Skip to main content

Foley Catheter

The Foley catheter is the universal indwelling urethral drainage catheter and the most commonly placed urinary device worldwide — approximately 100 million urinary catheters used globally each year.[1] Named after Frederic Eugene Basil Foley, who introduced the balloon-retained design into urological practice in 1937, its core design has remained largely unchanged for nearly 90 years.[2][3] For the reconstructive urologist and urogynecologist, the Foley is both the workhorse postoperative drainage device (urethroplasty, vesicovaginal-fistula repair, ureteral reimplant, radical cystectomy / neobladder, prostatectomy) and the leading source of iatrogenic urethral injury and stricture when mismanaged.

Design and construction​

The Foley is a flexible multi-lumen tube inserted transurethrally into the bladder and retained by an inflatable balloon — typically 5 mL or 10 mL, filled with sterile water (not saline, which can crystallize and obstruct the inflation channel).[4][5]

2-way Foley (standard)​

  • Two lumens: drainage (large) and balloon inflation (small).
  • 14–24 Fr typical; 16 Fr is the standard adult size.
  • 5–10 mL balloon standard; 30 mL variants used for prostatic-fossa hemostasis after TURP / simple prostatectomy and for bladder-neck retention.

3-way Foley (irrigation / CBI)​

  • Three lumens: drainage, balloon, and irrigation inflow.
  • Allows continuous bladder irrigation (CBI) for clot evacuation after TURP, simple prostatectomy, gross-hematuria management, or post-cystectomy.
  • 20–26 Fr typical with 30 mL balloon for prostatic-fossa tamponade.[5]

Material and coating variants​

MaterialNotes
LatexClassic, lowest cost; contraindicated in latex allergy.
Silicone-coated latex / PTFE-coated latexBalances cost and biocompatibility; reduced encrustation vs plain latex.
All-siliconeLatex-free; superior kink resistance and flow properties for longer dwell — but greater removal force required.[6] Preferred for chronic indwelling.
Hydrogel-coated / hydrophilic-coatedReduce urethral microtrauma, stricture, and CAUTI risk.[4]
Silver-alloy / nitrofurazone-impregnatedMarketed for CAUTI reduction; mixed evidence — IDSA does not recommend routine use.[7]

The smallest feasible diameter should be used to minimize urethral trauma.[4][7]

Indications​

Per the AAFP and IDSA frameworks[4][7][8]:

  • Acute urinary retention or bladder outlet obstruction.
  • Bladder decompression before, during, and after surgery.
  • Accurate urine-output monitoring in ICU / intraoperative settings when other methods are inadequate.
  • CBI after TURP, simple prostatectomy, radical cystectomy, open stone surgery, or for clot evacuation.
  • Post-reconstructive drainage — urethroplasty, vesicourethral anastomosis (VUA), bladder repair, fistula repair, ureteral reimplant — to protect anastomoses and divert urine during healing.
  • Open sacral / buttock / perineal wounds worsened by incontinence.
  • Neurogenic bladder (when intermittent catheterization is not feasible).
  • Hospice / palliative comfort care.

Catheters should not be used solely for staff convenience, incontinence-related dermatitis, urine culture in a voiding patient, or initial incontinence management.[4]

Contraindications​

Urethral catheterization is contraindicated in[4]:

  • Suspected urethral injury (e.g., blood at the meatus, high-riding prostate, perineal hematoma) — obtain retrograde urethrogram first.
  • Active urethral infection, trauma, or priapism.
  • Patient refusal.
  • Untreated bladder cancer (relative — risk of seeding / hematuria).

Insertion technique​

The IDSA bundle recommends[4][7]:

  • Aseptic technique with sterile gloves, drape, antiseptic meatal preparation, and single-use lubricant packet.
  • Water-soluble lubricant, ideally with lidocaine, to minimize discomfort and urethral trauma. Avoid petroleum-based lubricants — they degrade latex and silicone.
  • Hand hygiene before insertion and before / after every catheter manipulation.
  • Inflate the balloon with the manufacturer-recommended volume — overinflation causes bladder irritation; underinflation causes migration or leakage.[4]
  • Confirm balloon position is in the bladder before inflation — never inflate against resistance. Balloon inflation in the prostatic urethra is a leading cause of iatrogenic urethral injury.
  • Secure the catheter to the thigh or abdomen with adhesive tape, leg straps, or commercial anchor to prevent urethral traction injury.[7]

Maintenance​

Per IDSA and AAFP[4][7]:

