Urinary Catheterization

Urinary catheterization 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.

Purpose of Urinary Catherization

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

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

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

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

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

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

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

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

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

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

Types of Urethral Catheters and Methods

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 urinary catheterization (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. Advise the patient 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 urinary catheterization (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

This how to perform urinary catheterization. Note that there may be some variations on how to perform the procedure, like some practitioners may add application of lidocaine as an additional step in female urinary catheterization.

Male

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 non-anesthetic 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.

Female

Place all equipment within easy reach on an uncontaminated sterile field on a bedside tray. You may put the box containing the catheter and the drainage system between the patient’s legs, so that it is easily accessible during the procedure.
If not done already, attach the catheter to the collection system and do not break the seal unless a different type or size of catheter is required.
Test the retention balloon for leaks by inflating it with water.
Apply lubricant to the tip of the catheter.
Saturate the applicator swabs, cotton balls or gauze with povidone iodine.
Place the sterile fenestrated drape over the pelvis so that the vulva is exposed.
Gently spread the labia and expose the urethral meatus, using your nondominant hand. This hand is now contaminated and must not be removed from the labia or touch any of the equipment during the rest of the procedure.
Cleanse the area around the meatus with each cotton ball saturated in povidone iodine. Use a circular motion, beginning at the meatus and working your way outward. Discard or set aside the newly contaminated gauze or cotton balls.
Hold the lubricated catheter and gently pass it through the urethra, using your free hand. Urine should flow freely into the collection tubing. If the catheter accidentally passes into the vagina, it should be discarded and a new catheter used.
Inflate the balloon with the recommended volume of water, usually 10 mL. Resistance or pain may indicate that the balloon is in the urethra and not the bladder. If so, deflate the balloon, then insert it all the way before reinflation.
Pull the balloon up snug against the bladder neck, after the balloon has been inflated, by slowly withdrawing the catheter until resistance is felt.

How to care for a Catheter

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.

Nursing Interventions

Nursing interventions play a crucial role in preventing and managing complications associated with urinary catheterization. These interventions aim to maintain a closed drainage system, promote hygiene, and prevent catheter-associated urinary tract infections (CAUTIs). Here's a comprehensive overview of nursing interventions in urinary catheterization:

Pre-Catheterization Interventions:

Assess the Need for Catheterization: Evaluate whether urinary catheterization is truly necessary, considering alternative methods of urine drainage.
Obtain Informed Consent: Explain the procedure, risks, and benefits to the patient and obtain informed consent before catheter insertion.
Gather Supplies: Prepare all necessary sterile equipment, including the appropriate catheter size, lubricant, catheter insertion kit, drainage bag, and securement device.
Perform Hand Hygiene: Practice thorough hand hygiene before and after the procedure.

Catheter Insertion Technique:

Position the Patient: For females, the dorsal recumbent position is preferred, while for males, the supine position is recommended.
Maintain Patient Privacy: Ensure adequate privacy during the procedure.
Cleanse the Perineal Area: Cleanse the perineal area using a single-use antiseptic wipe, following a front-to-back motion to prevent bacterial spread.
Don Sterile Gloves: Wear sterile gloves to maintain a sterile field.
Apply Lubricant: Apply a sterile lubricant to the catheter tip to ease insertion and reduce discomfort.
Insert the Catheter: Gently insert the catheter into the urethral meatus, following the proper anatomical path.
Inflate the Balloon: Inflate the balloon with sterile water to the recommended volume, ensuring proper positioning within the bladder.
Secure the Catheter: Secure the catheter to the leg or thigh using a securement device to prevent dislodgement.

Post-Catheterization Care:

Maintain a Closed Drainage System: Keep the drainage bag below the level of the bladder to prevent urine backflow.
Secure the Drainage Bag: Secure the drainage bag to the bed frame or leg to prevent accidental disconnection.
Document Catheter Insertion: Document the details of catheter insertion, including the catheter type, size, and insertion date and time.
Monitor Urine Output: Monitor urine output regularly to ensure adequate bladder function.
Maintain Catheter Hygiene: Clean the insertion site daily with sterile water or antiseptic wipes.
Assess for Complications: Be vigilant for signs of complications, such as pain, bleeding, or urinary tract infection.

Catheter Removal:

Assess the Need for Catheter Continuation: Regularly evaluate whether catheter removal is indicated.
Prepare for Removal: Gather necessary supplies, including sterile gloves, lubricant, and a container for urine disposal.
Deflate the Balloon: Gently deflate the balloon using the release valve.
Withdraw the Catheter: Slowly withdraw the catheter, applying gentle traction.
Clean the Perineal Area: Cleanse the perineal area with sterile water or antiseptic wipes.
Document Catheter Removal: Document the details of catheter removal, including the date and time.
Monitor Post-Catheterization Status: Monitor the patient for signs of urinary retention or discomfort after catheter removal.
Provide Patient Education: Educate the patient on self-care measures after catheter removal, including proper hygiene and monitoring for signs of infection.