In this article, we discuss when a catheter might be needed and top tips on male & female catheterisation.

Before attempting catheterisation, always review the following

• Is the catheter needed?
  • For males, a bottle or a conveen (a urethral sheath or essentially a condom) can be great
  • Urine output might not need to be that strictly monitored
  • For urinary retention perhaps waiting to see if the patient voids (as long as it isn’t urgent!)
  • Could the patient have a trial without catheter to see if they need it?
• Are there any contraindications which warrant discussion with seniors?
  • Might be best to avoid in immunocompromised patients to avoid introducing infection
  • Pelvic trauma or recent surgery
• Should it be done by someone else?
  • Some patients are more difficult due to their anatomy: due to cancer, weight, age, prostatic hypertrophy etc. 
  • Consider if patients have had multiple attempts or required urology assistance below. Trauma or creating false lumens can make further attempts even more difficult. It is best to get senior help early!
• What type are you using?
  • Use the smallest possible (12-14f). 21-24f might be needed when there is haematuria (particularly with clots) – in this case, a triple lumen may be helpful to allow for irrigation. 
  • Most places only stock full length (40-45cm) male catheters to avoid accidentally inserting a female catheter into a male, but check this!
  • Consider latex allergy
  • Curved tip or more rigid catheters may be needed with senior input

Procedure

1. Introduce yourself to the patient, confirm this is the correct patient – if you’re lucky that this patient has spent some time on the ward and you know them, then the rapport built will make this a little less intrusive! If you’re unlucky, take a few minutes to build a rapport – a comfortable patient is more likely to relax in this type of situation.
2. Explain the procedure to the patient, the use of local anaesthetic and why it is needed – some patients are very scared or shy and would refuse this unless they understand the necessity.
3. Gain consent – the patient should verbally let you know they understand what you have explained and that it is okay to proceed.
4. If this procedure is done in the ward, ensure there is a chaperone – this will help and protect you – get a nurse, they’ve done lots of these procedures and can help you during the insertion.
5. Gather your equipment – most hospitals have a catheter kit that is sterile, so just grab this, a pair of sterile gloves, a catheter bag and the sized catheter required.
6. Position the patient supine and exposed below the waist (cover up with a sheet until ready). Remember to put an incopad under the patient in case of spillage.
7. Set up sterile field, wash hands, get gloved.
8. Set everything up in the order you’d need them – drape, sterile gauze, wet cotton balls, anaesthetic gel, catheter, water for the balloon, catheter bag. Check the number of ml required to inflate the catheter balloon!
9. Uncover the patient and drape the area.

Male Catheterisation
10. Cleaning the penis – using a sterile piece of gauze, use your non-dominant hand to hold the penis ensuring you retract the foreskin. Using your dominant hand, clean the penis with the wet cotton balls (use about 3).
11. Anaesthetic gel – warn the patient that they may feel a little stinging sensation that relieves quickly. Using your non-dominant hand, hold the penis slightly vertical and insert the gel into the meatus slowly. Wait for about 3 minutes for it to take effect.

Tip 1: When inserting the anaesthetic gel, if it is coming out from the meatus, you’re in the wrong place or holding the penis too tightly. Try to loosen your grip and feel for the meatus with the nozzle of the syringe and insert the gel, which should go in smoothly, and not fall out.

Tip 2: When you look into the penile opening a few minutes after injection of the anaesthetic gel, you will notice it would have dilated the urethral meatus and added lubrication, so you can see it clearly where the catheter will go and allow it to slide in easily.

12. Catheter insertion – remember to always hold the wrapper, not the catheter tip itself! Using your dominant hand, advance the tip of the catheter firmly. As you push the catheter in, pull back on the wrapper. Once you see urine, you know you’re in the bladder. Have your chaperone attach the catheter bag as you keep inserting the catheter until the end.
13. Water for Balloon – insert the amount required to secure the catheter in the bladder, then tug gently on the catheter until resistance to confirm it is held safely in the bladder. Check for pain throughout this and stop and withdraw the fluid if this occurs!

Tip 3: Make sure the retracted foreskin is put back in place as this could lead to the foreskin becoming stuck, swollen and unable to return to the original position (check: paraphimosis)

Female Catheterisation
10. Cleaning the genitalia – using a sterile piece of gauze, use your non-dominant hand to hold the labia apart ensuring you retract fully to expose the urethra. Using your dominant hand, clean with the wet cotton balls (use about 3).

Tip 1: It’s easier for female catheters to have an extra pair of hands, as identification is the toughest part when you’re only able to use one hand to open the labia.

11. Anaesthetic gel – this is the toughest part of female catheterisation, to identify the urethra. The best thing to do once you’ve identified the vagina is to separate the labia higher up from there, the urethra should ideally be just above that. The anatomy is somewhat harder to identify in patients that are older or overweight, so go slow. Once identified warn the patient that they may feel a little stinging sensation that relieves quickly. Insert the nozzle of the anaesthetic gel syringe into the urethra. Wait for about 3 minutes for it to take effect.
12. Catheter Insertion – Advance the catheter tip firmly as it tends to bend or slip out easily in females. Attach the catheter bag.
13. Water for Balloon – insert the amount required to secure the catheter in the bladder, then tug gently on the catheter until resistance to confirm it is held safely in the bladder. Check for pain throughout this and stop and withdraw the fluid if this occurs!

General Tips

• Don’t tear away a lot of the catheter wrapper, instead, expose the tip and a bit of the catheter so you have more control over the catheter when inserting. Don’t be discouraged if you can’t get the catheter in the first try, always ask the nurses, they’re basically experts!
• Always wear a face mask, it saves you in case of any splashes. Be wary of any urine dripping on your shoes!
• Don’t forget to clean up and ensure the patient is okay (this is a very intimate procedure). 
• Always expect urine to come out when you insert it correctly. 
  • If no urine passes, apply gentle suprapubic pressure. Consider inserting 10 ml of sodium chloride to irrigate feeling for easy flow & withdrawal of urine-stained sodium chloride
  • If still no urine, consider dehydration, incorrect insertion or pathology. Consider urological consultation
• If the patient complains of pain or there is blood – consider if you are causing trauma. It is much more difficult to insert a catheter in a patient with trauma so abandoning the procedure & early senior input is advised!

Things to Document

• Date/time
• Indication for catheterisation
• Type and size of a catheter inserted
• The volume used to inflate the balloon
• Residual volume & colour (include the presence of clots & their size)
• Aseptic non-touch technique observed
• Any samples collected
• Whether antibiotic cover was given

Further Management

• Advise the nurses of insertion as they will
  • Ensure the site of insertion is reviewed & cleaned according to local guidelines
  • Monitor for leaks or if the drainage stops
• Antibiotic cover is not routinely given for those with no evidence of infection. However, if you have any reasons to consider it or local guidelines differ – you should escalate accordingly
• Aim to remove the catheter as soon as possible. Long term use can lead to incontinence and sphincter dysfunction as well as urinary tract infections

Further Reading

• UpToDate – Placement & Management of Urinary Catheters
• OSCE Mark Sheet on Male Catherisation
• LITFL – Urinary Catheterisation
• Geeky Medics – Penile Catheterisation OSCE Guide
• YouTube Urinary Catheterisation Guide

By Dr Serisha Govender (FY1) & Dr Akash Doshi (CT2)