assignment on urinary catheterization

KYLE J. FLETKE, MD, DAE HYOUN JEONG, MD, AND ALEXANDER V. HERRERA, MD, MS

Am Fam Physician. 2024;110(3):251-258

Author disclosure: No relevant financial relationships.

Family physicians often treat patients who require urinary management with the use of external urinary devices, clean intermittent catheterization, or indwelling urinary catheterization. External urinary devices are indicated for urinary incontinence (postvoid residual less than 300 mL), urine volume measurement for hospitalized patients, nonsterile urine diagnostic testing, improved comfort for patients in hospice or palliative care, and fall prevention for high-risk patients. Indwelling urinary catheterization is indicated for severe urinary retention or bladder outlet obstruction; wound healing in the sacrum, buttocks, or perineal area; prolonged immobilization; and as a palliative measure for patients who are terminally ill. Clean intermittent catheterization is an alternative to indwelling urinary catheterization for acute or chronic urinary retention (postvoid residual greater than 300 mL) without bladder outlet obstruction, sterile urine testing, postvoid residual volume assessment, and wound healing. Suprapubic catheter placement is considered when long-term catheterization is needed or urethral catheterization is not feasible. Urinary catheters should not be used solely for staff or caregiver convenience, incontinence-related dermatitis, urine culture procurement from a voiding patient, or initial incontinence management. Common complications of urinary catheter use include obstruction, bladder spasm, urine leakage, and skin breakdown of the sacrum, buttocks, or perineum. The risk of catheter-associated urinary tract infections increases with the duration of catheter use. Urologist referral is indicated for patients requiring urinary management who have recurrent urinary tract infections, acute infectious urinary retention, suspected urethral injury, or substantial urethral discomfort or if long-term catheterization is being considered.

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Urinary Catheterization

Urinary catheterization is a nursing procedure that is a common practice in various medical settings, including hospitals, outpatient clinics, and home care, and can be temporary or long-term depending on the patient’s condition. The procedure is performed for patients who cannot urinate independently due to surgery , illness, or injury , and it assists in maintaining urinary function and managing specific medical conditions.

Despite the normally sterile urinary tract, introducing microorganisms through this procedure poses a risk of catheter-associated urinary tract infections. Bacteria can ascend from the bladder to the kidneys via the ureters . Even post-catheterization, infection risk remains elevated as natural defense mechanisms , such as flushing microorganisms through voiding, are bypassed. Therefore, maintaining meticulous sterile technique during catheterization is imperative.

Table of Contents

What is urinary catheterization, indications, contraindication, types of urinary catheter, supplies and equipment, inserting indwelling foley catheter, removing the indwelling foley catheter, references and sources.

Urinary catheterization is a medical procedure that involves the insertion of a thin, flexible tube into the bladder through the urethra or a surgical opening in the abdomen. This catheter allows for the drainage of urine from the bladder when normal urine flow is obstructed or when accurate measurement of urine output is required.

Urinary catheterization is indicated in a variety of clinical situations, including but not limited to:

1. Acute or chronic urinary retention . Inability to empty the bladder naturally due to obstruction, neurological conditions, or weakened bladder muscles.

2. Monitoring urine output. Critical in managing patients in intensive care units or during major surgeries where accurate measurement of urine output is necessary.

3. Collecting sterile urine samples . Necessary when uncontaminated urine specimens are required for diagnostic tests.

4. Perioperative use. During and after surgical procedures, particularly those involving the urinary tract or prolonged surgeries where bladder control may be compromised.

5. Management of severe incontinence . When other treatments are ineffective or impractical, particularly in patients with mobility impairments or severe neurological conditions.

6. Facilitation of healing. In patients with severe open sacral pressure ulcers or perineal wounds to keep the area dry and promote healing.

7. Bladder irrigation. To prevent or manage blood clots or debris in the bladder, especially post-operatively.

Avoid catheterization for the following situations that will further cause injury or complications. These may include:

1. Known or suspected carcinoma of the bladder . Inserting a catheter can potentially cause trauma or bleeding in patients with bladder cancer .

2. Anticoagulation/Antiplatelet Treatment. Patients on anticoagulant or antiplatelet therapy have an increased risk of bleeding , which can lead to uncontrolled hemorrhage during catheter insertion.

3. Acute Prostatitis: Severe inflammation of the prostate gland, as catheterization can exacerbate the condition and cause additional complications.

4. Recent Urethral Surgery: Patients who have undergone recent urethral surgery or have urethral strictures, as catheterization can disrupt the surgical site or worsen the stricture.

5. Severe Urethral Stricture Disease: Narrowing of the urethra that makes catheter insertion difficult or impossible without causing trauma .

Urinary catheters vary in the number of lumens. Some are equipped with balloons to secure the indwelling catheter, while others feature a closed drainage system.

1. Single-Lumen (straight) Catheters: These catheters have one lumen (channel) and are typically used for short-term catheterization such as during surgical procedures or for obtaining a urine sample.

2. Double-Lumen (indwelling) Catheters: Designed for indwelling use, with one lumen for urinary drainage and a second lumen for inflating a balloon to keep the catheter in place.

3. Triple-Lumen Catheters: Used for continuous bladder irrigation or for instilling medications into the bladder. One lumen drains urine, the second inflates the balloon, and the third delivers irrigation fluid.

Proper urinary catheterization requires specific supplies and equipment to ensure safety and reduce the risk of infection. These include:

• Sterile Catheters (For males, a urinary catheter size typically ranges from 12 to 16 French (Fr), while for females, it ranges from 10 to 14 French (Fr), selected based on individual anatomical considerations and clinical requirements.)
• Sterile gloves
• Antiseptic solution for periurethral cleaning
• Sterile water-based lubricant
• 10 mL syringes pre-filled with sterile water for inflating the catheter balloon.
• Urine drainage bag connected to the catheter
• Adhesive securement device or tape
• Urine receptacle
• Specimen container (if for urine culture)
• Bath blanket or sheet for draping
• Standing lamp or flashlight

Master the procedure of Foley catheter insertion for males and females, key for accurate urine output monitoring and addressing urinary retention :

1. Explain the procedure to the patient. Understanding the procedure can also help the patient remain calm and still, reducing the risk of complications.

2. Position the client in a supine position. Proper positioning (bend the knees gently and promote external rotation of the thighs for female clients) or (extend the knees and hips while gently separating the legs for male clients) provides optimal access to the urethra and facilitates the insertion process.

3. Perform hand hygiene and don sterile gloves. Maintaining hand hygiene and using sterile gloves are needed to prevent the invasion of pathogens into the urinary tract, thereby lowering the risk of infection, including catheter-associated urinary tract infection (CAUTI).

4. Gather all supplies. Ensure all required supplies are opened and readily available for the sterile hand (catheter kit, gloves, antiseptic solution, sterile drapes, lubricant, drainage bag ). This minimizes the risk of contamination and reduces the time the patient is exposed.

5. For male clients, drape the lower abdomen, leaving the genital area exposed. Secure the drape for accessibility. For females, drape the lower abdomen, exposing the urethral opening. Draping during catheter insertion maintains sterility by covering non-essential areas, ensuring a clean field for the procedure. It also respects the client’s privacy and dignity by selectively exposing only the necessary anatomical structures.

6. Place the catheter kit on the sterile field; between the legs for female, and either on top of the thighs or between the legs for male. Positioning the catheter kit in these specific locations facilitates ease of access during the procedure, ensuring efficiency and minimizing contamination risks.

7. Cleanse the urinary meatus : a. Females: With the nondominant hand, spread the labia to expose the urinary meatus. Using forceps in the other hand, wipe from the pubis to the rectum along the far labia with an antiseptic-soaked cotton ball, then discard. Repeat along the near labia and down the middle with new cotton balls each time. Clean from front to back, moving from the least contaminated area to the most contaminated, following medical asepsis principles.

b. Males: Using the non-dominant hand, hold the penis at the shaft below the glans, then clean the urethral meatus with circular motions using the dominant hand, starting from the center and moving outward. Use antiseptic solution to cleanse the penis, focusing on the meatus. This reduces the bacterial load on the skin, minimizing the risk of introducing pathogens during catheter insertion.

8. Apply lubrication to the catheter, using 2.5 to 5 cm (1 to 2 in.) for females and 15 to 17.5 cm (6 to 7 in.) for males. Females typically require a shorter length of lubrication (2.5 to 5 cm or 1 to 2 in.) because the female urethra is shorter and more accessible. In contrast, males need a longer length of lubrication (15 to 17.5 cm or 6 to 7 in.) due to the longer and more convoluted nature of the male urethra.

9. Hold the catheter 7.5 to 10 cm (3 to 4 inches) from the tip, loosely coiling the rest in palm of the hand. Make sure the urine bag is attached to the catheter. Holding the catheter near the tip allows for easier manipulation during insertion. Coiling it in the palm prevents the distal end from touching a unsterile area.

10. Insert the catheter : a. Females: Ask the client to take a slow deep breath; gently insert the catheter through the urethreal meatus as the client exhales. Then advance another 5 to 7.5 cm (2 to 3 inches) until urine flows then release the labia and use the nondominant hand to hold the catheter securely. Inserting the catheter as the client exhales relaxes the urethral sphincter, making insertion easier. Advancing the catheter further ensures it reaches the bladder for proper urine flow.

b. Males: Hold the penis upward and insert the catheter 7.5 to 10 cm (3 to 4 inches) from its tip into the urethral meatus. Advance it 17 to 22.5 cm (7 to 9 inches) until urine flows. Avoid forcing catheter insertion if resistance is encountered. Lower the penis once the bladder is empty, and for uncircumcised patients, remember to replace the foreskin. Gradual insertion prevents sudden movements that can cause urethral injury. Inform the client that a burning sensation is felt during catheter insertion into the urethra. Explain that this sensation is normal and will quickly subside.

11. Secure the catheter in position and inflate the balloon with the saline-filled syringe held in the other hand, attach the catheter to the urine drainage system, and secure it to the client’s inner thigh with adhesive tape. These steps ensure the catheter remains securely in place, allows for free urine drainage, and reduces the risk of trauma while maintaining patient comfort .

12. In case of patient discomfort, deflate the balloon, move the catheter forward by 1 inch, and reinflate it to confirm correct urethral placement. Securing and inflating the catheter balloon prevents accidental removal from the bladder. Discomfort may signal improper placement in the urethra, so deflating, adjusting, and reinflating the balloon ensures correct positioning, reducing discomfort and potential complications.

13. Hang the urine drainage bag below the level of the bladder by attaching to bed frame. Do not place it on the side rails or the floor. Check that drainage tubing is not kinked . Keeping drainage bags below bladder level helps maintain urine flow and prevent contamination. Attaching bags to side rails increases the chance of urethral trauma from pulling or accidental dislodgment.

14. Return the client to a comfortable position. Document the amount and characteristics of urine and the client’s response to the procedure. Returning the client to comfort post-IFC insertion prevents strain, while documenting urine characteristics and client response ensures accurate monitoring for complications like hematuria or discomfort, prompting timely intervention if needed.

Explore the essential steps in Foley catheter removal, prioritizing patient comfort and facilitating a smooth transition to natural bladder function.

1. Explain the procedure to the client Providing information about the catheter removal process helps alleviate patient anxiety and ensures their cooperation during the procedure.

2. Perform hand hygiene and don clean gloves Proper hand hygiene and wearing clean gloves prevent the introduction of pathogens, reducing the risk of infection.

3. Position the client comfortably and place a waterproof pad under the buttocks. Ensuring the patient is comfortably positioned, typically in a supine position (males) or dorsal recumbent postion (females), provides optimal access to the catheter and minimizes discomfort. A waterproof pad protects the bedding from potential urine leakage during catheter removal, maintaining cleanliness and patient dignity.

4. Attach a syringe to the balloon port. Deflate the balloon by slowly withdrawing all the sterile water. Attaching a syringe to the balloon port allows for controlled deflation of the balloon, a key step in safely removing the catheter without causing trauma to the urethra. Slowly withdrawing the sterile water from the balloon ensures it deflates completely, preventing urethral injury during catheter removal.

5. Ask the client to take deep breaths and gently withdraw the catheter. Encouraging deep breaths helps the patient relax, and gentle withdrawal minimizes discomfort and reduces the risk of urethral trauma.

6. Inspect the catheter for any signs of damage or residual balloon fluid. Inspecting the catheter ensures that the entire device has been removed intact and that no part of the balloon remains in the bladder, which could cause complications.

7. Dispose of the catheter and gloves properly and perform hand hygiene again Proper disposal of the used catheter and gloves prevents the spread of infection and maintains a clean environment.

8. Document the procedure in the client’s record. Accurate documentation provides a record of the procedure, including any observations or complications, and ensures continuity of care.

9. Monitor the client for urinary output and any signs of discomfort or infection. Monitoring the patient post-removal helps detect any immediate complications such as urinary retention or infection, allowing for prompt intervention if needed. The client may experience burning or irritation the first few times he or she voids after removal, due to urethral irritation.

