Urinary Catheter Placement

by Gul Pamucu Gunaydin

Case Presentation

A 75-year-old male patient was admitted to the emergency department with difficulty voiding. He had this complaint for over a year, and tonight, although he felt pain and distention in his lower abdomen, he could not urinate at all. On his physical exam, the patient had a palpable mass that was thought to be the distended bladder. He was agitated and tachycardic. He was diagnosed with acute urinary retention, and initial attempt to insert urinary indwelling catheter was failed. The second attempt with a Coude catheter was successful and 2 liters of urine was drained gradually. His rectal exam revealed prostate enlargement. He was discharged with instructions, uneventfully.

Procedure: Urinary Catheter Placement

Urinary catheter insertions is a common procedure in the ED. They may be external (condom) or indwelling (urethral, suprapubic). Condom catheters are indicated in men with functional disabilities such as restricted mobility or dementia with incontinence, who can void spontaneously. Suprapubic catheters are an option if urethral catheters fail. This chapter focuses solely on urethral urinary catheterization.

Emergency Indications

Short-term catheterization

  • Diagnostic
    • Diagnostic sampling (sterile urine sampling)
    • Monitoring urinary output (trauma, critically ill, burns)
    • Filling the bladder prior to pelvic ultrasound
    • Cystogram, cystourethrogram
    • Urine collection
    • Monitoring core body temperature
  • Therapeutic
    • Draining urine in acute urinary retention, urinary obstruction, inability to void
    • Irrigation of bladder to remove gross hematuria and clots/debris
    • Palliative care for terminally ill (e.g.to assist treatment of decubitus ulcers in incontinent patients by maintaining moisture free environment)
    • To warm hypothermic patients
    • Intubated patient
    • Emergency Surgery

Long-term catheterization

  • Bladder outlet obstruction
  • To reduce changes in patients who are terminally ill or cannot care for themselves
  • Neurogenic bladder
  • Urinary incontinence

Contraindications

Absolute

  • Trauma patient presenting with the following signs (known or suspected urethral damage):
    • Blood at meatus
    • Penile deformity
    • High riding prostate
    • Perineal hematoma
  • Allergy to latex, rubber or lubricants

Relative

  • Uncooperative patient
  • Recent bladder or urethral surgery
  • Urethral Stricture

Equipment and Patient Preparation

  • Urinary catheter: Catheters are classified according to the material it is made of, number of lumens and shape of the tip.
    • Number of lumens
      • One way-non balloon also known as straight, Nelaton or Robinson catheters are used for one time or intermittent drainage.
      • Two-way catheters have a balloon inflation channel and a urine drainage channel.
      • Foley catheter, which has a self-retaining balloon, is the most commonly used.
      • The triple lumen (three-way) indwelling catheter is used for bladder irrigation.
    • Shape of Tip
      • Coude or Tieman catheter curves 45 degrees at the tip and is designed to pass urethra in patients with prostatic enlargement; it offers rigidity too.
      • The Whistle Tip (Couvelaire Tip) catheter has a terminal and a lateral drainage eye used for large blood clots.
      • The Roberts tip catheter has an eye above and below the balloon to reduce the residual urine.
    • Catheter size is described in French units. It refers to the catheter’s circumference in millimeters. Start with 12-16 F for adults. Choose the smallest size that is enough for adequate drainage. If obstruction of the catheter due to blood or debris is expected, use a larger bore catheter (e.g., 18-24 F).
    • Catheter length: Adult indwelling catheters are available in a standard (male) length (40-45cm) and a shorter female length (20-26cm). Female length catheters should not be used in male patients because of the risk of inflating the balloon in the urethra.
  • Sterile gloves and drapes
  • Sterile gauze sponge or cotton balls
  • Antiseptic solution (Povidone-iodine or chlorhexidine)
  • Sterile local anesthetic lubricant gel: (% 2 lidocaine gel) anesthetizing the urethra with topical lidocaine gel instilled through a pre-loaded syringe reduces discomfort. The catheter tip is also lubricated prior to its insertion.
  • 10 ml syringe filled with sterile saline or sterile water
  • Sterile urine bag
  • Tape to secure the urine collection system

Procedure Steps

Universal precautions should be taken in all steps. Patient consent should be obtained before starting any procedure. Ensure the privacy of the patient. Aseptic insertion technique is recommended.

Female Patients

  1. Prepare all equipment on a tray covered with a sterile drape in a sterile fashion.
  2. Place the patient in the lithotomy position.
  3. Wear your sterile gloves.
  4. Check the balloon for patency.
  5. Place a fenestrated drape over the perineum.
  6. Spread the labia with your non-dominant hand.
  7. Use the forceps/pickups to hold the sterile sponge, soak it in the antiseptic solution, and clean the area from anterior to posterior and central to peripheral.
  8. Alternatively, you may change gloves after cleansing external genitals.
  9. Lubricate the tip of the catheter with %2 lidocaine gel.
  10. Pass the catheter through the meatus and advance it until the hub meets the urethral meatus, you should be able to see urine flowing. Insert the catheter 2-3 inch or 5-7.5 cm more, preferably until the hub to avoid inflating the balloon inside the urethra.
  11. Inflate the balloon with 10 ml of sterile water or saline using the filling port.
  12. Pull the catheter back until resistance is felt.
  13. Attach the urine collection bag.
  14. Secure the catheter to the anterior thigh.
  15. Remove gloves, dispose of waste appropriately, and wash hands.