  • Maintain a sterile, continuously closed drainage system — never break the closed system except for medically indicated reasons.
  • Keep the drainage bag below the level of the bladder at all times; never on the floor.
  • Prevent kinking of tubing; ensure unobstructed flow.
  • Daily meatal hygiene with soap and water (not antiseptic).
  • Maintain hydration (~ 30 mL/kg/day) to dilute urine and reduce blockage.
  • Treat constipation — stool burden impairs catheter drainage.
  • Long-term catheters: replace every 4 weeks (maximum 12 weeks), individualized to encrustation pattern.[4]

Removal​

Catheters should be removed as soon as the indication resolves[8][9]:

  • Passive balloon deflation is preferred — active aspiration creates ridging and increases removal-related urethral injury.
  • Perform a voiding trial — monitor for spontaneous urination within 6 hours.
  • Bladder ultrasound for post-void residual to identify retention.
  • Severe pain, significant urethral bleeding, or sudden inability to void warrants emergent evaluation.

Complications​

A multicenter patient-reported study found that 57% of patients reported at least one complication within 30 days of insertion, the majority noninfectious.[10]

Catheter-associated UTI (CAUTI)​

  • Bacteriuria develops at 3–8% per day; ~ 15% of patients have UTI by day 3, ~ 68% by day 8.[4][11][12]
  • CAUTI accounts for ~ 80% of hospital-acquired UTIs.[13]
  • Common organisms: E. coli, Candida spp, Enterococcus, Pseudomonas, Klebsiella.
  • Duration is the most important modifiable risk factor.[13]

Noninfectious complications (55% of patients in Saint 2018[10])​

  • Pain / discomfort
  • Hematuria
  • Bladder spasms
  • Urine leakage around the catheter — sign of bladder spasm, catheter obstruction, or undersized catheter
  • Skin breakdown
  • Urethral trauma / false passage / stricture — the dominant late reconstructive consequence

Long-term complications​

  • Encrustation and obstruction
  • Urethral erosion ("traumatic hypospadias" from chronic indwelling male catheter — preventable with proper securement)
  • Urethral stricture formation — see Male Urethral Stricture
  • Loss of bladder compliance with chronic indwelling
  • Balloon malfunction (failure to deflate)

CAUTI prevention​

The 2022 IDSA / SHEA / APIC update emphasizes a bundle approach[7]:

  • Limit catheter use to appropriate indications.
  • Remove as soon as possible — duration is the dominant risk factor.[13]
  • Consider alternatives: intermittent catheterization, external urinary devices (condom catheters, female perineal devices), suprapubic catheter for long-term needs.
  • Do not routinely use antimicrobial-impregnated catheters, bladder irrigation, or systemic antibiotic prophylaxis.
  • Do not screen for or treat asymptomatic bacteriuria — exceptions: pregnancy, mucosal-traumatizing urologic procedures.[7]

For pharmacologic CAUTI / suppressive strategies, see UTI Suppressive & Prophylactic Therapy and Non-Antibiotic UTI Prevention.

Difficult catheterization​

When standard placement fails — typically males with BPH, urethral stricture, or prior urethroplasty[14][15]:

  1. Adequate lubrication with lidocaine jelly; allow 2–3 min for anesthetic effect.
  2. Try a larger catheter (18–20 Fr) — paradoxically navigates better past prostatic curvature than a smaller flexible catheter.
  3. Coudé-tip catheter — angled tip negotiates prostatic urethra and elevated bladder neck. See Coudé Catheter.
  4. Liss maneuver / guidewire-stiffening — Amplatz Super Stiff wire through the catheter lumen increases catheter-body stiffness by ~ 359% without stiffening the tip, aiding passage through a tortuous urethra.[14]
  5. Point-of-care ultrasound to troubleshoot poor drainage, hematuria, balloon malposition.[16]
  6. Flexible cystoscopy + guidewire-assisted Council-tip catheter when blind techniques fail. See Council Tip Catheter.
  7. Suprapubic tube when retrograde access fails or is contraindicated. See Suprapubic Catheter.

Do not force a catheter against resistance — this is the dominant mechanism of iatrogenic urethral injury and downstream stricture. The Miller 2024 difficult-catheterization protocol reduced traumatic-catheterization rates from 3.0% → 0.2%; see Acute Urinary Retention.

Alternatives to indwelling Foley​

The AUA / SUFU NLUTD framework prefers alternatives whenever feasible[17]:

  • Intermittent catheterization — preferred over chronic indwelling for neurogenic bladder; lower CAUTI, stone, and bladder-cancer rates. See Intermittent Catheter.
  • External urinary devices (condom catheters, female perineal devices) — best for incontinence without obstruction, PVR < 100 mL. See Condom Catheters.
  • Suprapubic catheter — when long-term catheterization is needed and urethral access is not feasible; less urethral discomfort but higher bladder-stone risk. See Suprapubic Catheter.

