Introduction

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 (eg, during
surgery), or left indwelling for long-term drainage for patients with chronic urinary retention.
Patients of all ages may require urethral catheterization, but patients who are elderly or
chronically ill are more likely to require indwelling catheters, which carry their own independent
risks.

The basic principles underlying urethral catheterization are gender-neutral, but the specific
aspects important in the technique of male catheterization are described in this article. For a
procedural description for female patients, see Urethral Catheterization in Women.

Relevant Anatomy

The male urethra is a narrow fibromuscular tube that conducts urine and semen from the bladder
and ejaculatory ducts, respectively, to the exterior of the body (see the image below). Although
the male urethra is a single structure, it is composed of a heterogeneous series of segments:
prostatic, membranous, and spongy.

Male urethra and its segments.

Knowledge of male urethral anatomy is essential for all health professionals because urethral
catheterization is one of the most commonly performed procedures in health care. The male
urethra is susceptible to a variety of pathologic conditions, ranging from traumatic to infectious
to neoplastic. Pathophysiologic variants of the urethra may have devastating consequences, such
as renal failure and infertility. For more information about the relevant anatomy, see Male
Urethra Anatomy.

Key Considerations

Prophylactic antibiotics are recommended for patients with prosthetic heart valves, artificial
urethral sphincters, or penile implants.

The maximal recommended volume for urethral balloon inflation can be found on the inflation
valve (usually, 10-30 mL). See the image below.

Urethral catheter balloon volume

indicator.

Indications

Diagnostic indications include the following:

Collection of uncontaminated urine specimen

Monitoring of urine output

Imaging of the urinary tract

Therapeutic indications include the following[2] :

Acute urinary retention (eg, benign prostatic hypertrophy, blood clots) [3]

Chronic obstruction that causes hydronephrosis [4]

Initiation of continuous bladder irrigation

Intermittent decompression for neurogenic bladder

Hygienic care of bedridden patients

Contraindications

Urethral catheterization is contraindicated in the presence of traumatic injury to the lower urinary
tract (eg, urethral tear). This condition may be suspected in male patients with a pelvic or
straddle-type injury. Signs that increase suspicion for injury are a high-riding or boggy prostate,
perineal hematoma, or blood at the meatus. When any of these findings are present in the setting
of possible trauma, a retrograde urethrogram should be performed to rule out a urethral tear prior
to placing a catheter into the bladder.[2]

Preparation
Anesthesia

Topical anesthesia is administered with lidocaine gel 2%.[5, 6] Many facilities have a preloaded
syringe with an opening appropriate for insertion into the meatus available either separately or in
the catheter kit. To instill, hold the penis firmly and extended, place the tip of the syringe in the
meatus, and apply gentle but continuous pressure on the plunger. A gloved finger should be
placed at the urethral tip and held for a couple of minutes to allow the anesthetic to take effect.

For more information, see Topical Anesthesia.

Equipment

Equipment includes a commercial single-use urethral catheterization tray (see the image below)
and a sterile anesthetic lubricant (eg, lidocaine gel 2%) with a blunt tip urethral applicator or a
plastic syringe (5-10 mL).
 Commercial urinary
catheterization kit.

The contents of the catheterization tray are as follows:

Povidone-iodine

Sterile cotton balls

Water-soluble lubrication gel

Sterile drapes

Sterile gloves

[7, 8, 9]
Urethral catheter (see Catheter Types and Sizes, below)

Prefilled 10-mL saline syringe

Urinometer connected to a collection bag

Catheter types and sizes

Catheter sizes and types are as follows (see the images below):

Adults - Foley (straight tip) catheter (16-18F)

Adult males with obstruction at the prostate - Coud tip (18 F)

Adults with gross hematuria - Foley catheter (20-24F) or 3-way irrigation

catheter (20-30F)

Children - Foley; to determine size, divide child's age by 2 and then add 8
 Infants younger than 6 months - Feeding tube (5F) with tape

Urethral catheter types: 1)

Straight tip; 2) Coude tip; 3) 3-way catheter irrigation.

Urethral catheter types: 1)

Straight tip; 2) Coude tip; 3) 3-way catheter irrigation.

Catheter materials include the following:

Latex

Silastic (pure silicone or silicone-coated)

Silver alloy

Antibiotic-impregnated
Positioning

Place the patient supine, in the frogleg position, with knees flexed.

Technique
Overview

Explain the procedure, benefits, risks, complications, and alternatives to the patient or the
patient's representative.

Position the patient supine, in bed, and uncover the genitalia.

