Urinary catheterization

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In medicine, urinary catheterization is "employment or passage of a catheter into the urinary bladder (urethral catheterization) or kidney (ureteral catheterization) for therapeutic or diagnostic purposes.[1] It is performed using sterile technique, and only when necessary since it carries a risk of infection.

Integrity of the urethra must be verified before starting the procedure.

Basic procedures

The most commonly used type is called transurethral, which is threaded into the urethra. Another type usable in men is the "condom type", which carries a much lower accident and infection rate.

Neither of the preceding methods breaks the skin. A third method, which does require minor surgery, is a suprapubic catheter, which may be inserted during cystotomy; a similar technique during nephrostomy inserts a catheter in the kidney. While it must be performed by a physician, it offers the potential of reducing the time for muscles to recover after bladder surgery. It may be the only way to catheterize a patient if there are obstructions in the urethra.

Both transurethral and suprapublic catheterization usually use a catheter of the Foley type, which has an inflatable balloon at its tip, a balloon surrounding the hole through which urine flows. The balloon is inflated with saline solution and keeps the catheter from sliding out.

If the need is purely for an uncontaminated urinary specimen, an alternative is syringe aspiration of the bladder. Preferably, this should be guided by bedside ultrasonography. [2]

Transurethral catheter insertion

Obviously, the anatomical differences between men and women require variations in the insertion procedure, but there are common principles:[3]

  • Wash and disinfect the external genitalia
  • Inspect the catheter tip for any cracks or irregularities that might damage sensitive membranes. Lubricate it thoroughly with sterile lubricant.
  • Test-fill the balloon with saline, then deflate it.
  • Position the patient so the meatus (the opening to the urethra) and the urethra are in as straight a line as possible.
  • Be gentle. Constantly reassure the patient. Ask the patient to "bear down" to relax the sphincter muscle; coughing may hep.
  • Do not inflate the balloon, which holds the catheter in place internally, until urine flow has been verified. A lack of flow may indicate improper positioning or patient-specific blockages.

Complications

Urinary tract infection

For more information, see: Urinary tract infection.

Preventing cross infection (nosocomial infection) of the urinary tract is a national priority in the United States.[4][5] Regarding short-term catheterization:

Regarding long-term catheterization and prevention of urinary tract infections:

Removal of urinary catheters

For more information, see: urinary retention.

Retained volumes of more than 900 ml indicated reduced chance of successful removal of the catheter.[14] One protocol only inserts a urinary catheter for post-operative retention if the bladder is estimated to contain 500 ml or more of urine estimated by bladder scanning.[15]

Selected randomized controlled trials of adrenergic alpha-antagonists prior to removal of a catheter for acute urinary retention in men.[16][17][18][19]
Trial Adrenergic alpha-antagonist Outcome Result Conclusion
Alpha blocker Placebo
McNeil[16]
1999		 Alfuzosin 5 mg twice daily for 48 hours
(Alfuzosin half life is 10 hours)		 Satisfactory voiding 55% 29% Benefit, but no statistical significance
Lucas[17]
2005		 Tamsulosin 0.4 mg once daily for ≤ 8 days Re-catheterization 48% 26% Benefit
McNeil (Alfaur trial)[18]
2005		 Alfuzosin 10 mg once daily for 3 days Satisfactory voiding 62% 48% Benefit
Tibung (unpublished)
2006		 Alfuzosin 10 mg once daily for 2 days 58% 35% Benefit, but no statistical significance
Shah[19]
2005		 Alfuzosin 5 mg twice daily for 36 hours and then again for 2 weeks
(Alfuzosin half life is 10 hours)		 Void with less than 200 ml residual 50% 57% No benefit

Adrenergic alpha-antagonists might be effective (residual volume of <200 ml after removal of catheter) according to a systematic review by the Cochrane Collaboration.[20] This review found four trials of alfuzosin (10 mg once daily or 5 mg twice daily)[18] and one of tamsulosin (0.4 mg once daily)[17]. The adrenergic alpha-antagonists were started 24 to 72 hours before trial without a catheter (TWOC) in 4 trials and 8 days prior in one trial.

