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Guidelines for difficult urethral catheterization in males

Warren, Janelle DNP, MS, FNP-BC; Ruckle, Herbert C. MD, FACS

doi: 10.1097/01.NURSE.0000580652.96436.97

Abstract: Urethral characterization can be difficult for patients and providers alike. This article describes an evidence-based protocol for difficult urethral catheter insertions in male patients.

Urethral catheterization can be difficult for patients and nurses alike. Read about an evidence-based protocol for difficult urethral catheter insertions in male patients.

In Loma Linda, Calif., Janelle Warren is an FNP in the inpatient adult urology unit at Loma Linda University Medical Center, and Herbert C. Ruckle is a Roger Barnes chair and professor in the department of urology at Loma Linda University School of Medicine.

The authors have disclosed no financial relationships related to this article.



URETHRAL CATHETERIZATION is a common hospital procedure. If performed incorrectly, it may result in patient discomfort, infection, urethral injury, and/or emotional trauma.1 Up to 25% of all patients will require an indwelling urinary catheter while hospitalized. Of those, 0.3% will experience urethral trauma due to complications during insertion. One study estimated that urethral injuries could increase the cost of care by as much as $10,000 per patient.2

Due to the length and tortuous nature of the urethra, male patients may be challenging to catheterize.3 This article describes a step-by-step approach to performing difficult urethral catheter insertions in males using an evidence-based protocol.

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Background and patient risk

Difficult urethral catheterization is defined as failure to insert a catheter after multiple attempts, requiring urologic consultation.4 The short-term physiologic consequences of traumatic catheter insertion include bleeding, catheter-associated urinary tract infections, and increased length of stay and catheter days; none of these adverse events is reimbursed by Medicare or insurers.1,4 Long-term complications may include urethral strictures, penile pain, and the possible need for reconstructive surgery.1,2,5

Urethral stricture disease can make catheter insertion more difficult in males.6,7 Common causes include a history of sexually transmitted infections; scar tissue from previous difficult catheter insertions; benign prostatic hyperplasia (BPH) in men age 40 and older; and past urologic surgeries, such as a transurethral resection of the prostate.

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Anatomic considerations

Although many nurses have been taught to advance the catheter until urine flows, most hospital policies and procedures recommend inserting the catheter to the Y bifurcation or hub to avoid traumatic injury.8,9 To accurately determine the distance to the bladder from the urinary meatus and safely perform catheterizations, nurses must consider the anatomy of the urethra.8 While the female urethra measures approximately 2 in (5.1 cm), the male urethra measures about 8.1 in (20 cm)—approximately four times longer. Nurses may assume that there is a straight line from the urinary meatus to the bladder, but its large, S-shaped curve can make catheterization challenging (see Male reproductive system).8

Catheterization may cause anxiety in males, especially if they have experienced difficulty in the past. Additionally, many male patients are uncomfortable with female nurses touching their genital area, creating awkward interactions.10



Despite these anxieties, a common expectation among both male and female patients is that the nurse is competent in urinary catheter insertion and will not be rushed when performing the procedure.11 Although no one can be an expert in every bedside procedure, nurses can increase the likelihood of successful insertion in males by understanding anatomy, using an evidence-based protocol for difficult catheterizations, and reassuring the patient during the procedure.

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Evidence-based algorithm

To decrease the risk of injury, some healthcare institutions have developed evidence-based algorithms to guide decision-making and ensure patient safety throughout the procedure.6,12 Beginning with a review of the patient's self-reported symptoms and medical record, nurses can use the algorithm to identify the risk of a difficult insertion (see Evidence-based algorithm for difficult catheter insertions in male patients).

If patients are nonverbal or in an altered mental state, nurses can identify risk factors using the electronic medical record when performing medication reconciliation. For example, common clues may include medications to treat symptomatic BPH, such as finasteride, a 5 alpha-reductase inhibitor prescribed to decrease the size of the prostate, or tamsulosin, an antagonist of alpha1A adrenoceptors in the prostate prescribed to improve urine flow.13 A history of urologic surgery or repeated hospitalizations for urinary retention also suggests a risk for difficult urethral catheterization.

