Catheterization, Female

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Definition

Urinary catheterization is the insertion of a catheter through the urethra into the urinary bladder for withdrawal of urine. Straight catheters are used for intermittent withdrawals; indwelling (Foley) catheters are inserted and retained in the bladder for continuous drainage of urine into a closed system.

Purpose

Intermittent catheterization is used for the following reasons:• To obtain a sterile urine specimen for diagnostic evaluation; to empty bladder content when the patient is unable to void (urinate) due to urinary retention, bladder distention, and obstruction, or to measure residual urine after urination.

* To instill medication for a localized therapeutic effect and to instill contrast material (dye) into the bladder through the urethral catheter for cystourethralgraphy (x ray of the bladder and urethra).
* To empty the bladder for increased space in the pelvic cavity to protect the bladder during labor and delivery and during pelvic and abdominal surgery.
* To strictly monitor the urinary output and fluid balance of critically ill patients.

Indwelling catheterization is:

* Indicated as palliative care for terminally ill or severely impaired incontinent patients, for whom bed and clothing changes are uncomfortable, and as a way to manage skin ulceration caused or exacerbated by incontinence.
* Used to maintain a continuous out flow of urine for patients undergoing surgical procedures that cause a delay in bladder sensation, and for persons with chronic neurological disorders that cause paralysis or loss of sensation in the perineal area.
* Indicated for urologic surgery, bladder outlet obstruction, and for patients with an initial episode of acute urinary retention to allow the bladder to regain its tone.

Precautions

Because the urinary tract is normally a sterile system, catheterization presents the risk of causing a urinary tract infection (UTI). The catheterization procedure must be sterile and the catheter must be free from bacteria.

Urinary catheterization aids or replaces the body's normal ability to urinate. Intermittent use of the procedure can stimulate normal bladder function, however frequent and continuous catheterization can lead to total dependency. Catheterization is invasive and has the potential of injuring the urethra and bladder, inviting urinary tract infections. Therefore aseptic techniques should be use in all catheter management activities.

The normal flow of urine from the kidneys through the ureters, bladder, urethra prevents the movement of bacteria up through the urinary system. The antibacterial properties of the bladder wall, urethra lining, and low urine pH also serve as protective barriers to urinary tract infections. Urinary tract infections occur when bacteria invade the protective barriers of one or more urinary structures.
Infection control

Every attempt should be made to keep the urinary drainage system closed. Breaks in the system invite infections. Health care workers and patients should wash their hands before and after manipulation of the patient's catheter or collection system to control UTI. Cross-contamination is the most frequent cause of nosocomial (hospital acquired) catheter related infections. Good hand washing practices are the best prevention measure.

The extended portion of the catheter should be washed with a mild soap and warm water to keep it free of accumulated debris.

Frequent intermittent catheterization and long term use of indwelling catheterization predisposes the patient to UTI. Care should be taken to avoid trauma to the urinary meatus or urothelium (urinary lining) with catheters that are too large or inserted with insufficient use of lubricant. Patients with an indwelling catheter must be reassessed periodically to determine if alternative treatment will be more effective in treating the problem.
Description

The female urethral orifice is a vertical, slit-like or irregularly ovoid (egg shaped) opening, 4 or 5 mm in diameter, located between the clitoris and the vagina. The urinary meatus (opening) is concealed between the labia minora, which are the small folds of tissue that need to be separated in order to visualize the opening and insert the catheter. With proper positioning, good lighting and gloved hands, these anatomical landmarks can be identified. If necessary, provide perineal care to ensure a clean procedural environment.

Catheterization of the female patient is traditionally performed without the use of local anesthetic gel to facilitate catheter insertion. But since there are no lubricating glands in the female urethra (as found in the male urethra), the risk of trauma from a simple catheter insertion is more likely; therefore, ample supply of an anesthetic or antibacterial lubricant should be used.
Preparation

Health care practitioners performing the catheterization should have a good understanding of the anatomy and physiology of the urinary system, trained in antiseptic techniques and in catheter insertion and catheter care.

Determine the primary purpose for the catheterization and give the patient and/or caregiver a detail explanation. Patients requiring self-catheterization should be instructed and trained in the technique by a qualified health professional.

Sterile disposable catheterization sets are available in clinical settings and for home use. These sets contain most of the items needed for the procedure, such as antiseptic agent, perineal drapes, gloves, lubricant, specimen container, label, and tape. Anesthetic or antibacterial lubricant, catheter, and drainage system may need to be added. It is always wise to review the content of the pre-packaged catheterization set while assembling the materials.
Catheter choices

TYPES. Silastic catheters have been recommended for short-term catheterization after surgery because they are known to decrease incidence of urethritis. However, due to lower cost and acceptable outcomes, latex is the catheter of choice for long-term catheterization. Silastic catheters should be used for patients who are allergic to latex products.

There are also additional types of catheters:

* PTFE-coated latex Foley catheters
* hydrogel-coated latex Foley catheters
* pure silicone Foley catheters
* silicone-coated latex Foley catheter

SIZE. The diameter of the catheter is measured in millimeters. Authorities recommend the "narrowest and softest tube" that will serve the purpose. Rarely is a catheter larger than size 18 F required, and sizes 14 or 16 F are used more often. Catheters greater than size 16 F have been associated with patient discomfort and urine bypassing. A size 12 catheter has been successfully used in children and female patients with urinary restriction.

LENGTH. Female adult patients should be given the choice of a short, female length or a standard length catheter for urethral catheterization.

