Urinary catheterization is the insertion of a catheter through the urethra into the urinary bladder for withdrawal of urine. Straight catheters are used for intermittent withdrawals, while indwelling (Foley) catheters are inserted and retained in the bladder for continuous drainage of urine into a closed system.
Intermittent catheterization is used for the following reasons:
- Obtaining a sterile urine specimen for diagnostic evaluation.
- Emptying bladder contents when an individual is unable to void (urinate) due to urinary retention, bladder distention, or obstruction.
- Measuring residual urine after urinating.
- Instilling medication for a localized therapeutic effect in the bladder.
- Instilling contrast material (dye) into the bladder for cystourethralgraphy (x-ray study of the bladder and urethra).
- Emptying the bladder for increased space in the pelvic cavity to protect the bladder during labor and delivery or during pelvic and abdominal surgery.
- Monitoring accurately the urinary output and fluid balance of critically ill patients.
Indwelling catheterization is used for the following reasons:
- Providing palliative care for incontinent persons who are terminally ill or severely impaired, for whom bed and clothing changes are uncomfortable.
- Managing skin ulceration caused or exacerbated by incontinence.
- Maintaining a continuous outflow of urine for persons undergoing surgical procedures that cause a delay in bladder sensation, or for individuals with chronic neurological disorders that cause paralysis or loss of sensation in the perineal area.
- Included in standard preoperative preparation for urologic surgery and procedures for bladder outlet obstruction.
- Providing relief for persons with an initial episode of acute urinary retention, allowing their bladder to regain its normal muscle tone.
As of 2002, experts estimate that approximately 96 million urinary catheters are sold annually throughout the world. Men are less likely than women to use them.
The male urethral orifice (urinary meatus) is a vertical, slit-like opening, 0.15–0.2 in (4–5 mm) long, located at the tip of the penis. The foreskin of the penis may conceal the opening. This must be retracted to view the opening to be able to insert a catheter. With proper positioning, good lighting, and gloved hands, these anatomical landmarks can be identified. Perineal care or cleansing may be required to ensure a clean procedural environment.
The male urethra is longer than the female urethra and has two curves in it as it passes through the penis to the bladder. Catheterization of the male patient is traditionally performed without the use of local anesthetic gel to facilitate catheter insertion. Glands along the urethra provide some natural lubrication. Older men may require lubrication. In such an instance, an anesthetic or antibacterial lubricant should be used.
Once the catheter is inserted, it is secured as appropriate for the catheter type. A straight catheter is typically secured with adhesive tape. An indwelling catheter is secured by inflating a bulb-like device inside of the bladder.
Health-care practitioners performing the catheterization should have a good understanding of the anatomy and physiology of the urinary system, be trained in antiseptic techniques, and have proficiency in catheter insertion and catheter care.
After determining the primary purpose for the catheterization, practitioners should give the male patient and his caregiver a detailed explanation. Men requiring self-catheterization should be instructed and trained in the technique by a qualified health professional.
Sterile disposable catheterization sets are available in clinical settings and for home use. These sets contain most of the items needed for the procedure, such as antiseptic agent, gloves, lubricant, specimen container, label, and tape. Anesthetic or antibacterial lubricant, catheter, and a drainage system may need to be added.
TYPES. Silastic catheters have been recommended for short-term catheterization after surgery because they are known to decrease incidence of urethritis (inflammation of the urethra). However, due to lower cost and acceptable outcomes, latex is the catheter of choice for long-term catheterization. Silastic catheters should be reserved for individuals who are allergic to latex products.
There are additional types of catheters:
- PTFE (plastic)-coated latex indwelling (Foley) catheters
- hydrogel-coated latex indwelling catheters
- pure silicone indwelling catheters
- silicone-coated latex indwelling catheters
SIZE. The diameter of a catheter is measured in millimeters. Authorities recommend using the narrowest and softest tube that will serve the purpose. Rarely is a catheter larger than size 18 F(rench) required, and sizes 14 or 16 F are used more often. Catheters greater than size 16 F have been associated with patient discomfort and urine bypassing. A size 12 F catheter has been successfully used in children and in male patients with urinary restriction.
