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How To Do Urethral Catheterization in a Male

By

Paul H. Chung

, MD, Sidney Kimmel Medical College, Thomas Jefferson University

Last full review/revision Sep 2020| Content last modified Sep 2020
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Urethral catheterization is the standard method of accessing the urinary bladder. A flexible catheter is passed retrograde through the urethra into the bladder. Several types of catheters are available. Sometimes the urethra is impassable, requiring suprapubic catheterization of the bladder.

Indications

Contraindications

Absolute contraindications 

  • None

Relative contraindications

*Urethral injury may be suspected following blunt trauma if patients have blood at the urethral meatus (most important sign), inability to void, or perineal, scrotal, or penile ecchymosis, and/or edema. In such cases, urethral disruption should be ruled out with imaging (eg, by retrograde urethrography) before attempting urethral catheterization.

Complications

Complications include

  • Injury to the urethra, prostate, or bladder with bleeding (common)

  • UTI (common)

  • Creation of false passages

  • Scarring and urethral strictures

  • Paraphimosis, if the foreskin is not reduced after the procedure

Equipment

Prepackaged kits are typically used but the individual items needed include

  • Sterile drapes and gloves

  • Povidone iodine with application swabs, cotton balls, or gauze

  • Water-soluble lubricant

  • Urethral catheter* (size 16 French Foley catheter is appropriate for most men; in the setting of prostatic hypertrophy or urethral stricture, an alternate size or style of catheter may be required†)

  • 10-mL syringe with sterile water (for catheter balloon inflation)

  • Local anesthetic (eg, 5 to 10 mL of 2% lidocaine jelly in a syringe [with no needle]) for distention and anesthesia of the male urethra

  • Sterile collection device with tubing

*A closed-catheter system minimizes catheter-associated UTI.

†A coudé catheter is curved at the end and may facilitate passage in a male with significant prostatic hypertrophy.

Additional Considerations

Relevant Anatomy

  • The male urethra bends acutely at the pubis. Always hold the penis straight and upright, to smooth out the curve, when passing a catheter through the urethra.

Positioning

  • Position the patient supine with hips comfortably abducted.

Step-by-Step Description of Procedure

  • Place all equipment within easy reach on an uncontaminated sterile field on a bedside tray.  You may put the box containing the catheter and the drainage system between the patient’s legs, so that it is easily accessible during the procedure.

  • If not done already, attach the catheter to the collecting system and do not break the seal unless a different type or size of catheter or irrigation of the catheter is required.

  • Test the retention balloon for integrity by inflating it with water, and apply lubricant to the catheter tip.

  • Saturate the applicator swabs, cotton balls, or gauze with povidone iodine.

  • Place the sterile fenestrated drape over the pelvis so that the penis remains exposed.

  • Grasp the shaft of the penis using your nondominant hand, and retract the foreskin if the patient is uncircumcised. This hand is now nonsterile and must not be removed from the penis or touch any of the equipment during the rest of the procedure.

  • Cleanse the glans penis with applicator swabs, gauze, or cotton balls saturated in povidone iodine. Use a circular motion, beginning at the meatus, and work your way outward. Discard or set aside the newly contaminated items.

  • Inject viscous lidocaine into the urethra. Insert the hub of the lidocaine-containing syringe into the penile meatus and inject about 5 mL. Pinch the meatus closed, to retain the lidocaine within the urethra, for at least 1 minute. The lidocaine distends the urethra, as well as provides some anesthesia, thereby easing catheter passage.

  • Hold the catheter in your free hand. If a coudé catheter is being used, the tip should point upward, so as to track the superior urethral wall during insertion.

  • Advance the catheter slowly through the urethra and into the urinary bladder. Patient discomfort is common. Ask the patient to relax and take slow deep breaths as you continue to apply steady pressure on the catheter until it is fully advanced to the level of the side port. Urine should flow freely into the collection tubing.

  • Slowly inflate the balloon with 5 to 10 mL of water. Obvious resistance or patient discomfort suggests incorrect placement. If this happens, deflate the balloon, withdraw the catheter slightly, and then reinsert the catheter all the way before trying to reinflate the balloon.

  • Position the balloon at the bladder neck, after successful balloon inflation, by slowly withdrawing the catheter until you feel resistance.

  • To prevent paraphimosis, reduce the foreskin after the procedure.

Aftercare

  • Remove the drapes.

  • Secure the catheter to the thigh with an adhesive bandage, tape, or strap. Some advocate taping the catheter to the lower abdominal wall to minimize pressure on the posterior urethra.

  • Place the bag below the level of the patient to ensure that urine can drain via gravity.

Warnings and Common Errors

  • Be sure to maintain strict sterile technique during the procedure to avoid urinary tract infection.

  • Be sure to reduce the foreskin after the procedure.

  • Be careful not to use excessive force during insertion, which could potentially cause urethral injury.

Tips and Tricks

  • Do not continue attempts at catheter placement if significant resistance is met or if the catheter feels to be buckling inside the urethra and not advancing.

  • Urine will appear in the catheter before the balloon has advanced beyond the prostate. Continue advancing the catheter completely to the end of the catheter before inflating the balloon, to avoid inflating the balloon in the prostate or urethral lumen, which will cause significant bleeding.

  • If the catheter appears to be in the correct position, but urine does not return, lubricant may be obstructing drainage of urine. Flush the catheter with normal saline to dislodge the lubricant and see if urine returns.

  • If the balloon is difficult to inflate or the balloon port distends during inflation, the proximal end of the catheter is not in the correct position. Deflate the balloon and advance the catheter further into the bladder.

  • If correct positioning is questioned, flush the catheter with 30 to 60 mL of normal saline. If the fluid can be flushed and aspirated easily, then the catheter is in the correct position. A catheter that will not irrigate is not in proper position.

  • Consult a urologist for any questions regarding catheter size and style or difficulty placing a catheter.

Drugs Mentioned In This Article

Drug Name Select Trade
XYLOCAINE
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