Urethral catheterization

Written by Dr. Samuel Vincent G. Yrastorza, MD, FPUA and Timothy James O. Lam, MD
Illustrations by James Harold A. Barte, MD

1. Introduction

Urethral catheterization is a medical ward procedure used to drain the urinary bladder
for various clinical conditions. This manual will introduce the reader to the basics of
urinary catheterization, its indications, common terminologies regarding
catheterization, and includes a step-by-step illustrated guide on how to do it.

2. Indications

A. Drainage of urinary bladder

- Acute or chronic urinary retention (most common indication)
- Significant post void residual urine secondary to outlet or urinary bladder
pathology (e.g. neurogenic bladder)
- During and after surgical procedures (e.g. TURP)
- For urinary diversion to allow healing of an injured lower urinary tract (i.e.
bladder injury)
- To accurately assess urinary output (for critically ill patients)
- To collect urine specimen

B. Diagnostic or therapeutic procedures

- Urodynamic evaluation or bedside cystometry
- Radiographic studies (e.g. cystography)
- Instillation of pharmacologic agent into the bladder (e.g. chemotherapeutic
drugs for bladder carcinoma)
- Bladder irrigation

3.. Contraindications
- Acute prostatitis
- Suspected urethral injury in trauma patients with blood noted per meatus

Terminologies

a. French (Fr) - Refers to the outer diameter of the catheter where in

1 Fr = 0.33mm
24 Fr = 8mm

b. Indwelling - catheter maintained for a long period of time (i.e. days to weeks)
- Used for accurate output monitoring (i.e. hourly measurement of urine output)
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- Used as temporary or permanent drainage for urinary or bladder outlet

pathology

c. Intermittent - catheter is transiently inserted to drain urine and removed once the
bladder is completely emptied
- May be done regularly every 4-6 hours or whenever the patients feels fullness of
the bladder

- PARTS OF THE CATHETER

Catheter Tip
Inflation Funnel

Drainage Funnel
Drainage eye
Irrigation Funnel
Balloon Anchor

Catheter Shaft

Figure 1. Parts of the 3-way foley catheter

TYPES OF URINARY CATHETERS

A. According to number of lumens

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Single lumen 2-way catheter 3-way catheter

Figure 2. 3 types of urinary catheters according to number of funnels

Single lumen catheter

• Only one lumen for drainage of urine (drainage funnel only)

• No balloon for anchorage, usually used for intermittent catheterization

2-way catheter

• One lumen for drainage plus another lumen for balloon inflation (drainage
funnel plus inflation funnel)
• Usually used for indwelling catheterization wherein the balloon inflation helps
keep the catheter safely in place

3 way catheter

• One lumen for drainage, another for balloon inflation and a third lumen for
irrigating fluid
• Usually used when there is a need to continuously irrigate the urinary bladder
with sterile saline (i.e. Post TURP cases where the continuous bladder irrigation
prevents blood clot formation and helps stop bleeding)

B. According to material used:

• Latex
• Rubber
• Silicone
• Polyvinylchloride (PVC)

C. Most commonly used catheters in clinical practice:

• French 16 2- way foley catheter

– Readily available
– Used for acute urinary retention and post operative cases
• French 24 3- way catheter
– For post-TURP and post-TURBT cases and other cases requiring
continuous bladder irrigation to prevent clot formation
• Robinson’s catheter
– For intermittent catheterization

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BASIC ANATOMY

Male Anatomy Female Anatomy

A.Spongy urethra A. Urethra
B.Membranous urethra B. Urinary bladder
C.Prostatic urethra C. Uterus
D.Urinary bladder D. Vaginal canal
E.Prostate E. Cervix
F.Testis

A
E
F

Figure 3. Male anatomy

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C
E

Figure 4. Female anatomy

4.PREPARATION

a. EXPLAINING THE PROCEDURE AND GETTING CONSENT

- Firstly, introduce yourself.
- Explain to the patient the reason for catheterization and if inquired by the patient,
how the procedure will be performed. Also include the possible risk and
complications involved.
- Ask permission from the patient if you may proceed to do the procedure. Verbal
consent is sufficient for urinary catheterization.

