Transurethral catheterization

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Transurethral catheterization is a type of bladder catheterization procedure involving the insertion of a flexible catheter through the urethra into the bladder. It may be used for diagnostic evaluation or for conditions that require urinary drainage. It may be performed in both children and adults. There are no absolute contraindications to transurethral catheterization. It can be performed using an intermittent (straight) catheter (e.g., red rubber catheter) or an indwelling catheter (e.g., Foley catheter). Complications include hematuria, catheter-associated urinary tract infection (CAUTI), urethral injury, and catheter malfunction.

For other methods of urinary drainage, including suprapubic catheterization, see “Urinary drainage procedures.”

Diagnostic ^[2][3]

• Diseases requiring sterile sample collection for urinalysis and/or urine culture, e.g., UTI
• Diseases requiring measurement of postvoid residual volume, e.g., overflow incontinence ^[4]
• Patients who require measurement of urinary output, e.g., critically ill patients

Therapeutic ^[2][3]

• Conditions requiring complete or intermittent bladder drainage, e.g., urinary retention, urinary obstruction, neurogenic bladder
• Patients with impaired voiding and/or mobility, e.g., those with paralysis, injury, or receiving end-of-life care
• Bladder access required for treatment, e.g., bladder irrigation for bladder tamponade, intravesical chemotherapy for bladder cancer ^[5]

• Absolute: none
• Relative ^[2]
  • Alternative equally effective, less invasive procedures (e.g., clean catch urine, condom catheter) available
  • Acute bacterial prostatitis ^[6]
  • Known or suspected urethral injury ^[2][7]

We list the most important contraindications. The selection is not exhaustive.

Types of transurethral catheters ^[2]

• Foley catheter
  • A thin, flexible, sterile tube used for continuous drainage
  • Held in the bladder by a water-filled balloon
  • Three-way Foley catheter: a large-gauge Foley catheter with three channels, allowing for bladder irrigation
• Straight urinary catheter: a flexible catheter used for intermittent drainage that is removed after use ^[8]
• Coude catheter
  • A thin, flexible catheter with a semirigid curved tip used for both intermittent and continuous drainage
  • Most commonly used if there is difficulty inserting a flexible straight tip catheter (e.g., because of prostatic enlargement)

Transurethral catheter selection ^[2]

General catheter recommendations for different patient groups are shown below; catheter size may vary based on patient anatomy. ^[9]

• Adults: 14–16 Fr straight urinary catheter or Foley catheter ^[10]
• Patients with prostatic enlargement: 14–18 Fr coude catheter or 18–22 Fr Foley catheter
• Patients with gross hematuria: ≥ 20 Fr three-way Foley catheter

Landmarks ^[2]

• Penis
  • Urethral length: ∼ 20 cm
  • The urethra curves in an S-shape and passes through the prostate into the bladder.
• Vulva
  • The urethral meatus is located between the labia minora, directly superior to the vagina and inferior to the clitoris.
  • Rarely, locating the urethral meatus via palpation may be necessary.

Positioning ^[2]

• Patients with a penis: Place the patient supine and hold the penis taut and upright.
• Patients with a vulva: Place the patient in the frog-leg position.

The following equipment is included in most prepackaged catheterization kits. Become familiar with the equipment available. ^[2]

• Sterile gloves
• Sterile drape
• Antiseptic and applicator forceps
• Cotton swabs
• Lubricating jelly and/or viscous lidocaine
• Transurethral catheter
• Syringe containing water or air
• Collection bag or drainage system

• Gather equipment at the bedside.
• Ensure that the patient is in a comfortable position and that the urethral meatus is easily accessible.
• Put on PPE and place the sterile drape.
• Lubricate the catheter with viscous lidocaine and/or lubricating jelly.

For transurethral catheterization, the patient is draped prior to skin preparation.

Transurethral catheterization of the penis ^[2]

1. Uncircumcised or partially circumcised penis: Retract the foreskin with the nondominant hand.
2. Hold the penis taut and upright.
3. Cleanse the urethral meatus with antiseptic, moving outwards in a circular motion.
4. Inject 5–10 mL of viscous lidocaine into the urethra and allow time for the anesthetic to take effect.
5. Insert the entire length of the catheter into the urethra.
6. Inflate the catheter balloon using a syringe filled with the recommended volume of water or air.
7. Withdraw the catheter slowly until resistance is met.
8. Connect the catheter to a collection bag or drainage system.
9. Reduce the foreskin.
10. Attach the catheter to the patient's thigh using tape or a catheter securement device.

