URETHRAL CATHETERISATION

Temporary catheterisation

• To relieve acute retention of urine
• To improve pelvic access during surgery
• To measure urine output during and after major surgery and during major illnesses
• Following major trauma
• if there is blood at the tip of the penis or significant pelvic fracture, seek urology opinion before catheterisation

Long-term catheterisation

• Male patients with urinary retention and prostatic hypertrophy who are unfit for prostatectomy
• Patients with neurological problems if intermittent self-catheterisation not feasible
• e.g. multiple sclerosis, myelodysplasia or spinal cord injury
• In elderly or severely incapacitated incontinent patients as a last resort

• Previous radical prostatectomy. A urologist must catheterise
• urethral damage can easily occur
• Suspected urethral injury after pelvic trauma. Refer to urologist
• Blood at the tip of the penis. Seek urology advice
• Urinary tract infection. Avoid catheter if possible

• Sterile gloves
• Sheet of water-repellent paper with hole cut in centre
• Dressing pack with cotton balls, gauze swabs, gallipots
• Skin antiseptic
• Tube of lidocaine/chlorhexidine gel
• Appropriate urethral catheter. See Choice of catheter
• 10 mL syringe filled with sterile water
• Kidney dish
• Measuring jug
• Drainage bag

Choice of catheter

• Use catheter appropriate to task for which it is required
• Some female catheters are shorter than standard catheters
• do not use in men as balloon will damage urethra

Length of use

• Short-term (no more than 14 days), use ordinary latex catheter
• Longer term (more than 14 days), use silicone (Silastic) catheter with inflatable balloon

Diameter

• 12F or 14F usually suitable for women
• 14F or 16F usually suitable for men

Infection control

• Use silver-coated catheters for short period of catheterisation only
• not effective after approximately 5–7 days
• Consider for:
• critical care patients
• renal patients
• patients colonised with multi-resistant organism
• recommended by infection prevention and control team

• If not competent in procedure, organise supervision by a clinician experienced in the procedure 

Consent

• Explain procedure and reassure patient
• Obtain and record consent

Male catheterisation

Preparation

• Lay patient supine
• Open sterile pack
• Don sterile gloves
• Assistant opens catheter, syringe, and antiseptic/sodium chloride 0.9% onto pack
• Unless using pre-filled syringe, operator draws up water into syringe and keeps sterile
• Place sterile towel to protect area
• Use left hand to hold penis and right hand to insert catheter
• Clean penis with swab soaked in sodium chloride 0.9% or antiseptic
• retract prepuce as necessary and clean glans
• Massage lidocaine/chlorhexidine gel carefully down urethra to sphincter
• Gently compress distal urethra to prevent gel escaping
• Before proceeding to catheterisation, allow at least 5 min to elapse in a conscious patient

Procedure

• If procedure difficult or painful, or bleeding occurs, abandon procedure
• Hold penis vertically at commencement of catheterisation
• As catheter advanced into bladder, gradually pull penis downwards to straighten urethra and to align catheter with prostatic urethra
• urine will begin to drain if present
• After urine starts to drain, advance catheter another 4 cm
• Inflate catheter balloon with 5–10 mL water
• this should not cause any pain or bleeding
• Connect catheter bag
• Gently withdraw catheter until there is resistance
• Replace prepuce (if present) to avoid danger of paraphimosis

Female catheterisation

Preparation

• Lay patient supine
• Place patient’s thighs apart, knees flexed and feet together
• Open sterile pack
• Don sterile gloves
• Assistant opens catheter, syringe, and antiseptic/sodium chloride 0.9% onto pack
• Unless using pre-filled syringe, operator draws up water into syringe and keeps sterile
• Place sterile towel to protect area
• Part labia to reveal urethral meatus
• disinfect meatus with an antiseptic swab
• As female urethra is short, expect to use one third as much anaesthetic gel as would be required in a male patient
• Insert nozzle of lidocaine/chlorhexidine gel into meatus and instil 4–5 mL of gel
• Before proceeding to catheterisation, allow at least 5 min to elapse in a conscious patient

Procedure

• Part labia to reveal meatus and insert catheter until urine clearly draining
• catheter will usually pass without difficulty
• Inflate balloon with 5–10 mL water
• Connect catheter bag

Urethral

Failure of catheter to reach bladder

• Obtain specialist help
• Do not make further attempts

Bleeding

• Occurs particularly if catheter inflated in urethra
• Remove catheter. Contact urologist 

Obstructive renal failure

• Occurs in patients with chronic retention of urine
• Catheterisation followed by a spectacular post-obstructive diuresis
• profound metabolic consequences
• Be prepared to start an IV infusion
• patients may not be able to drink enough to replace their fluid losses
• Contact urology team
• best managed by urology as inpatients

• Record volume of urine that drains after catheter inserted
• Unless patient has evidence of sepsis, do not send any urine to microbiology
• not processed without a strong indication

• Connect catheter to a closed drainage bag that is emptied as necessary
• If system has to be opened (e.g. to change bag or to wash out clots occluding catheter), full sterile precautions essential

Infection risk

• Remove catheter ASAP to minimise risk of infection, especially ESBL
• An indwelling catheter almost always leads to bacteriuria within 2 weeks
• When bacteriuria established, even the most intensive antimicrobial treatment is unlikely to make urine sterile until catheter removed or replaced
• Without clinical evidence of infection, bacteriuria associated with an indwelling catheter does not require antimicrobial treatment 

Bacteraemia or septicaemia

• May be caused by overmanipulation
• As soon as suspected, give fluids IV and broad spectrum antimicrobial effective against Gram-negative organisms. See Antimicrobial guidelines

Irritation and leakage

• Bladder irritation can produce severe and painful bladder spasms
• can cause bypassing of urine alongside the catheter
• try reducing amount of fluid in balloon, or use smaller or less rigid catheter
• If there is leakage around catheter, it is futile to replace with a larger one
• commits patient to a spiral of increasing catheter size
• urethra becomes steadily more dilated until it can retain no catheter

Suspected blocked catheter

Blood clots

• Effective bladder washout for blood clots is a specialised technique. Refer to urology

Not blood clots

• Use a 50 mL catheter syringe to pass 20–30 mL water or sodium chloride 0.9%
• if catheter drainage not achieved, refer to urology

• Lay patient supine
• Don clean gloves
• Take 10 or 20 ml empty sterile syringe
• Deflate catheter balloon using the empty syringe and gently remove catheter
• Do not cut catheter

Complications

Failure to deflate balloon

• If catheter balloon fails to deflate, do not try to burst it by overdistension
• bladder may burst first
• Try aspirating with syringe applied more firmly to balloon port, ensure there is no kink in the catheter
• If it fails to deflate after few attempts, contact urology team

Severe pain

• Make sure patient is supine, balloon is fully deflated and there is no resistance while removing it
• If pain persists, contact urology team for advice