INTRODUCTION

Urethral catheterization is a routine medical procedure that facilitates direct drainage of the

urinary bladder. It may be used for diagnostic purposes (to help determine the etiology of

various genitourinary conditions) or therapeutically (to relieve urinary retention, instill

medication, or provide irrigation). Catheters may be inserted as an in-and-out procedure for

immediate drainage, left in with a self-retaining device for short-term drainage (eg, during

surgery), or left indwelling for long-term drainage for patients with chronic urinary retention.

Patients of all ages may require urethral catheterization, but patients who are elderly or

chronically ill are more likely to require indwelling catheters, which carry their own

independent risks. Newman DK. (2017).

In urinary catheterization, a latex, polyurethane, or silicone tube known as a

urinary catheter is inserted into the bladder through the urethra to allow urine to drain from

the bladder for collection. It may also be used to inject liquids used for treatment or diagnosis

of bladder conditions. A clinician, often a nurse, usually performs the procedure, but self-

catheterization is also possible. A catheter may be in place for long periods of time

(indwelling catheter) or removed after each use (intermittent catheterization). Thomsen TW,

Setnik GS. (2018).

Urinary catheters come in many sizes; can be used by men, women and children; and are

generally needed when someone is unable to empty his or her bladder. Most people require

the use of catheters for a short period of time; however, those with a severe illness or injury

may need to use urinary catheters for a much longer period of time. Haider MZ, Annamaraju

P. (2021).

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DEFINITION

Urinary catheterization refers to the insertion of a catheter tube through the urethra and into

the bladder to drain urine. Although not a particularly complex skill, urethral catheterization

can be difficult to master. Both male and female catheterizations present unique challenges.

Newman DK. (2017).

TYPES

There are 3 main types of catheters:

 Indwelling catheter

 Condom catheter

 Intermittent self-catheter

Indwelling Urethral Catheters

An indwelling urinary catheter is one that is left in the bladder. You may use an indwelling

catheter for a short time or a long time. Haider MZ, Annamaraju P. (2021).

An indwelling catheter collects urine by attaching to a drainage bag. The bag has a valve that

can be opened to allow urine to flow out. Some of these bags can be secured to your leg. This

allows you to wear the bag under your clothes. An indwelling catheter may be inserted into

the bladder in 2 ways:

 Most often, the catheter is inserted through the urethra. This is the tube that carries

urine from the bladder to the outside of the body.

 Sometimes, the provider will insert a catheter into your bladder through a small hole

in your lower belly. This is done at a hospital or provider's office.

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An indwelling catheter has a small balloon inflated on the end of it. This prevents the catheter

from sliding out of your body. When the catheter needs to be removed, the balloon is

deflated.

Condom Catheters

Condom catheters can be used by men with incontinence. There is no tube placed inside the

penis. Instead, a condom-like device is placed over the penis. A tube leads from this device to

a drainage bag. The condom catheter must be changed every day. Davis JE, Silverman MA.

(2019).

Intermittent Catheters

You would use an intermittent catheter when you only need to use a catheter sometimes or

you do not want to wear a bag. You or your caregiver will insert the catheter to drain the

bladder and then remove it. This can be done only once or several times a day. The frequency

will depend on the reason you need to use this method or how much urine needs to be drained

from the bladder. Haider MZ, Annamaraju P. (2021).

WHY URINARY CATHETERS ARE USED

A urinary catheter is usually used in people who have difficulty passing urine naturally. It can

also be used to empty the bladder before or after surgery and to help perform certain tests.

Panicker JN, et al., (2022).

Specific reasons include:

 to allow urine to drain if you have an obstruction in the tube that carries urine out of

the bladder (urethra) – for example, because of scarring or prostate enlargement

 to allow you to urinate if you have bladder weakness or nerve damage which affects

your ability to pee

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  to drain your bladder during childbirth, if you have an epidural anaesthetic

 to drain your bladder before, during and/or after some types of surgery, such as

operations on the womb, ovaries or bowels

 to deliver medication directly into the bladder, such

as during chemotherapy for bladder cancer

 as a treatment for urinary incontinence when other types of treatment haven’t worked

The catheter will be used until it’s no longer needed. This may be for a short time and will

be removed before leaving hospital, or it may be needed for longer or even permanently.

Panicker JN, et al., (2022).

INDICATIONS

Diagnostic indications include the following:

 Collection of uncontaminated urine specimen

 Monitoring of urine output

 Imaging of the urinary tract

Therapeutic indications include the following:

 Acute urinary retention (eg, benign prostatic hypertrophy, blood clots) [3]

 Chronic obstruction that causes hydronephrosis [4]

 Initiation of continuous bladder irrigation

 Intermittent decompression for neurogenic bladder

 Hygienic care of bedridden patients

Sabharwal S. (2019).