Sizing reference​

Clinical contextTypical size
Adult outpatient / inpatient indwelling14–16 Fr
Large patient, viscous urine, hematuria18–20 Fr
Post-TURP / simple prostatectomy CBI22–24 Fr 3-way, 30 mL balloon
Post-cystectomy / neobladder18–22 Fr
Post-urethroplasty14–16 Fr silicone
Pediatric5–10 Fr (weight-based)
Intermittent self-catheterization10–14 Fr straight

See Also​

Council Tip Catheter · Coudé Catheter · Intermittent Catheter · Suprapubic Catheter · Acute Urinary Retention

References​

1. Cameron AP, Werneburg GT. Foley catheter management: a review. JAMA Surg. 2025;160(6):701-707. doi:10.1001/jamasurg.2025.0565

2. Feneley RC, Kunin CM, Stickler DJ. An indwelling urinary catheter for the 21st century. BJU Int. 2012;109(12):1746-1749. doi:10.1111/j.1464-410X.2011.10753.x

3. DuBose JJ, Feliciano DV. Frederic Eugene Basil Foley (1891-1966) and the Foley-type balloon catheter. Am Surg. 2023;89(6):2931-2933. doi:10.1177/00031348221088969

4. Fletke KJ, Jeong DH, Herrera AV. Urinary catheter management. Am Fam Physician. 2024;110(3):251-258.

5. Phipps S, Lim YN, McClinton S, et al. Short term urinary catheter policies following urogenital surgery in adults. Cochrane Database Syst Rev. 2006;(2):CD004374. doi:10.1002/14651858.CD004374.pub2

6. Lawrence EL, Turner IG. Kink, flow and retention properties of urinary catheters part 1: conventional Foley catheters. J Mater Sci Mater Med. 2006;17(2):147-152. doi:10.1007/s10856-006-6818-0

7. Patel PK, Advani SD, Kofman AD, et al. Strategies to prevent catheter-associated urinary tract infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2023;44(8):1209-1231. doi:10.1017/ice.2023.137

8. American College of Emergency Physicians, et al. Geriatric emergency department guidelines. Ann Emerg Med. 2014;63(5):e7-25. doi:10.1016/j.annemergmed.2014.02.008

9. Ellahi A, Stewart F, Kidd EA, et al. Strategies for the removal of short-term indwelling urethral catheters in adults. Cochrane Database Syst Rev. 2021;6:CD004011. doi:10.1002/14651858.CD004011.pub4

10. Saint S, Trautner BW, Fowler KE, et al. A multicenter study of patient-reported infectious and noninfectious complications associated with indwelling urethral catheters. JAMA Intern Med. 2018;178(8):1078-1085. doi:10.1001/jamainternmed.2018.2417

11. Kidd EA, Stewart F, Kassis NC, Hom E, Omar MI. Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults. Cochrane Database Syst Rev. 2015;(12):CD004203. doi:10.1002/14651858.CD004203.pub3

12. Lam TB, Omar MI, Fisher E, Gillies K, MacLennan S. Types of indwelling urethral catheters for short-term catheterisation in hospitalised adults. Cochrane Database Syst Rev. 2014;(9):CD004013. doi:10.1002/14651858.CD004013.pub4

13. Chenoweth CE. Urinary tract infections: 2021 update. Infect Dis Clin North Am. 2021;35(4):857-870. doi:10.1016/j.idc.2021.08.003

14. Liss MA, Leifer S, Sakakine G, Esparza M, Clayman RV. The Liss maneuver: a nonendoscopic technique for difficult Foley catheterization. J Endourol. 2009;23(8):1227-1230. doi:10.1089/end.2009.0043

15. Willette PA, Coffield S. Current trends in the management of difficult urinary catheterizations. West J Emerg Med. 2012;13(6):472-478. doi:10.5811/westjem.2011.11.6810

16. Boivin Z, Li JJ, Gottlieb M, Liu RB. Troubleshooting Foley catheter problems using point-of-care ultrasound. J Emerg Med. 2025;78:12-18. doi:10.1016/j.jemermed.2025.07.049

17. Ginsberg DA, Boone TB, Cameron AP, et al. The AUA/SUFU guideline on adult neurogenic lower urinary tract dysfunction: treatment and follow-up. J Urol. 2021;206(5):1106-1113. doi:10.1097/JU.0000000000002239