BAHAN TUTOR SKENARIO 4

Bladder Catheterization

Mobeen Z. Haider; Pavan Annamaraju.

Author Information

Last Update: December 14, 2020.

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Continuing Education Activity

Bladder catheterization is a commonly performed procedure in all hospitals. It can be performed by

external, urethral, and suprapubic techniques. It is associated with complications including but not
limited to urinary tract infection which is the most common hospital-acquired infection. This activity
describes in detail the working knowledge for urethral catheterization, which is the most commonly
used method worldwide and highlights the role of an interprofessional healthcare team in improving
care for patients who undergo urethral catheterization.

Objectives:

Describe the process involved in bladder catheterization

Identify the indications for bladder catheterization.

Outlines the complications associated with bladder catheterization.

Explain the importance of improving care coordination amongst the interprofessional team to
improve outcomes for patients with bladder catheters.

Earn continuing education credits (CME/CE) on this topic.

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Introduction

Urinary bladder catheterization is performed for both therapeutic and diagnostic purposes.[1][2].
Based on the dwell time, the urinary catheter can be either intermittent (short-term) or indwelling
(long-term).

There are three types of urinary catheters based on the approach of insertion.

External catheters adhere to the external genitalia in men or pubic area in women and collect the
urine. They are useful for the management of urinary incontinence.
Urethral catheters are inserted through the urethra, with the tip advanced into the base of the
bladder.

Suprapubic catheters are inserted into the bladder surgically via a suprapubic approach.

Urethral catheterization is most commonly performed in routine clinical practice and is discussed in
this article.[2]

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Anatomy and Physiology

The urinary system comprising of kidneys, ureter, bladder, and urethra is involved in the production,
storage, and excretion of urine. Under normal conditions, in an adult, the kidneys produce
approximately 1500 ml of urine in a day. After passing through the ureters, the urine is stored in the
bladder. The capacity of the bladder can vary between 350 ml - 500 ml. Three sets of muscles control
urinary drainage from the bladder into the urethra. The internal sphincter located at the base of the
bladder is an involuntary smooth muscle. The voluntary striated external sphincter muscles
encompass the proximal part of the urethra. Lastly, the pelvic floor muscles support and provide
additional control.[3]

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Indications

The indications for bladder catheterization are:

Therapeutic

Urinary retention

Urinary retention can be acute or chronic. The causes of urinary retention can be:

Obstructive: Urinary obstruction can be intrinsic (within the urinary system) or extrinsic. Benign
prostatic hyperplasia (BPH), stones, strictures, stenosis, or a tumor can cause intrinsic obstruction.
BPH is the most common cause of urinary retention. If the blockage is from a pathology outside the
bladder, it is classified as extrinsic. An enlarged abdominal or pelvic organ can compress on the
bladder neck resulting in extrinsic obstruction.[1]

Infectious & Inflammatory: Cystitis, urethritis, prostatitis (common infectious etiology in men), and
vulvovaginitis in the woman can cause urinary retention.

Pharmacologic: Drugs with anticholinergic or alpha-adrenergic agonist properties.

Neurologic: Brain or spinal cord injury, cerebrovascular accident, multiple sclerosis, Parkinson
disease, and dementia can lead to urinary retention.[4]
Others: Trauma, psychogenic, Fowler syndrome in women.[1][5][6]

Perioperative

Bladder catheterization is performed perioperatively in most abdominopelvic surgeries, such as

urological and gynecological procedures. In cases of surgery on structures adjacent to the
genitourinary tract, sheath catheters are recommended.[1] Bladder catheterization is also useful in
surgical patients who require strict intraoperative urine output. Besides, it is helpful for the
management of postoperative urinary retention due to anesthesia, and to achieve better
postoperative pain control.[7]

Neurogenic bladder dysfunction

Urinary incontinence

Social and hygiene reasons[1]

Acutely ill patients requiring close urinary output measurement[8]

Chemotherapy drug delivery[8]

Bladder irrigation[8]

Diagnostic:

Measurement of urodynamics

Sample collection for urinalysis[8]

Radiographic studies (cystogram)

Indications for Removal

The need for a bladder catheter should be assessed daily and must be removed when the purpose
of the catheter insertion is served.[9] For intraperitoneal colorectal surgeries, the catheter can be
removed on postoperative day 1. In the case of mid to low rectal operations, the catheter can be
removed between postoperative days 3-6 based on the risk of urinary retention.[10]

Early removal of urinary catheters helps with ambulation and better post-op recovery.[7] For
patients with chronic urinary retention and incomplete bladder evacuation, intermittent
catheterization is useful.

