Asian Nursing Research 10 (2016) 173e181

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Asian Nursing Research

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Review Article

Is Bladder Training by Clamping Before Removal Necessary for

Short-Term Indwelling Urinary Catheter Inpatient? A Systematic
Review and Meta-analysis
Li-Hsiang Wang, MSN, Ph.D. candidate, 1, 2 Ming-Fen Tsai, PhD, 1
Chin-Yen Stacey Han, PhD, 1, 3 Yi-Chi Huang, MSN, 4 Hsueh-Erh Liu, RN, PhD 1, 5, 6, *
1
Department of Nursing, College of Nursing, Chang Gung University of Science and Technology, Tao Yuan, Taiwan
2
Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
3
Chang Gung University of Science and Technology, Tao Yuan, Taiwan
4
Department of Nursing, Chiayi Campus, Chang Gung University of Science and Technology, Chiayi, Taiwan
5
School of Nursing, College of Medicine, Chang Gung University, Tao Yuan, Taiwan
6
Department of Rheumatology, Chang Gung Memorial Hospital, LinKou, Taiwan

a r t i c l e i n f o s u m m a r y

Article history: Purpose: Urinary catheterization is a common technique in clinical practice. There is, however, no
Received 7 October 2015 consensus on management prior to removal of the indwelling catheter for short-term patients. This
Received in revised form systematic review examined the necessity of clamping before removal of an indwelling urinary catheter
21 June 2016
in short-term patients.
Accepted 27 June 2016
Methods: A systematic literature review was conducted using eight databases and predetermined
keywords-guided searches. Some 2,515 studies were evaluated. Ten studies that met the inclusion
Keywords:
criteria were selected.
catheters
device removal
Results: The quality of the studies was assessed using the Jadad scoring system. Only 40.0% of studies
indwelling were rated as high quality. This review found that catheter clamping prior to removal was not necessary
systematic review for the short-term patient. When made a comparison with the unclamping group, there was no signif-
icant difference in recatheterization risk, risk of urine retention, patients’ subjective perceptions and rate
of urinary tract infection.
Conclusions: This review indicated that bladder training by clamping prior to removal of urinary cath-
eters is not necessary in short-term catheter patients. In addition, clamping carries the risk of compli-
cations such as prolonging urinary catheter retention and urinary tract injury. Further investigation
requires higher quality methodologies and more diverse study designs.
Copyright © 2016, Korean Society of Nursing Science. Published by Elsevier. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction
Use of an indwelling urinary catheter is very common in clinical
practice. At least 15.0%e25.0% of inpatients have indwelling ure-
thral catheters, mostly on a short-term basis [1e3]. Urinary cath-
eters provide some information about physical function, but also
increase the chances of infection. Approximately 40.0% of nosoco-
mial infections originate from the urinary tract [4], and 80.0% occur
after placement of urinary catheters. Some 20.0%e50.0% of patients
whose urinary catheter remained in place for more than 1 week
* Correspondence to: Hsueh-Erh Liu, RN, PhD, School of Nursing, College of
Medicine, Chang Gung University, Tao Yuan, Taiwan.
E-mail address: sarah@mail.cgu.edu.tw
were found to have bacteriuria [3,5], and prolonged urinary cath-
eter use increased bacteriuria by 3.0%e10.0% per day [3,6e8]. The
most important risk factor for developing a catheter-associated
urinary tract infection (UTI) was prolonged use of an indwelling
catheter. This increased the risk of infection and the medical costs
associated with infection treatment, prolonged patients’ hospital
stay, and was potentially life threatening [3]. Centers for Disease
Control recommended in 2015 [9] that urinary catheters should
only be used for appropriate indications and should be removed as
soon as they are no longer needed.
Difficulty in voiding after removal of the catheter, especially in
aging patients with poor bladder contractile function, is another
concern. Clamping the indwelling urinary catheter before removal
was first recommended by Ross in 1936 [10]. The clamping process is

