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ORIGINAL
Impact of early urinary catheter removal on successful voiding
and physical function in stroke patients
Megumi Tsuda, Tomoya Fukawa, Yasuyo Yamamoto, Kei Daizumoto, Yutaro Sasaki, Yoshiteru Ueno, Ryotaro Tomida,
Yoshito Kusuhara, Kunihisa Yamaguchi, Masayuki Takahashi, and Hiro-omi Kanayama
Department of Urology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan

Abstract : Objective : The aim of the present study was to identify factors related to the success of trial withoutcatheter (TWOC) in patients with stroke and to examine the effect of the timing of urinary catheter removal on
the course of stroke. Methods : Patients who were admitted to the Stroke Care Unit of our institution between
March 2018 and October 2021 were included. To identify factors related to success of TWOC, a multivariate
analysis was performed on the patient’s condition at admission and catheter indwelling time. The patients weredivided into two groups by the timing of catheter removal, and we assessed the relationship between the timingof catheter removal successful TWOC and recovery of physical function. Results : A total of 118 patients were
included. The presence of comorbidities and scores of severity and function at admission were not predictors ofsuccessful voiding. The time to achieve voiding sussess was significantly shorter in the early catheter removalgroup than in the later group (p < 0.005). Interestingly, the early group also showed better improvements in physicalfunction. Conclusion : Early removal of catheters may lead to early recovery of bladder function, improvement ofphysical function, and lower risk of complications in patients with stroke. J. Med. Invest. 70 : 436-442, August, 2023
Keywords : Urinary catheter, voiding function, physical function, stroke

INTRODUCTION
Lower urinary tract dysfunction is a common complicationof cerebrovascular disease (1). Dysuria is particularly likely tooccur during the early weeks after onset, and urinary retention
occurs in 20–50% of poststroke patients (2, 3). To direct brain
damage, such as damage to the cerebral cortex, which leads
to dysfunctions in the control of voiding, and / or damage to the
cerebellum and thalamus, which is associated with the dysfunction of the pontine micturition centers, was caused dysuria (4).
In addition, the inability to communicate the urge to urinate,
impaired consciousness, temporary overinflation of the bladder,and restricted movement can affect dysuria after a cerebrovascular accident (2). The risks of stroke, such as diabetes, aging,sex, and physical inactivity, are associated with the risk of developing dysuria (5). Many of these factors directly affect urinary
function. Thus, the involvement of many factors other than neurological ones makes it difficult to explain the pathology.
Urinary catheters are often necessary in stroke patients because of acute urinary retention, the need for accurate urine output measurement in critically ill patients, and perioperative use
during surgical procedures (6). Although urinary retention that
occurs immediately after stroke often improves with time (2, 7),
it can persist for a long time, especially in patients with diabetes,
impairing activities of daily living (ADL), walking ability, andcommunication skills (2, 8).
Dysuria after stroke can lead to complications, such as urinary tract infection, urinary stones, and renal dysfunction (4, 9,10) ; thus, appropriate measures must be taken. In the chronic
phase, a urinary catheter should be placed only if the patient is
Received for publication January 10, 2023 ; accepted July 5, 2023.
Address correspondence and reprint requests to Yasuyo Yamamoto,Department of Urology, Tokushima University Graduate Schoolof Biomedical Sciences, 3-18-15 Kuramoto-cho, Tokushima 7708503, Japan and Fax : +81-88-633-7160. E-mail : yasuyoyamamo@
tokushima-u.ac.jp

refractory to treatment, and intermittent urinary drainage isdesirable when it is possible (4, 6, 11). However, stroke patients
may suffer from paralysis or cognitive decline, which makes
continence self-management difficult and requires continuous
catheterization (12). This condition reduces the rate of hospitaldischarge and increases the psychological and social burden on
patients, caregivers, and their family members (13, 14).
Furthermore, urinary catheter placement has been reported
to be associated with lower activity during hospitalization in theelderly (15), and catheter placement and urinary tract infections
in stroke patients have been shown to interfere with rehabilitation (16). Thus, stroke guidelines recommend early rehabilitationin environments with organized, interprofessional stroke care(11). However, there is no established management for poststroke dysuria.
The purpose of this study was to clarify the factors related tothe success of the trial without catheter (TWOC) and to assess
the effect of the timing of urinary catheter removal on voiding
success and the course of stroke.

