Urethral Catheterization in Men 

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.

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).

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] :

• Acute urinary retention (eg, benign prostatic hypertrophy, blood clots)^[3]
• Chronic obstruction that causes hydronephrosis^[4]
• Initiation of continuous bladder irrigation
• Intermittent decompression for neurogenic bladder
• Hygienic care of bedridden patients

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]

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 Anesthesia, Topical.

Equipment

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

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] (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 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 tapeUrethral 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.

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.

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.)

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.

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 video below.)

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 video below.)

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 video below.)

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.^[8] (See video below.)

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.)

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.)

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.)

Insertion of a Coudé Catheter

The Coudé catheter,^[9] 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.^[10]

Complications

Complications include the following:

• Infections^{[11, 12]} , including urethritis, cystitis, pyelonephritis, and transient bacteremia
• Paraphimosis, caused by failure to reduce the foreskin after catheterization
• Creation of false passages
• Urethral strictures
• Urethral perforation
• Bleeding