Urethral Catheterization

• Catheterization was developed in the 1920s by Dr. Frederick Foley.
• The urinary catheter was originally an open system, with the urethral tube draining into an open container.
• In the 1950s, a closed system was developed in which urine flowed through a catheter into a closed bag.
• Catheterization of the urinary bladder involves the insertion of a hollow tube into the bladder to remove urine. It is an aseptic procedure requiring sterile equipment.
• Urethral Catheterization is the process of passing a hollow tube through the urethra and advancing its tip into the base of the bladder.

Purpose of Catheterization

• Relieve urinary retention.
• Obtain a sterile urine specimen from a female patient.
• Measure residual urine.
• Empty the bladder before, during, or after surgery.
• Allows accurate measurement of urine output.

Urethral catheterization is a routine medical procedure, and the catheter may be inserted as:

• An in and out procedure for immediate drainage
• Left indwelling for long-term drainage in patients with chronic urinary retention

Diagnostic Indications

• Measurement of Urinary Output:
  • Critical monitoring of urine output in critically ill patients for accurate fluid balance assessment.
  • Intraoperative urine monitoring during major surgeries, especially in high-risk or lengthy procedures.
• Collection of Sterile Urine Samples:
  • Required when there is a risk of contamination from a midstream sample, especially for microbiological analysis.
• Measurement of Post-Void Residual Volume:
  • Useful in assessing bladder function, particularly in cases of suspected bladder outlet obstruction or detrusor underactivity.
• Radiologic Imaging and Urodynamic Studies:
  • Necessary for procedures like cystourethrograms and urodynamic studies requiring contrast administration or precise visualization of the urinary tract.

Therapeutic Indications

• Relief of Urinary Retention:
  • Acute urinary retention due to conditions like benign prostatic hyperplasia or urethral stricture.
  • Chronic urinary retention causing bladder dysfunction or discomfort.
  • Neurogenic bladder that fails to empty adequately.
• Bladder Decompression:
  • Pre- or post-surgical decompression of the bladder, particularly in surgeries involving the lower urinary tract or neighboring organs.
  • Prevention of bladder injury during extended surgeries, especially pelvic or abdominal procedures.
• Administration of Medications:
  • Direct instillation of medications into the bladder, such as chemotherapy for bladder cancer or antibiotic irrigation for bladder infections.
• Management of Incontinence in Specific Situations:
  • In palliative care where incontinence management is challenging and poses risks for skin breakdown.
  • Severe neurologic disorders causing refractory incontinence unresponsive to other management strategies.

• Suspected or Known Urethral Trauma:
  • Blood at the Meatus: A clear sign of potential urethral injury, often seen in cases of pelvic fractures.
  • Perineal Hematoma: Bruising in the perineal area can suggest an underlying injury to the urethra.
  • High-Riding Prostate: On rectal examination, a high-riding prostate may indicate urethral disruption following trauma.
  • Gross Hematuria: Visible blood in the urine may signal significant trauma to the urethra or bladder.
• Infectious and Inflammatory Conditions:
  • Evidence of Urethral Infection: Inserting a catheter in the presence of urethritis or other infections can worsen the infection and lead to complications.
  • Acute Prostatitis: Catheterization in cases of bacterial prostatitis risks spreading the infection and may lead to septicemia.
• Urethral Stricture: Narrowing of the urethra, which could make catheter insertion difficult or traumatic, increasing the risk of urethral injury.
• Patient Refusal: Respect for the patient's autonomy is crucial; catheterization should not be performed if the patient refuses, unless it's an emergency situation where consent is not feasible.
• Urethral Discomfort: Significant discomfort during attempted insertion may indicate anatomical or pathological barriers, suggesting the need for alternative approaches.
• Recent Urethral Surgery or Reconstruction:
  • Catheterization in patients with recent urethral surgery could disrupt healing and lead to complications in the postoperative period.

Based on Duration

• Indwelling Catheter (Foley Catheters):
  • Designed for continuous drainage, usually left in place for extended periods (e.g., days to weeks).
  • Commonly used in hospitalized patients or those requiring long-term urinary management.
• External Catheter:
  • Also known as a condom catheter, this type is typically used in males and is externally attached to the penis to collect urine.
  • It is a non-invasive alternative to internal catheters, often used for patients with temporary incontinence.
• Intermittent Catheter:
  • Also known as a "short-term" or "self-catheterization" catheter.
  • Inserted intermittently to drain the bladder and then removed, typically used in patients with neurogenic bladder or those who need occasional bladder emptying.