• Assadi, Farahnak. Strategies for Preventing Catheter-associated Urinary Tract Infections. International Journal of Preventive Medicine 9(1):p 50,
• Clayton, J. L. (2017). Indwelling Urinary Catheters: A Pathway to Health Care–Associated Infections. AORN Journal, 105(5), 446–452.
• Cooper, F. P., Alexander, C. E., Sinha, S., & Omar, M. I. (2016).  Policies for replacing long-term indwelling urinary catheters in adults. Cochrane Database of Systematic Reviews.
• Shaw, C., & Wagg, A. (2019). Long-term urinary catheterisation in community-dwelling adults. British Journal of Community Nursing, 24(6), 258–262.
• Berman, A., Snyder, S. J., & Frandsen, G. (2015). Kozier & Erb’s fundamentals of nursing: Concepts, process, and practice (10th ed.). Pearson.
• Potter, Patricia et al., (2019). Essentials for Nursing Practice 9th Edition

9 thoughts on “Urinary Catheterization”

AWESOME REFERENCE

The image link does not work. Can you please fix that?

Is an in & out straight cath on a male a clean or strile procedure?

sterile, always :)

Tnx for d update

Well prepared and organized. Thanks for the update

Theory is like practical

A huge thank you to the creators of this AWESOME content!!!

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Chapter 10. Tubes and Attachments

10.4 Urinary Catheters

Urinary elimination is a basic human function that can be compromised by illness, surgery, and other conditions. Urinary catheterization may be used to support urinary elimination in patients who are unable to void naturally. Urinary catheterization may be required:

• In cases of acute urinary retention
• When intake and output are being monitored
• For preoperative management
• To enhance healing in incontinent patients with open sacral and perineal wounds
• For patients on prolonged bedrest
• For patients needing end-of-life care

Catheter-Associated Urinary Tract Infections

Catheter-associated urinary tract infections (CAUTI) are a common complication of indwelling urinary catheters and have been associated with increased morbidity, mortality, hospital cost, and length of stay (Gould et al., 2009). Urinary drainage systems are often reservoirs for multidrug-resistant organisms (MDROs) and a source of the transmission of microorganisms to other patients (Gould et al., 2009). The most important risk factor for developing a CAUTI, a health care associated infection (HAI), is the prolonged use of a urinary catheter (Centers for Disease Control and Prevention [CDC], 2015). Urinary tract infections (UTIs) are the most commonly reported HAIs in acute care hospitals and account for more than 30% of all reported infections (Gould et al., 2009). Catheters in place for more than a few days place the patient at risk for a CAUTI. A health care provider must assess patients for signs and symptoms of CAUTIs and report immediately to the primary health care provider. Signs and symptoms of a CAUTI include:

• Fever, chills
• Lower abdominal pain
• Back or flank pain
• Urgency, frequency of urination
• Painful urination
• Change in mental status (confusion, delirium, or agitation), most commonly seen in older adults

The following are practices for preventing CAUTIs (Perry et al., 2014):

• Insert urinary catheters using sterile technique.
• Only insert indwelling catheters when essential, and remove as soon as possible.
• Use the narrowest tube size (gauge) possible.
• Provide daily cleansing of the urethral meatus with soap and water or perineal cleanser, following agency policy.
• Ensure a closed drainage system.
• Ensure that no kinks or blockages occur in the tubing.
• Secure the catheter tube to prevent urethral damage.
• Avoid use of antiseptic solutions on the urethral meatus and/or in the urinary bag.

Urinary Catheterization

Urinary catheterization refers to the insertion of a catheter tube through the urethra and into the bladder to drain urine. Although not a particularly complex skill, urethral catheterization can be difficult to master. Both male and female catheterizations present unique challenges.

Having adequate lighting and visualization is helpful, but does not ensure entrance of the catheter into the female urethra. It is not uncommon for the catheter to enter the vagina. Leaving the catheter in the vagina can assist in the correct insertion of a new catheter into the urethra, but you must remember to remove the one in the vagina.

For some women, the supine lithotomy position can be very uncomfortable or even dangerous. For example, patients in the last trimester of pregnancy may faint with decreased blood supply to the fetus in this position. Patients with arthritis of the knees and hips may also find this position extremely uncomfortable. Catheterization may also be accomplished with the patient in the lateral to Sims position (three-quarters prone).

The male urinary sphincter may also be difficult to pass, particularly for older men with prostatic hypertrophy.

There are two types of urethral catheterization: intermittent and indwelling.

Intermittent catheterization (single-lumen catheter) is used for:

• Immediate relief of urinary retention
• Long-term management of incompetent bladder
• Obtaining a sterile urine specimen
• Assessing residual urine in the bladder after voiding (if a bladder scanner is not available)

Indwelling catheterization (double- or triple-lumen catheter) is used for:

• Promoting urinary elimination
• Measuring accurate urine output
• Preventing skin breakdown
• Facilitating wound management
• Allowing surgical repair of urethra, bladder, or surrounding structures
• Instilling irrigation fluids or medications
• Assessing abdominal/pelvic pain
• Investigating conditions of the genitourinary system

The steps for inserting an intermittent or an indwelling catheter are the same, except that the indwelling catheter requires a closed drainage system and inflation of a balloon to keep the catheter in place. Indwelling catheters may have two or three lumens (double or triple lumens). Double-lumen catheters comprise one lumen for draining the urine and a second lumen for inflating a balloon that keeps the catheter in place. Triple-lumen catheters are used for continuous bladder irrigation and for instilling medications into the bladder; the additional lumen delivers the irrigation fluid into the bladder.

Indwelling urinary catheters are made of latex or silicone. Intermittent catheters may be made of rubber or polyvinyl chloride (PVC), making them softer and more flexible than indwelling catheters (Perry et al., 2014). The size of a urinary catheter is based on the French (Fr) scale, which reflects the internal diameter of the tube. Recommended catheter size is 12 to 16 Fr for females, and 14 to 16 Fr for males. Smaller sizes are used for infants and children. The balloon size also varies with catheters: smaller for children (3 ml) and larger for continuous bladder irrigation (30 ml). The size of the catheter is usually printed on the side of the catheter port.

An indwelling catheter is attached to a drainage bag to allow for unrestricted flow of urine. Make sure that the urinary bag hangs below the level of the patient’s bladder so that urine flows out of the bladder. The bag should not touch the floor, and the patient should carry the bag below the level of the bladder when ambulating. To review how to insert an indwelling catheter, see Checklist 80.

Removing a Urinary Catheter

Patients require an order to have an indwelling catheter removed. Although an order is required, it remains the responsibility of the health care provider to evaluate if the indwelling catheter is necessary for the patient’s recovery.

A urinary catheter should be removed as soon as possible when it is no longer needed. For post-operative patients who require an indwelling catheter, the catheter should be removed preferably within 24 hours. The following are appropriate uses of an indwelling catheter (Gould et al., 2009):

• Improved comfort for end-of-life care
• Assisting in the healing process of an open sacral or perineal pressure ulcer
• Patients requiring prolonged immobilization (unstable thoracic or lumbar fractures, multiple traumatic injuries)
• Select surgical procedures (prolonged procedures, urological surgeries, etc.)
• Intra-operative monitoring of urinary output
• Patients receiving large-volume infusions or diuretic intra-operatively

When a urinary catheter is removed, the health care provider must assess if normal bladder function has returned. The health care provider should report any hematuria, inability or difficulty voiding, or any new incontinence after catheter removal. Prior to removing a urinary catheter, the patient requires education on the process of removal, and on expected and unexpected outcomes (e.g., a mild burning sensation with the first void) (VCH Professional Practice, 2014). The health care provider should instruct patients to

• Increase or maintain fluid intake (unless contraindicated)
• Void when able and within six to eight hours after removal of the catheter
• Inform the health care provider when he or she has voided, and measure the amount, colour, and any abnormal findings; ensure first void (urine output) is measured as per agency policy
• Report any burning, pain, discomfort, or small amount of urine volume
• Report an inability to void, bladder tenderness, or distension
• Report any signs of a CAUTI

Review the steps in Checklist 81 on how to remove an indwelling catheter.

If a patient is unable to void after six to eight hours of removing a urinary catheter, or has the sensation of not emptying the bladder, or is experiencing small voiding amounts with increased frequency, a bladder scan may be performed. A bladder scan can assess if excessive urine is being retained. Notify the health care provider if patient is unable to void within six to eight hours of removal of a urinary catheter. If a patient is found to have retained urine in the bladder and is unable to void, an intermittent/straight catheterization should be performed (Perry et al., 2014).

Critical Thinking Exercises

• Describe the different techniques for cleansing a female and a male patient prior to catheterization.
• Your male patient complains of pain while you are inserting a urinary catheter. Describe your next steps.

Clinical Procedures for Safer Patient Care Copyright © 2015 by Glynda Rees Doyle and Jodie Anita McCutcheon is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Urinary Catheterization

Elimination

Discussion: In-depth Resource

This resource provides current and comprehensive health care information for school health nurses in two formats: a single web page and a downloadable, In-depth Urinary Catheterization 15 page pdf document . Search for related resources, including procedures, videos and skills checklists by selecting the [MORE INFORMATION] button at the bottom of this page.

Students who have difficulty or the inability to fully empty their bladder may require intermittent urinary catheterization at school. There are several health conditions that could result in the need for intermittent urinary catheterizations including neurogenic bladder, spina bifida, posterior urethral valves, urinary retention, & bladder exstrophy. The use of intermittent urinary catheterization assists the bladder in fully emptying which reduces pressure on the kidneys, promotes mucosal healing, and assists to prevent urinary tract infections (Tobias, 2017).

Neurogenic Bladder:

Neurogenic bladder, also known as neurogenic lower urinary tract dysfunction (NLUTD), is the abnormal function of either the bladder, bladder neck, and/or its sphincters related to a neurologic disorder. In children, the most common causes of neurogenic bladder are congenital neural tube defects (NTD), such as myelomeningocele , spinal dysraphism, or tethered

cord lesions but can also be caused by spinal cord injury or a spinal tumor. Urinary continence is achieved when the bladder stores urine, produced by the kidneys, & expels the urine when appropriate. Both storing and expelling urine require neurological input and disruption anywhere along the neural pathways can lead to various degrees of bladder dysfunction (Lucas, 2019).

Spina Bifida:

Spina bifida occurs when the spinal column of the fetus doesn’t close completely during the first month of pregnancy. This can damage the nerves and spinal cord. The symptoms of spina bifida vary from person to person. Students with spina bifida may need assistive devices such as braces, crutches, or wheelchairs. They may have learning difficulties, urinary or bladder problems and/or hydrocephalus (Medline Plus, 2016).

Posterior Urethral Valves:

“ Posterior urethral valves are obstructing membranous folds within the lumen of the posterior urethra” (Holmes, 2023). The obstructing tissue flaps cause a blockage that doesn’t allow urine to flow out of the bladder. After surgical treatment most children will have normal urinary function although some children may have lasting problems (Nationwide Children’s, 2023).

Urinary Retention:

Urinary retention is a condition in which the student is unable to fully empty urine from the bladder. Urinary retention can be caused from a blockage that partially or fully prevents the flow of urine, or the bladder does not have the capacity to completely expel all the urine.

Bladder Exstrophy:

“Bladder exstrophy is a complex congenital anomaly involving the musculoskeletal system and the urinary, reproductive, and intestinal tracts. It is characterized by an open, inside-out bladder on the surface of the lower abdominal wall and an open dorsal urethra” (Borer, 2023).

Mitrofanoff (Appendicovesicostomy) and Monti Procedure :

Mitrofanoff Procedure : The Mitrofanoff Procedure is a surgery that uses the appendix to create an alternative route for the intermittent catheterization. With this procedure, the appendix is removed from the colon and is then used to create a continent conduit between the abdomen and the bladder (Norman, Leach, & Taha, 2024).

The Monti Procedure :is similar to the Mitrofanoff Procedure however, a portion of the ileum (small intestine) is used to create the tube that connects the bladder to the abdominal wall (Kennedy Krieger Institute & Maryland State Department of Education, 2017).

Both of these procedures create a stoma in the student’s belly button or lower abdomen in which a catheter can be inserted to drain the urine from the bladder (Nationwide Children’s, n.d.). If the student will be having intermittent urinary catheterization performed in the school setting after the procedure is completed, the school nurse must discuss with the parents/guardians and health care provider how soon after surgery the site can be used for catheterization and when it would be appropriate for the school nurse to delegate the procedure to unlicensed assistive personnel (UAP).

There are a number of factors for the school nurse to consider when deciding whether to delegate this procedure to a UAP. This section will provide a list of questions that the school nurse should answer to assist them in determining whether it is appropriate and safe to delegate the procedure. It is also important to remember that the questions related to delegation need to be answered for every individual student. The decision to delegate is based on circumstances related to the student, the nurse, the UAP, and the situation.

Questions to Inform Safe Delegation: These delegation questions are based on the American Nurses Association’s Decision Tree for Delegation by Registered Nurses (ANA, 2012).

