Catheterisation: types, indications, advantages and complications

Urinary catheterisation is an invasive procedure that is very commonly required in patients. Doctors try to avoid it whenever possible as it is highly painful and may be associated with numerous complications. On the pain scale, it is ranked higher than a lumbar puncture and arterial blood gases sampling. In most hospitals, nurses perform catheterisation but doctors are required if there are difficulties in inserting catheters as in the cases of urethral strictures, prostate cancer patients and patients who have recently experienced trauma.

Indication for catheterisation
Types of catheters
- Deciding which type of catheter to use
- Sizing of urinary catheters
Drainage systems for urinary catheters
Technique of urinary catheter insertion
Issues with catheter management
Catheter removal
Complications associated with catheterisation

Doctors for Catheterisation

Indication for catheterisation

Before performing a catheterisation, the doctor should understand the aim behind the procedure. The indications of catheterisation can be classified into short-term and long-term indications.

Short term indications are the following:

Patients with acute urinary retention (inability to completely empty the bladder)
Emptying of the urinary bladder before surgery, including urological or pelvic surgery such as a removal of the uterus (hysterectomy)
For calculating the urinary output in patients who are critical

The long-term indications for catheterisation include the following:

Patients with chronic urinary retention due to obstruction at the outlet of the bladder that cannot be treated by other means
Patients with urinary incontinence (uncontrolled leakage of urine) in patients who are terminally ill or extremely frail and repeatedly wet the bed or when incontinence leads to local destruction of skin tissue

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Types of catheters

The kind of catheter depends on a lot of factors including the indication, the duration it is required for, the risk of infection and the patient’s choice.

They include the following:

External versus indwelling catheters: Condom catheters can be used in men with urinary incontinence and no urinary retention along with impaired function. They have the advantage of lower risk of infection and are more comfortable as compared to indwelling catheters but carry the disadvantages of having the risk of skin destruction and reduction in blood supply to the penis. Some patients may also have leakage from external catheters.
Intermittent catheterisation: This is used over long-term indwelling catheters in patients with a neuropathic bladder (disruption in the nervous supply of the bladder that leads to urinary retention). They’re commonly used in patients with spinal cord injuries. The advantage is that they carry a lower risk of urinary tract infection. The disadvantage is a higher risk of skin infections (cellulitis).

Catheters come in numerous sizes and can be made of different kinds of materials which include the following:

Latex
Silicone
Teflon

The types of catheters include the following:

Foley catheter (most commonly used)
Straight catheter
Coude tip catheter
Silver catheters which have antimicrobial properties

Self-retaining foley catheters are the most commonly used ones and are basically soft rubber tubes inserted inside the urinary bladder. They are held in place using a balloon at the end of the tube that is inflated using normal saline. Previously, foley catheters were made of latex but now silicone-based catheters are preferred as it helps in preventing skin irritation caused by latex. They are also more rigid and have a longer life, lasting up to two months. It is important to not leave the catheter inside beyond the recommended duration of time.

Deciding which type of catheter to use

Following are some examples of which type of catheter is used in different situations:

For hospitalised patients requiring a catheter for a short duration of time, a silver catheter may be used as it reduces the risk of urinary tract infections due to the antimicrobial properties.
Straight catheters may be used to take a urinary sample in some patients.
If a catheter is to be left inside for a longer duration, a silicone-based foley catheter is used because of its long life.
Catheters with a triple lumen may be used for patients undergoing bladder or prostate surgery as it is required for continuous irrigation of the urinary bladder.

Sizing of urinary catheters

Foley catheters are classified in terms of size in french grade or FG (1French = 1/3mm diameter). Selecting the correct size aids in improving patient comfort along with adequately draining urine. The smallest possible size that allows adequate and effective drainage should be inserted, as larger ones can lead to injuries.

The following scenarios may help in guiding the size of the catheter that should be used:

Initial catheterisation in females with clear urine: 10-12 french
Initial catheterisation in males with clear urine: 12-14 french
Initial catheterisation in males with slightly cloudy urine: 16 french
Initial catheterisation in males with moderately heavy debris or blood: 18 french
Children require smaller sizes of urinary catheters

Drainage systems for urinary catheters

The most common drainage system is the urinary drainage bag that is usually attached to the leg of the patients and can collect up to 750ml of urine. These bags usually hang with the help of a hanger on the side of the bed. It is essential that a closed drainage system be used (connecting the catheter to the drainage bag in a closed continuous unit) as it can help in decreasing the risk of a urinary tract infection.

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Technique of urinary catheter insertion

Catheters should be inserted via an aseptic ‘no-touch’ technique as it helps in reducing the risk of infections. Only the plastic packing can be touched and not the catheter inside it.