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CONTRAINDICATIONS

Urethral catheterization is contraindicated in the presence of traumatic injury to the lower

urinary tract (eg, urethral tear). This condition may be suspected in male patients with a

pelvic or straddle-type injury. Signs that increase suspicion for injury are a high-riding or

boggy prostate, perineal hematoma, or blood at the meatus. When any of these findings are

present in the setting of possible trauma, a retrograde urethrogram should be performed to

rule out a urethral tear prior to placing a catheter into the bladder. Sabharwal S. (2019).

PREPARATION

Anesthesia

Topical anesthesia is administered with lidocaine gel 2%. Many facilities have a preloaded

syringe with an opening appropriate for insertion into the meatus available either separately

or in the catheter kit. To instill, hold the penis firmly and extended, place the tip of the

syringe in the meatus, and apply gentle but continuous pressure on the plunger. A gloved

finger should be placed at the urethral tip and held for a couple of minutes to allow the

anesthetic to take effect. Shuman EK, et al. (2018).

Equipment

Equipment includes a commercial single-use urethral catheterization tray (see the image

below) and a sterile anesthetic lubricant (eg, lidocaine gel 2%) with a blunt tip urethral

applicator or a plastic syringe (5-10 mL).

The contents of the catheterization tray are as follows:

 Povidone-iodine

 Sterile cotton balls

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  Water-soluble lubrication gel

 Sterile drapes

 Sterile gloves

 Urethral catheter

 Prefilled 10-mL saline syringe

 Prefilled 10-mL saline syringe

Catheter types and sizes

Catheter sizes and types are as follows (see the images below):

 Adults - Foley (straight tip) catheter (16-18F)

 Adult males with obstruction at the prostate - Coudé tip (18 F)

 Adults with gross hematuria - Foley catheter (20-24F) or 3-way irrigation

catheter (20-30F)

 Children - Foley; to determine size, divide child's age by 2 and then add 8

 Infants younger than 6 months - Feeding tube (5F) with tape

Catheter materials include the following:

 Latex

 Silastic (pure silicone or silicone-coated)

 Silver alloy

 Antibiotic-impregnated

POSITIONING

Place the patient supine, in the frogleg position, with knees flexed. Shuman EK, et al. (2018).

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CATHETERIZATION TECHNIQUE

 Explain the procedure, benefits, risks, complications, and alternatives to the patient or the

patient's representative.

 Position the patient supine, in bed, and uncover the genitalia.

 Open the catheter tray and place it on the gurney in between the patient’s legs; use the

sterile package as an extended sterile field. Open the iodine/chlorhexidine preparatory

solution and pour it onto the sterile cotton balls. Open a sterile lidocaine 2% lubricant

with applicator or a 10-mL syringe and sterile 2% lidocaine gel and place them on the

sterile field.

 Don the sterile gloves and use the nondominant hand to hold the penis and retract the

foreskin (if present). This hand is the nonsterile hand and holds the penis throughout the

procedure.

 Use the sterile hand and sterile forceps to prep the urethra and glans in circular motions

with at least 3 different cotton balls. Use the sterile drapes that are provided with the

catheter tray to create a sterile field around the penis.

 Using a syringe with no needle, instill 5-10 mL of lidocaine gel 2% into the urethra. Place

a finger on the meatus to help prevent spillage of the anesthetic lubricant. Allow 2-3

minutes before proceeding with the urethral catheterization.

 Hold the catheter with the sterile hand or leave it in the sterile field to remove the cover.

Apply a generous amount of the nonanesthetic lubricant that is provided with the catheter

tray to the catheter.

 While holding the penis at approximately 90° to the gurney and stretching it upward to

straighten out the penile urethra, slowly and gently introduce the catheter into the urethra.

Continue to advance the catheter until the proximal Y-shaped ports are at the meatus.

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 Wait for urine to drain from the larger port to ensure that the distal end of the catheter is

in the urethra. The lubricant jelly–filled distal catheter openings may delay urine return. If

no spontaneous return of urine occurs, try attaching a 60-mL syringe to aspirate urine. If

urine return is still not visible, withdraw the catheter and reattempt the procedure

(preferably after using ultrasonography to verify the presence of urine in the bladder).

 After visualization of urine return (and while the proximal ports are at the level of the

meatus), inflate the distal balloon by injecting 5-10 mL of 0.9% NaCl (normal saline)

through the cuff inflation port. Inflation of the balloon inside the urethra results in severe

pain, gross hematuria, and, possibly, urethral tear.

 Gently withdraw the catheter from the urethra until resistance is met. Secure the catheter

to the patient's thigh with a wide tape. Creating a gutter to elevate the catheter from the

thigh may increase the patient's comfort. If the patient is uncircumcised, make sure to

reduce the foreskin, as failure to do so can cause paraphimosis.

Bono MJ, et al. (2021).

