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
  1. If Trauma, perform genital and Rectal Exam first
  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 Blockage
    1. Maximize patient hydration
    2. Consider Methanamine preparations to prevent blockage
    3. Consider Bladder irrigation
    4. Change catheter before expected time to obstruction
    5. Change catheter if no urine flow in 4 to 8 hours
    6. 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
  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
    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
        2. Another assistant applies suprapubic pressure
        3. Patient in Trendelenburg position
      4. Bleeding after Traumatic Foley Catheter removal
        1. Replace Urinary Catheter
        2. Consider hyperinflating foley balloon within Bladder
          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. Cravens (2000) Am Fam Physician 61(2): 369-76 [PubMed]
  3. Walsh (1998) Campbell's Urology, Saunders, p. 159-62