A novel two-catheter method for urethral catheterization

improves success rates of urethral catheterization

in female dogs and cats weighing less than ten kilograms
Josephine A. Dornbusch, DVM, MS1; Page E. Yaxley, DVM, DACVECC1; Ashley C. Hechler, DVM, MS, DACVIM2;
Julie K. Byron, DVM, MS, DACVIM1; Laura E. Selmic, BVetMed, MPH, DACVS-SA, DECVS1*

1Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH
2Bark City Veterinary Specialists, Park City, UT
*Corresponding author: Dr. Selmic (Selmic.1@osu.edu)
Received April 26, 2023
Accepted July 27, 2023
doi.org/10.2460/javma.23.04.0209

OBJECTIVE
To compare the success rates for urethral catheterization in clinical patients using the traditional and 2-catheter
techniques when placed by personnel of all experience levels.
ANIMALS
38 female cats and dogs weighing less than 10 kg were prospectively enrolled.
METHODS
Enrolled animals were randomized to have a urethral catheter placed by the traditional technique or the 2-catheter
method under sedation or general anesthesia. Any qualified hospital personnel of any experience level were allowed
to place the catheter. If after 5 minutes the animal was not successfully catheterized, the alternate method was
performed. The previous experience of the catheter placer, animal signalment, animal condition that necessitated
catheter placement, time to successful placement, and which technique was successful was recorded.
RESULTS
The 2-catheter technique was more successful than the traditional method (60.5% and 34.2%, respectively) for ure-
thral catheterization when used by a variety of hospital personnel. The 2-catheter technique was successful in 63.3%
of dogs and 66.6% of cats, while the traditional method was successful in 36.6% of dogs and 33.3% of cats. Eight of
9 (88.9%) novice catheter placers that placed their first urinary catheter in this study succeeded with the 2-catheter
technique and only 1 was successful with the traditional method.
CLINICAL RELEVANCE
The 2-catheter technique has a higher rate of success for placement of female urinary catheters in small patients that
are unable to have concurrent digital palpation. This technique may also be helpful in the inexperienced catheter
placer population to aid in guidance into the urethral papilla.

Keywords: catheter, techniques, urethral, traditional

U rethral catheterization is a common clinical skill

performed by veterinary technicians, general
practitioners, and specialists alike. While there is a
learning curve to successfully placing urethral cath-
eters in female cats and dogs, this skill can be devel-
oped via practice and adaptations to techniques to
improve the success of the procedure. Other stud-
ies have attempted to improve the accuracy of fe-
male urethral catheterization in cats and dogs, such
as methods that utilize a Seldinger technique and
guide wire, or even use of variably sized cylindrical
polypropylene guides in cadavers to aid in successful
catheter placement.1,2
Traditional urethral catheterization in female
dogs uses digital palpation to identify regional ana-
tomic landmarks and permits additional manipu-
lation of the catheter tip to help guide it ventrally
into the urethral orifice.3 Some practitioners may
also add in the use of a speculum or other device
to allow visualization of the urethral papilla.3 Small
dogs, puppies, and cats have an added challenge
because use of concurrent digital palpation or tradi-
tional speculums are unable to be performed due to
the small size of vestibule in this population. Because
of these limitations, the traditional method for these
patients is to blindly pass the catheter toward the

