative day Urinary symptoms immediately after surgery: A: 11/48; B: 7/47 Postoperative pyrexia (> 38° C): A: 17/48; B: 15/47
Sponsorship/Funding	Not reported
Notes	Postoperative pyrexia defined as > 38° C Antibiotics: Participants received amoxicillin and clavulanate potassium at the induction of general anaesthetic and again 6 hours after surgery (1.2 g); it was not explicitly stated whether other antibiotics except prophylaxis were administered pre‐ or postoperatively For postoperative pain management, participant‐controlled analgesia was given to participants
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"patients were randomised by random allocation of a number before the onset of the trial" ‐ no information given on the method of random sequence generation
Allocation concealment (selection bias)	Low risk	"allocated numbers were sealed in an envelope, which was opened at the time of surgery" ‐ conceals allocation to participants + investigators
Blinding of participants	High risk	No information given but can assume not blinded
Blinding of personnel	High risk	No information given but can assume personnel not blinded as intermittent vs indwelling
Blinding of microbiological outcome assessment	Low risk	Bacteriuria would be assessed by microbiologist who would not know what catheter the participant had
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	100 participants recruited, data only available for 95 participants. Indwelling 48, intermittent 47. No reason for 5 participants being lost to follow‐up
Selective reporting (reporting bias)	Low risk	Outcomes detailed in Methods all had data in Results. Unable to access protocol so some uncertainty surrounding reporting bias
Other bias	Low risk	Appears to be free of other sources of bias

Methods	RCT or quasi‐RCT: RCT Setting: Israel Period: not reported
Participants	Population: Women admitted for labour who had epidural analgesia Inclusion criteria: ASA physical status I and II, primiparous parturients who received patient‐controlled epidural analgesia for labour Exclusion criteria: Patients who had precipitous deliveries, pregnancy complications or history of drug abuse, those taking antibiotic therapy, and those with a history of urinary bladder pathology or UTI Age (mean, SD): A: 26 (4) years; B: 25 (4) years Dropouts (n of participants + reasons) 6 (3 in each group) due to precipitous labour Follow‐up: 48 hours after delivery
Interventions	A (n = 100): Urethral catheterisation (multi‐orifice Foley catheter) placed 90 minutes after epidural induction (average 3 cm cervical dilation) and removed after delivery B (n = 109): Intermittent catheterisation (multi‐orifice Foley catheter) placed 90 minutes after epidural induction (average 6 cm cervical dilation) and removed. Process repeated when clinical indication of urinary retention Intended duration of intervention: Until spontaneous voiding returned after delivery
Outcomes	Primary outcome (symptomatic UTI): not reported Bacteriuria: A: 29/100; B: 31/109. P = 0.9 Definition of Bacteriuria: 10⁵ or more colonies of the same species of bacteria per ml of urine found in 2 consecutive specimens of midstream voided urine, at 24 hours and 48 hours Number of catheterisations necessary: One: A: 100/100; B: 66/109 Two: A: 0/100; B: 23/109 Three: A: 0/100; B: 5/109 Rate of false positive urinary retention: A: 0/100; B: 8/109 Length of 1st stage of labour (mean + SD) (min): A: 373 ± 186; B: 374 ± 178. (P = 0.92) Length of the 2nd stage of labour (mean + SD) (min): A: 105 + 72 ; B: 75 + 52. (P = 0.002) Total fluid input (mean + SD) (ml): A: 2047 + 820 ml; B: 1780 + 620 ml. (P = 0.012, more fluid intake with urethral catheterisation) Total urine output (mean + SD): A: 690 + 470 ml; B: 540 + 380 ml. (P = 0.029, more urine output with urethral catheterisation) Spontaneous delivery: A: 78/100; B: 91/109. (P = 0.2) Instrumental delivery: A: 3/100; B: 4/109 Cesarean section: A: 19/100; B: 14/109
Sponsorship/Funding	"There was no financial support of this work"
Notes	Participants' labours were managed under the same passive and active labour protocol for both trial groups. Treatment group was heavier (average 4 kg), had oxytocin augmentation more frequently, and required higher doses of ropivacaine than the control group Not reported if prophylactic antibiotics used
