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Indications for insertion of an indwelling urinary catheter are as follows:
- Diagnostic or therapeutic drainage (as in acute retention of urine) of the urinary bladder
- Need for a reliable and frequent assessment of urine output (eg, for treatment of shock, critically ill patients)
- Need to perform retrograde cystography
- Bladder irrigation
- Patients with severe spinal cord injury
- Patients undergoing pelvic operations
Contraindications
- The following are only relative contraindications to insertion of an indwelling urinary catheter:
- Previous urethral surgery.
- Suspected or known urethra trauma (free-floating prostate, blood issuing from urethra meatus). In this case, perform a urethrogram before urethral catheterization is attempted.
- Acute cystitis, urethritis, pyelonephritis, and epididiymitis, unless obstruction is the predisposing cause of infection
- Urethral Stricture or obstruction
Equipment & Supplies Required
- Foley catheter of the appropriate size, material, and contour (different catheters are discussed below).
- Urinary drainage bag and connecting tube.
- Sterile lubricant (Xylocaine Jelly).
- Antiseptic solution (Betadine Solution) and sterile cotton balls to sterilize the male urethral meatus and the female perineum.
- Sterile disposable syringe, 10-mL, filled with enough sterile water to inflate the balloon on the catheter. The size of the balloon is usually printed on the catheter ( 10 mL).
- Sterile gloves and drapes.
Types of catheters used in the emergency
- Simple red rubber catheter used to drain urine temporarily
- Self- retaining catheters, most commonly used is the Foley’s catheter.
- Two-way Foley’s
- Three-way Foley’s (for bladder irrigation)
- Silicon coated Foley’s catheter (low reaction, longer indwelling
Size of the catheter
- Adult: 16F
- Children: 8F or 10F
- 1 French (F) indicates the circumference of the catheter being 1 mm.
Selecting a Catheter
- The Foley catheter is used in almost all cases when an indwelling urinary catheter is required. It consists of a double-lumen rubber tube with a terminal retaining balloon. The larger channel is for drainage of urine, and the smaller is for inflation of the balloon. Some indwelling catheters have a third lumen, for constant bladder irrigation. Foley catheters are of standard length (46 cm [18 in]) but come in varying diameters that are numerically graded (French system), with the larger number indicating a larger diameter. 10-mL balloons for routine catheterizations and 30-mL balloons for special situations. Most Foley catheters are made of rubber. Teflon or Silastic is sometimes used for long-term, indwelling catheters.
- For routine, short-term catheterization in males or females, a 14F or 18F rubber catheter with a 10-mL balloon is satisfactory. Smaller sizes are required for children.
- Men with prostatic hypertrophy may require larger catheters (eg, 20-22F).
Positioning of the Patient
- Females
- The patient should be in the lithotomy position. If she is comatose or under anesthesia, flex her knees and hips, and allow the legs to abduct. If the soles of the feet are pressed together, this position can easily be held by the patient without assistance.
- Males
- The patient should be supine.
Procedure
Catheterization of Females
- Assemble all necessary equipment.
- Open the catheter/dressing tray and selected catheter, and position them on a sterile field placed on a bedside table or stand so that all required materials are readily accessible.
- Place a generous amount of lubricant on the sterile field.
- Put on sterile gloves, and drape the perineal area.
- Make sure that the catheter is open and the lubricating jelly is accessible.
- Pour the antiseptic solution in provided tray, and moisten the cotton swabs with antiseptic solution.
- Be sure that the syringe is filled with enough sterile water to inflate the balloon being used.
- Using the left hand (standing on the patient’s right side), spread the labia and identify the superior fornix with the clitoris at the apex. Thoroughly cleanse the entire area with 4-5 swabs soaked in antiseptic. Clean the labia with front to back strokes with 2 successive swabs; then cleanse the urethral meatus with another 2 successive swabs.
- The left hand continues to hold the labia spread apart from the rest of the procedure.
- Make a loop in the Foley catheter for easier handling. Grasp the catheter with the right hand, coat the tip and proximal portion with lubricating jelly, and insert the catheter into the urethral meatus, which lies just below the clitoris. Advance the catheter until urine returns. Then advance it 4-5 cm (15/8-2 in) farther to make sure that the balloon is well within the bladder (Female urethra is 3.8 cm long).
- Inflate the balloon with the appropriate amount of sterile water (usually10 mL; the balloon volume is usually printed on the catheter), and withdraw the catheter gently until the balloon is pulled snugly against the trigone.
