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Urethral Catheterization in Men

  • Author: Gil Z Shlamovitz, MD, FACEP; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Jan 07, 2016
 

Overview

Introduction

Urethral catheterization is a routine medical procedure that facilitates direct drainage of the urinary bladder.[1] It may be used for diagnostic purposes (to help determine the etiology of various genitourinary conditions) or therapeutically (to relieve urinary retention, instill medication, or provide irrigation). Catheters may be inserted as an in-and-out procedure for immediate drainage, left in with a self-retaining device for short-term drainage (eg, during surgery), or left indwelling for long-term drainage for patients with chronic urinary retention. Patients of all ages may require urethral catheterization, but patients who are elderly or chronically ill are more likely to require indwelling catheters, which carry their own independent risks.

The basic principles underlying urethral catheterization are gender-neutral, but the specific aspects important in the technique of male catheterization are described in this article. For a procedural description for female patients, see Urethral Catheterization in Women.

Relevant Anatomy

The male urethra is a narrow fibromuscular tube that conducts urine and semen from the bladder and ejaculatory ducts, respectively, to the exterior of the body (see the image below). Although the male urethra is a single structure, it is composed of a heterogeneous series of segments: prostatic, membranous, and spongy.

Male urethra and its segments. Male urethra and its segments.

Knowledge of male urethral anatomy is essential for all health professionals because urethral catheterization is one of the most commonly performed procedures in health care. The male urethra is susceptible to a variety of pathologic conditions, ranging from traumatic to infectious to neoplastic. Pathophysiologic variants of the urethra may have devastating consequences, such as renal failure and infertility. For more information about the relevant anatomy, see Male Urethra Anatomy.

Key Considerations

Prophylactic antibiotics are recommended for patients with prosthetic heart valves, artificial urethral sphincters, or penile implants.

The maximal recommended volume for urethral balloon inflation can be found on the inflation valve (usually, 10-30 mL). See the image below.

Urethral catheter balloon volume indicator. Urethral catheter balloon volume indicator.

Indications

Diagnostic indications include the following:

  • Collection of uncontaminated urine specimen
  • Monitoring of urine output
  • Imaging of the urinary tract

Therapeutic indications include the following[2] :

Contraindications

Urethral catheterization is contraindicated in the presence of traumatic injury to the lower urinary tract (eg, urethral tear). This condition may be suspected in male patients with a pelvic or straddle-type injury. Signs that increase suspicion for injury are a high-riding or boggy prostate, perineal hematoma, or blood at the meatus. When any of these findings are present in the setting of possible trauma, a retrograde urethrogram should be performed to rule out a urethral tear prior to placing a catheter into the bladder.[2]

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Preparation

Anesthesia

Topical anesthesia is administered with lidocaine gel 2%.[5, 6] Many facilities have a preloaded syringe with an opening appropriate for insertion into the meatus available either separately or in the catheter kit. To instill, hold the penis firmly and extended, place the tip of the syringe in the meatus, and apply gentle but continuous pressure on the plunger. A gloved finger should be placed at the urethral tip and held for a couple of minutes to allow the anesthetic to take effect.

For more information, see Topical Anesthesia.

Equipment

Equipment includes a commercial single-use urethral catheterization tray (see the image below) and a sterile anesthetic lubricant (eg, lidocaine gel 2%) with a blunt tip urethral applicator or a plastic syringe (5-10 mL).

Commercial urinary catheterization kit. Commercial urinary catheterization kit.

The contents of the catheterization tray are as follows:

  • Povidone-iodine
  • Sterile cotton balls
  • Water-soluble lubrication gel
  • Sterile drapes
  • Sterile gloves
  • Urethral catheter [7, 8, 9] (see Catheter Types and Sizes, below)
  • Prefilled 10-mL saline syringe
  • Urinometer connected to a collection bag

Catheter types and sizes

Catheter sizes and types are as follows (see the images below):

  • Adults - Foley (straight tip) catheter (16-18F)
  • Adult males with obstruction at the prostate - Coudé tip (18 F)
  • Adults with gross hematuria - Foley catheter (20-24F) or 3-way irrigation catheter (20-30F)
  • Children - Foley; to determine size, divide child's age by 2 and then add 8
  • Infants younger than 6 months - Feeding tube (5F) with tape
    Urethral catheter types: 1) Straight tip; 2) Coude Urethral catheter types: 1) Straight tip; 2) Coude tip; 3) 3-way catheter irrigation.
    Urethral catheter types: 1) Straight tip; 2) Coude Urethral catheter types: 1) Straight tip; 2) Coude tip; 3) 3-way catheter irrigation.