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"randomized via computer‐generated code" ‐ adequate method of randomisation
Allocation concealment (selection bias)	Low risk	"maintained in sequentially numbered opaque envelopes" ‐ adequate method of allocation concealment
Blinding of participants	High risk	No information ‐ can be assumed participants could not be blinded as intermittent vs indwelling catheterisation
Blinding of personnel	High risk	No information ‐ can be assumed that personnel could not be blinded as required in participant care
Blinding of microbiological outcome assessment	Low risk	Symptomatic UTI would be assessed by microbiologist who would not know what catheter the participant had
Blinding of outcome assessment (detection bias)   All outcomes	Low risk	"Investigators were blinded as to treatment allocation, as the indwelling bladder catheter was hidden" ‐ adequate method of outcome assessor being blinded
Incomplete outcome data (attrition bias)   All outcomes	Low risk	"Of the 215 parturients who were recruited to the trial, 6 were excluded (3 each from the 2 trial groups) because of precipitous labors" ‐ no differential exclusion
Selective reporting (reporting bias)	Low risk	Outcomes given in Methods are reported in Results. Unable to access protocol so some uncertainty on selective reporting
Other bias	Low risk	Appears to be free of other sources of bias

Methods	RCT or quasi‐RCT: RCT Setting: The Netherlands Period: not reported
Participants	Population: all women with abnormal PVR after vaginal prolapse surgery Inclusion criteria: women, > 18 years old, abnormal PVR (> 150 ml) by bladder scan after vaginal prolapse surgery Exclusion criteria: Any neurologic or anxiety disorder, need for concomitant anti‐incontinence surgery Age (mean, SD): A: 61 (10) years; B: 60 (12) years Number of participants: Eligible: 147 Randomised: 87 Reported: 87 Dropouts (n of participants + reasons): none Follow‐up: duration of hospitalisation
Interventions	Time of intervention: 1st post‐operative day if PVR ≥ 150 ml A (n = 42): indwelling urethral catheter (14 french silicone) was inserted by nursing staff for 3 days B (n = 45): intermittent A SpeediCath^® (Coloplast, Humlebaek, Denmark) catheter was inserted with maximum interval 6 hours over 3 days Intended duration of catheterisation: Minimum of 3 days
Outcomes	Primary outcome (symptomatic UTI): A: 13/42; B: 5/45 Definition of symptomatic UTI: > 10⁵ cfu plus symptoms Bacteriuria: A: 15/42 (38%); B: 6/45 (14%). (P = 0.02, significant difference) Definition of bacteriuria: > 10⁵ cfu in voided culture obtained upon normalisation of PVR and cessation of catheterisation Duration of catheterization until normalisation of PVR (PVR < 150 ml) (median, range) (hours): A: TIC 72 (72 ‐ 144); B: 18 (5 ‐ 112) (P < 0.001) Number of catheter introductions (median, range): A: TIC 1 (1 ‐ 2); B: 3 (1 ‐ 18) (P < 0.001) Duration of hospitalisation (median, range) (days): A: 4 (1 ‐ 7); B: 2 (1 ‐ 6) (P < 0.001) Pain scores as a result of catheterisation (VAS 0 ‐ 100) (mean, SD): A: 34 (27); B: 29 (24) (P = 0.45) Difficulty with catheter use (VAS 0 ‐ 100) (mean, SD) A: 36 (32); B: 28 (25). (P = 0.20, NS) Participant satisfaction (VAS 0 ‐ 100) (mean, SD): A: 76 (24); B: 80 (22) (P = 0.41) Number of participants that would choose the same treatment again: A: 33/35; B: 37/38 (P = 0.60)
Sponsorship/Funding	"Funding: none"
Notes	All participants received prophylactic antibiotics, vaginal packing and 14 Fr indwelling catheter immediately after surgery PVRs determined by bladder scan. Urine cultures sent after completion of intervention Appropriate definitions for bacteriuria and UTI used Adequately powered No loss to follow‐up All participants received prophylactic antibiotics during surgery
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"computerised block randomisation was performed" ‐ adequate method of randomisation
Allocation concealment (selection bias)	High risk	"Blinding of the next treatment allocation was not possible"