BALLOON SIZE. Select a catheter with a balloon-filling volume of 0.33 fl oz (10 ml) for routine drainage. Sterile water must always be used to inflate the balloon as other fluids may contain particles, which could block the inflation channel. Some indwelling catheters are manufactured pre-filled with 0.33 fl oz (10 ml) of sterile water, ready for balloon inflation after catheter insertion.

DRAINAGE SYSTEM. Review the design, capacity, and emptying mechanism of the variety of urine drainage bags with the patient. Select the system that is most adaptable to the patient's lifestyle and her ability to manage the device independently. For women with normal bladder sensation, a catheter valve for intermittent drainage may be an acceptable option.
Procedure

The standard technique for catheter insertion is:

* Explain the procedure to the patient, position the patient and ensure privacy and good lighting.
* Wash hands, remove outer tray wrapper and put on sterile gloves before opening the sterile inner packet. Prepare a sterile field and place a specimen collection vessel between the patient's legs.
* Cleanse the labia according to established guidelines and identify the urethral meatus. If an anesthetic lubricating gel is used, instill approximately 0.16 fl oz (5 ml) of 2% lignocaine hydrochloride gel into the urethra or apply the gel to the meatus to achieve surface anesthesia within three to five minutes.
* Hold the catheter in the dominant hand and gently insert it into the urethral meatus; pass it slowly through the urethra and into the bladder. If the catheter is accidentally inserted into the vagina or the tip is contaminated, discard it and take new sterile catheter before proceeding.
* Once the urine starts to flow, collect the specimen and pass the catheter an additional 2 inches (5 cm) to ensure that the balloon is in the bladder before slowly inflating the balloon with 10 ml sterile water.

Aftercare

Patients using intermittent catheterization to manage incontinence may require a period of adjustment as they try to establish a catheterization schedule that is adequate for their normal fluid intake.

Antibiotics should not be prescribed as a preventative measure for patients at risk for urinary tract infections. Prophylactic use of antibacterial agents may lead to the development of drug-resistant bacteria. Patients who practice intermittent self-catheterization can reduce their risks for UTI by using antiseptic techniques for insertion and catheter care.

Attach the indwelling catheter to the drainage system, slightly curve the tubing, and anchor it to prevent urethral traction. In women the catheter should be secured to the anteromedial thigh with non-allergenic adhesive.
Complications

Complications that are liable to occur include:

* Trauma and/or introduction of bacteria into the urinary system, leading to infection and, rarely, septicemia.
* Trauma to the urethra and/or bladder from incorrect insertion or removal of the catheter with the balloon inflated. Repeated trauma may cause scaring and/or stricture, or narrowing of the urethra.
* Bypassing of urine around the catheter. Inserting a smaller catheter size can minimize this problem.

Sexual activity and menopause can also compromise the sterility of the urinary tract. Irritation of the urethra during intercourse promotes the migration of perineal bacteria into the urethra and bladder, causing UTIs. Postmenopausal women may experience more UTIs than younger women. The presence of residual urine in the bladder secondary to incomplete voiding provides an ideal environment for bacterial growth.
Results

Urinary catheterization should be avoided whenever possible. Clean intermittent catheterization, when practical, is preferable to long-term catheterization.

Catheters should not be changed routinely. When each patient is monitored for indication of obstruction, infection, or complications before the catheter is changed, some patients require catheter changes weekly, and others may need a change in several weeks. Fewer catheter changes will reduce trauma to the urethra and reduce incidence of UTI.
Health care team roles
Observation

Before commencing with the catheterization, the nurse should observe the patient's general condition, pal-pate the pubic area to note gross distension. The patient should be monitored for indications of infections and encourage adequate fluid intake.

The nurse should seek medical advice if the catheter cannot be inserted easily, or if the patient complains of undue pain or bleeding other than that associated with minor trauma.
Patient education

The patient and/or caregiver should be taught to use aseptic technique for catheter care. Nursing interventions and patient education can make a difference in the incidence of urinary tract infections in the hospital and nursing homes and home care units.

The sexuality of the patient with an indwelling catheter for continuous urinary drainage is seldom considered. If a patient is sexually active, the practitioner must explain that intercourse can take place with the catheter in place. The patient or her partner can be taught to remove the catheter before, and replace it with a new one following intercourse.
KEY TERMS

Catheterization—A procedure of inserting a catheter through the urethra into the bladder to remove urine.

Catheter—A tube for evacuating or injecting fluid.

Contaminate—To make an item unsterile or unclean by direct contact.

Foley catheter—A double channel retention catheter. One channel provides for the inflow and outflow of bladder fluid, the second (smaller) channel is used to fill a balloon that holds the catheter in the bladder.

Intermittent catheterization—Periodic catheterization to facilitate urine flow. The catheter is removed when the bladder is sufficiently empty.

Perineal area—The genital area between the vulva and anus in a woman.

Urinary incontinence—The inability to retain urine or control one's urine flow.

Urinary retention—The inability to void (urinate) to discharge urine.

Urethritis—Inflammation of the urinary bladder.
Resources
BOOKS

Nettina, Sandra M. Lippincott Manual of Nursing Practice. 7th edition. Philadelphia: Lippincott, 2001, pp.692-697.
PERIODICALS

Colley, Wendy. RGN, DNCret. FETC. "Know How." Nursing Times (July 2, 1997).

Cravens, David D., Steven Zweig. "Urinary Catheter Management." American Family Physicians 61, no. 2 (January 15, 2000): 369.

Sanyay Saint, Joann G. Elmore, Sean D. Sullivan, Scott S. Emerson, Thomas D. Koepsell, "The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis." American Journal of Medicine 105, no. 3 (September 1998): 236.

Aliene S. Linwood, B.S.N., RN, D.P.A., FACHE