Welcome to 2009 !!
Today I would like to discuss about, what I regard as the most appropriate technique for male urinary catheterisation.
Catheterisation of the male bladder is in my opinion a difficult technique to get right. Why you may ask [with a smirk and a frown]? Because it is not taken seriously enough by medical personnel. The disregard of proper aseptic technique can lead to hospital acquired infections with its attendant morbidity and potential mortality. If it were a central venous line insertion, the patient would have their skin sterilised with alcohol / iodine and draped before entering the vascular space. With the bladder however, there seems to be a more relaxed, less serious approach to the appropriate use of aseptic technique. This is clearly not ideal and needs attention.
I have seen one worrisome technique which involves using long sterile forceps to introduce the catheter into the urethra without using full aseptic procedures. This has the inherent risk of introducing infection and is prone to technical failure.
I would therefore like to introduce you to a different technique which uses full aseptic technique and is easier to perform and is used as the norm in the UK system.
Step 1: Explain to the patient what you are going to do. You should never start any technique without obtaining informed consent from the patient. Do not take it for granted that the patient will say yes to any procedure. In an unconscious patient, catheterisation should be considered in the context of it being in their best interest for purposes of monitoring urine output and relieving retention.
Step 2: In a private examination area, fully expose the penis. NOW WASH YOUR HANDS USING STERILISING DETERGENT. Set up a sterile procedure pack on your bedside trolley. On the sterile procedure area, ensure you have a kidney-dish, a fluid receptacle, cotton wool, sterile gel, one or two 10ml syringes, saline and / or antiseptic fluid, an appropriately sized male urinary catheter and sterile gloves of appropriate size. A 10 or 12 French size Foley catheter is usually appropriate for most males. Put on the sterile gloves and then drape the inguinal area with a sterile paper sheet with a hole made in the centre to allow the penis to be placed through it. Some kits come with the hole already made.
Ensure a catheter bag is prepared in advance for collecting the urine.
Step 3: Prepare sterile saline or antiseptic liquid in the small container on your sterile procedure pack. Open the tip of the catheter pack with only the tip of the catheter allowed to protrude and replace it on the sterile tray. Open a new sterile gel used only for catheterisation. Do not use one previously opened as there is a risk of contamination.
UK hospitals have sealed Lignocaine gel specially prepared for catheterisation. This type of gel reduces the pain associated with the procedure. Load 10ml of sterile water or saline into a disposable 10ml syringe for eventual injection into the balloon port of the catheter.
Step 4: With your non-dominant hand, in this example the left hand, retract the foreskin of the patient (this is now a dirty hand and should never be used to handle aseptic utensils after this). With the clean dominant (right) hand pick up a cotton wool ball soaked in saline/disinfectant and wipe the tip of the penis to remove any debris. Repeat this with a clean cotton wall ball. Remember to throw your dirty disposables in a bin and never put them back on your sterile tray! Some doctors double glove the clean hand in advance and remove the top glove to ensure the remaining glove is definitely sterile.
Step 5: Now pull the penis vertically until straight and squeeze the gel down the external os into the urethra via the syringe. Aim to instill approximately 10ml of gel. Gently squeeze the outer corona of the penis to close the external os for about 2 minutes to stop the gel coming out and to give time for the lignocaine to anaesthetise the urethra. If the plain gel comes in a tube, use the additional 10ml syringe and pre-load it with the gel before instilling it down the male urethra.
Step 6: Now the tricky bit. Pick up the opened catheter with your aseptic dominant (right) hand and place the tip into the external os of the penis and release the external pressure on the corona whilst still holding the penis straight and vertical. Extend the catheter slowly down the urethra by pushing forwards and withdrawing the catheter from its protective sheath.
The catheter may need to be moved backwards and forwards as the gel does not always coat the entire urethra.
When the prostate is reached there will be some resistance. Push slightly more on the catheter until the resistance is overcome. Sometimes the catheter needs to be twisted in a corkscrew motion to achieve entry past the prostate.
NEVER FORCE THE CATHETER as it can create a false track inside the prostate. If in trouble call your senior doctor or the on-call urologist for assistance as soon as possible.
Sometimes using a larger French size catheter can achieve entry where smaller diameter catheters have failed.
Another technique is to use a stiffer catheter made from silicon and plastic polymer to achieve entry.
Step 7: Advance the catheter to its full length and place the open end in the disposable kidney-shaped dish to collect any escaping urine. Inject 10ml slowly into the balloon port. If the patient experiences pain then STOP as the tip of he catheter may still be in the distal urethra. Advance the catheter further forwards and then retry.
All being well, the balloon should inflate without resistance. Now pull the catheter gently until you feel mild resistance (the balloon should be at the neck of the bladder). The urine should now be flowing out of the catheter's open end and attach it to the prepared catheter bag.
Step 8: Remember to retract the foreskin to avoid acute paraphimosis. Wipe up any excess gel and remove the drapes and re-gown the patient's lower region.
Step 9: Remember to measure the residual volume of urine, which will then allow you to ascertain the initial output in one hour. [After 1 hour, output equals total volume minus the residual volume; this needs to be followed hourly if clinically desirable]. Aim to attach the catheter bag to a dedicated stand or bedside structure so that the lower tip of the bag avoids touching the floor as it is otherwise a risk for contamination and hospital acquired infection. Ensure the bag lies at a level lower than the patient's bladder so that urine can actively drain away.
You're done! Once well practised, this technique should take 5-10 minutes to do (without complication) but has inherent measures in place to try and prevent infection through avoiding unnecessary contamination and uses a sterile gloved hand to do the manoeuvres rather than forceps.
Please consider this as an alternative technique for your patients.
As additional advice, in those patients with haematuria or heavy urine contamination, catheters can become blocked and if this does occur, you will hopefully get a call from the friendly ward nurse informing you that the patient's urine output has dropped or stopped. Please see my last blog about the assessment of reduced urine output. Any patient with a Foley catheter in situ who has a significant drop in urine output and who has no obvious reason for this should have catheter occlusion considered as a potential cause.
One way to tell is to instill 50ml of sterile water down the free end of the catheter and then to suck back on the plunger to see if fluid comes back out. If you get free flow of urine back then the catheter is unblocked. If nothing comes back then a new catheter should be placed instead. If only the water comes back then there may be a problem occurring higher up in the urinary system to account for the lack of draining urine or there may be an intra-renal or pre-renal cause that will need further assessment.
This set of instructions is only but a guide. At all times clinical judgment should be used when performing any invasive technique and the ultimate responsibility is yours. If in doubt, always discuss matters with your senior doctors before performing any invasive technique with which you have suboptimal experience and / or confidence. If you are in doubt, it is better to defer performing the technique yourself to someone who can do it (and preferably they can teach you how to do it at the same time). I do not subscribe to the adage of 'see one, do one, teach one' as it is prone to failure and teaching of poor technique. As a friend once said to me 'it is not practise that makes perfect but it is perfect practise that makes perfect'. Now I do subscribe to that !