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eMedicine Specialties > Clinical Procedures > Genitourinary Procedures

Urethral Catheterization, Men

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT

Updated: Aug 10, 2008

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, Women.

For more information on urinary retention, see the Medscape CME activity Management of Urinary Retention Reviewed.

Indications

  • Diagnostic
    • Collection of uncontaminated urine specimen
    • Monitoring of urine output
    • Imaging of the urinary tract
  • Therapeutic2
    • Acute urinary retention (eg, benign prostatic hypertrophy, blood clots)3  
    • Chronic obstruction that causes hydronephrosis4  
    • 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 concerning trauma, a retrograde urethrogram should be performed to rule out a ureteral 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. See Technique for details. For more information, see Anesthesia, Topical.

Equipment

  • Commercial single-use urethral catheterization tray

    Commercial urinary catheterization kit.

    Commercial urinary catheterization kit.


    • Povidone iodine
    • Sterile cotton balls
    • Water-soluble lubrication gel
    • Sterile drapes
    • Sterile gloves
    • Urethral catheter7 (see Catheter Types and Sizes below)
    • Prefilled 10-mL saline syringe
    • Urinometer connected to a collection bag
  • Sterile anesthetic lubricant (eg, lidocaine gel 2%) with a blunt tip urethral applicator or a plastic syringe (5-10 mL)

Positioning

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

Technique

  • 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.

    Preparatory solution in a commercial urinary cath...

    Preparatory solution in a commercial urinary catheterization kit.


  • Wear 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.

    Retraction of foreskin.

    Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109402.flv.


  • 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.

    Urethral preparation.

    Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109403.flv.


  • 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.

    Urethral analgesia.

    Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109405.flv.


  • 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.

    Foley lubrication.

    Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109407.flv.


  • While holding the penis at approximately 90 º 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

    Urethral catheterization.

    Presentation available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109408.flv.


  • 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).

    Urine return.

    Presentation available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109409.flv.


  • 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.

    Cuff inflation.

    Presentation available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109410.flv.


  • 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.

    Securing the catheter.

    Presentation available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109411.flv.


Pearls

  • Insertion of a Coudé catheter9 : The Coudé catheter, which has a stiffer and pointed tip, was designed to overcome urethral obstruction that a more flexible catheter cannot negotiate (eg, 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.
  • Prophylactic antibiotics are recommended for patients with prosthetic heart valves, artificial urethral sphincters, or penile implants.

Complications

  • Infections10,11
    • Urethritis
    • Cystitis
    • Pyelonephritis
    • Transient bacteremia
  • Paraphimosis, caused by failure to reduce the foreskin after catheterization
  • Creation of false passages
  • Urethral strictures
  • Urethral perforation
  • Bleeding

Catheter Types and Sizes

  • Adults: Foley (16-18 F)
  • Adults with obstruction at the prostate: Coudé (18 F)
  • Children: Foley (5-12 F)
  • Infants younger than 6 months: Feeding tube (5 F) with tape

Multimedia

Commercial urinary catheterization kit.

Media file 1: Commercial urinary catheterization kit.

Preparatory solution in a commercial urinary cath...

Media file 2: Preparatory solution in a commercial urinary catheterization kit.

Media file 3: Retraction of foreskin.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109402.flv.

Media file 4: Urethral preparation.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109403.flv.

Media file 5: Urethral analgesia.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109405.flv.

Media file 6: Foley lubrication.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109407.flv.

Media file 7: Urethral catheterization.

Presentation available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109408.flv.

Media file 8: Urine return.

Presentation available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109409.flv.

Media file 9: Cuff inflation.

Presentation available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109410.flv.

Media file 10: Securing the catheter.

Presentation available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79934-80716-109411.flv.

References

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

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

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

  4. Newman DK. The indwelling urinary catheter: principles for best practice. J Wound Ostomy Continence Nurs. Nov-Dec 2007;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. Aug 2003;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. Jun 2004;11(6):703-6. [Medline].

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

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

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

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

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

  12. Reichman E, Simon RR. Emergency Medicine Procedures. McGraw Hill; 2004.

Keywords

foley, urethral catheter, urinary catheter, urethral catheterization, catheter placement, catheter insertion, Coudé catheter, Coudé, foley catheter, urine specimen, urine output, urinary tract, urethral tear

Contributor Information and Disclosures

Author

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

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, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; 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, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

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, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

Acknowledgments

The author would like to thank Steven Rogers, RN, for his help in videography.

The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

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