Catheter materials include the following:

  • Latex
  • Silastic (pure silicone or silicone-coated)
  • Silver alloy
  • Antibiotic-impregnated

Positioning

Place the patient supine, in the frogleg position, with knees flexed.

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Technique

Overview

Explain the procedure, benefits, risks, complications, and alternatives to the patient or the patient's representative.

Position the patient supine, in bed, and uncover the genitalia.

Open the catheter tray and place it on the gurney in between the patient’s legs; use the sterile package as an extended sterile field. Open the iodine/chlorhexidine preparatory solution and pour it onto the sterile cotton balls. Open a sterile lidocaine 2% lubricant with applicator or a 10-mL syringe and sterile 2% lidocaine gel and place them on the sterile field. See the image below.

Preparatory solution in a commercial urinary cathe Preparatory solution in a commercial urinary catheterization kit.

Don the sterile gloves and use the nondominant hand to hold the penis and retract the foreskin (if present). This hand is the nonsterile hand and holds the penis throughout the procedure. See the video below.

Retraction of foreskin.

Use the sterile hand and sterile forceps to prep the urethra and glans in circular motions with at least 3 different cotton balls. Use the sterile drapes that are provided with the catheter tray to create a sterile field around the penis. See the video below.

Urethral preparation.

Using a syringe with no needle, instill 5-10 mL of lidocaine gel 2% into the urethra. Place a finger on the meatus to help prevent spillage of the anesthetic lubricant. Allow 2-3 minutes before proceeding with the urethral catheterization. See the video below.

Urethral analgesia.

Hold the catheter with the sterile hand or leave it in the sterile field to remove the cover. Apply a generous amount of the nonanesthetic lubricant that is provided with the catheter tray to the catheter. See the video below.

Foley lubrication.

While holding the penis at approximately 90° to the gurney and stretching it upward to straighten out the penile urethra, slowly and gently introduce the catheter into the urethra. Continue to advance the catheter until the proximal Y-shaped ports are at the meatus.[10] See the video below.

Urethral catheterization.

Wait for urine to drain from the larger port to ensure that the distal end of the catheter is in the urethra. The lubricant jelly–filled distal catheter openings may delay urine return. If no spontaneous return of urine occurs, try attaching a 60-mL syringe to aspirate urine. If urine return is still not visible, withdraw the catheter and reattempt the procedure (preferably after using ultrasonography to verify the presence of urine in the bladder). See the video below.

Urine return.

After visualization of urine return (and while the proximal ports are at the level of the meatus), inflate the distal balloon by injecting 5-10 mL of 0.9% NaCl (normal saline) through the cuff inflation port. Inflation of the balloon inside the urethra results in severe pain, gross hematuria, and, possibly, urethral tear. See the video below.

Cuff inflation.

Gently withdraw the catheter from the urethra until resistance is met. Secure the catheter to the patient's thigh with a wide tape. Creating a gutter to elevate the catheter from the thigh may increase the patient's comfort. If the patient is uncircumcised, make sure to reduce the foreskin, as failure to do so can cause paraphimosis. See the video below.

Securing the catheter.

Insertion of a Coudé Catheter

The Coudé catheter,[11] which has a stiffer and pointed tip, was designed to overcome urethral obstruction that a more flexible catheter cannot negotiate (eg, in patients with benign prostatic hypertrophy). To place a Coudé catheter, follow the procedure described above. The elbow on the tip of the catheter should face anteriorly to allow the small rounded ball on the tip of the catheter to negotiate the urogenital diaphragm.

Perineal Pressure Assistance

The distal tip of the catheter might become caught in the posterior fold between the urethra and the urogenital diaphragm. An assistant can apply upward pressure to the perineum while the catheter is advanced to direct the catheter tip upward through the urogenital diaphragm.

Urethral Catheter Removal

Use a syringe to empty the balloon, and then apply gentle traction. Pain, severe discomfort, resistance to withdrawal of the catheter, or failure to aspirate normal saline through the inflation valve should alert the practitioner to the possibility of a nondeflating urethral catheter.

The most common cause of a nondeflating urethral catheter is obstruction of the inflation channel, caused by a failed inflation valve or crystallization of the inflation fluid.

The first step in managing the nondeflating Foley balloon is to advance the catheter to ensure that it is actually in the bladder.

If this does not work, cut the balloon port proximal to the inflation valve. This removes the valve and should allow the water to spontaneously drain.

If this does not work, run a lubricated fine-gauge guidewire through the inflation channel. The guidewire or stylet should allow fluid to drain along the wire itself.

If this does not work, a 22-gauge central venous catheter can be passed over the guidewire. When the catheter tip is in the balloon, the wire can be removed, and the balloon should drain.

