II. Indications: Long-term indwelling catheterization
- Refractory Bladder outlet obstruction
- Neurogenic Bladder with Urinary Retention
- Complications of Incontinence
- Refractory skin breakdown
- Palliative Care for terminally ill
- Patient preference
III. Indications: Short-term catheterization
- Urologic or pelvic surgery
- Acute Urinary Retention (trial voiding at 14 days)
- Urinary output monitoring in critically ill
IV. Contraindication
- Artificial Urinary Sphincter
- Catheterization can damage the sphincter or increase infection risk
- Instead, use the devices buttons to open the sphincter (either transiently or persistently)
- Consider Suprapubic Catheterization (under Ultrasound guidance) if catheterization is needed
- Signs of Urethral Trauma
- If Trauma, perform genital and Rectal Exam first (or the preferred Retrograde Urethrogram)
- Blood at meatus
- Scrotal Hematoma
- High riding Prostate
V. Complications: Longterm catheterization
-
Urinary Tract Infection
- See Urinary Catheter associated Urinary Tract Infection
- Urosepsis
- Bacteriuria
- Single intermittent catheterization: 20% of elderly
- Bacteriuria occurs in most patients in 2-3 weeks
- Chronic renal inflammation
- Pyelonephritis
- Nephrolithiasis
- Cystolithiasis
VI. Management: Alternatives to Indwelling Urinary Catheters
- Intermittent catheterization (dysfunctional voiding)
- Spinal Cord Injury
- Nursing Home residents
- Surgery
- Hip Fracture repair
- Total abdominal Hysterectomy
- External Catheter (Condom catheter)
- Incontinent men without obstructive uropathy
- More comfortable than indwelling catheters
- Lower Incidence of bacteruria
- Skin breakdown may occur
-
Suprapubic Catheterization (short-term post-operative)
- Lower infection risk
- Improved comfort and convenience
- Risks
- Cellulitis
- Hematoma or leakage at puncture site
- Urethral Prolapse
VII. Preparations: Catheter Characteristics
- Catheter Material
- Latex: Long-term catheterization
- Silastic: Short-term catheterization or Latex Allergy
-
Minocycline and Rifampin impregnated catheters
- May reduce bacteriuria for up to 2 weeks
- Reference
- Catheter size
- Narrowest, softest efective tube
- Range: 12F (smallest) to 18F (largest)
- Most common: 14F to 16F
- Balloon size: 5 ml balloon with 5-10 ml fluid
- Narrowest, softest efective tube
VIII. Management: Urinary Tract Infection
IX. Management: Complications
- Urinary Catheter Obstruction
- Evaluation
- Nonverbal or demented patients may display increased Agitation with obstruction and Bladder Distention
- Bedside BladderPOCUS (Bladder Ultrasound)
- Demonstrates retained urine, increased Bladder sediment or blood and position of catheter balloon
- Clearing obstruction
- Reposition the patient supine and remove any kinks from the tubing
- Attempt Bladder Manual Irrigation
- Replace catheter if manual irrigation is unsuccessful
- Prevention
- Maximize patient hydration
- Consider Methanamine preparations to prevent blockage
- Change catheter before expected time to obstruction
- Change catheter if no urine flow in 4 to 8 hours
- Evaluate for UTI for more frequent catheter blockage
- Evaluation
- Urinary Catheter leakage
- Do not increase catheter diameter
- Evaluate for catheter blockage (above)
- Evaluate for Urinary Catheter associated UTI
- Consider Bladder Antispasmodic
- Urinary Catheter is stuck and cannot be removed
- Push Foley Catheter in further which may dislodge a kinked tube at the Urethra
- Cut the Foley Catheter (but not too close to the Urethral meatus)
- Consult urology
- Additional measures if urology is not available
- Thread Central Line over wire into the Foley Catheter and remove the wire to drain balloon
- Overinflate the Foley Catheter balloon until balloon rupture (risk of retained material in Bladder)
- Instill Mineral Oil into catheter balloon to dissolve the balloon
- Prevention
- Do NOT use saline to fill catheter balloon (saline crystalizes)
- References
- Morgenstern and Arcand in Herbert (2018) EM:Rap 18(6): 5
X. Technique: Catherization
- Pre and post-procedure Hand Hygiene
- Aseptic technique with sterile equipment
- Female placement
- Complicating factors making catheter insertion difficult
- Morbid Obesity
- Pelvic Fracture or Hip Fracture
- Elderly female (limited flexibility, vaginal stenosis)
- Methods
- Assistants retract tissue to optimize visualization of Urethra
- Place guiding hand against the underside of the Symphysis Pubis
- The Urethral insertion site should be immediately above the guiding hand
- Complicating factors making catheter insertion difficult
- Male placement
- Barriers
- Methods
- Help the patient calm (relaxes the external Urethral sphincter)
- Distend the Urethra with Lidocaine gel
- Pull the penis straight to apply tension and straightens the Urethra
- Larger catheters (e.g. 20 French) are preferred as less likely to coil and cause a false passage
- Exception: Urethral Strictures may require small catheters (16F, 14F, 12F)
- Coude catheters have angled tip that should be inserted with tip at 12:00 position to navigate bend
- Coated guidewire (e.g. Glidewire)
- Troubleshooting
- Estimate the distance the catheter passed before reaching obstruction
- Urine catheter inserted but no urine drained
- Advance catheter all the way to its hub
- Inject saline and aspirate for urine
- Penis Urethral meatus is not visualized (e.g. Obesity)
- Assistant retracts redundant tissue with both hands
- Another assistant applies suprapubic pressure
- Patient in Trendelenburg position (gravity may help move pannus out of the way)
- Insert pinky finger of non-dominant hand into recess to localize the glans penis and Urethral meatus
- Tight Phimosis interferes with catheter insertion
- Urethral meatus is visible
- Place a coated guidewire (Glidewire) or pediatric bougie into the distal Urethra
- Thread the catheter over the guidewire
- Urethral meatus is NOT visible
- Consider creating a dorsal slit (see Phimosis)
- Consider Suprapubic Catheter
- Urethral meatus is visible
- Hypospadias or Urethral Strictures
- Use a smaller, stiffer catheter
- Bleeding after Traumatic Foley Catheter removal (e.g. catheter out with balloon still inflated)
- Injury is typically not as severe as the initial bleeding would suggest
- Prostatic Urethra may be injured
- However injuries tend to spontaneously heal and bleeding spontaneously resolves
- Replace Urinary Catheter
- Use a larger catheter (18 or 20 fr) to allow residual clots to pass
- Consider coude tip catheter if injury related edema prevents catheter placement
- Consider hyperinflating foley balloon within Bladder (prevents repeat catheter dislodgement)
- Balloon 5 ml will accept up to 100 ml before rupturing
- Balloon 30 ml will accept 200-300 ml before rupturing
- Injury is typically not as severe as the initial bleeding would suggest
XI. References
- Mason and Bahnson in Herbert (2017) EM:Rap 3-4
- Bhanson and Swaminathan (2023) Foley Follies, EM:Rap, December, accessed 12/1/2023
- Cravens (2000) Am Fam Physician 61(2): 369-76 [PubMed]
- Walsh (1998) Campbell's Urology, Saunders, p. 159-62