Document facilitator: CNS – Urology
Senior document owner: Clinical Leader Urology / HHS Committee
Document number: 1.73
Issue Date 24 August 2018
Review Date 24 August 2021
Version 7
Type:
Guideline
Name:
Indwelling urethral catheterisation (Adults)
Purpose
To facilitate appropriate catheterisation, to reduce complications related to
catheterisation and to promote patient independence, comfort and dignity.
Scope
Includes: Medical staff, registered and enrolled nurses (under the direction and
delegation of an RN) and midwives experienced and competent in the procedure
should perform indwelling urinary catheterisation in the hospital and community
setting.
Staff and students learning to catheterise female and male patients can complete this
procedure under supervision.
Definitions
Catheter-associated Urinary Tract Infections (CAUTI)
The most important risk factor for developing a catheter-associated UTI (CAUTI) is
prolonged use of the urinary catheter. Catheter use and duration should be
minimised in all individuals, particularly those at higher risk for CAUTI such as
women, the elderly, and individuals with impaired immunity.
Policy content and guidelines
Indwelling catheterisation should be viewed as a last resort for continence
management and should only be used when other management strategies are
inappropriate or have failed.
Catheterisation is a sterile procedure and requires good technique supported by
learning resources on
Connect Me and references in this guideline.
Indications
To relieve acute urinary retention or bladder outlet obstruction
Close monitoring of urine output in acute renal failure and in the critically ill
patient
Peri operative use for selected surgical procedures patients undergoing
urologic surgery or to other adjoining structures of the genitourinary tract
Anticipated prolonged duration of surgery or patients anticipated to receive
large volume infusions or diuretics during surgery
To enable pre and post-operative bladder drainage e.g. Trans urethral
resection of prostate (TURP)
Indwelling uretheral catheterisation (Adults)
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Review Date 24 August 2021
Version 7
To facilitate irrigation of the bladder and management of haematuria/clot
retention
Epidural use and as wit
h obstetric bladder care and management (antenatal,
intrapartum and postpartum)
The need for intra operative monitoring during surgery
Chronic urinary retention in the symptomatic patient (e.g. renal impairment or
urinary tract infection) when intermittent self-catheterisation (ISC) is not an
option and retention cannot be corrected medically or surgically
To facilitate urodynamic studies or specialist radiological procedures
Instillation of drugs directly into the bladder
To measure residual urine after patient has voided in the absence of a
bladder scanner with intermittent in and out catheter
In patients with neurological disorders causing paralysis or loss of sensation
leading to voiding issues
Patients requiring prolonged immobilization e.g. multiple traumatic injuries
such as pelvic fractures
Where a patient with long term urological issues insists on this form of
management after informed discussion with the Senior Medical Officer
To manage intractable incontinence as a last resort or when incontinence
poses a risk of infection of nearby surgical sites or skin breakdown
Management of impaired skin integrity and to assist healing of open sacral or
perineal wounds
To improve comfort for end of life care when non-invasive measures have
failed.
Contra-indications
Urethral catheterisation should be avoided in circumstances where urethral trauma
may have occurred, e.g. pelvic fractures and ‘straddle’ injuries.
Risks and precautions
Urinary catheterisation is an invasive procedure, which potentially places the patient
at risk of infection and trauma. The patient must be fully assessed, have an indication
as listed above and consent to the procedure.
The incidence of bacteria in the urine (bacteriuria) has been estimated to be about
3% to 10% higher each day after catheter insertion (Niël-Weise 2012). This results in
approximately 50% of hospitalised patients catheterised for longer than 7 days
contracting an infection.
Significant force during catheterisation should be avoided as this may cause trauma
and the formation of false urethral passages. However, during male catheterisation it
is common to encounter some resistance, particularly in the bulbar urethra, prostatic
urethra and bladder neck. This can often be due to urethral/bladder neck spasm
and/or prostatic enlargement. Halting insertion and maintaining gentle insertion
Indwelling uretheral catheterisation (Adults)
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Document facilitator: CNS – Urology
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Document number: 1.73
Issue Date 24 August 2018
Review Date 24 August 2021
Version 7
pressure may overcome this. If insertion is still not possible then medical/urology
assistance may be required.
A check of patient allergies is required prior to catheterisation:
A very small number of patients may experience allergic reactions to latex, lignocaine
and chlorhexidine.
Equipment
Catheterisation pack
Males 10ml to 20ml of 2% lignocaine gel in pre-filled syringe
Females sterile lubricating Jelly or 5ml to 10ml of 2% lignocaine gel in pre-
filled syringe
Catheter selection:
o
BARDIA latex catheters for patients likely to require catheterisation short
term (less than one week) shall be used
o
BIOCATH Hydrogel coated Latex catheters for patients requiring longer
term catheterisation (urology, aged care, and community care) the use of
is recommended
o
All-silicone clear catheters for the rare patient with a known latex
allergy. These are available from the advanced wound care cupboard on
Level 6 and the Urology Department, Level 7 WRH and at Kenepuru
Community Hospital
o
Additional catheters t
ypes for those patients under the care of the CNS
Urology and/or the CNS Continence alternative products may be provided
for specific clinical indications.
