Urethral Catheterization - Indications, Procedure, and Complications

Introduction:

Urinary catheterization is the most commonly performed procedure for both therapeutic and diagnostic purposes. Depending on the requirement, the catheter can be used in the short and long term. Urethral catheters are those in which the tip is inserted into the base of the bladder through the urethra (the tube that ejects the urine out of the body).

What Are the Indications for Urethral Catheterization?

1. Therapeutic Purposes: Urinary retention may be acute or chronic. Acute urinary retention is an emergency condition that requires urethral catheterization. Chronic urinary retention can be due to long-standing pathology.

Causes:

• Obstructive: Urinary obstruction may be intrinsic (within the urinary system) or extrinsic (outside the bladder).

  • Intrinsic causes include benign prostatic hyperplasia (enlarged prostate as a result of aging), stones, strictures, stenosis (narrowing of the urethra resulting in blockage of urine), or a tumor that can cause intrinsic obstruction.

  • Extrinsic causes include an enlarged abdominal and pelvic organ compressing the bladder and neck, resulting in extrinsic obstruction.

• Infectious and Inflammatory: Cystitis, urethritis, prostatitis (infection of the prostate), and vulvovaginitis (infection of the vagina) in the woman can cause urinary retention.

• Pharmacologic: Drugs with anticholinergic (inhibits neurotransmission) properties can cause urinary retention.

• Neurologic: Brain and spinal cord injury, multiple sclerosis, cerebrovascular accident, Parkinson's disease, and dementia can lead to urinary retention.

• Others: Trauma, psychogenic, and Fowler syndrome (inability to pass urine) in women.

2. Perioperative Purposes:

• Urological and gynecological surgeries.

• Individuals who require strict intraoperative urine output.

• For pain control and managing postoperative urinary retention due to anesthesia.

• Neurogenic bladder dysfunction.

• Urinary incontinence.

• Social and hygiene reasons.

• Acutely ill persons who require close urinary output measurement.

• Chemotherapy drug delivery.

• Bladder irrigation.

3. Diagnostic Purposes:

• Measurement of urodynamics.

• Sample collection for urinalysis.

• Radiographic studies.

What Are the Contraindications?

• Blood at the meatus, where inserting the catheter can worsen an underlying injury.

• Urethral pain or discomfort.

• Evidence of urethral infection.

• Gross hematuria (blood in the urine).

• Low bladder volume.

• Refusal by the individual.

What Is the Equipment Required for Urethral Catheterization?

• Sterile gloves.

• Sterile water.

• Single-use lubricant and anesthetic gel.

• Catheter.

• Catheter bag.

• Waterproof pad (disposable).

What Are the Types of Catheters?

The catheters are classified depending on the composition and coating material.

• Based on Composition: Silicone, latex, and polyvinyl chloride.

• Based on Coating Material: Hydrogel, Teflon, and antimicrobial or latex with a silicone elastomer coat.

How to Select a Catheter for Urethral Catheterization?

The selection of a catheter type depends on the clinical condition, requirement, and individual risks. A trained physician should perform catheterization with a suprapubic catheter in situations where standard catheterization is impossible. For the short term, catheterization silver alloy-impregnated catheters are preferred as they reduce the incidence of urinary tract infection and bacteremia (presence of bacteria in the blood).

What Are the Preparatory Steps for Urethral Catheterization?

• Should carefully review the indications for urinary catheterization.

• A careful history is required to assess the need for a urological referral.

• The physician must clearly instruct the individual about the procedure and give appropriate time to respond to queries.

• A proper light source is mandatory.

• It is important to maintain the privacy of the individual during the procedure.

• The individual should lie on a firm, flat surface with the head resting on a pillow.

• The prone position is recommended for men, and the frog-leg position for women.

• One should place a disposable pad beneath the buttocks.

• Should perform hand hygiene.

• One should wear sterile gloves.

• Appropriate draping of the individual is necessary.

• Under sterile conditions, the physician should prepare the glans penis and the urethral meatus for urethral catheterization.