Based on Composition

• Silicone Catheters:
  • Biocompatible and less likely to cause irritation.
  • Preferred for long-term use due to their durability and reduced risk of encrustation.
• Latex Catheters:
  • Commonly used but may cause allergic reactions in some individuals.
  • More affordable than silicone but less durable for long-term use.
• PVC (Polyvinyl Chloride) Catheters:
  • Rigid, clear catheters often used for short-term catheterization.
  • Less flexible than silicone and latex, making them more suitable for intermittent use.

Coatings

• Teflon Coating: Reduces friction, making insertion easier and decreasing the risk of tissue irritation.
• Hydrogel Coating: Hydrophilic coating that absorbs water to create a smooth, lubricated surface, enhancing comfort during insertion and reducing friction.
• Antimicrobial/ Latex with Silicon Elastomer Coating: Catheters with antimicrobial coatings help prevent infection, making them suitable for long-term use.

Catheter Sizes and Types for Different Populations

Adults:

• Foley Catheter (Straight Tip): Commonly used in adults, with a typical size range of 16-18 Fr.
• For Males with Prostatic Obstruction: A Coudé tip catheter (18 Fr) is often used to navigate around prostatic enlargement.
• For Gross Hematuria: A Foley catheter (20-24 Fr) or a 3-way irrigation catheter (20-30 Fr) is used for managing large volumes of blood in the urine.

Children:

• Foley Catheter: Size is based on age. A simple formula to determine size is to divide the child's age by 2 and add 8. For example:
  • A 4-year-old child: (4/2) + 8 = 10 Fr catheter.
• Infants Younger Than 6 Months: A Feeding Tube (5 Fr) may be used as an alternative catheter for infants due to their small size and delicate anatomy.

Commonly Used Sizes:

• Females (Adults): 14 Fr is the most commonly used catheter size for female patients.
• Males (Adults): 16 Fr is commonly used for male patients.
• Adolescents: 14 Fr is often appropriate for adolescent patients.
• Younger Children: 6-12 Fr is preferred for younger children to minimize discomfort and potential injury.

Role in Urinary Function

• The urethra is involved in the passage of urine from the bladder to the exterior of the body.
• Urine produced by the kidneys travels through the ureters into the bladder, where it is stored until it is ready to be excreted.

Muscle Control of Urinary Drainage

• Three sets of muscles control the drainage of urine from the bladder into the urethra:
1. Involuntary Internal Sphincter: Controls the involuntary release of urine.
2. Voluntary External Sphincter: Allows for voluntary control over urination.
3. Pelvic Floor Muscles: Support and contribute to the control of urinary flow.

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Male Urethra

• The male urethra is a narrow fibromuscular tube that serves dual functions:
1. Urinary function: Conducts urine from the bladder to the exterior.
2. Reproductive function: Conducts semen from the ejaculatory ducts to the exterior during ejaculation.
• The male urethra is composed of three distinct segments:
1. Prostatic Urethra: Passes through the prostate gland.
2. Membranous Urethra: A short segment that passes through the pelvic floor muscles.
3. Spongy (Penile) Urethra: Runs through the penis and is the longest section of the male urethra.

Female Urethra

• The female urethra is relatively short, approximately 4 cm in length, compared to the male urethra.
• The urethra opens onto the perineum in the vestibule between the labia minora.
• The urethral orifice is located anteriorly to the vaginal opening and is approximately 2-3 cm posteriorly to the clitoris.

Considerations for Urethral Catheterization

• Prophylactic Antibiotics:
  • Prophylactic antibiotics are recommended for patients at higher risk of infection, including those with:
  • Prosthetic heart valves
  • Artificial urethral sphincters
  • Penile implants
• Maximal Volume for Balloon Inflation:
  • The maximal recommended volume for urethral balloon inflation is typically 10-30 mL. This volume can usually be found on the inflation valve of the catheter.
  • Overinflation can cause injury to the urethra or bladder.