http://dx.doi.org/10.1016/j.anr.2016.07.003
p1976-1317 e2093-7482/Copyright © 2016, Korean Society of Nursing Science. Published by Elsevier. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
174 L.-H. Wang et al. / Asian Nursing Research 10 (2016) 173e181
supposed to strengthen the bladder detrusor muscle, improve
muscle tone and sensation of the bladder, and stimulate normal
filling and emptying of the bladder [11,12]. There are, however,
several disadvantages to clamping, such as bladder over distension if
the clamping lasts too long [11], increased rate of re-indwelling by
up to 1.06 fold per indwelling urinary day [13], increased duration of
retaining the indwelling catheter and infection rate [11,14,15].
No clear guideline for bladder clamping has been listed in
clinical practice. Each practitioner makes their own decision to
clamp the catheter or not before removal based on their opinions of
necessity. Cochrane reviews and some trials showed insufficient
evidence that support the effectiveness of clamping in short-term
indwelling catheter patients [1,6]. In addition, the Healthcare
Infection Control Practices Advisory Committee (HICPAC) [16] and
the Joanna Briggs Institute (JBI) [17] showed that, in order to pre-
vent catheter-associated UTI, clamping indwelling catheters prior
to removal provided weak evidence, as the poor quality of meth-
odology in these studies was the major reasons [6,18].
Clearly, the necessity of clamping the urinary catheter before
removal still is an important issue needing to be explored. Does
clamping intervention before removal improve bladder function?
Does it prolong return to normal voiding or prolong catheter
retainment? Research evidence to support the management of
removal of urinary catheters are needed through systematic research
and quality appraisal. The purpose of this systematic review was to
identify the necessity of bladder clamping prior to removal of urinary
catheter in patients with short-term indwelling catheter.
Methods
Review questions
The “participant, intervention, comparision and outcome” or
PICO principle was used to formulate clinical questions that guided
the search strategy, as shown in Table 1. The main research question
was “What are the effects of urinary catheter clamping in short-
term inpatients with the indwelling catheter?”
Search strategy
Search terms (Table 1) were selected using keywords from
previous studies and dictionaries of Medical Subject Headings
Table 1 Research Question (PICO Framework).
Key element Description
Population Adult inpatient
Indwelling urinary
catheter up to 14 days.
Intervention Regular clamp on urinary
catheter and clamp off
before removal
Comparison Keeping the urinary catheter
on free draining until removal
Outcome Recatheterization after removal
of indwelling urinary catheter;
Timing of the first void; Volume
of first voiding; incidence of
urinary retention; and urinary
tract infection.
Note. PICO ¼ participant, intervention, comparsion and outcome.
* denotes the truncation to explore the potential references.
(MeSH terms); truncation symbols were used to broaden the
search strategy. Eight databases were independently searched:
Medline, EMBASE, CINAHL, PubMed, PsycINFO, ProQuest, Chinese
Electronic Periodical Service and the Cochrane Controlled Trials
Register. Search filters included English or Chinese language, and
adult participants. The search was also limited to papers pub-
lished prior to May 2016. Citation search of relevant published
studies and systematic reviews were also used to locate relevant
studies that may have been missed in the strategy described
above.
Selection criteria for studies
Studies were eligible for inclusion if they met the following
criteria: (a) randomized controlled trials or quasiexperimental
study design; (b) urinary catheter was inserted in adult inpatients
for up to 14 days; (c) with indwelling transurethral or suprapubic
urinary catheters; and (d) conducted an intermittent clamping
regimen. The exclusion criteria were as follows: (a) patients with