Blinding of participants	High risk	"because of the obvious dissimilarity of the intervention, blinding of the next treatment allocation was not possible" ‐ blinding did not occur
Blinding of personnel	High risk	"because of the obvious dissimilarity of the intervention, blinding of the next treatment allocation was not possible" ‐ blinding did not occur
Blinding of microbiological outcome assessment	Low risk	Microbiologist would assess urine culture, and would not know which type of catheter the participant had received
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given on other outcomes
Incomplete outcome data (attrition bias)   All outcomes	Low risk	7 lost to follow‐up in each group for pain scores. No differential dropout
Selective reporting (reporting bias)	Low risk	Outcome measures are all reported in Results. Unable to access protocol, some uncertainty of selective reporting
Other bias	Low risk	Appears to be free of other sources of bias

Methods	RCT or quasi‐RCT: RCT Setting: orthopaedic department at a Swedish University Hospital Period: September 2009 – May 2011
Participants	Population: patients undergoing hip surgery Inclusion criteria: patients undergoing hip fracture surgery or hip replacement surgery that was due to osteoarthritis Exclusion criteria: < 50 years, indwelling urinary catheter or cognitive impairment at admission or if, for any reason, the patients could not give their informed consent. Cognitive impairment was defined as disorientation in time, place or room, irrelevant conversation, disorganised thinking or agitation and assessed by the nurse on duty. Age (mean, SD): A: 72.1 (12.7); B: 71.9 (12.1) Number of participants: · Eligible: 459 · Randomised: 182 · Reported: 164 Dropouts (n of participants + reasons): Excluded: 8 excluded from group A (1 withdrawal; 1 deceased; 6 urine culture missing). 4 excluded from group B (1 had hip fracture twice + included twice, but excluded before analysis 2nd time; 1 withdrawal; 2 urine culture missing) Dropout: 1 dropout from group B at 4‐week follow‐up (deceased); 3 dropouts from group A (deceased) and 2 dropouts from group B at 4‐month follow‐up Follow‐up: 4 months after discharge
Interventions	Time of intervention: A (n = 93): indwelling Foley catheter inserted by registered nurses (RNs) or assistant nurses (ANs). Participants with hip fracture had catheter inserted upon arrival on orthopaedic ward. Participants with osteoarthritis were given the catheter in the morning on the day of the surgery B (n = 89): intermittent catheterisation introduced if participant was unable to urinate and bladder scan indicated ≥ 400 ml urine in the bladder Intended duration of catheterisation: A: catheter was removed on postoperative day 2. If bladder volume was ≥ 400 ml on bladder scan and participant was unable to urinate, they were recatheterised. B: unclear
Outcomes	Primary outcome (symptomatic UTI): NR Definition of symptomatic UTI: NR Bacteriuria: A: 10/85; B: 8/85 Definition of bacteriuria: ≥ 10⁵ cfu/ml with no more than 2 species of organisms Quality of life: EQ‐5D (n): Discharge: A: 0.32 (52); B: 0.32 (57) 4 weeks: A: 0.62 (52); B: 0.56 (57) 4 months: A: 0.68 (52); B: 0.73 (57) EQ VAS (n): Discharge: A: 0.52 (51); B: 0.52 (54) 4 weeks: A: 0.65 (51); B: 0.63 (54) 4 months: A: 0.68 (51); B: 0.69 (54) SF‐6D (n): Discharge: A: 0.50 (45); B: 0.51 (45) 4 weeks: A: 0.60 (45); B: 0.58 (45) 4 months: A: 0.63 (45); B: 0.65 (45) QALYs gained (n): EQ‐5D: A: 0.093 (52); B: 0.090 (57) (P = 0.904) EQ‐VAS: A: 0.044 (51); B: 0.045 (54) (P = 0.978) SF‐6D: A: 0.036 (45); B: 0.032 (45) (P = 0.616) Time to normal bladder function (hours) (median, IQR, n):   A: 48 (43 ‐ 55), 85; B: 24 (13 ‐ 48), 85 (P < 0.001) Number of intermittent catheterisations (median, IQR, n): A: 0 (0 ‐ 0), 85; B: 1 (0 ‐ 2), 85 (P < 0.001) Number of bladder scans to normal bladder function (median, IQR, n): A: 2 (1 ‐ 3), 85; B: 6 (4 ‐ 9), 85 (P < 0.001) Length of hospital stay, days (median, IQR, n): A: 8 (7 ‐ 12), 85; B: 8 (6 ‐ 11), 85 Total Costs (n): A: EUR 16.62, 85; B: EUR 17.98, 85 Costs incurred due to UTIs (EUR, n): A: 2.45, 85; B: 3.26, 85 Catheterisation costs, EUR (mean, SD, n): A: 16.6 (13.1), 85; B: 18.0 (13.6), 84 Catheterisation costs with no UTIs, EUR (mean, SD, n): A 13 (7.7), 85; B 16 (11.8), 84 Catheterisation costs, with UTIs EUR (mean, SD, n): A: 45 (10.2), 85; B 41 (6.5), 84 Total costs, EUR (mean, SD, n): A: 3954 (1743), 85; B: 3642 (1605), 84 Total costs, with no UTIs, EUR (mean, SD, n): A: 3791 (1736), 85; B: 3619 (1638), 84 Total costs, with UTIs, EUR (mean, SD, n): A: 5173 (1306), 85; B: 3862 (1329), 84
