Urinary Catheter Insertion

Introduction
The ability to insert a urinary catheter is an essential skill in medicine.
Catheters are sized in units called French, where one French equals 1/3 of 1 mm. Catheters vary from 12 (small) FR to 48 (large) FR (3-16mm) in size.
They also come in different varieties including ones without a bladder balloon, and ones with different sized balloons - you should check how much the balloon is made to hold when inflating the balloon with water!


Universal precautions
The potential for contact with a patient's blood/body fluids while starting a catheter is present and increases with the inexperience of the operator. Gloves must be worn while starting the Foley, not only to protect the user, but also to prevent infection in the patient. Trauma protocol calls for all team members to wear gloves, face and eye protection and gowns.


Indications
By inserting a Foley catheter, you are gaining access to the bladder and its contents. Thus enabling you to drain bladder contents, decompress the bladder, obtain a specimen, and introduce a passage into the GU tract. This will allow you to treat urinary retention, and bladder outlet obstruction.
Urinary output is also a sensitive indicator of volume status and renal perfusion (and thus tissue perfusion also).
In the emergency department, catheters can be used to aid in the diagnosis of GU bleeding.
In some cases, as in urethral stricture or prostatic hypertrophy, insertion will be difficult and early consultation with urology is essential.


Contraindications
Foley catheters are contraindicated in the presence of urethral trauma. Urethral injuries may occur in patients with multisystem injuries and pelvic factures, as well as straddle impacts. If this is suspected, one must perform a genital and rectal exam first. If one finds blood at the meatus of the urethra, a scrotal hematoma, a pelvic fracture, or a high riding prostate then a high suspicion of urethral tear is present. One must then perform retrograde urethrography (injecting 20 cc of contrast into the urethra).


Equipment
Sterile gloves - consider Universal Precautions Sterile drapesCleansing solution e.g. SavlonCotton swabs ForcepsSterile water (usually 10 cc)Foley catheter (usually 16-18 French)Syringe (usually 10 cc)Lubricant (water based jelly or xylocaine jelly)Collection bag and tubing


Procedure
Insertion of an urinary catheter in a female

Insertion of an urinary catheter in a male


Review the female anatomy in more detail
Review the male anatomy in more detail

1. Gather equipment.
2. Explain procedure to the patient
3. Assist patient into supine position with legs spread and feet together
4. Open catheterization kit and catheter
5. Prepare sterile field, apply sterile gloves
6. Check balloon for patency.
7. Generously coat the distal portion (2-5 cm) of the catheter with lubricant

8. Apply sterile drape
9. If female, separate labia using non-dominant hand. If male, hold the penis with the non-dominant hand. Maintain hand position until preparing to inflate balloon.
10. Using dominant hand to handle forceps, cleanse peri-urethral mucosa with cleansing solution. Cleanse anterior to posterior, inner to outer, one swipe per swab, discard swab away from sterile field.
11. Pick up catheter with gloved (and still sterile) dominant hand. Hold end of catheter loosely coiled in palm of dominant hand.
12. In the male, lift the penis to a position perpendicular to patient's body and apply light upward traction (with non-dominant hand)
13. Identify the urinary meatus and gently insert until 1 to 2 inches beyond where urine is noted
14. Inflate balloon, using correct amount of sterile liquid (usually 10 cc but check actual balloon size)
15. Gently pull catheter until inflation balloon is snug against bladder neck
16. Connect catheter to drainage system
17. Secure catheter to abdomen or thigh, without tension on tubing
18. Place drainage bag below level of bladder
19. Evaluate catheter function and amount, color, odor, and quality of urine
20. Remove gloves, dispose of equipment appropriately, wash hands
21. Document size of catheter inserted, amount of water in balloon, patient's response to procedure, and assessment of urine

Complications
The main complications are tissue trauma and infection. After 48 hours of catheterization, most catheters are colonized with bacteria, thus leading to possible bacteruria and its complications. Catheters can also cause renal inflammation, nephro-cysto-lithiasis, and pyelonephritis if left in for prolonged periods.
The most common short term complications are inability to insert catheter, and causation of tissue trauma during the insertion.
The alternatives to urethral catheterization include suprapubic catheterization and external condom catheters for longer durations.