Open the catheter tray and place it on the gurney in between the patients legs; use the sterile
package as an extended sterile field. Open the iodine/chlorhexidine preparatory solution and pour
it onto the sterile cotton balls. Open a sterile lidocaine 2% lubricant with applicator or a 10-mL
syringe and sterile 2% lidocaine gel and place them on the sterile field. See the image below.

Preparatory solution in a
commercial urinary catheterization kit.

Don the sterile gloves and use the nondominant hand to hold the penis and retract the foreskin (if
present). This hand is the nonsterile hand and holds the penis throughout the procedure. See the
video below.

Retraction of foreskin.

Use the sterile hand and sterile forceps to prep the urethra and glans in circular motions with at
least 3 different cotton balls. Use the sterile drapes that are provided with the catheter tray to
create a sterile field around the penis. See the video below.

Urethral preparation.
Using a syringe with no needle, instill 5-10 mL of lidocaine gel 2% into the urethra. Place a
finger on the meatus to help prevent spillage of the anesthetic lubricant. Allow 2-3 minutes
before proceeding with the urethral catheterization. See the video below.

Urethral analgesia.

Hold the catheter with the sterile hand or leave it in the sterile field to remove the cover. Apply a
generous amount of the nonanesthetic lubricant that is provided with the catheter tray to the
catheter. See the video below.

Foley lubrication.

While holding the penis at approximately 90 to the gurney and stretching it upward to straighten
out the penile urethra, slowly and gently introduce the catheter into the urethra. Continue to
advance the catheter until the proximal Y-shaped ports are at the meatus.[10] See the video below.

Urethral catheterization.

Wait for urine to drain from the larger port to ensure that the distal end of the catheter is in the
urethra. The lubricant jellyfilled 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 (preferably after using
ultrasonography to verify the presence of urine in the bladder). See the video below.

Urine return.

After visualization of urine return (and while the proximal ports are at the level of the meatus),
inflate the distal balloon by injecting 5-10 mL of 0.9% NaCl (normal saline) through the cuff
inflation port. Inflation of the balloon inside the urethra results in severe pain, gross hematuria,
and, possibly, urethral tear. See the video below.

Cuff inflation.

Gently withdraw the catheter from the urethra until resistance is met. Secure the catheter to the
patient's thigh with a wide tape. Creating a gutter to elevate the catheter from the thigh may
increase the patient's comfort. If the patient is uncircumcised, make sure to reduce the foreskin,
as failure to do so can cause paraphimosis. See the video below.

Securing the catheter.

Insertion of a Coud Catheter

The Coud catheter,[11] which has a stiffer and pointed tip, was designed to overcome urethral
obstruction that a more flexible catheter cannot negotiate (eg, in patients with benign prostatic
hypertrophy). To place a Coud catheter, follow the procedure described above. The elbow on
the tip of the catheter should face anteriorly to allow the small rounded ball on the tip of the
catheter to negotiate the urogenital diaphragm.

Perineal Pressure Assistance

The distal tip of the catheter might become caught in the posterior fold between the urethra and
the urogenital diaphragm. An assistant can apply upward pressure to the perineum while the
catheter is advanced to direct the catheter tip upward through the urogenital diaphragm.

Urethral Catheter Removal

Use a syringe to empty the balloon, and then apply gentle traction. Pain, severe discomfort,
resistance to withdrawal of the catheter, or failure to aspirate normal saline through the inflation
valve should alert the practitioner to the possibility of a nondeflating urethral catheter.

The most common cause of a nondeflating urethral catheter is obstruction of the inflation
channel, caused by a failed inflation valve or crystallization of the inflation fluid.

The first step in managing the nondeflating Foley balloon is to advance the catheter to ensure
that it is actually in the bladder.

If this does not work, cut the balloon port proximal to the inflation valve. This removes the valve
and should allow the water to spontaneously drain.

If this does not work, run a lubricated fine-gauge guidewire through the inflation channel. The
guidewire or stylet should allow fluid to drain along the wire itself.

If this does not work, a 22-gauge central venous catheter can be passed over the guidewire.
When the catheter tip is in the balloon, the wire can be removed, and the balloon should drain.

If the above techniques are unsuccessful, 10 mL of mineral oil may be injected through the
inflation port and will dissolve the balloon within 15 minutes. If this does not occur, an
additional 10 mL can be instilled.

If none of the above techniques are successful, a urologist should be consulted to rupture the
Foley balloon with a sharp instrument.[12]

Post-Procedure
Complications
Complications include the following:

Infections, [13, 14] including urethritis, cystitis, pyelonephritis, and transient

bacteremia

Paraphimosis, caused by failure to reduce the foreskin after catheterization

Creation of false passages

Urethral strictures

Urethral perforation

Bleeding

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.[15]