What are the procedures in attaching catheter to a male and female patient?

Overview

Urinary catheters are used for a wide variety of indications including to relieve urinary retention, measure urine output and collect urine samples.

Male catheterisation can be more difficult and higher risk than female catheterisation due to the length and course of the male urethra.

• Indications for catherisation are:
• Bladder drainage - for relief of acute urinary retention or bladder outlet obstruction
• Prevention of urinary retention due to clots
• Measurement of urine output
• Perioperative use - urologic surgery, prolonged surgery, large volumes of intraoperative infusion or diuretics, intraoperative urine output measurement
• Urine specimen collection in patients who are unable to voluntarily void
• To assist in the healing of perineal wounds in incontinent patients
• Instillation of medications into the bladder

• Contraindications to catheterisation include:
• Urethral trauma - e.g. due to pelvic fracture
• Urethral stricture
• Recent urologic surgery (men) - discuss with a urologist first

Urinary catherisation is not always appropriate - particularly given the risk of infection while a catheter is in situ. Catheters should not be used to control urinary incontinence, or manage confused patients. Prolonged bed rest is also not an indication for insertion. While catheters are often inserted to allow measuring of urine output, this is generally not required and in fact invasive then hourly urine output measuring is not required.

Equipment and Preparation

• The following are required for catheter insertion:
• Catheterisation pack
• Sterile gloves
• DecontaminantE.g. chlorhexidine
• LubricantWater-based lubricant
• Xylocaine gel (males)
• Foley catheterChoose right right size - generally 12-14Fr
• Kidney dishTo collect urine initially
• 10mL syringeTo inflate the balloon
• Sterile waterTo inflate the balloon
• Drainage bag

• Choosing a catheter

• A larger catheter is usually easier - go up a size rather than down if insertion is difficult.

• There are several types of catheters:
• Straight, single lumen - for collection of urinary specimens
• Double lumen (with balloon) - most patients
• Triple lumen - continuous irrigation for patients with clots or haematuria or post urologic surgery

• Catheter Size Guide

• 6-10 French - paediatric patients
• 12-14 French - most patients
• 16-20 French - patients with clots or haematuria
• 22 French (triple lumen) - continuous irrigation for patients with clots or haematuria or post urologic surgery

Catheter Insertion

• Introduction

• Explain the procedure and gain the patient's consent.
• Position the patient, supine with the legs spread and feet together.

• Preparation

• Place a drape underneath the patient's buttocks.
• Prepare your sterile field, placing all required equipment on the field in a sterile manner.
• Don and apron and googles, then scrub and don sterile gloves.
• Prepare the periurethral area, using a decontaminant such as chlorhexidine. Decontaminate a wide area. In a male, start with the glans and withdraw the foreskin in order to completely cover the area.
• Apply the fenestrated drape, and place the kidney dish between the patient's legs.

• Insertion

• Separate the labia, or elevate the penis straight upward using the non-dominant hand.
• In males, inject xylocaine gel through the urethra and hold the meatus closed in order to allow it to have an effect.
• Insert the catheter gently until urine starts draining, and use the kidney dish to collect this. In males, insert the catheter to the hilt; in females insert it until urine drains and then a further few cm.
• Inflate the balloon of the catheter using the volume of sterile water indicated on the catheter (this is usually 10mL).
• Retract the catheter until resistance is felt.
• Connect the drainage bag
• Secure the catheteras required.
• Remember to replace the foreskin in males!

• Finishing Up

• Dispose of all waste
• Remove gloves and wash your hands.

Complications

• Potential complications of urinary catheterisation include:
• Traumatic insertion - resulting in haematuria, false passage creation or urethral strictures
• Urinary tract infection - cystitis, pyelonephritis or sepsis
• Iatrogenic hypospadiasErosion of the urethral meatus due to downward pressure
• Bladder stonesParticularly with long-term catheterisation
• Bladder cancerRate, but long-term catheterisation is a risk factor

• Traumatic Insertion

• While inserting an indwelling catheter, it is possible to damage the urethral mucosa or even perforate the urethral wall, creating a false passage.

Clinical features of traumatic insertion include haematuria (blood in the urine bag) or urinary retention due to clots.

This can be prevented by using adequate lubrication, and inserting the catheter gently - don't push too hard against resistance.

• Urinary Tract Infection

• Catheterisation, and particularly long-term catheterisation, is associated with infection - this may manifest as cystitis, pyelonephritis or sepsis.

The catheter acts as a bridge for ascension of bacteria into the bladder; and residual urine within the bladder increased the risk of infection. Biofilms may develop which make the infection more difficult to eradicate.

Clinical features of cystitis (bladder infection) include burning around the catheter, the urge to urinate, lower abdominal pain, cloudy or bloody urine, and foul-smelling urine. Pyelonephritis (kidney infection) may manifest with fevers, nausea, vomiting and flank pain.

Catheter-associated UTIs can be prevented by inserting catheters only when clinical indicated; by rationalising the duration of the catheter; and by changing the catheter regularly if it is in long-term.

• Iatrogenic Hypospadias

• Erosion of the urethral meatus may occur following catheter insertion in males. This occurs due to continuous downward pressure of a long-term catheter on the meatus. 

This may manifest early with erythema surrounding the meatus, and eventually the mucosa will start to break down and erosion can occur. This may be associated with infection.

This complication can be prevented by fixing the catheter to the lower abdomen, in order to prevent downward pressure.

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References

 Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infection Control & Hospital Epidemiology. 2010 Apr 1;31(04):319-26. Igawa Y, Wyndaele JJ, Nishizawa O. Catheterization: possible complications and their prevention and treatment. International Journal of Urology. 2008 Jun 1;15(6):481-5. Lam TB, Omar MI, Fisher E, Gillies K, MacLennan S. Types of indwelling urethral catheters for short‐term catheterisation in hospitalised adults. The Cochrane Library. 2014 Jan 1. Willette PA, Coffield SK. Current trends in the management of difficult urinary catheterizations. Western Journal of Emergency Medicine. 2012 Jan 1;13(6).