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Contraindications

Contraindications to bladder catheterization include:

Blood at the meatus. Insertion of the catheter can worsen an underlying injury.

Gross hematuria

Evidence of urethral infection

Urethral pain or discomfort

Low bladder volume/compliance

Patient refusal [11]

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Equipment

Bladder catheterization requires the following equipment:

Sterile gloves

Sterile water

Single-use lubricant and anesthetic gel

Catheter

Catheter bag

Waterproof pad (disposable)[9]

Type and Choice of Catheter

The catheters can vary with the composition and coating material.

Composition: Silicone, latex, and PVC.

Coating: Teflon, hydrogel, and antimicrobial or latex with a silicone elastomer coat.[12]

The selection of a catheter type depends upon the clinical indication, dwell time, and individual
patient's risks.[2] A trained physician must perform catheterization with a Coude or suprapubic
catheter in cases where standard catheterization is unsuccessful. Silver alloy impregnated catheters
are preferred for short term catheterization(≤14 days) as they reduce the incidence of UTI and
bacteremia.[13]
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Preparation

Preparing for a catheterization involves the following steps:

Review indications and contraindications for the procedure. A careful history can help to assess the
need for urological referral.[14]

Give clear instructions to the patient about the procedure. Allow appropriate time to respond to
the queries of the patient.

A proper light source should be present.[9]

Maintain patient's privacy during the procedure.[9]

The patient should lie down on a firm flat surface with the head resting on a pillow.[15]

Appropriate positioning of the patient. Supine position for men and frog-leg position for women is
recommended.

Place a disposable pad beneath the patient's buttocks.[9]

Perform hand hygiene.

Wear sterile gloves.

Appropriately drape the patient.

Prepare the glans penis and the urethral meatus using a sterile technique. In women use the non-
dominant hand to expose the urethral meatus by separating the labia and prepare the meatus
with an antiseptic solution.[7]

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Technique

In Men:

Local anesthesia and the lubricant must be generously used. The lubricant gel should be milked
proximally with the distal urethra compressed to occlusion.[15] The penis is held using the
nondominant hand directed towards the ceiling or the umbilicus. The catheter is inserted into the
urethral meatus with the dominant hand until the Y of the catheter is at the urethral meatus.[15]
The return of urine in the attached bag is a sign of correct placement into the bladder. The catheter
balloon is then inflated using sterile water. The amount of water used for inflation varies with the
manufacturer’s recommendations.[7]

In Women:
After exposing the urethral meatus, a lubricated catheter tip is advanced in the meatus until there
is a spontaneous return of urine. The catheter balloon is then inflated as per the manufacturer’s
recommendations. In morbidly obese patients, exposing the meatus may require help from a
second person or placing the patient in a Trendelenburg position. Adequate swabbing with
povidone-iodine helps with visualizing the meatus. In the event a catheter is inserted in the vagina,
it should be left there until a new sterile catheter is successfully inserted into the meatus.[7]
Analgesia is of no proven clinical use in women.[15] Lubrication jelly should be applied to the tip of
the catheter. The application of lubricant to the urethral meatus is associated with difficulty in
catheter insertion.[15]

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Complications

Complications of urethral catheterization include:

Urinary tract infection (UTI) is the most common complication that occurs as a result of long term
catheterization.[7] The normal urinary flow prevents the ascension of microbes from the
periurethral skin avoiding the infection. Alteration of the defensive mechanism from the catheter
results in an increased risk of UTIs.[3] Escherichia coil and Klebsiella pneumonia are the most
common organisms implicated in UTIs.[3] Recurrent UTIs are associated with increased antibiotic
resistance.

