Catheterisation

High-Yield Tips

• For males, 16 Fr should be the minimum diameter.
• Though the recommended balloon inflation is around 10mL of water, you can inflate up to 60 cc before it bursts.
• Make sure the patient is relaxed; if they are tensing then it’s more difficult to insert the catheter.
• If male gets an erection there's no need to wait for it to disappear. You can still attempt but it will be more difficult.
• Don’t touch the tip (distal 3cm) of the catheter.
• Use a twisting motion when facing particularly high resistance.

Steps

1) Define indication for catheter.

1. Urinary retention (there is no consensus on definition using postvoid residual volume, but > 300mL probably sufficient to meet criteria).
2. To drain bladder prior to, during, or after surgery.
3. Measuring urine output (e.g. post-op, acutely unwell).
4. Treatment and/or investigation (e.g. intravesical medications, urine specimen collection).
5. To relieve urinary incontinence when no other means is practical (e.g. end-of-life comfort).

2) Collect equipment.

1. Catheterisation pack
2. Foley catheter
3. Diameter (French; Fr)
4. Length (cm). Male urethras are ~15-25 cm long whilst female urethras are ~3-4 cm long.
5. Sterile gloves
6. Bag to drain
7. Ensure bin is closeby
8. +/- tweezers to hold to clean the area
9. +/- betadine
10. DO NOT USE ALCOHOL (PINK) BASED WASHES TO CLEAN THE AREA → WILL STING AND CAUSE PAIN TO PATIENT
11. Specific syringe with topical local anaesthetic gel inside (for males to inject into penis)
12. Extra hands (e.g. have nurse or medical student on hand)

3) Consent the patient.

4) Set up the environment.

1. Patient should be lying in bed, as flat as possible. It’s ok for them to be flat even if they have heart failure because the flatter they are the straighter the urethra will be which makes your job easier and in 5 mins they won’t be too symptomatic.
2. Stand on the side so that you have your dominant hand over the patient that you can use to thread the catheter into the urethra.
3. Have the bed at the right height.
4. Have a cart with your equipment on it behind/lateral to you.

5) Open the pack.

6) Put on sterile gloves.

7) Unpack everything.

1. Wet 3x (M) or 4x (F) gauze with included normal saline or betadine.
2. Put one gauze on the patient mons area.
3. Clean first around urethra, then use subsequent gauze to clean more distally to urethra.
4. In males, whilst holding penis, place final gauze between scrotum and penis shaft to keep them separate and clean.
5. Squirt lubricant gel onto part of the sterile area.
6. +/- squirt the local into the male urethra if indicated.
7. Place the sterile drapes over the patient.
8. Fill the included 10mL syringe with sterile water (not normal saline as the normal saline may crystallise).
9. Hand the yellow insertion form/sticker to the helper (drop onto bed for them to pick up).

8) Ask helper to hand you the opened catheter.

1. Open by pulling apart the plastic covering vertically from middle.
2. DO NOT TOUCH THE TIP OF THE CATHETER (DISTAL 3CM).
3. Put the catheter through the lubricant gel.
4. Insert the syringe onto the end of the catheter.
5. Attach the bag onto the end of the catheter.

9) Insert the catheter.

1. M: Use underhanded spock grip with L hand to hold penis. F: Use L hand to separate labia
2. If patient is particularly overweight, may need assistance to hold pannus up.
3. Push it in.

• Do not use too much pressure as trauma is undesirable and can result in urethral strictures which are a preventable long-term complication.
• Use a twisting motion when facing particularly high resistance.

10) Ensure catheter is draining prior to inflating balloon.

Use one of the following options:

• Lower the bag
• Suprapubic pressure to see if this encourages drainage
• Aspirate using syringe.

11) Inflate balloon.

• If patient is particularly prone to catheter falling out, can inflate with further air or water to 20-30 cc (2-3 full 10 mL syringes).

12) Pull back so that catheter is right in the bladder neck.

13) Stick catheter to leg of patient.

• Ensure there is a mesentery separating the catheter tube from the leg (to prevent pressure sore on leg).
• If catheter will be in for a while, advise nursing staff to alternate leg that catheter is stuck to (to prevent pressure sore on penis/labia).

14) Ensure bag is lower than level of patient so gravity assists in draining (otherwise it won’t drain).

15) Educate patient that bladder will empty and that there is no need to push to urinate and that the urge to wee is because of the balloon inflated in the bladder.

16) Clean up the environment.

17) Complete the yellow form and put it in the patient notes.

Resources

1. https://geekymedics.com/penile-catheterisation-osce-guide/