- Collect a small amount of urine in a sterile container for appropriate studies (urinalysis should be obtained routinely), and then connect the catheter to the urinary drainage bag.
- Tape the Foley catheter and the urinary drainage tube to the upper thigh, leaving enough slack so that abduction of the legs will not put tension on the catheter.
- Note: The most common mistake in catheterization of the female bladder is to miss the urethral meatus and inadvertently slip the catheter into the vagina. No urine will return. Leave the catheter in place in the vagina as a marker. Obtain a new, sterile catheter, and try again. Remove the other catheter.
Catheterization of Males
- Steps 1-7 are the same as those described under Catheterization of Females, above.
- Using the left hand (standing on the patient’s right side), grasp the penis so that the shaft lies in the palm and the glans of the penis is free but secure. The penis should be held at a right angle to the abdomen. The left hand should remain in this position for the remainder of the procedure; it is no longer sterile.
- Sterilize the glans and urethral meatus with 3-4 swabs dipped in antiseptic solution.
- Put a single loop in the Foley catheter for easier handling, grasp the catheter in the right hand, and coat the tip of the catheter with lubricating jelly. It is often helpful to place some on the meatus as well. You can do it with the appropriated nozzle fitted in the tube of the jelly. Put the sterile tip of the nozzle inside the meatus and squeeze the tube, so the jelly enters into the urethra.
- Insert the catheter into the urethral meatus, and advance it down the penile urethra to the base of the penis with successive, steady movements.
- Advance the catheter through the membranous and prostatic urethra into the bladder.
- Advance the catheter to the hilt (even if urine is obtained earlier) to ensure that the balloon is not inflated in the urethra. As soon as the catheter has been advanced to the hilt, release the penis to free both hands for inflation of the balloon.
- Inflate the balloon with the proper amount of sterile water for its size (usually 10 mL), and withdraw the catheter until the balloon is pulled snugly against the trigone.
- Obtain a specimen for appropriate tests (at a minimum, routine urinalysis should be performed). Connect the urinary drainage system bag to the catheter, and tape the catheter to the upper thigh, leaving sufficient slack so that movement of the leg will not pull on the catheter.
- Problem Solving
- Males with Prostatic Enlargement or False Urethral Passages
- Conventional technique usually fails in patients with significant prostatic hypertrophy or false urethral passage. Listed below are a few techniques that have proved successful in catheterizing these patients. Caution: Reasonable persistence in attempting catheterization is acceptable; however, there comes a time when further manipulations may rupture the urethra or create new false passages. If attempts using the guidelines outlined below are still unsuccessful, consult a urologist, or insert a suprapubic catheter instead.
- Increase the size of the catheter—Large catheters are stiffer and provide more forceful dilatation of the prostatic urethra. The larger, blunt tip tends to follow the true urethra rather than smaller false passages.
- Lubricate the urethra—Fill a 30- to 50-mL sterile catheter-tipped syringe with the lubricating jelly and inject the jelly down the urethra with gentle pressure until no more can be injected. Then insert the catheter.
- Inject lubricating jelly while the catheter is being passed—Fill the syringe as outlined above, insert the tip into the catheter, and fill the catheter with jelly. As the catheter is being passed, slowly inject more lubricant to ensure that the entire length of the catheter is lubricated and to help dilate the urethra just ahead of the catheter tip.
- Use a Coude catheter—A Coude catheter has an upwardly deflected tip, which may navigate through a narrowed prostatic urethra more successfully than a standard Foley catheter.
- Traumatized Patients
- Most patients with major trauma have a Foley catheter inserted during resuscitation. A rectal examination must be performed before a catheter is inserted in a male patient with major blunt trauma. Feel for the prostate and make sure that it is firmly attached to the surrounding tissues. A free-floating prostate or gross blood escaping from the urethra signifies urethral rupture until proved otherwise. In either case, Foley catheterization is contraindicated, and a suprapubic catheter should be inserted instead.
- Males with Prostatic Enlargement or False Urethral Passages
Complications
- Urinary Tract infection(UTI)
- Excrustation
- Bleeding due to urethral or bladder trauma
- Urethral or bladder spasm
- Stone formation
- Blockage of the catheter
- Urethral stricture
- Paraphimosis
- Pressure necrosis of urethra
Documentation
- 1. Procedure and time done.
- 2. Size of catheter.
- 3. Amount of urine output.
- 4. Color and character of urine.
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