congenital abnormalities of the genitourinary system; (b) received
intermittent catheterization; (c) combined with drug treatment
(including medication affecting bladder contraction, prophylactic
antibiotics for UTI); (d) receiving pelvic floor exercise, or filling fluid
into the bladder; (e) removal of nephrostomy tubes; and (f) rele-
vant procedure not clearly reported.
Quality assessment of selected studies
Each of the two authors independently evaluated the quality of
methodology by the Jadad scoring system and the risk of bias in
each study. The possible range of Jadad scores was 0e5, and a score
of 3e5 indicated high quality [19].
Data extraction and management
After confirming the eligibility of studies, two reviewers inde-
pendently extracted the data from the included studies. The pa-
rameters extracted for each study included: study reference
(author, year of publication), study design, setting, participants
(number, mean age), types of interventions, types of control group,
and outcome measures. The findings are summarized in Table 2.
Search terms
Catheter, Indwelling/Indwelling Catheter/Indwelling Catheters/In-Dwelling
Catheters/Catheter, In-Dwelling/Catheters, In-Dwelling; Urinary catheter,
indwelling*/Urinary catheter*/Catheter, Urinary/Catheters, Urinary/Urinary
Catheter/Ureteral Catheters/Catheter, Ureteral; Urinary catheterization*/
Catheterizations, Urinary/Urinary Catheterizations/Catheterization, Urinary/
Catheterization, Ureteral/Catheterizations, Ureteral/Ureteral Catheterizations/Ureteral
Catheterization/ Catheterization, Urethral/Catheterizations, Urethral/ Urethral
Catheterizations/Urethral Catheterization/Foley Catheterization/Catheterization, Foley
Urinary catheter clamping*/Urinary catheter on and off*/Urinary catheter clamp and
release*/Urinary catheter close and open*/Clamping urinary catheter*/Bladder function
clamping*/Bladder function management*/Bladder function intervention*/Bladder
function retraining*/Bladder function training*/Foley catheter clamping*
 L.-H. Wang et al. / Asian Nursing Research 10 (2016) 173e181
Quantitative data synthesis
Data were synthesized by Review Manager (RevMan, Version
5.1) (The Nordic Cochrane Centre, The Cochrane Collaboration,
Copenhagen). This software was used to examine data homoge-
neity and calculate intervention differences. Tests for homogeneity
were performed to evaluate similarities between studies with p
value greater than .05 demonstrating acceptable homogeneity. If
there is homogeneity, we used a fixed effect model, or for hetero-
geneous studies, we used a random effect model to combine data in
the meta-analysis. Dichotomous data were calculated by the odds
ratio (OR) and 95% confidence intervals (CI), and continuous data
calculation used mean and standard deviation values. A p value of
less than .05 was considered a statistically significant difference.
Results
A total of 2,515 abstracts was obtained by searching through the
databases and 8 additional records were identified through other
sources. After removing 96 duplicates, 2,395 articles were poten-
tially relevant. After reviewing the titles and abstracts, 2,289 arti-
cles were excluded because they did not meet the inclusion criteria.
The full texts of 106 studies were examined in detail; only 10 papers
satisfied all the inclusion criteria and were therefore included in
this review. Details of the selection process of included and
excluded papers and retrieval of full text papers are shown in the
PRISMA flowchart in Figure 1.
A total of nine trials and 927 participants were included in this
review. One trial was a quasiexperimental study design and the
others used an experimental design. The studies were published
between 1981 and 2015. One trial included two control groups in
comparison [20]. Four of the nine studies were conducted in the
United States; the others were conducted in Sweden, Taiwan, the
United Kingdom, Spain, Italy and China. Most participants were
surgical patients or had undergone a surgical treatment [1,20e27];
