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Urinary Catheterization



A Tiemann-type catheter installed for a male doll in an exercise.

A Tiemann-type catheter installed for a male doll in an exercise.

Urinary or Urethral catheterization is a process in which a urinary catheter (such as a Foley catheter) is either inserted through a female patient’s urinary tract into their bladder or attached to a male patient’s penis. In this manner, the patient’s urine is collected and contained for various medical purposes. The procedure of catheterization will usually be done by a clinician, often a nurse, although self-catheterization is possible as well.

Urinary catheterization is a routine medical procedure that has both diagnostic and therapeutic purposes.

Contents

Purpose
Indication
Contraindication
Types of Catheter
Sex Differences
Equipment
Anesthesia
Pearls
Open Section
Positioning
Methods
Technique
How to care for a Catheter
Complications
Videos
References

Purpose

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Urinary catheters are used to drain the bladder. Health care providers may recommend a catheter for short-term or long-term use because of the following reasons:

  • Urinary incontinence (leakage of urine or the inability to control when urinating)
  • Urinary retention (being unable to empty the bladder when need to)
  • Surgery that made a catheter necessary, such as prostate or gynecological surgery
  • Other medical conditions such as multiple sclerosis, spinal cord injury, or dementia

Indication

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Diagnostic

  • Collection of uncontaminated urine specimen
  • Monitoring of urine output
  • Imaging of the urinary tract

Therapeutic

  • Acute urinary retention (eg, benign prostatic hypertrophy, blood clots)
  • Chronic obstruction that causes hydronephrosis
  • Initiation of continuous bladder irrigation
  • Intermittent decompression for neurogenic bladder
  • Hygienic care of bedridden patients

Contraindication

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Urinary catheterization is contraindicated in the presence of traumatic injury to the lower urinary tract (eg, urethral tear). This condition may be suspected in male patients with a pelvic or straddle-type injury. Signs that increase suspicion for injury are a high-riding or boggy prostate, perineal hematoma, or blood at the meatus. When any of these findings are present in the setting of concerning trauma, a retrograde urethrogram should be performed to rule out a urethral tear prior to placing a catheter into the bladder.

Types of Catheter

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Catheters come in many sizes, materials (latex, silicone, Teflon), and types (Foley, straight, coude tip). A Foley catheter, for example, is a soft, plastic or rubber tube that is inserted into the bladder to drain the urine.

In general, the smallest possible catheter will be used. Some people may need larger catheters to control urine leakage around the catheter or if the urine is thick and bloody or contains large amounts of sediment.

There are three main types of catheters:

  • Indwelling catheter
  • Condom catheter
  • Intermittent (short-term) catheter

Sex Differences

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In males, the catheter tube is inserted into the urinary tract through the penis. A condom catheter can also be used. In females, the catheter is inserted into the urethral meatus, after a cleansing using povidone-iodine. The procedure can be complicated in females due to varying layouts of the genitalia (due to age, obesity, Female genital cutting, childbirth, or other factors), but a good clinician should rely on anatomical landmarks and patience when dealing with such a patient.

Equipment

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Commercial single-use urethral catheterization tray

  • Povidone iodine
  • Sterile cotton balls
  • Water-soluble lubrication gel
  • Sterile drapes
  • Sterile gloves
  • Urethral catheter
  • Prefilled 10-mL saline syringe
  • Urinometer connected to a collection bag

Sterile anesthetic lubricant (eg, lidocaine gel 2%) with a blunt tip urethral applicator or a plastic syringe (5-10 mL)

Anesthesia

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Topical anesthesia is administered with lidocaine gel 2%. Many facilities have a preloaded syringe with an opening appropriate for insertion into the meatus available either separately or in the catheter kit. To instill, hold the penis firmly and extended, place the tip of the syringe in the meatus, and apply gentle but continuous pressure on the plunger.

Pearls

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Insertion of a Coudé catheter: The Coudé catheter, which has a stiffer and pointed tip, was designed to overcome urethral obstruction that a more flexible catheter cannot negotiate (eg, patients with benign prostatic hypertrophy). To place a Coudé catheter, follow the procedure described above. The elbow on the tip of the catheter should face anteriorly to allow the small rounded ball on the tip of the catheter to negotiate the urogenital diaphragm.

