Urethral Catheterization


Urethral Catheterization, Urinary Catheter, Urinary Catheterization, Bladder Catheterization, Foley Catheter

  • Indications
  • Long-term indwelling catheterization
  1. Refractory Bladder outlet obstruction
  2. Neurogenic Bladder with Urinary Retention
  3. Complications of Incontinence
    1. Refractory skin breakdown
    2. Palliative Care for terminally ill
    3. Patient preference
  • Indications
  • Short-term catheterization
  1. Urologic or pelvic surgery
  2. Acute Urinary Retention (trial voiding at 14 days)
  3. Urinary output monitoring in critically ill
  • Contraindication
  1. Artificial Urinary Sphincter
    1. Catheterization can damage the sphincter or increase infection risk
    2. Instead, use the devices buttons to open the sphincter (either transiently or persistently)
    3. Consider Suprapubic Catheterization (under Ultrasound guidance) if catheterization is needed
  2. Signs of Urethral Trauma
    1. If Trauma, perform genital and Rectal Exam first (or the preferred Retrograde Urethrogram)
    2. Blood at meatus
    3. Scrotal Hematoma
    4. High riding Prostate
  • Complications
  • Longterm catheterization
  1. Urinary Tract Infection
    1. See Urinary Catheter associated Urinary Tract Infection
    2. Urosepsis
    3. Bacteriuria
      1. Single intermittent catheterization: 20% of elderly
      2. Bacteriuria occurs in most patients in 2-3 weeks
  2. Chronic renal inflammation
  3. Pyelonephritis
  4. Nephrolithiasis
  5. Cystolithiasis
  • Management
  • Alternatives to Indwelling Urinary Catheters
  1. Intermittent catheterization (dysfunctional voiding)
    1. Spinal Cord Injury
    2. Nursing Home residents
    3. Surgery
      1. Hip Fracture repair
      2. Total abdominal Hysterectomy
  2. External Catheter (Condom catheter)
    1. Incontinent men without obstructive uropathy
    2. More comfortable than indwelling catheters
    3. Lower Incidence of bacteruria
    4. Skin breakdown may occur
  3. Suprapubic Catheterization (short-term post-operative)
    1. Lower infection risk
    2. Improved comfort and convenience
    3. Risks
      1. Cellulitis
      2. Hematoma or leakage at puncture site
      3. Urethral Prolapse
  • Preparations
  • Catheter Characteristics
  1. Catheter Material
    1. Latex: Long-term catheterization
    2. Silastic: Short-term catheterization or Latex Allergy
  2. Minocycline and Rifampin impregnated catheters
    1. May reduce bacteriuria for up to 2 weeks
    2. Reference
      1. Darouiche (1999) Urology 54:976-81 [PubMed]
  3. Catheter size
    1. Narrowest, softest efective tube
      1. Range: 12F (smallest) to 18F (largest)
      2. Most common: 14F to 16F
    2. Balloon size: 5 ml balloon with 5-10 ml fluid
  • Management
  • Complications
  1. Urinary Catheter Obstruction
    1. Evaluation
      1. Nonverbal or demented patients may display increased Agitation with obstruction and Bladder Distention
      2. Bedside BladderPOCUS (Bladder Ultrasound)
        1. Demonstrates retained urine, increased Bladder sediment or blood and position of catheter balloon
    2. Clearing obstruction
      1. Reposition the patient supine and remove any kinks from the tubing
      2. Attempt Bladder Manual Irrigation
      3. Replace catheter if manual irrigation is unsuccessful
    3. Prevention
      1. Maximize patient hydration
      2. Consider Methanamine preparations to prevent blockage
      3. Change catheter before expected time to obstruction
      4. Change catheter if no urine flow in 4 to 8 hours
      5. Evaluate for UTI for more frequent catheter blockage
  2. Urinary Catheter leakage
    1. Do not increase catheter diameter
    2. Evaluate for catheter blockage (above)
    3. Evaluate for Urinary Catheter associated UTI
    4. Consider Bladder Antispasmodic
  3. Urinary Catheter is stuck and cannot be removed
    1. Push Foley Catheter in further which may dislodge a kinked tube at the Urethra
    2. Cut the Foley Catheter (but not too close to the Urethral meatus)
    3. Consult urology
    4. Additional measures if urology is not available
      1. Thread Central Line over wire into the Foley Catheter and remove the wire to drain balloon