MATERIALS AND METHODS
Subjects

Patients who had strokes, were admitted to the Stroke Care
Unit of our institution between March 2018 and October 2021,
and had an indwelling urinary catheter were included in thisretrospective study. Patients with subarachnoid hemorrhage,
unknown stroke onset time, hemodialysis, advanced malignancy, or missing data at admission were excluded. Patients whodied during hospitalization or who underwent transurethral surgery were also excluded. Patients were excluded if they did nothave dysuria, defined as residual urine of ≥ 50 mL immediately
after removal of the urethral catheter (Figure 1).

Management of urinary drainage
The stroke rehabilitation program was indicated within 3

The Journal of Medical Investigation Vol. 70 2023

The Journal of Medical Investigation Vol. 70 August 2023

Figure1

437

Patient admitted to SCU for stroke with urinary catheter between March 2018 to October 2021, n=164

Final diagnosis of subarachnoid hemorrhage, n=16
Unknown onset time of stroke, n=1
Impossible to void due to hemodialysis, n=1
Patients with progressive malignant tumor, n=4
Date miss, n=3
Death during hospitalization, n=2
Transurethral surgery during hospitalization, n=1
Residual urine less than 50ml at removal of urinary catheter, n=18
Subject for analysis, n=118

Figure 1. Flowchart of patient selection

days of admission. The timing of removal of the urinary catheter
was determined when strict fluid output and balance checks
were no longer necessary, there was no evidence of UTI, andthe daily urine output was less than 1.5 L. If one of these conditions corresponded to the patient, the nurses of the Stroke Care
Unit consulted the urinary care team, including the physician,about when to remove the catheter. After reaching consensus,
the urinary catheter was removed as soon as possible. Oncethe catheter was removed, the diapers were checked every
hour for the presence or absence of micturition. Post-voiding
residual urine was measured by a well-trained nurse using a
portable ultrasound bladder scanner, Lilliam α-200 ® (Otsuka
Pharmaceutical Factory, Inc., Tokyo, Japan). If there was significant urinary retention (≥ 150 mL residual urine), intermittent
catheterization was performed. Within 24 hours after urethralcatheter removal, residual urine after voiding was measured
at least four times a day using a portable bladder scanner, andintermittent catheterization was performed if the residual urine
after voiding was greater than 150 mL. When over 24 hours
elapsed after the urethral catheter was removed, if the residual
urine after discharge was decreased, measurements were taken
less often. Intermittent catheterization was discontinued when
the post-voiding residual urine was consistently less than 150
mL more than a day, and this condition was defined as successful TWOC. However, if intermittent catheterization was neededagain during hospitalization, the state of TWOC was failure.
Re-catheterization was determined by the treating physician or
urologist responsible for the management of urinary drainage.
Re-intermittent catheterization and Re-catheterization were
defined as unsuccessful TWOC.

Clinical information
Patient data such as age, sex, height, weight, body mass index(BMI), type of stroke (ischemia, non-traumatic hemorrhage),length of hospitalization, time from admission to first removal ofurinary catheter, time from admission to success of TWOC, theincidence of UTIs, and the presence or absence of comorbidities
such as diabetes, neurological disease, paralysis, and neuropsychological impairment were obtained from medical records.
Stroke severity and functional outcome of activities of daily living (ADL) were measured at admission and discharge using the
National Institutes of Health Stroke Scale (NIHSS) and Barthel
Index (BI). To evaluate physical disability, the modified Rankinscale (mRS) was used prior to admission, at admission, and atdischarge. The data collected were compared and analyzed forthe successful and non-successful voiding groups. In addition,

to assess the impact of the timing of urinary catheter removal,
patients who achieved voiding success were compared and analyzed as two subgroups : those with urinary catheters in place for< 6 days and those with catheters in place for ≥ 6 days, 6 days wasapproximate average of catheter indwelling time.