only one trial involved stroke patients [28]. The operation sites
were as follows: two studies were related to bowel cancer surgery
[22,23]; one study was related to orthopedic surgery [1]; five
studies involved urogynecology-related surgery [20,23e27]; one
study did not mention the type of surgery [21]. There were 780
female participants (84.1%); one study only included male partici-
pants [28], while the other seven studies involved only female
patients. The age range of participants was 23e84 years.
There was divergence in the use of the clamping urinary cath-
eter intervention. Two study used Q3h clamping urinary catheter
[21,27], another used Q4h [1] and three studies used progressive
clamping intervention [23e25]. Five studies provided no detail
about the clamping procedure [20,22,25e27]. The release interval
ranged from 5 minutes [21,23] to 15 minutes [24,25]. As for the type
of the indwelling urinary catheter, one study used a suprapubic
catheter [22] and the others used a transurethral catheter. Time of
clamping began at postsurgery as follows: first day [24,26], second
day [1], third day [25,27] and fourth day [23]. The other studies did
not specify the timing [20e22,28].
The measured variables varied. Seven studies reported reca-
therization [1,20,22,23,25e27]. Time of first voiding after removal
of the urinary catheter was reported in three trials [21,23,26]. The
residual amount of the first voiding was reported in three studies
[21,25,26]. Urinary retention was measured in four trials
[1,20,22,25]. UTI was reported in six trials [1,20,22,24,25,27]. Most
studies used urine culture to diagnose UTI; only two studies failed
to specify how UTI was identified [1,20]. Patients’ subjective
perception was also reported in five trials [21e23,25,26]. One study
[23] reported that eight participants experienced frequent urina-
tion, but did not identify the group to which they belonged. The
175
diversity in measured variables of patients’ subjective perception
made meta-analysis impossible.
Methodological quality
Two reviewers independently evaluated the quality of meth-
odology in each study by using the Jadad scoring system and the
risk of bias. The possible range of Jadad scores was 0e5 and scores
of 3e5 indicated high quality [19]. Jadad scores ranged from 1 to 4
in all included studies. In total, 40.0% of the studies attained a Jadad
score as high quality, 50.0% of the studies are of medium quality,
and 10.0% of the studies are of poor quality (Table 2).
Meta-analysis for outcomes
Recatheterization after removal of urinary catheter
Seven studies reported the need for recatheterization following
removal of the urinary catheter [1,20,22,23,25e27]. This involved a
total of 927 patients, all of whom had received surgical in-
terventions. Figure 2 shows the effects of clamping on recathete-
rization. Homogeneity was achieved (c2 ¼ 3.69, p ¼ .595). The
recatheterization effect Z value was 1.68 [OR ¼ 0.66, 95% CI (0.41,
1.07), p ¼ .093]. There was no significant difference between the
clamping and the unclamping group. Different clamping proced-
ures were also compared. Only two studies related to the pro-
gressive clamping group [23,25]. Homogeneity was achieved
(c2 ¼ 0.96, p ¼ .327), and Z value was 1.65 [OR ¼ 0.53, 95% CI (0.25,
1.13), p ¼ .099]. Four studies used regular clamping technique
[1,20,22,27]. Homogeneity was achieved (c2 ¼ 2.23, p ¼ .526) and Z
value was 0.80 [OR ¼ 0.77, 95% CI (0.42, 1.44), p ¼ .424]. The results
showed that there was no difference between these two types of
clamping intervention in relation to recatheterization.
Timing of first voidings
The timing of the first voiding was reported in three studies
[21,23,26]. One study reported the mean of timing for the first
voiding (1.92 hours) in the clamping group and free draining (2.72
hours) goup (p < .05) [21]. No further data could be obtained.
Therefore, only two studies were included in meta-analysis. How-
ever, high heterogeneity (c2 ¼ 9.84, p ¼ .002, I2 ¼ 90%) and Z value
at 0.93 [Mean Difference, (MD)-53.81, 95% CI (167.71, 60.09),
