In the name of god

Principle Of Urethral Catheterization Dr. A Jabbari (MD) Tabriz university of medical science Urology department

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The word "katheter" came from "kathiemai — καθίεμαι" meaning "to sit" The word "katheter" came from "kathiemai — καθίεμαι" meaning "to sit". The ancient Greeks inserted a hollow metal tube through the urethra into the bladder to empty it and the tube came to be known as a "katheter".

Historical Background One of the earliest descriptions of a urinary catheter can be found in the Hippocratic text On Diseases (400 BC), in which bladder drainage was considered a basic skill in the armamentarium of Greek physicians

In Avicenna’s Canon of Medicine, mention is also made of urethral catheterization as a means to deliver intravesical therapy.

Indications The most common indications for the use of a bladder catheter can be broadly divided into two main categories: To allow the instillation of diagnostic or therapeutic agents To obtain drainage of bladder

Other indications.. To allow healing after lower urinary tract surgery/trauma To evacuate the bladder when the urine contains particulate matter, especially in combination with simultaneous irrigation (post transurethral resection, clot/purulent material evacuation)

The collection of microbiologic clean urine (uncooperative patients because of age or mental status or comorbidities that prevent voluntary voiding) To provide access to the bladder for urinary tract imaging studies such as cystography To allow instillation of pharmacologic agents for local therapy of some bladder pathologies

Catheter Selection The size and type of urinary catheter used depends on the indication for catheter insertion, age of the patient, and type of fluid expected to be drained

Catheter size Catheter size is measured in the French scale, whereby one Fr is equal to 0.33 mm As a general rule, catheter size should be the smallest size that can accomplish the desired drainage

Age in year Catheter size in Fr <5 5-8 5-10 8-10 10-14 10 >14

Material Modern urinary catheters are most frequently made of latex, rubber, silicone, and polyvinylchloride (PVC) Rubber and latex catheters are often chosen for short-term drainage. Silicone catheters are indicated for patients requiring a longer period of indwelling time Evidence suggests that the use of silicone catheters is associated with a lower incidence of urinary tract infections compared with those made of latex.

Number of Channels The most basic catheters are constructed with a single lumen to permit urinary drainage or irrigation/instillation. Additional lumens are added to permit addition of a retention balloon (two way ) and for simultaneous drainage and irrigation (three way )

Tip Shape

Straight without retainig mechanism One-time drainage, instillation or irrigation in children, females, and most males Robinson Nelaton Jaques

Straight with balloon Foley: continuous drainage or irrigation in children, females, and most males Madduri: used for urethrography, allows proximal and distal occlusion and contrast instillation in the intermediate section

Straight with 2 or 4 wings Malecot: continuous drainage or irrigation in children, females, and most males

Straight with umbrella Pezzer: continuous drainage or irrigation in children, females, and most males

Malecot vs Pezzer

Curved with balloon Coudé: continuous drainage or irrigation Ease of insertion males with enlarged prostate midlobe or high bladder neck

End hole catheters Councill: continuous drainage or irrigation in children, females, and most males (end hole permits insertion or exchange over a previously placed guidewire)

End hole catheter Whistle tip: has a large diameter end hole occupying half of its beveled tip ( for increased drainage/instillation capacity)

Technique of Catheter Insertion The patient should be in the supine position at a comfortable height for the physician performing catheterization In female patients a “frog-leg” position is most suitable, and the use of stirrups can be considered, especially in the obese Catheterization should be carried out in a sterile fashion with antiseptic preparation and draping of the patient’s meatal and genital area

If topical anesthesia is to be used,evidence suggests it requires a minimum of 10 minutes of exposure of low temperature(< 4° C) anesthetic gel(depending on the agent), sufficient volume of the agent (20 to 30 mL), and slow instillation time (>3 to 10 seconds) to have the most effect.

Catheterization in male Patients

After sterile skin preparation and draping, grasp the shaft of the penis with the nondominant hand (which is now regarded as contaminated) and hold the penis at a 90-degree angle or perpendicular to the patient. Insert the lubricated tip of the catheter into the urethral meatus and gently but firmly continue to advance the catheter for 7 to 10 cm, while simultaneously bringing the shaft of the penis to the horizontal plane or parallel to the patient

Once the entire length of the catheter has been introduced (up to the juncture of the connector or to the two-way bifurcation),wait for spontaneous urine passage, confirming proper placement of the catheter If spontaneous drainage of urine is not seen, gently press on the patient’s suprapubic area If despite this maneuver no drainage occurs, slowly instill 20 mL of saline using a catheter-tipped syringe into the drainage port of the catheter and then slowly aspirate the fluid instilled

Only when the position of the catheter has been verified should the retaining balloon be inflated Sterile water is the preferred solution for balloon inflation. Air is compressible and might leak, and electrolyte or glucose-based solutions can precipitate and occlude the tubing and valve mechanism

The catheter should be attached to a sterile closed bag system as soon as urine is draining The drainage bag should be placed below the level of the bladder to encourage one-way gravity flow with the tubing as straight as possible and avoiding kinks that might impair drainage.

ex vacuo hematuria In patients with acute urinary retention with significant bladder distension ,bladder drainage might precipitate decompression-induced hematuria. In these patients the catheter should be intermittently clamped and released to permit gradual bladder decompression over 30 to 60 minutes

Catheterization in female Patients

After antiseptic preparation and sterile draping, use the nondominant hand to spread the patient’s labia (now considered contaminated) to reveal the urethral meatus After lubrication,insert the tip of the catheter and gently advance using a slightly downward direction, until about half the length of the catheter has been inserted

In the obese patient, the use of one or more assistants to provide labial retraction or the use of stirrups can be helpful

postmenopausal vaginal atrophy or conditions resulting in the urethral meatus receding into the introitus: Holding the index and middle fingers of the nondominant hand together, slowly slide posterior along the introitus until the urethral meatus is palpated and then proceed to slide the fingers just distal to the inferior margin of the meatus. Using the dominant hand, pass the catheter along the groove made by the fingers

A second maneuver is to use a vaginal speculum to aid in the retraction and fixation of the introitus. Finally use a coudé tip catheter angled upward and gently slide the tip along the anterior vaginal wall in the midline, until it enters the meatus, and then advance into the bladder.

Special Considerations in Children Whenever possible the procedure should be explained in clear and age-appropriate language to the child

In female children the correct identification of the urethral meatus is essential to avoid unnecessary catheter contact with the sensitive introitus, leading to discomfort and possibly loss of cooperation by the child. The meatus is just above the superior margin of the introitus and frequently hidden by the superior portion of the hymen. Gentle downward pressure on the upper aspect of the hymen with a cotton ball may allow visualization of the meatus. Failing this maneuver, the catheter tip should be inserted just above the hymen in the midline

In uncircumcised boys, retract the foreskin only until the meatus is visible. In infants and children younger than 3 years of age, when the normal foreskin adhesions have not yet involuted, simply align the preputial opening with the meatus to assist catheter insertion.

Difficult Catheterization Difficulty inserting a catheter into the bladder is most commonly due to prostatic growth, urethral stricture(s), bladder neck contracture, or false passage from previous urethral instrumentation

After the catheter has been inserted using aseptic technique, it should immediately be connected to the sterile bag, because an aseptic closed drainage system minimizes the risk of catheter- associated urinary tract infections

Complications of Urethral Catheterization UTIs account for 40% of all nosocomial infections Inability to remove the catheter from the bladder Hematuria Urethral and meatal strictures Urethral perforation Allergic reactions Malignant neoplasms Stone formation Bladder neck and urethral erosions

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