Urethral Catheterization

Aka: Urethral Catheterization, Urinary Catheter, Urinary Catheterization, Bladder Catheterization, Foley Catheter

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II. Epidemiology

  1. Indwelling uretheral catheters Prevalence
    1. Community dwelling males 18 to 70 years old: 7%
    2. Skilled nursing facilities: 36%

III. Indications

  1. Long-term indwelling catheterization
    1. Refractory Bladder outlet obstruction (e.g. Benign Prostatic Hyperplasia)
    2. Neurogenic Bladder with Urinary Retention
      1. Spinal Cord Injury
      2. Multiple Sclerosis
      3. Parkinsonism
      4. Cerebrovascular Accident
    3. Complications of Incontinence
      1. Refractory skin breakdown (e.g. Decubitus Ulcer)
      2. Palliative Care for terminally ill
      3. Patient preference
  2. Short-term catheterization
    1. Urologic or pelvic surgery
    2. Acute Urinary Retention (trial voiding at 14 days)
    3. Urinary output monitoring in critically ill

IV. Contraindications: Indwelling Catheterization

  1. Artificial Urinary Sphincter
    1. Catheterization can damage the sphincter or increase infection risk
    2. Instead, use the devices buttons to open the sphincter (either transiently or persistently)
    3. Consider Suprapubic Catheterization (under Ultrasound guidance) if catheterization is needed
  2. Signs of Urethral Trauma
    1. If Trauma, perform genital and Rectal Exam first (or the preferred Retrograde Urethrogram)
    2. Blood at meatus
    3. Scrotal Hematoma
    4. High riding Prostate
  3. Other contraindications
    1. Priapism

V. Precautions

  1. Continually reassess need for indwelling Urinary Catheter and remove as soon as appropriate
  2. Consider alternatives to indwelling Urinary Catheters (e.g. external catheters and intermittent self-catheterization)
  3. Avoid indwelling catheterization for Incontinence alone

VI. Management: Alternatives to Indwelling Urinary Catheters

  1. External Catheter (Condom catheter in men, wicking device in women)
    1. Indications
      1. Incontinent women and Incontinent men without obstructive uropathy
        1. Do NOT use for obstructive cases (e.g. postvoid residual >300 ml)
        2. May be used for Urine Volume measurement (e.g. Congestive Heart Failure)
      2. Hospice or Palliative Care patients
      3. May reduce Fall Risk in patients
    2. Benefits
      1. More comfortable than indwelling catheters
      2. Lower Incidence of bacteruria
      3. Skin breakdown may occur
  2. Clean intermittent catheterization (dysfunctional voiding)
    1. Indications
      1. Chronic Urinary Retention (with or without Bladder outlet obstruction)
      2. Spinal Cord Injury
      3. Nursing Home residents
      4. Post-operative status
        1. Hip Fracture repair
        2. Total abdominal Hysterectomy
    2. Contraindications
      1. Unclean environment and conditions for self-catheterization
      2. Inadequate hand dexterity and coordination to perform Self Catheterization
      3. Acute infectious or Traumatic Bladder outlet obstruction
  3. Suprapubic Catheterization
    1. Indications
      1. Short-term post-operative
      2. Acute urinary obstruction and Urinary Retention with failed catheterization
      3. Alternative to Longterm Urinary Catheterization
    2. Contraindications
      1. Pregnancy
      2. Coagulopathy
      3. No urine in Bladder
      4. Infection overlying skin or abdominal wall region of Suprapubic Catheter placement
      5. Altered anatomy or anticipated significant adhesions (e.g. pelvic cancer, radiation, suprapubic mesh)
    3. Benefits
      1. Lower infection risk
      2. Improved comfort and convenience
    4. Risks
      1. Cellulitis
      2. Hematoma or leakage at puncture site
      3. Urethral Prolapse

VII. Preparations: Catheter Characteristics

  1. Catheter Material
    1. Latex: Long-term catheterization
    2. Silicone (e.g. Silastic): Short-term catheterization or Latex Allergy
      1. At small catheter sizes (e.g. 14F), may be more stiff than latex, aiding a difficult catheterization
  2. Minocycline and Rifampin impregnated catheters
    1. May reduce bacteriuria for up to 2 weeks
    2. Reference
      1. Darouiche (1999) Urology 54:976-81 [PubMed]
  3. Catheter size
    1. Balloon size: 5 ml balloon with 5-10 ml fluid
    2. Narrowest, softest effective tube
      1. Range: 12F (smallest) to 20F (with largest up to 24F)
      2. Most common: 14F to 16F
      3. Larger catheters (20F to 24F) indicated in BPH
      4. Smaller catheters (14 to 16F) indicated in known stricture