• Urethral catheterization will be challenging in the presence of urethral strictures; hence, a 14-French catheter should be used.

• In obstruction, the catheter must not be forced into the urethra.

How Is the Technique Performed?

In Men: Local anesthesia and lubricant must be applied to the top of the catheter. Then with the help of a non-dominant hand, the penis is directed toward the ceiling or the umbilicus. With the help of the dominant hand, the catheter is inserted until the Y of the catheter reaches the urethral meatus. Once urine gets collected in the bag, the correct catheter placement is indicated. Sterile water is used to inflate the catheter balloon. The amount of water required for inflation varies with the manufacturer's recommendations.

In Women: Analgesia is not required for urethral catheterization in women. Lubrication jelly is applied to the tip of the catheter. Then, the lubricated catheter tip is advanced into the urethral meatus. Once urine gets collected in the bag, the correct catheter placement is indicated. The catheter balloon is then inflated using sterile water, per the manufacturer's recommendations. For obese individuals, exposing the meatus may require help from a second person or placing the individual in a Trendelenburg position (head declined than the feet). Adequate swabbing with povidone-iodine helps in visualization. If the catheter is inserted in the vagina wrongly, it should not be removed until a new sterile catheter is successfully inserted into the meatus.

When Should the Catheter Be Removed?

The need for a urethral catheter should be assessed daily and must be removed at a prompt time. For colorectal surgeries, the catheter can be removed postoperatively on day one. In the case of mild to low rectal operations, the catheter can be removed three to six days postoperatively based on the risk of urinary retention. Early removal helps with ambulation and better postoperative recovery. For individuals with incomplete bladder evacuation and chronic urinary retention, intermittent catheterization is useful.

What Are the Complications of Urethral Catheterization?

• Urinary tract infection.

• Bladder infection.

• Pain.

• A transitory stinging sensation.

• Injuries to the urethra or bladder (less common).

• Catheter obstruction.

• Urine leakage.

• A negative effect for individuals with long-term indwelling catheters.

The other side effects associated with urinary catheters include:

• Bladder spasms and pain similar to stomach cramps.

• Blood or debris becomes trapped in the catheter tube, possibly due to a blockage in the drainage system.

• Catheter leakage, which can occur from a blockage or from straining during bowel movements if constipated

• Injuries to the urethra or bladder (less common).

• Bladder stones (less common, but potentially more likely with long-term catheter use).

How Should You Properly Care for an Urinary Catheter?

There are single-use and reusable catheters available. Reusable catheters should be cleaned with soap and water, and the entry point should also be cleaned to avoid the chance of a UTI. Single-use ones are available in sterile packaging. This type only requires cleaning of the area of insertion before insertion.

Drink plenty of water. It helps to make urine pale yellow or clear. Water is also the best way to lower the chances of urinary system infection.

Empty the urine from the drainage bag at least once every eight hours or when it gets full. If one need to clean the drainage bag, they can use a plastic squirt bottle containing a solution of vinegar and water or bleach and water.

How Can You Minimize the Risk of Side Effects From Urinary Catheter Use?

Here are some risk factors that increase the chance of side effects:

• Inadequate fluid intake. Due to this reason, one using a urinary catheter can have dehydration and increase the risk of UTIs. Pale urine is a sign individual is well-hydrated.

• The diet contains insufficient fiber. Consuming enough high-fiber foods like vegetables, grains, and fruits can help maintain regular bowel movements and prevent constipation-related catheter leakage.

• Twisting bends or improper placement of the urine bag can cause blockages or leaks.

• If one cannot clean the equipment or the skin properly, consider seeking assistance from a caregiver to ensure everything is cleaned regularly.

Conclusion:

The need for a catheter should be evaluated daily to avoid the risk of catheter-associated urinary tract infection. While a physician or nurse can place catheters, it is still mandatory for specific individuals to get a urologist's opinion. Interprofessional communication among health professionals enhances patient-centered care and improves outcomes.