Urethral Catheterization - Indications, Procedure, and Complications

Introduction:

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

What Are the Indications for Urethral Catheterization?

• 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).

1. 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.
2. Extrinsic causes include an enlarged abdominal and pelvic organ which compresses 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.

• Perioperative Purposes:

1. Urological and gynecological surgeries.

2. Individuals who require strict intraoperative urine output.

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

4. Neurogenic bladder dysfunction.

5. Urinary incontinence.

6. Social and hygiene reasons.

7. Acutely ill persons who require close urinary output measurement.

8. Chemotherapy drug delivery.

9. Bladder irrigation.

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 not possible. 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 give clear instructions to the individual about the procedure and should give appropriate time to respond to the queries.

• A proper light source is mandatory.

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

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

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

• Should place a disposable pad beneath the buttocks.

• Should perform hand hygiene.

• 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.

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

• In case of 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, that indicates the correct placement of the catheter. 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, that indicates the correct placement of the catheter. The catheter balloon is then inflated using sterile water, as 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 on day one postoperatively. 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 post-operative 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.

• Urethral injury.

• Catheter obstruction.

• Urine leakage.

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

Conclusion:

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