Urine and Catheter Management Activities

Urinary catheterization is the insertion of a catheter through the urethra into the urinary bladder for withdrawal of urine. Straight catheters are used for intermittent withdrawals; indwelling (Foley) catheters are inserted and retained in the bladder for continuous drainage of urine into a closed system.

Purpose Intermittent catheterization is used for the following reasons:

• To obtain a sterile urine specimen for diagnostic evaluation; to empty bladder content when the patient is unable to void (urinate) due to urinary retention, bladder distention, and obstruction, or to measure residual urine after urination.
• To instill medication for a localized therapeutic effect and to instill contrast material (dye) into the bladder through the urethral catheter for cystourethralgraphy (x ray of the bladder and urethra).
• To empty the bladder for increased space in the pelvic cavity to protect the bladder during labor and delivery and during pelvic and abdominal surgery.

To strictly monitor the urinary output and fluid balance of critically ill patients. Indwelling catheterization is:

• Indicated as palliative care for terminally ill or severely impaired incontinent patients, for whom bed and clothing changes are uncomfortable, and as a way to manage skin ulceration caused or exacerbated by incontinence. Used to maintain a continuous out flow of urine for patients undergoing surgical procedures that cause a delay in bladder sensation, and for persons with chronic neurological disorders that cause paralysis or loss of sensation in the perineal area.
• Indicated for urologic surgery, bladder outlet obstruction, and for patients with an initial episode of acute urinary retention to allow the bladder to regain its tone. Precautions Because the urinary tract is normally a sterile system, catheterization presents the risk of causing a urinary tract infection (UTI).

The catheterization procedure must be sterile and the catheter must be free from bacteria. Urinary catheterization aids or replaces the body’s normal ability to urinate. Intermittent use of the procedure can stimulate normal bladder function, however frequent and continuous catheterization can lead to total dependency. Catheterization is invasive and has the potential of injuring the urethra and bladder, inviting urinary tract infections. Therefore aseptic techniques should be use in all catheter management activities.

The normal flow of urine from the kidneys through the ureters, bladder, urethra prevents the movement of bacteria up through the urinary system. The antibacterial properties of the bladder wall, urethra lining, and low urine pH also serve as protective barriers to urinary tract infections. Urinary tract infections occur when bacteria invade the protective barriers of one or more urinary structures. Description The female urethral orifice is a vertical, slit-like or irregularly ovoid (egg shaped) opening, 4 or 5 mm in diameter, located between the clitoris and the vagina.

The urinary meatus (opening) is concealed between the labia minora, which are the small folds of tissue that need to be separated in order to visualize the opening and insert the catheter. With proper positioning, good lighting and gloved hands, these anatomical landmarks can be identified. If necessary, provide perineal care to ensure a clean procedural environment. Catheterization of the female patient is traditionally performed without the use of local anesthetic gel to facilitate catheter insertion.

But since there are no lubricating glands in the female urethra (as found in the male urethra), the risk of trauma from a simple catheter insertion is more likely; therefore, ample supply of an anesthetic or antibacterial lubricant should be used. Preparation Health care practitioners performing the catheterization should have a good understanding of the anatomy and physiology of the urinary system, trained in antiseptic techniques and in catheter insertion and catheter care. Determine the primary purpose for the catheterization and give the patient and/or caregiver a detail explanation.

Patients requiring self-catheterization should be instructed and trained in the technique by a qualified health professional. Sterile disposable catheterization sets are available in clinical settings and for home use. These sets contain most of the items needed for the procedure, such as antiseptic agent, perineal drapes, gloves, lubricant, specimen container, label, and tape. Anesthetic or antibacterial lubricant, catheter, and drainage system may need to be added. It is always wise to review the content of the pre-packaged catheterization set while assembling the materials. Procedure The standard technique for catheter insertion is:

• Explain the procedure to the patient, position the patient and ensure privacy and good lighting.
• Wash hands, remove outer tray wrapper and put on sterile gloves before opening the sterile inner packet. Prepare a sterile field and place a specimen collection vessel between the patient’s legs.
• Cleanse the labia according to established guidelines and identify the urethral meatus.

If an anesthetic lubricating gel is used, instill approximately 0. 16 fl oz (5 ml) of 2% lignocaine hydrochloride gel into the urethra or apply the gel to the meatus to achieve surface anesthesia within three to five minutes. Hold the catheter in the dominant hand and gently insert it into the urethral meatus; pass it slowly through the urethra and into the bladder. If the catheter is accidentally inserted into the vagina or the tip is contaminated, discard it and take new sterile catheter before proceeding.