Sponsorship/Funding	“supported by research grants from Örebro County Council Research Committee and the Swedish Association of Health Professionals.” “Astra Tech provided Lofric Primo‐catheters for the patients in the intermittent group”
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	“a random computer‐generated sequence was prepared by a statistician” – adequate method of randomisation, low risk of selection bias
Allocation concealment (selection bias)	Low risk	“sealed opaque envelopes” – adequate method of allocation concealment, low risk of bias
Blinding of participants	High risk	No information given. Can assume as intermittent vs indwelling that blinding was not possible for participants
Blinding of personnel	High risk	No information given. Can assume as intermittent vs indwelling that blinding was not possible for personnel
Blinding of microbiological outcome assessment	Low risk	Bacteriuria would be assessed by microbiologist who would not know what catheter the participant had received
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given
Incomplete outcome data (attrition bias)   All outcomes	Low risk	182 randomised, 89 intermittent 93 indwelling. Intermittent had 4 withdrawals (1 had 2 hip fractures and included twice but only analysed once; 1 withdrawn; 2 urine culture missing). Indwelling had 8 excluded (1 withdrawn, 1 deceased, 6 urine culture missing). 85 analysed in each group. 1 lost to 4‐week follow‐up in intermittent (deceased). 4‐month follow‐up, intermittent lost 2 (deceased); indwelling lost 3 (deceased). 82 completed trial in each group. Small differential dropout, but low risk of attrition bias
Selective reporting (reporting bias)	Low risk	All primary and secondary outcomes are reported in Results. Unable to access protocol so some uncertainty surrounding reporting bias
Other bias	Low risk	Catheters provided by Astra Tech for intermittent catheterisation. Unlikely to have had any influence on trial

Methods	RCT or quasi‐RCT: RCT Setting: Sweden Period: not reported
Participants	Population: men undergoing TURP Inclusion criteria: men undergoing TURP Exclusion criteria: History of urethral stricture; presence of urethral stricture at preliminary urethroscopy Age (mean, standard error): A: 73 (7) years; B: 73 (8) years; C: 71 (7) years Dropouts (n of participants + reasons): ad mortem before follow‐up (A: 3; B: 5; C: 6), additional catheter before follow‐up (A: 2; B: 4; C: 13), lost to follow‐up (A: 3; B: 2; C:4), history of urethral stricture (A: 1; B: 3; C: 0)
Interventions	A (n = 94): Urethral catheter (22f, teflon‐coated latex) B (n = 102): Urethral catheter (PVC) C (n = 102): Suprapubic catheter (PVC) Intended duration of intervention: A: 5.0 + 3 days; B: 2.9 + 2 days; C: 3.2 + 3 days
Outcomes	Primary outcome (symptomatic UTI): not reported Total post‐operative strictures: A: 14/102; B: 15/102; C: 4/94 Postoperative anterior urethral strictures: A: 11/102; B: 10/102; C: 1/94 Participant dissatisfied with TURP: A: 29/102; B: 23/102; C: 10/94 Dissatisfied participants with bladder neck strictures: A: 3/102; B: 3/102; C: 1/94 Dissatisfied participants with anterior urethral strictures: A: 9/102; B: 8/102; C: 1/94 Postoperative catheter time (mean, SE) (days): A: 5.0 (3); B: 2.9 (2); C: 3.2 (3) Time in hospital after resection (mean, SE) (days) : A: 5.7 (3); B: 5.1 (3); C: 7.1 (4)
Sponsorship/Funding	Not reported