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vaginal canal while directing it ventrally, without ad-
ditional aids to help guide it into the urethral orifice.
The authors of this report have previously described
a novel 2-catheter urethral catheterization technique
designed to improve the accuracy of catheterization
in this population of petite females and identified su-
perior accuracy with this method in populations of
healthy cats and dogs when placed by veterinarians
and veterinary students alike.4,5 This 2-catheter tech-
nique is designed to obstruct the vaginal canal simi-
larly to a finger during digital palpation to help direct
the catheter into the urethra during catheterization
when concurrent digital palpation is not possible, us-
ing readily available supplies that should be present
in most hospital practices.4,5
One of the limitations to previous studies was
the inherent “healthy” patient population, as clinical
disease may make catheterization more technically
challenging. Additionally, the 6 catheter placers from
these reports were able to place multiple urethral
catheters each day, which is not realistic in a clini-
cal setting and may artificially improve the accuracy
of this procedure.4,5 The objective of this prospective
study was to compare the success rates for urethral
catheterization in female cats and dogs weighing
less than 10 kg in the clinical setting using the tra-
ditional and 2-catheter techniques when placed by
personnel of all experience levels. The authors hy-
pothesized that the 2-catheter technique would be
more successful than the traditional method.
Methods
Animals
Female cats and dogs weighing less than 10 kg
that required urethral catheterization at The Ohio
State University Veterinary Medical Center from Au-
gust 1st, 2020, to November 17th, 2023, were pro-
spectively enrolled with informed owner consent.
This study was approved by The Ohio State Univer-
sity Institute of Animal Care and Use Committee
(2018A00000128-R1). Enrolled patients weighed
less than 10 kg and were catheterized either under
sedation or general anesthesia at the discretion of
the overseeing clinician. No animals were transi-
tioned from sedation to general anesthesia or vice
versa during the catheterization process, and the
sedation protocols were not standardized due to
variations in patient conditions. An a priori sample
size calculation using success rates from a previ-
ous study and calculating for a power of 80% and α
of 0.05 was used to determine that 38 animals was
needed to identify a significant difference between
the 2 techniques.5 Patient information collected in-
cluded the animal signalment, weight, reason for
catheterization, if the catheter placer was able to
palpate the urethral papilla, and whether sedation or
general anesthesia was used.
Catheter placers
Individuals placing the urethral catheter, referred to
as catheter placers, could be any qualified personnel of
1624 JAVMA | NOVEMBER 2023 | VOL 261 | NO. 11
any experience level. This included veterinary students,
veterinary technicians, interns, residents, or faculty. In-
formation was collected about the catheter placer in-
cluded their role within the hospital, how many female
urethral catheters they had successfully placed previ-
ously, and how many times they had used the 2-catheter
technique before.
Urinary catheterization
All catheter placers were provided with a printed
instruction pamphlet on how to perform the 2-cath-
eter and traditional techniques which included simple
instructions and visual diagrams (Supplementary Ma-
terial S1). The study protocol was explained to the
catheter placer by the primary author (JAD), who then
remained on speaker phone or in person for the entire
catheter placement procedure to ensure study proto-
col was followed and answered questions as needed.
Catheter placers were randomly assigned a catheter-
ization technique (either the 2-catheter technique or
the traditional method) by a single author (JAD) using
Google coin flip and the study protocol shown in the
flow chart (Figure 1) was followed.
Figure 1—This flow chart shows the study protocol for
each patient that was enrolled. Catheter placers (CPs)
were randomly assigned by coin flip 1 of the 2 tech-
niques to perform—either the traditional method or
the 2-catheter technique. If 5 minutes passed without
successful catheterization using the first technique,
the catheter placer switched to the alternate method.
If the alternate technique was also unsuccessful after 5
minutes, 1 of 3 actions was chosen: the catheter placer
could continue attempting catheterization with either
technique, pass off attempts at catheter placement to a
new catheter placer, or cease attempts entirely.
For the 2-catheter technique, a red rubber cath-
eter (Sovereign feeding tubes; MWI Animal Health;
10-Fr for cats, 18-Fr for dogs) was introduced into
the vestibule and advanced cranially until gentle re-
sistance was met at the cervix to obstruct the vaginal
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canal. The red rubber was left in place and reflected
dorsally out of the way with the non-dominant hand.
Then, a MILA foley indwelling urinary catheter (Foley
Catheters with wire stylet; MILA International; 5-Fr
for cats, 8-Fr for dogs) was passed into the vesti-
bule, directed along ventral midline at approximately
a 45-degree angle, along the ventral surface of the
red rubber catheter until it could be advanced into
the urethral orifice.6
For the traditional method, a MILA foley indwell-
ing urinary catheter (5-Fr for cats, 8-Fr for dogs) was
advanced into the vestibule along ventral midline di-
rected at approximately a 45-degree angle, probing
gently along the ventral surface until it could be ad-
vanced into the urethral orifice. If concurrent digital
palpation was able to be performed this was record-
ed and was allowed.
Statistical analysis
Binary logistic regression was performed (SPSS