Once the urine starts to flow, collect the specimen and pass the catheter an additional 2 inches (5 cm) to ensure that the balloon is in the bladder before slowly inflating the balloon with 10 ml sterile water. Aftercare Patients using intermittent catheterization to manage incontinence may equire a period of adjustment as they try to establish a catheterization schedule that is adequate for their normal fluid intake. Antibiotics should not be prescribed as a preventative measure for patients at risk for urinary tract infections. Prophylactic use of antibacterial agents may lead to the development of drug-resistant bacteria. Patients who practice intermittent self-catheterization can reduce their risks for UTI by using antiseptic techniques for insertion and catheter care. Attach the indwelling catheter to the drainage system, slightly curve the tubing, and anchor it to prevent urethral traction.

In women the catheter should be secured to the anteromedial thigh with non-allergenic adhesive. Complications Complications that are liable to occur include:

• Trauma and/or introduction of bacteria into the urinary system, leading to infection and, rarely, septicemia.
• Trauma to the urethra and/or bladder from incorrect insertion or removal of the catheter with the balloon inflated. Repeated trauma may cause scaring and/or stricture, or narrowing of the urethra.
• Bypassing of urine around the catheter. Inserting a smaller catheter size can minimize this problem.

Sexual activity and menopause can also compromise the sterility of the urinary tract. Irritation of the urethra during intercourse promotes the migration of perineal bacteria into the urethra and bladder, causing UTIs. Postmenopausal women may experience more UTIs than younger women. The presence of residual urine in the bladder secondary to incomplete voiding provides an ideal environment for bacterial growth. Catheterization, Male Definition Urinary catheterization is the procedure of inserting a catheter through the urethra into the bladder to remove urine.

Intermittent catheterization is performed for periodic relief of bladder distension; indwelling (Foley) catheters are inserted and retained in the bladder for continuous drainage of urine into a closed system. Purpose Intermittent catheterization is recommended to obtain a sterile urine specimen, to relieve urinary retention, for urologic surgery or surgery on contiguous structures, for critically ill patients requiring accurate measurement of intake and output, and for temporary obstruction of the bladder opening due to injury.

Indwelling catheterization is recommended for continuous drainage of urine when the bladder outlet obstruction can not be corrected by medical or surgical intervention; in cases of intractable skin ulceration caused or exacerbated by exposure to urine; and as palliative care for terminally ill or severely impaired incontinent patients. Precautions The urinary tract is normally a sterile system. The normal flow of urine from the kidneys through the ureters, bladder, and urethra prevents the migration of bacteria up through the urinary system.

Antibacterial properties of the bladder wall, urethra, low pH of urine, and the prostatic fluid in men also inhibit bacteria growth. Urinary tract infections (UTI) usually result from bacterial invasion of the protective barriers of one or more urinary structures. As a result, urinary catheterization should be avoided whenever possible. Precautions must be taken to keep the procedure sterile and the catheter free from bacteria. The extended portion of the catheter should be washed with a mild soap and warm water to keep it free of accumulated debris.

Frequent intermittent catheterization and long-term use of indwelling catheters predisposes the patient to UTI. Care should be taken to avoid trauma to the urinary meatus and urothelium (urinary lining) with catheters that are too large or inserted with an insufficient amount of lubricant. Further medical advice should be sought if the catheter cannot be inserted easily, or the patient complains of undue pain or bleeding other than that associated with minor trauma. Every attempt should be made to keep the urinary drainage system closed.

Breaks in the system invite infections. Health care workers and patients should wash their hands before and after manipulation of the patient’s catheter or collection system to control UTI. Cross-contamination is the most frequent cause of nosocomial (hospital acquired) catheter related infections. Good hand washing practices are the best prevention measure. Patients with indwelling catheters should be re-evaluated periodically to determine if an alternative treatment method will be more effective.

Intermittent catheterization is preferable to chronic indwelling atheterization in certain patients with bladder dysfunction. It has become the standard care for patients with spinal cord injuries. Elderly patients, following surgical repair of hip fractures, regain the ability to control urination more quickly on a program of intermittent catheterization every six to eight hours compared to the use of indwelling catheters. Intermittent catheterization may be performed four or five times a day by the health care practitioner or care-giver. Patients who are interested in self-catheterization should be instructed and trained by a qualified health professional.

This is also true for patients who require indwelling catheterization, as the procedure for insertion is similar to that for intermittent catheterization, with added responsibility of inflating the balloon. Preparation Health care practitioner performing the catheterization should have a good understanding of the male urinary system anatomy and physiology and should be trained in aseptic technique, catheter insertion technique, and catheter care. Sterile disposable catheterization sets are available in clinical settings and for home use.