Do not attempt to force passage of the catheter through the urethra or inflate the balloon if there is significant resistance or patient discomfort, as this can lead to injury.

If a coude catheter is used, ensure the tip of the catheter points cephalad (toward the dorsum of the penis) during insertion.

Transurethral catheterization of the vulva ^[2]

1. Use the nondominant hand to spread the labia. ^[2]
2. Cleanse the urethral meatus with antiseptic, moving outwards in a circular motion.
3. Pass the catheter into the urethra and slowly advance.
4. Once urine return is noted, advance the catheter multiple centimeters further.
5. Inflate the catheter balloon using a syringe filled with the recommended volume of water or air.
6. Withdraw the catheter slowly until resistance is met.
7. Connect the catheter to a collection bag or drainage system.
8. Attach the catheter to the patient's thigh using tape or a catheter securement device.

If the catheter enters the vagina, it should be discarded and insertion reattempted with a new catheter to minimize the risk of infection.

Problems during insertion ^[2]

Vulvar urethra

The most common problem is difficulty locating the urethral meatus . Potential solutions include:

• Placing the patient in the lithotomy position
• Using a speculum to aid visualization
• Palpating the urethral meatus to perform blind insertion

Penile urethra

• Urethral obstruction
  • Try a different catheter (e.g., smaller gauge, coude catheter) or adjust the technique.
  • Avoid using force because of the risk of injury.
  • In patients with external urethral sphincter spasm:
    • Ask the patient to relax the perineum and rectum.
    • Exert constant, soft pressure on the catheter. ^[2]
  • Consult urology if there is concern for injury or if catheter insertion is still unsuccessful.
• Difficulty finding the urethral meatus
  • Phimosis
    • Urgently consult urology if a catheter cannot be passed in a patient with phimosis and acute urinary retention.
    • If urology is unavailable, consider dilation of the phimotic opening and blind passage of the catheter.
    • In severe cases, creation of a dorsal slit to expose the urethral meatus may be necessary.
  • Foreskin edema (e.g., in critically ill patients with anasarca)
    • Exclude paraphimosis and other reasons for penile strangulation, e.g., foreign object.
    • Apply a cold compress or compressive dressing for 10 minutes to reduce the swelling.

Balloon inflation

• Ensure the balloon is in the bladder before inflating.
• Penis: Insert the entire length of the catheter prior to inflation.
• Vulva: Advance the catheter multiple centimeters further after urine return is noted prior to inflation.

Avoid inflating the balloon within the urethra as this can cause serious injury.

Problems with indwelling catheters ^[2][11]

• Catheter obstruction
  • Attempt catheter irrigation with sterile saline to dislodge the obstruction.
  • If unsuccessful, consider catheter replacement.
• Leakage around the catheter
  • Evaluate for catheter obstruction and CAUTI and treat as indicated.
  • See “Treatment of urge incontinence” for treatment of leakage secondary to overactive bladder.
• Balloon will not deflate
  • Cut the inflation port off of the catheter and use a needle and syringe to aspirate fluid.
  • If unsuccessful, attempt to deflate the balloon by passing a guidewire (e.g., from a central line kit) through the inflation channel.
• Traumatic catheter removal
  • Consult urology.
  • If urology is unavailable, attempt gentle replacement with a new catheter; if any resistance is encountered:
    • Discontinue replacement efforts.
    • Obtain a retrograde urethrogram.

• Urine flowing into the drainage system (i.e., catheter and drainage system clamps open)
• Sterile urine samples obtained and sent for laboratory studies if needed
• Bladder irrigation initiated if necessary
• Patient and/or family educated about catheter care

See “Urinalysis” and “Urine culture.”

• Urethral injury
• Hematuria ^[2]
• Paraphimosis (if the foreskin is not reduced) ^[12]
• Catheter malfunction (e.g., catheter obstruction)
• Catheter-associated UTI
• Bladder injury
• Prostate injury
• Post-obstructive diuresis
• Electrolyte imbalance after bladder irrigation

We list the most important complications. The selection is not exhaustive.