Removing the catheter at midnight might be the most effective determinant according to a systematic review of 11 randomized controlled trials, including one of nonsurgical patients[21], by the Cochrane Collaboration.[22] The benefit is mainly for postsurgical patients; however, in the one trial of nonsurgical patients, the catheter was removed at the wrong time in 20% of patients.[21]

Using intermittent catheterization for postoperative patients was "associated with a lower risk of bacteriuria than indwelling urethral catheterization, but might be more costly...limits catheterization to those people who definitely need it" according to a systematic review of three postoperative randomized controlled trials by the Cochrane Collaboration.[10][15]

Regarding how long to wait until a voiding without catheter trial, "a tendency for later removal to be associated with fewer short-term voiding problems, but increasing risk of urinary tract infection, more dissatisfaction and longer hospital stay" according to a systematic review of thirteen randomized controlled trials, including one trial of non-surgical patients[14], by the Cochrane Collaboration.[22]

Intermittent clamping of catheters is of uncertain benefit.[23][22] This consists of two cycles of clamping the tube for two hours and releasing it for five minutes, to help restore bladder muscle tone. Since the act of removal often stimulates a strong urge to void, the patient should be given a bedpan or urinal before starting to remove the catheter. [24]

References

  1. ↑ Anonymous (2024), Urinary catheterization (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Adam J Rosh (9 April 2009), "Suprapubic Aspiration", eMedicine
  3. ↑ Manual of Critical Care Procedures, Springhouse Corporation, 1994, ISBN 0874346916, pp. 415-426
  4. ↑ Anonymous (2009). HHS Action Plan to Prevent Healthcare-Associated Infections: Executive Summary. U.S. Department of Health & Human Services. Retrieved on 2009-01-07.
  5. ↑ Anonymous (2009). HHS Action Plan to Prevent Healthcare-Associated Infections: Prevention – Prioritized Recommendations. U.S. Department of Health & Human Services. Retrieved on 2009-01-07.
  6. ↑ Schumm K, Lam TB (2008). "Types of urethral catheters for management of short-term voiding problems in hospitalized adults: a short version Cochrane review". Neurourology and urodynamics 27 (8): 738–46; discussion 747–8. DOI:10.1002/nau.20645. PMID 18951451. Research Blogging.
  7. ↑ Schumm K, Lam TB (2008). "Types of urethral catheters for management of short-term voiding problems in hospitalised adults.". Cochrane Database Syst Rev (2): CD004013. DOI:10.1002/14651858.CD004013.pub3. PMID 18425896. Research Blogging.
  8. ↑ Niël-Weise BS, van den Broek PJ (2005). "Antibiotic policies for short-term catheter bladder drainage in adults.". Cochrane Database Syst Rev (3): CD005428. DOI:10.1002/14651858.CD005428. PMID 16034973. Research Blogging.
  9. ↑ Saint S, Kaufman SR, Rogers MA, Baker PD, Ossenkop K, Lipsky BA (July 2006). "Condom versus indwelling urinary catheters: a randomized trial". Journal of the American Geriatrics Society 54 (7): 1055–61. DOI:10.1111/j.1532-5415.2006.00785.x. PMID 16866675. Research Blogging.
  10. ↑ 10.0 10.1 Niël-Weise BS, van den Broek PJ (2005). "Urinary catheter policies for short-term bladder drainage in adults". Cochrane Database Syst Rev (3): CD004203. DOI:10.1002/14651858.CD004203.pub2. PMID 16034924. Research Blogging.