• Has the school nurse performed an initial assessment of the student to determine their needs? The school nurse should not delegate the procedure to a UAP until they have completed the initial assessment.
• Does school district policy, the school nurse’s job description, and the UAP’s job description allow procedures related to intermittent urinary catheterization to be delegated? Although the Missouri Nurse Practice Act allows for registered nurses to delegate intermittent urinary catheterization, the district may have policies that prohibit or limit the school nurse’s ability to delegate. Additionally, the school nurse’s and UAP’s job descriptions may restrict delegation as well.
• Is the school nurse competent to perform this procedure or does the school nurse need to acquire some knowledge or skills to be competent in this procedure? If the school nurse is not competent or does not feel comfortable performing this procedure they should not delegate this procedure to a UAP. The school nurse must first acquire the necessary knowledge and skill to perform this procedure competently before they can delegate it to someone else.
• Is the student’s condition stable? Is this a new procedure for the student?  How predictable are the outcomes of the procedure? A school nurse should not delegate intermittent urinary catheterization to a UAP if this is a new procedure for the student. The outcomes are not predictable and thus the school nurse should perform the procedures until the student’s condition has stabilized.
• Does the procedure require an initial or ongoing assessment to be performed during the procedure? If an initial or ongoing assessment is required for the procedure to be performed, the procedure should not be delegated. 
• Does the UAP have the appropriate knowledge, skills, abilities, and willingness to perform the procedure? All these factors need to be considered. Although a UAP may be competent to perform the procedure they may not be willing to do so and in that situation another UAP should be identified and trained. The registered nurse must retain responsibility for the procedure until training is complete.
• Is there a procedure and/or protocol in place for this procedure? A delegated nursing procedure must have an established sequence of steps that the UAP can follow. These steps should have a predictable outcome and should be outlined in a written procedure or protocol. If the written procedure/protocol hasn’t been developed, the nurse should retain responsibility for the procedure until the procedure/protocol is in place. 
• Is the school nurse able to provide supervision to the UAP (direct or indirect depending on the situation)? If the school nurse is not able to provide supervision, then the procedure should not be delegated. The school nurse will need to assess the situation to determine if direct or indirect supervision is required. The school nurse may also need to reassess the situation if the environment changes, for example, if the procedure is going to be performed during a time that the school nurse is not contracted to provide nursing services (i.e., over the weekend, during the summer, or if the school nurse is part-time).
• Is the student ready to assume some responsibility for the procedure? The school nurse should resume responsibility for the procedure since the school nurse is the only one who can initiate teaching. The school nurse would also want to observe the student performing the procedure to ensure that the student is competent. Once the school nurse has determined that the student is competent and can safely perform the procedure independently, they can delegate the supervision of the student to a UAP. If at a future date the school nurse is needed to teach the student additional skills, the school nurse would again need to resume responsibility for the procedure until the time in which the school nurse determined the student to be competent.

The Decision to Delegate:

There may be times when the school nurse and school administrator have conflicting opinions on the delegation of a procedure to a UAP. The school nurse may feel that delegation is not appropriate or the administrator may want the school nurse to delegate a procedure to an UAP that the school nurse feels is not competent. In these situations the school nurse may need to educate the administrator that the school nurse has a professional and legal responsibility to determine if delegation of a nursing procedure is appropriate and safe (ANA, 2012). See Fact Sheet for School Administrators, Families, and School Personnel: Nursing Delegation Requires the School Nurse and Navigating Delegation in the School Setting (pdf) to assist school nurses’ communication with the school administration.

School Environment

Physical Education and Recess:

The school nurse should review the health care provider’s order to see if there are any activity restrictions associated with the student’s underlying health condition that may require activity restrictions or precautions during physical education class or at recess.

Latex Allergy:

Students who require intermittent urinary catheterization may have a latex allergy. See the  Anaphylaxis Whole Package resource for more information on anaphylaxis management.

An important first step when caring for a student who has a health condition that requires an intermittent urinary catheterization would be to complete a health history and physical assessment, preferably with the student and their parents present.

Health History Questions: The school nurse may want to ask the student and their parents/guardians the following questions:

• Current health conditions
• Note any medications that could affect urine color, volume, or odor
• Previous hospitalizations and surgeries
• Most recent hospitalization
• Catheter type
• Catheter size
• Schedule for catheterization
• How long catheter should be reused
• Cleaning technique for used catheter
• Whether urine output should be measured
• Perineal cleaning solution
• Baseline urine characteristics
• History of urinary tract infections
• Student position during catheterization
• Fluid intake goals
• Insurance coverage
• Health care provider(s) name and contact information
• Home health agency, if applicable
• Preferred hospital, if applicable

(Kennedy Krieger Institute & Maryland State Department of Education, 2017)

Assessment Questions: The school nurse may want to consider asking the student and their parents/guardians the following additional questions:

• How does this health condition impact the student’s daily life?
• How often does the student miss school due to their health condition(s)?
• Tell me about your friends.
• How often do you spend time with them?
• Has the student shared information about their health condition(s) with their friends/peers?
• How independent is the student in their intermittent urinary catheterization?
• Does the student require activity precautions to prevent injury?
• Does the classroom environment support the student’s needs and/or equipment (i.e., desk/seating options, maneuverability space, electrical outlets, flash pass for bathroom or nurse)?
• Does the student have specific hydration requirements?
• What are the student’s and the parent’s goals associated with intermittent urinary catheterization?
• Does the student and/or their parents have any concerns related to the student’s health condition?
• What challenges does the student face in dealing with their health condition?
• Do you feel the student has been sufficiently supported by school staff in managing their health condition?
• Who has the student been going to when they need help?
• How often does the student have bad feelings about coming to school because they are worried/afraid/embarrassed about something (peers, assignments, teacher)?
• Has the student had to change any of their social activities because of their health condition?
• Has the student ever been picked on or bullied?
• Does the student have a 504 Plan or Individualized Education Program (IEP)?
• Would the student benefit from evaluations or assessments in any of the following areas: physical therapy, occupational therapy, speech and language therapy, assistive technology, adapted physical education, functional behavior, psychology, hearing and vision?
• Would the student benefit from additional academic support and/or modified education (i.e., copies of notes, extra time, reduced workload, simplified instructions, alternative formats for presentation of material, 504/IEP)?
• Does the student have an Individualized Health Care Plan (IHCP)?
• Is there a need for a specific plan for this student’s individual needs if there is a crisis in the building?
• If shelter-in-place were required or the school day needed to be unexpectedly extended, what additional supplies, equipment, and health care provider orders would be needed?
• How is the student transported to and from school?

(Clarke, Embury, Yssel, 2014; Llorens, McKee, & Dempsey, 2020)

Maintaining the Student’s Privacy:

The student’s privacy is an important consideration when planning for and performing the procedure. The school nurse should collaborate with the student, their parents or guardians, and the student’s health care team to establish a plan that ensures the student’s safety, promotes the student’s health and independence, and protects the student’s privacy. The plan should address:

• Does the student want to come to the health room?
• It is preferable that the student would have a private bathroom to use.
• The student may prefer to keep their supplies with them but extra supplies should be stored in the bathroom that the student uses.
• An extra change of clothing may also be recommended.

(Bradley, 2020; Fortuna, Korcal, & Thomas, 2018)

Scheduling of Catheterizations:

Students who require intermittent urinary catheterizations will most likely have a schedule of when the catheterization should occur. The school nurse should collaborate with the student and their educational team to schedule the urinary catheterization at times that are least disruptive to the student’s schedule. For example, elementary age students should be allowed to perform the catheterization at times that would not disrupt their lunch or recess, as these are important social times in a student’s day. Additionally, the school nurse should plan for times when the student will be more physically active, such as during physical education or recess, and schedule the catheterization prior to those activities so there is no urinary incontinence (Fortuna, Korcal, & Thomas, 2018).

Transition Planning:

The nurse should assess the student’s current and desired level of independence to determine what goals should be established for the student. Additionally, the school nurse should discuss with the student and family what steps have been initiated related to transition planning. The school nurse should consider including goals related to self-management and decision-making skills in the student’s Individualized Health Care Plan (IHCP) (NASN, 2019b) and consider how those goals can be expanded upon each year to support independence, if appropriate.

Communication

It is important for the school nurse to discuss with the student and their family the best way(s) to communicate with them. Does the parents/guardian have a preference (i.e., email, text, telephone call)? Do the parents prefer to have the communications sent to both parents or is there a parent who manages the communication with the school nurse?

The school nurse may want to consider having the parents/guardians complete a Health Insurance Portability and Accountability Act (HIPAA) compliant medical release form to facilitate communication with the student’s health care team. Although HIPAA does not require parental consent to allow the school nurse to discuss the student’s treatment plan, such as medications and nursing procedures, with the student’s health care provider, having a signed consent form would undoubtedly make the process go smoother for all involved parties (U.S. Department of Health and Human Services & U.S. Department of Education, 2008). See the FERPA HIPAA Consent Sample (NASN).

The school nurse should determine the baseline characteristics of the student’s urine and should discuss with the parents or guardians and health care provider when the parent or guardian or health care provider should be informed about urinary changes, for example, change in urine color, amount, smell, or if the student develops a fever.

There are typically no medications associated with this procedure itself but students who require intermittent urinary catheterization may take antispasmodic medications, anticholinergic medications to reduce detrusor muscle tone bladder pressure, and/or sympathetic agonist medications to enhance sphincter competence (Norman, Leach, & Taha, 2024).

Field Trips

Field trips and other out of school activities can add a layer of complexity to the care of a student who requires intermittent urinary catheterization. There are several variables that the school nurse will want to consider and plan for, including:

• Who will accompany the student on the field trip to perform necessary procedures or administer medication? The individual who will be providing the care or performing the procedure must have the knowledge, ability, skills, and willingness to perform the procedure (Erwin, Clark, & Mercer, 2014).
• Where will the supplies be stored? It is important to have all needed supplies readily available. Supplies should not be left on the bus but should be with the student at all times.
• How will the student’s privacy be protected? The school nurse should discuss with the student and their family where the procedures will be performed during the field trip and the student and family’s expectations related to privacy as a private bathroom may not be available.
• How will safety and cleanliness be ensured?  In addition to privacy, the school nurse must think through possible scenarios on where the procedure may be performed and what additional precautions and supplies may be needed to ensure safety and cleanliness.
• Will the student’s intermittent urinary catheterization schedule need to be altered due to travel, availability of a restroom and/or privacy concerns? The travel schedule, restroom availability, and/or privacy concerns may impact the student’s catheterization schedule. The school nurse should discuss the need for modifications with the student and parents/guardians. In addition, the school nurse should review the health care provider’s order to determine if a modification to the order or a new order for the field trip would be necessary.
• How will the procedure be documented? Timely documentation is a key nursing component.The nurse should consider how the procedure that occurs on a field trip will be documented (Erwin, Clark, & Mercer, 2014).
• Is the field trip occurring out of state or out of the country? Field trips that occur out of the student’s home state will require some additional planning. If the school nurse will be accompanying the student on the field trip, they will want to determine if the state(s) that will be traveled through or visited are a part of the Nurse Licensure Compact . If the school nurse will not be accompanying the student but instead will be delegating the procedures, the school nurse will want to review the other state’s nurse practice acts and associated rules and regulations to determine if the procedure can be delegated to a UAP in that state. For out of the country field trips, the school nurse should discuss with school administration any applicable laws to determine what additional steps may be needed. In addition, the U.S. Embassy can provide information on points of contact for destination countries.

(Erwin, Clark, & Mercer, 2014; NASN, 2019a; Wisconsin Department of Public Instruction, 2019)

It is important to note that the Section 504 of the Rehabilitation Act does not allow for a student with a disability to be excluded from a field trip due to their disability.

Documentation

The medical management of a student who requires intermittent urinary catheterization in the school setting will require the school nurse to acquire and complete numerous forms of documentation.

Health Care Provider Order:

For students who require intermittent urinary catheterization at school, the following information should be included in the health care provider’s order:

• Name of the student
• Date of birth
• For example, for fever or changes in urine appearance or smell
• Whether the student can perform self-catheterization
• Whether the student can carry their own supplies

(Association for the Bladder Exstrophy Community, 2022). 

The Association for the Bladder Exstrophy Community has developed a sample Physician Order for School Intermittent Catheterization form.

Parent/Guardian Authorization : In addition to the health care provider’s order, the school nurse will also need written authorization from the parents/guardians to perform the intermittent urinary catheterization procedure at school. The authorization form can be a separate document that just the parents/guardians sign or a document can be developed that combines the health care provider’s order and parent authorization in one form.

Procedures: The urinary catheterization procedure needs to be documented, whether it is completed by the school nurse, a UAP, or if the student completed the procedure. The procedure and the outcomes of the procedure should be documented in the student’s health record. The school nurse will want to ensure that the documentation is completed when the procedure is completed during field trips, before or after school, and/or during any school-sponsored activities. 

Staff Competency Validation: If the urinary catheterization is delegated to a UAP the school nurse should document that the UAPs knowledge, abilities, and skills have been assessed. Many times these factors are documented on a skills competency checklist (see Skill Competency Checklists). There should be a place on the skills competency checklist for the school nurse and UAP to sign to indicate that they feel competent and are willing to perform the procedure. Once the procedure has been delegated the school nurse is responsible for periodic evaluation of the UAP and their competency. The school nurse must determine how often the supervision is needed. After the school nurse has re-evaluated the UAP’s competency, they should document the date of the evaluation (Shannon & Kubelka, 2013; Selekman & Ness, 2019). The school nurse should organize the competency documentation in a way that easily allows them to determine when subsequent evaluation and documentation of competency is needed. For more information, see the Delegation section.