      2. Overinflate the Foley Catheter balloon until balloon rupture (risk of retained material in Bladder)
      3. Instill Mineral Oil into catheter balloon to dissolve the balloon
    5. Prevention
      1. Do NOT use saline to fill catheter balloon (saline crystalizes)
    6. References
      1. Morgenstern and Arcand in Herbert (2018) EM:Rap 18(6): 5
  • Technique
  • Catherization
  1. Pre and post-procedure Hand Hygiene
  2. Aseptic technique with sterile equipment
  3. Female placement
    1. Complicating factors making catheter insertion difficult
      1. Morbid Obesity
      2. Pelvic Fracture or Hip Fracture
      3. Elderly female (limited flexibility, vaginal stenosis)
    2. Methods
      1. Assistants retract tissue to optimize visualization of Urethra
      2. Place guiding hand against the underside of the Symphysis Pubis
        1. The Urethral insertion site should be immediately above the guiding hand
  4. Male placement
    1. Barriers
      1. Urethral Stricture (typically obstructs on first few cm of insertion)
      2. Penile Urethra turns 90 degrees before reaching the prostatic Urethra
      3. External Urethral sphincter lies between penile and prostatic Urethra (most common obstruction)
      4. Prostate
    2. Methods
      1. Help the patient calm (relaxes the external Urethral sphincter)
      2. Distend the Urethra with Lidocaine gel
      3. Pull the penis straight to apply tension and straightens the Urethra
      4. Larger catheters (e.g. 20 French) are preferred as less likely to coil and cause a false passage
        1. Exception: Urethral Strictures may require small catheters (16F, 14F, 12F)
      5. Coude catheters have angled tip that should be inserted with tip at 12:00 position to navigate bend
      6. Coated guidewire (e.g. Glidewire)
        1. Used by urologists in seldinger technique
        2. Pass the wire into the Bladder first, then the catheter over the wire
        3. Pediatric bougie can be used as a substitute if inserted only into the distal Urethra
          1. Deeper insertion risks Urethral injury (e.g. false passage) and Bladder injury
    3. Troubleshooting
      1. Estimate the distance the catheter passed before reaching obstruction
      2. Urine catheter inserted but no urine drained
        1. Advance catheter all the way to its hub
        2. Inject saline and aspirate for urine
      3. Penis Urethral meatus is not visualized (e.g. Obesity)
        1. Assistant retracts redundant tissue with both hands
        2. Another assistant applies suprapubic pressure
        3. Patient in Trendelenburg position (gravity may help move pannus out of the way)
        4. Insert pinky finger of non-dominant hand into recess to localize the glans penis and Urethral meatus
      4. Tight Phimosis interferes with catheter insertion
        1. Urethral meatus is visible
          1. Place a coated guidewire (Glidewire) or pediatric bougie into the distal Urethra
          2. Thread the catheter over the guidewire
        2. Urethral meatus is NOT visible
          1. Consider creating a dorsal slit (see Phimosis)
          2. Consider Suprapubic Catheter
      5. Hypospadias or Urethral Strictures
        1. Use a smaller, stiffer catheter
      6. Bleeding after Traumatic Foley Catheter removal (e.g. catheter out with balloon still inflated)
        1. Injury is typically not as severe as the initial bleeding would suggest
          1. Prostatic Urethra may be injured
          2. However injuries tend to spontaneously heal and bleeding spontaneously resolves
        2. Replace Urinary Catheter
          1. Use a larger catheter (18 or 20 fr) to allow residual clots to pass
          2. Consider coude tip catheter if injury related edema prevents catheter placement
        3. Consider hyperinflating foley balloon within Bladder (prevents repeat catheter dislodgement)
          1. Balloon 5 ml will accept up to 100 ml before rupturing
          2. Balloon 30 ml will accept 200-300 ml before rupturing
  • References
  1. Mason and Bahnson in Herbert (2017) EM:Rap 3-4
  2. Bhanson and Swaminathan (2023) Foley Follies, EM:Rap, December, accessed 12/1/2023
  3. Cravens (2000) Am Fam Physician 61(2): 369-76 [PubMed]
  4. Walsh (1998) Campbell's Urology, Saunders, p. 159-62