If the above techniques are unsuccessful, 10 mL of mineral oil may be injected through the inflation port and will dissolve the balloon within 15 minutes. If this does not occur, an additional 10 mL can be instilled.

If none of the above techniques are successful, a urologist should be consulted to rupture the Foley balloon with a sharp instrument.[12]

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Post-Procedure

Complications

Complications include the following:

Noninfectious complications of short- and long-term catheterization include accidental removal, catheter blockage, gross hematuria, and urine leakage, and these are at least as common as clinically significant urinary tract infections in this patient population.[15]

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Contributor Information and Disclosures
Author

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Additional Contributors

Andrew K Chang, MD Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center

Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The author and editors of Medscape Reference would like to thank Steven Rogers, RN, for his help in videography.

The author and editors of Medscape Reference also gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

References
  1. Thomsen TW, Setnik GS. Videos in clinical medicine. Male urethral catheterization. N Engl J Med. 2006 May 25. 354(21):e22. [Medline]. [Full Text].

  2. Hadfield-Law L. Male catheterization. Accid Emerg Nurs. 2001 Oct. 9(4):257-63. [Medline].

  3. Selius BA, Subedi R. Urinary retention in adults: diagnosis and initial management. Am Fam Physician. 2008 Mar 1. 77(5):643-50. [Medline].

  4. Newman DK. The indwelling urinary catheter: principles for best practice. J Wound Ostomy Continence Nurs. 2007 Nov-Dec. 34(6):655-61; quiz 662-3. [Medline].

  5. Gerard LL, Cooper CS, Duethman KS, Gordley BM, Kleiber CM. Effectiveness of lidocaine lubricant for discomfort during pediatric urethral catheterization. J Urol. 2003 Aug. 170(2 Pt 1):564-7. [Medline].

  6. Siderias J, Guadio F, Singer AJ. Comparison of topical anesthetics and lubricants prior to urethral catheterization in males: a randomized controlled trial. Acad Emerg Med. 2004 Jun. 11(6):703-6. [Medline].

  7. Schumm K, Lam TB. Types of urethral catheters for management of short-term voiding problems in hospitalised adults. Cochrane Database Syst Rev. 2008 Apr 16. CD004013. [Medline].

  8. Kiddoo D, Sawatzky B, Bascu CD, Dharamsi N, Afshar K, Moore KN. Randomized Crossover Trial of Single Use Hydrophilic Coated vs Multiple Use Polyvinylchloride Catheters for Intermittent Catheterization to Determine Incidence of Urinary Infection. J Urol. 2015 Jul. 194 (1):174-9. [Medline].

  9. Lam TB, Omar MI, Fisher E, Gillies K, MacLennan S. Types of indwelling urethral catheters for short-term catheterisation in hospitalised adults. Cochrane Database Syst Rev. 2014 Sep 23. 9:CD004013. [Medline].

  10. Daneshgari F, Krugman M, Bahn A, Lee RS. Evidence-based multidisciplinary practice: improving the safety and standards of male bladder catheterization. Medsurg Nurs. 2002 Oct. 11(5):236-41, 246. [Medline].

  11. Cockett AT, Cockett WS. Case against the catheter: Emile Coudé. Urology. 1978 Nov. 12(5):619-20. [Medline].

  12. Shapiro AJ, Soderdahl DW, Stack RS, North JH Jr. Managing the nondeflating urethral catheter. J Am Board Fam Pract. 2000 Mar-Apr. 13(2):116-9. [Medline].

  13. Wyndaele JJ. Complications of intermittent catheterization: their prevention and treatment. Spinal Cord. 2002 Oct. 40(10):536-41. [Medline].

  14. Hart S. Urinary catheterisation. Nurs Stand. 2008 Mar 12-18. 22(27):44-8. [Medline].

  15. Hollingsworth JM, Rogers MA, Krein SL, et al. Determining the noninfectious complications of indwelling urethral catheters: a systematic review and meta-analysis. Ann Intern Med. 2013 Sep 17. 159(6):401-10. [Medline].

 
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Urethral catheter balloon volume indicator.
Commercial urinary catheterization kit.
Urethral catheter types: 1) Straight tip; 2) Coude tip; 3) 3-way catheter irrigation.
Urethral catheter types: 1) Straight tip; 2) Coude tip; 3) 3-way catheter irrigation.
Preparatory solution in a commercial urinary catheterization kit.
Retraction of foreskin.
Urethral preparation.
Urethral analgesia.
Foley lubrication.
Urethral catheterization.
Urine return.
Cuff inflation.
Securing the catheter.
Male urethra and its segments.
 
 
 
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