Insertion of a Coudé Catheter

The Coudé catheter, which has a stiffer and pointed tip, was designed to overcome urethral

obstruction that a more flexible catheter cannot negotiate (eg, in patients with benign

prostatic hypertrophy). To place a Coudé catheter, follow the procedure described above. The

elbow on the tip of the catheter should face anteriorly to allow the small rounded ball on the

tip of the catheter to negotiate the urogenital diaphragm. Bono MJ, et al. (2021).

Perineal Pressure Assistance

The distal tip of the catheter might become caught in the posterior fold between the urethra

and the urogenital diaphragm. An assistant can apply upward pressure to the perineum while

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the catheter is advanced to direct the catheter tip upward through the urogenital diaphragm.

Bono MJ, et al. (2021).

URETHRAL CATHETER REMOVAL

 Use a syringe to empty the balloon, and then apply gentle traction. Pain, severe

discomfort, resistance to withdrawal of the catheter, or failure to aspirate normal saline

through the inflation valve should alert the practitioner to the possibility of a nondeflating

urethral catheter.

 The most common cause of a nondeflating urethral catheter is obstruction of the inflation

channel, caused by a failed inflation valve or crystallization of the inflation fluid.

 The first step in managing the nondeflating Foley balloon is to advance the catheter to

ensure that it is actually in the bladder.

 If this does not work, cut the balloon port proximal to the inflation valve. This removes

the valve and should allow the water to spontaneously drain.

 If this does not work, run a lubricated fine-gauge guidewire through the inflation channel.

The guidewire or stylet should allow fluid to drain along the wire itself.

 If this does not work, a 22-gauge central venous catheter can be passed over the

guidewire. When the catheter tip is in the balloon, the wire can be removed, and the

balloon should drain.

 If the above techniques are unsuccessful, 10 mL of mineral oil may be injected through

the inflation port and will dissolve the balloon within 15 minutes. If this does not occur,

an additional 10 mL can be instilled.

 If none of the above techniques are successful, a urologist should be consulted to rupture

the Foley balloon with a sharp instrument.

Hazelett SE, Tsai M, Gareri M, Allen K. (2018).

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POST-PROCEDURE

COMPLICATIONS

Complications include the following:

 Infections, including urethritis, cystitis, pyelonephritis, and transient bacteremia

 Paraphimosis, caused by failure to reduce the foreskin after catheterization

 Creation of false passages

 Urethral strictures

 Urethral perforation

 Bleeding

Noninfectious complications of short- and long-term catheterization include accidental

removal, catheter blockage, gross hematuria, and urine leakage, and these are at least as

common as clinically significant urinary tract infections in this patient population. In patients

who have subclinical bacteriuria, the catheter can become obstructed as a result of sediment

buildup. Villanueva C, Hemstreet GP. (2018).

INDICATIONS FOR URETHRAL CATHETERIZATION IN A MALE

 Relief of acute or chronic urinary retention, such as due to urethral or prostatic

obstruction (obstructive uropathy) or neurogenic bladder

 Treatment of urinary incontinence

 Monitoring of urine output

 Measurement of postvoid residual urine volume

 Collection of sterile urine for culture (usually for infants and women only)

 Diagnostic studies of the lower genitourinary tract

 Bladder irrigation or instillation of medication

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CONTRAINDICATIONS TO URETHRAL CATHETERIZATION IN A MALE

Absolute contraindications

 Suspected urethral injury

Relative contraindications

 History of urethral strictures

 Current urinary tract infection (UTI)

 Prior urethral reconstruction

 Recent urologic surgery

 History of difficult catheter placement

*Urethral injury may be suspected following blunt trauma if patients have blood at the

urethral meatus (most important sign), inability to void, or perineal, scrotal, or penile

ecchymosis, and/or edema. In such cases, urethral disruption should be ruled out with

imaging (eg, by retrograde urethrography) before attempting urethral catheterization.

COMPLICATIONS OF URETHRAL CATHETERIZATION IN A MALE

Complications include

 Injury to the urethra, prostate, or bladder with bleeding (common)

 UTI (common)

 Creation of false passages

 Scarring and urethral strictures

 Paraphimosis, if the foreskin is not reduced after the procedure

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EQUIPMENT FOR URETHRAL CATHETERIZATION IN A MALE

Prepackaged kits are typically used but the individual items needed include

 Sterile drapes and gloves

 Povidone iodine with application swabs, cotton balls, or gauze

 Water-soluble lubricant

 Urethral catheter (size 16 French Foley catheter is appropriate for most men; in the

setting of prostatic hypertrophy or urethral stricture, an alternate size or style of

catheter may be required)

 10-mL syringe with sterile water (for catheter balloon inflation)

 Local anesthetic (eg, 5 to 10 mL of 2% lidocaine jelly in a syringe [with no needle])

for distention and anesthesia of the male urethra

 Sterile collection device with tubing

*A closed-catheter system minimizes catheter-associated UTI.