Individualized Health Care Plan (IHCP): IHCPs should outline the plan of care for the student, including but not limited to:

• Actions the school nurse will take to support the student’s educational attainment.
• The education and training that will be provided to school personnel.
• The accompanying expected outcomes for each of the nursing interventions.
• If the student has other health condition(s) that would require an emergency action plan or an evacuation plan, the IHP should include the development of these plans (NASN, 2020)
• Student goals related to independence and transition planning and actions that the school nurse will take to assist the student in meeting these goals.
• Prior to completing the IHCP, the school nurse should complete a health history and physical assessment of the student. For more information on health history see the Students section.

Section 504 Plan: Students who require urinary catheterization may qualify for a Section 504 Plan since they have a physical or mental impairment that impacts one or more major life activities, which includes the functioning of major bodily systems such as the urinary system. If the student has been identified as qualifying for a 504 Plan, the school nurse may be involved in identifying appropriate accommodations and writing the plan. Once developed, the school nurse will want to frequently review, update, and document in the 504 Plan (NASN, 2020).

Go to https://showmeschoolhealth.org > Just in Time > Search for ‘Urinary Catheterization”.

Emergency Preparedness

The student who requires intermittent urinary catheterization would rarely have an emergency associated with their catheterization needs but they may have other health conditions that would require emergency planning, especially if the student has limited mobility. The school nurse should assess the student’s health conditions and determine if emergency plans are necessary, including emergency evacuation plans.

If the student has an anaphylactic allergy to latex, then the school nurse should develop the appropriate emergency plans for the student and provide the school community with the necessary education and training. See the Anaphylaxis Whole Package resource for more information on anaphylaxis management.

Shelter-in-Place and Other Emergency Events:

The school nurse should collaborate with the school administrators and school staff to determine what supplies may be needed if there were a lockdown or shelter-in-place situation. The emergency preparedness plan should address the following:

• Location of extra supplies in case of lock-down.
• Health care provider’s orders for intermittent urinary catheterization that would be necessary if there was an unplanned extended school day or shelter-in-place.
• Additional accommodations that may be required during an emergency (i.e., extra staff to help support the student’s needs).
• Equipment &/or transportation evacuation needs if the child has limited mobility.

(Center for Inclusive Child Care, 2020; Federal Emergency Management Agency, 2009)

For more emergency planning information see Missouri School Boards’ Association’s Emergency Planning Guide for Students & Staff with Special & Functional Needs in Schools.

Legal Issues

Section 504 Plan :

Students requiring intermittent urinary catheterization may qualify for a Section 504 Plan. Section 504 of the Rehabilitation Act of 1973 as amended through the Americans with Disabilities Amendment Act (ADAA) in 2008 ensures that students who have disabilities have access to a free and appropriate public education (FAPE) (U.S. Department of Education, 2023).  FAPE provides a student with a physical or mental impairment that impacts one or more major life activities, which includes the functioning of major bodily systems such as the urinary system, with related services and accommodations in the general education classroom (U.S. Department of Education, 2023; NASN, 2023).  If the student does not have a 504 Plan the school nurse should determine if an evaluation is indicated (see Students section for questions to ask student and family to determine if 504 or IEP evaluation is indicated). If it is determined that the student qualifies for a Section 504 Plan, the school nurse may want to consider the appropriateness of the following accommodations:

• Allow the student to use the restroom whenever there is a need.
• Allow the student to leave class early or arrive late without being penalized.
• The option for the student to use a private restroom.
• Academic support if they miss class due to health concerns (including health care provider appointments, hospitalization, or illness).
• Permission to always use a water bottle.
• The provision of necessary accommodations on field trips and other school sponsored activities.

Individualized Education Program (IEP):

In addition to their health condition, a child who requires intermittent urinary catheterization may also have another condition, such as an intellectual disability or significant developmental delay, that qualifies them for an IEP (U.S. Department of Education, 2018). An IEP is developed by a multidisciplinary special education team. The IEP outlines the plans for special education services for the student who has a qualifying disability that interferes with learning. The IEP plan identifies what services and accommodations are needed to support the student’s education needs (NASN, 2020d). Many interventions provided as part of the IEP plan are “related services”, which include school nursing services and school health services (U.S. Department of Education, 2017).

Association for the Bladder Exstrophy Community:

• Supporting Children in Bladder Exstrophy in School
• Physician Order for School Intermittent Catheterization
• School Bathroom Toolkit

Kennedy Krieger Institute’s Specialized Health Needs Interagency Collaboration:

• A Guide for School Personnel Working With Students With Spina Bifida
• Spina Bifida

Society of Urologic Nurses and Associates:

• Methods and Types of Urinary Catheters Used for Indwelling or Intermittent Catheterization
• Intermittent Self-Catheterization Patient Education Checklist

Spina Bifida Association:

• Continence Management at School

American Nurses Association. (2012). Principles of delegation. Available at: https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf

Association for the Bladder Exstrophy Community. (2022). Bathroom toolkit. Available at: https://www.bladderexstrophy.com/bathroom-toolkit/

Borer, J.G. (2023, October 17). Clinical manifestations and initial management of infants with bladder exstrophy. Available at:  https://www.uptodate.com/contents/clinical-manifestations-and-initial-management-of-infants-with-bladder-exstrophy

Bradley E. (2020). Achieving independence in toileting: Self-catheterization efficacy and the role of the school nurse. NASN School Nurse (Print), 35(6), 314–318. https://doi.org/10.1177/1942602X20942533

Center for Inclusive Child Care. (2020). Tip sheets. Emergency planning for children with disabilities. Available at: https://www.inclusivechildcare.org/sites/default/files/courses/swf/Emergency%20Planning%20for%20Children%20with%20Disabilities.pdf

Clarke, L.S., Embury, D.C., Yssel, N. (2014). Supporting students with disabilities during school crisis. A teacher’s guide. Teaching Exceptional Children, 46(6), 169-78. doi/10.1177/0040059914534616

Erwin, K., Clark, S., & Mercer, S.E. (2014). Providing health services for children with special health care needs on out-of-state field trips. NASN School Nurse, 29(2), 84-8. doi: 10.1177/1942602X13517005

Federal Emergency Management Agency. (2009). Evacuating the special needs population. Available at: https://training.fema.gov/programs/emischool/el361toolkit/assets/evacuatingspecialneedspopulation.pdf

Fortuna, S. M., Korcal, L., & Thomas, G. (2018). Bladder management in children: Intermittent catheterization education. NASN School Nurse (Print), 33(3), 178–185. https://doi.org/10.1177/1942602X18756164

Holmes. N. (2023, April 3). Management of posterior urethral valves. Available at: https://www.uptodate.com/contents/management-of-posterior-urethral-valves

Kennedy Krieger Institute & Maryland State Department of Education. (2017, July). Factsheet: Bladder surgery. Available at: https://www.kennedykrieger.org/sites/default/files/library/documents/community/specialized-health-needs-interagency-collaboration-shnic/information-school-nurses/shnic-bladder-surgery-factsheet-7-20-17.pdf

Llorens, A., McKee, S., & Dempsey, A.G.). (2020). In A.G. Dempsey (Ed.). Pediatric health conditions in schools. (pp. 26-27). New York, NY: Oxford Press.

Lucas E. (2019). Medical management of neurogenic bladder for children and adults: A review. Topics in Spinal Cord Injury Rehabilitation, 25(3), 195–204. https://doi.org/10.1310/sci2503-195

Medline Plus. (2016, October 24). Spina bifida. Available at: https://medlineplus.gov/spinabifida.html

National Association of School Nurses. (2019a). School-sponsored trips -The role of the school nurse (Position Statement). Silver Spring, MD: Author.

National Association of School Nurses. (2019b). Transition planning for students with healthcare needs (Position Statement). Silver Spring, MD: Author. Available at: https://www.nasn.org/nasn-resources/professional-practice-documents/position-statements/ps-transition

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National Association of School Nurses. (2023). IDEIA and Section 504 Teams – The school nurse as an essential team member (Position Statement). Author.

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Nationwide Children’s. (n.d.). What is the mitrofanoff procedure (Appendicovesicostomy)? Available at: https://www.nationwidechildrens.org/specialties/urology/procedures/mitrofanoff

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Shannon, R. A., & Kubelka, S. (2013). Reducing the risks of delegation: use of procedure skills checklists for unlicensed assistive personnel in schools, Part 2. NASN School Nurse (Print), 28(5), 222–226. https://doi.org/10.1177/1942602X13490030

Spina Bifida Association. (2018). Guidelines for the care of people with spina bifida. Available at: https://www.spinabifidaassociation.org/guidelines/

Tobias, N.E. (2017). Practical considerations and current best practice for pediatric clean intermittent catheterization. Pediatric Nursing, 43(6), 267-273.

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Urology Care Foundation. (2021b, September). What is neurogenic bladder? Available at: https://www.urologyhealth.org/urology-a-z/n/neurogenic-bladder

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Renee Falkner, BSN, RN School Nurse Supervision Specialist | Therapylog

Katherine Park, DNP, RN, NCSN Nationally Certified School Nurse, Pierremont Elementary Adjunct Professor, Maryville University School of Nursing

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Nursing Fundamentals II

Lesson 3. catheterization of the male and female patient, lesson objectives.

3-1. Select the purposes of urinary catheterization.

3-2. Identify three types of urinary catheters.

3-3. Select nursing implications, which apply to care of a patient with an indwelling urinary catheter.

3-4. Select the appropriate equipment and technique used in catheterizing a male patient.

3-5. Select the appropriate equipment and technique used in catheterizing a female patient.

3-1. INTRODUCTION

Catheterization of the urinary bladder is the insertion of a hollow tube through the urethra into the bladder for removing urine. It is an aseptic procedure for which sterile equipment is required.

3-2. PURPOSES OF URINARY CATHETERIZATION

Purposes for urinary catheterization include the following.

a. Relieve Urinary Retention. Urine retained in the bladder for any reason causes the patient discomfort and increases the likelihood of infection. A catheter may be inserted to relieve urinary retention when a patient is temporarily unable to void or has difficulty releasing urine from the bladder due to an obstruction of the urethra or at the meatus.

b. Obtain a Sterile Urine Specimen from a Female Patient. At one time, this was considered necessary to obtain a urine specimen entirely free of contamination. Most physicians now order a collection of a voided, midstream clean-catch specimen.

c. Measure Residual Urine. Catheterization can be done to measure the amount of residual urine in the bladder when voiding only partly empties it.

d. Empty the Bladder Before, During, or After Surgery. A catheter may be inserted before or following abdominal surgery, especially if the patient cannot be up and about. Catheterization to keep the bladder empty of urine during a surgical procedure permits the surgeon a better view and palpation of internal tissue, and prevents accidental injury to the bladder. Catheterization may also be used to prevent urine from touching sutures in the perineum.

3-3. URINARY CATHETER SIZES

The French scale (Fr.) is used to denote the size of catheters. Each unit is roughly equivalent to 0.33 mm in diameter (that is, 18 Fr. indicates a diameter of 6 mm). The smaller the number, the smaller the catheter. A larger sized catheter is used for a male because it is stiffer, thus easier to push the distance of the male urethra. Catheters come in several sizes:

a. Number 8 Fr. and 10 Fr. are used for children.

b. Number 14 Fr. and 16 Fr. are used for female adults.

c. Number 20 Fr. and 22 Fr. are usually used for male adults.

3-4. TYPES OF URINARY CATHETERS

The catheters most commonly used are made of plastic. Each type of catheter (figure 3-1) has a rounded tip to prevent injury to the meatus or the urethra. The Foley catheter is frequently used. It is usually inserted by the nurse. The Malecot four-wing catheter and the dePezzer mushroom catheter are inserted by the urologist using a stylet. The stylet is removed after the catheter has been inserted. Because they are very difficult to sterilize, catheters should be considered disposable and discarded after they have been removed.

a. Intermittent Catheter. An intermittent catheter is used to drain the bladder for short periods (5-10 minutes). It may be inserted by the patient.

b. Retention/Indwelling Catheter. This type of catheter is placed into the bladder and secured there for a period of time. It is used following surgery, bladder injury, or in bladder infections. It may also be used for an incontinent or nonresponsive patient.

(1) It provides continuous temporary or permanent drainage of urine.

(2) It is used for gradual decompression of an over distended bladder.

(3) It is used for intermittent drainage and irrigation.

(4) The most commonly used indwelling catheter is the Foley catheter. A drainage tube and collection device are connected to the catheter. It has a balloon at the distal end, which is inflated with sterile water or saline to prevent the catheter from slipping out of the bladder. It is multi-lumened (having several passages within the catheter). One lumen provides a passage for fluid to inflate the balloon. This passage may be self-sealing or may require a clamp. The second lumen is the passage through which the urine drains. Some indwelling catheters have a third lumen for instilling irrigation fluid.

c. Supra Pubic Catheter. This type of catheter is inserted into the bladder through a small incision above the pubic area. It is used for continuous drainage.