p ¼ .346] meant that meta-analysis was not a suitable choice.
UTI
Six studies reported the occurrence of UTI [1,21,22,24,25,27].
This diagnosis was identified by urine culture in 4 trials
[21,22,24,25], and two study failed to specify the diagnostic pro-
cedure [1,27]. All studies were conducted on surgical patients.
Homogeneity was achieved (c2 ¼ 0.61, p ¼ .976) and Z value was
1.22 [OR ¼ 0.73, 95% CI (0.43, 1.21), p ¼ .271] (Figure 3). No signifi-
cant difference between clamping and unclamping group was
found. Furthermore, different clamping procedures were
compared. Two studies used the progressive clamping technique
[23,25]. Homogeneity was achieved (c2 ¼ 0.07, p ¼ .801) and Z value
was 0.89 [OR ¼ 0.74, 95% CI (0.38, 1.44), p ¼ .373], whereas four
studies used regular clamping techniques [1,20,22,27]. Homoge-
neity was achieved (c2 ¼ 0.74, p ¼ .864) and Z value was 0.65
[OR ¼ 0.76, 95% CI (0.33, 1.73), p ¼ .516]. These results indicated that
no significant difference in UTI was found between these two
clamping interventions.
176
Table 2 Description of Included Studies (N ¼ 10).
First author,
year & country
Oberst 1981 USA [23]
Williamson 1982 USA [21]
Bergman 1987 USA [24]
Guzman 1994 Spain [20]
Ratnaval 1996 UK [22]
Sun 2004 Taiwan [25]
Nyman 2010 Sweden [1]
L.-H. Wang et al. / Asian Nursing Research 10 (2016) 173e181
Patients Average Sample size Intervention Main findings Jadad
Duration of description score
EG CG
indwelling
Bowel cancer patients 6d 52 58 EG: Clamp schedule 1. Voiding dysfunction: EG 3
from postsurgery had lower voiding
day 4 to day 10, dysfunction rate than CG
remove progressive did at removal of
clamping; each catheter immediately &
clamping has a at discharge.
5-min release 2. First voiding time: EG
draining. had shorter first voiding
CG: Free draining and time than CG did.
removed on
postoperative day
10.
Ongoing surgery female NA 4 4 EG: Q3H clamping then 1. First voiding time: EG 2
patients & indwelling catheter release for 5 min. had shorter first voiding
for at least 36 h CG: Free draining. time than CG did.
2. Residual urine amount:
EG had less residual
urine than CG did.
3. Patients’ perceived
symptoms: In EG, 1
patient felt burning & 2
complained of bladder
filling during the first
voiding but did not feel
pressure or pain. In CG 1
patient experienced
bladder and sphincter
spasm.
Urodynamic stress CG: 3.4 d 44 45 EG: Clamping schedule 1. Length of 3
urinary incontinent EG: 3.5 d from postsurgery catheterization: EG was
day 1, progressive similar to CG in retention
clamping & each time of urinary catheter.
clamping has a 2. UTI: EG had higher rate
15-min release than CG.
draining.
CG: Free draining.
Undergoing vaginal surgery CG 1:24h 33 103 EG: Indwelling catheter 1. UTI: CG2 had the highest 2
CG2: 72h within 72 h & rate; CG1 was the same
EG: NA clamping. as EG.
CG 1: Free draining & 2. Urinary retention: EG had
removal after 24 h. higher rate than CG, CG2
CG 2 : Free draining & was higher than CG1.
72 h remove.
Pelvic colorectal surgery, EG:7.2 d 24 26 EG: Suprapubic 1. Mean catheter retention 2
male patients CG: 7.5 d catheter clamped time: No difference
prior to removal; between groups.
remove catheter at a 2. Complications: EG had
residual volume of < fewer complications in
50 mL. urine retention, frequent
CG : Transurethral voiding,
catheter with free recatheterization & UTI.
draining.
Genuine stress incontinent EG: 5 d 43 43 EG: Clamping schedule 1. Voiding difficulty: EG 2
CG: 1 d from postsurgery patients experienced
day 3, clamp for 1 h more voiding difficulty
45 min & release for than CG did.
15 min until day 5. 2. Bacteriuria: EG patients
CG: Remove on had more than CG did.
postsurgery day 1. 3. Felt incomplete emptying
or voiding frequency
&/or urgency: Both
groups the same. CG had
more frequency &/or
urgency than EG did.
4.Recatheterization:CG
had higher rate than EG
did.
Hip fracture EG: 45 h 55 58 EG: Clamping schedule 1. Return normal bladder 3
CG: 43 h from postsurgery function time:
 L.-H. Wang et al. / Asian Nursing Research 10 (2016) 173e181 177