†A coudé catheter is curved at the end and may facilitate passage in a male with significant

prostatic hypertrophy.

Villanueva C, Hemstreet GP. (2018).

Additional Considerations for Urethral Catheterization in a Male

 Sterile technique is necessary to prevent a lower urinary tract infection.

Relevant Anatomy for Urethral Catheterization in a Male

 The male urethra bends acutely at the pubis. Always hold the penis straight and

upright, to smooth out the curve, when passing a catheter through the urethra.

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Positioning for Urethral Catheterization in a Male

 Position the patient supine with hips comfortably abducted.

INDICATIONS FOR URETHRAL CATHETERIZATION IN A FEMALE

 Relief of acute or chronic urinary retention, such as due to urethral obstruction

(obstructive uropathy) or neurogenic bladder

 Treatment of urinary incontinence

 Monitoring of urine output

 Measurement of postvoid residual urine volume

 Collection of sterile urine for culture

 Diagnostic studies of the lower genitourinary tract

 Bladder irrigation or instillation of medication

CONTRAINDICATIONS TO URETHRAL CATHETERIZATION IN A FEMALE

Absolute contraindications

 None

Relative contraindications

 History of urethral strictures

 Current urinary tract infection (UTI)

 Prior urethral reconstruction

 Suspected urethral injury

 Recent urologic surgery

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  History of difficult catheter placement

*Urethral injury may be suspected following blunt trauma if patients have blood at the

urethral meatus (most important sign), inability to void, or perineal or labial ecchymosis,

and/or edema. In such cases, urethral disruption should be ruled out with imaging (eg, by

retrograde urethrography and sometimes also cystoscopy) before doing urethral

catheterization. Newman DK. (2017).

COMPLICATIONS OF URETHRAL CATHETERIZATION IN A FEMALE

Complications include

 Urethral or bladder trauma with bleeding or microscopic hematuria (common)

 UTI (common)

 Creation of false passages

 Scarring and strictures

EQUIPMENT FOR URETHRAL CATHETERIZATION IN A FEMALE

Prepackaged kits are typically used but the individual items needed include

 Sterile drapes and gloves

 Povidone iodine

 Applicator swabs, sterile gauze, or cotton balls

 Water-soluble lubricant

 Urethral catheter (size 16 French Foley catheter is appropriate for most adult

women)*

 10-mL syringe with water (for catheter balloon inflation)

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  Sterile collection device with tubing

POSITIONING FOR URETHRAL CATHETERIZATION IN A FEMALE

 To expose the vulva, position the patient supine in either lithotomy or frog position

(hips and knees partially flexed, heels on the bed, hips comfortably abducted).

Newman DK. (2017).

PREVENTING INFECTION

Everyday care of the catheter and drainage bag is important to reduce the risk of infection.
Such precautions include:

 Urinary catheterization should be done in a sterile aseptic manner.

 Cleansing the urethral area (the area where the catheter exits body) and the catheter
itself.

 Disconnecting the drainage bag from catheter only with clean hands

 Disconnecting the drainage bag as seldom as possible.

 Keeping the drainage bag connector as clean as possible and cleaning the drainage
bag periodically.

 Use of a thin catheter where possible to reduce the risk of harming the urethra during
insertion.

 Drinking sufficient liquid to produce at least two litres of urine daily

 Sexual activity is very high risk for urinary infections, especially for catheterized
women.

There is no clear evidence that any one catheter type or insertion technique is superior
compared to another in preventing infections or complications. In the UK it is generally
accepted that cleaning the area surrounding the urethral meatus with 0.9% sodium chloride
solution is sufficient for both male and female patients as there is no reliable evidence to
suggest that the use of antiseptic agents reduces the risk of urinary tract infection. Villanueva

15
C, Hemstreet GP. (2018).

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SUMMARY/CONCLUSION

A urinary catheter is a tube placed in the body to drain and collect urine from the bladder.

Urinary catheters are used to drain the bladder. Your health care provider may recommend

that you use a catheter if you have:

 Urinary incontinence (leaking urine or being unable to control when you urinate)

 Urinary retention (being unable to empty your bladder when you need to)

 Surgery on the prostate or genitals

 Other medical conditions such as multiple sclerosis, spinal cord injury, dementia, or

other operations

Catheters come in many sizes, materials (latex, silicone, Teflon), and types (straight or coude

tip). A Foley catheter is a common type of indwelling catheter. It has soft, plastic or rubber

tube that is inserted into the bladder to drain the urine.

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Davis JE, Silverman MA. Urologic procedures. In: Roberts JR, Custalow CB, Thomsen TW,
eds. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute
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Haider MZ, Annamaraju P. Bladder catheterization. StatPearls [Internet]. 2021 Jan.

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