Notes	Strictures assessed at 6 ‐ 24 months postoperatively Strictures were defined as urethra with diameters < 19 mm in size Treatment groups had higher rates of residual adenoma and recurrent cancer than controls (NS) Anterior urethral strictures not counted towards the total number of strictures among the 3 groups No power analysis Participants received Pivmecillinam and Pivampicillin if they had no bacteriuria at time of operation as prophylaxis, or if they had bacteriuria at time of operation it was used as a treatment. 1st dose was given 1 hour preoperatively, and last dose on the day the catheter was removed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"Patients were randomly divided into 3 groups" ‐ no information given on method of randomisation
Allocation concealment (selection bias)	Unclear risk	No information given
Blinding of participants	High risk	No information given. Can be assumed 2 groups receiving transurethral catheter remained blinded but suprapubic did not
Blinding of personnel	High risk	No information given. Can be assumed that surgeons inserting catheter were not blinded. Again, clinicians not involved in surgery likely to be blinded to material of transurethral catheter but not blinded to suprapubic group
Blinding of microbiological outcome assessment	Low risk	No microbiological outcomes reported, therefore no risk of bias from reporting of microbiological outcomes.
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given
Incomplete outcome data (attrition bias)   All outcomes	High risk	"suprapubic drainage group 13 patients were excluded because they needed a transurethral catheter before followup" ‐ none excluded from transurethral, differential dropout
Selective reporting (reporting bias)	Low risk	Outcomes detailed in Methods matched in outcomes reported in Results. Unable to access protocol so some uncertainty surrounding reporting bias
Other bias	Low risk	Appears to be free of other sources of bias

Methods	RCT or quasi‐RCT: RCT Setting: Australia Period: February 1984 – May 1984
Participants	Population: patients who presented with acute urinary retention via emergency room or developing retention whilst in hospital Inclusion criteria: not reported Exclusion criteria: not reported Age (mean, SD)/(median, range): not reported Number of participants: · Eligible: · Randomised: 60 · Reported: 52 Dropouts (n of participants + reasons): 2 excluded due to history of urethral stricture. 3 had infected initial urine culture. 3 required for antibiotics for other reasons. Not reported which group. Follow‐up: 12 days
Interventions	Time of intervention: A: indwelling urethral catheters inserted by members of nursing staff. Urine sample obtained every 2 days until catheter removed for bacteriological culture, organism count + repeat specimens B: suprapubic catheters inserted by resident medical officers. Urine sample obtained every 2 days until catheter removed for bacteriological culture, organism count + repeat specimens Intended duration of catheterisation: not reported
Outcomes	Primary outcome (symptomatic UTI): not reported Definition of symptomatic UTI: not reported Bacteriuria: Proportion of men with infection at 12 days follow‐up: A: 80%; B: 40% Proportion of men with infection at 12 days follow‐up, analysed with ‘life‐table procedure’: A: 90%; B: 25% Definition of bacteriuria: ≥ 10⁸ organisms Quality of life:   Catheter‐associated discomfort: A: 17/?; B: 0/? Dysuria: A: 19/?; B: NR Erythema around catheter: A: NR; B: 4/? Catheter ceased draining: A: NR; B: 1/? Macroscopic haematuria: A: 0/?; B: 4/20 Cost (AUD): Catheter: A: 1.10; B: 14.00 Other equipment: A: 7.67; B: 7.47 Labour: A: 4.00; B: 5.00 Adjustment for recatheterisations: A: x 2.6; B: x 1.05 Total: A: 33.20; B: 27.77
Sponsorship/Funding	Not reported
Notes	Number in each group not reported “Suprapubic catheters were inserted by resident medical officers whereas urethral catheters were inserted by members of the nursing staff” – bias as groups not treated equally Contacted St. George Hospital for contact details for Dr. David R Hunt. Retired and no contact details available, unable to contact
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	No information given on method of randomisation
Allocation concealment (selection bias)	Unclear risk	No information given on method of allocation concealment
Blinding of participants	High risk	No information given on blinding, but as suprapubic vs indwelling can assume blinding did not occur.