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b. PREPARATION OF MATERIALS

Figure 5. Materials needed for cleansing the genital area

Make sure the following are available:

a. Foley catheter
b. Drainage/urine bag
c. Lubricant
d. Sterile gloves
e. Antiseptic (e.g. povidone iodine)
f. Sterile cotton balls
g. 10cc syringe
h. Sterile water – refrain from using IV fluid preparations which could
precipitate and clog the balloon access preventing its deflation at the
time of catheter removal (i.e. crystalloids)
i. Adhesive tape

Note: Ensure that the balloon is intact. Inflate and deflate the balloon with air or sterile water
to test for damage or leakage.

c. POSITIONING THE PATIENT

- Male: Supine
- Female: Lithotomy or Frog Leg

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Figure 6. Supine in males and lithotomy in females

d. GLOVING
- Do proper sterile gloving, making sure to maintain sterility throughout the
procedure.

e. PREPARING THE PATIENT’S GENITALS

- Cleanse the patient’s genitals using aseptic technique.

A. Male: Cleanse the penis starting from the urethra proceeding outwards in a circular
motion. Repeat the process two more times to ensure adequacy of aseptic technique.

B. Female: Cleanse the vulva from front to back starting at midline then proceeding
laterally. Repeat the process two more times to ensure adequacy of aseptic technique.

Figure 7. Holding the penis in males and exposing the urethra in females

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5. INSERTION OF THE URINARY CATHETER

A. LUBRICATE THE CATHETER

- Ensure adequate lubrication of the mid-distal portion of the catheter
- Optional: injection of lubricant with or without anesthetics (e.g. cathejell) into the
urethra

Figure 8. Lubricating the distal end of the foley catheter

B.PROPER IDENTIFICATION OF THE URETHRAL MEATUS

i) Male: Proper holding of the penis

- Using your non-dominant hand, hold the penis just below the glans penis in between
the 2nd and 3rd digits with the palmar aspect of the hand facing the ceiling.
- Pull the penis up and cranially to straighten the urethra leaving the
bulbomembranous area as the only remaining angle to traverse.

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Figure 9. Holding the penis in males and exposing the urethra in females

Figure 10. Pulling the penis upward and cranially to straighten the urethra leaving the
bulbomembranous area as the only remaining angle to traverse.

ii) Female: Proper exposure of the urethral meatus

- Using your non-dominant hand, spread the labia apart to provide adequate
exposure of the urethral meatus (located just below the clitoris)

C. INSERTION OF THE CATHETER INTO THE URETHRA

a. Females: Gently insert the tip of catheter into the urethra and continue inserting until
egress of urine from the catheter is appreciated. Once with flow of urine, further
advance the catheter by 2-4 cm to ensure that the balloon is well within the bladder.
(The female urethra is about 3.5-4 cm in length)

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b. Males: Gently insert the tip of the catheter into the urethra and continue inserting up to
the “Y” or bifurcation of the catheter to ensure that the balloon is well within the
urinary bladder before inflating it.

Figure 11. Catheter tip inserted all the way into the urinary bladder

Note: Inflating the balloon while it is still in the urethra may cause urethral injury.

D. INFLATE THE CATHETER BALLOON AND ENSURE ANCHORAGE

- Using a syringe filled with 10cc of sterile water, inflate the balloon with 5-10 cc of
sterile water through its port.
- Once inflated, gently pull the proximal portion catheter until resistance is felt. This
resistance denotes that the inflated balloon is seated against the neck of the bladder
ensuring anchorage of the catheter.

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Figure 12. Inflating the balloon with sterile water

Note:
- Volume of sterile water used to inflate the balloon may vary with different catheters.
- Using saline or other IV fluid may cause precipitation of salts in the balloon causing
obstructing and difficulty in deflating the balloon when warranted

E. CONNECT THE CATHETER TO THE DRAINAGE BAG

- Attach the urine port of the catheter to the drainage bag ensuring that the drainage
bag is securely closed to avoid spillage.
- Anchor the catheter to the inguinal area of the patient to avoid accidental yanking.
- Fasten the drainage bag on the side of the bed where convenient.

Figure 13. Proper anchorage of the urethral catheter

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6.CONTINUING CATHETER CARE

a. Remove the catheter at the earliest possible time (as clinically indicated)
b. For indwelling catheters
• Daily care must be provided by cleaning the catheter at the urethral meatus with
povidone iodine. Gently pull the catheter up pulling about 1-2 cm of the catheter
out of the urethral meatus and then swabbing this short area with povidone
iodine.
• Change the catheter with a new one when the urine starts to become cloudy or
when there is suspicion that infection is starting to set in

Reference:
1. Wein, et. al. (2011). Campbell-Walsh Urology 10th Edition. Philadelphia. Saunders

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