Perineal pressure assistance: The distal tip of the catheter might become caught in the posterior fold between the urethra and the urogenital diaphragm. An assistant can apply upward pressure to the perineum while the catheter is advanced to direct the catheter tip upward through the urogenital diaphragm.

Open Section

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Prophylactic antibiotics are recommended for patients with prosthetic heart valves, artificial urethral sphincters, or penile implants.

Catheter types and sizes

o Adults: Foley (16-18 F)
o Adults with obstruction at the prostate: Coudé (18 F)
o Children: Foley (5-12 F)
o Infants younger than 6 months: Feeding tube (5 F) with tape

Positioning

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Place the patient supine, in the frogleg position, with knees flexed.

Methods

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Indwelling Urethral Catheters

An indwelling urinary catheter is one that is left in place in the bladder. Indwelling catheters may be needed for only a short time, or for a long time. These catheters attach to a drainage bag to collect urine. A newer type of catheter has a valve that can be opened to allow urine to flow out, when needed. An indwelling catheter may be inserted into the bladder in two ways:

  • Most often, the catheter is inserted through the urethra, which is the tube that brings urine from the bladder to the outside of the body
  • Sometimes, the doctor will insert a tube, called a suprapubic catheter, into the bladder from a small hole in the patient’s belly. This is done as an outpatient surgery or office procedure.

An indwelling catheter has a small balloon inflated on the end of it. This prevents the catheter from sliding out of the body. When it’s necessary to remove the catheter, the balloon is deflated.

Condom Catheters

Condom catheters are most frequently used in elderly men with dementia.There is no tube placed inside the penis. Instead, a condom-like device is placed over the penis. A tube leads from this device to a drainage bag. The condom catheter must be changed every day.

Intermittent (Short-Term) Catheters

Some people only need to use a catheter on occasion. Short-term, or intermittent, catheters are removed after the flow of urine has stopped.

How to perform (Men):

1. Assemble all equipment: catheter, lubricant, drainage receptacle (container).
2. Wash your hands thoroughly with soap and water and clean the penis and opening of the urethra.
3. Lubricate the catheter.
4. Hold the penis on the sides, perpendicular to the body.
5. Begin to gently insert and advance the catheter.
6. You will meet resistance when you reach the level of the prostate. Try to relax by deep breathing, and continue to advance the catheter.
7. Once the urine flow starts, continue to advance the catheter another 1 inch. Hold it in place until the urine flow stops and the bladder is empty.
8. Remove the catheter in small steps to make sure the entire bladder empties.
9. Wash the catheter with soap and water. If the catheter is disposable, discard it right away. If it is reusable, rinse the catheter completely and dry the outside. Store the catheter in a clean, dry, secure location.
10. Record the amount of urine obtained, as instructed by your health care provider.

How to perform (Women):

1. Assemble all equipment: catheter, lubricant, drainage receptacle.
2. Wash your hands thoroughly with soap and water and clean the vulva and opening of the urethra.
3. Lubricate the catheter.
4. Locate the urethral opening. The opening is located below the clitoris and above the vagina.
5. Spread the lips of the vagina (labia) with the second and fourth finger, while using the middle finger to feel for the opening.
6. Begin to gently insert the catheter into the opening. Guide it upward as if toward the belly button.
7. Once the catheter has been inserted about 2 – 3 inches past the opening, urine will begin to flow.
8. Once the urine flow starts, continue to advance the catheter another 1 inch and hold it in place until the urine flow stops and the bladder is empty.
9. Withdraw the catheter in small steps to make sure the entire bladder empties.
10. Wash the catheter with soap and water. If the catheter is disposable, discard it right away. If it is reusable, rinse the catheter completely and dry the outside. Store the catheter in a clean, dry, secure location.
11. Record the amount of urine obtained, as instructed by your health care provider.

Some women may perform the procedure standing up with one foot on the toilet. This position is also recommended when there is a question about the cleanliness of the toilet, such as in public facilities.

The catheter may be reuse for 2 – 4 weeks. It may be helpful to soak the catheter in a white vinegar solution once a week to control odor and remove thick mucus deposits. The health care provider may recommend other cleaning or sterilization techniques if infections often occur.

