Urinary Catheterization — Procedure

Overview

Indications

1. Acute urinary retention
2. Urethral or prostatic obstruction compromising renal function
3. Urine output monitoring in critically ill/injured patients
4. Collection of a sterile urine specimen
5. Intermittent bladder catheterization in neurogenic bladder dysfunction
6. Urologic study of the lower urinary tract

Contraindications

• Suspected urethral disruption from pelvic trauma (blood at the meatus, perineal hematoma, high-riding prostate)
• Recent reconstructive surgery of the urethra or bladder neck (relative)
• Known urethral stricture (relative — may dilate)
• Acute infection of the prostate/urethra (relative)
• Combative or uncooperative patient (relative)

Equipment

Anatomical Considerations

Step-by-Step Procedure

Preparation

1. Explain the procedure to the patient and obtain consent. Apprehension is common — reassurance about positioning reduces patient anxiety.
2. Position the patient:
   • Female: Supine, frog-leg or lithotomy (stirrups preferred). Adequate hip abduction is essential — adducted legs make catheterization very difficult.
   • Male: Supine.
3. Gather all equipment before starting. Once the genitalia have been touched with the nondominant hand, that hand is contaminated and must not handle sterile equipment.
4. Open the catheterization tray and establish a sterile field at the bedside.
5. Don sterile gloves.

Cleansing

1. With the nondominant hand, expose the meatus:
   • Female: Separate the labia minora and hold throughout the procedure.
   • Male: Retract the foreskin (if present), expose the glans.
2. With the dominant hand, cleanse the meatus and surrounding area with antiseptic solution in a circular motion from the meatus outward. Use separate swabs for each wipe.

Lubrication & Anesthesia

1. Lubricate the catheter generously with water-soluble jelly.
2. Males: Instill 5 mL of 2% viscous lidocaine (or anesthetic lubricant gel) into the urethra via syringe before passing the catheter — this provides topical anesthesia and distends the urethra. Warn the patient of mild urethral discomfort and the urge to void.

Catheter Insertion

1. Identify the urethral meatus (first opening superior to the vaginal introitus).
2. Gently pass the catheter ~7–8 cm (3 inches) following the slight posterior-to-downward urethral course toward the bladder.
3. Urine flow confirms correct bladder placement. Any catheter that inadvertently enters the vagina must be discarded and a fresh catheter used.

1. Hold the penis taut and directed toward the umbilicus with the nondominant hand to straighten urethral folds.
2. With the dominant hand, pass the catheter slowly and gently up the full length of the catheter — advance to the junction of the catheter and the balloon inflation port (the "hilt"). This is critical: inflating the balloon within the urethra causes significant injury.
3. Urine flow confirms bladder placement.
4. For men >50 years or known BPH, a coudé catheter with the curved tip directed at 12 o'clock (anterior) is preferred to navigate the prostatic urethra.

Balloon Inflation & Securing

1. Inflate the balloon with 10 mL of sterile water or tap water (not saline — it can crystallize in the valve over time; however, either is acceptable clinically).
2. If resistance or perineal/penile discomfort occurs during inflation → immediately deflate, reposition or advance the catheter further, then re-inflate. Resistance indicates the balloon is still in the urethra.
3. Gently withdraw the catheter until you feel resistance — the balloon is now seated at the bladder neck.
4. Connect to a closed-drainage bag. Secure the catheter to the inner thigh (female) or lower abdomen/thigh (male) with tape to prevent traction injury.
5. Replace the foreskin (if retracted in uncircumcised males) to prevent iatrogenic paraphimosis — this is a commonly missed step.

Post-Procedure

• Document the residual urine volume drained.
• If >500–1000 mL is obtained acutely, clamp temporarily to prevent decompression haematuria (some clinicians); evidence is mixed.
• Maintain a closed drainage system at all times; keep the bag below bladder level to prevent reflux.
• Use the smallest suitable catheter bore to minimize urethral trauma.

Complications

Catheter Care Guidelines (CDC Category I — Strongly Recommended)

• Use catheters only when indicated; remove as soon as possible
• Maintain a closed sterile drainage system
• Obtain urine specimens aseptically (via sampling port, not by breaking the circuit)
• Maintain unobstructed urine flow
• Hand hygiene before and after any catheter manipulation