3-5. PREPARING FOR CATHETERIZATION

A catheter should be used only when absolutely necessary and the catheterization procedure itself should be done only by trained personnel under sterile conditions. Infection is a major risk of urinary catheterization.

a. Gather All Equipment.

(1) Disposable indwelling catheter kit. The kit contains the required equipment needed for catheterization and is packaged to ensure that the equipment is sterile. The kit includes the catheter, a drape, a receptacle to receive urine, materials to clean the area of insertion, a lubricant, a specimen container, and sterile gloves.

(2) Flashlight or lamp.

(3) Urine collection bag.

(4) Velcro leg strap or anchoring tape.

(5) Disposal bag.

(6) Waterproof pad or Chux®.

b. Explain the Procedure to the Patient. Advise the patient that he may feel a burning sensation and pressure as the catheter is inserted, and that he will feel that he needs to void after the catheter is in place. Do not suggest to the patient that he may feel pain; however, introducing a catheter in swollen or injured tissue may cause discomfort.

c. Provide for Privacy and Adequate Lighting.

(1) Close the door or pull the curtain surrounding the patient’s bed and position the flashlight or lamp at the end of the bed.

(2) Position the female patient in a dorsal recumbent position with the knees flexed and the feet about two feet apart. Place Chux® under the patient’s buttocks. Cover the upper body and each leg. Place the catheter set between the female patient’s legs.

(3) Position a male patient in a supine position. Place Chux® under the patient’s buttocks. Drape the patient so that only the area around the penis is exposed. Place the catheter set next to the legs of the male patient.

3-6. INSERTING THE FOLEY CATHETER IN A MALE PATIENT

The following procedures are used to insert the Foley catheter in a male patient.

a. Cleanse the genital and perineal areas with warm soap and water. Rinse and dry.

b. Wash your hands carefully.

c. Open the sterile catheterization kit, using sterile technique.

d. Put on the sterile gloves.

e. Open the sterile drape and place on the patient’s thighs. Place fenestrated drape with opening on the penis.

f. Apply sterile lubricant liberally to the catheter tip. Lubricate at least six inches of the catheter. Leave the lubricated catheter on the sterile field.

g. Pour the antiseptic solution over the cotton balls.

h. Place the urine specimen collection container within easy reach.

i. Grasp the patient’s penis between your thumb and forefinger of your nondominant hand. Retract the foreskin of an uncircumcised male. The gloved hand that has touched the patient is now contaminated.

j. Use the forceps to hold the cotton balls (figure 3-2). This will maintain the sterility of one hand. Using the forceps, pick up one cotton ball and swab the center of the meatus outward in a circular manner.

k. Continue outward, using a new cotton ball for each progressively larger circle. Clean the entire glands. Deposit each cotton ball in the disposal bag. After the last cotton ball is used, drop the forceps into the disposal bag as well.

l. Hold the penis at a 90-degree angle (figure 3-3). Advance the catheter into the patient’s urinary meatus. You may encounter resistance at the prostatic sphincter.

(1) Pause and allow the sphincter to relax.

(2) Lower the penis and continue to advance the catheter.

NOTE: Never force the catheter to advance. Discontinue the procedure if the catheter will not advance or the patient has unusual discomfort. Get assistance from the charge nurse or physician.

m. When the catheter has passed through the prostatic sphincter into the bladder, urine will start to flow into the collection bag if it is preconnected. If it is not preconnected, collect a specimen if required, then place the end of the catheter into the tubing of the sterile receptacle.

n. Attach the syringe to the balloon port and inject the water slowly to inflate the balloon. Connect the urine collection bag if it is not preconnected.

o. Anchor the catheter tubing to the lateral abdomen with tape (figure 3-4).

p. Secure the urinary collection bag below the level of the bladder and off the floor. Coil any extra tubing on the bed.

q. Remove your gloves, the drapes and protectors from around the patient, and any lubricant or antiseptic on the patient’s skin.

r. Discard disposable equipment and return reusable equipment to the appropriate area.

s. Record the time that the procedure was done and by whom, the patient’s reaction to the procedure, all patient teaching done and the patient’s level of understanding. Report any significant observations to the charge nurse to include:

(1) The amount, color, and clarity of the urine.

(2) Any difficulties with the procedure.

(3) The presence of blood in the urine.

3-7. INSERTING THE FOLEY CATHETER IN A FEMALE PATIENT

a. Wash the area around the meatus with warm soap and water. Rinse and dry.

b. Wash your hands.

d. Put on sterile gloves.

e. Place the fenestrated drape on the patient with the hole over the female genitalia.

f. Apply sterile lubricant liberally to the catheter tip. Lubricate at least three inches of the catheter for the female. Leave the lubricated catheter over the cotton balls.

g. Place the urine specimen collection container within reach.

h. Place the thumb and forefinger of your nondominant hand between the labia minora, spread and separate upward. The gloved hand that has touched the patient is now contaminated.

i. Using the forceps, pick up a cotton ball saturated with antiseptic solution. Use one cotton ball for each stroke. Swab from above the meatus downward toward the rectum.

j. Keeping the labia separated, cleanse each side of the meatus in the same downward manner (figure 3-5). Do not go back over any previously cleansed area.

k. Deposit each cotton ball into the disposal bag. After the last cotton ball is used, deposit the forceps into the bag as well.

l. Continue to hold the labium apart after cleansing. Insert the lubricated catheter into the female patient’s urinary meatus (figure 3-6).

m. Angle the catheter upward as it is advanced. If the catheter will not advance, instruct the patient to inhale and exhale slowly. This may relax the sphincter muscle. Do not force the catheter.

n. When urine starts to flow, insert the catheter approximately one inch further. Place the cup under the stream of flowing urine to obtain a sterile specimen if required.

o. Hold the catheter in place while the urine drains into the collection container.

NOTE: If the catheter is inadvertently placed in the patient’s vagina, leave it in place temporarily. Insert another catheter properly by repeating the entire procedure using another sterile set; then remove the catheter from the vagina.

p. Attach the syringe to the balloon port of the catheter. Inject the water slowly to inflate the balloon. If the water will not inject easily or the patient complains of pain, deflate the balloon completely and advance the catheter further, then re-inflate.

q. Remove the syringe. To position the balloon correctly, pull on the catheter gently until you feel resistance.

r. Connect the drainage bag to the catheter. Secure the catheter to the inner aspect of the female patient’s thigh (figure 3-7).

s. Attach the urinary drainage bag to the bed, below the level of the bladder but off the floor. Coil any extra tubing on the bed.

t. Remove any lubricant or antiseptic on the patient’s skin. Remove your gloves, the drapes and the Chux® from around the patient.

u. Discard disposable equipment and return reusable equipment to the appropriate area.

v. Record the time that the procedure was done and by whom, the patient’s reaction to the procedure, all patient teaching done, and the patient’s level of understanding. Report observations to the charge nurse to include:

(2) Any difficulty with the procedure.

3-8. MAINTAINING AN INDWELLING CATHETER

When an indwelling or retention catheter is inserted, the nurse is responsible for the daily care required to maintain proper drainage and reduce the possibility of an infection occurring. Always have a confident, reassuring, and professional attitude when maintaining the catheter so that the patient will not feel embarrassed.

a. Wash your hands before and after caring for the patient and wear gloves when handling an indwelling catheter.

b. Clean the perineal area with soap and water twice daily and after each bowel movement, especially around the meatus. Use a separate area of the cloth for each stroke.

c. In some cases, an antiseptic may be used for perineal care. Povidone iodine (Betadine) is most commonly recommended.

d. Avoid use of lotions or powder in the perineal area.

e. Arrange for the patient to take a shower or tub bath when permitted. The collecting container may be hung over the side of the tub. The catheter should be clamped temporarily if the collecting container is higher than the bladder.

f. A leg bag (figure 3-8) may be worn in the shower. This device allows the ambulatory patient to move about freely and dress in his usual clothing. Keep the tubing intact and free of kinks.

g. Open the port at the bottom of the urinary collecting bag. This permits all the connections and tubing between the catheter and drainage device to remain closed while permitting you to measure and dispose of accumulated urine.

h. Teach the patient to maintain the catheter. Self-care helps the patient develop a feeling of independence and promotes cleanliness. If the patient is ambulatory, instruct him in use of the leg bag. Encourage the patient to intake 2500 cc to 3000 cc of fluid daily.

i. Change the indwelling catheter as necessary or in accordance with local policy.

3-9. IRRIGATING AN INDWELLING CATHETER

The purpose of irrigating a catheter is to remove particles that are interfering with the drainage of urine. A catheter that drains well does not need irrigating, except to instill medication. If the patient has a generous fluid intake (2500 cc to 3000 cc of fluid daily), the increase in urine production will dilute the particles that form and irrigate the catheter naturally; thus, invasive procedures may be avoided. Because the drainage system is opened when irrigation takes place, sterile technique is followed.

a. Gather sterile supplies and equipment:

(1) Asepto syringe.

(3) Tubing protector.

(4) Gauze moistened with antiseptic.

(5) Sterile normal saline (or other irrigation solution).

b. Using gauze moistened with antiseptic solution, wipe the area where the catheter and tubing join.

NOTE: Some catheters have a self-sealing port with a separate lumen through which irrigation solution may be instilled (see figure 3-9). This allows irrigation without separation of the catheter from the collecting device and reduces the possibility of contamination.

c. Place the sterile tubing protector on the end of the drainage tubing. An alternative is to cover the opening with sterile gauze moistened with antiseptic.

d. Fill the syringe with 30 to 60 cc of solution and insert the syringe tip well into the end of the catheter.

e. Gently compress the ball or end of the syringe to instill the irrigating solution. Do not apply force. Replace the catheter if it cannot be irrigated.

f. Allow the instilled solution to flow back into the basin by gravity.

g. Connect the catheter and drainage tube.

h. Note the total amount of solution used for irrigating and measure the amount of solution returned in the basin. In some cases there is less solution returned than solution instilled. Both amounts must be recorded. The amount that remains will eventually drain into the collection bag.

i. Discard the solution drained into the basin. Replace or protect the irrigating equipment.

j. Record that the irrigation was done, by whom, and the patient’s response to the procedure.

3-10. REMOVING AN INDWELLING CATHETER

Eventually, a catheter must be removed because the need for it no longer exist or it is crusting and must be changed. The nurse usually removes the catheter.

a. Assemble all supplies and equipment.

(1) 10 cc syringe.

(2) Washcloth and towel.

(3) Exam gloves.

(4) Soap and water.

b. Identify the patient and explain the procedure to him. Advise him that there will be a slight burning during removal of the catheter.

c. Provide privacy and assist the female patient into a dorsal recumbent position. The male should be in a supine position. Place Chux® under the patient’s buttocks and provide proper draping.

d. Wash your hands and put on exam gloves.

e. Empty the balloon by inserting the barrel of the syringe and withdrawing the amount of fluid used during inflation.

f. Pinch off and gently pull on the catheter near the point where it exits from the meatus.

g. Clean the perineum or penis with soap and water. Dry the area well.

h. Inspect the catheter to be sure no remnants remained in the bladder. If the catheter is not totally intact, report this promptly and save the catheter for further inspection.

i. Empty the drainage bag. Measure the amount of urine and record on the intake and output (I&O) sheet.

j. Remove the gloves and wash your hands.

k. Discard disposable supplies and return reusable supplies and equipment to the appropriate area.

l. Record that the catheter was removed, the time and date and by whom. Note the amount, color, and clarity of the urine in the drainage bag. Also document all patient teaching done and the patient’s level of understanding.

m. After removal of the catheter, assess the patient for 24 hours for patterns of urinary elimination. Note the time and amount of the first voided urine. Report any of the following:

(1) Inability to void within 8 to 10 hours.

(2) Frequency, burning, dribbling, or hesitation in starting the stream of urine.

(3) Cloudiness or any other unusual color or characteristic of the urine.

n. Provide a level of fluids similar to the intake when the catheter was in place.

o. Record that the catheter was removed, the date and time, and by whom.

3-11. CLOSING

Catheterization can be done without embarrassment and with little discomfort for both the male and female patient. Your observation of urinary output and characteristics of the urine aids in early detection of infection or any other complications. Always remember, you are accountable for responsible care and the safety of the patient.

Basic Nursing Education

How To Do Urethral Catheterization in a Male

• Indications |
• Contraindications |
• Complications |
• Equipment |
• Additional Considerations |
• Relevant Anatomy |
• Positioning |
• Step-by-Step Description of Procedure |
• Aftercare |
• Warnings and Common Errors |
• Tips and Tricks |

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.

(See also Bladder Catheterization .)

Indications for Urethral Catheterization in a Male

Relief of acute or chronic urinary retention, such as due to urethral or prostatic obstruction ( obstructive uropathy ) or neurogenic bladder

Treatment of urinary incontinence

Monitoring of urine output

Measurement of postvoid residual urine volume

Collection of sterile urine for culture (usually for infants and women only)

Diagnostic studies of the lower genitourinary tract

Bladder irrigation or instillation of medication

Contraindications to Urethral Catheterization in a Male

Absolute contraindications  

Suspected urethral injury*

Relative contraindications

History of urethral strictures

Current urinary tract infection (UTI)

Prior urethral reconstruction

Recent urologic surgery

History of difficult catheter placement

*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 of Urethral Catheterization in a Male

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 for Urethral Catheterization in a Male

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)

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 for Urethral Catheterization in a Male

Sterile technique is necessary to prevent a lower urinary tract infection . 

