Catheterization, Male

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Definition

Urinary catheterization is the procedure of inserting a catheter through the urethra into the bladder to remove urine. Intermittent catheterization is performed for periodic relief of bladder distension; indwelling (Foley) catheters are inserted and retained in the bladder for continuous drainage of urine into a closed system.

Purpose

Intermittent catheterization is recommended to obtain a sterile urine specimen, to relieve urinary retention, for urologic surgery or surgery on contiguous structures, for critically ill patients requiring accurate measurement of intake and output, and for temporary obstruction of the bladder opening due to injury.

Indwelling catheterization is recommended for continuous drainage of urine when the bladder outlet obstruction can not be corrected by medical or surgical intervention; in cases of intractable skin ulceration caused or exacerbated by exposure to urine; and as palliative care for terminally ill or severely impaired incontinent patients.
Precautions

The urinary tract is normally a sterile system. The normal flow of urine from the kidneys through the ureters, bladder, and urethra prevents the migration of bacteria up through the urinary system. Antibacterial properties of the bladder wall, urethra, low pH of urine, and the prostatic fluid in men also inhibit bacteria growth. Urinary tract infections (UTI) usually result from bacterial invasion of the protective barriers of one or more urinary structures. As a result, urinary catheterization should be avoided whenever possible. Precautions must be taken to keep the procedure sterile and the catheter free from bacteria. 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 catheters predisposes the patient to UTI. Care should be taken to avoid trauma to the urinary meatus and urothelium (urinary lining) with catheters that are too large or inserted with an insufficient amount of lubricant. Further medical advice should be sought if the catheter cannot be inserted easily, or the patient complains of undue pain or bleeding other than that associated with minor trauma.

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. Patients with indwelling catheters should be re-evaluated periodically to determine if an alternative treatment method will be more effective.
Description

Intermittent catheterization is preferable to chronic indwelling catheterization in certain patients with bladder dysfunction. It has become the standard care for patients with spinal cord injuries. Elderly patients, following surgical repair of hip fractures, regain the ability to control urination more quickly on a program of intermittent catheterization every six to eight hours compared to the use of indwelling catheters.

Intermittent catheterization may be performed four or five times a day by the health care practitioner or care-giver. Patients who are interested in self-catheterization should be instructed and trained by a qualified health professional. This is also true for patients who require indwelling catheterization, as the procedure for insertion is similar to that for intermittent catheterization, with added responsibility of inflating the balloon.
Preparation

Health care practitioner performing the catheterization should have a good understanding of the male urinary system anatomy and physiology and should be trained in aseptic technique, catheter insertion technique, and catheter care.

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 agents, perineal drapes, gloves, lubricant, specimen container, label, and adhesive strips. Local anesthetic gel, antibacterial lubricant, catheter, and drainage system may need to be added. It is wise to check the content of the pre-packaged catheterization set when assembling materials and supplies.
Catheter choices

Silastic catheters have a decreased incidence of urethritis and are recommended for short-term and intermittent catheterization. Latex is the catheter of choice for long-term catheterization. Silastic catheters are recommended for patients who are allergic to latex products.

There are additional types of Foley catheters:

* PTFE-coated latex
* hydrogel-coated latex
* silicone-coated latex
* pure silicone

Select the smallest and softest catheter available. Catheters larger than 18 F are seldom used. Catheters size 14 or 16 F are used more frequently. A size 12 F catheter has been used successfully in catheterizing men with acute urinary retention. When indwelling catheters are required, select a catheter that can be inflated with 5 to 10 ml of sterile water.

Review the design, capacity, and emptying mechanism of a variety of urine drainage systems available. Select the system that is most adaptable to the patient's lifestyle and ability to manage the device independently. For patients with normal bladder sensation, a catheter valve for intermittent drainage may be an acceptable option.
Procedural precautions

Before starting the catheterization, observe the patient's general condition and palpate the suprapubic area to detect gross distension. The genital area should be washed with a mild soap and warm water and patted dry.

Phimosis is constriction of the prepuce (foreskin) so that it cannot be drawn back over the glans penis. This may make it difficult to identify the external urethral meatus. Care should be taken when catheterizing men with phimosis to avoid trauma from forced retraction of the prepuce or by incorrect positioning of the catheter.

The male urethra is longer than the female urethra and has two curves in it as it passes through the penis to the bladder, which makes catheter insertion more difficult. One curve can be straightened out by lifting the penis; the other curve is fixed. The penis should be held upright, at right angle to the patient's body when the catheter is inserted. The male urinary meatus is located at the end of the penis and is exposed by retracting the prepuce in uncircumcised patients. Men with a retracted penis can be even more difficult to catheterize. Gentle finger pressure on both sides of the penis will often cause the penis to emerge and extend from the body to facilitate the catheterization.