Drainage Bags

A catheter is usually attached to a drainage bag. There are two types:

  • A leg bag is a smaller drainage device that attaches by elastic bands to the leg. It is usually worn during the day, because it fits discreetly under pants or skirts. It is easily emptied into the toilet.
  • A down drain is a larger drainage device. It may be used during the night. This device is hung on the bed or placed on the floor.

The drainage bag must always stay lower than the bladder to prevent urine from flowing back up into the bladder. Empty the drainage device at least every 8 hours, or when it is full.

Some experts recommend cleaning the drainage bag periodically. Remove the drainage bag from the catheter (attach the catheter to a second drainage device during the cleaning).

Cleanse and deodorize the drainage bag by filling the bag with two parts vinegar and three parts water. You can substitute chlorine bleach for the vinegar and water mixture. Let this solution soak for 20 minutes. Hang the bag with the outlet valve open to drain and dry the bag.

Technique

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Note: This technique is for male urethral catheterization, refer to the video for the female urethral catheterization.

· Explain the procedure, benefits, risks, complications, and alternatives to the patient or the patient’s representative.

· Position the patient supine, in bed, and uncover the genitalia.

· Open the catheter tray and place it on the gurney in between the patient’s legs; use the sterile package as an extended sterile field. Open the iodine/chlorhexidine preparatory solution and pour it onto the sterile cotton balls. Open a sterile lidocaine 2% lubricant with applicator or a 10-mL syringe and sterile 2% lidocaine gel and place them on the sterile field.

· Wear sterile gloves and use the nondominant hand to hold the penis and retract the foreskin (if present). This hand is the nonsterile hand and holds the penis throughout the procedure.

· Use the sterile hand and sterile forceps to prep the urethra and glans in circular motions with at least 3 different cotton balls. Use the sterile drapes that are provided with the catheter tray to create a sterile field around the penis.

· Using a syringe with no needle, instill 5-10 mL of lidocaine gel 2% into the urethra. Place a finger on the meatus to help prevent spillage of the anesthetic lubricant. Allow 5-10 minutes before proceeding with the urethral catheterization.

· Hold the catheter with the sterile hand or leave it in the sterile field to remove the cover. Apply a generous amount of the nonanesthetic lubricant that is provided with the catheter tray to the catheter.

· While holding the penis at approximately 90º to the gurney and stretching it upward to straighten out the penile urethra, slowly and gently introduce the catheter into the urethra. Continue to advance the catheter until the proximal Y-shaped ports are at the meatus.

· Wait for urine to drain from the larger port to ensure that the distal end of the catheter is in the urethra. The lubricant jelly–filled distal catheter openings may delay urine return. If no spontaneous return of urine occurs, try attaching a 60-mL syringe to aspirate urine. If urine return is still not visible, withdraw the catheter and reattempt the procedure (preferably after using ultrasonography to verify the presence of urine in the bladder).

· After visualization of urine return (and while the proximal ports are at the level of the meatus), inflate the distal balloon by injecting 5-10 mL of 0.9% NaCl (normal saline) through the cuff inflation port. Inflation of the balloon inside the urethra results in severe pain, gross hematuria, and, possibly, urethral tear.

· Gently withdraw the catheter from the urethra until resistance is met. Secure the catheter to the patient’s thigh with a wide tape. Creating a gutter to elevate the catheter from the thigh may increase the patient’s comfort. If the patient is uncircumcised, make sure to reduce the foreskin, as failure to do so can cause paraphimosis.

How to care for a Catheter

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To care for an indwelling catheter, cleanse the urethral area (where the catheter exits the body) and the catheter itself with soap and water every day. Also thoroughly cleanse the area after all bowel movements to prevent infection.

If you have a suprapubic catheter, the opening in your belly and the tube must be cleansed daily with soap and water, then covered with dry gauze.

Drinking plenty of fluids can help prevent infections.

Wash hands before and after handling the drainage device. Do not allow the outlet valve to touch anything. If the outlet becomes obviously dirty, clean it with soap and water.

Some people have occasional leakage of urine around the catheter. This may be caused by a catheter that is too small, improper balloon size, constipation, urinary tract infections, or bladder spasms.

If bladder spasms occur or there is no urine in the drainage bag, the catheter may be blocked by blood or thick sediment. Or, there may be a kink in the catheter or drainage tubing. Sometimes spasms are caused by the catheter irritating the bladder. Such spasms can be controlled with medication, although most patients eventually adjust to the irritation and the spasms go away. Irrigating (or flushing) the catheter may help reduce spasms.