Blinding of personnel	High risk	“Suprapubic catheters were inserted by resident medical officers whereas urethral catheters were inserted by members of the nursing staff”
Blinding of microbiological outcome assessment	Low risk	Bacteriuria would be assessed by microbiologist who would not know what catheter the participant had
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given on blinding. No information given on primary outcome so unclear risk of detection bias
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	No information given on number of participants randomised to each intervention. 60 participants randomised, 52 completed trial
Selective reporting (reporting bias)	Unclear risk	No information given on outcomes being reported. Unable to access protocol so uncertainty surrounding reporting bias
Other bias	Low risk	Appears to be free of other sources of bias

Methods	RCT or quasi‐RCT: RCT Setting: Brazil Period: 2000 ‐ 2004
Participants	Population: men undergoing open prostatectomy for BPH Inclusion criteria: All patients undergoing open prostatectomy for BPH (prostate > 80 g) Exclusion criteria: Not defined Age (mean, SD): A 71.4 (8.0) years; B 74.1 (6.8) years. Number of participants: Eligible: Randomised: 59 (A: 29; B: 30) Reported: 59 Dropouts (n of participants + reasons): not reported Follow‐up: mean follow‐up A: 19.7 months, B: 21.4 months
Interventions	All participants received both a urethral catheter (22f 3‐way) and a suprapubic catheter (20f) placed intraoperatively. One of these catheters was removed during the inpatient stay "once the urine had cleared." A: Discharged with urethral catheter B: Discharged with suprapubic catheter Duration of Intervention: Catheter removed on postoperative day 7 if the "patient voided well with a minimal PVR."
Outcomes	Primary outcome (symptomatic UTI): A: 2/29; B: 3/30 Definition of symptomatic UTI: UTI for this subset of men was defined as leucocituria AND positive culture (> 10⁴ cfu/ml) AND symptoms (e.g. fever, malaise, haematuria, pain, etc.) Overall complications: A: 10/29; B: 9/30. Early complications: A: 6/29; B: 5/30 Late complications: A: 4/29; B: 4/30 Number of participants with wound infection: A: 4/29; B: 1/30 Number of participants with urethral stricture: A: 1/29 (3.4%); B: 1/30 (3.3%) Number of participants with epididymitis: A: 0/29; B: 1/30 Number of participants with stress incontinence (any participant who had urinary leakage as a complaint or when questioned): A: 1/29; B: 2/30 Number of participants with bladder neck contracture: A: 1/29; B: 1/30 Number of participants with meatal stenosis: A: 1/29; B: 0/30
Sponsorship/Funding	Not reported
Notes	Contacted Dr. Korkes (fkorkes@terra.com.br) about the definition used for UTI in the study. Response received, with the following definition: "UTI for these subset of men was defined as leucocituria AND positive culture (>10⁴ cfu/ml) AND symptoms (e.g..: fever, malaise, hematuria, pain, etc.)" No power analysis performed to determine whether it can support "no difference between groups for any outcomes" Mean follow‐up: A: 21.4 months; B: 19.7 months Complication outcomes not well defined Antibiotic prophylaxis use not reported
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"prospectively randomized in two groups" ‐ no further information given
Allocation concealment (selection bias)	Unclear risk	No information given
Blinding of participants	High risk	No information given but as urethral vs suprapubic can assume no blinding occurred
Blinding of personnel	High risk	No information given but as urethral vs suprapubic can assume no blinding occurred.
Blinding of microbiological outcome assessment	Low risk	Symptomatic UTI would be assessed by a microbiologist for positive urine culture, who would not know the type of catheter a participant had
Blinding of outcome assessment (detection bias)   All outcomes	Unclear risk	No information given
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	No information given on number randomised, dropout rate and numbers lost to follow‐up. Most of the results reported as percentage instead of raw numbers
Selective reporting (reporting bias)	Unclear risk	Method stated "data regarding complication rates and postoperative outcomes were then assessed" ‐ Results cover expected complications. Unable to access protocol, some uncertainty about selective reporting
Other bias	Low risk	Appears to be free of other sources of bias