Urinary catheterisation

Guideline for the insertion of an indwelling urinary catheter

 
Indications

• Intermittent
  • Measurement of bladder residual volume.
  • Obtaining uncontaminated urine for microscopy and culture (especially in females or young children).
  • Facilitating adequate bladder emptying (e.g. in conditions associated with atonic bladder).
  • Intravesical installation of drugs (e.g. contrast media in suspected bladder trauma or for micturating cysto-urethrography, instillation of local cytotoxic agents).
  • Urodynamic assessment.
• Continuous
  • Acute or chronic urinary retention
  • Accurate measurement of urine output and to aid fluid balance (e.g. postoperatively)
  • Long term (e.g. when TURP is medically contraindicated).

Contraindications

• Urethral disruption, including blood at the urethral meatus in the setting of pelvic trauma.
• Postoperative urological patients. Always consult the urologist first if the patients\ has had bladder neck or prostate surgery.
• Known stricture or ‘impossible insertion last time’.

Equipment

• Catheter dressing pack (kidney bowl, small ‘wash pots’ ´ 2, gauze swabs, sterile fenestrated drape)
• Catheter (appropriate size ´ 2)
• 10-mL syringe with 10 mL sterile water
• Skin cleaning solution (e.g. saline)
• Lignocaine gel
• Sterile gloves
• Sterile urine drainage bag and bedside holder
• Woven adhesive tape
• Specimen jar for laboratory urine analysis.

Choose the correct catheter

• Lumen
  • Single lumen—these catheters have no balloon and are used for in/out catheterisation
  • Double lumen—two-way catheters have a draining lumen and a balloon inflation lumen and are used for continuous catheterisation
  • Triple lumen (or three-way catheters)—have a draining lumen, a balloon inflation lumen and an irrigation lumen. Insert when blood, clots or debris are to be washed out of the bladder (e.g. post TURP).
• Size
  • Catheter size refers to the circumference of the catheter, not the luminal diameter and is recorded in French sizes (1 French (F) = 1 Charrière = 0.33 mm).
  • Choose the smallest catheter that will allow adequate urinary drainage. Size 12–14F is usually adequate for males and females. Use size 16—20F if the patient has urine with debris, mucous, blood clots or haematuria, which may occlude smaller lumens. A 22F triple lumen is the standard size for bladder irrigation and ‘washout’. Smaller sizes (6–10F) are available for children.

Procedural technique: Male catheterisation

• Explain the procedure to the patient.
• Open all necessary equipment onto a clean trolley.
• Wash hands thoroughly, perform thorough antiseptic hand wash and put on sterile gloves.
• Draw up sterile water for balloon inflation.
• Place fenestrated drape over the patient’s perineum.
• Gently retract the patient’s foreskin and swab the urethral opening and glans with sterile gauze soaked in saline.
• Hold the penis firmly and in an upright position and instil lignocaine gel into the urethra. Approximately 20 mL (2 syringes) of gel is required to reach the proximal end of the urethra in a male. Gently squeeze the end of the penis to close off the urethra so that lubricant gel is retained.
• Hold the tip of the penis in this position for 90 seconds to allow the anaesthetic gel to work.
• Open the catheter wrapping at the distal (tip) end only and insert the catheter gently and slowly into the urethra, withdrawing the plastic covering in stages, and avoiding unnecessary touching of the sterile outside surface.
• Advance catheter to the hilt and wait for urine to flow.
• Inflate balloon with 10 mL sterile water (or as indicated on the hilt of the catheter). Stop immediately if the patient experiences pain, as the balloon may be lodged in the urethra.
• Once balloon is inflated, gently retract the catheter until resistance is felt.
• Always reposition the foreskin to prevent paraphimosis developing.
• Connect bag aseptically to catheter.
• Attach catheter to patient’s inner upper thigh using non-allergenic tape, allowing a gentle curve from the external urethral meatus to the skin, without tension.
• Reasons for failure
  • Urethral/penile stricture: usually require smaller size catheter. Be careful, never use force and if in doubt, call a urologist.
  • Enlarged prostate: generally the larger the prostate, the larger and stiffer the catheter required.

Female catheterisation

• Explain the procedure to the patient.
• Open all necessary equipment onto a clean trolley.
• Wash hands thoroughly, perform thorough antiseptic hand wash and put on sterile gloves.
• Draw up sterile water for balloon inflation.
• Open the catheter wrapping at the distal (tip) end and, holding the proximal portion (still in the wrapping), lubricate the catheter tip with lignocaine gel.
• Position the patient as for a vaginal examination, flat on her back with knees and hips flexed and ankles together. Allow the knees to rest gently in full abduction.
• Drape the perineum using a fenestrated sheet.
• Use non-dominant gloved hand to gently separate labia minora and clean the area with saline.
  Note: The hand holding the labia must be kept in place until catheter is successfully inserted and urine flows.
• Locate the urethral opening (inferior to the clitoris), and swab anterior to posterior with cleaning solution.
• Instil small amount of lignocaine gel to tip of urethral meatus and introduce well-lubricated catheter into urethra until urine flows.
• Empty bladder completely.
• Inflate balloon with 10 mL of sterile water.
• Connect bag aseptically to catheter.
• Attach catheter to patient’s upper thigh using non-allergenic tape, allowing a gentle curve from the external urethral meatus to the skin, without tension.

Complications

• Unable to pass catheter
  • Do not persist with multiple attempts at catheterisation as it will only result in urethral trauma. Consult urology early for consideration of suprapubic catheterisation.
• Urethral trauma
• Introduction of infection, bacteraemia.

Documentation

It is important to document the procedure fully in the notes for both male and female catheterisation.

• Date, time and reason for catheter insertion.
• Catheter make, size (F), material, balloon size and amount of fluid used in balloon.
• Any problems encountered during or following catheter placement, such as traumatic catheterisation or, in particular, failure to pass.

Handy Hints

• Do not over- or underfill the catheter balloon, as this will lead to balloon distortion, causing the catheter tip to deviate within the bladder, and can potentially result in bladder wall necrosis.
• Urine must flow from an inserted catheter before the balloon can be inflated. Urine may not initially flow because of obstruction by lubricating gel. You may be able to expedite flow by gently suctioning the catheter with a syringe, or applying suprapubic pressure to the patient.
• If the patient is immunosuppressed, or has prosthetic heart valves, catheter insertion may cause a serious bacteraemia and bacterial seeding. Senior advice should be sought with regard to prophylactic antibiotics prior to catheter insertion.

Date implemented – 05/2009
Revision date – currently being revised
Author – Mike Cadogan