Urethral Catheterization in Women

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 in patients with chronic urinary retention.

Patients of all ages may require urethral catheterization, but those who are elderly or chronically ill are more likely to require indwelling catheters, which carry their own independent risks.[2] The basic principles underlying urethral catheterization are gender-neutral (see Urethral Catheterization in Men), but certain aspects of the procedure require particular attention in the female urethra.

Relevant Anatomy

The developed female urethra is a 4-cm tubular structure that begins at the bladder neck and terminates at the vaginal vestibule (see the image below). It is a richly vascular spongy cylinder and is designed to provide continence.

The female urethra is suspended by the urethropelvic ligament with its 2 sides (the abdominal side being the endopelvic fascia and the vaginal side being the periurethral fascia). The female urethra pierces the pelvic diaphragm and the perineal membrane just posterior to the pubic symphysis. Distally, it exhibits more genital characteristics, becoming rich in glands and developing a squamous epithelium.

For more information about the relevant anatomy, see Female Urethra Anatomy. See also Female Urinary Organ Anatomy and Bladder Anatomy.

Diagnostic indications for urethral catheterization in women include the following:

• Collection of an uncontaminated urine specimen

• Monitoring of urine output

• Imaging of the urinary tract

Therapeutic indications include the following:

• Acute urinary retention[3] (eg, blood clots)

• Chronic obstruction that causes hydronephrosis[4]

• Initiation of continuous bladder irrigation

• Intermittent decompression for neurogenic bladder

• Hygienic care of bedridden patients

Traumatic injury to the lower urinary tract (eg, urethral tearing) is a contraindication for urethral catheterization in women.

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, whereas intraperitoneal urinary bladder injuries usually call for operative repair.

A larger than standard catheter should be used when the indication for placement is continuous bladder irrigation for 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.

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

Consider suprapubic catheterization if vaginal hygiene is impaired.

 

A typical commercial single-use urethral catheterization tray (see the first, second, and third images below) includes the following:

• Preparatory solution (eg, povidone-iodine or chlorhexidine)

• Sterile cotton balls

• Water-soluble lubrication gel

• Sterile drapes

• Sterile gloves

• Urethral catheter

• Prefilled saline syringe, 10 mL

• Urinometer connected to a collection bag (see the fourth image below)

  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 urine collection bag. Image courtesy of Michel Rivlin, MD, and G Rodney Meeks, MD.

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

Catheter sizes are as follows:

• Adults - Foley catheter (16-18 French)

• Children - Foley catheter (5-12 French)

• Infants younger than 6 months - Feeding tube (5 French) with tape

• Adults with gross hematuria - Catheter (20-24 French)

Catheter types are as follows[5] :

• Latex

• Silastic (pure silicone or silicone-coated)

• Silver alloy

• Antibiotic-impregnated

The steps in the procedure, along with its benefits, risks, complications, and alternatives, must be explained to the patient or the patient’s representative.

Topical anesthesia is provided with 2% lidocaine gel. This and other viscous water-based lubricants facilitate the insertion of urethral catheters. Lidocaine gel has the added benefit of providing urethral anesthesia.[6, 7] When topical anesthesia is being used, the tip of the gel applicator should be inserted into the meatus and the gel pushed into the urethra before the Foley catheter is inserted.

The patient should be supine, in the frog-leg position, with knees flexed and genitalia uncovered.

The timing of long-term indwelling urinary catheter changes should be individualized. Indications for changing the catheter include obstruction (eg, 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 catheters do but are cheaper than nonlatex catheters.[8]

With the patient in position, open the catheter tray and place it on the gurney between the patient’s legs; use the sterile package as an extended sterile field. Open the preparatory solution, and pour it onto the sterile cotton balls (see the image below). Open a sterile 2% lidocaine lubricant with an applicator or a 10-mL syringe, and place these materials on the sterile field.

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.

With the sterile hand and a sterile forceps, apply preparatory solution to the urethra and the surrounding vulva in circular motions, using 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.[9] The decision to anesthetize the urethra should be made in conjunction with the patient. If the urethra is to be anesthetized, use the commercial applicator or a syringe with no needle to instill 5 mL of 2% lidocaine gel 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. Remove the cover to expose the tip (see the image below). Apply a generous amount of either a nonanesthetic lubricant or the remaining lidocaine gel.

Slowly and gently introduce the catheter into the urethra. Continue to advance the catheter either to a point several centimeters beyond where urine is first obtained or until the proximal Y-shaped ports are at the meatus (see the video below).

To confirm that the distal end of the catheter is in the bladder, wait for urine to drain from the larger port. 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 the catheter inside 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 Foley catheter’s balloon should be aborted if the patient reports any pain as a result of the inflation; a painful inflation is probably taking place in the urethra rather than in the bladder. Inflation of the balloon inside the urethra results in severe pain, gross hematuria, and, possibly, urethral tearing.

Gently withdraw the catheter from the urethra until resistance is met. Secure the catheter to the patient’s thigh with a wide tape (see the video below). Creating a gutter with tape to elevate the catheter from the thigh may enhance the patient’s comfort.

Complications of urethral catheterization in women may include the following:

• Infections,[10, 11] including urethritis, cystitis, pyelonephritis, and transient bacteremia

• Creation of false passages

• Urethral strictures

• Urethral perforation

• Bleeding

• Altered micturition[12]

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.[13]  In patients who have subclinical bacteriuria, the catheter can become obstructed as a result of sediment buildup.[14]

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Class Summary

The use of a urethral anesthetic in female patients is controversial. The decision to anesthetize the urethra should be made in conjunction with the patient. Local anesthetics block the initiation and conduction of nerve impulses.Anesthetics used for the urethra include lidocaine.

Lidocaine (Xylocaine)

Lidocaine inhibits depolarization of type C sensory neurons by blocking sodium channels. Use the commercial applicator or a syringe with no needle to instill 5 mL of 2% lidocaine gel 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. Remove the cover to expose the tip. Apply a generous amount of either a nonanesthetic lubricant or the remaining lidocaine gel.