The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Urethral (Foley) Catheterization

by Rodd Daigle with
Patrick Hymel

Indications

• Acute retention of urine with inability to void
  
• Collection of an uncontaminated urine sample for diagnostic testing
  
• Urethral or prostatic obstruction resulting in hydronephrosis and decreased renal function
  
• Urine output monitoring in the surgical patient
  
• Urine output monitoring in the unstable, critically ill patient
  
• Urologic study of urinary tract anatomy
  
• Pelvic ultrasound in pregnancy

Contraindications

• A Trauma patient with suspected urethral injury; look for blood at the meatus or for a perineal or scrotal hematoma. These signs point to an anterior (bulbous and penile) urethral injury and this is a contraindication for urethral catheterization. The most common mechanism for this injury would be direct trauma to the urethra (fall-astride injuries, straddle injury, kick to groin). Also, if a prostate exam reveals a highriding or detached prostate, this is also a contraindication. This points to a posterior (prostatomembranous) urethral injury. Either a suprapubic catheter or urethral catheter placement coaxially over a guidewire under fluoroscopic control must then be performed.
• Catheterization should generally be avoided when less invasive methods may obtain the same information. REMEMBER: Bacteria will follow the catheter into the bladder leading to a urinary tract infection. To avoid this complication it should be used only when necessary and removed as soon as it is not needed.

Prerequisites

• Patients with known valvular heart disease or fever with a tender prostate are candidates for prophylactic antibiotic treatment.

Equipment

• Foley catheter
  • Adults, use an 18 French (Fr)
    
  • Infants or neonates < 6 mos, use a 5 French feeding tube
    
  • Age 6 mos- 2 yo use 8 Fr, 3 - 7yo use 10 Fr, 8-12yo use 12 Fr
• Sterile tray
  
• Sterile drapes
  
• Sterile gloves
  
• Sponges (5-10)
  
• Antiseptic solution
  
• Water soluble lubricant for catheter
  
• Sterile specimen cup with lid
  
• Forceps
  
• 10-ml syringe of sterile water
  
• sterile drainage bag with tubing

Note: all of the above equipment should be sterile, and usually comes prepackaged as a catheterization kit.

Procedure

• First make sure all needed equipment is on hand.
  
• Position the patient in a comfortable supine position
• General Procedure:
  1. Place the catheter tray between the patient's knees and unwrap the tray in a sterile manner (grab the blue paper at the very edges).
     
  2. Put on the sterile gloves that should be on top of the tray in a sterile manner.
     
  3. Pour the Betadine into the appropriate tray (near the sponges).
     
  4. Squeeze the lubricant out of the syringe in which it is contained into an empty area so that you may lubricate the tip of the catheter with it.
     
  5. Test the catheter's balloon by injecting the saline syringe (then withdraw it). You may have to unwrap some of the catheter to do this, but it is not necessary to unwrap the entire catheter.
     
  6. Lubricate the tip of the catheter with the jelly. Do not put an excess amount or it will obstruct the catheter's opening. After you do this, carefully lay the catheter down on the tray so that it does not become contaminated.
     
  7. Expose and cleanse the urethra and the surrounding tissue. REMEMBER: The hand with that you actually grab the penis or spread the labia with is now CONTAMINATED! Do not reach back into the tray with this hand. Use the dominant hand to swipe the tip of the penis or female urethral opening with the Betadine sponges.
     
  8. Using the sterile dominant hand, gently pass the catheter into the urethra (Note: 5 ml of lidocaine jelly squirted into the male urethra can help with urethral distension and topical anesthesia).
     
  9. Once the catheter has reached the bladder (indicated by urine passing in the tube), slowly inflate the balloon with 5 ml of saline.
     
  10. Gently pull the catheter until the balloon contacts the bladder neck.
      
  11. Secure the catheter to the medial thigh with tape.
• Male Catheterization Notes:
  1. The penis should be gently stretched straight up in order to straighten the urethra with the nondominant hand.
     Grab it firmly! The Betadine will make it slippery.
     
  2. The catheter must be inserted at least 24 cm before the balloon can be inflated
     
  3. The balloon is just passing the membranous urethra at the first sign of urine return.
     
  4. The catheter is usually inserted to the balloon-inflating sidearm channel before the balloon is inflated.
     
  5. A Coude catheter passes more easily over an enlarged median lobe of the prostate.
• Female Catheterization Notes:
  1. A frog-legged position or a table with stirrups will aid in visualization of the urethra.
     
  2. Use the nondominant hand to spread apart the labia majora and minora, and the other hand to insert the catheter. Exposure of the urethral opening can best be achieved by inserting two fingers just inside the inner labia, spreading the fingers slightly, then pulling upwards towards the patient's head. BE GENTLE!
     
  3. The female urethra is very short, and thus urine may begin to come through before the balloon has disappeared into the meatus.
     
  4. About half of the total length of the catheter should be inserted before the balloon is inflated.
     
  5. The female urethra travels slightly upward as it approaches the bladder just behind the symphysis pubis, so do not force the catheter downward.

Complications

• Bacturia
• Epididymitis
  
• Pyelonephritis
  
• Sepsis
• A false urethral channel may be created.
  
• Paraphimosis and gangrene of the penis may occur in the uncircumcised patient if the retracted foreskin is not replaced over the glans penis after catheterization.
• Urethritis
  
• Urethral strictures
  
• Bladder stones
  
• Hematuria
  
• Retained catheters
  
• Rarely, bladder perforation and urethral erosion by a penile prosthesis.

Follow Up

• Remember that the catheter is a path for bacteria to follow. It should be removed AS SOON as it is no longer required. Remember to think of this when on rounds.

Interpretation of Results

• Clear urine should be obtained following catheterization, although hematuria is common immediately following the procedure.
  
• No pain should be felt upon balloon inflation if the catheter is positioned properly in the bladder.

Related Procedures
Suprapubic aspiration of the bladder:

So what do you do if your patient has a urethral injury which precludes catheterization, but has a full urinary bladder? A large bore central venous catheter may be inserted into the bladder suprapubically with the Seldinger technique. The needle should be inserted 2 finger-breadths above the pubic symphysis, and urine should be aspirated. The catheter should be threaded enough to coil within the lumen of the bladder. A small amount of contrast dye should be injected into the bladder, and an x-ray should be obtained to confirm placement.