The following items are essential for performing urethral catheterization, ensuring the procedure is conducted safely, with minimal discomfort, and maintaining sterile technique:

• Catheter:
  • Foley Catheter: The most commonly used indwelling catheter, available in various sizes (e.g., 14-18 Fr for adults).
  • Intermittent Catheter: For short-term use and self-catheterization.
  • Coudé Catheter: For patients with prostate enlargement or obstruction.
• Sterile Gloves: To maintain an aseptic technique and minimize the risk of infection.
• Lubricating Jelly: Sterile, water-soluble lubricant to reduce friction and ease catheter insertion, minimizing discomfort.
• Antiseptic Solution: Povidone-iodine or chlorhexidine to clean the urethral opening and surrounding skin, reducing the risk of infection.
• Cotton Balls or Gauze Pads: Used for cleaning and wiping the genital area before and during the procedure, as well as to absorb excess antiseptic solution.
• Sterile Drape: Used to maintain a sterile field and cover the patient’s genital area during the procedure.
• Syringe for Balloon Inflation: A 10-30 mL syringe used for inflating the catheter’s balloon (in the case of indwelling Foley catheters) to hold it in place within the bladder.
• Collecting Bag: A urine collection bag for draining the urine once the catheter is inserted. It may be a leg bag (for ambulatory patients) or a drainage bag (for patients lying in bed).
• Sterile Tray: A sterile tray to hold all necessary equipment and ensure it remains clean and sterile during the procedure.
• Scissors: Used to cut tape or other materials, such as when securing the catheter or adjusting the collection bag.
• Urinary Drainage System (if applicable): A drainage bag or leg bag for collecting urine after catheter insertion.
• Mouth Mask and Eye Protection (optional): For healthcare workers in high-risk settings or to protect from bodily fluid exposure during the procedure.
• Assistant: An assistant to help with patient positioning, maintaining a sterile field, and assisting in coordinating the procedure.

Preparation and Patient Assessment

• Explain the Procedure: Inform the patient about the procedure, its purpose, and what to expect. Answer any questions and address concerns to alleviate anxiety.
• Ensure Privacy: Ensure the patient is in a private and comfortable setting. Position the patient appropriately (e.g., lithotomy position for females, supine or slightly flexed legs for males).
• Check for Contraindications: Review the patient’s medical history to ensure there are no contraindications to catheterization (e.g., traumatic urethral injury, blood at meatus, perineal hematoma, or patient refusal).

Gather Required Equipment

Ensure all the necessary equipment is available and sterile:

Prepare the Patient and Sterile Field

• Hand Hygiene: Perform thorough hand washing and wear sterile gloves to maintain aseptic technique.
• Position the Patient: Position the patient in the correct position:
  • Females: Lithotomy position (lying on back with legs bent and spread apart).
  • Males: Supine position with legs slightly flexed and apart.
• Drape the Patient: Use sterile drapes to cover the patient’s body, exposing only the genital area. This helps maintain a sterile field.

URETHRAL CATHETERIZATION IN MALE PATIENTS

3. Cleaning the Area

• Clean the penis with an antiseptic solution (such as Povidone-iodine or chlorhexidine) to reduce the risk of infection.
• Use your non-dominant (dirty) hand to hold the glans penis through the sterile drape hole. Ensure that your hand does not touch the penis.
• Use the other hand (dominant or clean hand) to hold a sterile swab soaked in antiseptic solution (e.g., sterile Savlon or chlorhexidine).
• Retract the foreskin (if applicable) using your clean hand and clean the urethral orifice and glans penis thoroughly, starting from the urethral meatus and working outwards in a circular motion.

4. Topical Anesthesia

• Apply topical anesthesia to the urethra using lidocaine gel.
• Using a syringe without a needle, instill 5-10 mL of 2% lidocaine gel into the urethral meatus. The gel will provide local anesthesia, making the procedure more comfortable.

5. Waiting Time

• Allow 2-3 minutes for the anesthesia to take effect before proceeding with catheter insertion.

7. Inserting the Catheter (continued)

• Hold the penis at a 90° angle to the body (perpendicular to the gurney) and gently stretch it upward. This helps straighten the urethra for easier catheter insertion.
• Insert the catheter gently into the urethral meatus. Advance the catheter slowly and carefully, avoiding any forceful pressure. Continue advancing the catheter until urine begins to flow, which indicates that the catheter has reached the bladder.
• Once urine starts to flow, the catheter is in the correct position. For indwelling catheters (e.g., Foley), advance the catheter approximately 2-3 inches beyond the sphincter to ensure it is securely placed within the bladder.

8. Inflating the Balloon (for Indwelling Catheters)

• Once proper placement is confirmed, attach a syringe with sterile saline to the balloon inflation port of the catheter.
• Inflate the balloon with the recommended amount of sterile saline (usually 5-10 mL), ensuring it is inflated fully. The balloon should be inflated inside the bladder, not the urethra, to avoid injury.
• Gently pull on the catheter to ensure the balloon is securely lodged in the bladder and preventing dislodgement.