To perform the procedure:

* Position the patient in a horizontal recumbent position.
* Place the opened catheterization tray on the bedside stand in comfortable reaching distance.
* Retract the foreskin. Using an aseptic technique, clean the prepuce and insert anesthetic gel to anesthetize the glans penis and dilate the prepuce exposing the meatus. Anesthetic gel can then be introduced into the urethra and catheterization can commence.
* Use two or three aseptic swabs to clean the meatus with circular motion, beginning with the center of the opening and rotating outwards.
* Lubricate about 8 inches (20 cm) of the catheter.
* Hold the penis in the dominant hand and pull it upward and slightly backward to straighten the urethra.
* Gently insert the catheter with a smooth continuous motion until urine begins to flow. Do not force.
* Once the urine starts to flow, collect the specimen. Advance the catheter an additional 5 cm before inflating the balloon with 5 to 10 ml of sterile solution to hold the catheter in place.
* Connect the indwelling catheter to the drainage system. Put a slight curve in the catheter and anchor it to the upper outer thigh with hypoallergenic adhesive to prevent urethral traction.

Aftercare

Patients using intermittent catheterization as treatment of incontinence or retention will have a period of adjustment as they try to establish a catheterization schedule adequate for their normal fluid intake. The urinary drainage system should be kept closed. Breaks in the drainage unit may result in an infection. Avoiding cross-contamination is important in controlling catheter-related UTIs. Practitioners and caretakers should always wash their hands before and after handling a patient's catheter or urine collection unit.

The extended portion of the catheter should be washed with a mild soap and warm water to remove accumulated debris. Patients with indwelling catheters should be re-evaluated periodically to determine if an alternative treatment method will be more effective.

Catheters should not be changed routinely. Each patient should be monitored for indication of obstruction or complications before changing the catheter. Some patients require catheter changes weekly, and others may need a change in several weeks.

In summary, the following guidelines are recommended for male catheterization:

* Catheterize the patient only when it is absolutely necessary.
* Secure the catheter properly.
* Maintain a closed sterile urine collection system and unobstructed urine flow.
* Avoid catheter irrigation unless it is needed to prevent or relieve bladder obstruction.
* Always use the smallest effective catheter.
* Do not change the catheter as an elective treatment option.
* Isolated minor episodes of UTI should not be treated with antibiotics. Antibiotic prophylaxis promotes emergence of drug-resistant bacteria.
* Provide continuing education in catheter care for practitioners and caretakers.

Complications

A few complications that may rise during the procedure are:

* urinary tract infections and catheter obstruction
* trauma and/or the introduction of bacteria into the urinary system, leading to infection and, rarely, septicemia
* trauma to the bladder, urethra, and meatus caused by incorrect insertion of the catheter or forceful removal with the bladder inflated by confused patients
* scaring, stricture and/or narrowing of the urethra due to repeated trauma
* urine bypass around the catheter (A smaller catheter size may minimize leakage.)
* leakage around the catheter due to forceful bladder spasms that overwhelm the catheter's drainage capacity

Results

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. Practically every patient with chronic catheterization and frequent intermittent catheterization will develop bacteriuria. Some physicians do not recommend antibiotic therapy for asymptomatic bacteriuria. When symptomatic infections are treated in patients with indwelling catheters, the catheter is removed and a fresh urine specimen is obtained for culture to determine the source of the infection and direct the medical therapy.
Health care team roles

The physician orders the catheter and a registered nurse performs the procedure and provides patient education. Catheterization is a rather simple procedure, but female nurses are sometimes reluctant to perform urethral catheterization on male patients despite established patient care guidelines and advice on the male catheterization procedure. However, both intermittent and indwelling male catheterization is required to achieve optimum quality of life; therefore nurses should make the best possible practice and techniques available. Before commencing with the catheterization, the health care professional observes the patient's general condition, palpates the pubic area to note gross distension, monitors the patient for indications of infections, and encourages adequate fluid intake.
Patient education

The nurse usually teaches the patient and/or caregiver 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, 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 patient or her partner can be taught to remove the catheter before inter-course, and replace it with a new one following inter-course.
KEY TERMS

Bacteriuria—Bacteria in the urine (asymptomatic or symptomatic).

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

Phimosis—Tightness of the foreskin, which cannot be drawn back from the glans penis.

Prepuce—A fold of cutaneous tissue over the glans penis.

Urinary catheterization—The insertion of a catheter through the urethra into a patient's bladder.

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

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

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

Cravens, David D. and Steven Zweig. "Urinary Catheter Management." American Family Physician 16, no. 12 (January 15, 2000): 369.

Marchiondo, Kathleen. "A New Look at Urinary Tract Infection." American Journal of Nursing 98, no. 3 (March 1998):p34-39.

Pomfret, Ian. "Women at Work." Nursing Times 95, no. 6 (February 10, 1999): 59-60.

Aliene S. Linwood, BSN, RN, D.P.A., FACHE