VIII. Technique: Catherization

  1. General
    1. Pre and post-procedure Hand Hygiene
    2. Aseptic technique with sterile equipment
    3. Water-soluble, sterile lubricant (e.g. surgilube)
      1. Avoid petroleum-based lubricants (degrade silicone and latex catheters)
    4. Topical Anesthetic (e.g. Lidocaine Gel 2%)
      1. Lidocaine Gel 2% Available in prefilled syringes (20 mg per 5 ml, e.g. Urojet)
    5. Catheter balloon inflation
      1. Inflate with 5-10 ml of sterile water or saline
      2. Overinflation risks Bladder neck irritation
      3. Underinflation risks leakage and displacement
    6. Catheter securement
      1. Leg straps, adhesive anchors and adhesive tape
      2. Proper securement decreases risk of Urethral traction, Trauma and catheter displacement
    7. Maintenance of catheter
      1. Clean the catheter and Urethral meatus daily with soap and water
      2. Monitor catheter tubing for obstruction and kinking
      3. Keep catheter bags below level of Bladder to prevent urinary reflux from bag to Bladder (infection risk)
      4. Maintain oral hydration (prevents catheter obstruction, and reduces Urinary Tract Infection risk)
      5. Prevent Constipation (reduces Urinary Catheter function)
      6. Catheters are typically replaced every 4 weeks (maximum 12 weeks)
        1. Immediately replace obstructed catheters
        2. Modify catheter change schedule per patient needs
      7. Limit urine testing to symptomatic CAUTI
        1. See Urinary Catheter associated Urinary Tract Infection
        2. See Prevention of Urinary Catheter associated UTI
        3. Avoid prophylactic Antibiotics
        4. Avoid routine screening Urine Culture
    8. Catheter removal
      1. Completely deflate the Urinary Catheter balloon
      2. Voiding trial with assessement of spontaneous urination within 6 hours of removal
      3. Evaluate post-void residual urine (Bedside Ultrasound and confirm <300 ml)
      4. Patient should return for signs infection, obstruction, severe pain
      5. Perform post-removal Bladder Training to rebuild Bladder capacity and urine control
        1. Scheduled and delayed voids
        2. Pelvic Floor Exercises (e.g. Kegal Exercises)
  2. Female placement
    1. Complicating factors making catheter insertion difficult
      1. Morbid Obesity
      2. Pelvic Fracture or Hip Fracture
      3. Elderly female (limited flexibility, vaginal stenosis)
    2. Methods
      1. Assistants retract tissue to optimize visualization of Urethra
      2. Place guiding hand against the underside of the Symphysis Pubis
        1. The Urethral insertion site should be immediately above the guiding hand
  3. Male placement
    1. Barriers
      1. Urethral Stricture (typically obstructs on first few cm of insertion)
      2. Penile Urethra turns 90 degrees before reaching the prostatic Urethra
      3. External Urethral sphincter lies between penile and prostatic Urethra (most common obstruction)
      4. Prostate
    2. Methods
      1. Help the patient calm (relaxes the external Urethral sphincter)
      2. Distend the Urethra with Lidocaine gel (and allow at least a minute for Anesthetic activity)
      3. Pull the penis straight (90 degrees to body) to apply tension and straighten the Urethra
      4. Advance the catheter until the hub approaches the meatus and urine starts to flow
        1. With resistance at the Prostate, ask the patient to take a deep breath, and attempt to relax
        2. Continue with gentle pressure to allow the catheter to pass beyond the Prostate, into the Bladder
      5. Larger catheters (e.g. 20 French) are preferred as less likely to coil and cause a false passage
        1. Exception: Urethral Strictures may require small catheters (16F, 14F, 12F)
      6. Coude catheters have angled tip that should be inserted with tip at 12:00 position to navigate bend
      7. Coated guidewire (e.g. Glidewire)
        1. Used by urologists in seldinger technique
        2. Pass the wire into the Bladder first, then the catheter over the wire
        3. Pediatric bougie can be used as a substitute if inserted only into the distal Urethra
          1. Deeper insertion risks Urethral injury (e.g. false passage) and Bladder injury
    3. Troubleshooting
      1. Estimate the distance the catheter passed before reaching obstruction
      2. Urine catheter inserted but no urine drained
        1. Advance catheter all the way to its hub
        2. Inject saline and aspirate for urine
      3. Penis Urethral meatus is not visualized (e.g. Obesity)
        1. Assistant retracts redundant tissue with both hands
        2. Another assistant applies suprapubic pressure
        3. Patient in Trendelenburg position (gravity may help move pannus out of the way)
        4. Insert pinky finger of non-dominant hand into recess to localize the glans penis and Urethral meatus
      4. Tight Phimosis interferes with catheter insertion
        1. Urethral meatus is visible
          1. Place a coated guidewire (Glidewire) or pediatric bougie into the distal Urethra
          2. Thread the catheter over the guidewire
        2. Urethral meatus is NOT visible
          1. Consider creating a dorsal slit (see Phimosis)
          2. Consider Suprapubic Catheter
      5. Hypospadias or Urethral Strictures
        1. Use a smaller, stiffer catheter
      6. Bleeding after Traumatic Foley Catheter removal (e.g. catheter out with balloon still inflated)
        1. Injury is typically not as severe as the initial bleeding would suggest
          1. Prostatic Urethra may be injured
          2. However injuries tend to spontaneously heal and bleeding spontaneously resolves
        2. Replace Urinary Catheter
          1. Use a larger catheter (18 or 20 fr) to allow residual clots to pass
          2. Consider coude tip catheter if injury related edema prevents catheter placement
        3. Consider hyperinflating foley balloon within Bladder (prevents repeat catheter dislodgement)
          1. Balloon 5 ml will accept up to 100 ml before rupturing
          2. Balloon 30 ml will accept 200-300 ml before rupturing
      7. Difficult catheter passage (esp. BPH)
        1. Coude tip catheter
        2. Larger bore catheters
        3. Instill saline rapidly through catheter tip while advancing