Appropriate catheter size, length and type:
o Males length: 30-40cm (size 14ch or 16ch)
o Females standard length (size 12ch or 14ch)
o Males and females with haematuria, needing continuous bladder irrigation
or bladder washouts should preferably have a size 20ch, 22ch or 24ch
three way irrigation catheter inserted
o Larger catheter sizes and three way irrigating catheters will be reserved
for specific circumstances e.g. patients needing continuous bladder
irrigation or bladder washouts and will not be generally available except in
urology wards or via the CNS
Sterile water and syringe to inflate the catheter balloon to recommended size
Sterile gloves
Normal Saline for cleansing is appropriate (ANZUNS, 2013)
Appropriate drainage bag
Rubbish bag
Incontinence sheet.
Securement device, e.g. Catheter Strap, FlexTrac, Statlock
Indwelling uretheral catheterisation (Adults)
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Procedure
Wash or gel hands, assemble equipment and explain the procedure and
purpose to the patient in compliance with the 5 moments of hand hygiene
Note: Catheterisation is a sterile procedure and requires good technique to
maintain this and for this reason two people may be helpful
Provide good lighting, as this is necessary to see the meatus clearly in female
patients
Provide privacy and avoid interruptions during catheterisation
Protect bed/stretcher with incontinence sheet under the patient’s buttocks
Assist the patient to lie in a dorsal recumbent position, with knees up and out
and feet together for females, or legs flat and slightly parted for males
Encourage patients to relax as much as possible, keep their eyes open during
the procedure and avoid tensing their legs and buttocks
Open catheterisation pack
Open out the catheter onto the sterile field, the inner protective bag may be
partially left on or fully removed depending on operator preference
Pour the normal saline into sterile container provided
Empty sterile water into tray ready for balloon inflation
Wash/gel hands and apply sterile gloves
The lignocaine gel syringe currently used by CCDHB (Montavit) is a break off
tip accordion syringe which requires emptying completely and maintaining
pressure until after removal from urethra.
Draw up sterile water according to the amount recommended on catheter
balloon
Drape the patient with the sterile drape to provide a sterile field to work on
Place the sterile receptacle on the sterile drape between the patient’s legs
Female catheterisation
Thoroughly cleanse the external and internal labial area and perineum with
normal saline, swabbing from anterior to posterior, discarding each swab after
use
Lubricate the end of the catheter with lubricating Jelly
Non-dominant hand should hold labial folds apart to facilitate identification of
the urethral meatus. With obese/immobile ladies an assistant may be
required to help support the legs and hold labial folds apart
Leaving the distal end of the catheter in the receptacle on the sterile field,
insert the catheter into the urethra until urine begins to flow. Advance the
catheter again 12 cm
Inflate the balloon with the correct amount of sterile water, balloon inflation
should not cause discomfort
Indwelling uretheral catheterisation (Adults)
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Once the balloon is safely inflated with the correct quantity of sterile water,
gently pull the catheter forwards until resistance is felt and then attach the
selected drainage system
Ensure that the catheter is secured to the patient.
Male catheterisation
Successful male catheterisation is assisted by adequately filling the whole length of
the urethra with lubricating/anaesthetic gel. A medicine standing order supports this
practice in the community.
Pick up the penis with non-dominant hand. Retract foreskin if uncircumcised
Thoroughly cleanse the meatus and glans (head) of the penis removing any
smegma that may have accumulated under the foreskin. Cleanse from the
meatus down the shaft of the penis
Insert the nozzle of the lignocaine syringe into the urethral meatus and
maintain sufficient pressure to attain a seal and prevent gel from oozing
everywhere. Gradually instil the entire contents into the urethra, warning the
patient that the gel may sting initially. Pinch the head of the penis and
remove the nozzle. Use a finger to massage the gel down the underside
shaft of the penis. Continue to pinch the head of the penis to prevent loss of
gel
Use sterile gauze swabs to hold the penis with non-dominant hand
Lubricate the first 3cm of the catheter either with lignocaine gel or sterile
lubricating jelly. Pick up catheter 6–7 cm from tip. Hold securely and gently
insert into penis
The penis should be held upward at a 60–90 degree angle to patient’s legs,
so that it is as nearly perpendicular to patient’s body as possible. This
reduces the usual S- shaped curve of the male urethra, facilitating passage of
the catheter
If resistance is encountered halt insertion and wait 30-60secs, encouraging
the patient to relax as much as possible
Male urethral catheters must be inserted fully, before attempting to
inflate the balloon. This means that the bifurcation of the catheter should be
at the urethral meatus
before the balloon is inflated. This method may help to
ensure that the balloon is completely in the bladder. Failure to advance the
catheter this far, even if urine starts to drain, may result in balloon inflation
potentially damaging or rupturing the urethra.