statistical software version 28; IBM) to assess for
statistically significant association with successful
catheterization, and success on first catheterization
attempt. Variables including which technique that
was assigned first, species of the animal, whether se-
dation or general anesthesia was used, the catheter
placer’s prior experience with female urethral cathe-
terization, if a catheter placer had previously partici-
pated in this study with another patient, and the first
catheterization attempt on the animal were assessed
for association with catheterization outcome.
Results
Thirty-eight animals (6 cats and 32 dogs) were
prospectively enrolled. Patient conditions that lead
to need for urethral catheterization included in-
tervertebral disk herniation (n = 13), lower urinary
obstruction or cystic calculi (8), renal disease (6),
comatose state (4), to aid in identification of the
urethra during hemipelvectomy surgery (2), ven-
tilator patients (2), and 1 each for maintenance of
patient hygiene for severe wounds, monitoring in a
patient with severe hypotension, and management
of a spinal fracture case. Enrolled canines were clas-
sified as Miniature Dachshund (n = 13), mixed-breed
dog (7), Chihuahua (2), Yorkshire Terrier (2), Shih
Tzu (2), and 1 each of Havanese, Jack Russell Terrier,
Cavalier King Charles Spaniel, Pug, Pekingese, and
Pomeranian. The cats were all classified as domestic
short-, medium-, or long-haired mixed breeds. Four
of the 32 dogs had vaginal diameters of sufficient
size to allow the catheter placer to digitally palpate
the region of the urethral papilla with a pinky finger,
weighing 6.6- to 9.8-kg (mean, 8.3 kg). General an-
esthesia was used in 16 animals, a variety of sedation
protocols were used in 20, and 2 animals required
neither because of comatose states.
Twelve of the 38 animals (31.5%) required a sec-
ond person to attempt urethral catheterization after
the first individual was unsuccessful with both tech-
niques, resulting in a total of 50 catheter placers. Some
of these individuals participated in catheterization of
JAVMA | NOVEMBER 2023 | VOL 261 | NO. 11
more than 1 patient over the course of the study, re-
sulting in 40 unique individuals. Catheter placers had
placed a median of 3 female urinary catheters previ-
ously (range 0 to approximately 100) and had used
the 2-catheter technique a median of 0 times previ-
ously (range, 0 to 13). Only 2 catheter placers had
ever used the 2-catheter technique before participa-
tion in this study, and 12 catheter placers had never
placed any female urinary catheter before this report.
Catheter placers were categorized as follows: resident
(n = 22), veterinary technician (10), intern (9), faculty
(6), and veterinary student (3).
Half (n = 25) of the individuals attempted the tra-
ditional technique first and the other half attempted
the 2-catheter method first. Successful catheteriza-
tion was performed in 36 of 38 pets using the tradi-
tional (n = 13 [34.2%]) and 2-catheter (23 [60.5%])
techniques, respectively. The first attempt at cath-
eterization was associated with a higher likelihood
of successful catheterization (P < .001), and the
technique used that ultimately resulted in success-
ful catheterization was not significant (P = .1). When
success rates were analyzed by species, cats were
successfully catheterized with the traditional and
2-catheter techniques in 33.3% (n = 2) and 66.6% (n
= 4) of cases respectively, while dogs were success-
fully catheterized with the traditional and 2-catheter
in 36.6% (n = 11) and 63.3% (19) respectively. All 4
dogs that were able to have concurrent digital pal-
pation during attempts at the traditional method
were successfully catheterized, 3 with the 2-catheter
technique (2 of which were successful with a second
catheter placer after the first was unable to catheter-
ize) and 1 with the traditional method. Five of the
6 cats were successfully catheterized with the first
catheterization technique the catheter placer was
assigned, while only 1 needed conversion to the
alternate method. More detailed results using each
technique are provided (Figure 2).
Nine novice catheter placers were able to suc-
cessfully place their first female urethral catheter
during this study (6 were assigned the 2-catheter
technique first, and 3 were assigned the traditional
method first). Eight of these 9 (88.9%) were success-
ful with the 2-catheter technique and only 1 novice
catheter placer was successful with the traditional
method. The technique that was successful was not
significantly associated with catheter placer previ-
ous experience at traditional urethral catheteriza-
tion (P = .08). Two patients were never able to be
catheterized and attempts were eventually ceased.
Time to successful catheterization was longer with
the 2-catheter technique compared to the tradition-
al method at a median of 97.4 (range, 15.4 to 306)
seconds compared to 41.95 (range, 12.9 to 220.1)
seconds. General anesthesia was more likely to re-
sult in successful catheterization with the traditional
technique with an OR of 4.3 (P = .049). Which tech-
nique was successful was not significantly associated
with patient species (P = .88) or the weight of the
patient (P = .65). Which technique was assigned first
(P = .06), the species of the animal (P = .16), whether
sedation or general anesthesia was used (P = .53),
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Figure 2—Results of each catheter placer are shown here (50 catheter placers for the 38 animals). This chart dis-
plays how many successful or unsuccessful catheterizations were performed on the first attempt and the number of
instances catheter placers were required to switch to the alternate method. Instances where a catheter placer was
unsuccessful using the second technique resulted in switching to an alternate catheter placer. There were only 2
patients that were never able to be successfully catheterized.

