Table of Contents
Overview #
Inserting an indwelling catheter is a common procedure done on the ward to relieve urinary retention or measure urine output. However, like any procedure, there are risks and contraindications, and therefore should only be inserted if there is an appropriate indication.
Indications #
- Relieve urinary retention
- During surgeries or after spinal cord injury, or other periods of prolonged immobilisation, to manage urine output (1)
- Measurement of hourly urine output
- Measurement of daily urine output for a diagnostic test (2)
- Collection of a clean urine sample when the patient is incontinent, however usually an ‘in and out’ catheter is used for this
- Bladder washout
Contraindications #
- Urethral trauma is the only absolute contraindication (2)
- This should be suspected when there is pelvic injury with associated meatal blood, boggy prostate or perineal hematoma (1)
- Discuss with a senior clinician about alternatives, such as a suprapubic catheter
- Known abnormalities of the urethra (1)
- False passages
- Strictures
- Tumour
- Discuss with a senior clinician prior to insertion
Risks #
- Urinary infection
- Urethral injury and resulting stricture
- Includes risks of urethral trauma if incorrectly removed (e.g. a confused patient may pull it out when the balloon is still inflated)
- Creation of a false passage
- Haemorrhage
- Paraphimosis if foreskin is not replaced
Equipment #
- Catheter pack
- Drape
- Forceps
- Gauze
- Kidney dish
- 10 mL syringe
- 10 mL sterile water for injection (not saline)
- Chlorhexidine irrigation solution 0.1%
- Lignocaine 2% gel (male) or sterile lubricating gel (female)
- Foley catheter 14 Fr (male) or 12 Fr (female)
- If replace a long-term catheter, ensure you are inserting the correct size i.e. the same as previously used
- Catheter bag
- Sterile gloves
- Large tegaderm
Procedure #
- Obtain informed consent(3)
- Perform hand hygiene
- Open catheter pack creating your aseptic field
- Open sterile water, chlorhexidine, lubricant and catheter into your aseptic field
- Open sterile gloves and catheter bag in their own aseptic field
- Remove patient’s undergarments and position patient supine
- For females, knees should be bent, heels to hips and knees parted
- Don your sterile gloves
- Apply drapes around patient’s groin
Males
- Using your non-dominant hand, hold and lift the penis perpendicular to the body with a gauze swab, and retract foreskin if non-circumcised
- Using your dominant hand, clean the urethral opening with chlorhexidine soaked gauze held in forceps
- Use a circulation motion form the urethral opening to the base of the penis
- Discard the swabs into waste bag
- Insert the lignocaine gel into the urethra
- Hold the urethra opening closed, waiting 2-3 mints for the gel to work
- Insert the catheter using constant pressure, while slowly lowering the penis to become level with the body
- Advance the catheter completely until the connection portion
- Ensure the urine is flowing and the catheter is completely advanced before inflating the balloon with sterile water
- Inflate the balloon slowly, checking that patient does not feel pain
- Withdraw the catheter slightly until resistance is felt
- Attach the catheter to the drain bag
- If required, collect a urine same before attaching the catheter to the drain bag
- Secure the catheter to the thigh with tegaderm, ensuring the patient can move freely without dislodging it
- Replace the foreskin
- Dispose of gloves and other used articles
- Perform hand hygiene
Females
- Lubricate the catheter with sterile lubricating gel
- Using your non-dominant hand, part the labia and identify the urethra
- Using your dominant hand, clean the urethral opening with chlorhexidine soaked gauze held in forceps
- Clean using motions from urethra to vagina, discarding the swab after each use
- Insert the catheter using constant pressure
- Advance the catheter completely until the connection portion
- Ensure the urine is flowing and the catheter is completely advanced before inflating the balloon with sterile water
- Inflate the balloon slowly, ensuring the patient does not feel pain
- Withdraw the catheter slightly until resistance is felt
- Attach the catheter to the drain bag
- If required, collect a urine same before attaching the catheter to the drain bag
- Secure the catheter to the thigh with tegaderm, , ensuring the patient can move freely without dislodging it
- Dispose of gloves and other used articles
- Perform hand hygiene
Children
- While the procedure remains the same as adults, an appropriate catheter should be chosen depending on the age of the child (3)
- A balloon is not used if the children is 6 months and younger (3)
- Lignocaine gel is not used if the male child is 3 years and younger, sterile lubricating gel is used instead (3)
Table 1. Sizes of catheters used in paediatric patients, adapted from The Royal Children’s Hospital Melbourne (3)
| Age | Weight | Foley |
| Neonate | <1200 g – 2500g | Seek senior help, an umbilical catheter is required |
| 0-6 months | 3.5-7 kg | 6 Fr |
| 1-3 years | 10-14kg | 8 Fr |
| 5-8 years | 18-27 kg | 10 Fr |
| 12 years | Varies | 12-14 Fr |
Troubleshooting #
- Unable to advance the catheter (3)
- For males, lower the penis so that it is horizontal and in line with the body
- For males, increase traction on penis and apply gentle pressure on the catheter
- For females, if the catheter has entered the vagina, get a second catheter and try again with the first catheter in situ