Table 2 (continued )

First author, Patients Average Sample size Intervention Main findings Jadad
year & country Duration of description score
EG CG
indwelling

day 2, Q4h clamp No difference between

Wahyu 2011 USA [28]
Chou 2014 China [26]
Fanfani 2015 Italy [27]
until bladder scanner groups.
showed normal 2. Recatheterization: EG
bladder function & CG had similar rates.
(residual amount <
150 mL) then
remove catheter.
CG: Free draining and
removal on
postsurgery day 2.
Stroke acute stage patients NA 7 7 EG: Clamping catheter. Residual urine amount: EG 1
CG : Free draining. had less than CG did.
Gynecology-related surgery NA 114 116 EG: Clamping schedule Recatheterization: EG 3 2
from postsurgery cases, CG 5 cases.
day 1. Patients’ perceived
CG: Free draining. symptoms: In EG, 3
cases, & in CG 4 cases of
felt discomfort.
First time voiding
(M ± SD): EG, 2.07 ± 0.51
h; CG, 2.09 ± 0.55 h.
First voiding volume (ml)
(M ± SD): EG
253.94 ± 39.85, CG
255.88 ± 50.36.
Radical hysterectomy EG: 4 d 55 56 EG: Clamping schedule Recatheterization: 11 cases 4
CG: 3 d from postsurgery each in the two groups.
day 3, Q3h clamp UTI: 5 cases each in the
then removal on two groups.
day 4.
CG: Free draining then
removed on day 3.

Note. CG ¼ control group; EG ¼ experimental group; NA ¼ not available; ; OP ¼ operation; UTI ¼ urinary tract infection.

Patients’ subjective perceptions of voiding-related symptoms
Four studies measured patients’ subjective perceptions of
voiding-related symptoms after removal of the urinary catheter
[21,22,25,26]. All participants were surgical inpatients. Two studies
reported the perceptions of urinary frequency and/or urinary ur-
gency [22,25], one reported incomplete voiding [25], one
mentioned burning sensation, spasm or filling during voiding [21],
and one only documented discomfort during voiding [26]. We
excluded one study with wide variation [21]. Then, the homoge-
neous results were obtained (c2 ¼ 4.07, p ¼ .131, I2 ¼ 51%) and Z
value was 1.91 [OR ¼ 0.53, 95% CI (0.28, 1.02), p ¼ .056] (Figure 4). It
showed that clamping made no significant difference on patients’
subjective perceptions of voiding-related symptoms.
Urinary retention
Four studies reported incidence of urinary retention
[1,20,22,25]. Three of these studies involved abdominal or pelvic-
related surgery [20,22,25], and one involved orthopedic surgery
[1]. Two studies were excluded due to wide variation [1,25], and
only two studies were retained in this analysis. Homogeneity was
achieved (c2 ¼ 0.65, p ¼ .420), Z value was 0.91 [OR ¼ 1.39, 95% CI
(0.68, 2.84), p ¼ .363] (Figure 5). Results of these limited studies
showed that there was no significant difference in the incidence of
urinary retention between these two groups.
Discussion
Bladder training encourages people to extend the time between
voiding and regain continence ability. In some cases, were found
bladder training could improve voiding function in patients with
long-term indwelling catheter or incontinence. In clinical situation,
we indwelling urinary catheter for some purpose. They almost are
short-term indwelling. It's confusion from limited scientific litera-
ture to known the necessity of clamping in short-term indwelling
patients. This systematic review was undertaken to investigate the
necessity of clamping short-term indwelling catheter before its
removal in adult patients. Ten studies were included in our analysis.
Half of Ten studies were included in our analysis. Half of them were
published before 2000's, and the others were published after
2000's. The results of the limited studies showed that no significant
differences between clamping and unclamping groups existed in
relation to risk of recatheterization, urine retention, subjective
symptoms related to voiding, and the rate of UTI. Compared with
the systematic review done by Griffiths and Fernandez [6], we
included 10 studies with 927 participants and added two clamping
strategies to make comparison. Similar results were found in the
present analysis. From the limited evidence found here, the rec-
ommendations from HICPAC and JBI, that clamping indwelling
catheters prior to removal was not necessary nowadays were again
supported. The use of indwelling catheters is very common in
clinical practice. During indwelling, the muscle and the sphincter of
the bladder is at rest. For the longest time, it needs to be restimu-
lated by training to recover its physical function [12]. Some studies
showed that clamping intervention could strengthen the detrusor
muscle, improve muscle tone and bladder sensation, and stimulate
normal filling and emptying of the bladder [11,12]. Others, however,
concluded that clamping training increased duration of the
indwelling catheter, infection rate and cost in cases of short-term
indwelling catheter [14,15,30]. It is still a confusing situation for
both patients and healthcare providers.
178 L.-H. Wang et al. / Asian Nursing Research 10 (2016) 173e181