the catheter placer’s prior experience with female

urethral catheterization (P = .52), and if a catheter
placer had previously participated in this study with
another patient (P = .33) were not associated with
catheterization success rate.

Discussion
The results from this study show that urethral
catheterization can be performed in clinical patients
weighing less than 10 kg with a higher rate of suc-
cess using the 2-catheter technique (60.5%) than the
traditional technique (34.2%), though this trended
toward significance but was not statistically sig-
nificant. Urethral catheterization in females is more
technically challenging than in males, with variable
success rates depending on personnel experience
and patient condition.1–3 This study used a heterog-
enous population of catheter placers with a wide va-
riety of experience levels and patients with various
clinical conditions which may have made some cases
more challenging. Despite this mixture of popula-
tions which may have lowered overall success rates
within both groups, the 2-catheter technique result-
ed in a higher success rate that the authors believe to
be significant for the clinical setting.
Previous experience with female urethral cath-
eterization varied within catheter placers, with indi-
viduals that had previously placed an estimated 100
urethral catheters to 12 novice individuals who had
never successfully placed any prior to participation in
this study. Nine of those novice catheter placers were
able to successfully place their first urethral catheter
during this study, 88.9% of them using the 2-catheter
technique. A visual representation (Figure 3) was
able to show which technique a catheter placer was
successful with when stratified by experience level
Figure 3—A histogram showing which technique was
used to successfully place the urethral catheter is shown
here. Along the x-axis, catheter placers were grouped
based on the number of successfully placed female uri-
nary catheters the individual had placed prior to partici-
pation in this study. The 2-catheter technique was more
successful in this population than the traditional method,
with less experienced catheter placers having higher
proportions of success using the 2-catheter technique,
and more modest portions of more experienced catheter
placers successfully using the 2-catheter method.
and noted higher rates of success using the 2-cath-
eter technique, which was even more pronounced in
the less experienced catheter placer groups. While
not directly assessed during this report as this study
was not designed to evaluate successful technique
based on catheter placer experience, inexperienced
catheter placers may find the aid of the red rubber
catheter within the vaginal canal helpful in guid-
ing the urethral catheter into the urethral papilla in
this challenging patient population compared to the
traditional method.
Time to successful catheterization was longer us-
ing the 2-catheter technique (at approximately one
and a half minutes) compared to just under a min-
ute for the traditional method. This time difference

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would not be clinically significant in a hospital setting
as it would still save substantial time by avoiding the
need to find an additional staff member to perform
the technique from scratch. Improving the likelihood
of successful catheterization can theoretically de-
crease the number of personnel needed to perform
this procedure, leaving veterinary team members free
for other tasks at a time when veterinary teams are
frequently short-staffed.7
Only 2 of the catheter placers that participated
in this study had experience with the 2-catheter
technique prior to participation in this study, and
only participated when at least 1 other individual
had failed to catheterize a patient. The remaining
catheter placers learned the 2-catheter technique
with a verbal explanation and standardized visual aid
(Supplementary Material S1). Variations in learning
styles and experience of the catheter placers may
have altered the rate or time to successful catheter
placement with either method. Additionally, patients
with lower urinary obstruction that required de-
obstruction, or patients that were provided with a
lighter plane of sedation, may have been more tech-
nically challenging to catheterize. Variables in pa-
tient condition and catheter placer experience may
have altered success rates for successful catheteriza-
tion in this study.
The 2-catheter technique provides an alternate
method to place urethral catheters in a technically
challenging patient population with a high rate of suc-
cess and can be considered as a good alternative in a
< 10-kg patient population, or patients where concur-
rent digital palpation is either not possible or is more
limited due to vaginal diameter. This technique may
also be easier for novice or less experienced catheter
placers that are not as familiar with the regional anat-
omy based on the results from this report.
JAVMA | NOVEMBER 2023 | VOL 261 | NO. 11
Acknowledgments
This study was funded by the AKC Canine Health Foun-
dation Clinician-Scientist Fellowship Program (JAD).
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Supplementary Materials
Supplementary materials are posted online at the journal
website: avmajournals.avma.org
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