Procedure: Male catheter

Procedure, instructions and discussion

Male indwelling catheter insertion

Note: this is for uncomplicated catheterisation. See this post for complex IDC insertion or failed male catheter insertion

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Instructions

Indications

• Urinary retention
• Diagnostic collection (if unable to void)
• Urine output measurement (critically ill)
• Preserve skin integrity
• Patient comfort (as part of end-of-life care)

Contraindications (ABSOLUTE/relative)

• Trauma with suspected urethral injury
• Recent urological surgery

Alternatives

• No catheter (measure urine, MSU collection, skin care)
• Suprapubic catheter

Informed consent

VERBAL – IF HAS CAPACITY

• Simple procedure with a low risk of complications

NOT REQUIRED – IF LACKS CAPACITY

• Emergency procedure to prevent pain and distress
• Brief verbal explanation of the procedure is still recommended.

Potential complications

• Pain
• Failure (including creation of a false passage)
• Allergy
• Urethral trauma and haemorrhage
• Paraphimosis
• Pressure injury around insertion site
• Urinary tract infection
• Urethral stricture

Infection control

• Standard precautions
• PPE: sterile gloves, apron, protective eyewear/shield

MAINTAINING AN ASEPTIC FIELD THROUGHOUT CATHETERISATION REQUIRES PRACTICE AND GOOD TECHNIQUE

Area

• Private bed space with good lighting

Staff

• Procedural clinician
• Assistant

Equipment

STANDARD CATHETERIZASTION EQUIPMENT

• Absorbent towel under patient
• Sterile tray, gauze squares, cotton balls (cleaning tray)
• 0.9% sodium chloride (for cleaning)
• Forceps for application
• Extra sterile tray (drainage tray)
• Fenestrated drape
• Lubricant (lignocaine gel)
• 16-18G urethral catheters (non-latex)
• Luer lock syringe (10ml)
• Sterile water for injection
• Catheter drainage bag
• Catheter securing device

Positioning

• Supine

Medication

• 5ml of 2% lignocaine gel (lubricant)

Sequence (Seldinger Catheterisation)

• Open fenestrated drape and place it over patient’s penis
• Place the cleaning tray with saline and gauze between patient’s legs on the fenestrated drape
• Using a gauze square, hold the patient’s penis and retract foreskin if uncircumcised (using non-dominant hand)
• Clean urethral meatus and glans penis with gauze soaked with 0.9% sodium chloride (forceps in dominant hand)
• Discard cleaning gauze after one downwards wipe, and once cleaning complete, discard cleaning tray
• Inject the lignocaine gel into the urethra ensuring firm seal around meatus, clamping the urethra for 2-3 minutes
• Place tray for drainage between patient’s legs on the fenestrated drape
• Remove 16G catheter from plastic sleeve, ensuring to maintain sterility of the catheter (non-touch technique)
• Lubricate sterile catheter and insert into urethral meatus (holding penis at 90 degrees to the patent body)
• When resistance is felt, lower penis and continue insertion until the start of the Y junction of catheter
• If resistance occurs on insertion, apply constant sustained pressure for 30 seconds (passing prostate)
• When urine flows, inflate balloon with 10ml sterile water (or balloon volume as marked on catheter)
• If resistance or discomfort after inflation, deflate the balloon and reposition with further insertion
• After passage and inflation, withdraw the catheter until resistance is met (confirming bladder position)
• Reposition foreskin if required (avoiding paraphimosis)
• Connect the catheter drainage bag and secure catheter
• If unable to insert a catheter, reattempt changing to 18g catheter size (Coude tip if available)
• If unable to insert after two attempts, seek assistance from a senior clinician
• A new catheter should be used for each attempt

Post-procedure care

DOCUMENT PROCEDURE

• Completion
• Size of catheter
• Residual volumes
• Number of attempts
• Immediate complications
• Document management plan for catheter

Tips

• A larger catheter will pass an enlarged prostate more easily than a smaller one (allows sustained pressure)
• Coudé tip (curved tip) catheters may enable easier catheter insertion with enlarged prostate
• Catheters should be removed as soon as the clinical need has been resolved
• Routine antibiotic prophylaxis for high-risk patients only (trauma, prosthetic heart valves, immunosuppression)
• Catheterising spinal patients involves risk of autonomic dysreflexia (monitor BP, drain only 250ml every 15 minutes)

Discussion

Clinicians should select the smallest sized catheter that will enable adequate access and drainage. For males, this will usually be a 16-18G catheter, however the heavier the sediment, haematuria or clots, the larger the catheter required to reduce the chance of obstruction. Large clots and haematuria will require a 20-24g three-way catheter to facilitating irrigation. Three-way catheters are generally placed after discussion with urology.

Urethral disruption is associated with pelvic trauma or penile fracture. Blood at the meatus is the classical sign of urethral trauma. The traditional teaching requiring assessment for a high-riding prostate is probably overemphasised, as this sign is subjective and insensitive. In most trauma settings, a gentle, single passage of a urethral catheter by an experienced clinician may be attempted with minimal risk of exacerbating an underlying urethral injury. Any difficulty would suggest that urology advice and suprapubic catheterisation are required.

Meatal cleaning for catheterisation can be completed with saline or antiseptic solution. We suggest saline cleaning to reduce the chance of reducing the bacterial growth of urine samples sent for culture. The available evidence does not suggest this leads to higher levels of contamination.

References

• Cadogan M. Coudé tip catheter. LITFL
• NSW Ministry of Health. Adult urethral catheterisation for acute care settings. Sydney: NSW Health; 2015. GL2015_16. Available from: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_016.pdf
• NSW Agency for Clinical Innovation. Male indwelling urinary catheterisation (IUC) – adult. Sydney: ACI; 2014. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0020/256133/ACI_Male_IUCv3.pdf
• Catheterisation: indwelling catheters in adults – urethral and suprapubic. 2012. Arnhem: European Association of Urology Nurses; 2012. Available from: https://nurses.uroweb.org/guideline/catheterisation-indwelling-catheters-in-adults-urethral-and-suprapubic/
• Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.
• Schaeffer AJ. Placement and management of urinary bladder catheters in adults. In: UpToDate. Waltham (MA): UpToDate. 2019 July 2. Available from: https://www.uptodate.com/contents/placement-and-management-of-urinary-bladder-catheters-in-adults
• Sliwinski A, D’Arcy FT, Sultana R, Lawrentschuk N. Acute urinary retention and the difficult catheterization: current emergency management. Eur J Emerg Med. 2016 Apr;23(2):80-8.

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