“Intermittent catheterization (IC) and self‐catheterization (ISC) are nowadays considered the methods of choice for the management of neurogenic lower urinary tract (LUT) dysfunction. Nevertheless, many still choose indwelling urethral catheterization (ID) or suprapubic catheterization (SC) as a means of management of urinary incontinence due to difficulty in performing IC/ISC or persistent leakage between catheterizations.”1
“Long‐term indwelling catheters are used commonly in people with lower urinary tract problems in home, hospital and specialized health‐care settings. There are many potential complications and adverse effects associated with long‐term catheter use. The effect of health‐care policies related to the replacement of long‐term urinary catheters on patient outcomes is unclear.”2
“A urinary catheter is passed through the urethra into the bladder to drain urine. This procedure is performed using sterile equipment under aseptic technique by qualified clinicians.
Indications for catheterization
- “To relieve urinary retention
- To monitor accurate urinary output
- To instill medications
- To manage and maintain urinary system during surgical procedure
- Establish bladder irrigation for management of haematuria
- To manage fistula and promote healing
- To conduct investigative procedures
- To preserve skin integrity
- To provide end-of-life care.”3
“As catheters inserted for urinary retention or monitoring of urine output are short term this influences the choice of a catheter to be used. A size 12-16 Foley catheter is generally sufficient for both adult men and women. The smallest size catheter that will drain the contents of the bladder should be selected. The urethral mucosa contains elastic tissue which will close around the catheter so there are fewer problems with leakage and pain. Potential side effects of large catheters include: Pain and discomfort Pressure ulcers, which may lead to stricture formation Blockage of paraurethral ducts Abscess formation”4
Some women who self-catheterize oftentimes encounter difficulties in comfortably doing so. Certain anatomical features and decreased motor skills may hinder the ability for some women to properly visualize the site of insertion, called urinary meatus.
“Women infrequently pose a challenge for urinary catheter placement. Most issues are related to vaginal atrophy or retraction of the urethral meatus into the vagina. In females, shorter catheters may be used for one-time catheterizations and may prevent difficult catheterizations.”5
In other cases where a clinician or caregiver is the one inserting the catheter, they may also find it difficult under certain conditions. For instance, in a supine position, the opening meatus can droop and slightly cave into the vaginal opening, making it difficult for the person inserting the catheter to find the urinary meatus. This especially occurs as the female genitalia loses elasticity over the years.
“The anatomy of the urethra makes it sensitive to trauma during catheterization. The lumen of the urethra is a convoluted, ribbon-like structure, only dilating during urination or when accommodating a urethral catheter. The urethra is lined with transitional epithelium; underlying the epithelium lays is a thin layer of tissue that is rich in blood vessels. Therefore, any trauma to the epithelium during urethral catheterization provides convenient entry sites for microorganisms into the blood and lymphatic system.”6
For patients whose urinary meatus is not easily visible. The following ‘thumb technique’ has proven quite convenient, reducing catheterization duration and lessening pain from the insertion experience.
“A one-finger assessment of the vagina is made in an attempt to locate the urethral meatus along the anterior vaginal wall; it may simply help estimate the length of anterior vaginal wall up to the vault. A 16F catheter is mounted on a male catheter introducer bent to achieve an angle of 30° along its distal end. It is then gently slid along the anterior vaginal wall until it ‘drops’ into the urethral opening without resistance. At this stage, the introducer is disengaged and slowly withdrawn as the catheter is eased across the urethra into the bladder.”7
Collect the catheter supplies and have them at the ready for catheterization. Fold a towel several times and fold it under the patient’s back who should be in a supine position. The idea of adding the towel under the sacral region is to achieve a better angle of insertion since the hip is slightly elevated. If approved by a physician, topical lidocaine jelly can be applied to assist with mitigating pain and increasing comfort since the invasiveness of this procedure can be quite hurtful.
Using the thumb of your hand of less dexterity, position it roughly 0.5” – 1” beneath the clitoris and gently press in and up to reveal the opening meatus. This also has the effect of tightening surrounding tissue, thus adding stability.
If the urinary meatus slips due to excessive moisture, a good tip is to use a 4×4 sterile gauze with the “thumb technique” to add a bit more friction and prevent the urinary meatus from slipping as you bring it up with the weak handed thumb. Moreover, it keeps the labia minora from getting in the way of proper visualization.
When beginning insertion, grasping the catheter no more than two inches from the distal portion should be consciously practiced to provide stability and preventing it from accidentally moving and make its way into the vaginal opening.
The “thumb technique” is also preferred over the so-called ‘wink’ technique, which is when a providone iodine swab is used to wipe the area to find the urinary meatus. This is because it is much easier to locate the meatus even if it is slightly nested in the vaginal opening with the thumb technique; the ‘wink’ technique alone makes it more difficult to properly find it, should it be concealed. In any case, once the tissue is stable by using the thumb technique, you can then apply the ‘wink’ method to easily locate the opening.