- Ask the patient to cough to help locate the urethra, this will cause the urethra to bulge
- Gently rotate the catheter while inserting
- Remove the catheter and apply more lubricant before reattempting
- Remove the catheter and reattempt with a catheter of a smaller size
- Seek assistance from a senior clinician
- No urine draining from the catheter
- No urine could be secondary to a blocked catheter or decreased urine output
- A bladder scan may help you quickly assess which cause is more likely
- Check catheter is not kinked and has not migrated out of bladder (3)
- Try gently flushing catheter with 10 mL of sterile water to ensure blood clots or mucus is not blocking catheter tip (3)
- If large clots are noted, notify a senior clinician to consider reinserting a larger catheter for bladder washout
- Check the patient is not hypovolemic, consider bladder scan to confirm no urine in bladder, and treat hypovolemia after notifying a senior clinician
- Post obstructive diuresis
- Defined as urine output is greater than 200 mL/hr over 2 consecutive hours or greater than 3 L in 24 hrs
- Notify a senior clinician
- Encourage oral intake of fluids and start a strict fluid balance
- If haemodynamic instability, notify a senior clinician and start IV normal saline, replacing half of the urine output (4)
- There are no clinical benefits to clamping the catheter (4)
- Haematuria
- Blood could be secondary to trauma from the procedure, or due to conditions such as bladder cancer, urinary tract infection or glomerulonephritis
- Collect a sample of urine for urine dipstick, MCS and red cell morphology
- In most cases, blood in the urine can just be monitored
- If gross frank blood is noted with haemodynamic instability, obtain IV access, collect a FBE, coagulation screen and group and hold, start IV normal saline and notify a senior clinician
- If the patient is hemodynamically stable, still obtain IV access and collect a FBE, coagulation screen and group and hold, but IV hydration may not be required immediately
- If clots are noted, ensure the urine is still draining. Large clots obstructing urine flow may require assistance from a senior clinician to washout the bladder
- Catheter bypassing
- Urine bypassing a catheter can occur due to various reasons, including small catheter size, under-inflated balloon, obstruction and bladder spasms (1)
- Ensure the catheter is still draining as urine may be overflowing around a blocked catheter, refer to ‘No urine draining from the catheter’ above
- Ensure the catheter balloon is still inflated. While holding the catheter tubing firmly, empty the balloon to ensure 10 mL of water is present. If not, reinflate the balloon with 10 mL of water (3)
- Ensure the patient is not constipated
- If ongoing bypassing, discuss with a senior clinician to consider removing the catheter and reinserting a larger catheter or starting anticholinergic agents to relieve bladder spasms
- Catheter associated urinary tract infection
- 95% of catheterised patients will have bacterial colonisation at four weeks (1)
- Antibiotics should be started in patients with symptoms of a urinary infection – see ‘Urinary tract infections’
- If treating for a urinary tract infection, the catheter should be changed once antibiotics have been started (1)
- Urinary retention prior to catheterisation or during trial of void
- Ask the patient to sit on the toilet/beside commode (not bedpan)
- This is a better position, compared to lying flat, to support the physiology of voiding
- Address uncontrolled pain
- Mobilise the patient
- Treat constipation
- An enema that resolves constipation may also resolve urinary retention
- However, if the patient is retaining significant volumes of urine (>600mL) with increasing abdominal pain, then an indwelling catheter should be inserted with informed patient consent
- Ask the patient to sit on the toilet/beside commode (not bedpan)
Documentation #
- Document indication for catheterisation
- Document informed consent from the patient, and if any other staff members/chaperones were present
- Document catheter size and type
- Document procedure and amount of water used to inflate the catheter balloon
References #
- Gilbert B, Naidoo TL, Redwig F. Ins and outs of urinary catheters. AJGP [Internet]. 2018 Mar;47(3) [cited 2021 Aug 27]. Available from: https://www1.racgp.org.au/ajgp/2018/march/ins-and-outs-of-urinary-catheters. doi: 10.31128/AFP-10-17-4362
- Schaeffer AJ. Placement and management of urinary bladder catheters in adults. In: Richie JP, Chen W, editors.;UpToDate. [Internet]. Waltham (MA): UpToDate Inc; 2021. [updated 2021 Mar 24; cited 2021 Aug 27]. Available from: https://www.uptodate.com/contents/placement-and-management-of-urinary-bladder-catheters-in-adults
- The Royal Children’s Hospital Melbourne. Indwelling urinary catheter – insertion and ongoing care [Internet]. Melbourne (VIC): The Royal Children’s Hospital Melbourne; 2020 [updated 2020; cited 2021 Aug 27]. Available from: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Indwelling_urinary_catheter_insertion_and_ongoing_care/
- Barrisford GW, Steele GS. Acute urinary retention. In: O’Leary MP, Hockberger RS, Givens J, editors.;UpToDate. [Internet]. Waltham (MA): UpToDate Inc; 2021. [updated 2021 Jun 29; cited 2021 Aug 27]. Available from: https://www.uptodate.com/contents/acute-urinary-retention
Contributors
Reviewing Consultant/Senior Registrar
Katie Liao
Dr Paula Loveland
