urinary bladder catheterization

Patients with chronic difficulty urinating sometimes are given indwelling urinary catheters; as an alternative, they may be given bladder training instruction, or assistance with toileting. When this is ineffective they may be instructed in the technique of clean, intermittent self-catheterization. To do this, they need to learn about their urethral anatomy and about methods they can use to avoid introducing microorganisms into the urinary bladder (handwashing, periurethral and catheter cleansing, and catheter storage). Most patients need to catheterize themselves four or five times daily. Carefully performed intermittent catheterization is less likely to cause urinary tract infection than is chronic indwelling urinary catheterization. Individuals who have difficulty retaining urine (urinary incontinence) should receive bladder training and assistance in toileting at specific intervals rather than having an indwelling urinary catheter. See: illustration

Patient care

After the procedure and expected sensations are explained to the patient, the proper equipment is assembled, sterile gloves are donned, a sterile field created, and the indwelling catheter is connected to a closed drainage bag, if not preconnected. The balloon at the tip of this catheter is inflated (and deflated) before its insertion to make sure that it will stay in place after entering the bladder. The patient is properly positioned and draped (see instructions for female and male patients); the urethral orifice is prepared with antiseptic solution and the catheter is gently inserted. Sterile technique is maintained throughout these procedures. The indwelling catheter is advanced beyond the point where urinary flow begins, and the balloon inflated with the specified amount of sterile water, then the catheter is permitted to slip back slightly. The drainage tube is secured to the patient's leg, then looped on the bed, and the tubing leading to the collection bag is straightened to facilitate gravity drainage. The collection bag is suspended above the floor. The drainage tube is prevented from touching a surface when the collection bag is emptied; the spout is wiped with an alcohol swab before being refastened to the bag. The meatal area should be cleansed daily and inspected for inflammation. The patient's ability to void and remain continent is periodically evaluated and catheterization is discontinued when possible. Results of the procedure, including the character and volume of urine drained and the patient's response, are observed and documented. The patient should be draped to limit embarrassment and provided warmth and privacy, exposing only the genitalia area.

Female: The patient should be in the dorsal recumbent position on a firm mattress or examining table to enhance visualization of the urinary meatus. Alternately, the lithotomy position, with buttocks at the edge of the examining table and feet in stirrups, may be used. For female patients with difficulties involving hip and knee movements, the Sims' or left lateral position may be more comfortable and allow for better visualization. Pillows may be placed under the head and shoulders to relax the abdominal muscles.

Male: The patient should be in a supine position with legs extended. Lubricant is applied to the catheter or may be instilled directly into the urethra with a prefilled syringe to facilitate passage of the tube. After the procedure, care should be taken to return the male patient’s prepuce to its normal position to prevent any subsequent swelling.

Unless otherwise restricted, oral intake should be encouraged to maintain adequate urine output, and urine inspected for cloudiness and changes in color or odor, any of which indicate the need for urine culture to test for infection. When removing the indwelling catheter, the patient should be draped, the genitalia cleansed, and the balloon fully deflated using a syringe. The catheter is then gently rotated to ensure that it is not adhering to urogenital tissue, and should easily slip out into the gloved hand. Pulling the glove off over the catheter tip, then wrapping glove and catheter in a waterproof wrapper or bag, provides “double bagging” for disposal.

A high rate of morbidity and mortality is associated with long-term use of indwelling urinary catheters (7 days or longer). Indwelling urinary catheters should be used only for very brief periods or specific concerns, such as urinary retention that cannot be managed with other methods, or palliative care. Most indwelling catheters are made of latex. Silicone catheters should be used in patients with latex allergies. Silver-coated urinary catheters may result in fewer infections than silicone, silicone-coated, or the common hydrogel-coated latex catheters. Experts advocate using the smallest size catheter effective for the patient – usually 14 or 16 French, with a 5-ml balloon. Catheters 18 French or larger create discomfort, increase the risk of blocking the periurethral glands, and can lead to urinary tract infection and urethral irritation and erosion. For long-term use, inflate a 5-ml balloon with 10 ml of water, as underinflation can lead to balloon distortion and catheter deflection. The 30-ml balloon is useful for a short time following genitourinary surgery to decrease bleeding and prevent dislodgement. Urethral catheter tubing should be secured to prevent tension on the bladder neck and accidental dislodgement. For males, securing the tubing restraint on the abdomen works best; for females, the anterior medial thigh. The common practice of changing catheters monthly is based on Medicare and Medicaid reimbursement structures; however, data on the frequency for change are lacking. Thus change is probably best individualized to the patients or carried out following manufacturer’s recommendations for the various types of catheters. Drainage bags should be emptied every 4 to 6 hr (minimum) to avoid migration of bacteria to the catheter lumen. If a patient develops symptoms of a urinary tract infection (fever, chills, malodorous or cloudy urine, hematuria, and/or suprapubic pain), antibiotic therapy should be instituted and a sample of urine sent for culture. Prophylactic antibiotics are not recommended with indwelling urinary catheterization, as they lead to drug-resistant infectious agents.