If the balloon is fully into the
bladder, balloon inflation should be easy and painless.
Once the balloon is safely inflated with the correct quantity of sterile water,
gently pull the catheter forwards until resistance is felt and then attach the
selected drainage system.
Ensure that the foreskin is re-extended over the head of the penis.
Ensure that the collection bag tubing is secured to the patient
Indwelling uretheral catheterisation (Adults)
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Following the procedure
Remove all the equipment and rubbish
Assist the patient to a comfortable position
The catheter should be attached to the patient’s thigh to secure and prevent
traction
Ensure the drainage bag is positioned below thigh level for drainage
Wash/gel your hands
Documentation
On completion of the procedure, record information in the relevant documents. This
should include:
Date and time of catheterisation, name and signature of the nurse
The indication for catheterisation/change of catheter and clinical need for the
continued use of an indwelling catheter should be reassessed regularly
Catheter type, length and size
Amount of water instilled into the balloon
Any problems during the procedure
In uncircumcised males that the foreskin has been returned over the glans
penis
Colour and amount of urine drained within the first 30 minutes
A review date to assess the need for continued catheterisation or date of next
anticipated change of catheter
If discharging home with a catheter:
Provide initial supplies including a spare leg bag, bed bag.
Provide the patient with verbal and written advice regarding catheter care via
Cap Docs.
Looking after your catheter at home – Urethral or Suprapubic
Refer the patient to Community Health Services for District Nursing input,
ongoing supplies and support. The referral should include:
o Attention for appropriate Continence Service i.e Wellington (includes
Porirua), Kapiti Coast or the Hutt Valley
o date of catheter insertion
o proposed future catheter changes or removal and a follow-up plan.
Note: Advice on catheterisation can be sought through:
the Urology Department (8060690) and the CNS Urology (0277068096)
Continence Service and CNS Continence CCDHB (Ext 6358)
Indwelling uretheral catheterisation (Adults)
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Review Date 24 August 2021
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Removal of Urethral Catheter
Generally this procedure can be uncomfortable and oral analgesia may be useful
reducing pain. Explain procedure to patient
Consider providing
oral analgesia 30 minutes prior to catheter removal
and when required after removal
For particularly anxious patients consider the use of inhalational analgesics
for example Entonox or Penthrox during procedure
Patients to be warned of expected discomfort as the catheter and deflated
balloon passes through the length of the urethra
Check volume of water in balloon – refer to patient documentation
Attach syringe to catheter valve to deflate balloon
Do not use suction on the syringe but allow the water to come back passively,
ensure the balloon is fully deflated before catheter removal
In a supported supine position ask the patient to breathe in and out and stay
as relaxed as possible ; as patient exhales, gently remove the catheter
Clean urethral meatus and clear away equipment
Provide guidance on how much fluid the patient may be expected to drink
once their catheter has been removed
Provide a urinal or measuring jug if required.
If urge/stress incontinence or urethral bleeding is likely once the catheter has
been removed ask the patient if they would care to use an appropriate sized
continence pad with suitable underwear.
References
ANZUNS, Australia and New Zealand Urological Nurses Society (2013)
catheterisation Clinical Guidelines, Versio
n 2 www.anzuns.org
Geng V, Cobussen-Boekhorst H, Farrell J et al (2012) Evidence Based Guidelines for
best practice in urological health Care Catheterisation: Indwelling catheters in adults
Urethral and Suprapubic EAUN p1-114
Hooten, T., Bradley, S.F., et al., (2010) Prevention and Treatment of Catheter-
Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice
Guidelines from the Infectious Diseases Society of America.
Clinical Infectious Diseases, 2010: p. 625-663
Niël-Weise BS, van den Broek PJ, da Silva EMK, Silva LA. (2012) Urinary catheter
policies for long-term bladder drainage. Cochrane Database of Systematic Reviews
2012, Issue 8. Art. No.: CD004201. DOI: 10.1002/14651858.CD004201.pub3.
SUNA, Society of Urological Nurses & Associates (2010)
Prevention and control of catheter associated urinary tract infection (CAUTI) Clinical
Practice Guideline, 14)
Indwelling uretheral catheterisation (Adults)
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Document facilitator: CNS – Urology
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Review Date 24 August 2021
Version 7
Wilde MH, McMahon JM, Crean HF and Brasch J (2016) Exploring relationships of
catheter associated UTI and Blockage in people with long-term indwelling urinary
catheters Journal of Clinical Nursing 26: 2558-2571
Wilde MH (2016) Best Practices: Basic Care in Indwelling Urinary Catheter
Management International Continence Society Teaching Module
https://www.ics.org/Documents/DocumentsDownload.aspx
Disclaimer: This document has been developed by Capital & Coast District Health
Board (CCDHB) specifically for its own use. Use of this document and any reliance
on the information contained therein by any third party is at their own risk and
CCDHB assumes no responsibility whatsoever.
Indwelling uretheral catheterisation (Adults)
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