DRAINAGE SYSTEM. The health-care provider should discuss the design, capacity, and emptying mechanism of several urine drainage bags with the patient. For men with normal bladder sensation, a catheter valve for intermittent drainage may be an acceptable option.
PROCEDURE. When inserting a urinary catheter, the health care provider will first wash the hands and put on gloves and clean the tip of the penis. An anesthetic lubricating gel may be used. The catheter is threaded up the
Men using intermittent catheterization to manage incontinence may require a period of adjustment as they try to establish a catheterization schedule that is adequate for their normal fluid intake.
Antibiotics should not be prescribed as a preventative measure for men at risk for urinary tract infection (UTI). Prophylactic use of antibacterial agents may lead to the development of drug-resistant bacteria. Men who practice intermittent self-catheterization can reduce their risk for UTI by using antiseptic techniques for insertion and catheter care.
The extended portion of the catheter should be washed with a mild soap and warm water to keep it free of accumulated debris.
Phimosis is constriction of the prepuce (foreskin) so that it cannot be drawn back over the glans penis. This may make it difficult to identify the external urethral meatus. Care should be taken when catheterizing men with phimosis to avoid trauma from forced retraction of the prepuce or by incorrect positioning of the catheter.
Complications that may occur from a catheterization procedure include:
- Trauma or introduction of bacteria into the urinary system, leading to infection and, rarely, septicemia.
- Trauma to the urethra or bladder from incorrect insertion or attempting to remove the catheter with the balloon inflated. Repeated trauma may cause scarring or stricture (narrowing) of the urethra.
- Passage of urine around the catheter. Inserting a different catheter size can minimize this problem.
The presence of residual urine in the bladder due to incomplete voiding provides an ideal environment for bacterial growth.
Urinary catheterization should be avoided whenever possible. Clean intermittent catheterization, when practical, is preferable to long-term catheterization.
Catheters should not be routinely changed. Each man should be monitored for indication of obstruction, infection, or complications before the catheter is changed. Some men require daily or weekly catheter changes, while others may need one change in several weeks. Fewer catheter changes will reduce trauma to the urethra and reduce the incidence of UTI.
Because the urinary tract is normally a sterile system, catheterization presents the risk of causing a UTI. The catheterization procedure must be sterile and the catheter must be free from bacteria.
Frequent intermittent catheterization and long-term use of indwelling catheterization predisposes a man to UTI. Care should be taken to avoid trauma to the urinary meatus or urothelium (urinary lining) with catheters that are too large or inserted with insufficient use of lubricant. Men with an indwelling catheter must be reassessed periodically to determine if alternative treatment will be more effective in treating the problem.
The man and his caregiver should be taught to use aseptic technique for catheter care. Nursing interventions and patient education can make a difference in the incidence of urinary tract infections in hospitals, nursing homes, and home care settings.
The sexuality of a man with an indwelling catheter for continuous urinary drainage is seldom considered. If the patient is sexually active, the man or his partner can be taught to remove the catheter before intercourse and replace it with a new one afterwards.
Morbidity and mortality rates
Injuries resulting from catheterization are infrequent. Deaths are extremely rare. Both complications are usually due to infections that result from improper catheter care.
An alternative to catheterization is to use a pad to absorb voided urine.
See also Catheterization, female.
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American Board of Urology. 2216 Ivy Road, Suite 210, Chaarlottesviille, VA 22903. (434) 979-0059. <http://www.abu.org/>.
American Foundation for Urologic Disease. 1128 North Charles Street, Baltimore, MD 21201. (800) 242-2383. <http://www.afud.org/>.
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L. Fleming Fallon, Jr, MD, DrPH
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Urinary catheterization can be performed by health-care practitioners, by home caregivers, or by men themselves in hospitals, long-term care facilities, or personal homes.
QUESTIONS TO ASK THE DOCTOR
- Will the catheterization be intermittent or indwelling?
- If intermittent, who will change the catheter and how long will it remain in place?
- If indwelling, how often will the catheter be changed and who will change it?
- Who will teach me or my caregiver how to insert and remove the catheter, monitor it, and perform routine care?