A chronic bladder infection can occur from urinary (10-100 ml) stasis at the base of the bladder,
which is obstructed by the balloon of the catheter.[16]

Pain due to traction on the drainage bag.[8]

A transitory stinging sensation is common in men that often occurs during lubrication and can be
minimized by cooling the gel to 4°C.[8]

Paraphimosis[8]

Urethral injury[17]

Catheter obstruction can occur due to the sediment buildup in patients with subclinical bacteriuria.
Flushing can often relieve the blockage. If unsuccessful catheter replacement may be required.[18]

Urine leakage from the urethral meatus extrinsic to the catheter may occur as a result of bladder
spasms. These spasms can be painful and can be alleviated with anticholinergic medications like
oxybutynin.

A negative effect on the quality of life, especially for patients with longterm indwelling catheters.[6]

Due to these complications, indications for the bladder catheterization must be carefully reviewed
before the procedure.

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Clinical Significance
Bladder catheterization is a commonly performed hospital procedure. Therefore physicians and
nurses must be aware of its indications, contraindications, and be familiar with the scenarios where
a urology consultation is warranted.[15] The need for a bladder catheter should be evaluated daily.
Prompt removal of the catheter decreases the risk of urinary tract infection.[9]

Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated

infection and accounts for more than $131 million of medical expenditure annually.[19][20] 70% of
healthcare-associated UTIs are attributed to catheters. The risk of bacterial colonization of the
catheter increases with the duration ranging from 3-10% per day to 100% in long term indwelling
catheters. According to the National Healthcare Safety Network (NHSN), a diagnosis of CAUTI is
considered in a patient with fever and bacteriuria, who has an indwelling catheter for at least two
days.[19] The IDSA (Infectious Diseases Society of America) recommends considering CAUTI as a
diagnosis of exclusion in a febrile patient. Antibiotic therapy for asymptomatic bacteriuria is
inappropriate and is associated with drug resistance and increased risk of Clostridium difficile
infection.[21] When treating a catheter-associated UTI, indwelling catheters for greater than two
weeks must be removed.[20] CAUTI prevention is possible by avoiding unnecessary catheter
insertion and by frequently assessing the need and aiming for early removal.[20][21]

Acute urinary retention is an emergency that requires urinary catheterization. Urethral strictures are
one of the leading causes of urinary retention in patients younger than fifty years. Urethral
catheterization can be challenging in the presence of urethral strictures and must be attempted with
a 14 French catheter. If an obstruction is encountered, the catheter should not be forced into the
urethra.[9] Blood at the meatus can be due to urethral trauma. Repeated attempts of catheter
insertion may further increase the risk of injury and the creation of a false passage. Urology must be
promptly consulted in challenging cases of urinary catheterization.[15]

Asymptomatic bacteriuria (ASB) is defined by at least ≥ 100,000 colony-forming units [CFU]/mL or

≥100,000,000 CFU/L of a bacteria isolated from a voided urine specimen without any signs or
symptoms of UTI. Antimicrobial therapy should not be prescribed for ASB due to an increased risk of
antimicrobial resistance and adverse effects. Screening and treatment of asymptomatic bacteriuria
are indicated in pregnant women and in patients expected to have a urologic endoscopic procedure
that is associated with mucosal trauma.[22]

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Enhancing Healthcare Team Outcomes

A myriad of clinical conditions may require bladder catheterization. While a physician or a nurse can
place the catheter in most cases, consultation with urology is necessary for specific patients. The
nurses are essential members of the interprofessional group, as they will predominantly perform the
procedure. They also monitor the catheter and assist with the education of the patient and family as
needed. The pharmacist will ensure that the patient is not on any medication that can precipitate
urinary retention. The physical therapist also plays a role in early mobilization, voiding exercises, and
rehabilitation. Interprofessional communication and care coordination among health professionals
are vital to enhancing patient-centered care and improve outcomes.