  11. ↑ Jahn P, Preuss M, Kernig A, Seifert-Hühmer A, Langer G (2007). "Types of indwelling urinary catheters for long-term bladder drainage in adults". Cochrane database of systematic reviews (Online) (3): CD004997. DOI:10.1002/14651858.CD004997.pub2. PMID 17636782. Research Blogging.
  12. ↑ Hagen S, Sinclair L, Cross S (2010). "Washout policies in long-term indwelling urinary catheterisation in adults.". Cochrane Database Syst Rev 3: CD004012. DOI:10.1002/14651858.CD004012.pub4. PMID 20238325. Research Blogging.
  13. ↑ Moore KN, Fader M, Getliffe K (2007). "Long-term bladder management by intermittent catheterisation in adults and children". Cochrane database of systematic reviews (Online) (4): CD006008. DOI:10.1002/14651858.CD006008.pub2. PMID 17943874. Research Blogging.
  14. ↑ 14.0 14.1 Taube M, Gajraj H (February 1989). "Trial without catheter following acute retention of urine". Br J Urol 63 (2): 180–2. DOI:10.1111/j.1464-410X.1989.tb05160.x. PMID 2641206. Research Blogging.
  15. ↑ 15.0 15.1 Lau H, Lam B (2004). "Management of postoperative urinary retention: a randomized trial of in-out versus overnight catheterization.". ANZ J Surg 74 (8): 658-61. DOI:10.1111/j.1445-1433.2004.03116.x. PMID 15315566. Research Blogging.
  16. ↑ 16.0 16.1 McNeill SA, Daruwala PD, Mitchell ID, Shearer MG, Hargreave TB (1999). "Sustained-release alfuzosin and trial without catheter after acute urinary retention: a prospective, placebo-controlled.". BJU Int 84 (6): 622-7. PMID 10510105.
  17. ↑ 17.0 17.1 17.2 Lucas MG, Stephenson TP, Nargund V (2005). "Tamsulosin in the management of patients in acute urinary retention from benign prostatic hyperplasia.". BJU Int 95 (3): 354-7. DOI:10.1111/j.1464-410X.2005.05299.x. PMID 15679793. Research Blogging.
  18. ↑ 18.0 18.1 18.2 McNeill SA, Hargreave TB, Roehrborn CG, Alfaur study group (2005). "Alfuzosin 10 mg once daily in the management of acute urinary retention: results of a double-blind placebo-controlled study.". Urology 65 (1): 83-9; discussion 89-90. DOI:10.1016/j.urology.2004.07.042. PMID 15667868. Research Blogging.
  19. ↑ 19.0 19.1 Shah T, Palit V, Biyani S, Elmasry Y, Puri R, Flannigan GM (2002). "Randomised, placebo controlled, double blind study of alfuzosin SR in patients undergoing trial without catheter following acute urinary retention.". Eur Urol 42 (4): 329-32; discussion 332. PMID 12361896.
  20. ↑ Zeif HJ, Subramonian K (2009). "Alpha blockers prior to removal of a catheter for acute urinary retention in adult men.". Cochrane Database Syst Rev (4): CD006744. DOI:10.1002/14651858.CD006744.pub2. PMID 19821385. Research Blogging.
  21. ↑ 21.0 21.1 Webster J, Osborne S, Woollett K, Shearer J, Courtney M, Anderson D (2006 Mar-Apr). "Does evening removal of urinary catheters shorten hospital stay among general hospital patients? A randomized controlled trial.". J Wound Ostomy Continence Nurs 33 (2): 156-63. PMID 16572016.
  22. ↑ 22.0 22.1 22.2 Griffiths R, Fernandez R (2007). "Strategies for the removal of short-term indwelling urethral catheters in adults". Cochrane Database Syst Rev (2): CD004011. DOI:10.1002/14651858.CD004011.pub3. PMID 17443536. Research Blogging.
  23. ↑ Fernandez RS, Griffiths RD (2005). "Clamping short-term indwelling catheters: a systematic review of the evidence". J Wound Ostomy Continence Nurs 32 (5): 329–36. PMID 16234728. [e]
  24. ↑ Bass LS et al. (1994), Manual of Critical Care Procedures, Springhouse, ISBN 0-87434-691-6, p. 425

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