9. Securing the Catheter

• Use catheter securing devices or adhesive tape to attach the catheter to the patient’s thigh or abdomen. This will reduce the risk of the catheter being pulled out accidentally and minimize irritation.
• Ensure the catheter is securely fixed and avoid tension on the tubing.

10. Connecting to a Urine Collection Bag

• Connect the catheter to a sterile urine collection bag, ensuring it is securely attached.
• Make sure that the tubing is free from kinks or blockages and that the collection bag is positioned below the level of the bladder. This helps prevent urine backflow and reduces the risk of infection.

11. Post-Procedure Care

• Check for Proper Drainage: Observe the urine flow to ensure that urine is draining freely into the collection bag. If there is no urine flow, check for any kinks or obstructions in the catheter or tubing.
• Monitor Comfort: Regularly assess the patient’s comfort and check for any signs of complications such as discomfort, infection, or blockage.
• Patient Education: Provide the patient with instructions on caring for the catheter. Emphasize the importance of maintaining hygiene, monitoring for signs of infection, and ensuring the urine collection bag stays below the bladder level.

12. Dispose of Used Equipment

• Dispose of all used equipment, including gloves, swabs, and sterile drapes, in appropriate biohazard containers.
• Ensure that the patient’s genital area is cleaned to remove any residual antiseptic or lubricating gel, using sterile cotton balls or gauze.

13. Documentation

• Document the procedure thoroughly, including:
  • The type of catheter used (Foley, intermittent, or Coudé)
  • The balloon inflation volume (if applicable)
  • The patient's response to the procedure
  • Any complications or difficulties encountered during the procedure

14. Monitoring for Complications

• Infection: Monitor for signs of infection such as fever, pain, or foul-smelling urine.
• Discomfort: Monitor the patient for any discomfort related to the catheter or the procedure.
• Catheter Dislodgement: Ensure the catheter remains securely in place.

URETHRAL CATHETERIZATION IN FEMALE PATIENTS

1. Positioning the Patient

• Position the female patient in a supine position with her legs bent at the knees and spread apart, exposing the genital area.

2. Cleaning the Area

• Use your non-dominant hand to separate the labia minora, exposing the urethral opening.
• With your clean (dominant) hand, use sterile swabs soaked in antiseptic solution to clean the area, starting from the urethral meatus and working outward.

3. Topical Anesthesia

• If desired, apply a topical anesthetic (e.g., lidocaine gel) to the urethra to reduce discomfort during the procedure.
• Apply the gel gently using a sterile syringe, allowing time for it to take effect (2-3 minutes).

4. Lubrication of the Catheter

• Apply sterile, water-soluble lubricating gel to the catheter tip to minimize friction and patient discomfort during insertion.

5. Inserting the Catheter

• Hold the labia apart with one hand, and with the other hand, gently insert the catheter into the urethral meatus.
• Advance the catheter slowly and carefully until urine begins to drain, confirming correct placement.

6. Inflating the Balloon (for Indwelling Catheters)

• If using an indwelling catheter, inflate the balloon with sterile water once urine flow is established, ensuring the balloon is placed inside the bladder.

7. Securing the Catheter

• Secure the catheter in place using adhesive tape or a catheter securing device.
• Attach the catheter to a urine collection bag, ensuring there are no kinks in the tubing and the bag is positioned below the bladder.

General Considerations for Both Genders

1. Aseptic Technique

• Always maintain strict aseptic technique to prevent infection. This includes proper hand hygiene, sterile gloves, and cleaning of the genital area with antiseptic solutions.

2. Patient Comfort

• Communicate with the patient throughout the procedure, explaining each step and ensuring they are as comfortable as possible.

3. Monitoring

• Regularly monitor for signs of complications such as catheter-associated urinary tract infections (CAUTI), bladder injury, or discomfort.

4. Documentation

• Thoroughly document the procedure details, including the type of catheter used, balloon inflation volume, and any complications or issues encountered.

Infections

• Urethritis
• Cystitis
• Pyelonephritis
• Transient bacteremia

Paraphimosis - Caused by failure to reduce the foreskin after catheterization.

Urethral Strictures

Urethral Perforation

Bleeding

Non-infectious Complications

• Accidental removal
• Catheter blockage
• Gross hematuria
• Urine leakage

The importance of the knowledge of urethral catheterization cannot be overemphasized, as it is one of the most commonly performed procedures in healthcare. Hence, healthcare workers ought to have a working knowledge of the procedure to ensure better care for patients.