Tamarah Westmoreland, MD
Urethral catheterization is a useful procedure for the surgical patient. One of the more important indications for this procedure is to accurately measure urine output. Urine output is a critical parameter for the patient's hemody-namic status. Another indication is the relief of urinary retention, which could be due to medications, neurologic injury, or loss of bladder tone. Temporary treatment of urinary incontinence, collecting urine for bacterial culture, and treatment of perineal wounds are also reasons to use urethral catheterization. Urethral catheterization may also be necessary for the treatment of urinary obstruction, which may lead to hydronephrosis. Lastly, the chronically bedridden patient may require a urinary catheter for hygiene.
The judicious use of the urinary catheter is important to prevent injury to the patient.1 Trauma to the perineal or pelvic regions can be a contraindication to the use of a urinary catheter. During the physical examination of the trauma patient, it is imperative to complete a rectal examination and closely examine the urethral meatus. If the patient has a high riding prostate or blood at the urethral meatus, a urinary catheter should not be inserted. The patient could have a posterior urethral disruption due to a pelvic fracture or an anterior urethral injury caused by straddle trauma.
To place a urinary catheter, it is imperative that you confirm that your equipment is functional. After placing the male patient in a supine position, his legs should be spread slightly. Using the nondominant hand, the penis should be grasped near the urethral meatus with mild tension. The nondominant hand is no longer sterile. Using the dominant hand, the glans, meatus, and foreskin, if present, should be prepped sterilely. The urinary catheter, which is commonly a no. 16-20 French Foley catheter, is well lubricated with K-Y jelly. The catheter should be inserted into the penis while maintaining mild tension on the penis. Insert the catheter until the sidearm for the balloon is reached. Flow of urine through the catheter confirms its placement in the bladder. If no urine is obtained after placing the catheter, suprapubic pressure should be applied and irrigation of 30 cc of fluid may be used. If the irrigation freely returns, it is highly likely that the catheter has formed a false tract in the penis and does not dwell within the urethra. If this is the case, the catheter should be removed, and a urologist should be consulted. Also, if the patient is very hemodynamically depleted, he may need hydration to produce urine. Once placement of the urinary catheter is confirmed, the balloon should be inflated with 5 cc of sterile water. If a disproportionate amount of resistance is noted when inflating the balloon, then the catheter should be removed and reinserted. Once the balloon is inflated, the catheter should be withdrawn carefully to settle the balloon at the bladder neck. The catheter should be connected to a closed drainage system. The catheter should be taped to the patient's leg to prevent dislodgement.
Female urethral catheterization uses the same sterile technique as in a male. The female patient should lie in a supine position with her legs abducted in a frog-leg position. After sterilely draping the patient, the nondominant hand should spread the labia. This hand is contaminated and should be used to maintain the labia out of the sterile field. The introitus should be prepped anterior to posterior. The lubricated catheter should be inserted to approximately 10-15 cm. Once again, return of urine confirms bladder placement. If no urine is returned, proceed with the same techniques as in the male patient. After confirming bladder placement, the balloon should be inflated with 5 cc of sterile water. The catheter should be carefully withdrawn to place the balloon at the bladder neck. The catheter should then be connected to the closed drainage system and taped to the patient's leg to prevent accidental removal.
There are many reasons urethral catheter placement may be difficult. In the awake patient, a common reason is anxiety of the patient. A urethral stricture may also be present. In the male patient, a stricture at the meatus or prostatic hypertrophy may be preventing catheterization. It is important to ensure that the catheter is well lubricated. If there is pain, a 2 percent Xylocaine jelly can be used. If the patient has continued anxiety, an anxiolytic can be used. A meatus stricture can be relieved with the use of a hemostat. A very helpful adjunct is the Coudé urinary catheter, which has a bend at the tip of the catheter. When using this catheter, it is important that the tip is pointed anteriorly. If the Coudé catheter cannot be easily passed, a urologist should be consulted. The urologist may place a catheter with cystoscopic guidance, or a suprapubic catheter may have to be used.
Careful, aseptic technique in placement of urinary catheters is critical in prevention of complications. The most common complication is the development of a urinary tract infection. This may be due to the practitioner's technique or a preexisting infection in the patient. Infection can also be caused by balloon inflation in the prostatic urethra. Quick recognition of the urinary tract infection can help prevent sepsis. Another complication is the creation of a false passage leading to urethral disruption. This can be prevented by careful technique in maintaining slight tension on the penis and by not forcing the catheter during insertion. If the vagina is inadvertently catheterized, the catheter should be removed, and a fresh, sterile catheter should be used to catheterize the urethra. If there is urine leakage around the catheter, a larger catheter may need to be placed. In addition, the balloon volume should be monitored to ensure that it has not become deflated. Hemorrhage and stricture formation are also complications that may be encountered.
Urethral catheterization is an important adjunct for the surgical patient. Proper handling of the urinary catheters and good aseptic technique can minimize the complications and maximize the benefit of this procedure.
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