Please watch below videos (manikin and patient examples)

Male Patients

  1. Perform step 1 to 4 of female patient catheterization.
  2. Firmly hold the penis with the non-dominant hand, and position the penis 45 to 90 degrees to the coronal plane, apply gentle traction. Retract the foreskin if the pa
  3. tient is not circumcised.
  4. Use the forceps/pickups to hold the sterile sponge, soak it in antiseptic solution and paint the area in a sterile fashion with the antiseptic solution.
  5. Alternatively, you may change gloves after cleansing external genitals.
  6. Inject 10 mL of 2% lidocaine gel into the urethra through the meatus before insertion of the catheter.
  7. Perform step 10-15 of female catheterization.
  8. When the procedure is finished, don’t forget to reduce foreskin to prevent iatrogenic paraphimosis.

Please watch below videos (manikin and patient examples)

Hints and Pitfalls

  • Universal availability and ease of insertion of urinary catheters often lead to the inappropriate and prolonged use of these catheters. Insert catheters only for appropriate indications and leave catheters in place only as long as needed.
  • A tense patient means a tight urethral sphincter; encourage the patients to relax by taking deep breaths and relax urinary sphincter muscles as if going to void.
  • Always be gentle; never force the catheter since this may cause urethral trauma.
  • If no urine has returned, do not inflate the balloon.
  • Even when urine is flowing, it is possible for the eye of the catheter to lie within the bladder while the balloon remains within the prostatic urethra; so, always advance the catheter until the hub.
  • If there is pain during inflation of the balloon, stop immediately since the balloon may still be in the urethra.
  • Once inserted, the catheter should be secured to prevent traction and damage from movement and catheter kinks.
  • Place the urinary drainage bag below the level of the patient’s bladder, not allowing it to touch the floor.
  • For difficult urinary catheterization, change the size: 20-24 F catheter for benign prostate hyperplasia, small caliber for the urethral stricture (12-16 F).
  • If catheterization is unsuccessful, it is best to avoid multiple blind attempts since they increase the risk of infection, exacerbate the patient’s discomfort, and produce urethral congestion and edema, rendering further attempts even more challenging.
  • Patients occasionally experience hypotension and hematuria when the large volume from the bladder is drained rapidly but has little clinical significance, and gradual emptying is not necessary.

Post-Procedure Care and Recommendations

  • Patients’ follow up with urology should be arranged.
  • Discharge instructions:
    • If you develop any symptoms of a urinary tract infection, contact your doctor immediately.
    • Take enough fluids to maintain adequate urine flow.
    • Be careful not to pull the catheter accidentally, avoid twisting and kinking of the catheter.
    • Keep the bag lower than the bladder to prevent back flowing.
    • Avoid disconnecting the catheter and drain tube.
    • Empty the bag regularly. The drainage spout should not touch anything while emptying the bag.
  • Alpha blockers may be started to patients with prostate enlargement.

Complications

  • Discomfort, pain
  • Inability to pass the catheter
  • Misplacement of the catheter
    • Vagina
    • Ureter
    • Renal Pelvis
  • Traumatic complications to lower urinary tract – proper insertion technique is the single most important factor for preventing injury.
    • Passage of the catheter into a false lumen
    • Intraurethral balloon distention
    • Hematuria
    • Rupture of urethra 11 (may cause urethral stricture in the long term) 5
    • Bladder perforation
    • Hydro uterus
    • Paraphimosis
    • Vena cava air embolism
  • Infections: UTI accounts for 32% of all healthcare-associated infections. A majority of these infections are attributable to the use of an indwelling catheter. Use of best practice techniques by emergency nurses can help prevent UTIs from occurring as a result of urinary catheter insertions in the emergency department. Earlier catheter removals, use of smaller bore catheters, a closed drainage system, optimal hygienic techniques (hand-washing, sterile catheterization techniques) by health care workers, and removal of the catheter when infection is suspected are effective in minimizing the incidence of infection.
    • Urinary tract infection
      • Urethritis
      • Prostatitis
      • Epididymoorchitis
      • Cystitis
      • Pyelonephritis
      • Bacteriemia, urosepsis
  • Latex allergies
  • Obstruction or blockage of catheter results from precipitated mucus, protein, crystals, blood clots, and bacteria.