Statistical Analysis
Patient characteristics in the successful and unsuccessful
TWOC groups, or in the < 6 days and ≥ 6 days of catheter insertion groups, were compared using Fisher’s exact test for categorical variables and the Mann–Whitney U test for continuous
variables. Multivariate logistic regression analysis was used
for the multivariate analysis. The cumulative incidence wasassessed using the Gray test to describe the effect of catheter
removal timing on voiding success. All statistical analyses were
performed using EZR (Saitama Medical Center, Jichi Medical
University, Saitama, Japan). Statistical significance was set at
p < 0.05.

RESULTSA total of 118 patients (65 men and 53 women) were includedin this study. Seventy-four of the 118 patients (62.7%) had voiding success at the time of discharge. There were no significant
differences in age, sex, and clinical data, such as length of hospitalization, complications, aphasia, or type of stroke, between
the voiding success and failure groups. The incidence of UTIs
during hospitalization was significantly higher in the voiding
failure group (10 vs. 5, p = 0.02) (Table 1). Multivariate analysis
revealed that the duration of indwelling urinary catheter use
significantly affected the success of TWOC (hazard ratio, 2.516,
95% confidence interval, 1.467–4.314, p = 0.001) (Table 2).
To assess the impact of the timing of urinary catheter removal on voiding success and physical performance, we divided
the patients into two groups (< 6 days vs. ≥ 6 days of catheter
insertion). The characteristics at admission of both groups areshown in Table 3, showing no significant difference between
the groups except for BMI (p = 0.026). The group with catheters
placed for less than 6 days showed a significantly shorter timeto achieve voiding success of the TWOC (14 median days vs 36
days, p < 0.01) (Figure 2). Furthermore, the total NIHSS score
was improved at discharge (p < 0.001), and the BI (p < 0.001)
and mRS scores (p < 0.001) significantly improved in the earlycatheter removal group (Table 4).

M. Tsuda, et al. Early urinary catheter removal in stroke

438

Table 1. Characteristics of study subjects
Success of TWOC,n = 74

Non success of TWOC,n = 44p-value

0.99

Characteristics on admissionAge

74.0 ± 9.8

74.0 ± 12.9

over 75 years old

37 (50.0)

21 (47.7)

under 75 years old

37 (50.0)

23 (52.3)

Sex

0.341

Female36 (48.6)

Male

38 (51.4)

27 (61.4)

23.2 ± 3.8

22.8 ± 3.6

Ischemia

48 (64.9)

28 (63.6)

Hemorrhage

26 (35.1)

16 (36.4)

Diabetes mellitus

18 (24.3)

11 (25.0)

1

Neurological disorder29 (39.2)

18 (40.9)

1

Neuropsychological impairment

42 (56.8)

21 (47.7)

0.241

Paralysis

69 (93.2)

40 (90.9)

0.726

BMI (kg / m²)

17 (38.6)

Stroke type

0.513
1

Complications

Aphasia38 (51.3)

22 (50.0)

0.851

NIHSS

17.8 ± 10.1

14.6 ± 8.5

0.064

Barthel index

7.0 ± 18.3

3.2 ± 11.1

0.157

mRS 0

50

33

0.644

mRS 1

4

5

mRS 2

5

3

mRS 3

4

3

mRS 4

4

0

mRS 5

0

0

mRS before admissionmRS on admission

0.318

mRS 0

1

1

mRS 1

0

1

mRS 2

1

3

mRS 3

8

2

mRS 4

18

11

mRS 5

46

26

Hospital stay (day)26.0 ± 19.8

25.6 ± 15.6

0.904

Catheter indwelling time (day)6.35 ± 7.80

6.93 ± 8.34

0.709

5 (6.8)10 (22.7)

