Urethral Catheterization in Women 

  • Author: Gil Z Shlamovitz, MD; Chief Editor: Edward David Kim, MD, FACS   more...
 
Updated: Apr 22, 2011
 

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 (as during surgery), or left indwelling for long-term drainage for patients with chronic urinary retention. The procedure is depicted in the video below.

Urinary catheterization. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD.

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 female catheterization are described in this article.

For a procedural description for male patients, see Urethral Catheterization in Men.

Key Considerations

Use a larger-size catheter when the indication for placement is continuous bladder irrigation due to hematuria and clots. A 3-way catheter (with an additional port) is often used in conjunction with a large-volume reservoir to create a "Murphy drip" for continuous irrigation.

Ultrasonography may be used to verify the presence of the catheter inside the bladder if urine is not returned upon placement.

Prophylactic antibiotics are recommended for patients with a prosthetic heart valve or an artificial urethral sphincter.

Lidocaine gel and other viscous water-based lubricants facilitate the insertion of urethral catheters. Lidocaine gel has an added benefit of providing urethral anesthesia.[2, 3] The tip of the gel applicator should be inserted into the meatus and the gel pushed into the urethra prior to Foley insertion when topical anesthesia is being used.

Inflation of the Foley catheter's balloon should be aborted if the patient reports any pain as a result of the inflation, as such an inflation is likely taking place in the urethra and not the bladder. Inflation of the balloon inside the urethra results in severe pain, gross hematuria, and, possibly, urethral tear.

Timing of long-term indwelling urinary catheter changes should be individualized. Indications for changing the catheter include obstruction (by encrustation or mucus), symptomatic infection, or leakage around the catheter. Latex catheters are prone to encrustation and require more frequent changes than silicone or hydrogel-coated latex but are cheaper than nonlatex catheters.[4]

Consider suprapubic catheterization if vaginal hygiene is impaired.

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:

Contraindications

Traumatic injury to the lower urinary tract (eg, urethral tear) is a contraindication.

Suspected bladder injury is not a contraindication to placement of a urethral catheter. A urethral catheter allows drainage of urine from an injured urinary bladder and provides a route for contrast administration during cystoscopy. Extraperitoneal urinary bladder injuries are usually treated conservatively with an indwelling catheter, while intraperitoneal urinary bladder injuries usually require operative repair.

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Preparation

Anesthesia

Topical anesthesia is provided with lidocaine gel 2%. For application details, see Technique, below. For more information, see Anesthesia, Topical.

Equipment

Commercial single-use urethral catheterization tray includes the following (see the images below):

Commercial urinary catheterization kit. Commercial urinary catheterization kit. Preparatory solution in a commercial urinary cathePreparatory solution in a commercial urinary catheterization kit. Urinary catheterization kit. Image courtesy of MicUrinary catheterization kit. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD. Urinary catheterization supplies. Image courtesy oUrinary catheterization supplies. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD. Urinary catheter urine collection bag. Image courtUrinary catheter urine collection bag. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD.
  • Povidone-iodine solution (eg, Betadine)
  • Sterile cotton balls
  • Water-soluble lubrication gel
  • Sterile drapes
  • Sterile gloves
  • Urethral catheter
  • Prefilled saline syringe, 10 mL
  • Urinometer connected to a collection bag

Sterile anesthetic lubricant (eg, lidocaine gel 2%) with a blunt-tipped urethral applicator or a plastic syringe (5-10 mL) is indicated.

Catheter sizes are as follows:

  • Adults - Foley catheter (16-18F)
  • Children - Foley catheter (5-12F)
  • Infants younger than 6 months - Feeding tube (5F) with tape
  • Gross hematuria in adults - Catheter (20-24F)

Catheter types are as follows:

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

Positioning

The patient should be supine, in the frog leg 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 cathePreparatory solution in a commercial urinary catheterization kit.

Don the sterile gloves and use the nondominant hand to separate the labia with the thumb and index finger. This hand is now nonsterile and is used to expose the vulva throughout the procedure.

Use the sterile hand and sterile forceps to apply preparatory solution to the urethra and the surrounding vulva in circular motions with at least 3 different cotton balls. Without moving the nondominant hand, apply the sterile drapes that are provided with the urinary catheterization tray to create a sterile field around the vulva.

The use of a urethral anesthetic in female patients is controversial.[7] The decision to anesthetize the urethra should be made in conjunction with the patient. To anesthetize the urethra, use the commercial applicator or a syringe with no needle to instill 5 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 for the anesthetic to take effect before proceeding with the urethral catheterization.

Hold the catheter with the sterile hand or leave it in the sterile field to remove the cover. Apply a generous amount of a nonanesthetic lubricant or the remaining lidocaine gel. The catheter tip is shown in the image below.

Urinary catheter tip. Image courtesy of Michel RivUrinary catheter tip. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD.

Slowly and gently introduce the catheter into the urethra. Continue to advance the catheter either several centimeters beyond where urine is first obtained or until the proximal Y-shaped ports are at the meatus. The procedure is shown in the video below.

Urinary catheterization. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD.

Wait for urine to drain from the larger port to ensure that the distal end of the catheter is in the bladder. 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. Ultrasonography may be used at this point to verify the presence of urine in the bladder.

After visualization of urine return, 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 will result in severe pain, gross hematuria, and, possibly, urethral tear.

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 with tape to elevate the catheter from the thigh may increase the patient's comfort. Taping the catheter is shown in the video below.

Taping of urinary catheter. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD.
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Post-Procedure

Complications

Complications include the following:

  • Infections[8, 9] , including urethritis, cystitis, pyelonephritis, and transient bacteremia
  • Creation of false passages
  • Urethral strictures
  • Urethral perforation
  • Bleeding
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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.

Specialty Editor Board

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.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

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, and 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, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association

Disclosure: Lilly Consulting fee Advisor; Astellas Consulting fee Speaking and teaching; Watson Consulting fee Speaking and teaching; Allergan Consulting fee Speaking and teaching

References

  1. Ortega R, Ng L, Sekhar P, Song M. Videos in clinical medicine. Female urethral catheterization. N Engl J Med. Apr 3 2008;358(14):e15. [Medline].

  2. Doherty W. Instillagel: an anaesthetic antiseptic gel for use in catheterization. Br J Nurs. Jan 28-Feb 10 1999;8(2):109-12. [Medline].

  3. 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].

  4. Wong ES, Hooton TM. Guideline for Prevention of Catheter-associated Urinary Tract Infections. http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html. Centers for Disease Control and Prevention Web site. Available at http://www.cdc.gov. Accessed July 10, 2009.

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

  6. 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].

  7. Tanabe P, Steinmann R, Anderson J, Johnson D, Metcalf S, Ring-Hurn E. Factors affecting pain scores during female urethral catheterization. Acad Emerg Med. Jun 2004;11(6):699-702. [Medline].

  8. Kunin CM. Urinary-catheter-associated infections in the elderly. Int J Antimicrob Agents. Aug 2006;28 Suppl 1:S78-81. [Medline].

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

 
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Commercial urinary catheterization kit.
Preparatory solution in a commercial urinary catheterization kit.
Urinary catheterization kit. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD.
Urinary catheterization supplies. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD.
Urinary catheter tip. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD.
Urinary catheter urine collection bag. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD.
Urinary catheterization. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD.
Taping of urinary catheter. Image courtesy of Michel Rivlin, MD, and G. Rodney Meeks, MD.
 
 
 
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