Relevant Anatomy for Urethral Catheterization in a Male

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 for Urethral Catheterization in a Male

Position the patient supine with hips comfortably abducted.

Step-by-Step Description of Urethral Catheterization in a Male

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.

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 for Urethral Catheterization in a Male

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 for Urethral Catheterization in a Male

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 for Urethral Catheterization in a Male

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 probably 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.

Copyright © 2024 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved.

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Urinary Catheter Management

Affiliations.

• 1 University of Maryland School of Medicine, Baltimore, MD.
• 2 University of California, San Francisco, CA.
• 3 Oregon Health and Sciences University, Portland, OR.
• PMID: 39283848

Family physicians often treat patients who require urinary management with the use of external urinary devices, clean intermittent catheterization, or indwelling urinary catheterization. External urinary devices are indicated for urinary incontinence (postvoid residual less than 300 mL), urine volume measurement for hospitalized patients, nonsterile urine diagnostic testing, improved comfort for patients in hospice or palliative care, and fall prevention for high-risk patients. Indwelling urinary catheterization is indicated for severe urinary retention or bladder outlet obstruction; wound healing in the sacrum, buttocks, or perineal area; prolonged immobilization; and as a palliative measure for patients who are terminally ill. Clean intermittent catheterization is an alternative to indwelling urinary catheterization for acute or chronic urinary retention (postvoid residual greater than 300 mL) without bladder outlet obstruction, sterile urine testing, postvoid residual volume assessment, and wound healing. Suprapubic catheter placement is considered when long-term catheterization is needed or urethral catheterization is not feasible. Urinary catheters should not be used solely for staff or caregiver convenience, incontinence-related dermatitis, urine culture procurement from a voiding patient, or initial incontinence management. Common complications of urinary catheter use include obstruction, bladder spasm, urine leakage, and skin breakdown of the sacrum, buttocks, or perineum. The risk of catheter-associated urinary tract infections increases with the duration of catheter use. Urologist referral is indicated for patients requiring urinary management who have recurrent urinary tract infections, acute infectious urinary retention, suspected urethral injury, or substantial urethral discomfort or if long-term catheterization is being considered.

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Strategies to prevent catheter-associated urinary tract infections in acute-care hospitals: 2022 Update

• Source: Infect Control Hosp Epidemiol. 44(8):1209-1231
• Alternative Title: Infect Control Hosp Epidemiol
• Description: The intent of this document is to highlight practical recommendations in a concise format designed to assist physicians, nurses, and infection preventionists at acute-care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates the | published in 2014. It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission. More ▼ -->
• Subjects: [+] Catheters Hospitals Humans Infection Control Physicians United States
• Pubmed ID: 37620117
• Pubmed Central ID: PMC11287483
• Document Type: Journal Article
• Funding: CC999999/ImCDC/Intramural CDC HHSUnited States/
• Collection(s): CDC Public Access
• Main Document Checksum: [+] urn:sha-512:b3245f01b7ddcdc0440bd7c7c71dcd6c5400f8f37fefd400e63d36bd65b0b80a95e3d9174eab3c124707570312005e19d84f95be033416724e4f67d875a92f17
• Download URL: https://stacks.cdc.gov/view/cdc/159481/cdc_159481_DS1.pdf

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Diagnosis, Management, and Prevention of Catheter-Associated Urinary Tract Infections

Carol e. chenoweth.

a Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, 3119 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5378, USA

Carolyn V. Gould

b Centers for Disease Control and Prevention, 1600 Clifton Road Northeast, Mailstop A-31, Atlanta, GA 30333, USA

Sanjay Saint

c Division of General Medicine, Department of Internal Medicine, University of Michigan Health System and Veterans Affairs Ann Arbor Healthcare System, 2800 Plymouth Road, Building 16, Room 430 West, Ann Arbor, MI 48109-2800, USA

Urinary tract infection (UTI) is one of the most common health care–associated infections (HAIs), representing up to 40% of all HAIs. 1 – 3 Most health care–associated UTIs (70%) are associated with urinary catheters, but as many as 95% of UTIs in intensive care units (ICUs) are associated with catheters. 4 , 5 Approximately 20% of patients have a urinary catheter placed at some time during their hospital stay, 6 , 7 especially in ICUs, in long-term care facilities, and increasingly in home care settings. 3 , 4 , 8 The Centers for Disease Control and Prevention (CDC) estimated that up to 139,000 catheter-associated UTIs (CAUTIs) occurred in US hospitals in 2007. 4

CAUTIs are associated with increased morbidity, mortality, and costs. Hospital-associated bloodstream infection from a urinary source has a case fatality of 32.8%. 9 , 10 Each episode of CAUTI is estimated to cost $600; if associated with a bloodstream infection, costs increase to $2800. 11 Nationally, CAUTIs result in an estimated $131 million annual excess medical costs. 4

Moreover, in October 2008, the Centers for Medicare and Medicaid Services (CMS) included hospital-acquired CAUTI under conditions that are no longer reimbursed for the extra costs of managing a patient. 11 To date, there has been no measurable effect of the CMS policy to reduce payments for CAUTIs on CAUTI rates or preventive practices. 12 – 14 Nevertheless, the prevention of CAUTIs has become a priority for most hospitals because 65% to 70% of CAUTIs may be preventable. 15

EPIDEMIOLOGY OF CAUTIs

Likely as a result of widespread interventions occurring nationwide, rates of CAUTIs in ICUs reporting to the CDC decreased significantly between 1990 and 2007. 4 In 2010, the rates of CAUTIs reported to the CDC’s National Healthcare Safety Network (NHSN) ranged from 4.7 per 1000 catheter-days in burn ICUs to 1.3 per 1000 catheter-days in medical/surgical ICUs. 4 Pediatric ICUs reported similar rates of CAUTI, 2.2 to 3.9 per 1000 catheter-days 16 ; however, CAUTIs are infrequently identified in neonatal ICUs. 17 Inpatient wards reported rates equivalent to ICU settings, with a range from 0.2 to 3.2 per 1000 catheter-days. Among inpatient wards, rehabilitation units had the highest rates of CAUTIs. 5 , 16

Microbial Cause of CAUTIs

Most microorganisms causing CAUTIs are from the endogenous microbiota of the perineum that ascend the urethra to the bladder along the external surface of the catheter. 18 A smaller proportion of microorganisms (34%) are introduced by intraluminal contamination of the collection system from exogenous sources, frequently resulting from cross-transmission of organisms from the hands of health care personnel. 18 , 19 Approximately 15% of episodes of health care–associated bacteriuria occur in clusters from patient-to-patient transmission within a hospital. 2 , 19 Rarely, organisms, such as Staphylococcus aureus , cause UTI from hematogenous spread.

Enterobacteriaceae, especially Escherichia coli and Klebsiella spp, are the most common pathogens associated with CAUTI; but in the ICU setting, Candida spp (18%), Enterococcus spp (10%), and Pseudomonas aeruginosa (9%) are more prevalent ( Table 1 ). 16 , 20 , 21 European hospitals report a similar spectrum of microorganisms associated with nosocomial UTIs, except for Pseudomonas spp, which were isolated in only 7% of urine cultures. 22

Selected microorganisms associated with CAUTIs

Abbreviation: LTACH, long-term acute care hospitals.

Data from Chitnis A, Edwards J, Ricks P, et al. Device-associated infection rates, device utilization, and antimicrobial resistance in long-term acute care hospitals reporting to the National Healthcare Safety Network, 2010. Infect Control Hosp Epidemiol 2012;33(10):993–1000; and Sievert D, Ricks P, Edwards J, et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009–2010. Infect Control Hosp Epidemiol 2013;34(1):1–14.

Among E coli isolates reported to the NHSN from CAUTIs in ICU and non-ICU settings in 2009 to 2010, 29.1% and 33.5%, respectively, were resistant to fluoroquinolones. 21 Many Enterobacteriaceae produced extended-spectrum beta-lactamases; 26.9% of K pneumonia/oxytoca and 12.3% of E coli isolates from patients with CAUTIs were resistant to extended-spectrum cephalosporins. Alarmingly, during this same time period, 12.5% of Klebsiella spp from patients with CAUTIs were resistant to carbapenems. 21 Although long-term acute care hospitals (LTACHs) had a prevalence of carbapenem-resistant Enterobacteriaceae (CRE) in CAUTI isolates similar to that reported in ICUs, a greater percentage of LTACHs reported a CRE CAUTI compared with ICUs. 20

Enterococci emerged as a commonly reported cause of health care–associated UTIs between 1975 and 1984. Although the clinical significance of enterococci isolated from urine is questionable, urinary drainage devices serve as a reservoir for emergence and spread of vancomycin-resistant strains in short- and long-term acute care settings. 20 , 21 Also rarely associated with complications when isolated from the urine, 23 Candida spp account for 28% of CAUTIs reported from ICUs. 20 S aureus are an infrequent cause of CAUTI but, when identified, should prompt consideration for coinciding bacteremia or endocarditis. 10 , 24 CAUTI associated with long-term catheters are associated with 2 or more organisms in 77% to 95% of episodes, and 10% have more than 5 species of organisms present. 3

Biofilms, composed of clusters of microorganisms and extracellular matrix (primarily polysaccharide materials), form on the internal and external surfaces of urinary catheters shortly after insertion. 19 , 25 Typically, the biofilm is composed of one type of microorganism, although polymicrobial biofilms are possible. Microorganisms within the biofilm ascend the catheter to the bladder in 1 to 3 days. Antimicrobials penetrate into biofilms poorly, and microorganisms grow more slowly in biofilms, decreasing the effects of many antimicrobials. 19 , 25 The microorganisms, resistance patterns, and biofilm factors mentioned earlier have significant implications for the management of CAUTIs.

Risk Factors for CAUTIs

Table 2 outlines major modifiable and nonmodifiable risk factors for CAUTI, which have importance for the design and implementation of interventions for the prevention of CAUTI. The duration of catheterization is the dominant risk factor for CAUTI. 1 , 3 , 26 Women have a higher risk of UTI than men, and heavy bacterial colonization of the perineum increases that risk. Other factors that increase the risk of CAUTI include rapidly fatal underlying illness, more than 50 years of age, nonsurgical disease, hospitalization on an orthopedic or urological service, catheter inserted outside the operating room, diabetes mellitus, and serum creatinine greater than 2 mg/dL at the time of catheterization. Nonadherence to aseptic catheter care recommendations has been associated with an increased risk of bacteriuria; conversely, systemic antibiotics have a protective effect on bacteriuria (relative risk 2.0–3.9). 2 , 3 Independent risk factors for urinary tract–related bloodstream infections in patients with bacteriuria include neutropenia, renal disease, and male sex. 27

Risk factors for CAUTIs

DIAGNOSIS OF CAUTIS

Clinical diagnosis of a CAUTI is challenging because pyuria and bacteriuria are almost uniformly present, but neither are reliable indicators of symptomatic UTI in the setting of catheterization. 28 – 31 Symptomatic UTI is defined by the presence of symptoms or signs referable to the urinary tract associated with significant bacteriuria. 28 Fever or other systemic symptoms may be the only clinical indication of UTI in patients who are critically ill or who have spinal cord injuries. 2 , 3 However, outside these patient populations, additional urinary tract-specific signs and symptoms should be sought for the diagnosis of UTI. 28 , 30

Defining significant bacteriuria is difficult because some level of bacterial colonization is universal in urine from catheterized patients. Colony counts in urine as low as 10 2 colony-forming units (CFU)/mL can be associated with symptoms, and colony counts of this level rapidly increase to more than 10 5 CFU/mL within 24 to 48 hours. 28 , 32 , 33 Therefore, the National Institute on Disability and Rehabilitative Research defined bacteriuria in catheterized patients as growth of 10 2 CFU/mL or more of a predominant microorganism. 33 Other guidelines have defined 10 3 CFU/mL as a more reasonable threshold for significant bacteriuria, balancing the sensitivity of detecting CAUTI with the feasibility of the microbiology laboratory to quantify microorganisms. 28

Asymptomatic bacteriuria is defined as bacteriuria in patients without signs or symptoms referable to the urinary tract. 28 The distinction from symptomatic UTI is clinically important because asymptomatic catheter-associated bacteriuria and funguria rarely result in adverse outcomes (eg, pyelonephritis, perinephric abscess, bacteremia) and generally do not require treatment. 30 Nevertheless, a large proportion of antimicrobials in hospitalized patients are prescribed for the treatment of UTIs, most often asymptomatic bacteriuria. 34 – 36

MANAGEMENT OF CAUTIS

The treatment of asymptomatic catheter-associated bacteriuria or candiduria is not indicated except in patients who are at a high risk for the development of complications, such as pyelonephritis or bloodstream infection. 37 Screening and treating pregnant women for asymptomatic bacteriuria to prevent pyelonephritis are recommended. In addition, patients undergoing genitourinary procedures likely to induce mucosal bleeding should be screened and treated in advance for asymptomatic bacteriuria. 28 , 37 As with asymptomatic bacteriuria, asymptomatic candiduria generally does not require treatment, except in neutropenic patients and other high-risk patients noted earlier. 38 Furthermore, because of poor specificity of fever and frequency of bacteriuria and funguria in hospitalized patients with urinary catheters, a thorough investigation for other sources of fever should be conducted before diagnosing a UTI.