IX. Complications: Longterm

  1. Urinary Tract Infection (31% of patients)
    1. See Urinary Catheter associated Urinary Tract Infection
    2. See Prevention of Urinary Catheter associated UTI
    3. Urosepsis
    4. Bacteriuria
      1. Single intermittent catheterization: 20% of elderly
      2. Bacteriuria occurs in most patients in 2-3 weeks
  2. Urinary Catheter Obstruction (24%)
    1. Evaluation
      1. Nonverbal or demented patients may display increased Agitation with obstruction and Bladder Distention
      2. Bedside BladderPOCUS (Bladder Ultrasound)
        1. Demonstrates retained urine, increased Bladder sediment or blood and position of catheter balloon
    2. Clearing obstruction
      1. See Bladder Irrigation
      2. Reposition the patient supine and remove any kinks from the tubing
      3. Attempt Bladder Manual Irrigation
      4. Replace catheter if manual irrigation is unsuccessful
    3. Prevention
      1. Maximize patient hydration (>30 ml/kg/day)
      2. Consider Methanamine preparations to prevent blockage
      3. Change catheter before expected time to obstruction
      4. Change catheter if no urine flow in 4 to 8 hours
      5. Consider catheter valve (Bladder fills until catheter valve opened, similar to intermittent voiding)
      6. Evaluate for UTI for more frequent catheter blockage
  3. Urinary Catheter leakage
    1. Do not increase catheter diameter
    2. Evaluate for catheter blockage (above)
    3. Evaluate for Urinary Catheter associated UTI
    4. Consider Bladder Antispasmodic
  4. Urinary Catheter is stuck and cannot be removed
    1. Push Foley Catheter in further which may dislodge a kinked tube at the Urethra
    2. Cut the Foley Catheter (but not too close to the Urethral meatus)
    3. Consult urology
    4. Additional measures if urology is not available
      1. Thread Central Line over wire into the Foley Catheter and remove the wire to drain balloon
      2. Overinflate the Foley Catheter balloon until balloon rupture (risk of retained material in Bladder)
      3. Instill Mineral Oil into catheter balloon to dissolve the balloon
    5. Prevention
      1. Do NOT use saline to fill catheter balloon (saline crystalizes)
    6. References
      1. Morgenstern and Arcand in Herbert (2018) EM:Rap 18(6): 5
  5. Bladder spasms
    1. Consider Bladder Antispasmodic
    2. Consider urology referral for intravesical Botulinum Toxin
  6. Other complications
    1. Accidental Urinary Catheter dislodgement (12%)
    2. Restricted activity of daily living (40% of patients)
    3. Sexual Dysfunction after catheter removal (5% of patients)
    4. Chronic renal inflammation
    5. Nephrolithiasis
    6. Cystolithiasis

X. Resources

  1. Indwelling Urinary Catheter placement (American Urologic Association, for medical students)
    1. https://www.auanet.org/meetings-and-education/for-medical-students/medical-students-curriculum/bladder-drainage

XI. References

  1. Mason and Bahnson in Herbert (2017) EM:Rap 3-4
  2. Bhanson and Swaminathan (2023) Foley Follies, EM:Rap, December, accessed 12/1/2023
  3. Warrington (2025) Crit Dec Emerg Med 39(4): 22-3
  4. Walsh (1998) Campbell's Urology, Saunders, p. 159-62
  5. Cravens (2000) Am Fam Physician 61(2): 369-76 [PubMed]
  6. Fletke (2024) Am Fam Physician 110(3): 251-8 [PubMed]

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