# Urinary Catheterisation

## Overview

This module describes how to insert a catheter through the urethra and into the urinary bladder.

## Indications

1. Drainage:

   1. To manage incomplete bladder emptying and urinary retention
   2. To drain the bladder during surgical or obstetric procedures
   3. Irrigation and drainage after urological surgery
   4. Palliation of chronic urinary incontinence

2. Instilling medications or contrast agents

3. To obtain a sterile urine specimen

4. Fluid balance monitoring in critically ill patients

## Contraindications

1. Urethral injuries or abnormalities
   Urethral injuries or abnormalities

   Blood at the meatus, urethral pain, a boggy prostate, or perineal haematoma are suggestive of urethral injury. Other urethral abnormalities include urethral infections, false passages, severe strictures, and tumours.

## Patient information & consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“I need to place a thin tube in your bladder to drain urine into a bag. I will either strap it to your leg, or it will be placed on a bag stand.”

### What can my patient expect?

“It may feel slightly uncomfortable when I pass the tube.”

### What is my patient’s role?

“Tell me if you have any allergies. Stay still and try to remain relaxed while I insert the tube; it’ll help it to pass more easily. Let me know if you experience any pain. Afterwards, keep the bag lower than the level of your bladder, and tell the nursing staff if there are any problems with your catheter such as leaking or the plaster coming loose.”

## Preparation

Prepare a trolley with equipment.

### Documentation

1. Patient notes

### Equipment

1. Sterile gloves

2. Alcohol-based hand rub

3. A sterile pack

4. Povidone iodine skin disinfectant or normal saline (follow hospital protocol)

5. 10 ml syringe

6. 10 ml

   sterile water
   sterile water

   Using normal saline can cause crystals to form, preventing balloon deflation. Using air can cause the balloon to float, preventing effective bladder drainage.

7. Catheter drainage bag

8. Urinary catheter
   Urinary catheter

   Foleys catheters can stay in for 2-12 weeks. if a longer period is required, consider using a silicone catheter. For permanent catheterisation if the patient cannot self catheterise, consider a supra pubic catheter.

   (Generally 16-18 Fr for males, 14-18 Fr for females and 5-10 Fr for children)

9. Lubricant jelly or local anaesthetic jelly

10. Surgical tape or a transparent film dressing

## Site & Positioning

The patient should be positioned supine. Females should bring their heels to their buttocks with their legs separated.

## Procedure

Wash the perineal area with soap and water, using unsterile gloves.

Follow medical asepsis with sterile gloves.

1. Perform hand hygiene.

2. Open the sterile pack and create a sterile field on a clean, dry surface. Pour 10 ml sterile water into the empty well. Pour disinfectant into the well containing cotton balls. Open the syringe, catheter and bag onto the sterile field. Squeeze some lubricant jelly onto the sterile field.

3. Don sterile gloves. Place a drape under the patient’s genital area.

4. Test
   Test

   Draw up water. Open the catheter and connect the syringe to the balloon port. Inflate the balloon and deflate. Keep the syringe attached to the port.

   that the catheter balloon is working.

5. Connect the catheter to the collection bag.

6. Separate the labia/hold the penis with your non-dominant hand. This hand is now non-sterile.

   Clean
   Clean

   Clean the entire glans of the penis in men, or the inner labia in women, starting at the meatus and cleaning outward. Use a new cotton ball for each stroke. In women, always use anterior-to-posterior strokes.

   the urethral area using your sterile hand, taking care not to touch the patient’s skin.

7. Use your dominant, sterile hand to pick up the catheter. Lubricate the tip.

8. Insert
   Insert

   In men, hold the penis facing the ceiling to facilitate insertion. If you feel resistance lower down, try angling the shaft towards the feet and advance the catheter gently.

   the catheter all the way to the Y-connection.

9. Observe urine drainage into the urine drainage tube/urine bag.

10. Inject 10 ml water into the balloon port while observing for discomfort; stop if this occurs.

11. In men,

    place the foreskin back in position
    place the foreskin back in position

    This prevents paraphimosis, or entrapment of the foreskin behind the glans, which can become a medical emergency.

    .

12. Gently retract the catheter until you feel resistance.

13. Secure the catheter to the inner thigh in women, or the

    abdomen in men
    abdomen in men

    This reduces the risk of the catheter eroding through the urethra.

    . Place the drainage bag below the level of the bladder.

14. Dispose of medical waste safely.

15. Record completion of the procedure in patient notes.

## Troubleshooting

I inserted the catheter into the vagina.

Leave that catheter in place for the moment, so you know where not to insert on your next try. Get a new catheter. Look for the urethral meatus just above the vagina. Remove the incorrectly placed catheter after placing one successfully.

I’m encountering resistance.

This may be at the level of the external sphincter. Ask the patient to cough to help you to pass the catheter. In men, the prostate may interfere with catheter insertion. Do not use force to pass the prostate. Try gently re-angling the catheter as you insert it. Try using gentle traction on the penis. In some cases, the obstruction may be due to strictures. If you are unable to pass the catheter, attempt a smaller size. If unsuccessful, call a senior clinician for advice.

I inserted the catheter, but there is no urine drainage.

If the patient experiences pain with balloon inflation, you are probably in the urethra. Deflate the balloon and re-insert or advance the catheter until you see urine drainage.

If the patient did not experience pain during inflation, it is likely that you have reached the bladder. There may be lubricant jelly temporarily obstructing urine flow, or the bladder may be empty. Press gently on the suprapubic area to encourage urine flow.

Evaluate for urine drainage after 30 minutes if no urine was seen initially.

## Risks

1. Urinary structural trauma

2. Catheter-associated urinary tract infections (CAUTI)

3. Catheter

   blockage
   blockage

   Flush with sterile water; if unsuccessful at resolving blockage, replace the catheter.

4. Catheter

   leakage
   leakage

   Replace the catheter with a larger one. If the patient is experiencing bladder spasms, the pressure generated may be overwhelming the drainage ability of the catheter. In this case, treat the bladder spasm.

5. Non-deflating balloon
   Non-deflating balloon

   Advance the catheter to ensure it is in the bladder. Inject 1-2 ml of sterile water into the balloon port. Try deflating very slowly. Try cutting off the balloon port flush to the catheter. Call urology. It may be necessary to insert a ureteric guide wire to pop the balloon, or to puncture it suprapubically.

   on removal

6. Paraphimosis

7. Urethral erosion due to improper securing of tape

8. Patient removal of catheter with balloon inflated in confused patients

9. Pain or discomfort related to the catheter

## References

1. Shah J. Catheterisation. Ann R Coll Surg Engl. 2012;94(1):5-7. doi:10.1308/003588412X13171221500303. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3954178/

2. Haider MZ, Annamaraju P. Bladder Catheterization. [Updated 2021 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560748/

3. Cravens DD, Zweig S. Urinary catheter management. Am Fam Physician. 2000;61(2):369-376. Available from: https://www.aafp.org/link_out?pmid=10670503

4. Vetrosky D. Urinary Bladder Catheterization. In: Dehn RW, Asprey DP, eds. Essential Clinical Procedures. 3rd edition. Elsevier; 2013.