0.02*

Characteristics during hospitalization

UTI (%)

Note : Values are presented as mean ± standard deviation or number (%). *p < 0.05
BMI : body mass index ; UT : urinary tract infection. NIHSS : National Institutes of Health Stroke Scale,mRS : Modified Rankin Scale

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The Journal of Medical Investigation Vol. 70 August 2023
Table 2. Multivariate analysis of factors associated with TWOC
HR

95%CI

p-value

Age

1.203

[0.745-1.943]

0.449

Sex

1.182

[0.723-1.933]

0.504

Diabetes mellitus

0.948[0.543-1.654]

0.851

Aphasia

1.165[0.716-1.893]

0.539

Catheter indwelling time

2.516

[1.467-4.314]

0.001

Note : Age (over 75 years old : 1, under 75 years old : 0). Sex (male : 0, female : 1).
Diabetes mellitus (yes : 1, no : 0). Aphasia (yes : 1, no : 0).
Catheter indwelling time (within 5 days : 1, above 5 days : 0).
Abbreviations : HR, hazard ratio ; CI, confidence interval

Table 3. Characteristics of Patients in early catheter removal and late catheter removal groupsAge< 6 days group,n = 71≥ 6 days group,n = 47p-value

73.7 ± 11.1

74.5 ± 11.0

0.719

Sex

0.341

Female37 (52.1)

28 (59.6)

Male

34 (47.9)

19 (40.4)

BMI (kg / m²)

23.7 ± 3.5

22.1 ± 4.0

Ischemia

50 (70.4)

26 (55.3)

Hemorrhage

21 (29.6)

21 (44.7)

19 (26.8)

10 (21.3)

Stroke type

0.026
0.117

Complications
Diabetes mellitus

0.522

Neurological disorder27 (38.0)

20 (42.6)

0.702

Paralysis

68 (95.8)

41 (87.2)

0.153

Aphasia36 (50.7)

24 (51.1)

1

NIHSS on admission

15.7 ± 8.3

18.1 ± 11.4

0.176

Barthel index on admission

7.0 ± 17.3

3.4 ± 13.8

0.229

0 points

52

31

1 points

88

mRS before admission

0.482

2 points

3

4

3 points

6

2

4 points

2

2

5 points

00Note : Values are presented as mean ± standard deviation or number (%).
BMI, body mass index ; NIHSS, national Institutes of Health Stroke Scale ; mRS, Modified
Rankin Scale

440

Figure2 Cumulative incidence for success rate

M. Tsuda, et al. Early urinary catheter removal in stroke< 6days≥ 6daysNo. of Patients71
47< 6days≥ 6daysMedian(day)36
14
p<0.01Day< 6days≥ 6daysFigure 2. Cumulative incidence for success rate

Table 4. Univariate analysis of variaties associated with physical function and ADL< 6 days group,n = 71≥ 6 days group,n = 47p-value< 0.001*

NIHSS at discharge

8.42 ± 6.44

14.38 ± 9.79

ΔNIHSS

7.23 ± 9.55

3.74 ± 9.57

0.054

Barthel Index at discharge

37.3 ± 34.5

13.3 ± 20.6

< 0.001*

Δbarthel Index

30.2 ± 33.2

9.9 ± 17.1

mRS at discharge< 0.001*< 0.001*

0 points

10

1 points

20

2 points

80

3 points

17

4

4 points

30

16

5 points

13

27

Note : Values are presented as mean ± standard deviation, *p < 0.05
NIHSS : National Institutes of Health Stroke Scale, mRS : Modified Rankin Scale
Δ : difference between admission score and discharge score