An evidence-based algorithm eliminates guesswork by guiding a nurse's choice of catheter based on patient risk factors. For male patients with no known risk factors, for example, nurses may proceed with a 16 or 18 French straight tip urinary catheter. For those who meet the criteria for a difficult insertion, the algorithm prompts nurses to use a 16 or 18 French Coude catheter. The Coude catheter has a firm, curved tip that allows for easier passage through the S curve of the urethra and an enlarged prostate. If permitted by the healthcare facility's policies and procedures, nurses with the appropriate training can use Coude catheters without a provider's order.3,6,14

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Insertion procedure

Before starting the insertion, nurses should explain the procedure to patients and answer their questions. Reassure apprehensive patients with information about interventions that will minimize discomfort, such as “I am going to use anesthetic gel to make putting the catheter in more comfortable,” or “I am using a special catheter that will make it less painful for someone who has a hard time during catheterization.” Having patients practice relaxation techniques, such as breathing in and out slowly, can help relax the abdominal muscles and urinary sphincter.10,15

For patients who have already experienced a difficult catheterization, nurses may consider using an anesthetic gel or injecting a sterile lubricant directly into the urethral meatus to reduce pain, ease insertion, and distend the urethra.15,16 Nurses must obtain a provider order for anesthetic gels and allow 3 to 5 minutes for the medication to numb the urethra before insertion.14,16,17

The nurse should hold the penis taut with a firm stretch at a 90-degree angle to straighten the urethra when inserting the catheter. If using a Coude catheter, the nurse should ensure the curved tip is pointing upward toward the patient's head during insertion. If resistance is encountered approximately two-thirds of the way at the external urethral sphincter, the nurse should ask the patient to strain as if passing urine, which may help advance the catheter to the Y bifurcation.14 Additionally, the presence of a nurse colleague may be helpful for assistance in providing emotional support to the patient, including relaxation techniques such as deep breathing.

If inserting a straight tip catheter, the nurse may encounter resistance or catheter coiling in the urethra. Following the algorithm's prompts, the nurse would then switch to a 16 or 18 French Coude catheter. Although it may seem counterintuitive, switching to a smaller French catheter is not advised if the first attempt is unsuccessful because smaller catheters are more likely to buckle or coil.14

If urine does not return when the catheter is advanced to the Y bifurcation, palpate the bladder to determine fullness. Because the lubricant may be occluding the catheter, preventing urine flow, the catheter should be flushed with 60 mL of sterile 0.9% sodium chloride solution.12 The catheter balloon should not be inflated until urine returns and the nurse is confident that the catheter has been fully inserted to the Y bifurcation. If there is any doubt that the catheter is in the bladder or concern about it coiling in the urethra, stop the insertion procedure and notify the healthcare provider for a urologic consultation.



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Putting algorithms into practice

In the following case example, the nurse uses an evidence-based algorithm to improve patient outcomes.

JS was admitted to a telemetry unit with worsening heart failure. He had not urinated in 8 hours and was experiencing extreme discomfort from bladder distension. Mary, a nurse, received a provider order for an indwelling urinary catheter for JS and reviewed his health history for risk factors, such as BPH or urologic surgery. She informed the patient that she would be inserting a urethral catheter and asked if he had been catheterized before. He nodded and described his painful previous experience.

Mary had just completed training on an evidence-based algorithm for difficult male urethral catheterization and recognized that JS met the criteria for a difficult catheterization. She obtained an order for anesthetic gel to make JS more comfortable during the procedure. As the gel took effect, Mary obtained a 16 French Coude catheter kit and informed JS that it was specifically designed for male patients who had experienced a painful catheterization.

With help from a nurse colleague, Mary began the insertion procedure but encountered resistance as she advanced the catheter. She asked JS to take slow, deep breaths and then hold his breath and bear down as if he were urinating. Mary continued carefully until the catheter was advanced to the Y bifurcation and urine returned. She inflated the catheter balloon and finished the procedure. The evidence-based algorithm had been effective, and she would incorporate it into her practice for future patients.

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Coude urinary catheter; straight tip urinary catheter; indwelling urinary catheter; urethral catheterization

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