Figure 1. PRISMA flowchart for inclusion process. Note. ICP ¼ Intermittent Catheterization Program.

This review included studies involving pelvic and intestinal
surgery patients. These surgical sites are more susceptible to
limited muscle exertion during urination. Our results showed that
clamping had no impact on the main selected outcomes. Similar
findings have been reported for urinary catheter clamping in pa-
tients undergoing gynecologic surgery, that is, the procedure had
no effect in preventing urinary retention and urinary infection [29].
Clamping programs were divided into two groups: progressive
clamping procedure and regular clamping interval. Our advanced
analysis found that there was no difference between these two
clamping programs in relation to recatheterization. Since only one
study examined progressive clamping with urinary retention, further
inference was not possible. Some researchers, however, have argued
that progressive clamping was beneficial for urinary function [12].
 L.-H. Wang et al. / Asian Nursing Research 10 (2016) 173e181 179

Figure 2. Forest plot for recatheterization. Note. CI ¼ confidence interval.

Figure 3. Forest plot for urinary tract infection. Note. CI ¼ confidence interval.

Figure 4. Forest plot for patients’ perceptions of voiding-related symptoms. Note. CI ¼ confidence interval.
180 L.-H. Wang et al. / Asian Nursing Research 10 (2016) 173e181
Figure 5. Forest plot for urinary retention. Note. CI ¼ confidence interval.
This review indicated that the clamping group had a longer
duration of urinary catheterization than the unclamping group.
Prolonged duration of retention increased the risk of complications
from catheterization [30]. At the same time, the use of clamping
could increase both the workload of nurses and the potential risk of
bladder/urinary system injury due to failure to reopen it.
This review had several limitations. First, less than half of the
studies were regarded as high quality. These methodological
shortcomings limited the availability of evidence. Second, some
studies did not provide detailed descriptions of the intervention
procedure, and some data were unavailable. The review may,
therefore, be limited by publication bias. Third, only one study
included nonsurgical patients, which restricted the ability to draw
inferences to other medical patients.
Conclusion
We explored the issues of clamping indwelling urethral cath-
eters before removal it based on limited evidence. From on our
review, no significant difference was found between the clamping
and unclamping groups in the outcomes of recatheterization,
urinary retention, UTI and patients’ subjective perceptions of
voiding related symptoms. The limited evidence obtained from
this review does not provide a robust base to overrule the existing
guidelines.
Implications for practice and research
The results provided weak evidence that catheter clamping
before removal is not necessary in short-term inpatients. It sup-
ported the guideline proposed by HICPAC and JBI that clamping
indwelling catheters prior to removal is not necessary. In managing
short-term indwelling catheter patients, if there is no indicator for
continued use of a urinary catheter, nurses should unplug the
catheter earlier to reduce potential complications. Still, nurses and
other healthcare providers need to monitor patients’ urination and
assess bladder fullness closely after removal of the catheter.
The low quality in methodology and the nature of study pop-
ulations in the original studies limited the applicability of our re-
view. For further study, study designs with high quality (i.e.,
randomzied controlled trials), patients with various diagnosis, and
multicenter trials were strongly suggested.
Conflicts of interest
The authors have no conflict of interest to declare.
Acknowledgments
We thank Dr Paul Glasziou, at the Centre for Research in
Evidence-Based Practice, Faculty of Health Sciences and Medicine,
Bond University, Australia, who provided helpful advice on the
research.
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