How to Perform Male Urethral Catherization

URETHRAL CATHETERIZATION

• Indications:
  • Therapeutic
    • Urinary retention
    • Urinary output monitoring
    • Evacuation of blood clots
    • Intravesical chemotherapy
    • Postoperative urethral stenting
  • Diagnostic
    • Collection of urine for culture
    • Measurement of the postvoid residual urine
    • Retrograde instillation of contrast agents (cystourethrography)
    • Urodynamic studies
    
    
• Contraindications:
  • Acute prostatitis
  • Suspected urethral disruption associated with blunt or penetrating trauma
    • Blood at urethral meatus
    • Hemiscrotum
    • Perineal ecchymoses
    • Nonpalpable prostate
    • Inability to void
  • Severe urethral stricture

• Anesthesia:
  Recommend 2% lidocaine jelly

• Equipment:
  • Urethral catheterization kit (includes Foley catheter, povidone-iodine solution, lubricating jelly, 10-ml syringe with sterile normal saline, gloves, sterile towels, and urinary drainage bag)
  • Recommend 18F Foley catheter for male and 16F for female patients
  • Recommend 22F–24F Foley catheter for blood clot irrigation
  
  
• Positioning:
  Supine (men)

• Technique:
• Place sterile towels around the penis.
  

• Test the balloon of the catheter, lubricate the catheter with lubricating jelly, and set it aside on the sterile field.
• Retract the foreskin (if present). Grasp the penis laterally with the nondominant hand and place it on maximum stretch perpendicular to the body to straighten the anterior urethra.
• Swab the glans with povidone-iodine with the dominant hand. Observe sterile technique at all times.
• Inject 10 ml of 2% lidocaine jelly into urethra. Place a sterile urethral clamp for 5 minutes to provide anesthesia as well as additional lubrication. If lidocaine jelly is not available, it is helpful to inject 10 ml of lubricating jelly into the urethra.
• Grasp the catheter with the dominant hand.
  
• Using steady, gentle pressure, advance the catheter into the urethra until both the hub of the catheter is reached and urine is returned. Inflate the balloon with 10 ml normal saline.
  

• If urine is not returned, irrigate the catheter to confirm correct placement prior to inflating the balloon.
• Replace the foreskin to prevent a paraphimosis. Connect the catheter to a urinary drainage bag.
• If the catheter cannot easily be passed, a strategy for successful catheterization must be planned.

• Strategies for Difficult Catheterization of Men
  If resistance is met during catheter advancement, manually palpate the catheter tip to define the point of obstruction along the urethra . Once the location and nature of the lesion is defined, the next step is to develop a strategy for bypassing the obstruction.

• Anterior urethral obstruction”urethral stricture, a concentric
  narrowing of the lumen by scar tissue. Can occur at the fossa navicularis, bulbous urethra, or along the penile urethra.
  • Etiology: sexually transmitted disease, prior urethral instrumentation including transurethral resection of prostate (TURP), trauma.
  • Signs/symptoms: splayed and/or slow stream, straining.
  • Strategy for penile urethral stricture:
    • Use 16F or smaller straight-tip Foley catheter.
    • If unsuccessful, consult urology department to attempt catheter placement.
  • Strategy for bulbous urethral stricture:
    • Same as above.
    • If unsuccessful, 16F coudé-tip catheter will better negotiate the natural angle of the bulbomembranous junction. A coudé catheter has a curved tip that enables one to better engage the normal S-shaped curve of the bulbomembranous junction or to bypass an enlarged, obstructing prostate in the male urethra. To insert a coudé catheter, always keep the angled tip pointing superiorly and follow steps 6a–6j.
• Posterior urethral obstructions
  • Spasm of the external urinary sphincter
    • Etiology: contraction of the voluntary sphincter secondary to anxiety or pain. Often the cause of unsuccessful catheterization of men < 50 years old.
    • Signs: As the catheter tip approaches the sphincter, the patient becomes tense and complains of pain.
    • Strategy: (a) Inject 10 ml of lubricant (water-soluble jelly works as well as 2% lidocaine jelly). (b) After reaching the sphincter, pull the catheter back a few centimeters. (c) Distract the patient with conversation and by having him breathe deeply. (d) Advance the Foley catheter steadily with a slow, gentle pressure when the patient is relaxed.
  • Benign prostatic hypertrophy (BPH)
    • Suspect with age >60 years, prior transurethral resection of the prostate (TURP), treatment with finasteride (Proscar), terazosin (Hytrin), doxazosin (Cardura), or tamsulosin (Flomax).
    • Symptoms: hesitancy, intermittent and/or slow stream, straining, sensation of incomplete emptying.
    • Strategy: (a) A large catheter (18F or 20F) provides the additional stiffness needed to overcome the obstruction. A coudé-tip catheter is often helpful for negotiating the angle between the bulbous and membranous urethra . (b) Use the two-person technique: While catheter placement is attempted in the usual fashion, the assistant places a lubricated index finger in the rectum and palpates the apex of the prostate. The tip of the catheter usually can be felt just distal to the apex . The index finger presses anteriorly, thus elevating the apex and straightening out the area of obstruction.
      

• Prostate cancer: typically is not the sole cause of difficult catheterization unless the cancer is locally advanced. Strategy is similar to that for BPH.
• Bladder neck contracture.
  • Etiology: prior open or radical retropubic prostatectomy, bladder neck incision, or TURP.
  • Symptoms: hesitancy, intermittent and/or slow stream, straining, sensation of incomplete emptying.
  • Strategy: (a) Attempt a 12F catheter placement, following steps 6a6. (b) Consult urology department.