Urethral catheterization is insertion of a flexible catheter through the urethra into the urinary bladder.
Several types of catheters are available. If a catheter cannot be inserted, suprapubic aspiration of the bladder may be necessary. (See also Bladder Catheterization, How To Do Urethral Catheterization in a Male, and Urinary Tract Infection in Children.)
Bladder catheterization can be done for diagnosis and/or treatment.
The main reason to insert a bladder catheter in male children is to
- Collect a sterile urine sample for testing in very young children who cannot void on command
Less common reasons include:
- Relief of acute or chronic urinary retention (obstructive uropathy)
- Intermittent catheterization of a neurogenic bladder
- Instillation of contrast agent for cystourethrography
- Bladder irrigation
- Instillation of a drug
- Monitoring of urine output in certain hospitalized patients (indwelling catheter; not discussed here)
- Suspected urethral disruption from recent urethral trauma
In trauma patients, lower urinary tract disruption (suggested by perineal hematoma, bleeding from the meatus, or pelvic bone injury) should be ruled out by retrograde urethrography (and sometimes cystoscopy) before doing bladder catheterization
- Known major abnormalities of the lower urinary tract
- History of urethral strictures
- Prior urethral or bladder neck reconstruction
- History of difficult catheter placement
Sometimes prepackaged kits are available; if not, equipment required typically includes
- Sterile drapes and gloves
- An absorbent underpad
- Antiseptic solution (eg, povidone iodine, chlorhexidine) with applicator sticks, cotton balls, or gauze pads
- Sterile water-soluble lubricant (with or without 2% lidocaine)
- Sterile cup for collecting urine specimen
- Urethral catheter size varies with age: neonate (full term) to 6 months—5 to 6 French (Fr); infant or toddler—6 to 8 Fr; prepuberal child—10 to 12 Fr; adolescent—12 to 14 Fr
- Washcloth for removing antiseptic solution after the procedure
- Sterile technique is necessary to prevent a lower UTI.
- Ensure the patient is not allergic to latex or povidone iodine.
- If doing multiple procedures, do bladder catheterization first as the child may void during the other procedures.
- The pediatric male anatomy is similar to the adult's, with a difference in size.
- The male urethra bends acutely at the pubis. Hold the penis straight and upright, to smooth out the curve, when passing a catheter through the urethra.
- Position the patient supine with hips comfortably abducted, knees bent in frog position (hips and knees partially flexed, heels on the bed, hips comfortably abducted).
- A clinical assistant should hold the legs or knees.
Step-by-Step Description of Procedure
The in-and-out insertion of a catheter will be described here.
- Allow one or both parents or caretakers to remain present to comfort the child. Having them hold the child's hand, provide a stuffed animal for the child to play with, or engage in other distraction techniques can help. Occasionally sedation is needed.
- Place all equipment within easy reach on an uncontaminated sterile field on a bedside tray.
- Open the prepackaged kit, taking care not to contaminate the contents.
- Place the absorbent underpad with the plastic side down beneath the buttocks.
- Remove diaper if present and clean the area with a wet washcloth using soap and water. Dry the area with a dry towel. Then wash your hands with soap and water.
- Put on gloves using sterile technique.
- Apply the sterile lubricant to the end of the catheter and place on the sterile field.
- Saturate the application sticks, cotton balls, or gauze pads 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, hold the penis perpendicular to the abdominal wall, and apply gentle traction. Retract the foreskin if the patient is uncircumcised. Do not force the foreskin to retract. Remember to hold the sides of the penis and not directly underneath; the urethra runs through here and you may compress the area, making it difficult to advance the catheter. This hand is now nonsterile and must not be removed from the penis or touch or any of the equipment during the rest of the procedure. If needed, new sterile gloves can be used.
- Cleanse the glans penis with each application stick, gauze pad, or cotton ball saturated in povidone iodine. Use a circular motion, beginning at the meatus, and work your way outward. Discard or set aside the newly contaminated application sticks, gauze pads, or cotton balls. If using povidone iodine, clean 3 times then allow the area to dry.
- Hold the catheter in your dominant free hand.
- Advance the catheter slowly through the urethra just until urine is obtained. If the patient is old enough to cooperate, ask him to relax and take slow deep breaths as you continue to apply steady pressure. There may be some resistance due to bladder sphincter contraction during insertion of the catheter. Maintain steady gentle pressure so the catheter will advance when the sphincter relaxes. Do not poke repeatedly or force the catheter. Urine should flow freely.
- Collect urine in the specimen container. If the volume is insufficient, gently massage the lower abdomen over the bladder (suprapubic area).
- Remove the catheter by pulling out gently.
- Remove all remaining povidone iodine with a wet washcloth.
- Reposition the foreskin in the uncircumcised male over the glans to avoid paraphimosis.
- Reduce the foreskin of uncircumcised patients by returning it to its normal position over the glans, to prevent paraphimosis.
- Remove the drapes.
Warnings and Common Errors
- To prevent causing a UTI, maintain strict sterile technique during the procedure.
- To prevent causing paraphimosis, reduce the foreskin after the procedure by returning it to its normal position over the glans.
- To prevent causing blind passages and urethral injury, do not use excessive force during insertion.
Tips and Tricks
- If the foreskin cannot be fully retracted, do not force it. A little gentle retraction may be enough to adequately see the meatus.
- Remember to hold the sides of the penis and not directly underneath; the urethra runs through here and you may compress the area, making it difficult to advance the catheter.
- Do not proceed with continued attempts at catheter placement if significant resistance is met or if the catheter feels as if it is buckling inside and not advancing.
- If the catheter appears to be in the correct position but urine does not return, lubricant may be obstructing the drainage of urine. With the catheter held in the current position, flush the catheter with normal saline to dislodge the lubricant and see if urine returns prior to proceeding with the remaining steps.
- If the catheter appears to be in the correct position but urine does not return and there is the possibility of anuria due to dehydration, consider providing hydration (appropriate to patient's clinical condition) before the procedure is attempted again.
- Consult urology for any issues with catheter placement or guidance on catheter size and style in select clinical scenarios. In certain situations where a catheter cannot be placed, a suprapubic percutaneous aspiration may be indicated.
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