“There are many pitfalls to urinary catheter insertion and an assistant is recommended. This can be difficult or impossible in the community. Catheterization in the surgery or at an outpatient appointment can allow the required assistance and use of a tilting couch or trolley. The non-touch technique is taught to all those inserting catheters.”8
If the catheter is accidentally inserted into the vagina, not removing would add the benefit of providing a sort of marker so that you can properly reposition the catheter for insertion while avoiding the already discovered ‘false path’. However, do not insert this catheter back into the urethra. Discard and use a new sterile one.
“Proper placement technique is critical, as failed attempts at catheterization may lead to iatrogenic injury. Forcing a catheter past the point of resistance can cause injuries ranging from a mucosal tear to more serious false passages (perforations), which are associated with infection, urethral stricture, and subsequent surgical management. In turn, urethral stricture may make future catheterizations problematic. The most common injury sites are the posterior and bulbous urethra. The most frequent injuries are false passages created by forceful catheterization, as well as mucosal and submucosal tissue tears caused by balloon inflation in an improper position in the urethra. Bleeding typically is the first sign that an injury has occurred. Besides making manual catheterization more difficult, bleeding also complicates subsequent endoscopic procedures that may be required.”9
The thumb method has assisted many physicians and patients in overcoming the duration of insertion and the amount of pain/discomfort experienced.
“Women in their late 80s-90s need urethral catheterization either for monitoring urine output, nursing care or urinary retention. However, with severe postmenopausal vaginal atrophy, the urethra recedes significantly making its visualization for catheterization impossible. This necessitates cystoscopic catheterization over a guide-wire. In patients with urinary retention and bladder not accessible for insertion of suprapubic catheter, urethral catheterization with a flexible cystoscope is the only safe option available which, however, may not be feasible in emergency situations.”10
“Catheterization must be performed using sterile technique and extreme care to prevent infection and injury; maintain a closed drainage system after catheter insertion. Common sources of difficulty: catheter too large, advancing catheter too rapidly and forcefully, failure to wait for the sphincter to relax.”11
“There are a variety of complications associated with indwelling catheters. Regular review for these complications is required to enable timely treatment to prevent pain and discomfort to the patient, this includes the severity and frequency of the complication, any triggers, interventions that have already been used to treat the complication and its effect. Observation of the patient concentrating on the catheter entry site, catheter position, type and size, support system being used, drainage system, urine color, volume contents and odor, skin condition, and personal hygiene are all required. Catheterization is an invasive procedure that can cause embarrassment, physical and physiological discomfort. Explaining the procedure and providing the reason for catheterization will reduce patient anxiety. It is important that the healthcare professional performing the procedure takes time to complete a brief medical history especially about any urological and gynecological conditions before commencing the procedure.”12
(1) Catheterization: Possible complications and their prevention and treatment. Igawa, Y., Wyndaele, J., & Nishizawa, O. International Journal of Urology. 2008. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1442-2042.2008.02075.x
(2) Policies for replacing long‐term indwelling urinary catheters in adults. Alexander, C., Sinha, S., Omar, M., & Cooper, F. 2016. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011115.pub2/full
(3) Female Indwelling Urinary Catheterisation (IUC) – Adult. ACI Urology Network Nurses Working Group. ACI Urology Network- Nursing. 2008. https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/256132/ACI_Female_IUCv2.pdf
(4, 12) Urinary Catheterisation & Catheter Care. Canterbury District Health Board. SElf- Directed Learning Package. 2015. https://edu.cdhb.health.nz/Hospitals-Services/Health-Professionals/Education-and-Development/Self-Directed-Learning/Documents/LEARNING%20PACKAGE%20Catheterisation.pdf
(5, 9) Current Trends in the Management of Difficult Urinary Catheterizations. WIllette, P., & Coffield, S. West JEM: Integrating Emergency Care WIth Population Health. 2012. https://escholarship.org/uc/item/0114p0n5
(6) Catheter care: RCN guidance for health care professionals. Royal College Of Nursing. The Royal College Of Nursing. 2019. https://www.google.com.mx/url?sa=t&rct=j&q=&esrc=s&source=web&cd=13&cad=rja&uact=8&ved=2ahUKEwiqx5qM44zjAhUNZFAKHZTlCQI4ChAWMAJ6BAgEEAI&url=https%3A%2F%2Fwww.rcn.org.uk%2F-%2Fmedia%2Froyal-college-of-nursing%2Fdocuments%2Fpublications%2F2019%2Ffebruary%2F007-313.pdf&usg=AOvVaw1Pfq31s6TOqbb6mQIYFvNe
(7, 10) Technique of Urethral Catheterisation in Very Elderly Women. Chitale, S., & Hudson, R. Annals: The Royal College of Surgeons of England. 2007. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2121233/
(8) Urinary catheterisation: Indications, technique and managing failure. Ahluwalia, A., Rossiter, D., & Menezes, P. SAGE Journal. 2018. https://journals.sagepub.com/doi/pdf/10.1177/1755738017707551
(11) Catheterization (Urethral). Regina Qu’Appelle Health. Regina Qu’Appelle Health . 2016. http://www.rqhealth.ca/C.9.pdf