Bladder retraining protocol

Objective: to restore a normal pattern of voiding and continence after removal of an indwelling catheter, or in patients recovering from over-distension injury, acute retention, or post-stroke voiding dysfunction.

Distinguish the terms. Bladder retraining = progressive lengthening or shortening of the inter-voiding interval, with intermittent catheterisation where retention persists. Bladder training = education, bladder records, pelvic floor and other behavioural techniques for stress and urge incontinence. Both are patient-dependent and require adequate cognition, physical function and motivation.

Step 1 — Remove the indwelling catheter. Clamping the catheter before removal is not necessary and is not recommended.

Step 2 — Treat urinary tract infection if present.

Step 3 — Start a toileting schedule: on waking; every 2 hours during the day and evening; before getting into bed; and every 4 hours at night.

Step 4 — Monitor with a bladder record, documenting: frequency, timing and amount of continent voids; frequency, timing and amount of incontinence episodes; fluid intake pattern; and post-void catheter (or ultrasound) residual volume.

Step 5 — If the patient is having difficulty voiding (complete retention, or very low output such as 240 mL in 8 hours despite adequate intake):

Perform bladder ultrasound or in-and-out catheterisation every 6–8 hours, recording the volume, until residuals fall to ≤200 mL.

Teach triggering techniques — running water, stroking the inner thigh, suprapubic tapping.

Teach complete-emptying techniques — bending forward, suprapubic pressure, double voiding.

If high residuals persist beyond 1–2 weeks, consider urodynamic evaluation.

Step 6 — If the patient is voiding too frequently (more often than 2-hourly):

Check post-void residual to confirm complete emptying.

Encourage the patient to delay voiding as long as possible, with emptying techniques and pelvic floor exercises.

If frequency, nocturia, urgency or incontinence persists — rule out reversible causes (UTI, drug effect, hyperglycaemia, heart failure) and consider further evaluation for other pathology.

Duration and referral: a patient still having voiding difficulty after 1–2 weeks of the protocol should be re-examined for reversible causes and referred for urological assessment to exclude correctable lower genitourinary pathology.

Value: this protocol should enable removal of most indwelling catheters in acute hospitals and many in long-term care, thereby reducing catheter-associated infection, bladder stones, urethral trauma and immobility.

SHEA/IDSA/APIC 2022 CAUTI Compendium (published 2023) makes structured catheter removal protocols with a trial of void, including nurse-driven and automatic stop-orders, an essential practice — bladder retraining is therefore now an infection-prevention intervention, not merely a rehabilitation one.

Portable bladder ultrasound has replaced routine in–out catheterisation for residual measurement during retraining, avoiding repeated instrumentation and its infection risk.

AUA/SUFU 2024 reinforces that behavioural and bladder-training programmes remain foundational and should be offered to all patients, including those proceeding directly to drug or advanced therapy.

Objective: restore normal voiding and continence after catheter removal.

Do not clamp the catheter before removal.

Toilet on waking, 2-hourly by day, before bed, 4-hourly at night.

Catheterise or scan 6–8 hourly until residuals are ≤200 mL.

Trigger techniques: running water, inner-thigh stroking, suprapubic tapping.

Emptying techniques: bending forward, suprapubic pressure, double voiding.

Persistent difficulty beyond 1–2 weeks → urodynamics and urology referral.