Complications

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  • Urethritis
  • Cystitis
  • Pyelonephritis
  • Transient bacteremia
  • Paraphimosis, caused by failure to reduce the foreskin after catheterization
  • Creation of false passages
  • Urethral strictures
  • Urethral perforation
  • Bleeding

Videos

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Male Urethral Catheterization Tutorial


References

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1. Moy ML, Wein AJ. Additional therapies for storage and emptying failure. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Sauders Elsevier; 2007: chap 70.

2. Wierbicky J, Nesathurai S. Spinal cord injury (thoracic). In: Frontera WR, Silver JK, Rizzo Jr TD, eds. Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, Pa: Saunders Elsevier; 2008: chap 147.

3. “Medline Plus Medical Encyclopedia, Clean intermittent self-catheterization

4. Selius BA, Subedi R. Urinary retention in adults: diagnosis and initial management. Am Fam Physician. 2008;77:643-650.

5. “Medline Plus Medical Encyclopedia, Urinary Catheters”

6. Garbutt, R. B., McD Taylor, D., Lee, V. and Augello, M. R. (2008), Delayed versus immediate urethral catheterization following instillation of local anaesthetic gel in men: A randomized, controlled clinical trial. Emergency Medicine Australasia, 20: 328–332. doi: 10.1111/j.1742-6723.2008.01105.x

Last updated on September 24, 2010

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11 Responses to “Urinary Catheterization”

  • markee says:

    thanks, it was really helpful

  • This is a wonderful summary, I discovered your webpage doing research aol for a related subject matter and arrived to this. I couldnt get to much different details on this blog post, so it was pleasant to find this one. I likely will be back again to look at some other posts that you have another time.

  • Julie says:

    Very helpful- thanks for giving us a real human model!

  • van says:

    2 to 3 minutes is not enough time for the anesthetic to take effect. A recent Australian study looked at its effectiveness when instilled 2 minutes before catheter insertion and found that it did not decrease the amount of pain experienced by the patient. The recommended time is at least 5 and up to 10 minutes. A hyams clamp can be used to keep the anesthetic in place. If you wait just 2 minutes, there is no need for the lidocaine–it won’t do anything.

  • Can you please provide us the link to the new study? We need a reference before we can update. Thanks for letting us know…

  • van says:

    Emergency Medicine Australia
    Volume 20 (#4)
    pages 328-332
    08/08

    also you can go to google and type in “Australia Urethral Catheterization”

    Thank you

    Campbell-Welsh Urology–a medical textbook–is also a good source.

  • Thanks… the article has been updated. Much appreciated.

  • Alice Behr says:

    I care for a spinal cord injured male patient, and almost any contact with his penis causes a spontaneous erection, even routine perineal washing or adjusting the sheets. This causes difficulty inserting a catheter, which causes discomfort for him, and concerns me. It took some time for me to be comfortable dealing with a a male with reflexive erections in general, but now I am concerned because I feel a lot more resistance inserting a catheter into him than with most male patients, particularly during the last few inches – I’m assuming that this involves his prostate and/or urogenital diaphragm. Do you have any suggestions or tips? As he doesn’t have normal sensation below his shoulders (C4-5 injury), I have considered many things, including manually inducing an orgasm to allow his penis to become flaccid, but I’m not sure that would be appropriate, or even helpful. I’ve tried waiting up to 15-20 minutes after inserting the lidocaine gel, but the erections are quite persistent – Any ideas, suggestions, or tips would be greatly appreciated!
    Thank you,
    Ali

  • Michael says:

    Hello Alice. I think the suggested time for catheter insertion is 5-10 mins. And also, it’s kind of weird because the erections actually facilitates the insertion, not the other way around.

    There might be something clogging in there or it’s also possible that it may be psychological. Have you told the patient to relax?

    Be sure to clean off any excess jelly also because it will dry up and cause rough spots on the catheter. If the catheter has rough spots from dried soap or jelly, and an erection occurs, it will feel like sandpaper and thus cause discomfort to the patient.

  • Thanks for the videos, was very helpful!

  • cutty says:

    tnx it really helpx me on my assignment

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