Urinary Catheterization

Urinary or Urethral catheterization is a process in which a urinary catheter (such as a Foley catheter) is either inserted through a female patient's urinary tract into their bladder or attached to a male patient's penis. A balloon located at the end of the catheter is usually inflated with sterile water to prevent the catheter from slipping out. In this manner, the patient's urine is collected and contained for various medical purposes. The procedure of catheterization will usually be done by a clinician, often a nurse, although self-catheterization is possible as well.

Urinary catheterization is a routine medical procedure that has both diagnostic and therapeutic purposes.

Types of Catheterization

Catheters come in a large variety of sizes; materials (latex, silicone, PVC, or Teflon); and types (Foley catheter, straight catheter, or coude tip catheter). In the case of internal catheters, those inserted into the urethra, the smallest size is usually recommended, although a larger size is sometimes needed to control leakage of urine around the catheter. A large size can also become necessary when the urine is thick, bloody or contains large amounts of sediment. Larger internal catheters, however, are more likely to cause damage to the urethra. Some people have developed allergies or sensitivities to latex after long-term latex catheter use. In such cases, silicone or Teflon types should be used.

Proper catheter use can also often be determined by the length of time for which the process is necessary: long-term (often called indwelling) or short-term use.

Sex Differences

In males, the catheter tube is inserted into the urinary tract through the penis. A condom catheter can also be used. In females, the catheter is inserted into the urethral meatus, after a cleansing using povidone-iodine. The procedure can be complicated in females due to varying layouts of the genitalia (due to age, obesity, Female genital cutting, childbirth, or other factors), but a good clinician should rely on anatomical landmarks and patience when dealing with such a patient.

Indication

Diagnostic

o Collection of uncontaminated urine specimen
o Monitoring of urine output
o Imaging of the urinary tract

Therapeutic

o Acute urinary retention (eg, benign prostatic hypertrophy, blood clots)
o Chronic obstruction that causes hydronephrosis
o Initiation of continuous bladder irrigation
o Intermittent decompression for neurogenic bladder
o Hygienic care of bedridden patients

Contraindication

Urinary 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 concerning trauma, a retrograde urethrogram should be performed to rule out a urethral tear prior to placing a catheter into the bladder.

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.

Equipment

Commercial single-use urethral catheterization tray

o Povidone iodine
o Sterile cotton balls
o Water-soluble lubrication gel
o Sterile drapes
o Sterile gloves
o Urethral catheter
o Prefilled 10-mL saline syringe
o Urinometer connected to a collection bag

Sterile anesthetic lubricant (eg, lidocaine gel 2%) with a blunt tip urethral applicator or a plastic syringe (5-10 mL)

Positioning

Place the patient supine, in the frogleg position, with knees flexed.

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.

· Wear 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 90º 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.

· 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.

Pearls

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, 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.

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

Complications

-Infections

o Urethritis
o Cystitis
o Pyelonephritis
o Transient bacteremia

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

-Creation of false passages

-Urethral strictures

-Urethral perforation

-Bleeding

Open Section

* Prophylactic antibiotics are recommended for patients with prosthetic heart valves, artificial urethral sphincters, or penile implants.

* Catheter types and sizes

o Adults: Foley (16-18 F)
o Adults with obstruction at the prostate: Coudé (18 F)
o Children: Foley (5-12 F)
o Infants younger than 6 months: Feeding tube (5 F) with tape

Reference

http://www.emedicine.com
Served as Primary source.

http://www.wikipedia.org
Served as Secondary source.

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