These sets contain most of the items needed for the procedure, such as antiseptic agents, perineal drapes, gloves, lubricant, specimen container, label, and adhesive strips. Local anesthetic gel, antibacterial lubricant, catheter, and drainage system may need to be added. It is wise to check the content of the pre-packaged catheterization set when assembling materials and supplies. Procedural precautions Before starting the catheterization, observe the patient’s general condition and palpate the suprapubic area to detect gross distension.

The genital area should be washed with a mild soap and warm water and patted dry. Phimosis is constriction of the prepuce (foreskin) so that it cannot be drawn back over the glans penis. This may make it difficult to identify the external urethral meatus. Care should be taken when catheterizing men with phimosis to avoid trauma from forced retraction of the prepuce or by incorrect positioning of the catheter. The male urethra is longer than the female urethra and has two curves in it as it passes through the penis to the bladder, which makes catheter insertion more difficult.

One curve can be straightened out by lifting the penis; the other curve is fixed. The penis should be held upright, at right angle to the patient’s body when the catheter is inserted. The male urinary meatus is located at the end of the penis and is exposed by retracting the prepuce in uncircumcised patients. Men with a retracted penis can be even more difficult to catheterize. Gentle finger pressure on both sides of the penis will often cause the penis to emerge and extend from the body to facilitate the catheterization. To perform the procedure:

• Position the patient in a horizontal recumbent position.
• Place the opened catheterization tray on the bedside stand in comfortable reaching distance.
• Retract the foreskin. Using an aseptic technique, clean the prepuce and insert anesthetic gel to anesthetize the glans penis and dilate the prepuce exposing the meatus. Anesthetic gel can then be introduced into the urethra and catheterization can commence.
• Use two or three aseptic swabs to clean the meatus with circular motion, beginning with the center of the opening and rotating outwards.
• Lubricate about 8 inches (20 cm) of the catheter. Hold the penis in the dominant hand and pull it upward and slightly backward to straighten the urethra.
• Gently insert the catheter with a smooth continuous motion until urine begins to flow. Do not force.
• Once the urine starts to flow, collect the specimen. Advance the catheter an additional 5 cm before inflating the balloon with 5 to 10 ml of sterile solution to hold the catheter in place.
• Connect the indwelling catheter to the drainage system. Put a slight curve in the catheter and anchor it to the upper outer thigh with hypoallergenic adhesive to prevent urethral traction.

Aftercare Patients using intermittent catheterization as treatment of incontinence or retention will have a period of adjustment as they try to establish a catheterization schedule adequate for their normal fluid intake. The urinary drainage system should be kept closed. Breaks in the drainage unit may result in an infection. Avoiding cross-contamination is important in controlling catheter-related UTIs. Practitioners and caretakers should always wash their hands before and after handling a patient’s catheter or urine collection unit. The extended portion of the catheter should be washed with a mild soap and warm water to remove accumulated debris.

Patients with indwelling catheters should be re-evaluated periodically to determine if an alternative treatment method will be more effective. Catheters should not be changed routinely. Each patient should be monitored for indication of obstruction or complications before changing the catheter. Some patients require catheter changes weekly, and others may need a change in several weeks. In summary, the following guidelines are recommended for male catheterization:

• Catheterize the patient only when it is absolutely necessary.
• Secure the catheter properly. Maintain a closed sterile urine collection system and unobstructed urine flow.
• Avoid catheter irrigation unless it is needed to prevent or relieve bladder obstruction.
• Always use the smallest effective catheter.
• Do not change the catheter as an elective treatment option.
• Isolated minor episodes of UTI should not be treated with antibiotics. Antibiotic prophylaxis promotes emergence of drug-resistant bacteria.
• Provide continuing education in catheter care for practitioners and caretakers.

Complications

A few complications that may rise during the procedure are:

• urinary tract infections and catheter obstruction trauma and/or the introduction of bacteria into the urinary system, leading to infection and, rarely, septicemia
• trauma to the bladder, urethra, and meatus caused by incorrect insertion of the catheter or forceful removal with the bladder inflated by confused patients
• scaring, stricture and/or narrowing of the urethra due to repeated trauma
• urine bypass around the catheter (A smaller catheter size may minimize leakage. )
• leakage around the catheter due to forceful bladder spasms that overwhelm the catheter’s drainage capacity Results Urinary catheterization aids or replaces the body’s normal ability to urinate.

Intermittent use of the procedure can stimulate normal bladder function. However frequent and continuous catheterization can lead to total dependency. Practically every patient with chronic catheterization and frequent intermittent catheterization will develop bacteriuria. Some physicians do not recommend antibiotic therapy for asymptomatic bacteriuria. When symptomatic infections are treated in patients with indwelling catheters, the catheter is removed and a fresh urine specimen is obtained for culture to determine the source of the infection and direct the medical therapy.