DISCUSSION
To identify the factors that interfere with the voiding successof TWOC, we first evaluated the relationship between voiding
success at discharge and clinical factors associated with urination, such as age, history of diabetes and hypertension, andneurological assessment. Although men are generally thought
to be more likely than women to develop urinary retention
due to benign prostatic hyperplasia and complications (17), no
association was found between sex and voiding success rate atdischarge. Similarly, a history of diabetes, hypertension, andother conditions was not predictive of the voiding success of
TWOC. Some previous reports have shown that urinary catheters were more likely to be placed in older patients, patientswith higher NIHSS scores on admission, and patients withneurological deterioration (9). In addition, cognitive dysfunction
has been reported to be associated with urinary retention (2).
However, in the present study, there was no association between
the acquisition of voiding success and physical condition before or
immediately after stroke onset, or the severity of cerebrovascular disease at the time of admission. In addition, no association
was found between successful TWOC and cognitive dysfunction
during hospitalization. These results may be explained by thefact that this study focused only on patients who had an indwelling urinary catheter ; therefore, only patients with relatively
severe stroke were included.
Urinary catheterization has been reported as a possible risk
not only for UTI development but also for complications such as
deep vein thrombosis and pneumonia (16, 18). The rate of use ofindwelling urinary catheters in stroke patients varies by region

The Journal of Medical Investigation Vol. 70 August 2023
and type of stroke, ranging from 6–60% (9, 16, 19). Stroke has
been reported to cause immunodeficiency owing to sympathetic
activation and loss of immune cell function (20), and patientswith indwelling urinary catheters are particularly susceptible
to UTI. In addition, the development of UTI and its associatedsymptoms, including infection-related fever, hypoxia, and electrolyte imbalance, can impair recovery from stroke and havebeen reported to be associated with worse neurological outcomes,mortality, poorer recovery of physical function, prolonged hospitalization, and increased post-stroke care costs (20-23). Early
rehabilitation in stroke has been shown to improve the long-term
recovery of functional abilities and general health (24), reduce
long-term mortality and facilitate hospital discharge (25). Complications associated with urinary catheter insertion may interrupt rehabilitation. There are no definitive guidelines regarding
the appropriate timing of urinary catheter removal in stroke
patients who require catheterization. We therefore assessed theimpact of catheter removal timing on the clinical course of stroke
patients. The results showed that patients in the early catheter
removal group achieved voiding success earlier than those in thelater catheter removal group did. The frequency of UTI was significantly lower in the early catheter removal group and, interestingly, the early catheter removal group showed significantly
better ADLs and recovery from a stroke at discharge, suggestingthat early removal of urinary catheters in stroke patients maylead to effective rehabilitation implementation as well as reduced
incidence of UTIs. Early removal of urinary catheters may leadto early recovery of bladder function, improvement of physicalfunction, and lower risk of complications, such as the incidence of
UTIs in patients with stroke.
The limitations of this study are as follows. It was a retrospective study, and urinary catheter removal was not defined byprotocol, so catheter removal was at the discretion of the treating
physician or urologist meaning that the patient’s condition could
not be ruled out completely. Because patients without catheterization were excluded, comparisons with these patients were notevaluated. The analysis was performed only during acute-care
hospitalization, and long-term outcomes were not analyzed.
Although rehabilitation was started within 3 days of admissionin all patients, the timing of initiation and rehabilitation were
not defined by a protocol, and the possibility that rehabilitationdiffered depending on the patient’s condition other than thepresence of a catheter cannot be ruled out. Although we found noassociation between improvement in dysuria and diabetes mellitus, we may have underestimated the impact of diabetes mellitus
because we did not confirm the presence of diabetic peripheral
neuropathy at the time of stroke onset.
The establishment of appropriate urinary drainage management in stroke patients may lead to improved outcomes,
including not only urinary tract management but also functional
improvement of patients, and prospective studies are needed.

CONFLICT OF INTEREST DISCLOSURE
Authors have no potential conflict of interest to report.

ACKNOWLEDGMENT
We would like to thank Editage (www.editage.com) for English language editing.

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