Asymptomatic bacteriuria, persisting for 48 hours after the removal of a urinary catheter, has a high risk of progressing to symptomatic UTI; treatment in hospitalized women has been shown to decrease the risk of subsequent UTIs. 39 Therefore, considering the treatment of women with asymptomatic bacteriuria persisting 48 hours after catheter removal is recommended. 28 , 37 , 39 When indicated, 3 to 7 days of appropriate antimicrobial therapy based on culture results should be adequate for the treatment of asymptomatic bacteriuria. 28 , 37

Repeated antimicrobial treatment of bacteriuria during long-term catheterization is a significant risk for colonization with multidrug-resistant organisms, and most of this use is inappropriate. 34 , 35 A recent study reported that a 1-hour educational session reduced inappropriate use of antibiotic therapy for inpatients with positive urine cultures. 40 In addition, audit and feedback to care providers decreased overdiagnosis of CAUTIs and associated inappropriate antibiotic use in another study. 36 Educational efforts aimed at reducing unnecessary urine cultures (eg, pan-culturing for fever without a thorough clinical assessment) would also prevent the inappropriate treatment of bacteriuria and funguria.

Because of the presence of biofilm, leaving the catheter in place during the treatment of CAUTIs makes eradicating bacteriuria or candiduria difficult and can lead to the development of antimicrobial resistance. The management of symptomatic CAUTIs should include removing or replacing the urinary catheter if it has been in place for at least 2 weeks. 28 , 41 In terms of antimicrobial therapy, symptomatic CAUTIs may be treated with 7 days of appropriate antimicrobials if patients have a prompt resolution of symptoms; therapy should be lengthened to 10 to 14 days for those with a delayed response. 28 Initial empiric therapy should be based on local epidemiologic data regarding causative microorganisms of CAUTIs and antimicrobial resistance patterns. Once culture data become available, antimicrobial therapy should be adjusted as necessary, ideally providing the narrowest spectrum of coverage possible while still providing adequate treatment of the UTI. Symptomatic CAUTIs caused by Candida species should be treated with 14 days of antifungal agents. 38

PREVENTING CAUTIS

General strategies, formulated for the prevention of all HAIs, including strict adherence to hand hygiene, are critical for the prevention of CAUTIs. 42 The urinary tract of hospitalized patients, especially those in an ICU setting, represents a significant reservoir for multidrug-resistant organisms. Therefore, precautions recommended for prevention of transmission of multidrug-resistant organisms should be scrupulously observed in catheterized patients. 43 Limiting unnecessary use of antimicrobials, as part of an overall antimicrobial stewardship program, is another important general strategy to prevent the development of antimicrobial resistance related to urinary catheters. 44

The measurement and feedback of results of interventions to the clinical care team is an essential component of any improvement program. The CDC NHSN CAUTI rate (symptomatic UTI per 1000 urinary catheter-days) is the most widely accepted measure for CAUTI surveillance and is endorsed by the Infectious Diseases Society of America, the Society of Healthcare Epidemiology of America, and the Association for Professionals in Infection Control and Epidemiology. 28 , 45 , 46 In addition, beginning in 2012, the CMS has required as a condition of participation that hospitals, long-term care hospitals, and inpatient rehabilitation facilities submit ICU CAUTI rates to the NHSN. A modified definition of UTI is recommended for surveillance in long-term care facilities. 47 Efforts are currently underway to revise the CDC’s NHSN UTI surveillance definitions to improve specificity and clinical relevance of the measure.

However, a population-based measure, using hospital-days as the denominator, has been suggested as an alternative measure to assess improvement interventions at individual hospitals. 48 Other measures, such as rates of asymptomatic bacteriuria, percentage of patients with indwelling catheters, percentage of catheterization with accepted indications, and duration of catheter use, have been used in improvement studies and collaboratives with good success. 49

Several guidelines with specific recommendations for the prevention of CAUTIs have been developed or recently updated ( Box 1 ). 28 , 45 , 46 , 50 However, in 2005, a nationwide survey identified that one-third of hospitals did not conduct surveillance for UTIs, more than one-half did not monitor urinary catheters, and three-quarters did not monitor the duration of catheterization. 12 , 51 In a follow-up study, after the enactment of the CMS nonpayment rule, still no CAUTI prevention practices had been adopted in more than half of the hospitals, except for the use of bladder ultrasound. 12 Even in ICUs, only a small proportion of surveyed sites had policies supporting bladder ultrasound (26%), catheter removal reminders (12%), or nurse-initiated catheter discontinuation (10%). 52 The systematic adoption of prevention practices has begun to be observed through the use of bundles and collaboratives, as detailed later. 49 , 53

Strategies for prevention of CAUTIs

Avoid insertion of indwelling urinary catheters

• Placement only for appropriate indications (see Box 2 )
• Institutional protocols for placement, including perioperative setting

Early removal of indwelling catheters

• Checklist or daily plan
• Nurse-based interventions
• Electronic reminders

Seek alternatives to indwelling catheterization

• Intermittent catheterization
• Condom catheter
• Portable bladder ultrasound scanner

Aseptic techniques for care of catheters

• Sterile insertion
• Closed drainage system
• Maintain gravity drainage
• Avoid routine bladder irrigation

Data from Refs. 28 , 45 , 46 , 50

A qualitative study of 12 hospitals participating in a statewide program identified barriers to adoption of the key interventions to reduce unnecessary use of urinary catheters. Common barriers included difficulty with nurse and physician engagement, patient and family request for indwelling catheters, and catheter insertion practices and customs in emergency departments. 54 In addition, qualitative studies have revealed that staff variations of the perceived risk and perceived strength of evidence supporting preventive practices should be incorporated into implementation plans. 55 , 56

Limiting Use of Urinary Catheters

The foremost strategy for CAUTI prevention is avoidance of or decreasing the duration of urinary catheterization. Catheter utilization varies by ICU type, with the lowest rate in pediatric medical ICUs (0.16 urinary catheter-days/patient-days) and the highest rates reported in trauma ICUs (0.80 urinary catheter-days/patient-days). 16 Decreasing catheter utilization requires interventions at several stages of the lifecycle of the urinary catheter. 26

The first stage in decreasing catheter utilization is limiting the placement of indwelling urinary catheters. Overall, urinary catheters are overused and the documentation surrounding catheterization is inconsistent 7 , 57 – 59 ; urinary catheters are placed for inappropriate indications in 21% to 50% of catheterized patients. 7 , 60 Written policies and criteria for indwelling urinary catheterization, based on accepted indications, is a first step in limiting the placement of urinary catheters; but tracking indications for catheters with feedback to the care team is also important ( Box 2 ). 45 , 50 Some hospitals have had success by targeting interventions for limiting the placement of urinary catheters in emergency departments and operating rooms, locations where the initial placement often takes place. 61

Appropriate indications for indwelling urinary catheters

Acute urinary retention or bladder outlet obstruction

Need for accurate measurements of urinary output

Perioperative use for selected surgical procedures

• Surgical procedures of anticipated long duration
• Urologic procedures
• Intraoperatively for patients with urinary incontinence
• Need for intraoperative urinary monitoring or expected large volume of intravenous infusions

Urinary incontinence in the setting of open perineal or sacral wounds

Improve comfort for end-of-life care or patient preference

Modified from Gould C, Umscheid C, Agarwal R, et al. Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated infections 2009. Infect Control Hosp Epidemiol 2010;31:319–26.

Once catheters are placed, strategies for early removal become necessary to limit the duration of catheterization. Relying on physicians’ orders alone may be inadequate for the management of catheters because, in one study, 28% of physicians were unaware that their patient had a catheter. 7 Nurse-driven interventions have demonstrated effectiveness in reducing the duration of catheterization. 62 – 64 This type of intervention was implemented in a statewide effort that resulted in a significant decrease in catheter use and an increase in appropriate indications of catheters. 49

Computerized physician order entry systems may offer a more cost-effective and efficient system to reduce both the placement of catheters and the duration of catheterization. 65 A systematic review and meta-analysis found that urinary catheter reminder systems and stop orders seem to reduce the mean duration of catheterization by 37% and CAUTIs by 52%. 66

Hospitals have also shown success in decreasing urinary catheter prevalence and CAUTIs through the multimodal interventions noted earlier. 67 , 68 One institution used a multifaceted intervention, which included education, system redesign, rewards, and feedback managed by a dedicated nurse, resulting in a marked decrease in the daily prevalence of urinary catheter days. 67 Strategies to address barriers to the implementation of urinary catheterization bundles include incorporating planned toileting into other patient safety programs, discussing the risk of indwelling urinary catheters with patients and their families, and engaging emergency department personnel to ensure appropriate indications for catheter use are followed have been promoted. 54

Perioperative Management of Urinary Catheters

Approximately 85% of patients admitted for major surgical procedures have perioperative indwelling catheters. Those patients catheterized longer than 2 days are significantly more likely to develop UTIs and are less likely to be discharged to home. 69 Older surgical patients are at the highest risk for prolonged catheterization; 23% of surgical patients older than 65 years are discharged to skilled nursing facilities with an indwelling catheter in place and have substantially more rehospitalization or deaths within 30 days. 70 Therefore, specific protocols for the management of postoperative urinary catheters are important for reducing urinary catheterization utilization and patient outcomes; the Surgical Care Improvement Project has added the removal of urinary catheters as one of their measures.

In a large prospective trial of patients undergoing orthopedic procedures, patients were entered into the following protocol: (1) limiting catheterization to surgeries of more than 5 hours or for total hip and knee replacements and (2) the removal of urinary catheters on postoperative day 1 after total knee arthroplasty and postoperative day 2 after total hip arthroplasty. This intervention resulted in a two-thirds reduction in the incidence of UTIs. 71

Alternatives to Indwelling Urinary Catheters

A randomized trial demonstrated a decrease in bacteriuria, symptomatic UTI, or death in patients who used condom catheters when compared with those with indwelling catheters; this benefit was seen primarily in men without dementia. 72 Condom catheters have also been reported to be less painful than indwelling catheters in some men. 72 , 73 Therefore, condom catheters may be considered in place of indwelling catheters in appropriately selected male patients without urinary retention or bladder outlet obstruction.

Patients with neurogenic bladder and long-term urinary catheters, in particular, may benefit from intermittent catheterization. 50 Intermittent catheterization may also be beneficial for short-term urinary retention. A recent meta-analysis reported a reduced risk of bacteriuria with the use of intermittent catheterization in patients following hip or knee surgery compared with indwelling catheterization. 74 Combining the use of a portable bladder ultrasound scanner with intermittent catheterization may reduce the need for indwelling catheterization. 45 , 75

Aseptic Techniques for Insertion and Maintenance of Urinary Catheters

When indwelling catheterization is necessary, aseptic catheter insertion and maintenance is recommended for preventing CAUTIs. Urinary catheters should be inserted by a trained health care professional using a sterile technique. 50 Cleaning the meatus before catheter insertion is recommended; but ongoing daily meatal cleaning with an antiseptic has not shown benefit and may increase rates of bacteriuria compared with routine care with soap and water. 50 Sterile lubricant jelly should be used for insertion, but antiseptic lubricants are not necessary. 50

Maintaining a closed urinary catheter collection system is important to reduce the risk of CAUTIs. Opening the closed system should be avoided, especially when sampling urine that may be performed aseptically from a port or from the drainage bag. 50 Prophylactic instillation of antiseptic agents or irrigation of the bladder with antimicrobial or antiseptic agents has shown no benefit in preventing bacteriuria and is not recommended. 50 Finally, routine exchange of urinary catheters is not recommended except for mechanical reasons because bacteriuria and biofilms return quickly. 2

Use of Antiinfective Catheters

Antiseptic or antimicrobial impregnated urinary catheters have been studied extensively as an adjunctive measure for preventing CAUTIs with variable results. 76 , 77 However, almost all previous studies used bacteriuria as the primary end point rather than symptomatic UTIs, thus limiting their clinical relevance. In a Cochrane review, silver alloy catheters were found to significantly reduce the incidence of asymptomatic bacteriuria in adult patients catheterized less than 7 days, but the effect was diminished in those catheterized for greater than 7 days. 77 A recent multicenter randomized controlled trial that did use symptomatic CAUTIs as the end point reported no significant clinical benefit with the use of silver alloy-coated or nitrofural-impregnated catheters during short-term (<14 days) catheterization. 78 Few studies have evaluated antiseptic and antimicrobial catheters in long-term urinary catheterization. 79 Therefore, there is no recommendation for routine use of antiinfective urinary catheters to prevent CAUTIs. 50 Despite these recommendations, a national study in 2009 revealed that 45% of nonfederal and 22% of Department of Veterans Affairs hospitals used antimicrobial catheters; hospitals using antiinfective catheters often based their decisions on hospital-specific pilot studies. 12

IMPLEMENTATION: THE ROLE OF BUNDLES, COLLABORATIVES, AND LEADERSHIP

Recently, bundles of interventions have been used with success for the prevention of HAIs, including CAUTIs. The Bladder Bundle outlined using the mnemonic ABCDE in Box 3 applied was successfully adopted by the Michigan Hospital Association Keystone initiative. 49 , 53 After the implementation of this initiative, Michigan hospitals used more key prevention practices and had a lower rate of CAUTIs when compared with hospitals in the rest of the country. 80 Finally, the important role of local hospital leadership and followership for ensuring effective implementation of preventive initiatives has recently been highlighted. 81 – 83 The Web site www.catheterout.org provides a list of common barriers along with solutions that hospitals may wish to use in their CAUTI prevention programs.