The following equipment is required to perform a successful insertion of catheter:

Sterile gloves
Antiseptic solution
Swabs
Antiseptic anesthetic gel
Range of urinary catheters
Urine bag with tube
Syringe with normal saline to inflate the balloon of the foley catheter

Technique for catheter insertion in men

Following is the process for inserting a catheter in men:

The patient should be lying on his back.
The non-dominant hand should be used to hold the penis in place. This hand is considered to be non-sterile during the procedure. The foreskin should be retracted.
The tip of the penis should be cleaned with an antiseptic solution.
A small amount of anaesthetic gel is to be inserted inside the urethra directly using a single-use insertion device. Wait for three minutes for the anaesthetic gel to perform its action.
Connect the urinary drainage bag to the catheter before the procedure to prevent spillage of urine.
Insert the catheter into the urethra till you encounter a small resistance. This is the second urethral curve. To further insert it, straighten the penis and push the catheter inside further.
Once you can notice urinary flow, the catheter should be pushed in as far as it can go. This helps avoid the balloon from being inflated while it is still at the level of the prostate.
The balloon should then be inflated with a small amount of normal saline (usually 10-15 ml).
Retract the catheter slowly till you can feel a slight tug, which indicates that the balloon is against the neck of the urinary bladder. The urine should flow freely at this point.
Make sure that you reposition the foreskin to avoid any complications like paraphimosis.
The tube of the catheter should be taped to the inner thigh to prevent any pressure on the tube.

Technique for catheter insertion in women

It is very similar to male catheterisation. It should be remembered that the urethra in females is shorter and identification of the urinary orifice can sometimes be problematic.

The patient should be lying on her back.
The urethral area is to be cleaned with an antiseptic solution.
Put the anaesthetic solution on the tip of the urinary catheter.
The labia (lip-like structures) should be opened.
Slide the catheter inside slowly.
If you are having some difficulties in identifying the urethral opening, you can try palpating the area in front of the vagina. You may feel a horseshoe-like ride. The index finger can be used to guide the catheter into the opening.
The catheter can be pushed slowly till about 10cm into the urinary bladder.
Inject normal saline inside the balloon of the foley catheter.
Slowly retract the catheter till you can feel a soft tug that indicates that the balloon is against the neck of the urinary bladder.
The urine would flow freely now.
The tube of the catheter should be taped to the inner thigh to prevent any pressure on the tube.

Problems that can occur while inserting the urinary catheter

Various problems can occur while insertion, including the following:

Phimosis: It is a complication only seen in males. It refers to the inability to retract the foreskin. If the opening can be seen slightly and is adequate, insert the catheter blind. In case the opening is too narrow, try dilation of the opening with the help of a smaller catheter.
Inability to pass the catheter past the prostate: This occurs only in males. A larger catheter size should be tried as it may help the distortion of this section of the urethra caused by the prostate. You can also use a silicone catheter as it is very rigid.
Inability to pass the bladder neck: You can use a smaller size to overcome this issue.
Sometimes, the lumen of the catheter becomes blocked: This occurs in patients with urinary retention. Catheters with small diameters may be inserted easily and slide inside the urethra but can lead to the formation of strictures (restriction).

Issues with catheter management

There are numerous issues that can occur due to problems with catheter management. These may include the following:

Leakage: Try using a smaller catheter size. Do exclude conditions like constipation and catheter blocks.
Crust formation: it can occur due to the accumulation of various minerals and other materials like proteins or bacteria. It results in recurrent blocks. It is advisable to increase fluid intake and to consume acidifying substances like vitamin C and cranberry juice.
Inflammation and irritation: This depends on the catheter material used. In this case, a different catheter type is to be used.
Blockage of urinary catheter: This requires a change of catheter. Try changing catheters regularly as there may be a blockage each time by the end of the life of the catheter.

Catheter removal

The following should be kept in mind while removing a catheter:

Previously, catheters were removed early in the morning, so that if the patient is unable to pass urine afterwards, it is noted easily and followed by re-catheterisation. Some doctors recommend removing it at night just before going to sleep as normally people empty their bladder before going to bed; if the patient is unable to pass urine in the morning, the catheter is inserted again. A proper time must be selected and one should avoid disrupting the patient’s sleep.
When it’s time to remove the urinary catheter, a syringe can be attached to the opening connected to the balloon and the normal saline inside the balloon removed. The catheter can then be slowly pulled out.
In case the balloon cannot be completely emptied, try being extremely soft and slow with the traction on the plunger of the syringe. You may also need to inject 1-2 ml of water to remove any adhesions. You can try rotating the catheter while pulling on the plunger. The catheter may also be cut just outside the urethra. Make sure that it does not go back inside the bladder. You can put a safety pin to prevent this - leave the catheter for an hour or two and allow the balloon to empty completely.
If the balloon still remains rigid, you can locate and puncture it by a digital examination, using a small needle. This is usually done through the rectum in males and the vagina in females.
In case a doctor over-inflates the balloon and bursts it, a cystoscopy (visualising the bladder with a camera) followed by removal of any remaining pieces is required.

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