Urine leakage around the catheter

  • Fragmentation or fracture and retainment of the catheter
  • Catheter knotting
  • Balloon rupture
  • Calculi formation
  • Bladder spasms contraction
  • Accidental removal of the catheter
  • Stricture formation in long-term

Pediatric, Geriatric, Pregnant Patients and Other Considerations

  • Use 6-10 F catheters for pediatric patients, 12F for patients age >12 years, 5F for infants
  • Difficult urethral catheterization (DUC) is where the urological consult is requested to insert a urinary catheter. Many causes of DUC have been identified including anxiety, poor technique, urethral stricture, phimosis, bladder neck contracture, false passages, benign prostatic hyperplasia, unfavorable body habitus and patient positioning.
  • To prevent infections:
    • Insert catheters using aseptic technique and sterile equipment
    • Maintain a closed drainage system
    • Maintain unobstructed urine flow

References and Further Reading

  • Ramakrishnan K, Mold J. Urinary Catheters: A Review. The Internet Journal of Family Practice [serial on the Internet]. 2004; 3(2). http://ispub.com/IJFP/3/2/4596. Accessed March 1, 2016.
  • Cravens DD, Zweig S. Urinary catheter management. Am Fam Physician 2000;61:369-76.
  • Highton P, Wren H. Urethral catheterisation (male and female). The Foundation Years. 2008; 4:5.
  • Parker D, Callan L, Harwood J, Thompson DL, Wilde M, Gray M. Nursing interventions to reduce the risk of catheter-associated urinary tract infection. Part 1: Catheter selection. J Wound Ostomy Continence Nurs. 2009;36(1):23-34.
  • Willette PA, Coffield S. Current trends in the management of difficult urinary catheterizations. West J Emerg Med. 2012;13(6):472-8.
  • Manojlovich M, Saint S, Meddings J, Ratz D, Havey R, Bickmann J, Couture C, Fowler KE, Krein SL. Indwelling Urinary Catheter Insertion Practices in the Emergency Department: An Observational Study. Infect Control Hosp Epidemiol. 2016;37(1):117-9.
  • Devine AL. Female catheterisation: what nurses need to know! Accid Emerg Nurs. 2003;11(2):91-5.
  • Kashefi C, Messer K, Barden R, Sexton C, Parsons JK. Incidence and prevention of iatrogenic urethral injuries. J Urol. 2008;179(6):2254-7.
  • Dyc NG, Pena ME, Shemes SP, Rey JE, Szpunar SM, Fakih MG. The effect of resident peer-to-peer education on compliance with urinary catheter placement indications in the emergency department. Postgrad Med J. 2011;87(1034):814-8.
  • Villanueva C, Hemstreet GP 3rd. Difficult male urethral catheterization: a review of different approaches. Int Braz J Urol. 2008;34(4):401-11
  • Buddha S. Complication of urethral catheterisation. Lancet. 2005;365(9462):909.
  • Belizario SM. Preventing urinary tract infections with a two-person catheter insertion procedure. Nursing. 2015 Mar;45(3):67-9.
  • Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31(4):319-26.
  • J Baker KS, Dane B, Edelstein Y, Malhotra A, Gould E. Ureteral rupture from aberrant Foley catheter placement: a case report. Radiol Case Rep. 2013 Jan;7(1):33-40.
  • Bradley A, Sozener C. Incidentally Discovered Foley Catheter Placement Into a Transplanted Kidney. Urology. 2015;86(3):e11-2.
  • Chavez AH, Reilly TP, Bird ET. Vena cava air embolism after traumatic Foley catheter placement. Urology. 2009;73(4):748-9.
  • Burnett KP, Erickson D, Hunt A, Beaulieu L, Bobo P, Shute P. Strategies to prevent urinary tract infection from urinary catheter insertion in the emergency department. J Emerg Nurs. 2010;36(6):546-50.
  • Lo E, Nicolle LE, Coffin SE, Gould C, Maragakis LL, Meddings J, Pegues DA, Pettis AM, Saint S, Yokoe DS. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 May;35(5):464-79. doi: 10.1086/675718.

Links To More Information

  • Thomsen TW, Setnik GS. Videos in clinical medicine: male urethral
    catheterization. N Engl J Med. 2006;354(21):e22.
  • Manzano S, Vunda A, Schneider F, Vandertuin L, Lacroix LE. Videos in clinical medicine: catheterization of the urethra in girls. N Engl J Med 2014;371:e2-e2
  • Lacroix LE, Vunda A, Bajwa NM, Galetto-Lacour A, Gervaix A. Catheterization of the Urethra in Male Children. N Engl J Med 2010; 363:e19
  • Ortega R, Ng L, Sekhar P, Song M. Videos in clinical medicine: female urethral catheterization. NEJM. 2008;358(14):e15.
  • Shlamovitz GZ. Urethral Catheterization in Men. Available from: http://emedicine.medscape.com/article/80716-overview#a4. March 2016.
  • Shlamovitz GZ. Urethral Catheterization in Women. Available from: http://emedicine.medscape.com/article/80735-overview. Accessed March 2016.
  • How to catheterize a male. – theNursePath. https://thenursepath.blog/2016/12/15/how-to-catheterise-a-male/