The ABCDE for preventing CAUTIs

• Adherence to general infection control principles (eg, hand hygiene, surveillance and feedback, aseptic insertion, proper maintenance, education) is important.
• Bladder ultrasound may avoid indwelling catheterization.
• Condom catheters or other alternatives to an indwelling catheter, such as intermittent catheterization, should be considered in appropriate patients.
• Do not use the indwelling catheter unless you must.
• Early removal of the catheter using a reminder or nurse-initiated removal protocol seems to be warranted.

From Saint S, Olmsted RN, Fakih MG, et al. Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle. Jt Comm J Qual Patient Saf 2009;35(9):449–55; with permission.

CAUTIs are common, costly, and cause significant patient morbidity. CAUTIs are associated with hospital pathogens with a high propensity toward antimicrobial resistance. The treatment of asymptomatic CAUTIs accounts for excess antimicrobial use in hospitals and should be avoided. The duration of urinary catheterization is the predominant risk factor for CAUTI; preventive measures directed at limiting the placement and early removal of urinary catheters have a significant impact on decreasing CAUTIs. Bladder bundles, collaboratives, and the support of hospital leaders are powerful tools for implementing appropriate preventive measures against CAUTI.

• Catheter-associated urinary tract infection (CAUTI) is often caused by hospital-based pathogens with a propensity toward antimicrobial resistance.
• The diagnosis of CAUTI is problematic because pyuria and bacteriuria are not reliable markers of infection. The treatment of bacteriuria in the absence of symptoms is not indicated, except in patients at risk of developing pyelonephritis or bloodstream infection (ie, pregnancy, urologic procedures with bleeding).
• Indwelling urinary catheters that have been in place for more than 2 weeks should be removed when treating CAUTI.
• The duration of urinary catheterization is the predominant risk for CAUTI; preventive measures directed at limiting the placement and early removal of urinary catheters significantly reduce CAUTI rates.
• Bladder bundles, collaboratives, and certain behaviors of hospital-based leaders are powerful tools for implementing preventive measures for CAUTI.

Disclosures/Conflict of Interest:

C.E. Chenoweth, C.V. Gould: None; S. Saint: Honoraria and speaking fees from academic medical centers, hospitals, specialty societies, group-purchasing organizations (eg, Premier, VHA), state-based hospital associations, and nonprofit foundations (eg, Michigan Health and Hospital Association, Institute for Healthcare Improvement) for lectures about catheter-associated urinary tract infection and implementation science.

Publisher's Disclaimer: Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

How To Do Urethral Catheterization in a Female

• Indications |
• Contraindications |
• Complications |
• Equipment |
• Additional Considerations |
• Relevant Anatomy |
• Positioning |
• Step-by-Step Description of Procedure |
• Aftercare |
• Warnings and Common Errors |
• Tips and Tricks |

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. If the urethra is impassable, suprapubic catheterization of the bladder will be necessary.

(See also Bladder Catheterization .)

Indications for Urethral Catheterization in a Female

Relief of acute or chronic urinary retention, such as due to urethral obstruction ( obstructive uropathy ) or neurogenic bladder

Treatment of urinary incontinence

Monitoring of urine output

Measurement of postvoid residual urine volume

Collection of sterile urine for culture

Diagnostic studies of the lower genitourinary tract

Bladder irrigation or instillation of medication

Contraindications to Urethral Catheterization in a Female

Absolute contraindications

Relative contraindications

History of urethral strictures

Current urinary tract infection (UTI)

Prior urethral reconstruction

Suspected urethral injury *

Recent urologic surgery

History of difficult catheter placement

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

Complications of Urethral Catheterization in a Female

Complications include

Urethral or bladder trauma with bleeding or microscopic hematuria (common)

UTI (common)

Creation of false passages

Scarring and strictures

Equipment for Urethral Catheterization in a Female

Prepackaged kits are typically used but the individual items needed include

Sterile drapes and gloves

Povidone iodine

Applicator swabs, sterile gauze, or cotton balls

Water-soluble lubricant

Urethral catheter (size 16 French Foley catheter is appropriate for most adult women)*

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

Sterile collection device with tubing

* A closed catheter system minimizes catheter-associated UTI .

Additional Considerations for Urethral Catheterization in a Female

Sterile technique is necessary to prevent a UTI .

Relevant Anatomy for Urethral Catheterization in a Female

The female urethral meatus appears as an anterior-posterior slit located anterior to the vaginal opening and about 2.5 cm posterior to the glans clitoris. If the meatus recedes superiorly into the vagina, as can happen in older women, it can often be palpated in the midline as a soft mound surrounded by a firm ring of periurethral tissue.

Positioning for Urethral Catheterization in a Female

To expose the vulva, position the patient supine in either lithotomy or frog position (hips and knees partially flexed, heels on the bed, hips comfortably abducted).

Step-by-Step Description of Urethral Catheterization in a Female

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 collection system and do not break the seal unless a different type or size of catheter is required.

Test the retention balloon for leaks by inflating it with water.

Apply lubricant to the tip of the catheter.

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

Place the sterile fenestrated drape over the pelvis so that the vulva is exposed.

Gently spread the labia and expose the urethral meatus, using your nondominant hand. This hand is now contaminated and must not be removed from the labia or touch any of the equipment during the rest of the procedure.

Cleanse the area around the meatus with each cotton ball saturated in povidone iodine. Use a circular motion, beginning at the meatus and working your way outward. Discard or set aside the newly contaminated gauze or cotton balls.

Hold the lubricated catheter and gently pass it through the urethra, using your free hand. Urine should flow freely into the collection tubing. If the catheter accidentally passes into the vagina, it should be discarded and a new catheter used.

Inflate the balloon with the recommended volume of water, usually 10 mL. Resistance or pain may indicate that the balloon is in the urethra and not the bladder. If so, deflate the balloon, then insert it all the way before reinflation.

Pull the balloon up snug against the bladder neck, after the balloon has been inflated, by slowly withdrawing the catheter until resistance is felt.

Aftercare for Urethral Catheterization in a Female

Remove the drapes.

Secure the catheter to the thigh with an adhesive bandage or tape.

Hang the bag in a dependent position, so that urine can drain via gravity.

Warnings and Common Errors for Urethral Catheterization in a Female

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

Tips and Tricks for Urethral Catheterization in a Female

It is often helpful to have an assistant to help expose the meatus in women, especially those who are obese or have pelvic organ prolapse. Gentle retraction of the labia is helpful.

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URINARY BLADDER CATHETERIZATION

Urinary catheterization is a medical procedure in which a thin, flexible tube called a catheter is inserted into the urinary bladder through the urethra to drain urine. This procedure may be necessary for various reasons, and it can be performed in different settings, such as hospitals, clinics, or even at home under certain circumstances.

Here are some common reasons for urinary catheterization:

• Urinary Retention: When a person is unable to empty their bladder naturally, either due to a medical condition, surgery, or other factors, a catheter may be inserted to allow for the drainage of urine.
• Surgery: Catheterization is often performed before, during, or after certain surgical procedures, especially those involving the genitourinary system or pelvic area.
• Monitoring Urine Output: In critically ill patients or those undergoing surgery, healthcare providers may use catheters to closely monitor urine output and assess kidney function.
• Urinary Incontinence: In some cases, especially in individuals with severe urinary incontinence, catheters may be used as a means of managing and collecting urine.

There are different types of urinary catheters, and the choice depends on the specific needs of the patient and the medical situation. The main types include:

• Indwelling Catheters (Foley Catheters): These are left in place for an extended period and have a balloon at the tip to hold them in the bladder. They are often used for patients who are unable to void on their own.
• Intermittent Catheters: These are inserted and removed several times a day to empty the bladder. They are commonly used for short-term purposes or in cases where regular emptying is needed.
• External Catheters (Condom Catheters): These are used in males and are attached externally to the penis to collect urine. They are typically used for managing urinary incontinence.

Urinary catheterization is the introduction of a tube (a catheter) through the urethra into the urinary bladder to drain the bladder

Urinary catheterization is an aseptic method of introducing the catheter into the urinary bladder through the external urethra for withdrawal of urine

• To obtain a clear specimen for diagnostic purpose
• To relieve distension of bladder caused by retention of urine
• To determine whether the failure to void is due to retention or suppression
• To determine the amount of residual urine present in the bladder
• To empty the bladder prior to surgery, bladder, irrigation or before instillation of a drug
• To avoid soiling and infection of the wound following operations on the genital region
• To manage incontinency, when all other measures to prevent skin breakdown have failed
• To provide for intermittent or continuous bladder drainage and irrigation
• To prevent urine from passing over a wound, e.g. after repair of the perineum

Principle Involved

• Pathogenic organisms are transmitted from the source to a new host directly on by contaminated articles
• Urinary bladder is a sterile cavity and the urinary meatus act as a portal of entry for pathogenic organisms
• Cleaning an area minimize the spread of organisms
• A break in the integrity of the skin and mucus membrane provides ready entrance for microorganism
• Lubrication reduces friction
• Through knowledge of anatomy and physiology of the genitourinary system facilitates catheterization of the urinary bladder
• Systematic ways of doing saves times, energy and material
• Unfamiliar situation produce anxiety

General Instruction

• Apply all the nursing measures to induce urination before the catheterization of the bladder
• Observe strict aseptic techniques to prevent the urinary tract infection
• Catheterization should be done slowly and never use force
• Always catheterize in a good light
• Clean the perineum from the pubis downwards to the anal region
• Use one cotton ball for one swabbing
• Do not touch the portion of the catheter that is going into the urinary tract
• Lubricate the catheter well before introducing into the urinary tract
• Keep the patient relaxed by providing privacy and adequate explanations

Preliminary Assessment

• Doctors order for any specific precautions
• Identify the purpose of catheterization
• Level of consciousness
• Any contraindications
• General condition of the patient
• Mental status to follow instructions
• Articles available in the unit

Preparation of Patient and Environment

• Explain the sequence of the procedure
• Arrange the articles at the bed side locker
• Provide privacy
• Position the patient in dorsal recumbent
• Place the Mackintosh and towel under the buttocks
• Provide adequate light by placing extra spotlight

Types of Urinary Catheters

• Round-ended catheter
• Double lumen catheter
• Triple lumen catheter
• Tirmann catheter
• Whistle-tipped catheter

A sterile tray containing:

• Catheter of correct size
• Small bowl containing an antiseptic
• Cotton swabs
• Pair of gloves
• Thumb forceps and artery forceps-one each
• Sterile kidney tray – 1 prefilled syringe with sterile water
• Sterile towel, sterile drainage tubing and collection bag
• Test tube or specimen bottle
• Small cup containing lubricant

A clean tray containing

• Mackintosh and towel
• Flashlight or spotlight
• Bath blanket
• Kidney tray
• Adhesive tape and scissors
• Bed pan to empty the urine from the kidney tray
• Measuring jar
• Urobag or collection bag
• Scrub hands as for a surgical procedures
• Lift the draping sheet back towards abdomen
• Open the sterile tray with aseptic techniques
• Place the sterile towel and the slit in position
• Place the sterile kidney tray on the sterile towel in front of the patient
• Lubricate the catheter and place it in the sterile tray ready for insertion
• Clean the perineum with the cotton balls dipped in the antiseptic lotion using the forceps
• Discard the swab in the paper bag and discard the forceps in an unutterable kidney tray
• Pick up the catheter with the gloved hand, holding it about 7.5 cm from the tip and place the distal end in the sterile kidney tray
• Gently insert the catheter about 5 to 7.5 cm (female) the urine will flow into the kidney tray
• Collect the urine specimen if required. Attach the drainage tubing if an indwelling catheter is put in

Clean the Perineum in Female Patients

• Clean only in one direction
• Use one swab for one swabbing
• Clean labia majora on both sides
• Clean the inside of the labia majora on both sides
• Clean the labia minora on the both sides
• Clean the vulva

Cleaning the Perineum for Male Patients

• Retract the foreskin during the cleaning process
• Draw the penis upward and forward at 90 degree angle to the patients leg in order to straighten the urethra before the catheter is introduced
• Foreskin is replaced as quickly as possible after the insertion of the catheter
• Wash and dry the perineum
• Remove the drapes, replace the garments and bed covers
• Place the patients comfortably
• Take all the articles to the utility room, clean it and replace it
• Send specimen to the laboratory immediately
• Record the procedure in the nurse’s record sheet

Types of catheterization

• Intermittent catheterization
• Short-term indwelling catheterization
• Long-term indwelling catheterization

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